Reading of the Week: Care – At the System Level, At the Individual Level

From the Editor

As stigma fades, there is increasing interest in mental health care. But how can we best help those who need help?

This week, we consider three selections. From an opinion piece written by a politician to a study in a leading journal, there is a common thread: how to improve care, whether at the individual level or at the system level.

In our first selection, we consider a new paper from The Canadian Journal of Psychiatry. Evgenia Gatov (a senior epidemiologist at ICES) and her co-authors consider trauma in the inpatient population, with a big finding. “In this population-based study of adult psychiatric inpatients in Ontario, Canada, almost one in three individuals reported prior experiences of interpersonal trauma.”

19609_mainInpatient Care: a need for trauma care?

In our second selection, Dr. Adam Philip Stern (of Harvard Medical School) discusses the challenges of being a patient and a psychiatrist. Dr. Stern – ill with cancer – is in psychotherapy. He discusses much, including the value of connectedness.

And, in our third selection, we look at an essay by Boris Johnson (the new Prime Minister of the United Kingdom) who discusses depression and work. He advocates for tax changes making it easier for companies to help mentally ill employees.

Enjoy.

DG

Selection 1: “Epidemiology of Interpersonal Trauma among Women and Men Psychiatric Inpatients: A Population-Based Study”

Evgenia Gatov, Nicole Koziel, Paul Kurdyak, Natasha R. Saunders, Maria Chiu, Michael Lebenbaum, Simon Chen, Simone N. Vigod

The Canadian Journal of Psychiatry, 1 July 2019  Online First

cjp

Close to one in three individuals affected by mental illness – women more so than men – report having experienced interpersonal trauma of a sexual, physical, or emotional nature. Trauma is at least 2 to 3 times more common among individuals with mental illness than among those without. In those with severe mental illness, including schizophrenia; trauma is even more common, with prevalence estimates approaching 37% for sexual and 47% for physical trauma. While symptoms of trauma and stressor-related disorders such as post-traumatic stress disorder (PTSD) require treatment in and of themselves; interpersonal trauma, even in the absence of these conditions, can negatively affect mental illness treatment trajectories. A history of interpersonal trauma is associated with impaired engagement with clinical providers, higher likelihood of substance use relapse, and lower antidepressant response rates. As such, recognition of trauma exposure and a trauma-informed approach to care are key to effective mental health and addictions (MHA) care.

Psychiatric inpatient units are where individuals with the most severe and complex mental illnesses receive treatment. Since interpersonal trauma can strongly impact mental illness presentations and treatment trajectories, it is important to consider it in the context of inpatient services.

So begins a new paper by Gatov et al.

Here’s what they did:

  • Drawing on health-administrative databases, they designed a “population-based, cross-sectional study.”
  • The study included Ontario residents who were 18 and older and had a psychiatric hospitalization between April 1, 2009, and March 31, 2016.
  • Statistical analyses were done, including an attempt to analyze “prevalence in women versus men using modified Poisson regressions with robust standard errors, generating age-adjusted prevalence ratios (aPR) with 95% confidence intervals (CI).”

Here’s what they found:

  • The databases contained 160,436 inpatients.
  • Demographically: the average age of inpatients was 42.0 (SD= 16.9) with the majority from urban areas (89.9%), and about one-third (28.1%) lived in the lowest-income neighborhoods.
  • “About 31.7% of inpatients (n= 50,832) reported experiencing lifetime interpersonal trauma, including physical (n = 31,111; 19.4%), sexual (n = 24,654; 15.4%), and emotional (n = 42,046; 26.2%).”
  • “Lifetime history of trauma was significantly more common in women than in men (39.6% vs. 24.1%; aPR = 1.68), with the largest relative difference for sexual trauma (aPR = 2.81)… About 14.5% of women reported experiencing a lifetime history of all three types of trauma compared to 5.0% of men (aPR = 2.99).” See the graph below.

traumadata

There is much to like in this paper. The sample size is large, adding nicely to the literature (past studies have drawn from smaller samples sizes).

In terms of limitations, given that the work is based on patients reporting trauma to nursing staff early in the hospitalization, we can wonder about under-reporting.

The data pushes us in a direction: should more trauma-informed care be built into the inpatient experience? The authors clearly think so: “The results support action toward incorporating a trauma-informed approach to care for all inpatients to improve response to treatment, optimize transition back to the community postdischarge, and improve well-being and quality of life.”

https://journals.sagepub.com/doi/full/10.1177/0706743719861374

 

Selection 2: “Chasing My Shadow as a Cancer Patient in Talk Therapy”

Adam Philip Stern

The New York Times, 11 July 2019

the_new_york_times_logo

Harvard Medical School sends out an email when an esteemed faculty member passes away, and more often than not I delete it without clicking. I feel shame for not taking the time to read about the death of colleague whose life was devoted to medicine or science, but I do think about death a lot for someone my age – perhaps too much.

As a Stage 4 kidney cancer patient at age 35, I ruminate more about legacy than I’d like.

So begins a personal essay by Dr. Stern.

He has much to say on his life – and his life as a patient.

  • On family. “Which of my older family members will have to endure the cruel task of attending my funeral? Will my wife be able to find happiness while being a widow who lovingly raises our little boy? He’s only 2 years old now. Will he even remember me when this is all over?”
  • On his career. “I was a mere assistant professor of psychiatry when I learned that the statistical odds were that I’d most likely die before my career had a chance to take off. Would anyone care about the 20 or so academic publications I poured my heart and mind into these last five years?”
  • On being a patient. “Being in therapy as a psychiatrist is an odd experience, a bit like Peter Pan chasing his shadow. I know how I’d respond to someone like me. Sometimes it aligns with how my therapist reacts and sometimes it doesn’t.”

His initial ambivalence with therapy is interesting, however, the therapy becomes a source of strength.

The idea of what talk therapy is has evolved, but how people connect will always be at the very core of why it helps.

https://www.nytimes.com/2019/07/11/well/live/chasing-my-shadow-as-a-cancer-patient-in-talk-therapy.html

 

Selection 3: We can improve mental health, save money and boost the economy all in one go

Boris Johnson

The Daily Telegraph, 14 July 2019

telegraph

It is one of the most fascinating and consoling features of the life of Sir Winston Churchill that, for all his giant strengths of courage and resilience, he was also prone to bouts of depression. He called it his ‘Black Dog’. And there was only one means by which he really succeeded in chasing that Black Dog away. It certainly wasn’t alcohol. It was the same therapy that lifts the spirits of hundreds of millions if not billions of people around the world – and that cure is work.

In Churchill’s case that meant the almost superhuman production of books, speeches and articles. He wrote more words than Dickens and Shakespeare combined – and that is before we have even considered his epic memoranda, or the industriousness of his oil painting.

It was with work that he pitchforked off his depression…

So begins an essay by British MP Boris Johnson, who moved into 10 Downing Street yesterday.

Johnson notes that work can be helpful to those with depression – but it can also be a source of stress.

He sounds an optimistic note:

We know that people can be helped, that therapies exist, and that they are effective, that seemingly invincible darkness can be dispelled and that people’s lives can be turned around. We grasp the crucial importance of sport, and physical exercise.

But he describes a system of tax disincentives:

As things stand, mental health and occupational health services are taxable as benefits in kind. That means they incur both income tax and national insurance… At most, employers can get a modest reimbursement of £500, but only if an employee is off for more than 28 days – a hopeless incentive, since the whole objective should be to keep the employee in the workplace, or to ensure that time off is as brief as possible.

He closes by arguing for a policy review so that government can “offer preferential tax treatment to companies that look after employees in work – giving them the counselling and the help they need to do their jobs.”

Johnson doesn’t offer much in way of details, and changes to tax policy can be challenging. Would there be caps on these preferential tax treatments? Would certain types of care be supported, but not others? How to avoid the expensive US experiment with employer-sponsored wellness programs with its middling results?

Still, it’s interesting to note that in his last essay before being elected leader of his party, Prime Minister Johnson wrote on mental illness.

For those interested in a response to his idea, columnist Arwa Mahdawi of The Guardian writes a critical essay. If Johnson is a bit light on details, Mahdawiis a bit heavy on partisanship.

https://www.telegraph.co.uk/news/2019/07/14/can-improve-mental-health-save-money-boost-economy-one-go/

https://www.theguardian.com/commentisfree/2019/jul/16/boris-johnson-working-harder-mental-health-tax-privatising-nhs

Canadian employers and mental health benefits have been discussed in past Readings, including Starbucks decision to better cover the costs of psychotherapy.

http://davidgratzer.com/reading-of-the-week/reading-of-the-week-starbucks-big-mental-health-announcement-and-more/

 

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.

1 Comment

  1. I realize that there is a lot of interest currently in trauma informed care and that it contains approaches that may be very valuable for some populations. However, I have concerns about applying a trauma lens to patients with schizophrenia. It’s unclear in this article if the traumas that are being reported occurred after the onset of the illness. It often takes a long time for people with this disorder to receive appropriate treatment. As families can explain, people with untreated psychosis are extremely vulnerable and are often having harrowing and damaging experiences as they interact with a world they can no longer understand.

    Unfortunately, many of us are seeing how ideas associated with trauma-informed care are leading to even more parent blaming among service providers than already exists. This recent blog by a young woman with schizophrenia describes how hard it was to convince her therapist that her parents hadn’t abused her:

    https://www.psychologytoday.com/us/blog/recovery-road/201906/schizophrenia-and-trauma?fbclid=IwAR2CLQfKqvPPFNTmoo_B4w5-48LTM7bFcb7kv_t58PFRyCItwFiDnqw2chg

    Psychiatrists might be interested in this article by an American colleague who describes the arrivel of trauma informed training at his hospital:

    https://www.mdedge.com/psychiatry/article/103429/unmasking-trauma-informed-care

    And this recent article by a service user in the UK discusses the role trauma theories play in approaches to severe mental illnesses that result in poorer services for this population:

    https://morningstaronline.co.uk/article/f/traumatic-power-struggle-within-mental-health

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