From the Editor
Earlier this week, a patient mentioned that, until recent events, he hadn’t heard of Wuhan, China. Today, it would seem, we are all familiar with this city.
Much reporting and commentary have focused on infections and deaths. But what are the psychiatric implications of the outbreak? This week, we have three selections. In the first, we look at a short and thoughtful paper from The Lancet Psychiatry that tries to answer this question. Dr. Yu-Tao Xiang (University of Macao) and his colleagues note: “In any biological disaster, themes of fear, uncertainty, and stigmatisation are common and may act as barriers to appropriate medical and mental health interventions.”
In the second selection, we review a new study that uses an online mindfulness-based cognitive therapy aimed at patients with residual depressive symptoms, involving 460 participants. Zindel V. Segal (University of Toronto) and his co-authors find that the intervention “resulted in significant improvement in depression and functional outcomes compared with [usual depression care] only.”
And in the third selection, Drs. Pier Bryden and Peter Szatmari, both of the University of Toronto, discuss their new book. They open their Globe essay with a simple question: “What can I do to help my child?”
Selection 1: “Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed”
Yu-Tao Xiang, Yuan Yang, Wen Li, Ling Zhang, Qinge Zhang, Teris Cheung, Chee H. Ng
The Lancet Psychiatry, 4 February 2020
So far, mental health care for the patients and health professionals directly affected by the 2019-nCoV epidemic has been under-addressed, although the National Health Commission of China released the notification of basic principles for emergency psychological crisis interventions for the 2019-nCoV pneumonia on Jan 26, 2020.
So notes Xiang et al. in their new paper.
The paper observes a lack of information:
To date, epidemiological data on the mental health problems and psychiatric morbidity of those suspected or diagnosed with the 2019-nCoV and their treating health professionals have not been available; therefore how best to respond to challenges during the outbreak is unknown.
Drawing on the experience with SARS, they note the psychological impact to patients.
- “Patients with confirmed or suspected 2019-nCoV may experience fear of the consequences of infection with a potentially fatal new virus, and those in quarantine might experience boredom, loneliness, and anger.”
- “Symptoms of the infection, such as fever, hypoxia, and cough, as well as adverse effects of treatment, such as insomnia caused by corticosteroids, could lead to worsening anxiety and mental distress.”
- “In the early phase of the SARS outbreak, a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality, were reported.”
The paper makes some recommendations. We highlight a few.
“Multidisciplinary mental health teams established by health authorities at regional and national levels (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) should deliver mental health support to patients and health workers.”
“Secure services should be set up to provide psychological counselling using electronic devices and applications (such as smartphones and WeChat) for affected patients, as well as their families and members of the public. Using safe communication channels between patients and families, such as smartphone communication and WeChat, should be encouraged to decrease isolation.”
“Suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals working in hospitals caring for infected patients should receive regular clinical screening for depression, anxiety, and suicidality by mental health workers.”
Based on experience from past serious novel pneumonia outbreaks globally and the psychosocial impact of viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are crucial and pressing goals.
This is an important and timely paper.
While so much attention has focused on the infections and spread (for obvious reasons), Xiang et al. do an excellent job of reminding us of the possible psychiatric issues. Their recommendations are very practical. Of course, given the chaos of the outbreak and the dearth of resources, some recommendations seem more aspirational at this point (unfortunately).
Selection 2: “Outcomes of Online Mindfulness-Based Cognitive Therapy for Patients With Residual Depressive Symptoms: A Randomized Clinical Trial”
Zindel V. Segal, Sona Dimidjian, Arne Beck, Jennifer M. Boggs, Rachel Vanderkruik, Christina A. Metcalf, Robert Gallop, Jennifer N. Felder, and Joseph Levy
JAMA Psychiatry, 29 January 2020 Online First
Depression is the second leading cause of disability worldwide, with the frequently chronic and recurrent nature of the disorder contributing significantly to the global burden of disease.Even low to moderate levels of residual depressive symptoms (RDS) are associated with significant impairment,greater social role strain,and risk of a negative prognosis.Despite the availability of antidepressant medication, most patients with depression who achieve a clinical response to antidepressant medications experience RDS.
So begins a paper by Segal et al.
Here’s what they did:
- They conducted a randomized clinical trial in health clinics at Kaiser Permanente Colorado, Denver.
- Participants were recruited between March 2, 2015, and November 30, 2018, and were 18 or older. They had had at least one depressive episode, and had residual symptoms (a PHQ-9 score between 5 and 9).
- The Mindfulness Mood Balance (MMB) intervention: “The MMB treatment was developed to provide the core components of the in-person mindfulness-based cognitive therapy program in an online, 8-session, self-administered platform.”
- Outcomes were assessed for a 15-month period.
Here’s what they found:
- There were 460 participants, evenly divided into the intervention and non-intervention groups.
- Demographically: the mean age was 48.3; the majority were women (75.6%) and white (91.9%). Participants reported a mean of 7.5 previous episodes of depression and the vast majority were on antidepressants (78%).
- Participants had greater reductions in depressive and anxiety symptoms (see the figure below for the PHQ-9 scores), higher rates of remission, and lower rates of relapse compared with participants who received usual care only. There was also improvement on secondary measures (including quality of life).
They write that the intervention “resulted in significant improvement in depression and functional outcomes compared with the usual depression care only.”
This is a good and timely paper. As we look to improve depression outcomes, the intervention studied here – an online psychotherapy – is very compelling, with implications on reducing residual symptoms (good) but also preventing relapse (very good).
The cost? Minimal. There is some coaching associated with the stand-alone site. The authors note: “$96.67 for a mean of 2.34 hours per participant… and included orientation and follow-up telephone calls, emails, website tracking, and supervision.” (This calculation seems crude, but the central point is that the overall costs are minimal, especially compared the health costs of relapse.)
There are, of course, limitations. Among them: the demographics of the sample.
Still, there is much to like in this low-cost intervention. The authors didn’t do an economic analysis, but it’s difficult not to believe that the intervention paid for itself.
Selection 3: “Children and teens might hide their mental-health struggles. But adults can’t look away”
Pier Bryden and Peter Szatmari
The Globe and Mail, 23 January 2020
‘What can I do to help my child?’
As child and youth psychiatrists, this is a question we often hear from parents sitting across from us in our offices. Whether their child is struggling with anxiety, depression, an eating disorder, substance abuse or another mental illness, their concern is the same, and often accompanied by self-blame, confusion and worry. That they missed the signs. That their child inherited a family mental illness. That the choices they’ve made – a demanding job or a big move – or inevitable life events, such as divorce or loss, are the cause of their child’s distress.
So begins an essay by Drs. Bryden and Szatmari.
They review the literature on youth with a Canadian focus:
- “Between 10 per cent and 20 per cent of children and teenagers globally suffer from a mental-health disorder and 70 per cent of adult mental illnesses begin in childhood or adolescence.”
- “In recent years, rates of emergency-room visits and hospital admissions for self-harm and suicide attempts have climbed exponentially in Canada.”
- “Although we don’t have recent national suicide data yet available, we are concerned that our youth suicide rates may also be rising, as they currently are in the United States.”
And they offer practical advice, starting with a very practical piece of advice:
“For any parent wondering how they can help their child, this is our answer: Don’t look away.”
They mention the importance of early intervention and urge family to connect with family doctors, teachers, and school counsellors.
The best thing you can do to support your child’s physical and mental health is to learn about other risk factors, especially family history and childhood experiences that may put your child at increased risk of mental illness (and make sure your information is from a reliable source). While there are no guarantees, providing your child with a structure that promotes healthy sleep, good nutrition, physical activity, appropriate screen-time use and positive, caring relationships from an early age may prevent (and will certainly mitigate) these factors from causing harm.
With more and more people seeking care for psychiatric problems – for themselves or for a loved one – this essay is a nice introduction to their new book, Start Here: A Parent’s Guide to Helping Children and Teens Through Mental Health Challenges, which reviews psychiatric disorders in a readable and clear way. For us clinicians, the book provides useful pointers on communicating with our patients and their families; it is a valuable resource.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.