From the Editor
This week, we consider three provocative but thoughtful essays.
In the first selection, Vrije Universiteit Amsterdam’s Pim Cuijpers – a highly published researcher in depression – wonders what needs to be done to improve depression outcomes. In this JAMA paper, he notes the importance of the task: “One estimate suggests that approximately 30% of patients with depressive disorders have a chronic course with limited response to treatment.”
Is ketamine a possible breakthrough for depression? Cuijpers ask.
In the second selection, the University of Toronto’s Dr. Paul Kurdyak considers how to address the shortage of psychiatrists – and notes, in this healthydebate.ca essay, that the problem is more complicated than some would suggest; he argues that the supply of psychiatrists across Ontario has little impact on access because of practice styles.
Finally, in the third selection, Columbia University’s Matthew L. Goldman and his co-authors note that doctors are screened for TB. They ask: “Should physicians also be screened for mental health conditions such as depression or burnout?”
“The Challenges of Improving Treatments for Depression”
JAMA, 30 November 2018 Online
In the past few decades substantial progress has been made in the research and development of treatments for major depression. Many different types of medications and psychotherapy are currently available and rigorous studies have shown that antidepressants are more effective than placebo, and several types of psychotherapies are more effective than waiting list or other controls. These findings suggest that many patients with depression can be successfully treated. Based on these significant and positive effects, many of these treatments are included in treatment guidelines and are widely used in clinical practice. However, not all patients with depression recover with available treatments and several important challenges need to be resolved to improve existing treatments and to increase the number of patients who benefit from them.
So begins a short paper by Cuijpers.
He starts by noting research challenges:
- “In a meta-analysis that included 44 240 patients from 177 studies, 54% of patients responded to antidepressants, whereas 38% responded to placebo.”
- “Comparable numbers have been reported for psychotherapies with response rates of 54% compared with response rates of 41% across control conditions.”
But if there are challenges, he reminds us that the need is great:
One estimate suggests that approximately 30% of patients with depressive disorders have a chronic course with limited response to treatment.
How to proceed?
A straightforward approach in the short-term is to develop treatments that are more effective than the current ones in acute phase depression.
He suggests a few things:
- “Considerable evidence indicates that these internet-based interventions are effective and require less resources.”
- “Another priority is to increase research on the treatment of chronic and resistant depression.”
- He makes special note of the potential of ketamine.
Because of the public health effects of depression and the enormous related adverse effects on the quality of life of patients, it should be a priority to search for methods to increase the number of patients who benefit from treatment and in this way reduce the burden of depression.
A few thoughts:
- This is a good essay.
- He makes good points, particularly about the chronic nature of depression for some patients. That’s relevant, of course, from a psychiatric perspective, but also from a public health one.
- I like his comment about internet-based interventions. But in our enthusiasm for something new, we shouldn’t forget its challenges. When Shen et al. considered apps for depression, they put forward a few common-sense criteria and found that 75% of available apps were thus excluded. This study, reviewed in a earlier Reading, can be found here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-depression-is-there-an-app-for-that/.
- It’s difficult to disagree with a call for more research in chronic and resistant depression. I wonder, though, if more “real world” trials (including people with co-morbidities) would yield more helpful results over time than traditional studies (rich in exclusion criteria).
- And the comments on ketamine are timely. (As an aside, last Sunday’s New York Times included a long essay on the potential of ketamine by writer Moises Velasquez-Manoff. You can find the NYT article here: https://www.nytimes.com/2018/11/30/opinion/sunday/suicide-ketamine-depression.html.)
Psychiatrists and Better Access
“There’s a shortage of psychiatrists in Ontario. But do we really need more?”
Healthydebate.ca, 14 November 2018 Open Access
In August, the Coalition of Ontario Psychiatrists, a partnership between the Ontario Psychiatric Association and the Ontario Medical Association, released a report warning Ontarians about an ongoing crisis of access to mental health care due to a shortage of psychiatrists. The report makes three recommendations: 1) to increase exposure to psychiatry in medical school; 2) to increase the number of psychiatrists trained in Ontario; and 3) to increase payment to psychiatrists.
There are a few problems with these recommendations. First and most important, their implementation doesn’t guarantee that access to mental health care in Ontario will improve. There is a shortage of psychiatrists in some areas of Ontario, and an abundance of psychiatrists in cities like Toronto and Ottawa. Many psychiatrists in large urban areas adopt small practices and see patients frequently, often over several years. This means that these psychiatrists are effectively inaccessible. If we train more psychiatrists only to have them practise this way, the access issues in regions with very few psychiatrists will not be addressed.
Second, the time it takes to recruit more people to psychiatry and to train is a lengthy and expensive process—nine years from the start of medical school. People with mental illnesses can’t wait—we need more and better access now. The most urgent issue is not a shortage of psychiatrists, but poor access to mental health services more generally.
Psychiatrists are only a part of a broader mental health system.
So begins an essay by Dr. Kurdyak.
In it, he makes several points about access:
- “In my opinion, mental health care should start in primary care.” And he acknowledges, this is already happening. Drawing on the example of how health care handles diabetes, he observes that many people with mental health problems begin accessing care through their primary care providers.
- There are many psychiatrists, including at hospitals. “[F]or the most part, these services are not well-integrated into the broader health care system, and people who need them as well as their providers do not know how to access them.”
- He also sees a mismatch between the need for services, and the mental health services that are offered. “Furthermore, there is no guarantee that these services will be well-matched to people’s needs.” Drawing on his own research, he notes that: “10 percent of full-time psychiatrists in Toronto were seeing fewer than 40 patients total annually.”
He looks internationally for ideas.
For example, in the U.S., many service provider organizations have adopted a coordinated care approach for the management of common mental illnesses like depression. A team of mental health professionals embedded in primary care clinics systematically screen for mental illness and, when an illness is identified, ‘treat to target,’ systematically measuring patients’ responses to evidence-based treatment. Psychiatrists provide oversight and supervision, their expertise effectively reaching a much larger number of individuals than would occur if they were providing care directly to patients. Moreover, because response to treatment is being monitored, the team knows when things are not going well, prompting the psychiatrist to get directly involved in cases that are more complex. Larger numbers of patients get evidence-based treatment and the specialized care of a psychiatrist goes to those who need it.
A few thoughts:
- This is a good essay.
- Dr. Kurdyak responds to the Coalition of Ontario Psychiatrists paper. The authors of that paper argue that there is a shortage of psychiatrists today, and it will worsen with time. To address this gap, they call for more exposure of medical students to psychiatry, more psychiatry residency spots, and better compensation for psychiatrists. You can find the Coalition paper here: https://www.eopa.ca/sites/default/uploads/files/Ontario%20Needs%20Psychiatrists%20FINAL%20-%20August%207%2C%202018.pdf.
- As stigma fades and demand grows, we have an opportunity to reach more people. But unless we are creative – Dr. Kurdyak suggests looking internationally for ideas, which is reasonable – this opportunity will pass.
Better Physician Mental Health
“Potential Risks and Benefits of Mental Health Screening of Physicians”
Matthew L. Goldman, Carol A. Bernstein, Richard F. Summers
JAMA, 30 November 2018 Online First Open Access
Physicians are familiar with the yearly routine of being screened for tuberculosis, reviewing their vaccine status, and getting the influenza vaccination. Should physicians also be screened for mental health conditions such as depression or burnout?
The prevalence of and challenges associated with depression, burnout, and suicide have been increasingly recognized. Physicians die by suicide at rates higher than the general population, and suicides are more often related to job stress and inadequate treatment. Although definitive data on comparative rates of mental illness among physicians are lacking, resident physicians likely experience depression more than the general population.
Physicians with common mental disorders often do not receive the care they need. Medical interns have identified barriers to seeking treatment such as concerns about confidentiality or judgments of colleagues; preference to manage problems on their own; concern about harming their career; and practical factors such as time, cost, and limited access to care.
Hospitals and other health care institutions are focusing more on improving retention of physicians and preventing resource-intensive adverse outcomes such as leaves of absence, attrition, or even suicide. As institutions work toward improving the well-being of clinicians, an important question should now be asked: Should institutions be responsible for ensuring that physicians are regularly screened for mental health conditions?
Matthew L. Goldman
So beings a paper by Goldman et al.
They argue that there would be significant advantages of screening.
Screening physicians for mental health conditions is consistent with the premise that early detection can create opportunities for engaging at-risk physicians in evidence-based treatments. Screening tools have been validated for detection of suicidal ideation, depression, alcohol use disorders, and other mental illnesses in the general population. Based on 9 good- to fair-quality trials, the US Preventive Services Task Force (USPSTF) ‘recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.’
The paper, though, is balanced, and acknowledges risks:
- Confidentiality. “Confidentiality is widely regarded as a barrier to physician access to mental health services.” They note that institutions would have a difficult time implementing screening while maintaining confidentiality for physicians.
- Licensure. “Given the present risk of being subjected to mandated reporting in certain states, some physicians are understandably concerned that seeking mental health care might force them to report incomplete information in the application or risk investigation by a state medical board.” With that in mind, they wonder if some may be tempted to provide incomplete information on screening to avoid licensure investigations.
- False positives. “Although the USPSTF recommends depression screening in the adult population, there is a lack of consensus as to whether this improves outcomes.” They also note false positive can result from fatigue and other factors.
A few thoughts:
- This is a provocative piece.
- Can depression really be compared to TB?
- At its core, this paper wrestles with the following: on the one hand, physicians are individuals and should be treated with dignity; on the other hand, doctors have a role in the public’s health, and thus are expected to practice in a competent manner.
- A less coercive approach: making it easier for physicians to get mental health care when they feel it’s needed.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.