From the Editor
Family physician colleagues talk about how many patients now disclose mental health problems. Our EDs see more patients with mental illness than ever. Antidepressant use has doubled between 2000 and 2015 across OECD countries.
So is mental illness more common than before?
Just last week, a CBC reporter asked me this question. She noted that the rise of businesses offering mindfulness and the proliferation of mental health apps. But as stigma fades and people are more comfortable talking about mental illness, it’s also possible that more people are seeking care, but that there aren’t more people with illness.
Mental illness: more commonly discussed, more common?
In our first selection, we consider a new paper from Acta Psychiatrica Scandinavica. Dirk Richter (of Bern University of Applied Sciences) and his co-authors use a systematic review and meta-analysis to see if adult mental illness is increasing over time. “We conclude that the prevalence increase of adult mental illness is small and we assume that this increase is mainly related to demographic changes.”
In the second selection, we consider a new JAMA review of the evidence – or lack of evidence – for medical use of cannabis. Dr. Kevin P. Hill (of Harvard Medical School) writes: “Insufficient evidence exists for the use of medical cannabis for most conditions for which its use is advocated.”
In the third selection, Yale School of Medicine med student Eli Neustadter discusses a challenging patient and the connection they form. “MB and I also found time to meet weekly in a quiet room with nothing but two chairs, two guitars, and two picks.”
There will be no Readings for the next two weeks. The conversation will continue after Labour Day.
Selection 1: “Is the global prevalence rate of adult mental illness increasing? Systematic review and meta-analysis”
Dirk Richter, Abbie Wall, Ashley Bruen, Richard Whittington
Acta Psychiatrica Scandinavica, 8 August 2019 Online First
Currently, numerous media reports and many lay and expert commentators suggest a belief that distress in general and mental illness more specifically are on the rise. These claims are usually supported by data on utilization of mental health care and by monitoring of health-related indicators such as suicides. The claim of rising mental illness – if supported by rigorous research – would have important implications not only for public mental health in terms of potential failure of treatment approaches but also for wider society in terms of understanding living conditions that sociologists see to be deteriorating and stress terminologies such as social suffering or social pathology.
So begins a paper by Richter et al.
Here’s what they did:
- The authors searched several databases, including Pubmed.
- “Inclusion criteria were publications on repeated cross-sectional studies with at least two time points on any kind of mental illness in adult populations (18 years+).” Studies needed to include clinical interviews and/or validated scales (like the PHQ-9).
- Exclusion criteria included cohort studies.
- Data was extracted by one of the authors and cross-checked by the others.
- “The meta-analysis was conducted utilizing a methodology usually applied to intervention studies that compare intervention and control conditions with odds ratios and 95%-confidence intervals (CI hereafter) as the effect size metric.”
Here’s what they found:
- The original search included almost 9,000 publications, and ended up with 42 papers for the meta-analysis, most from Western Europe.
- They did a Forest plot – see below.
- “We have conducted a meta-analysis and a meta-regression on prevalence changes in adult mental illness since the 1970s. Overall, we found evidence of a small but significant increase over time (OR 1.18). This result is based on studies that are very heterogeneous in their characteristics and in their outcomes. While our funnel plot does not suggest that there is a ‘small study effect’ present as is known from trial meta-analyses, we cannot rule out a publication bias.”
The paper is interesting, and seeks to be a global analysis. The paper isn’t perfect, of course. The data has a Western European bias, and may not reflect a true global picture. And some have claimed that we see more depression and anxiety in the adolescent population, which wasn’t included in this study. (For the record, I’m not persuaded about teens.)
Still, in this study of studies, there is scant evidence for a dramatic increase in mental illness. Interesting.
Selection 2: “Medical Use of Cannabis in 2019”
Kevin P. Hill
JAMA, 9 August 2019 Online First
Nearly 10% of cannabis users in the United States report using it for medicinal purposes. As of August 2019, 33 states and the District of Columbia have initiated policies allowing the use of cannabis or cannabinoids for the management of specific medical conditions.
So opens a concise paper by Dr. Hill.
Indications for Therapeutic Use Approved by the US Food and Drug Administration
“The cannabinoids dronabinol and nabilone were approved by the FDA for chemotherapy-induced nausea and vomiting in 1985, with dronabinol gaining an additional indication for appetite stimulation in conditions that cause weight loss, such as AIDS, in 1992. Recently, a third cannabinoid, cannabidiol (CBD), was approved by the FDA for the management of 2 forms of pediatric epilepsy…”
Other Medical Indications
“Taken together, at best, there is only inconclusive evidence that cannabinoids effectively manage chronic pain, and large numbers of patients must receive treatment with cannabinoids for a few to benefit, while not many need to receive treatment to result in harm.”
“There is strong evidence to support relief of symptoms of muscle spasticity resulting from multiple sclerosis from cannabinoids as reported by patients, but the association is much weaker when outcomes are measured by physicians.”
Recent Clinical Trials
“Numerous other medical conditions, including Parkinson disease, posttraumatic stress disorder, and Tourette syndrome, have a hypothetical rationale for the use of cannabis or cannabinoids as pharmacotherapy based on cannabinoid effects on spasticity, anxiety, and density of cannabinoid receptors in areas implicated in development of tics, such as the basal ganglia and cerebellum. The strength of the evidence supporting the use of cannabinoids for these diseases is weak…”
Neurologic Adverse Effects Are Better Defined Than Physical Adverse Effects
“Chronic cannabis use is associated with an increased risk of psychiatric illness and addiction. There is a significant association—possibly a causal relationship—between cannabis use and the development of psychotic disorders, such as schizophrenia, particularly among heavy users.”
Dr. Hill concludes: “Insufficient evidence exists for the use of medical cannabis for most conditions for which its use is advocated.”
As our patients grow more interested in cannabis for medical reasons, Dr. Hill’s summary is highly relevant – if concerning, given the push of industry.
Selection 3: “Working in Recovery: A Medical Student’s Experience”
Psychiatric Services, 24 July 2019 Online First
I was both excited and nervous to start my psychiatry subinternship on an inpatient unit at a community hospital. I had already decided to pursue a psychiatry residency and had gained clinical experience working in a psychiatric emergency department and a clinical research unit during my clerkships. This rotation would be different: I would be working closely with patients staying in the hospital for longer periods for intensive psychosocial rehabilitation. I prepared diligently by reviewing psychopharmacology, learning DSM diagnostic criteria for common conditions, and memorizing the steps of the mental status exam. I remember asking the attending psychiatrist if he could recommend any readings to me; he told me simply to come with open eyes and an open mind.
So begins a paper by Neustadter, a medical student.
He notes the disappointment of his first interview with this patient who has borderline personality disorder and substance use.
My attending asked if I wanted to conduct the intake interview, and although I was nervous, I agreed, wanting to demonstrate that I could be a competent contributor. I vividly remember how MB appeared to me that afternoon: a young man with a gentle appearance, hunched shoulders, and downcast eyes… Nervously, with my notes in hand, I started my interview: ‘What brings you here today?’ He resisted eye contact and, after several moments of silence, told me that it had been a long day and asked if we could talk another time.
Indeed, the patient had proven challenging: “Daily progress notes suggested that the patient was ‘resistant’ to medical advice, and past admission summaries noted ‘non-optimal’ plans for discharge. His medication regimen was long and complicated and included prescriptions that may have contributed to his addiction.”
But Neustadter discovers that they have a common interest in music. They then agree to play together. “MB and I also found time to meet weekly in a quiet room with nothing but two chairs, two guitars, and two picks.”
He taught me a song he wrote, and I played lead melody while he strummed the chords and sang. His music was grungy and moody, structured by minor chords, and when he sang, he appeared both shy and proud to show me this side of himself. During these meetings, we also had long conversations. He shared more about his past, including times when his life was especially difficult. He also spoke of his aspirations and concerns about the future. In the course of our conversations, MB articulated some unique beliefs that were not noted in his chart and that were suggestive of schizotypal experience. When I later reviewed the DSM with his comments in mind, I was able to contribute new information to the team’s working formulation of his personality. Sitting beside me with two guitars between us, MB spoke more openly about his concerns that any changes to his medication would increase his anxiety, but he was ready to start planning.
The piece discusses the bond created. “Sharing these moments made me feel I was reaching a privileged insight; I felt trusted.” Neustadter doesn’t white-wash a challenging case – post-rotation, this medical student visits the team, only to discover that the challenges persist.
This paper reminds us that connecting with our patients may involve clinical interviews, but it may involve other things, too.
For the record, I think Neustadter will make a fine resident of psychiatry.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.