From the Editor
Welcome to first Reading of the Week of 2016.
Continuing the format started in December, I’ve made several selections here. This week: the obituary of an influential psychiatrist, a clever paper on values and schizophrenia, and a report that considers the use of psychiatric services in Ontario.
In general, Readings in this format don’t have a common theme. That said, this week, a common thread runs through the three selections: challenging assumptions.
Dr. Agid and his co-authors look at the values of those with schizophrenia, challenging the assumption that our patients value what we value; the HQO-ICES report challenges what we think we know about psychiatric care and care delivery in Canada’s largest province. And what can be said of Dr. Robert Spitzer? Well, he made a career out of challenging psychiatric assumptions – much to his credit, and to our benefit.
Values and Schizophrenia
“Values in First-Episode Schizophrenia”
Ofer Agid et al., The Canadian Journal of Psychiatry, November 2015
Functional impairment continues to represent a major challenge in schizophrenia. For example, a recent study of 1175 first-episode patients reported that more than 40% did not meet criteria for functional remission, and only 29% met criteria for both symptomatic and functional remission at a 2-year follow-up. Considerable work, including our own, has addressed the importance of the illness’ different symptom domains; positive, negative, and cognitive symptoms can each contribute to impaired functional recovery.
So begins a clever and unusual paper on the first episode experience that attempts to shed light on the fact that patients are often impaired but not unhappy.
Let me explain: On the one hand, it’s well established that many patients with this illness don’t achieve pre-morbid functionality. (I remember vividly the post-first break world of a former U of T double major student who struggled to take a significantly reduced course load.) On the other hand, studies consistently show that many of these patients “reported a level of happiness comparable with control subjects, even in the face of the prominent functional deficits.” (The patient, for the record, was okay with taking two courses – his mother, however, was beside herself.) Call it the first-episode paradox.
Dr. Ofer Agid of the Centre for Addiction and Mental Health and his co-authors ask a simple question: is this a matter of values?
In the paper, 56 patients in full remission and 56 controls were studied. They did the Schwartz Value Survey; the patient group also did a variety of other scales.
The main finding? Values differed. See below for a radar chart – note the significant differences in values of Tradition, Power, and Self-direction (where the blue and red lines don’t overlap).
The authors conclude:
What are the implications of these findings? First and foremost, there is evidence of differences in values between schizophrenia and matched control subjects, supporting the hypothesis that people with schizophrenia hold to a different value system. Regarding the differences, in simplest terms it may be argued that people with schizophrenia place more emphasis on traditions, reflected in a greater acceptance of the customs and ideas that traditional culture or religion provide, in conjunction with a decreased interest in change.
This is a good study. It leads to many questions. For instance, do patient values change over the course of the illness? And this study attempts to understand better the patient experience and his or her values. Nice.
Dr. Robert Spitzer, RIP
“Robert Spitzer, 83, Dies; Psychiatrist Set Rigorous Standards for Diagnosis”
Benedict Carey, The New York Times, 26 December 2015
Dr. Robert L. Spitzer, who gave psychiatry its first set of rigorous standards to describe mental disorders, providing a framework for diagnosis, research and legal judgments – as well as a lingua franca for the endless social debate over where to draw the line between normal and abnormal behavior – died on Friday in Seattle. He was 83.
So begins a New York Times obituary of a psychiatrist who has a lasting influence on our field: Robert Spitzer. Dr. Spitzer isn’t exactly a household name, yet he can claim several accomplishments, including as the main author of a psychiatry book that became an international bestseller despite being essentially a long, elaborate list: DSM-III.
New York Times’ reporter Benedict Carey is a skilled writer and here he describes well the life-work of a person whose influence is still felt.
In the early 1960s, the field was fighting to sustain its credibility, in large part because diagnoses varied widely from doctor to doctor. For instance, a patient told by one doctor that he was depressed might be called anxious or neurotic by another. The field’s diagnostic manual, at the time a pamphlet-like document rooted in Freudian ideas, left wide latitude for the therapist’s judgment. Dr. Spitzer, a rising star at Columbia University, was himself looking for direction, increasingly frustrated with Freudian analysis.
A chance meeting with a colleague working on a new edition of the manual – the Diagnostic and Statistical Manual of Mental Disorders, or the DSM – led to a job taking notes for the committee debating revisions. There he became fascinated with finding reliable means for measuring symptoms and behavior – i.e., assessment.
The article goes on the describe Spitzer’s views on homosexuality, helping to move it out of the realm of illness, as many psychoanalysts perceived it to be.
DSM-III is a major development and Spitzer rightly deserves credit for his work in improving the reliability of the field. Today, a patient with schizophrenia can be seen in Winnipeg or Toronto or Halifax, and receive the same diagnosis. Gone is the wild randomness and arbitrariness of the diagnoses of old. Of course, large problems remain, including the validity of our diagnoses – nothing in DSM-III (or IV or 5) helps us understand if there really is, say, one schizophrenia illness or, in fact, several diseases sharing common symptoms. That isn’t a failing of Spitzer, of course, but the limits of medical science. After all, we lack the understanding of neurophysiology to move beyond lists of lists in terms of diagnoses.
Report: Psychiatric Services in Ontario
“Taking Stock: A report on the quality of mental health and addiction services in Ontario”
Susan Brien et al., Health Quality Ontario-Institute for Clinical Evaluative Sciences, December 2015
Mental illness and addiction affects one in five people worldwide over their lifetime. Depression, one of the most common mental illnesses, is predicted to become the illness that has the biggest impact on people’s lives globally by 2030.
The story is similar in Ontario. While most Ontarians report that their mental health is very good or excellent, at least one million people across the province are affected by a mental illness or addiction each year.
Dr. Paul Kurdyak, Research Program Lead and Adjunct Scientist, Mental Health and Addictions Research Program, ICES
So begins a new report, jointly published by Health Quality Ontario and the Institute for Clinical Evaluative Sciences.
The report opens by noting strong need: roughly two million Ontarian are affected by mental health illnesses and addictions. And mental health casts a long shadow over the health care system: with expenditures of $3.5 billion (2013-14), and accounting for roughly 10% of all physician visits (overwhelming to family physicians).
Contact, of course, occurs in different ways. Let me pick up on one statistics reported: a surprisingly large number of people access mental health and addiction services through the ED. (More than one in three people with an anxiety disorder start their journey with an emergency doc, not the family doc.) See below.
The report doesn’t have the numbers to flush this out – but it’s possible to speculate that larger problems with access exist. After all, the person with Generalized Anxiety Disorder who ends up in the ED is a patient who is likely further along in his or her illness, a comment on many problems, from ease of access to stigma.
What enlivens this report is a series of patient and provider stories – collectively, they are quite moving. April, a registered message therapist, for example, describes her struggle with depression: “It’s like being in a dark hole. It’s just overwhelming hopelessness. It feels like you have a huge weight all of the time.”
This report is both hopeful and concerning. On the positive side, it’s thoughtfully done and sheds light on the use of and access to services in Ontario. For too long, health spending – and, in particular, mental health spending – has been a black box. Strip away the glossy photos and the large text, and the health services research underneath is important, representing a step in the right direction by allowing us to get a better sense of what’s going on. On the negative side, the report suggests deeply uneven access. Let’s return to the ED stat: imagine the public outcry if a third of cancers were picked up in hospital emergency departments.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.