From the Editor

She was offered CBT through our outpatient program. Though we encouraged her to come, she didn’t even attend one session. Was the problem partly with the rigidity of our program which wasn’t tailored to her cultural background or language? Can we do better? 

Dr. Nusrat Husain (of the University of Manchester) and his co-authors attempt to answer these questions in a new RCT published in The Lancet. In their study, British south Asian women with postnatal depression were randomized to a culturally-adapted form of CBT or treatment as usual. “Participants in the [intervention] group were estimated to be almost twice as likely to have recovered at 4 months than those in the control group.” We consider the paper, the accompanying Comment, and the implications for clinical care.

In the second selection, Drs. Carlos Blanco (of the National Institutes of Health) and Craig B. H. Surman (of Harvard University) write about ADHD for adults. In a new JAMA Psychiatry Viewpoint, they argue that more needs to be done, especially given the adverse outcomes of untreated ADHD. “A tension exists between undertreatment of adults with ADHD and overuse of addictive treatments for the condition.”

Finally, we explore the latest news with recent articles from The Washington PostThe Globe and Mail, and The New York Times. The topics: ChatGPT for psychotherapy, the generosity of Bruce McKean, and the street psychiatry in LA.

DG

Selection 1: “Efficacy of a culturally adapted, cognitive behavioural therapy-based intervention for postnatal depression in British south Asian women (ROSHNI-2): a multicentre, randomised controlled trial”

Nusrat Husain, Farah Lunat, Karina Lovell, et al.

The Lancet, 12 October 2024

Postnatal depression affects around one in eight women globally and typically presents within the first few weeks after giving birth. It has substantial public health implications due to its association with several adverse outcomes in children, including impaired cognitive, socioemotional, and physical development. Moreover, it contributes considerably to the intergenerational transmission of health and socioeconomic inequalities globally. Common perinatal mental disorders, including postnatal depression, are associated with long-term societal costs; in the UK, for example, these costs amount to approximately £8.1 billion for each 1-year birth cohort…

Despite postnatal depression being acknowledged as a major public health concern, a substantial treatment gap still exists, whereby a large proportion of those with clinically relevant symptoms do not seek or are unable to access treatment – in the UK, for example, this proportion is as high as 60%. Closing such treatment gaps is now a global priority. Although progress has been made, considerable disparities remain in providing timely mental health care and addressing inequalities in access, experience, and outcomes. These disparities are particularly pronounced for women from minority ethnic backgrounds, such as south Asian women…

So begins a paper by Husain et al.

Here’s what they did:

  • They conducted “a randomised controlled trial, with culturally adapted recruitment and an internal pilot, comparing the PHP (intervention group) with treatment as usual (control group) in British south Asian women with postnatal depression.” 
  • It was done across five UK centres (northwest England, Yorkshire, the Midlands, London, and Glasgow).
  • Participants met the DSM-5 criteria for depression and had infants aged 0–12 months. Exclusion criteria included psychosis.
  • The intervention: “The PHP was delivered over 12 group sessions in 4 months.” They included “culturally relevant adaptations for British south Asian women” with nine culturally specific topics (including “the role of religion and spirituality in mental health”). The PHP was delivered by non-specialist workers. (!)
  • The primary outcome: “recovery from depression (defined as a Hamilton Depression Rating Scale [HDRS] score ≤7) at 4 months after randomisation, and an assessment was also done at 12 months.”

Here’s what they found:

  • 9 136 were approached; after screening and consent, 732 were randomized, with 368 to the PHP and 364 to the treatment-as-usual (control) group. 
  • Demographics. Participants had a mean age of 31 years and seven years of marriage. Many had a previous child. Participants were mainly Pakistani (55%), Indian (24%), or Bangladeshi ethnicity (18%).
  • Four months. The proportion of participants who showed recovery from depression on the HDRS was significantly higher in the PHP group (49%) than in the control group (37%); the adjusted odds ratio was 1.97.
  • One year. “At the 12-month follow-up, this difference was no longer significant (1.02…).” See figure below.
  • Parenting competence. “The PHP programme showed significant improvement over treatment as usual in the participants’ sense of parenting competence at 12 months, but not at 4 months.”
  • Attrition. The number who were lost to treatment was similar though slightly higher in the intervention group.

A few thoughts:

1. This is an impressive study, with a smart design, seeking to address a practical issue, and published in a big journal.

2. The main finding in six words: the intervention worked at four months.

3. But, at a year, there was no difference. The authors argue that the early recovery was important since it’s “a crucial time when maternal depression is likely to impact various infant outcomes.”

4. Angela Taft and Bijaya Pokharel (both of La Trobe University) write an accompanying Comment. They are effuse in their praise, calling the study “a major achievement.”

“Challenging the commonplace notion of these minority ethnic groups being hard to reach and easy to ignore, ROSHNI-2 implemented multifaceted community engagement strategies to build trust, to engage other family members, and to destigmatise mental health issues in south Asian communities.

The authors see great clinical implications: 

“This culturally adapted CBT model, a successful postnatal depression treatment, should be adapted for other underserved communities where mental health and its treatment are stigmatised, building better access, acceptability, and stronger data on implementation effectiveness among our diverse minority ethnic communities.”

Angela Taft

The full Comment can be found here:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01854-3/abstract

5. On a pivot, the authors drew a page from the work of Dr. Vikram Patel and others who work in low-income countries: they trained up non-specialist workers. That is less costly than recruiting psychologist – obviously – but it also allows an opportunity to recruit providers who reflect the diversity of different communities. Nice.

6. Like all studies, there are limitations, and the authors note several including the focus on British south Asian women, thus limiting the generalizability of findings to other minority ethnic groups elsewhere.

7. Past Reading have considered culturally-adapted care. A past Reading analyzed the Zhou et al. study that offered CBT-insomnia for Black women, finding greater insomnia improvement. You can find it here:

https://davidgratzer.com/reading-of-the-week/reading-of-the-week-tailoring-cbt-for-black-women-the-new-jama-psych-paper-also-meds-transgender-individuals/

The full Lancet paper can be found here:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01612-X/fulltext


Selection 2: “Diagnosing and Treating ADHD in Adults Balancing Individual Benefits and Population Risks”

Carlos Blanco and Craig B. H. Surman

JAMA Psychiatry, 23 October 2024  Online First

Many clinicians are uncomfortable diagnosing ADHD in adults or prescribing stimulants due to concerns that stimulants may be diverted or not used as prescribed and the lack of US published treatment guidelines for ADHD in adults. Meanwhile, patients fear being stigmatized and seen as drug seeking, which increases barriers to treatment, even as untreated ADHD is associated with multiple adverse outcomes, including increased mortality. Health care administrators and policymakers seek optimization of ADHD treatment access while minimizing risk of individual and population-level adverse events.

So begins a Viewpoint by Drs. Blanco and Surman.

They focus on five issues; here we summarize three.

The need for clinicians to better understand and diagnose ADHD in adults

“Initially considered exclusively a disorder of childhood and adolescence, it is now widely accepted that ADHD can continue after adolescence and that symptoms may fluctuate over the life span of an individual. ADHD impacts approximately 2.5% to 4% of US adults, with an estimated US yearly burden of over $100 billion. Appropriate treatment of ADHD follows from an accurate diagnosis. Existing diagnostic criteria for ADHD in adults are a modified version of pediatric criteria that probably underemphasize phenotypic attributes, such as executive function and emotional regulation challenges. This may decrease diagnostic accuracy and clinician confidence and lead to underdiagnosis or misdiagnosis of ADHD in adults, lowering overall quality of care. Ongoing work to improve the operationalization of diagnostic criteria could increase diagnostic accuracy in adults…”

The treatment for adult ADHD outside of specialized clinics is often not based in evidence

“Risks and benefits of several medications have been evaluated in many short-term studies (eg, studies lasting several weeks) but in only a few long-term studies (lasting up to 2 years for stimulants and up to 4 years for atomoxetine), most of which have no comparator group. While stimulants are widely considered to have greater efficacy than nonstimulants, direct comparisons between treatments and real-world effectiveness data are rare. There is limited guidance on what constitutes an adequate trial of these prescribed treatments, how long to maintain treatment before reevaluating or stopping, how to choose between different formulations and compounds, the role of nonstimulants and behavioral therapy options, and how to sequence or augment treatments. Development and iterative refinement of treatment guidelines or treatment algorithms could have significant benefits for patients and public health…”

It is imperative to balance individual benefit and population risk

“Health care systems should maximize individual and population health rather than create unnecessary barriers to care. For medications with risk for the development of substance use disorders, such as stimulants, this requires the ability to minimize their use in at-risk individuals and prevent spillover effects, such as diversion. This is akin to considerations applied to antibiotic selection to ensure effective treatment of individual patients while preventing development of community resistance.”

A few thoughts:

1. This is a good Viewpoint.

2. They raise solid points. The analogy to antibiotic treatment is interesting.

3. Are we so concerned about substance misuse that we end up undertreating the illness?

The full JAMA Psych Viewpoint can be found here:

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2825280


In the News

Part of an occasional series.


“Despite uncertain risks, many turn to AI like ChatGPT for mental health”

Daniel Gilbert

The Washington Post, 26 October 2024

“It was the anniversary of the day her baby daughter died, and though 20 years had passed, Holly Tidwell couldn’t stop crying. ‘I wonder if there’s something wrong with me,’ she confided in a trusted source.

“The response was reassuring and empathetic. ‘The bond you had, even in those brief moments, is profound and lasting,’ she was told. ‘Remembering your daughter and honoring her memory is a beautiful way to keep that connection alive.’

“The words came not from a friend or therapist, but from an app on her phone powered by artificial intelligence called ChatOn.”

The article describes some of the advantages of AI for mental health, including the potential to address access problems in the United States (and beyond). Gilbert interviews a couple of people who use ChatGPT and find its comments helpful. But the writer is balanced in his approach, also noting the tendency of chatbots to “go off the rails” – including one designed for those with eating disorders which made inappropriate comments (it once recommended skinfold calipers for measure body fat).

There are then both potential and clear problems. The article focuses on today’s chatbots – but what will things look like in a few years with advancing technology?

https://www.washingtonpost.com/business/2024/10/25/ai-therapy-chatgpt-chatbots-mental-health/


“CAMH reveals identity of megadonor who has given $200-million to the hospital”

Marcus Gee

The Globe and Mail, 24 October 2024

“A few years ago, out of the blue, a guy e-mailed the CAMH Foundation, the group that raises funds for Canada’s biggest mental-health institution, the Centre for Addiction and Mental Health. He said he was thinking of donating some money.

“After giving him a tour of the sprawling CAMH campus on Toronto’s Queen Street West, a guide asked him what sum he had in mind. Fifty million dollars, he said.”

The story, of course, gets better: Bruce McKean goes on to donate $203 million in total.

The article describes the generous donor who “favours lumberjack shirts and jeans, grew up in modest circumstances in postwar Victoria.” It notes his time in the civil service, his personal connection to a person with mental illness, and his incredible wealth (he invested in his son-in-law’s startup, Shopify). And it describes the decision of McKean and his wife to give away their newfound wealth.

The article notes that the last unnamed building on the CAMH campus will be named after McKean’s foundation. It doesn’t mention that just a couple of decades ago, none of the buildings were named – a consequence of the many years of stigma. #Progress

https://www.theglobeandmail.com/canada/article-mystery-camh-donor-mental-health/


“Under an L.A. Freeway, a Psychiatric Rescue Mission”

Ellen Barry

The New York Times, 20 October 2024

“In a downtown Los Angeles parking lot, a stretch of asphalt tucked between gleaming hotels and the 110 freeway, a psychiatrist named Shayan Rab was seeing his third patient of the day, a man he knew only as Yoh.

“Yoh lived in the underpass, his back pressed against the wall, a few feet from the rush of cars exiting the freeway. He made little effort to fend for himself, even to find food or water. When outreach workers dropped off supplies, he often let people walk away with them.”

So begins a gripping and important article on street psychiatry in Los Angeles. Barry focuses on Dr. Rab and other physicians who attempt to work with people who are ill and marginalized – literally seeing them under bridges and underpasses. Yoh (his legal name is Eric Covington) engages with the team, gaining housing and starting medications.

This summary is a nice way to end this week’s Reading – like the first selection, a reminder that it is possible to reach people who may seem beyond reach.

https://www.nytimes.com/2024/10/20/health/los-angeles-homeless-psychiatry.html

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