From the Editor
I saw an older patient in the emergency room recently. He described feeling overwhelmed. Fearful of the pandemic, he explained that he had rarely left his apartment since it began. “I’m so isolated.”
Many find themselves in a similar situation. What could help? In a new JAMA Psychiatry paper, Maninder K. Kahlon (of The University of Texas at Austin) and co-authors describe a focused intervention involving laypeople doing an empathy-focused program by phone. Do the calls work? They found it reduced loneliness, anxiety, and depression. They note the potential: “The use of lay callers, deliberate but brief approach on training, and the use of ubiquitous telephones made the approach easily deployable and scalable.”
In an editorial, The Lancet Psychiatry considers our digital moment. Though they note the trendiness of the idea of digital psychiatry, they urge us to push: “Come 2 years or 20, we want to stop talking about digital psychiatry’s potential for improving public mental health and start marking its clear clinical progress.”
Finally, in our third selection, we look at a new paper from The New England Journal of Medicine. Drs. Angela Desmond and Paul A. Offit (both of the University of Pennsylvania) consider the history of vaccines, and look ahead: “With the recent authorization of mRNA vaccines, we have entered the fifth era of vaccinology.”
Please note that there will be no Reading next week.
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On a pivot –
Since 2014, the Reading of the Week has been providing summaries and commentary on the latest in the psychiatric literature. Two years ago, we conducted a short survey to get your feedback. We are hoping to get feedback again to improve the Readings.
We would like to invite you to join one of our online focus groups to hear your opinions and suggestions. If you are interested in participating, please email firstname.lastname@example.org by April 12 with your preferred time slots from the following options – psychiatrists: April 21 at 4 pm or April 22 at 4 pm; residents: April 28 at 4 pm and April 29 at 4 pm. (Note: all times are in EST.) Time commitment: under an hour. If the above time slots do not work for you, please email Smit to arrange an interview time at your convenience, preferably between April 21 and April 30, 2021.
Selection 1: “Effect of Layperson-Delivered, Empathy-Focused Program of Telephone Calls on Loneliness, Depression, and Anxiety Among Adults During the COVID-19 Pandemic: A Randomized Clinical Trial”
Maninder K. Kahlon, Nazan Aksan, Rhonda Aubrey, et al.
JAMA Psychiatry, 23 February 2021 Online First
Loneliness has been indicated as a risk factor for overall mortality and conditions from stroke to heart disease. It is associated with depression and anxiety, even if the direction and degree of causality is unclear. With the onset of coronavirus disease 2019 (COVID-19), there has been concern about the effect of increased isolation on loneliness and other mental health conditions. For older adults, those most socioeconomically vulnerable are likely to be at greatest risk.
Few interventions have been shown to be effective, and the mental health workforce is already constrained. A systematic review of randomized interventions through 2010 found that structured, cognitive behavioral therapy (CBT)-based approaches were most effective but require trained counselors.
In March 2020, we became aware of the challenges facing Meals on Wheels Central Texas (MOWCTX) clients because of reduced contact. In response, we designed a program that could be rapidly spun up and deployed. The telephone calls program involves laypeople engaging regularly, with empathetic intention, through telephone calls with participants.
So begins a paper by Kahlon et al.
Here’s what they did:
- They recruited and followed up “adults who were assigned to receive calls (intervention group) or no calls (control group) via block randomization.”
- The intervention: “Sixteen callers, aged 17 to 23 years, were briefly trained in empathetic conversational techniques. Each called 6 to 9 participants over 4 weeks daily for the first 5 days, after which clients could choose to drop down to fewer calls but no less than 2 calls a week.”
- “Loneliness, depression, and anxiety were measured using validated scales at enrollment and after 4 weeks.”
- Statistical analyses were done.
Here’s what they found:
- 240 entered the study.
- Demographics. “Participants were aged 27 to 101 years, with 63% aged at least 65 years, 56% living alone, 79% women, and 39% Black or African American… All reported at least 1 chronic condition.”
- Loneliness. An improvement of 1.1 on the UCLA Loneliness Scale and 0.32 on the De Jong scale.
- Depression. An improvement of 1.5 on the Personal Health Questionnaire for Depression.
- Anxiety. An improvement of 1.8 on the Generalized Anxiety Disorder scale.
- “The effect sizes were generally small to moderate for those outcomes that showed a statistically significant difference in improvements between intervention and control groups…” See figure below.
A few thoughts:
- This is a very relevant paper as we continue to struggle with the pandemic – and the lockdowns and restrictions.
- There is much to like here, including the use of laypeople. Mental health interventions don’t necessarily require trained professionals.
- For the record, the training here was light, and required less than two hours. To be more specific: “Callers were trained through a 1-hour videoconferenced session. The goal presented to callers was to learn from those they called by asking specific questions about topics raised by participants. No conversational prompts were provided nor training on CBT or its components. A short video was used to demonstrate techniques through role playing. Separately, callers received handouts and videotaped instructions on the logistics of the program (<1 hour).”
- Could other interventions use laypeople? Dr. Vikram Patel uses this approach in his global psychiatry work in low-income nations. Are we missing out in our high-income nations? Looking back at the study: this intervention offers good results with minimal training and is highly scalable. Nice.
The full JAMA Psychiatry paper can be found here:
Selection 2: “Digital psychiatry: moving past potential”
The Lancet Psychiatry, April 2021
When it comes to public health in the 21st century, scientific breakthroughs and new technologies are likely to be the easy parts. Pfizer managed to develop, test, and get approval for their COVID-19 vaccine in less than a year; a technical tour de force driven by novel mRNA vaccine technology. But the realities of getting this and similar vaccines into people’s arms have begun to set in: insufficient infrastructure and clinical staff, systemic inequalities in health care, and widespread misinformation campaigns leading to vaccine hesitancy.
Similar to vaccinologists who needed a technical breakthrough to quickly address the COVID-19 pandemic, clinicians desperately need new science and technology to deal with mounting public mental health problems. Based on recent funding and literature trends, it appears psychiatry is placing a big bet on digital psychiatry to deliver better mental health at scale.
So begins a new editorial.
They ask a series of questions. Here, we focus on three:
On the therapeutic alliance
“Can the all-important therapeutic alliance between clinicians and service users operate in a digital environment, and if so, how? A recent survey of suicide risk prediction tools across NHS mental health trusts shows clearly how new tools can fall flat clinically and is a warning sign for the hurdles digital psychiatry will likely face in real-world settings.”
“How will digital psychiatry reach those most in need in community settings? Despite the democratising potential of digital technologies promised by tech companies, too often the benefits divide along all-too-familiar race and economic lines. In New York City (NY, USA), one of the world’s wealthiest cities, mandatory virtual learning during COVID-19 lockdowns has made the inequalities of an already unfair education system even worse, as children in low-income households disproportionately lack access to devices and high-speed internet.”
“How will digital psychiatry protect service users? 2 years ago, in an editorial on digital health, we wrote that while it’s never been easier to collect new mental health data, it’s also never been easier to have them sold or stolen. This is still true and likely will be for the foreseeable future. Although most scientific fields generally speak positively about so-called big data, given the stigma that still surrounds mental illness and the real risks that data commercialisation and hacks have for service users, digital psychiatry does not have the luxury of assuming bigger datasets are necessarily a good thing.”
A few thoughts:
- This is a good and relevant editorial.
- We are having a digital moment: app use, for example, appears to be markedly up with the pandemic; the client base of Talk Space, a commercial therapy app, grew by a third during the first weeks of the lockdown.
- I’ll pick up on the comments about digital privacy. We tend not to discuss such matters. Though my patients often mention apps and ask for recommendations, rarely (and not surprisingly) do they ask about digital privacy policies. But in a paper considering 36 apps for smoking cessation and depression, the authors found that 33 transmitted data to third parties. Huckvale et al. conclude: “most apps offer users no way to anticipate that data will be shared in this way.”
The full editorial can be found here:
Selection 3: “On the Shoulders of Giants – From Jenner’s Cowpox to mRNA Covid Vaccines”
Angela Desmond and Paul A. Offit
The New England Journal of Medicine, 25 March 2021
In September 2008, Katalin Karikó, Drew Weissman, and their colleagues at the University of Pennsylvania modified messenger RNA (mRNA) using nucleoside analogues. These modifications stabilized the molecule and eliminated its capacity for inducing innate immunity, thereby making mRNA a promising tool for both gene replacement and vaccination. In December 2020, on the basis of safety and efficacy data generated in two large, placebo-controlled studies, the Food and Drug Administration (FDA) issued emergency use authorizations for two mRNA vaccines for the prevention of Covid-19. Clearance of this hurdle by the first mRNA vaccines represents the most recent in a series of breakthroughs in the realm of viral vaccines, each building on the last and each with a compelling record of disease prevention.
So begins a paper by Desmond and Offit.
“The first major vaccine-related advance occurred in 1796, when Edward Jenner, a physician working in southern England, found that an animal virus (cowpox) could protect against disease caused by a human virus (smallpox). One hundred years would pass before viruses would be identified as causative agents of disease; nevertheless, the notion that infectious diseases could be prevented by vaccination was born.”
“The second breakthrough occurred nearly a century after the first. In 1885, Louis Pasteur found that the spinal cords of rabbits that had been experimentally inoculated with rabies virus were no longer infectious after 15 days of desiccation. On July 6, 1885, Joseph Meister, a 9-year-old boy who had been attacked by a rabid dog 2 days earlier, visited Pasteur’s laboratory. Using a series of inoculations with suspensions of desiccated rabbit spinal cords, Pasteur saved Meister’s life. Rabies, a disease with a mortality of virtually 100%, was now preventable after exposure. Pasteur had opened the door for vaccines made with physically or chemically inactivated viruses.”
“The third major advance in vaccinology occurred in 1937, when Max Theiler attenuated yellow fever virus by means of serial passage in mouse and chicken embryos. By forcing the virus to grow in nonhuman cells, Theiler introduced a series of blind genetic alterations in the virus that rendered it less capable of causing disease but still capable of inducing protective immunity.”
“The fourth breakthrough occurred in 1980, when Stanford biochemists Richard Mulligan and Paul Berg published findings from their experiments that involved transfecting monkey kidney cells with an Escherichia coli gene and thereby causing mammalian cells to make a bacterial protein. Recombinant DNA technology was born.”
They note the profound impact of vaccines in the United States and in the world:
- “After the introduction of Salk’s inactivated polio vaccine, for example, the incidence of polio dropped from 29,000 cases in 1955 to fewer than 900 in 1962. With the introduction of Sabin’s live attenuated vaccine in the early 1960s, polio was eliminated from the United States.”
- “The measles vaccine has nearly eliminated a virus that previously caused 2 million to 3 million infections, 50,000 hospitalizations, and 500 deaths every year in the United States…”
- “The rubella vaccine, now used in 173 of 194 WHO member states, has reduced the number of global rubella cases from 671,000 in 2000 to 49,000 in 2019.”
They argue that, with the mRNA vaccines, we have had a fifth breakthrough. “This class of vaccines doesn’t contain viral proteins; rather, these vaccines use mRNA, DNA, or viral vectors that provide instructions to cells on how to make such proteins. The SARS-CoV-2 pandemic will be an important test of whether these new platforms can fulfill their promise of creating safe, effective, and scalable vaccines…”
A few thoughts:
- This short paper provides a great background on the major story of this year: the vaccine rollout.
- This paper is relevant for all clinicians. It is particularly relevant for those of us in mental health care? COVID-19 has significantly higher mortality for those with major mental illness.
- Drs. Desmond and Offit don’t discuss vaccine hesitation or the challenges of reaching special populations, like those with major mental illness – a tough population to reach historically, with only one in four opting for a flu shot. A past Reading drew from a couple of recent papers: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-vaccines-vaccine-hesitation-mental-illness-with-papers-from-jama-psychiatry-and-nejm-and-more/
The full NEJM paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.