From the Editor
I’m separated from everyone else.
These are the words of a young patient with depression. We often use diagnoses and lists of symptoms to understand patients. But how do patients themselves understand their illness? In the first selection, Dr. Paolo Fusar-Poli (of King’s College London) and his co-authors attempt to answer that question with a “bottom-up” approach. In a new World Psychiatry paper, they describe the experiences of adolescents with mental disorders. “The study was co-designed, co-conducted and co-written by junior experts by experience – representing different genders, ethnic and cultural backgrounds, and continents – and academics, refining an earlier method developed by our group to investigate the lived experience of psychosis and depression.” We examine the paper and its implications.
Much has changed over the past eight years – who was talking about pandemics in 2016? Last week, the Canadian Network for Mood and Anxiety Treatments (CANMAT) released its first major depression update in eight years. So how has depression management changed? In the second selection, Dr. Raymond Lam (of the University of British Columbia), the co-first author, discusses the update in a Quick Takes podcast interview. “They really are the most widely used guidelines in the world.”
And in the third selection, in a letter to the editor, Nick Kerman (of the University of Toronto) writes about the recent homelessness paper from JAMA Psychiatry, summarized in a Reading earlier this month. He notes the striking finding: 26% meet the criteria for antisocial personality disorder. “Could it really be 1 in 4 or is there something else that could explain the finding?”
DG
Selection 1: “The lived experience of mental disorders in adolescents: a bottom-up review co-designed, co-conducted and co-written by experts by experience and academics”
Paolo Fusar-Poli, Andrés Estradé, Cecilia M. Esposito, et al.
World Psychiatry, 10 May 2024
Recent meta-epidemiologic findings indicate that the onset of the first mental disorder occurs before the age of 14 in one-third, before the age of 18 in almost half, and before the age of 25 in about two-thirds of individuals, with a peak age at onset of 14.5 years across all mental disorders. Most adult mental disorders originate during adolescence (i.e., between 10 and 19 years of age), when rapid growth and development take place in the brain. The incidence of mental health problems in adolescents is reported to be increasing worldwide.
Early onset is a main driver of the high personal burden of most mental disorders, compounded by frequent comorbidities, and reflecting a complex etiopathological interplay of genetic and environmental factors. A related driver is the global crisis of the mental health care system, which is typically split around the age of 18 (children and adolescent vs. adult mental health care), leading to a lack of continuity of care.
So begins a paper by Fusar-Poli et al.
Here’s what they did:
- “We established a collaborative core writing team of experts by experience (patients, their families and carers) and academics. This team conducted a comprehensive systematic search of Web of Science, PubMed and EBSCO… We included qualitative studies providing first-person accounts…”
- “Independent researchers performed a thematic synthesis of selected sources based on line-by-line coding of the text in the Results/Findings sections of the articles, and generation of a preliminary list of descriptive themes and sub-themes of the lived experience of mental disorders in adolescents.”
- “In a subsequent step, we promoted a collaborative and iterative sharing and analysis of the preliminary experiential themes and sub-themes in three workshops… Overall, we involved 18 young experts by experience of variable gender, age and ethnicity from three continents…”
- “In a final step, the selection of experiential themes was revised and enriched by adopting a phenomenologically-informed perspective…”
Here’s what they found:
The authors focused on three themes.
Theme 1: The inner subjective experience of mental disorders in adolescents
On ADHD
“The lack of control may generate the feeling of being left behind: ‘I wish people understood, I’m not stupid… I’m not as fast as you’.”
On eating disorders
“Adolescents with eating disorders often strive for an idealized image of themselves, originating from deep feelings of inadequacy. Even small details are scrutinized as they strive for an unattainable and unrealistic ideal and desperately attempt to recover their identity: ‘I wish I had her body’; ‘Look at her legs, I wish mine were like that’ (personal communication).”
On autism spectrum disorders
“Adolescents with autism spectrum disorders typically feel very different from their peers: ‘It is like… American people write back and forth, and Chinese [people] write up and down’. Sometimes they explain their neurodiversity in terms of a biological condition: ‘Just the paths of how things transmit in a neuro-typical brain and an autistic brain’.”
Theme 2: The lived experience of adolescents with mental disorders in the wider society
On suffering a painful lack of understanding
“The subjective suffering of adolescents is enhanced by the parents’ lack of understanding or acknowledgement of their mental disorder: ‘The first thing they [the parents] felt was like ‘this is not a real illness’ ‘you should not be telling us about this’… I felt I was being put under the rug’ (personal communication). They may not feel accepted for who they are with the existing disorder, struggling to meet their parent’s expectations: ‘My dad says things like ‘I didn’t raise you to be sad, I raised you to be strong because this is something from a weak person’’.”
Theme 3: The lived experience of adolescents with mental disorders in receiving mental health care
On emotional barriers
“The difficulty in accepting the diagnosis of a mental disorder frequently represents the first barrier to receiving help: ‘I didn’t accept what I had, and I didn’t want any medicine’. Furthermore, many adolescents, once they have recognized their mental fragility, describe a variety of emotional barriers hindering the start of the treatment process… The main help-seeking difficulty is related to embarrassment and shame: ‘Sometimes I get embarrassed to talk to someone else’.”
On medications and shame
“The experience of receiving medication among adolescents with a mental disorder is highly variable. A range of emotions and feelings may arise, hindering drug treatment to the point of outright rejection: ‘I don’t want to take them at all’. Shame is the emotion that most contributes to rejection and poor compliance: ‘I mean, it’s really difficult… It totally can embarrass you if you have to take it in front of other people’.”
A few thoughts:
1. This an amazing paper with good insights, a unique approach, and published in a very big journal.
2. The approach is fresh and needed.
3. The illness experience would be challenging at any age but seems particularly difficult in adolescence. To make a difficult situation worse, there is often a lack of continuity of care with mental health services as patients “age out” of youth services.
4. Further to that point, one patient commented: “You don’t want to have to re-live… Re-living it every time brings back the pain… And, then to have – you know – two or three new counsellors over a few years ends up destroying you’.”
5. Some of the authors were involved in similar efforts looking at depression and psychosis. These two papers were considered in past Readings and can be found here and here:
The full World Psych paper can be found here:
https://onlinelibrary.wiley.com/doi/full/10.1002/wps.21189
Selection 2: “The new CANMAT depression update”
Raymond Lam
Quick Takes, 15 May 2024
In this episode of Quick Takes, I speak with Dr. Raymond Lam, executive chair of CANMAT and the BC Leadership Chair in Depression Research at UBC.
In our interview, we review the new depression update which focuses on eight questions. We discuss various topics covered in this update: the importance of recognizing childhood maltreatment, digital interventions, when to recommend exercise (and how to discuss it with your patients), and other topics.
Here, I highlight several comments:
On the biggest surprise
“The surprising thing was how much literature there is. It’s amazing to me.
“For this particular update, we updated our literature review since 2016. We focused only on meta-analyses and systematic reviews… There were over 700 systematic reviews and meta-analyses published. It really illustrates how hard it is for busy clinicians to keep up with this huge amount of literature, and where guidelines can help synthesize some of that and provide recommendations for that huge amount of research that’s being done.”
On childhood maltreatment
“There is the recognition now that childhood maltreatment – physical, emotional, sexual trauma – is a big risk factor for development of depressive disorders.
“And it’s very important for us to recognize because it has clinical relevance in terms of the treatments that we will want to use, and also in terms of the response. Patients are more difficult to treat when people have this history of childhood maltreatment. It’s an important aspect to recognizing and assessing depression.”
On digital interventions
“We’re really talking about online and mobile apps. The issue is that, unfortunately, the evidence for many of these interventions is still slim. And we are always trying to balance the evidence versus what people are actually using and what might be helpful for them. And it was a controversial area in terms of our experts not always agreeing in terms of what the evidence was. In the end, we recommended guided digital health interventions – things like online cognitive behaviour therapy programs that are guided by either a coach or a therapist. When they’re unguided or self-directed, hardly anybody ever does them; the retention rates are very low.”
On exercise
“The evidence base has greatly expanded, with randomized controlled trials and meta-analyses all showing good benefits of moderate exercise; Health Canada recommends exercise as helpful for depression. Of course, there needs to be some motivation for people to do exercise. And so, usually supervised exercise programs are more helpful.
“In terms of speaking to patients: start off small. So just increasing activity of any kind is helpful. And then starting to increase the amount of exercise whether that’s even starting with daily walks, for example. Getting something that’s doable in.”
On his role in the next update and his 20+ years of involvement
“I’m definitely not leading the next update.
“One of the things we did with these guidelines is to involve junior colleagues who we are sure will be able to take over the mantle of leading the new depression guidelines the next time.”
The above answers have been edited for length.
The podcast can be found here, and is just over 35 minutes long:
And, yes, we will return to the update next week with five takeaways.
Selection 3: Letter to the Editor
Dear Editor,
Re: “Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness: A Systematic Review and Meta-Analysis”
The Reading of the Week for 2 May 2024, included the selection of a new systematic review and meta-analysis by Richard Barry and colleagues in JAMA Psychiatry that estimated the prevalence of various mental disorders among people experiencing homelessness. The article’s main findings largely replicated and add further support to earlier meta-analyses by Stefen Gutwinski (2021), Seena Fazel (2008), and Getinet Ayano (2019-2021). However, there is one staggering diagnostic estimate in the new article that previous reviews did not examine: the pooled prevalence of antisocial personality disorder (ASPD), which was estimated at 26.1%. Discussion of the applicability of ASPD to people experiencing homelessness has been discussed for decades, with Carol North asking whether or not it was a valid diagnosis for this population back in the early 1990s (and concluding that it was).
Yet, Barry et al.’s estimate warrants pause and the question: Could it really be 1 in 4 or is there something else that could explain the finding?
The articles includedin the meta-analysis are likely important here. For example, in the doctoral dissertation by Edwards (2004), which was included in the meta-analysis, item-level means for ASPD criteria are presented as measured by the Structured Interview for DSM-IV Personality. Excluding conduct disorder symptoms, the highest individual items among those assessed as meeting ASPD diagnostic criteria were: repeated arrests, impulsivity or failure to plan ahead, and consistent irresponsibility. The lowest: lack of remorse. We know that people experiencing homelessness are at greater risk of criminal justice involvement for non-violent reasons than housed counterparts. Impulsivity or failure to plan ahead is a challenge as well; it is hard to plan ahead when constantly needing to address immediate needs for shelter and food. Consistent irresponsibility centres around work terminations and absences, and lack of financial follow-through; other experiences that could be greatly challenged by homelessness and poverty (or, one of the other mental illnesses that are common within the population). It is difficult to discern which of the other 84 studies in Barry et al. were used in the ASPD prevalence computations without reviewing each individually. Nevertheless, my fear is that the findings overinflate the prevalence of ASPD in homeless populations, which risks further stigmatization of people experiencing homelessness. I must acknowledge my own biases here though, as my concern of the high prevalence of ASPD may also reflect assumptions and perceptions that I hold of this diagnosis.
Ultimately, the prevalence of ASPD is certainly higher among people experiencing homelessness than the general population. People with substance use disorders have higher rates of ASPD and the former is widespread in homeless populations (43%, according to Barry et al.). ASPD is higher among people in prison, and incarceration is a risk factor for homelessness. However, there is value in treading carefully and critically around conclusions about the prevalence of ASPD in homeless populations, given that other circumstances and factors related to homelessness may inflate estimates.
Nick Kerman, PhD
Centre for Addiction and Mental Health
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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