From the Editor
The first reported cases were almost three years ago. Yet, with this pandemic, many questions remain. No wonder. The patient experience is so varied. Some of our patients complain of time-limited, mild symptoms. Others seem affected by ongoing, non-physical symptoms. And many haven’t had any symptoms.
How common are neurological and psychiatric problems? Do they last? Are they less common with newer variants? This week, in the first selection, we consider a new Lancet Psychiatry paper; Max Taquet (of the University of Oxford) and his co-authors try to answer these questions and others. Drawing on the health records of almost 1.3 million people with a recorded diagnosis of COVID-19 and focusing on 14 different outcomes (including anxiety and mood disorders) across eight nations, they find: “post-COVID neurological and psychiatric outcomes followed different risk trajectories: the risk of cognitive deficit, dementia, psychotic disorder, and epilepsy or seizures remained increased at 2 years after a COVID-19 diagnosis, while the risks of other diagnoses (notably, mood and anxiety disorders) subsided early and showed no overall excess over the 2-year follow-up.” We look at the paper and its clinical implications.
In this week’s second selection, we consider a new Quick Takes podcast interview with David Clark (of the University of Oxford). Prof. Clark speaks about IAPT, the UK’s program to expand access to psychotherapy, which he co-founded. “We’ve still got some distance to go, though, but the IAPT services are seeing about a million people a year who wouldn’t have previously had psychological therapy.”
Primary care has an essential role in our health care system. In the third selection, Emily Rhodes (of the Ottawa Hospital Research Institute) and her co-authors mull physicians and their personal connection to primary care in a new JAMA Network Open paper. They find: physicians are less likely to be rostered with family docs, and less likely to visit them. They conclude: “Emphasis on the importance and improvement of access to primary care for physicians is a potential means to improve overall health for physicians and patients.”
Selection 1: “Neurological and psychiatric risk trajectories after SARS-CoV-2 infection: an analysis of 2-year retrospective cohort studies including 1 284 437 patients”
Maxime Taquet, Rebecca Sillett, Lena Zhu, et al.
The Lancet Psychiatry, 17 August 2022 Online First
Since the early stages of the pandemic, COVID-19 has been known to be associated with an increased risk of many neurological and psychiatric sequelae. However, more than 2 years after the first case was diagnosed… important questions remain unanswered.
So begins a new paper by Taquet et al.
Here’s what they did:
“In this analysis of 2-year retrospective cohort studies, we extracted data from the TriNetX electronic health records network, an international network of de-identified data from health-care records of approximately 89 million patients collected from hospital, primary care, and specialist providers… A cohort of patients of any age with COVID-19 diagnosed between Jan 20, 2020, and April 13, 2022, was identified and propensity-score matched (1:1) to a contemporaneous cohort of patients with any other respiratory infection. Matching was done on the basis of demographic factors, risk factors for COVID-19 and severe COVID-19 illness, and vaccination status… We assessed the risks of 14 neurological and psychiatric diagnoses after SARS-CoV-2 infection and compared these risks with the matched comparator cohort. The 2-year risk trajectories were represented by time-varying hazard ratios (HRs) and summarised using the 6-month constant HRs (representing the risks in the earlier phase of follow-up, which have not yet been well characterised in children), the risk horizon for each outcome (ie, the time at which the HR returns to 1), and the time to equal incidence in the two cohorts.”
Here’s what they found:
- “We identified 1 487 712 patients with a recorded diagnosis of COVID-19 during the study period… of whom 1 284 437 were adequately matched.”
- Demographics. Most patients were adults, with a mean age of 42.5 years, and the majority were female (57.8%) and White (56.0%).
- Psychiatric disorders. “Risks of the common psychiatric disorders returned to baseline after 1-2 months (mood disorders at 43 days, anxiety disorders at 58 days) and subsequently reached an equal overall incidence to the matched comparison group (mood disorders at 457 days, anxiety disorders at 417 days). By contrast, risks of cognitive deficit (known as brain fog), dementia, psychotic disorders, and epilepsy or seizures were still increased at the end of the 2-year follow-up period.”
- Age. “Post-COVID-19 risk trajectories differed in children compared with adults: in the 6 months after SARS-CoV-2 infection, children were not at an increased risk of mood (HR 1.02…) or anxiety (1.00…) disorders, but did have an increased risk of cognitive deficit, insomnia, intracranial haemorrhage, ischaemic stroke, nerve, nerve root, and plexus disorders, psychotic disorders, and epilepsy or seizures (HRs ranging from 1.20 to 2.16…).”
- Variants. “Risk profiles were similar just before versus just after the emergence of the alpha variant… Just after (vs just before) the emergence of the delta variant increased risks of ischaemic stroke, epilepsy or seizures, cognitive deficit, insomnia, and anxiety disorders were observed, compounded by an increased death rate.”
- Omicron. “With omicron, there was a lower death rate than just before emergence of the variant, but the risks of neurological and psychiatric outcomes remained similar.”
A few thoughts:
1. This is a good study.
2. The above summary doesn’t capture the nuance and detail of this paper, which draws on a wealth of data across multiple countries.
3. The study in brief: while some psychiatric problems proved transient (mood and anxiety), others didn’t (psychosis and cognitive deficits).
4. The bad news about omicron: “The comparable risks seen after the emergence of omicron indicate that the neurological and psychiatric burden of COVID-19 might continue even with variants that lead to otherwise less severe disease.”
5. The authors note several limitations, including: “our COVID-19 cohorts are probably enriched for symptomatic cases because self-diagnosed or asymptomatic COVID-19 is less likely to be coded in the health record…” Obviously, this paper has focused on those who are more ill – and thus more affected by the virus.
6. The clinical implications are clear: some psychiatric problems are more worrisome than others. Timing is also important: “If no anxiety disorder has been diagnosed within 2 months of a COVID-19 diagnosis then, from that time onwards, a patient can be reassured that their risk is no longer any greater than after another respiratory infection… By contrast, the absence of risk horizons within the first 2 years of a COVID-19 diagnosis (ie, ongoing risk trajectories) for some diagnoses (eg, psychotic disorders, epilepsy or seizures, cognitive deficit, and dementia) indicate that patients and clinicians must remain vigilant about the possibility of these delayed sequelae.”
The full Lancet Psychiatry paper can be found here:
Selection 2: “Expanding Access to Psychotherapy: David Clark on the English Experience”
Quick Takes, August 2022
With the pandemic dragging on, everyone feels a bit exhausted – and we are all looking for some good news. In the second podcast on innovation in mental health (as part of the Quick Takes series), we consider the British experiment to expand access to publicly-funded psychotherapy.
In Canada, according to a recent paper, just 13% of people with depression have access to psychotherapy. In this interview, I talk with Prof. David Clark. We discuss England’s Improving Access to Psychological Therapies program, which he co-founded. Clark details how this data-driven program has changed the lives of over eight million people by providing evidence-based care for anxiety and depression. With a commitment to capturing the outcomes of every patient, IAPT has transformed mental health care in England.
We highlight from the podcast.
David Clark, Chair of Experimental Psychology at the University of Oxford.
“We had the same problem that you have here in Canada. We have psychological therapies that are very powerful, very effective for mental health conditions, but very few people got them. And so, we created the Improving Access to Psychological Therapies (or IAPT) program, which trains 16,000 new psychological therapists and then delivers evidence-based treatments. And a really key component of it is that we try and capture the outcomes on everyone who has a course of treatment and published that data.”
“We thought about one in every two people should be able to recover. So about 50%. We’re at 52% the moment. And we also thought that quite a few people may not fully recover, but they show really worthwhile improvements and we hoped we might get to 70%… that’s essentially where we’re at.”
The big surprise
“We should be offering people up to 15 or 20 sessions because that’s what the clinical guidelines say. But we find that quite a lot of people recover with substantially less. The sort of optimal average number of sessions for a service is about nine. But that doesn’t mean you limit people to nine sessions. Of course, you allow people to have up to 20 or so. But because a lot of people recover with less, that’s how you get that average. So it’s not a very expensive intervention.”
The above answers have been edited for length.
The podcast can be found here, and is 10 minutes long:
Selection 3: “Primary Care Physician Use and Frequency of Visits Among Physicians in Ontario, Canada”
Emily Rhodes, Claire Kendall, Robert Talarico, et al.
JAMA Network Open, 19 August 2022
Primary care is an essential part of the health care system. Primary care services are intended to be the first point of contact for new medical concerns; to provide long-term, comprehensive patient-centered care; and to coordinate specialist care… When seeking care for themselves, physicians have unique circumstances in that they may be more aware of their medical condition and may have greater access to primary care physicians (PCPs) and specialists. It is unknown, however, how this knowledge translates to health-seeking behavior for both primary and specialist-based care among physicians… Some physicians face barriers to accessing care, including time constraints, confidentiality concerns, and stigma. A perceived pressure to remain healthy to maintain the trust of their patients and respect of their colleagues may lead physicians to seek informal care or ‘hallway medicine’ (ie, obtaining prescriptions or informal advice from colleagues) from their peers.
Here’s what they did:
“This population-based, retrospective cohort study used registration data from the College of Physicians and Surgeons of Ontario, Canada, from January 1, 1990, to March 31, 2018. Data for all newly practicing physicians as of March 31, 2018, were linked to Ontario health administrative databases. Data were analyzed from August 25, 2020, to August 6, 2021… The main outcomes were enrollment in a PCP practice and visits with a PCP.”
Here’s what they found:
- 19 581 physicians were matched to 97 905 nonphysicians.
- Demographics. Physicians were in their 40s (mean age: 43.99) and the majority were male (53.27%).
- Enrollment and visits. “Physicians were less likely to be enrolled with a PCP than were nonphysicians (81.8% vs 86.4%… adjusted odds ratio [OR], 0.75…) and had fewer primary care visits during the preceding 2 years (adjusted relative rate ratio [RRR], 0.59…).”
- Age and gender. “Physicians aged 40 years or older and male physicians were less likely to be rostered (ages 40-44 years: OR, 0.70… male: OR, 0.60…) and more likely to have a lower frequency of PCP visits (ages 40-44 years: RRR, 0.53; male: RRR, 0.50) compared with nonphysicians.”
A few thoughts:
1. This is a good study.
2. While other work has been done in this area, the authors did a cohort study, rather than drawing on survey results.
3. A quick summary of the results: docs tended to engage less with family physicians (both in terms of practice enrollment and visits). Ouch.
4. The implications for medical culture? “From the first day of medical school, the culture should encourage a model of healthy physicians that acknowledges the high pressures of the environment, promotes the concept of PCP involvement to enhance resiliency and performance, and decreases the stigma around accessing health care. The shift in medical culture could also help to reduce the guilt that physicians may feel toward their patients or colleagues when they need to cancel patient care and ask for clinical coverage.”
5. What about mental health? “Mental health visits in the past 2 years were most frequent among psychiatrists (28.5%), followed by PCPs (17.3%) and internal medicine physicians (14.5%), and the lowest frequency of mental health visits in the past 2 years was observed among surgeons (10.7%).”
The JAMA Network Open paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.