From the Editor
As clinicians, we often think about symptoms and symptom scales – important measures of a patient’s journey. Patients may focus on other things, like functionality, including employment.
Do antipsychotics help those with psychosis for their ability to work? Do some antipsychotics provide more advantage than others? Dr. Marco Solmi (of the University of Ottawa) and his co-authors try to answer these questions in a new American Journal of Psychiatry paper. They draw on Swedish databases involving more 21,000 people. They conclude: “Among individuals with first-episode nonaffective psychosis, antipsychotic treatment (with long-acting injectables in particular) was associated with about 30%–50% lower risk of work disability compared with nonuse of antipsychotics in the same individuals, which held true beyond 5 years after first diagnosis.” We consider the paper and its clinical implications.
In the second selection, Florence Dzierszinski (of the University of Ottawa) and her co-authors look at mental health research funding in Canada. In a Commentary for The Canadian Journal of Psychiatry, they argue that funding is lacking and, in fact, declining. They write that: “Adequate research funding could go a long way to addressing prevention, care, and treatment for the one in four Canadians who experience mental health problems in a given year, improving outcomes for individuals and for Canada’s society and economy.”
And in the third selection, published by CBC First Person, Darleen Murdoch talks about her career and retirement – and her diagnosis. She notes that, during her first hospitalization decades before, she was told by her physician she would never work. She writes: “In my own way, I have proven to the medical field that ‘miracles’ can happen.”
Selection 1: “Effectiveness of Antipsychotic Use for Reducing Risk of Work Disability: Results From a Within-Subject Analysis of a Swedish National Cohort of 21,551 Patients With First-Episode Nonaffective Psychosis”
Marco Solmi, Heidi Taipale, Minna Holm, et al.
The American Journal of Psychiatry, December 2022
Little is known about the effectiveness of long-term antipsychotic treatment on functional outcomes compared with symptom reduction in people with schizophrenia spectrum disorders. A 20-year follow-up cohort study in patients with first-episode schizophrenia showed that continuous antipsychotic treatment is associated with lower relapse risk compared with discontinuation, any time after onset. Evidence from 75 randomized controlled trials confirmed the effectiveness of antipsychotics in preventing relapse of schizophrenia during up to 2 years of follow-up. However, findings from a 2013 study in patients with first-episode psychosis raised the question of whether long-term antipsychotic treatment might worsen functioning, and new randomized controlled trials have been initiated to replicate or confute those findings.
One specific element of functioning is work ability. Reducing work disability can reduce indirect costs of schizophrenia and enable patients to be involved in gainful employment and to experience a sense of accomplishment, a structure for daily routine, and the possibility of belonging to a social group through interactions with coworkers. Only scant evidence is available on work functioning from randomized controlled trials of antipsychotics. Of 167 placebo-controlled randomized controlled trials over 60 years, 10 studies measured functioning…
Here’s what they did:
“A within-subject design was used to study the risk of sickness absence or disability pension during antipsychotic use compared with nonuse during a maximum of 11 years of follow-up (2006–2016) in a Swedish nationwide cohort of patients with first-episode nonaffective psychosis… The within-subject analyses were conducted with stratified Cox regression models, adjusted for time-varying factors, using each individual as her or his own control to eliminate selection bias. The primary outcome was work disability (sickness absence or disability pension).”
Here’s what they found:
- “21,551 individuals with a first-episode nonaffective psychosis were included in the cohort.”
- Demographics. “The mean age was 29 years, 60.7% were male, and 31.6% were first-generation migrants.”
- Treatment. “During follow-up (median=4.8 years…), 7,685 patients were treated with antipsychotics”
- “45.9% of first-episode patients had work disability during the median length of follow-up of 4.8 years.”
- Antipsychotics. “The risk of work disability was lower during use compared with nonuse of any antipsychotic (adjusted hazard ratio [aHR]=0.65…).”
- Specific antipsychotics. “The lowest adjusted hazard ratios emerged for long-acting injectable antipsychotics (aHR=0.46…), oral aripiprazole (aHR=0.68…), and oral olanzapine (aHR=0.68…).” Also – “Long-acting injectables were associated with lower risk than olanzapine, the most commonly used oral antipsychotic (aHR=0.68…).” See figure below.
A few thoughts:
1. This is a good paper, and there is much to like here: an impressive dataset and publication in a major journal.
2. The big finding in a not-so-big sentence: antipsychotics mattered, especially the use of long-acting injectables. “The risk [of work disability] was >50% lower with LAIs and around 30% lower with oral aripiprazole, oral olanzapine, and oral risperidone.”
3. Why the benefit of antipsychotics? Clinicians are likely unsurprised by the finding, reasoning that those on medications are less likely to be symptomatic and thus more able to gain and hold employment. For the record, the authors weigh in: “We hypothesize that antipsychotics exert their action at least partially via their effect on positive symptoms, enabling psychosocial rehabilitation and/or return to functionality in a sizable subgroup of patients. Indeed, antipsychotics are particularly effective in treating positive symptoms, among other symptoms, and symptomatic remission is a prerequisite of functional recovery for most patients.”
4. From a clinical perspective, when speaking to patients and their families about the benefits of antipsychotics, should we be mentioning work ability? Should we spend more time promoting LAI formulations of antipsychotics?
5. Like all papers, there are limitations. The authors note: “we did not have information on other possible nonpharmacological treatments, such as vocational rehabilitation, as well as other within-subject factors that might change over time (e.g., alcohol use) which may have affected the ability to work.”
6. To return to a point made earlier in this Reading: the agenda of patients is often different than those of their clinicians. In a past Reading, we looked at a Lancet Psychiatry paper that considered patients with depression, drawing on French survey results. A major focus for patients: functionality. That paper can be found here:
The full AJP paper can be found here:
Selection 2: “Underfunding of Innovative Mental Health Research: A Call for Action”
Florence Dzierszinski, Ian Arnold, Katharine Gillis, et al.
The Canadian Journal of Psychiatry, 14 November 2022 Online First
As researchers in mental health and funders of mental health research through the Royal-Mach-Gaensslen Prize, we believe that support for mental health research is crucial in Canada today and needs to be increased. There is much public discussion about the substantial burden that mental illness represents for society and the economy, but support for research that will lead to novel ways to prevent, diagnose and treat mental illness remains inadequate.
So begins a paper by Dzierszinski et al.
They draw on a 2020 research funding report:
- “Mental health in Canada receives less research funding than cancer, neurological diseases, or infectious diseases.”
- “Funding per year lived with disability for mental health was US$95 (C$126), compared with US$1,701 (C$2,257) for cancer, US$304 (C$403) for neurological diseases and US$2,468 (C$3,275) for infections.”
- “Mental health research spending in Canada has declined overall, from US$122.2 million in 2015 to US$89.9 million in 2019.”
They consider government funding of medical research. “Research specifically in mental illness and behavioural conditions accounted for $413.6 million over that period or approximately 3% of total CIHR investments.” They focus on chairs: “Federal granting agencies also fund 2285 Canada Research Chairs in universities across Canada. Currently, 32 are in mental and behavioural disorders, although some chairs in psychology also have a mental health focus.”
The authors report on a qualitative survey of Royal-Mach-Gaensslen Prize winners, finding that they hoped for flexibility with funding, as well as long-term support.
The authors argue: “Mental health research in Canada cannot keep pace with the growing need for prevention, diagnostics, and treatments. The percentage of Canadians expressing the need for mental health care in a given year continues to increase, while overall funding for mental health research in Canada remains low.”
They note several gaps need to be addressed, including the lack of mid-career funding. And they wonder about a greater role for charities. “One way to further boost funding is to ‘leverage’ donations and funding from not-for-profit organizations with matching grants from public agencies. Canada also lacks a national philanthropic organization to fund mental health research, with public visibility and fundraising clout, similar to the Heart and Stroke Foundation and the Canadian Cancer Society. To grow the philanthropic and private-sector contributions in this area, the creation of a national organization would be beneficial.”
They close with a call to action: “We call on public and not-for-profit funders of health research to increase flexible funding for innovative mental health research and to hold a summit on addressing the challenge of funding for mental health research.”
A few thoughts:
1. This is a good commentary.
2. Mental health stigma has faded. The lingering effects of stigma, however, are still felt – witness the research funding gap.
3. The point about philanthropic contributions is excellent.
The full CJP Commentary can be found here:
Selection 3: “The doctor wrote me off. But miracles happen and now it’s 20 years since my last mental breakdown”
CBC First Person, 31 December 2022
‘She will never work again,’ the young psychiatrist with piercing blue eyes told my sister.
I stood there shivering in my flimsy orange hospital shorts and gown. My room at the Queen’s Medical Centre in Honolulu was ice cold and poorly lit. Even though we were in tropical Hawaii, the ward was drab and permeated with the stench of unwashed bodies.
Carol had travelled from Vancouver to escort me home.
So begins an essay by Murdoch.
She writes: “I was 25 and, despite Carol’s support, I thought my life was over. And yet, here’s what I’ve learned. Even with debilitating mental illness – and when a doctor writes you off – medical miracles can happen, especially with faith, supportive family, perseverance and the right medication.”
She describes her first episode: “The crisis in Hawaii started a few days after I landed. It was 1976. I was deeply depressed due to a painful divorce and even the gently swaying palm trees could not overcome my melancholy… Lonely and afraid, I experienced a manic episode in which I thought I was the heroine in a Hollywood movie. I ran toward the menacing blue ocean. I slipped on the damp grass and fell dangerously close to a cliff. Bystanders alerted police who escorted me to the hospital.”
After her hospitalization, she dealt with depression. Over time, she put her life together and found a great partner. “Somehow, in our relationship, he helped me see more clearly when I was close to the edge and, in that context, I developed better control of how to calm down. Being secure and feeling his love helped me realize I could be whatever I wanted to be.”
“With this support, I also flourished at work. In 1999, Dave and I moved to Alberta and I started working at the University of Calgary’s Faculty of Social Work. At the same time, I got new medication. With the benefits from advancements in science, my mind became so clear that I went from constantly worrying about mistakes to being recommended for a work award. At home, Dave ceased to be my caregiver. We became real partners.”
She has recently retired and comments: “In the end, I had a full career. I proved the doctors wrong because I worked 34 years at two universities before retiring at 68. I had 10 bipolar episodes in total, but none within the past 20 years.”
A few thoughts:
1. This is a great essay.
2. Murdoch tells a compelling story of illness and recovery. (Tying back to the first selection, note how important work is to her identity.)
3. To state the obvious: comments that we make to patients can have a lasting impact. Of course, none of us were in that Hawaiian hospital years ago, but Murdoch’s description seems highly credible.
The CBC essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
January 19, 2023 at 3:27 pm
I understand the importance of this research and certainly want all people capable of work to have a chance to develop a rewarding work life.
However, I think there is an unexamined topic waiting to be explored.
With the current prevalence of the “recovery model,” there is a lot of emphasis on the capacity of people with some kind of mental health challenge to maintain a paid work life. What isn’t taken into account are the well-researched and common cognitive losses associated with schizophrenia. When health authorities in BC adopted this model, my daughter, who lives with schizophrenia, was negatively impacted. The contacted agency, who arranged her valuable supported volunteer experiences, explained that, since she was 30, the only help available would now be in the stream leading to paid competitive employment.
There is a widespread lack of appropriate services for people with severe mental illnesses. This includes services that recognize the many people with schizophrenia who need help with the tasks of daily living. There is an emerging recognition among families who supply all this help that, once we are not here, the mental health system is not equipped to meet these needs.
Here are some suggestions:
> Create a national mental illness literacy program so that there is better public understanding and acceptance of illnesses like schizophrenia.
> Promote the implementation of the evidence based cognitive remediation programs that are more widespread in many other countries.
> Redevelop psycho-education programs for people with schizophrenia. These have disappeared and this lack of appropriate psycho-education for clients contributes to so many people not staying on antipsychotic medications that they need.
> Ensure that the overly empowered peer work force is not able to undermine medically necessary treatments. Current training of this work force does not include any training about mental illnesses like schizophrenia. At the same time, peers are able to promote alternative understandings of “mental health issues.” Here is a link to a publicly funded study group connected to the ever increasing number of the Hearing Voices Network groups; as in this announcement much of the studying focuses on the work of people like Will Hall who teaches people to get off of antipsychotic medications; I’ve never seen any presentations offered on beliefs from mainstream psychiatry:
> Train all mental health professionals about illnesses like schizophrenia and train them to work cooperatively with family caregivers. My daughter, whose illness has always been understood to be severe, has only been able to enjoy years of stability because we were able to find psychiatrists and others who worked cooperatively with us.
My immersion in the community of family caregivers lets me see how rare this cooperation is.
In the name of fighting stigma and promoting inclusion of neuro-diverse people, the existence and needs of people with disorders like schizophrenia are ignored; in fact, with the gradual dismantling of helpful mental health acts, this population has been tremendously harmed. I discussed some of these problems and their relation to the stance taken by the powerful disability rights organizations in this article: