From the Editor
A recent New York Times article notes that adolescents are increasingly looking for information on mental health and turning to TikTok. Such is life at a time when stigma fades: people are curious, though not necessarily going to the best places for information.
But are we reaching people earlier in their illness experience? We hope that the answer is yes – a new paper with British Columbian data, however, suggests that police apprehensions are more common, as are involuntary admissions, indicating that more people are in crisis. In the first selection from The Canadian Journal of Psychiatry, Jackson P. Loyal (of Simon Fraser University) and his co-authors draw on administrative databases and find a major shift: “While roughly half of the people hospitalized for mental health and substance use disorders were admitted voluntarily in 2008/2009, by 2017/2018 this fell to approximately one-third.” We look at the paper and its clinical implications.
In the second selection, Dr. Carlos Blanco (of the National Institute on Drug Abuse, United States) and his co-authors consider the rise of telepsychiatry, noting that 39% of mental health care in the US is now virtual. In this new JAMA Psychiatry Viewpoint, “Expansion of telepsychiatry creates new opportunities to increase treatment access, while it poses overlapping challenges to multiple stakeholders…”
And in the third selection, Dr. Nicholas Zhenwei Oh (of the Ministry of Health Holdings, Singapore) writes personally and thoughtfully about the loss of a patient by suicide. He goes into detail on his own experience during training. “Patient suicide is possibly the great equaliser amongst psychiatrists, psychiatry trainees, and perhaps any other clinician who has experienced a patient’s suicide. My own experience came suddenly and unexpectedly, and it will likely leave a psychological scar as a grim reminder of one of the lowest points of my career.”
DG
Selection 1: “Trends in Involuntary Psychiatric Hospitalization in British Columbia: Descriptive Analysis of Population-Based Linked Administrative Data from 2008 to 2018”
Jackson P. Loyal, M. Ruth Lavergne, Mehdi Shirmaleki, et al.
The Canadian Journal of Psychiatry, 6 October 2022 Online First
Involuntary hospitalization occurs when a person with a serious mental disorder is detained against their will in order to receive medical treatment and supervision. Globally, there is significant variation in trends in involuntary hospitalizations. Between 2008 and 2017, involuntary hospitalizations increased in 11 Western European countries, decreased in 4 Nordic countries, and remained relatively constant in New Zealand and Italy… In the United States between 2011 and 2018, increases were observed in 15 states while decreases were observed in 7 states. Differences in trends may be due to differences in demographics, economics, healthcare provision, and legal frameworks regarding involuntary hospitalization and geographic variation of mental disorder prevalence.
So begins Loyal et al.
Here’s what they did:
“We used population-based linked administrative data to examine and compare trends in involuntary and voluntary hospitalizations for mental and substance use disorders. We described patient characteristics (sex/gender, age, health authority, income, urbanity/rurality, and primary diagnosis) and tracked the count of involuntarily hospitalized people over time by diagnosis. Finally, we examined population-based prevalence over time by age and sex/gender.”
Here’s what they found:
- Involuntary hospitalizations. “Involuntary hospitalizations among British Columbians ages 15 and older rose from 14,195 to 23,531 (65.7%) between 2008/2009 and 2017/2018.” The population grew 15.2% over that time. See figure below.
- Voluntary hospitalizations. “Voluntary admissions remained relatively stable”
- Apprehensions. “Apprehensions involving police increased from 3,502 to 8,009 (128.7%).”
- Demographics. “In 2017/2018, 45.1% of involuntary patients and 49.3% of voluntary patients were female… The majority (58.9%) of involuntary patients were between the ages of 15 and 44.”
- Diagnoses. “The most common diagnosis for involuntary patients in 2017/2018 was mood disorders (25.1%), followed by schizophrenia (22.3%) and substance use disorders (18.8%).”
- Change. “Over time, we observed the greatest increase in total hospitalizations related to substance use, and dramatic increases in involuntary hospitalizations of young adults, especially women ages 15-24.”
A few thoughts:
1. This is a good study.
2. To summarize it in six words: police apprehensions and involuntary admissions increased.
3. What explains the rise? “People are not receiving care until they are in crisis at which point they are involuntarily hospitalized.” The authors note problems with access including at the primary care level – one million British Columbians don’t have a family doctor.
4. From a system perspective, apprehensions and involuntary admissions are unfortunate; people take longer to get better (they tend to be more ill) and at significant cost. Of course, consider the patient experience: a person in a mental health crisis is seen by a man with a gun in a uniform, then rushed to a hospital where his or her rights are taken away. That’s not to tap our inner-Szasz. Of course, the resulting care can be incredibly important but it’s far from ideal. (As the authors note: “Between 2013 and 2017, there were 127 deaths in BC during or shortly after police–civilian encounters, of which more than two-thirds involved a mental health issue. While police apprehensions play a role in connecting people to healthcare services, the potential for negative, sometimes fatal, encounters highlights the need to focus on minimizing police apprehension.”)
5. How do these numbers compare to other provinces? A BJPsych Open study, using Ontario data, noted a sharp rise in involuntary hospitalizations (from 70.7% of admissions in 2009 to 77.1% in 2013). That paper was reviewed in a past Reading:
Soon to be released Ontario data on apprehensions shows an increase in recent years, especially during the pandemic
6. Like all studies, there are limitations. The authors note several, including: “Our analysis is descriptive, so we cannot determine causal factors driving increasing involuntary hospitalizations, nor the impacts of involuntary hospitalization.”
The full CJP paper can be found here:
https://journals.sagepub.com/doi/10.1177/07067437221128477
Selection 2: “Implications of Telepsychiatry for Cost, Quality, and Equity of Mental Health Care”
Carlos Blanco, Melanie M. Wall, Mark Olfson
JAMA Psychiatry, 19 October 2022 Online First
The COVID-19 pandemic has triggered a rapid expansion of telepsychiatry. A 2022 study of 126 million patients across all 50 states found that 39% of mental health visits were virtual. It is expected that telepsychiatry will continue to expand after the COVID-19 pandemic subsides. Advantages of telepsychiatry include greater access, flexibility, convenience of routine care, and potential for increased privacy. However, in contrast to the decades of accumulated knowledge concerning cost, quality, and equity of in-person care, our understanding of telepsychiatry is still a nascent science.
So begins a paper by Blanco et al.
Noting the state rules around telepsychiatry, they wonder about reducing overall costs for US patients. “Telepsychiatry expansion could help decrease the cost of mental health care. Relaxation of licensing regulations could increase availability of clinicians, stimulate market competition, and lead to lower prices as a way to compete for patients. Eliminating commuting times for patients and clinicians along with greater flexibility in scheduling virtual rather than in-person care could further increase the functional supply and reach of clinicians including in underserved areas. Greater office sharing could lower overhead costs. Fewer missed appointments could increase treatment adherence, which, combined with broader access to experts, may improve clinical outcomes resulting in fewer failed treatments and decreased need for hospitalization and emergency care.”
They consider larger issues around care:
Quality of care
“Expansion of telepsychiatry can also influence quality of care. Some studies suggest that outcomes are similar in virtual and in-person care, but whether that holds across disorders, levels of symptom severity, and populations is unknown… crude implementation and scaling up of telepsychiatry care could lead to worse overall quality of care and patient outcomes. Fortunately, small amounts of monitoring can lead to substantial increases in quality of care. Thus, even modest advances in the assessment of the quality of telepsychiatry could lead to large increases in its value. Expansions of telepsychiatry could also help generalize standards of care, reduce unjustified practice variation, and moderate legal liability risks associated with deviations from standards of care.”
Patient centeredness
“To ensure patient centeredness, patient preferences in delivery modality (virtual vs in person) should be carefully assessed without constraints imposed by clinicians, health care systems, or payers. Optimal hybrid models may vary by disorder type and chronicity, stage of care, and prevailing barriers to accessing high-quality care.”
Equity
“Equity is also a key consideration. Lower costs could reduce inequities, as financial barriers to care have greater influence on those with fewer economic resources. To ensure that expansion of telepsychiatry reduces rather than exacerbates inequities by expanding access primarily for those with greater resources, it will be important to address the digital divide (ie, the gap between those with and without knowledge and easy online access). Investing in information infrastructures necessary to provide telepsychiatry will be central to improving care across populations and achieving equity.”
They close by observing the advantages to clinicians: “access to larger patient populations through virtual care could offer opportunities to better match their skills to patients’ needs, which may lead to increased productivity and income.”
A few thoughts:
1. This is a good Viewpoint paper, and it raises important questions.
2. Though intended for an American audience, it’s relevant in Canada and elsewhere, though the focus on cost isn’t quite as emphasized here.
3. The authors are right: equity is a key consideration. Remember: 28 million North Americans lack access to reliable broadband. (!)
The JAMA Psychiatry Viewpoint can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2797207
Selection 3: “Patient Suicide – All for One”
Nicholas Zhenwei Oh
Academic Psychiatry, 13 October 2022
‘I should tell you something… My patient just committed suicide.’ I finally sent this message to my supervisor, after struggling for half an hour to make myself sound as calm as possible. Did I sound like I was admitting a mistake? Did I actually need to inform my supervisor, or should I have acted more responsibly by keeping the burden to myself? After all, he was my patient. He hadn’t been seen by any other psychiatrist. Minutes felt like hours as I awaited my supervisor’s reply.
So begins a paper by Dr. Oh.
He notes his initial thoughts: “I scrutinised my own documentation, reconsidered my diagnosis and management plans, and looked for potential mistakes. The last clinic visit replayed in my mind repeatedly. How could I have allowed this? Why did his family call me; should I call them back? I couldn’t tell anyone else, I didn’t want to be judged. Why couldn’t this news have waited until the suicide was confirmed, maybe it was just an accident? Back home, I struggled to sleep. More questions and doubts flooded my mind. Is this the end of my career? Will they file a lawsuit?”
Though he was very concerned about the conversation with his supervisor – “I was ready to defend myself” – the experience was good: “Rather than an inquiry, my supervisor reassured me simply that everything I had done was reasonable, and proceeded to talk about patient suicide being a real emotional ‘occupational hazard,’ an inevitable setback in every psychiatrist’s career. I was given the space to share my anxieties; we talked for an hour.”
That said, he found a “sharing session” with psychiatrists about patient suicides to be very helpful. “Whereas my supervisor helped me to process my own experience, the collective reflections of multiple psychiatrists informed a different perspective – the eerie universality of the multi-faceted emotional journey of a patient’s suicide. Regardless of their seniority or experiences with patient suicide, the guilt, sadness, anger, doubt, and other emotions were strikingly similar.”
He argues that psychiatry trainees need help in dealing with patient suicide.
“Almost half of psychiatry trainees in one review had encountered at least one patient suicide, and the trauma that they experienced was more intense compared to senior physicians. This has to be taken seriously, as there is unfortunately increased suicide risk in those who have experienced suicide, which can described as an interpersonal crisis rather than a personal tragedy. Trainees may be especially vulnerable because of their limited clinical experience with suicidal patients, erroneously perceiving the clinical failure of a suicide to be a personal failure. Their early experiences with suicide may therefore shape their future behaviours and coping skills, and it would be undesirable to leave them to cope in uncertainty and isolation instead of fostering their growth.”
A few thoughts:
1. This is a good essay.
2. The loss of a patient to suicide is difficult for any clinician; during training, as Dr. Oh observes, it’s particularly challenging. Qayyum et al. provide suggestions in a thoughtful paper, “Recommendations for Effectively Supporting Psychiatry Trainees Following a Patient Suicide.” That paper can be found here:
https://link.springer.com/article/10.1007/s40596-020-01395-7
3. Suicide has been discussed in past Readings. In September, we looked at the Furqan et al. paper which considered the impact of patient suicide on psychiatrists, using a qualitative analysis. “Patient suicide is often associated with grief, shock, anxiety and guilt; emotions which are mediated by physician, patient, relational and institutional factors and have important ramifications on psychiatrists’ well-being and clinical practice.” That Reading can be found here:
The full Academic Psychiatry paper can be found here:
https://link.springer.com/article/10.1007/s40596-022-01718-w
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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