From the Editor
“Sleep is one of the indispensable needs of human beings and is essential for maintaining physical and mental health.”
So writes Yueheng Tang (of the Huazhong University of Science and Technology) and co-authors in a new paper on insomnia. That topic is always relevant; with a third wave and the ongoing stresses of the pandemic, more people than ever seem to be struggling with insomnia. In the past few weeks, I’ve received a flurry of questions from patients and non-patients about remedies for insomnia.
What to make of aromatherapy? It’s trendy – but is it evidence based? In a new paper for the Journal of Affective Disorders, Tang et al. consider aromatherapy which “has a long history in China, and it has been used to strengthen the body and treat diseases since ancient times.” They conduct a meta-analysis, drawing on sixteen articles. They find: “Aromatherapy has a significant effect on improving sleep quality.” We consider the paper and ask: should we recommend this to our patients?
In the second selection, we look at a new podcast that explores Ramadan and its clinical implications. In this Quick Takes episode, I’m joined by Drs. Juveria Zaheer and Zainab Furqan (both of the University of Toronto). They discuss fasting, mental disorders, and offer some suggestions. For example, with drug regiments: “if a medication is dosed twice daily, we can ask if it can be given safely during the interval when the interval between doses is shortened? So can we give it then in the evening or at dawn and then at sunset again? Or can we give it as one dose? And we need to think about the side effects of the medication.”
Finally, in our third selection, a reader writes us. Dr. Suze G. Berkhout (of the University of Toronto) responds to the paper by Drs. Angela Desmond and Paul A. Offit considering the history of vaccines. “The story the authors tell is history as it is written by the victors: emphasizing the hard work and successes of scientists, while failing to acknowledge the ways in which vaccine technologies have also been part of an exclusionary politics of biomedicine.”
Note that there will be no Reading next week.
Selection 1: “The Therapeutic Effect of Aromatherapy on Insomnia: a Meta-Analysis”
Yueheng Tang, Minmin Gong, Xin Qin, Hao Su, Zhi Wang, Hui Dong
Journal of Affective Disorders, 1 June 2021
Drug therapy, psychotherapy, physiotherapy, and cognitive-behavioral therapy for insomnia (CBTI), are commonly used treatments for insomnia currently. However, as the number of insomnia patients increases rapidly, more feasible treatments are needed for insomnia. Recently, more and more studies have found that aromatherapy is one of the non-drug treatments to improve sleep quality. Aromatherapy has a long history in China, and it has been used to strengthen the body and treat diseases since ancient times. Aromatherapy works by inhaling, massaging, bathing and other ways to apply aromatic extracts to the human body. Compared with drug therapy, aromatherapy is more economical, simpler to use, and has fewer side effects. It is widely used in relieving stress, improving sleep disorders, and the treatment of depression, anxiety, etc….
There are many clinical studies on the use of aromatherapy in the treatment of insomnia. The results show that aromatherapy has a significant effect on improving sleep quality in different populations through different ways, but different studies are different in application fields, types, duration, and so on, the quality of these studies is also uneven. At present, there is no systematic comprehensive analysis of randomized controlled trials (RCTs) investigating the efficacy of aromatherapy in the treatment of insomnia. Therefore, this paper con- ducts a meta-analysis of the therapeutic effect of aromatherapy on insomnia, in order to verify the therapeutic effect of aromatherapy on insomnia and to provide guidance for the clinical use of aromatherapy in the future.
So opens a paper by Yang et al.
Here’s what they did:
- They performed a literature search of several databases including Pubmed.
- “The interventions consisting of all types of aromatherapy (inhalation, massage, skin application, capsule preparation, etc.).”
- Exclusion criteria included the aromatherapy being combined with other therapies (like music therapy).
- The outcome measure was the Pittsburgh Sleep Quality Index (PSQI).
- Statistical analyses were done.
Here’s what they found:
- “This meta-analysis included 19 comparisons involving a total of 1346 insomnia patients.”
- “These studies were published between 2014 and 2020 (of which 18 (94.74%) occurred in the past five years), mainly in Iran, China, Turkey.”
- “Each comparison included 30 to 158 patients (6 comparisons for adult individuals, 6 for cancer patients, 3 for cardiac patients, 2 for postpartum women, and 2 for inpatients).”
- “The aromatic substances used in these studies include lavender, rosemary, orange peel, tea tree, peppermint, blended, and mixed essential oils. The intervention duration ranges from 3 days to 8 weeks…”
- “The results showed that aromatherapy had a significant effect on improving sleep quality (WMD: -2.52…).” See below.
- The inhalation group did better than the massage group.
A few thoughts:
- This is a good paper.
- This is a timely paper.
- They found a robust result, and one that does favour the use of aromatherapy, especially in the form of inhalation.
- Like all studies, there are limitations; the authors note the need for use of PSQI, a reasonable scale choice, but one that would exclude some studies.
- A meta-analysis is only as good as the papers it draws from. A quick glance at these studies shows great diversity, including papers considering university students, burn patients, and people with cancer who are receiving chemotherapy; none of the participants were from North America. The journals themselves are very diverse, as well. The authors comment on this: “It is worth mentioning that the heterogeneity of this meta-analysis was high, and the sensitivity analysis of the included studies showed high stability…”
- The authors did a sub-group analysis and they found: “Different intervention duration does not seem to have a significant effect on the efficacy of aromatherapy.”
- So are we persuaded? Maybe not. The sub-group analysis is worth consideration, for example – any exposure to an intervention (aromatherapy) was more important than the duration of that exposure. That’s an unusual finding. It’s difficult to argue against a low-cost intervention but there seems to be more robust evidence for certain medications and other interventions (sleep hygiene, CBT-I, etc.).
The full paper can be found here:
Selection 2: “What every physician should know about Ramadan and its clinical implications”
Juveria Zaheer and Zainab Furqan
Quick Takes, 12 April 2021
Ramadan is a period of spiritual significance for Muslims around the world; some 80% of Muslims in North American fast during Ramadan – meaning that they abstain from food, water and sexual activity from dawn till sunset. As clinicians, what should we know about Ramadan and its clinical significance? In this podcast, I speak with two guests: Dr. Juveria Zaheer (a CAMH psychiatrist) and Dr. Zainab Furqan (a senior resident, joining UHN as a psychiatrist in July).
I highlight from the discussion:
On culturally safe care
Dr. Furqan: “Culturally safe care acknowledges the reality that people that we’re seeing come from very different backgrounds (cultural, spiritual, socioeconomic), and recognizes that we as clinicians have our own biases and assumptions.
“Culturally safe care means creating a space where the patient can come as a whole person with all their diverse backgrounds and identities and have their needs met…”
On a typical day during Ramadan (and its implications for mental disorders)
Dr. Furqan: “People wake up often at around 4:00 or 4:30 AM before the sun rises. They have a meal and then they often go back to sleep for a few hours before getting up and starting their day. And then during that day, they’re not eating or drinking. And then at night when the sun sets, they have a meal that we call Iftar (breaking of the fast) where they can eat again.
“And so often sleep patterns are very much changed. And so for illness like bipolar disorder – where sleep disturbances can trigger manic depressive episodes – this becomes particularly relevant.”
Dr. Zaheer: “Alcohol use is is forbidden. But many Muslims do engage in alcohol use. And so if you stop alcohol use suddenly during Ramadan, you may be at risk for withdrawal.”
Dr. Furqan: “It will be really important for clinicians to advise people that there is a risk of lithium toxicity with prolonged periods of dehydration or fluid restriction. And so especially when fasts are very long, caution needs to be exercised.”
On exemptions from fasting
Dr. Zaheer: “In Islam, you can get a medical exemption from fasting. So Imams (spiritual providers) will say, ‘go talk to your doctor.’ And we want to do no harm. So we’ll say that they don’t have to fast. But we need to remember Ramadan is a period of social connectedness, of reflection, of great meaning.”
On a general approach to patients
Dr. Zaheer: “‘I know Ramadan is coming up, what are your thoughts on the medications you’re taking?’ I think just that opening of a conversation goes so far. And it’s really important to consider it to be a conversation. One of the really important places to start is to ask someone, ‘do you generally fast? Were you planning to fast this year? What does fasting mean for you?’ To try to understand someone’s cultural context before discussing medications or diagnosis…”
(The above answers were edited for length.)
The podcast can be found here, and is just over 22 minutes long:
Selection 3: Letter to the Editor: “A History Written by the Victors of Science Doesn’t Tell the Whole Story”
Re: “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
I was pleased to see your inclusion of the NEJM commentary by Drs. Angela Desmond and Paul Offit in the most recent reading of the week, and your comments regarding their piece. The authors provide a gloss of the history of vaccine development, highlighting major accomplishments and turning points in the pathway of disease eradication. As you point out, they do not discuss vaccine hesitancy or the challenges of vaccine access for those who are in vulnerable communities. What the authors do offer to this end is to say that work needs to be done to build trust and ensure equitable benefits from vaccination. While this is of course true, Desmond and Offit’s framing of the challenges is limited, insofar as it situates the problem as one that occurs after a vaccine is produced – as though the scientific work of developing and testing vaccines has no relevance on issues of equity, justice, or the structural reasons for concerns that are flagged as vaccine hesitancy.
The story the authors tell is history as it is written by the victors: emphasizing the hard work and successes of scientists, while failing to acknowledge the ways in which vaccine technologies have also been part of an exclusionary politics of biomedicine. A more complete, more quotidian history of vaccines would tell us, for instance, how HeLa cells were central to the creation of the polio vaccine, which required massive amounts of the immortal cell line in its evaluation (Turner 2012). HeLa cells are so named for Henrietta Lacks, a Black woman who hailed from an impoverished community in Virginia. When she sought care for what was ultimately cervical cancer, the cell line was created from pieces of her cervical tumour without either her knowledge or permission by the physicians involved in her care (Skloot 2010). HeLa cells have been central to numerous scientific breakthroughs and medical innovations, including the foundational study demonstrating the mechanism of SARS-CoV-2 infectivity in humans (Zhou et al. 2020). And yet the proceeds of innovations (be they material or social capital) have arguably not circled back to the kin or community of Henrietta Lacks. Moreover, the non-consensual use of BIPOC community members’ biological matter for science has continued through the latter parts of the twentieth century (TallBear 2007).
The last hundred years of vaccine (and other intervention) trials is likewise a history marred by injustices. In Canada, the 1930s BCG vaccine trials backed by the National Research Council and Indian Affairs tested the vaccine on Indigenous children from the Qu’Appelle reserves while failing to improve housing, water, and food security on reserve—interventions shown by the Qu’Appelle Demonstration Health Unit to cut tuberculosis rates in half in the years leading up to the trial. These interventions were seen as more costly than a successful vaccine would be. Nonetheless, an argument of potential benefit to the study population justified the potential risks (Lux 1998). In more recent history, controversy emerged in relation to single dose AZT trials for the prevention of vertical transmission of HIV (Wendler et al. 2004). While these were not vaccine trials, the intervention was studied in the global south where, it was argued, there was neither the infrastructure nor the funds to provide standard care, which consists of long-term combination antiretroviral therapy. Although a standard therapy existed at the time and was known to dramatically decrease vertical transmission of HIV, it was inaccessible to the population in question, given the trial locations. In both of these instances, racialized socioeconomic disparity has been the driver of equipoise.
SARS-CoV-2 vaccine trials have been underway for months now, and many of these have flagged issues of ethnoracial diversity amongst trial participants as essential to attend to, given the disproportionate impacts of COVID-19 on BIPOC communities. The UCSD trial, for instance, has focused its efforts in National City, which has a 63.8% Latinx population and the second-highest COVID mortality rates in San Diego county (www.nbcsandiego.com). Calls to diversify trial populations fall short though, when the trials rely on structural disadvantages that are not redressed through known, effective public policy interventions (Varma et al. 2021). Medical research in postcolonial contexts often sees scientific practices and ethical standards travel in divergent ways – such research invites and supports investigations that would be considered unethical in another socioeconomic context (Crane 2010). These are the histories that drive issues such as vaccine hesitancy and they demand to be grappled with as issues that suffuse the whole of the scientific process.
Suze G. Berkhout, MD, PhD
University of Toronto
Crane J. Adverse events and placebo effects: African scientists, HIV, and ethics in the ‘global health sciences.’ Social Studies of Science. 2010; 40(6):843-870.
Lux M. Perfect Subjects: Race, Tuberculosis, and the Qu’Appelle BCG Vaccine Trial. Canadian Bulletin of Medical History. 1998;15:277-295.
Skloot R. The Immortal Life of Henrietta Lacks. 2010; New York: Random House.
TallBear K. Narratives of race and indigeneity in the Genographic Project. J Law Med Ethics. 2007 Fall;35(3):412-24.
Turner T. Development of the Polio Vaccine: A Historical Perspective of Tuskegee University’s Role in Mass Production and Distribution of HeLa Cells.J Health Care Poor Underserved. 2012;23(4):5-10.
Varma S, Vora K, Fox K, Berkhout S, Benmarhnia T. Why Calls to Diversify Trial Populations Fall Short. Med. 2021; 2:25-28.
Wendler D, Emanuel EJ, Lie RK. The standard of care debate: can research in developing countries be both ethical and responsive to those countries’ health needs? Am J Public Health. 2004;94(6):923-928.
Zhou P, Yang XL, Wang XG, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020; 579: 270–273.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.