From the Editor
After his manic episode, the first patient I treated with bipolar disorder was low in mood for months, able to get out of bed, but not able to work. I remember him sitting in my office talking about feeling overwhelmed. For many people with bipolar disorder, the depressive episodes are long and debilitating. And for us clinicians, these episodes are difficult to treat. (I remember feeling overwhelmed, too.)
Can light therapy help?
The first selection seeks to answer that question. Light therapy, after all, has shown its utility in depression, including for those with a seasonal pattern to their lows. But bipolar depression? In a new Canadian Journal of Psychiatry paper, Dr. Raymond W. Lam (of UBC) and his co-authors do a systematic review and meta-analysis. They included seven papers. “This meta-analysis of RCTs found positive but nonconclusive evidence that light therapy is efficacious and well tolerated as adjunctive treatment for depressive episodes in patients with BD.”
Is the virus racist? In the second selection, we look at a provocative paper from The British Journal of Psychiatry written by Drs. Anuj Kapilashrami and Kamaldeep Bhui (both of Queen Mary University of London). Considering how COVID-19 affects certain groups more than others, they also note that mental illness is more common among minorities, and they argue that: “societal structures and disadvantage generate and can escalate inequalities in crises.” They offer a word of caution: “What is surprising is it takes a crisis to highlight these inequalities and for us to take note, only to revert to the status quo once the crisis is over. ”
Finally, we consider an essay from The New York Times. Lori Gottlieb, a psychotherapist, discusses her practice in a world of pandemic. “Suddenly, her sobs were drowned out by a loud whooshing sound.” She wonders if the toilet is the new couch.
Selection 1: “Light Therapy for Patients With Bipolar Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials”
Raymond W. Lam, Minnie Y. Teng, Young-Eun Jung, Vanessa C. Evans, John F. Gottlieb, Trisha Chakrabarty, Erin E. Michalak, Jill K. Murphy, Lakshmi N. Yatham, Dorothy K. Sit
The Canadian Journal of Psychiatry, May 2020
Bipolar disorder (BD), a common psychiatric condition with a prevalence of 1-2%, is associated with significant impairment in psychosocial functioning and is currently one of the leading causes of disability worldwide. Much of this disease burden is associated with depressive episodes, which dominate the episode course of BD and are more frequent and longer in duration than manic or hypomanic episodes. Bipolar depression is challenging to treat, and there are fewer available treatments for bipolar depression compared to mania. Hence, additional evidence-based treatment options for bipolar depression is a recognized unmet need.
Because many patients with BD are taking mood-stabilizing and other medications, adjunctive nonpharmacological treatments for bipolar depression are particularly needed. Alternative and nonpharmacological treatments are also identified by patients as a research priority. Light therapy, consisting of daily exposure to bright artificial light, is an evidence-based nonpharmacological treatment for seasonal and nonseasonal major depressive disorder (MDD) that has a low side effect burden and can be used by patients alongside other treatments.
So begins a paper by Lam et al.
Here’s what they did:
- They drew from major databases, including Web of Science, with papers published up to June 30, 2019.
- Studies selected: randomized, double-blind, placebo-controlled trials of light therapy in patients with bipolar disorder.
- “The primary outcome was change in clinician-rated depressive symptom score…”
- Secondary outcomes included clinical response and remission.
Here’s what they found:
- They found 7 studies, with 259 patients. All used the same depression scale (the HAM-D).
- Meta-analysis, primary outcome: “Compared with control conditions, active light therapy was associated with a significant improvement in clinician-rated depressive symptoms… representing a small- to-moderate effect size…” See figure below.
- Secondary outcomes: “There was also a significant difference in favor of light therapy for clinical response (odds ratio [OR] = 2.32…).” Remission results weren’t significant. Also, “there was no difference in affective switches between active light and control conditions (OR= 1.30…).”
This is a good study, and the authors do a solid job of pulling together the available literature. Light therapy appears to be helpful (mild to moderate effect size) without creating problems (i.e., no difference in affective switches when compared to controls).
There are clear limitations with the study. As the authors note: “Interpretation of the positive findings are also constrained by limitations of the analysis, including variable quality and heterogeneity of the included studies, variable parameters of light treatment, small sample sizes, short duration of follow-up, and some control conditions (e.g., dim light, low-density negative ions) having potentially active treatment effects.”
Not surprisingly, the authors call for more research: “Given the importance of finding new nonpharmacological adjunctive treatments for BD, priority should be given to further research to improve the evidence base for light therapy. Future studies would benefit from designs that include larger sample sizes, longer follow-up periods, standardization of light therapy parameters, and measures of expectation of response for sham conditions…”
Selection 2: “Mental health and COVID-19: is the virus racist?”
Anuj Kapilashrami and Kamaldeep Bhui
The British Journal of Psychiatry, 5 May 2020 Online First
The COVID-19 coronavirus pandemic has dramatically changed the lives of people across the world, not only directly because of poor health with flu-like symptoms, hospital admission and death, but also indirectly by virtue of restrictions introduced to reduce infection. There are major consequences for businesses, employment, income, mobility, social contact and support, leisure and physical activity, and entrenched long-term health consequences due to isolation, bereavements and fears about infection; for those with existing conditions, there is a greater risk of deterioration and need for intensive care, and the very real possibility of the illness being fatal.
As evidence on risks and burden emerges from different parts of the world, it is clear that COVID-19 is simultaneously an inequality amplifier and a stark reminder of the unequal world we inhabit. On the one hand, it exposes the deep-rooted social inequalities prevalent in society – differentially affecting the more vulnerable, for example, those in precarious employment, migrants and refugees, women in abusive relationships, those in receipt of care services and, in particular, those with existing mental health conditions. On the other, it calls for assessment of the disproportionate burden of the impact along different aspects of social location. Clarion calls to examine differences based on gender have more recently been joined by the need to examine race/ethnicity.
So begins a paper by Drs. Kapilashrami and Bhui.
They make several points:
How to explain racial/ethnic differences in COVID-19 mortality?
“Three key explanations have dominated these studies: genetic and physiological vulnerabilities such as angiotensin-converting enzyme 2 (ACE2) receptor regulation and comorbidities to which minorities are more susceptible; cultural and behavioural factors that make for greater risks of infection and reveal the futility of universal public health messages; and socio-logical and structural conditions that are conducive to generating, sustaining and escalating inequalities.”
Does ethnicity supersede socioeconomic disadvantage?
“Yet the high rates of infection and death of healthcare workers from ethnic minorities raises questions about how ethnicity might supersede (and may act independently from) socioeconomic disadvantage. Interpretation of these data will have to account for greater concentration of ethnic minority populations in London and the West Midlands, where the UK outbreak is concentrated, as well as differentiate between healthcare workers and populations in general for their distinct experiences. For example, health literacy and cultural explanatory models for ‘pandemics’ may influence lay health risk behaviours and actions.”
Is there an NHS underclass?
“Workforce race equality data have revealed inequalities in pay and career progression opportunities, and experiences of discrimination and bullying in the UK’s National Health Service (NHS).”
Inequalities in research fuel inequalities in solutions
“Ethnic inequalities in the experience and outcomes of illnesses, especially mental illnesses, have a long research history of contested explanations and evidence that fails to capture the complexity of life-course adversity, combined with social structures and interactions with pathophysiologies.”
Crisis-driven legislative change furthers inequalities
“These actions, although taken in crisis, reflect underlying structures and prioritisation of one form of crisis (COVID-19) over another (mental health emergency and loss of liberty), with potentially long-term and more catastrophic outcomes.”
When ‘normality’ is itself a state of crisis
“So how has this parlous state of affairs arisen? The virus is not sentient or racist, but our social structures and reactions to crisis reflect values and power structures that continue to discriminate and determine poorer outcomes for some more so than others.”
They close with a series of recommendations:
“To avert the bigger global crisis that looms, at the least we need to gather better data on ethnicity and other aspects of social location. We then need to test preventive policies and systemic interventions to tackle clustered social disadvantage that is exploited in disease scenarios by nefarious viruses and reactive policies and practices that, however well intentioned, sustain and widen inequalities.”
This is an important paper.
The authors ask tough questions and make strong statements. (Substitute “medicare” for “NHS.”)
In recent days, people have been discussing inequities in society. Drs. Kapilashrami and Bhui focus on health outcomes and mental health. The virus isn’t really racist, they note – but then, who is?
Selection 3: “In Psychotherapy, the Toilet Has Become the New Couch”
The New York Times, 30 April 2020
Every day since the onset of the coronavirus outbreak, friends and family have been checking in on me – and not just in the general way that we all seem to be checking in on the people we love. They worry that the kind of work I do might make me sick – emotionally, that is.
As a psychotherapist, I’m on the front lines of the mental health fallout from Covid-19, and those who care about me imagine that I’m being exposed to a toxic daily dose of devastating stories of anxiety and loss of every conceivable kind – loss of loved ones, loss of health, loss of jobs, loss of stability, loss of physical presence, loss of touch, loss of daily routines, loss of weddings and graduations and holiday gatherings, and loss of even the ability to smile at neighbors while walking around the block (with our mouths now covered by masks).
So begins a New York Times article by Gottlieb.
She notes the changes in her practice:
“Last month, when I stopped seeing patients in my office and began conducting virtual sessions from my home, I thought it would seem inappropriate to laugh at something that ordinarily might be funny – like the screen suddenly freezing at an inopportune moment – so I suppressed it, only to learn later that my patients had been holding back their laughter too. We worried that laughing amid so much suffering would seem insensitive.”
And the way patients find private space.
“My patients sheltering at home have had to find a place for their therapy sessions where nobody else can hear them. Sometimes they find privacy in a bedroom or a closet or a car, but often it’s in a bathroom, with my patient sitting on a toilet seat while we speak.
“One day, as a patient was crying, feeling terrified and helpless after talking to her mother in a nursing home thousands of miles away where another resident had contracted the virus, she leaned back and accidentally hit the lever that flushes the toilet. Suddenly, her sobs were drowned out by a loud whooshing sound.”
She goes on to mention that both she and the patient found the moment funny.
Readers can decide if they find Gottlieb humorous (if they do, she apparently has a book). But this piece complements well selections from recent weeks that have mulled our digital moment – in particular, The Globe and Mail essay by Dr. Sediqzadah and the JAMA Psychiatry paper by Shore et al. With so much virtual care, who is left behind? Some of Gottlieb’s patients struggle to find private space, using their bathrooms. My colleagues tell stories of patients retreating to their cars. Ouch.
Abacus Data recently did a poll of Canadians (commissioned by the CMA); they found that 91% of Canadians who connected with their doctor virtually were satisfied. We can’t forget, however, that some had no access to the technology making this possible, and others have been forced into their bathrooms.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.