From the Editor
It’s disabling and difficult to treat.
Can we prevent depression in older adults? Prevention is, of course, an important goal for any psychiatric disorder, reducing distress and health care costs. And the morbidity of major depressive disorder is great. A patient recently commented on his depressive episode: “I wouldn’t wish this on my worst enemy.”
Dr. Michael R. Irwin (of the University of California, Los Angeles) and his co-authors offer interesting data in a new JAMA Psychiatry paper. Focused on elderly adults with insomnia, they provided a form of CBT in an RCT. They find: “In this trial of older adults without depression but with insomnia disorder, delivery of CBT-I prevented incident and recurrent major depressive disorder by more than 50% compared with SET, an active comparator.” We review this big paper and its clinical implications.
Less time with depression, more time for dancing
In the other selection, we consider homeless youth. In a new Canadian Journal of Psychiatry paper, Sean A. Kidd (of the University of Toronto) et al. draw on national survey data. “Youth homelessness is a wicked social problem with variable definitions, multiple determinants, corollaries, and outcomes.” They note the connection to sexual violence and make policy recommendations.
Selection 1: “Prevention of Incident and Recurrent Major Depression in Older Adults With Insomnia: A Randomized Clinical Trial”
Michael R. Irwin, Carmen Carrillo, Nina Sadeghi, et al.
JAMA Psychiatry, 24 November 2021 Online First
Late-life depression (major depressive disorder in adults ≥ 60 years) has a 12-month prevalence that exceeds 10% in community-dwelling, older adults and is a significant risk factor for cognitive decline, disability, medical comorbidity, and all-cause mortality, with suicide rates highest for older men. However, older adults with depression often do not receive diagnosis and treatment, and even with treatment, only approximately one-third achieve remission, with an estimated remaining disease burden of 60%. Effective depression prevention is urgently needed. However, such efforts have been neglected for community-dwelling, older adults, which is striking given that older adults account for nearly 20% of the population in the US, are most vulnerable to depression burden, and report the lowest use of mental health services.
Insomnia, occurring in nearly 50% of persons 60 years or older, contributes to a 2-fold greater risk of major depression. Pharmacotherapy is often used to treat insomnia, although medication provides only temporary remediation and poses risk for daytime effects and dependency. Among the nonpharmacologic treatments for insomnia, a universal behavioral program is sleep education therapy (SET), which targets day-to-day behavioral and environmental factors that contribute to poor sleep. Another nonpharmacologic treatment, cognitive behavioral therapy for insomnia (CBT-I), combines cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation; CBT-I is recommended as the first-line treatment for insomnia disorder.
In patients with residual or concurrent depression, CBT-I can improve insomnia symptoms but has only mixed results for depression outcomes. In adults, not older adults, with subsyndromal depressive symptoms and insomnia, 2 prevention trials found that digitally based insomnia treatment programs reduced depressive symptoms in the short term, although this outcome might be viewed as treatment of subthreshold symptoms. Neither study demonstrated prevention of major depression.
In this selective prevention trial, we present primary end point results during 36 months of follow-up in which we examined whether CBT-I compared with SET, an active comparator condition, would prevent incident or recurrent major depressive disorder, as defined by DSM-5 criteria in community-dwelling, older adults with insomnia disorder and minimal depressive symptoms.
So begins a paper by Irwin et al.
Here’s what they did:
- They conducted an assessor-blinded, parallel-group, single-site randomized clinical trial.
- Inclusion criteria: “adults 60 years or older with insomnia disorder who had no major depression or major health events in past year.”
- People were recruited from July 1, 2012, to April 30, 2015.
- Follow up: 36 months (after the protocol was modified).
- Participants were randomized to 2 months of CBT-I or SET. “The CBT-I contained 5 components: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. Together these components target sleep-related physiologic and cognitive arousal to reestablish restorative sleep function.” SET (or sleep education therapy) was more basic; “SET is an active comparator condition that improves insomnia symptoms but is less robust and durable than CBT-I.”
- “The primary outcome was time to incident major depressive disorder as diagnosed by interview…”
Here’s what they found:
- 291 participants were randomized; 156 to the CBT-I group, 135 to the SET group.
- Demographics. The participants tended to be older (mean age: 70.1), female (57.7%) and White (82.8%).
- Completions. “After protocol modification… 81 (51.9%) of the CBT-I participants and 77 (57.0%) of the SET group completing 36 months of follow-up.”
- “Incident or recurrent major depression occurred in 19 participants (12.2%) in the CBT-I group and in 35 participants (25.9%) in the SET group, with an overall benefit (hazard ratio, 0.51…) consistent across subgroups.” See the figure below.
- “Remission of insomnia disorder continuously sustained before depression event or during follow-up was more likely in CBT-I participants (26.3%) compared with the SET participants (19.3%).”
- “Those in the CBT-I group with sustained remission of insomnia disorder had an 82.6% decreased likelihood of depression (hazard ratio, 0.17) compared with those in the SET group without sustained remission of insomnia disorder.”
A few thoughts:
- This is a good paper.
- There is much to like here: an RCT published in a good journal, with an active comparator condition.
- A three-word summary of the results: the CBT-I worked.
- What’s the potential? The authors write: “Community-level screening for insomnia concerns in older adults and wide delivery of CBT-I–based treatment for insomnia could substantially advance public health efforts to treat insomnia and prevent depression in this vulnerable older adult population.”
- Like all studies, there are limitations. The authors note: “a differential rate of discontinuation in the first 24 months after treatment…” That said, they argue that it didn’t affect the results.
- The paper runs with an editorial by Pim Cuijpers (of the Vrije Universiteit Amsterdam) and Dr. Charles F. Reynolds III (of the University of Pittsburgh),“Increasing the Impact of Prevention of Depression – New Opportunities.” They discuss the study, finding much to like:
The article by Irwin and colleagues… reports a completely new and innovative way of increasing the effect of preventive interventions on the disease burden of depression. Their study was aimed to reduce the incidence of major depression not only in older adults with insomnia but also in those with no current depressive disorder. Insomnia has been associated with an increased risk of developing major depression, but participating in an intervention for insomnia is less stigmatizing than participating in an intervention for depression. This study indicates that an intervention aimed at insomnia can effectively reduce the incidence of major depression in those without a depressive disorder at the start of the intervention, meaning that depression can be prevented effectively without even using the word depression and thus avoid the associated stigma. The study by Irwin and colleagues found that this innovative preventive strategy is effective in older adults, which is important because insomnia and depression are highly prevalent in this population and the uptake of both preventive and treatment services is low. Older adults can therefore benefit considerably from this new approach.
They also note the larger implications: “Insomnia is, however, not only a problem in older adults. Approximately one-third of the general adult population experiences symptoms of insomnia, and approximately 10% meet the criteria for a sleep disorder. Insomnia is also an important public health challenge in the adult population because it is associated with considerably reduced productivity, increased health care use, increased risks of unintentional injury, excess mortality and morbidity, and huge economic costs. Effective interventions for insomnia are therefore highly relevant from a public health perspective. If such interventions can also reduce the incidence of major depression in adults not (yet) meeting the criteria for depressive disorders, the public health importance of these interventions would be considerably further increased.”
That editorial can be found here:
- Both the authors of the paper and the editorial find great potential in CBT-I. Could this intervention be delivered digitally, at least for some patients? Previous papers have weighed that option – potentially very attractive given the low cost and scalability.
Past Readings have considered the benefits and problems of digital mental health, including the recent paper by Torous et al. published in World Psychiatry: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-reading-of-the-week-high-tech-and-low-tech-opportunities-for-mental-health-care/
The full JAMA Psychiatry paper can be found here:
Selection 2: “The Second National Canadian Homeless Youth Survey: Mental Health and Addiction Findings”
Sean A. Kidd, Stephen Gaetz, Bill O’Grady, et al.
The Canadian Journal of Psychiatry, October 2021
While population estimates must be considered cautiously due to methods limitations, it is estimated that there are over 30,000 youth experiencing homelessness in Canada annually. Within this population, there is overrepresentation among subpopulations that experience systematic discrimination such as Indigenous peoples and sexual and gender minorities. Canadian studies suggest that at least two-thirds of this population experience childhood abuse or neglect alongside problematic school trajectories and bullying, family violence and disruption, mental health challenges, and interactions with criminal justice and child protection systems. The majority cycle in and out of varying degrees of homelessness, and homelessness amplifies stressors including the persistent exposure to violence and victimization and a range of deprivations. Outcomes include high levels of mental and physical health problems and high mortality rates, with suicide and drug overdose the primary causes. Efforts to support youth in transitions out of homelessness are routinely thwarted by underfunded and suboptimal services and an underdeveloped intervention evidence base with a few exceptions (housing and housing stabilization, addictions).
So begins a paper by Kidd et al.
Here’s what they did:
- They “analyzed the mental-health-related data from the 2019 Without a Home–National Youth Homelessness Survey that was administered through convenience sampling at 98 agencies serving homeless youth in 49 communities across Canada.”
- “The survey was cross-sectional and self-administered, assessing a range of demographic information, pre- and post-homelessness variables, and mental health indicators.”
- Several scales were used to assess mental health and substance use, including the GAIN Short Screen and the Connor-Davidson Resilience Scale.
- Statistical analyses were done, including logical regression.
Here’s what they found:
- A total of 1 376 youth completed the survey.
- Data was collected from all provinces, spare PEI, with most in Ontario (57.7%).
- Demographics. Participants tended to be male and White, but there were others (for example, 24.9% were Indigenous-identified); the mean age was 20.5 years. They had been homeless on average for 3.6 y
- 35% reported at least 1 suicide attempt, and 33.1% reported a drug overdose requiring hospitalization.
- “Female gender (cisgender) youth reported greater distress and lower resilience…”
- “There was some indication that racialized, non-Indigenous youth and, more specifically, Black-identified youth, appear to be reporting less distress and greater resilience than other youth.”
A few thoughts:
- This is a good paper.
- The above summary doesn’t quite do the full paper (and its nuanced statistical analyses) justice.
- The authors note: “Prestreet sexual violence exposure may be particularly impactful as a risk signal for younger youth while prestreet physical violence may be a stronger risk factor for males.” (!)
- What are the implications for public policy? The authors see several: “The findings of the current study validate those of the first national survey and inform the tailoring of interventions to the unique needs of specific subgroups – such as girls and women, Indigenous, and LGBTQ youth. In particular, a close attention to assessing violence exposure and intervening to reduce violence exposure and address trauma are essential in the effort to better serve those in greatest risk and distress.” Very reasonable.
The full Canadian Journal of Psychiatry paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.