From the Editor
This month, the Reading of the Week celebrates a big birthday, its ninth. The first Reading was emailed out in September 2014. Many thanks for your ongoing interest and support. I’m looking forward to the next nine years.
Many young people with bipolar attempt suicide. What can be done to help them? In the first selection, Tina R. Goldstein (of the University of Pittsburgh) and her co-authors attempt to answer that question in a just-published JAMA Psychiatry paper. In their RCT involving youth with bipolar spectrum disorder, participants were enrolled in DBT or they received standard-of-care psychological support. “These findings support DBT as the first psychosocial intervention with demonstrated effects on suicidal behavior for adolescents with bipolar spectrum disorder.” We consider the paper and its clinical implications.
In the second selection, journalist and bestselling author Anna Mehler Paperny discusses coercive care in a new Quick Takes podcast interview. Mehler Paperny’s perspective on involuntary care is informed by her writing on the issue – and her lived experience. She worries that public debate may be driven by a desire to address public disorder rather than genuinely prioritizing the well-being of those with mental illness. “Coercive care is having a moment.”
And in the third selection, Dr. Rachel Gibbons (of the UK Royal College of Psychiatrists) considers suicide in a new BJPsych Bulletin paper. She opens by disclosing that three of her patients died by suicide early in her career. She then reviews “truths” about suicide. “In research we conducted, around two-thirds of psychiatrists and other clinicians felt it was their job to predict suicide. Our fantasy that we can do this, and our fear that we can’t, becomes a constant preoccupation in our work, distracts us from providing therapeutic care and closes our hearts to those in distress.”
Selection 1: “Dialectical Behavior Therapy for Adolescents With Bipolar Disorder: A Randomized Clinical Trial”
Tina R. Goldstein, John Merranko, Noelle Rode, et al.
JAMA Psychiatry, 13 September 2023
Up to 50% of youth with bipolar spectrum disorder (BP) attempt suicide, and psychological autopsy studies indicate that of all psychiatric diagnoses, BP imparts the greatest risk of death by suicide in youth. Expert practice parameters for early-onset BP include a combination of pharmacotherapy and psychotherapy. Several psychosocial interventions have demonstrated efficacy for mood stabilization and decreased recurrence risk for youth with BP. Yet to our knowledge, no treatment expressly targets suicidal behavior in this population…
Dialectical behavior therapy (DBT) is an evidence-based psychosocial treatment developed for adults with borderline personality disorder with demonstrated efficacy in decreasing suicidal behavior. Randomized clinical trials and meta-analyses examining DBT for suicidal and self-harming adolescents support the efficacy of DBT over comparator treatments in reducing suicidal ideation, self-harm, and suicide attempts, rendering DBT a well-established treatment for suicidal youth. Yet youth with BP were largely excluded from these trials despite their elevated risk status.
So begins a paper by Goldstein et al.
Here’s what they did:
- They recruited adolescents (aged 12 to 18 years) who were diagnosed with bipolar spectrum disorder from a specialty outpatient psychiatric clinic.
- Participants were randomly assigned to one year of DBT consisting of 36 sessions or standard of care (SOC) psychotherapy. All youth received medication management according to a flexible algorithm. In terms of the DBT: therapists “used the DBT for Adolescents with BP manual based on recommendations by Miller et al on DBT for suicidal adolescents.” In terms of the SOC psychotherapy: therapists were trained in “empirically supported approaches for early-onset mood disorders and BP, including psychoeducational, cognitive behavioral, family-focused, interpersonal, family systems, and supportive therapy…”
- Primary outcome: suicide attempts over one year and mood symptoms. Suicide attempts were measured using two scales: Adolescent Longitudinal Follow-Up Evaluation, or ALIFE, and the Columbia-Suicide Severity Rating Scale Pediatric Version, or C-SSRS.
Here’s what they found:
- 199 youth were assessed for eligibility, with 100 randomized for the study (57 declined to participate).
- Demographics. 85% were female. The mean age was 16.1 years. 74% were White; 17%, Asian; 6%, Black.
- Mood. “Both treatment groups demonstrated significant and similar improvement in mood symptoms and episodes over 1 year (standardized depression rating scale slope, −0.17…; standardized mania rating scale slope, −0.24…).”
- Suicide attempts. “DBT was significantly more effective than SOC psychotherapy at decreasing suicide attempts over 1 year (ALIFE: incidence rate ratio [IRR], 0.32…; C-SSRS: IRR, 0.13…).” See figure below.
- Risk. “Decreased rate of suicide attempts in DBT was moderated by presence of lifetime history of suicide attempt and time (IRR, 0.23…) and mediated by improvement in emotion dysregulation (IRR, 0.61…), particularly for those with high baseline emotion dysregulation (standardized β, −0.59…).”
- Drop outs. There were more DBT participant drop outs (20) than those in the SOC psychotherapy (16).
A few thoughts:
1. This is a good study: an RCT, with a clear intervention, published in a big journal.
2. The main findings in two sentences: “Findings indicate youth who received DBT had fewer suicide attempts over 1 year. Further, suicide attempts declined to a greater extent over time among those receiving DBT compared with those receiving SOC psychotherapy, particularly among participants with a recent and/or lifetime history of suicide attempt.”
4. The authors note several limitations, including about the demographics. “The sample predominately includes individuals assigned female sex at birth, non-Hispanic White, and from middle-class backgrounds – common among treatment-seeking samples but not representative of adolescents with BP.”
5. Are youth in the community likely to receive so much therapy? The authors note that they aren’t. “Although youth randomized to SOC psychotherapy received fewer psychotherapy sessions on average than those randomized to DBT, the SOC psychotherapy treatment dose remains substantially greater than that received by most youth with BP in the community and also greater than that received in the community by this sample in the year preceding study entry. As such, although less intensive than DBT, SOC psychotherapy in this study was more rigorous and intensive than what youth with BP generally receive in the community.” Is such an intervention practical, then? Incorporating DBT would be a significant build – in terms of training and retaining therapists. As well, roughly a quarter of potential participants declined to be involved in the study, perhaps because of the time demands. Would it be possible to offer less intensive forms of DBT or even DBT skills? Would there be more value in targeting some of the patients with bipolar (like those with a history of past suicide attempts) but not necessarily all patients?
The full JAMA Psych paper can be found here:
Selection 2: “The debate over coercive care in mental health”
Anna Mehler Paperny
Quick Takes, September 2023
New York. California. Alberta. Across North America, there is growing interest in getting more people with mental health problems into care – even against their will. Why is this happening? What should we worry about? We discuss the complex balance between patient rights and the need for intervention, and the importance of collaboration between clinicians and patients.
Highlights from the discussion:
On the recent focus on coercive care
“I think it is having a moment. We’re seeing multiple jurisdictions either float the idea or roll out new policies, procedures, legislation that would facilitate increased use of coercive care.
“The why is a little harder to figure it out. On the one hand, you could say that people are seeing a need. Now if there is a need, is it because we’re seeing greater acuity of illness? Or is it because we’re seeing more people affected? Is it due to other forces making people more sick?
“We’re also seeing a distaste for disorder. There’s a desire on the part of governments, fueled by pressure from members of the public to address disorder, to address people on the streets, to address issues around substance use. There’s a heightened need for concern because this is not motivated by even superficially the best interests of the people being coerced. It’s moved by a desire to help the orderly public and their desire to deal with instances of ‘messiness’ in the public eye.”
On the impact of involuntary care
“Being involuntarily hospitalized has a real effect on you. It changes the way you see yourself. It changes the way you see your care practitioners. It changes the way you regard treatment. It certainly changes the way that you see coercive care going forward. And while I understand why I was involuntarily hospitalized on multiple occasions, it also could have really turned me off treatment.”
On a message to psychiatrists
“I’m glad that they’re in this field and that they care about this work. I recognize that people with severe mental illness are often challenging to deal with. That said. the imperative to treat someone as a human being with respect cannot be overstated. That becomes more important when you are engaging in coercion and not less so.”
On her next book
“It’s about police interactions with people experiencing mental illness.”
The above comments have been edited for length.
The Quick Takes podcast can be found here, and is just over 26 minutes long:
Selection 3: “Eight ‘truths’ about suicide”
BJPsych Bulletin, 14 September 2023
Suicide has defined my psychiatric career. I was delighted to get my first consultant job working in an in-patient unit. However, in my second week I had my first patient die by suicide. In my third week I had my second patient die by suicide. In my third month there was a very distressing and violent death by suicide on the ward…
After these tragic deaths, the part of me that thought I could bring something therapeutic to my work as a consultant psychiatrist died. How could I have had three deaths like this? It must have something to do with me. I must have caused or at the very least significantly contributed to them. Between each death, I had no time to reinstate my defences, and after my first 6 months as a consultant I was permeated by the experience of suicide. At the time I felt deeply ashamed, humiliated and alone. In common with many doctors, I continued working… in a state of abject panic, terrified by every patient that I had contact with, incapacitated and unable to make even the simplest clinical decision.
So begins a paper by Dr. Gibbons.
She notes the lack of support. “In 2009, no one around me was talking about suicide; there was no support and no resources to normalise my experience.” So she formed a peer support group. “Gradually, over time, I started feeling that I could breathe again. This peer support group is still running 14 years later…”
The author describes eight “truths.” Here we summarize three:
We will never know why someone died by suicide
“The true reasons why someone has died by suicide will never be known. The person who could shed some light on the situation is no longer present, and even when people have been interviewed after making very serious attempts on their life, they are frequently unclear as to why they did it and can be as shocked and surprised as everyone else by their actions. Only around a quarter of people who die leave a suicide note, and they very rarely give any good reasons for their death. As a result, those bereaved are left in a state of unbearable pain and uncertainty. This can be temporarily mitigated by generating simple narratives where the death is conceptualised as an accident, or the result of their own or others’ negligence.”
Everyone is shocked by the death
“There is much discussion about the predictability of individual suicide; however, many deaths are not preceded by warnings, and frequently those who die have hidden their intent from those around them. For the bereaved, it is important to recognise the death is a ‘bolt from the blue’ (a phrase often used by those bereaved) because very quickly narratives are constructed, as described above, where the death could have been foreseen, mistakes made and blame apportioned. The National Confidential Inquiry finds each year that around 73% of people who die by suicide have not been in touch with mental health services in the year preceding their death. For the 27% who have and have had a risk assessment tool filled in at their last contact, 83% have been rated as no or low risk.”
No one is to blame for someone else’s death by suicide
“When affected by suicide, the capacity to mentalise, to think and symbolise, is lost. In this non-mentalising state, the only option is to think concretely, and shades of grey cannot be conceptualised. ‘Blame’ is a word that comes out of this non-mentalising state of mind. It implies that there is one aetiological factor, and that we know what this is. In reality this could not be further from the truth. Suicide is multifactorial and complex. ‘Responsibility’ is a mentalising word and allows for many different factors to be involved. We can then think about what our responsibility was, and different narratives can be explored, including the part the deceased has played in their own demise.”
The paper closes with comments about suicide and our work. “Concern about suicide cannot just be focused on those working in mental health, giving them the impossible task of predicting the unpredictable and controlling the uncontrollable.”
A few thoughts:
1. This is a thoughtful paper.
2. She is clear on the impact that the suicides had on her: “In retrospect, I now know that I had, and have, a post-traumatic stress disorder, and many other clinicians are also suffering in this way.” (!)
3. The impact of patient suicide on psychiatrists and residents of psychiatry has been considered in past Readings, including a podcast interview with Dr. Juveria Zaheer (of the University of Toronto). She discusses her own experience: “I’ll never forget when it happened.” That Reading can be found here:
The full BJPsych Bulletin paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.