From the Editor
“For me, it feels like gravity just starts working on my body harder than it works everywhere else in the world.”
So comments a person with depression about his experience. Typically, we describe depression with a list of symptoms from the DSM-5. But how do patients understand their illness? In a new World Psychiatry paper, Dr. Paolo Fusar-Poli (of King’s College London) and his co-authors attempt to answer that question with a “bottom-up” approach. “To our best knowledge, no [depression] studies have adopted a bottom-up approach (from the lived experience to theory), whereby a global network of experts by experience and academics are mutually engaged in co-writing a joint narrative.” We look at the paper and its implications.
In the second selection, from The New York Times, reporter Trip Gabriel writes an obituary for Dr. John A. Talbott, an American psychiatrist who had championed deinstitutionalization, only to later regret the move away from hospital care. Dr. Talbott once wrote: “The disaster occurred because our mental health delivery system is not a system but a non-system.”
At this time of year, The BMJ runs its light-hearted Christmas issue, featuring much British humour. In the third selection, Ruchita Iyer (of the University of Texas Southwestern) and her co-authors describe a deception trial that increased patient satisfaction without increasing physician time. The “nudge” intervention involved: “Chair placement, defined as positioning the chair within 3 feet (0.9 m) of the bedside and facing the bed.”
There will be no Readings for the next two weeks. We will return with force (though no British humour) on 11 January 2024.
All the best in the holiday season.
Selection 1: “The lived experience of depression: a bottom-up review co-written by experts by experience and academics”
Paolo Fusar-Poli, Andrés Estradé, Giovanni Stanghellini, et al.
World Psychiatry, October 2023
Depressive disorders are common worldwide, affecting 3.8% of the general population… Over the past decade, several psychopathological investigations of the essential depressive phenomena have been published. However, these top-down (i.e., from theory to lived experience) publications are limited by a narrow academic focus and a language that may blur the understanding of the lived experience. On the other hand, several reports written by affected individuals describe the subjective experience of depression, but these analyses are limited by fragmented, particular and contextual narratives that do not fully advance the broader understandability of the experience…
This paper is a bottom-up, co-written review of what is like to be depressed. We present a detailed account of depression by drawing on real-world lived experiences and first-person perspective narratives, enriched by phenomenological insights.
So begins a paper by Fusar-Poli et al.
Here’s what they did:
- “We established a collaborative core writing team of experts by experience (patients, their families and carers) and academics (psychiatrists, psychologists, philosophers, and social researchers). This team conducted a comprehensive systematic search of Web of Science, PubMed and EBSCO… We included qualitative studies providing first-person accounts and involving adult participants (≥18 years), published in English, Spanish or Portuguese.”
- “Four independent researchers conducted a thematic synthesis of selected sources based on line-by-line coding of the text in the Results/Findings sections of the papers and generation of a preliminary list of descriptive themes and sub-themes of the lived experience of depression. Further complementary sources, such as autobiographical books written by experts by experience, were included to better characterize the lived experience of depression reported outside the medical field… The material was then shared across the core writing team and preliminarily classified across three overarching descriptive themes…”
- “We promoted a collaborative and iterative sharing and analysis of the preliminary experiential themes and sub-themes in virtual workshops involving a wider global network of experts by experience and their carers…”
- “In a final step, the selection of experiential themes was revised and enriched by adopting a phenomenologically-informed perspective…”
The authors focus on three themes.
Theme 1: The Subjective World of Depression
Feeling overwhelmed. “The most typical experience in depression is struggling with overwhelmingly negative emotions, such as guilt and despair, fear, anger and boredom… ‘One awful thing about my depression was the tremendous sense of guilt that I was unable to attach to any memory, or action or any part of myself.’”
Feeling stuck. “Individuals with depression frequently report low levels of vital energy: ‘My vital energy is depleted.’ This loss of energy, the driving force that pushes us to get involved in the world and directs our lives, can lead to a sense of exhaustion, or even paralysis…”
Theme 2: The Experience of Depression in the Social and Cultural Context
Different cultures. “The subjective experience of depression is deeply influenced by other people and by sociocultural contexts characterized by specific norms and values. For example, the biomedical model, which predominates in Western societies, posits that depression is primarily an ‘inner’ and individual mood disorder. This model is not universally accepted, coexisting and conflicting with other models of depression (e.g., religious), in particular (but not exclusively) in low- and middle-income countries: ‘I’ve seen a psychiatrist and a bomoh [traditional Malay medicine practitioner]. I knew it was not right to see bomoh, but I do believe the bomoh will help me strengthen my faith…’”
Depression in ethnic and racial minorities. “Cultural differences in the experiences of depression are also a significant challenge for ethnic and racial minorities. Their suffering can be exacerbated by a mistrust of health care professionals because of a lack of reciprocal understanding: ‘What do they understand about our ways? I wouldn’t tell them – they would laugh at us and think we were strange, so I don’t tell them’ (South Asian in the UK).”
Theme 3: The Lived Experience of Recovering from Depression
Contrasting attitudes. “Individuals often describe contrasting experiences of recovery from depression, reflecting an ambivalent attitude concerning different components of the process… As the healing processes seem to involve something unpredictable, some patients may prefer to speak about ‘discovery’ rather than ‘recovery’: ‘I think rather than the word ‘recovery’, it’s more ‘discovery’… it’s a journey of discovery that does not necessarily have an end.’”
Ambivalence about medications. “A variety of experiences and a certain ambivalence have emerged in narratives about receiving pharmacological treatments: ‘Depression cannot be cured despite medicine. However, I feel uncomfortable without medicine. I have to take it every day as long as I live, even if the fear of side effects bothers me.’”
A few thoughts:
1. This is an impressive paper, offering a unique look at depression, clearly written (despite the many co-authors) and published in one of the biggest journals in psychiatry.
2. The effort involved was remarkable: involving experts from 11 countries, drawing from studies and other sources, with multiple steps.
3. The above summary doesn’t quite capture the depth of the paper which offers insights and observations that all clinicians should read.
4. For the record, most people with lived experience expressed a need for professional support to accompany them in recovery: “There was always that net underneath me to catch me if I was falling and I couldn’t stop it.”
5. The authors did a “bottom up” approach in describing psychosis that was published last year. That was considered in a past Reading, which can be found here:
The full World Psych paper can be found here:
Selection 2: “Dr. John A. Talbott, Champion of Care for the Mentally Ill, Dies at 88”
The New York Times, 9 December 2023
Dr. John A. Talbott, a psychiatrist who championed the care of vulnerable populations of the mentally ill, especially the homeless – many of whom were left to fend for themselves in the nation’s streets, libraries, bus terminals and jails after mass closures of state mental hospitals – died on Nov. 29 at his home in Baltimore. He was 88…
Dr. Talbott was an early backer of a movement known as deinstitutionalization, which pushed to replace America’s decrepit mental hospitals with community-based treatment. But he became one of the movement’s most powerful critics after a lack of money and political will stranded thousands of the deeply disturbed without proper care.
So begins an obituary by Gabriel.
The reporter describes a remarkable career that spanned more than 60 years. “Dr. Talbott held many of the leading positions in his field. He was president of the American Psychiatric Association; director of a large urban mental hospital, Dunlap-Manhattan Psychiatric Center, on Wards Island; chairman of the department of psychiatry at the University of Maryland, Baltimore; and editor of three prominent journals: Psychiatric Quarterly, Psychiatric Services and The Journal of Nervous and Mental Disease – which he was editing at his death.”
He was probably best known for his early advocacy of deinstitutionalization, which “cut the number of patients in state hospitals by 75 percent, to fewer than 140,000 in 1980 from 560,000 in 1955.” Later, however, he became a vocal critic. In the journal Hospital and Community Psychiatry, he wrote: “The chronic mentally ill patient had his locus of living and care transferred from a single lousy institution to multiple wretched ones.”
During his APA presidency, that organization released its first major report on the homeless mentally ill, describing deinstitutionalization as “a major societal tragedy,” and estimating that up to 50 percent of homeless people had chronic mental illnesses. It argued: “Hardly a section of the country, urban or rural, has escaped the ubiquitous presence of ragged, ill and hallucinating human beings, wandering through our city streets, huddled in alleyways or sleeping over vents.”
“Dr. Talbott exerted influence not as a researcher of the brain or neurological drugs but as a hospital leader, an academic and a member of blue-ribbon panels – including President Jimmy Carter’s Commission on Mental Health – and, especially, through prolific writings. A clear and muscular polemicist, he wrote, edited or contributed to more than 50 books.”
Gabriel writes about his background. Dr. Talbott was born on Nov. 8, 1935, in Boston to a homemaker and a physician. His education: “He graduated from Harvard College in 1957 and received his M.D. from the Columbia College of Physicians and Surgeons in 1961. He did further training at Columbia Presbyterian Hospital/New York State Psychiatric Institute and the Columbia University Center for Psychoanalytic Training and Research.”
A few thoughts:
1. Dr. Talbott had a remarkable career.
2. Like others, he was initially enthusiastic about deinstitutionalization. As Gabriel notes, “Community psychiatry was supposed to be the alternative for patients no longer warehoused in run-down, often abusive state hospitals. A new generation of drugs held promise that patients could live at least semi-independently.” Though Dr. Talbott lived and worked in the United States, deinstitutionalization also took place in Canada and across the west. At the old Queen Street Mental Health Centre, one of the founding hospitals of what is now the CAMH (where I work), the number of beds dropped by 75% over a 20-year period.
3. The reality of deinstitutionalization left Dr. Talbott bitter and disappointed.
4. No wonder. In some ways, we are still living with its problems, including homelessness for many with severe, persistent mental illness.
The full NYT obituary can be found here:
Selection 3: “Effect of chair placement on physicians’ behavior and patients’ satisfaction: randomized deception trial”
Ruchita Iyer, Do Park, Jenny Kim, et al.
The BMJ, Christmas 2023
Etiquette based medicine is a practice that emphasizes good manners and behaviors when communicating with patients, and such practice has been shown to have a beneficial effect on the physician-patient relationship. Sitting at the bedside of a patient is one of the etiquette behaviors that has been associated with improved patient-physician communication, patients’ satisfaction, and trust. In the midst of busy rounds, however, it might be a challenge for healthcare professionals to sit with patients on a regular basis, with previous studies finding that hospitalist physicians sit during one in five encounters with patients…
A nudge is defined as an attempt to predictably influence an individual’s judgment, choice, or behavior by targeting subconscious routines and biases present in decision making. Nudges have been successfully leveraged to modify physicians’ behavior and have resulted in, for example, increased flu vaccination rates and more frequent prescribing of statins. Choice architecture is a specific nudge strategy that influences the social and physical environment in which decisions are made. Choice architecture studies have shown that intentional placement of healthier food options improves health conscious decisions…
So begins a paper by Iyer et al.
Here’s what they did:
- They conducted a “single center, double blind, randomized controlled deception trial” where hospitalist physicians providing direct care services had observed encounters of patients. The deception: the physicians were told that the aim of the study was “to observe variation in practice and to provide medical students on the research team with an opportunity to expand their experience of inpatient internal medicine.”
- “Each patient encounter was randomized to either chair placement (≤3 feet (0.9 m) of patient’s bedside and facing the bed) or usual chair location (control).” See pictures below.
- “The primary outcome was the binary decision of the physician to sit or not sit at any point during a patient encounter.” Secondary outcomes included patient satisfaction surveys: the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).
Here’s what they found:
- 51 internists were followed for 125 patient encounters that were randomized (60 to chair placement and 65 to control).
- Demographics. 51% of the internists were female with an average age of 36 years.
- Sitting. “38 of the 60 physicians in the chair placement group sat during the patient encounter compared with five of the 65 physicians in the control group (odds ratio 20.7…).”
- Risk difference. “The absolute risk difference between the intervention and control groups was 0.55 (95% confidence interval 0.42 to 0.69). Overall, 1.8 chairs needed to be placed for a physician to sit. Intervention was associated with 3.9% greater TAISCH scores (effect estimate 3.9…) and 5.1 greater odds of complete scores on HCAHPS..”
- Time. “Chair placement was not associated with time spent in the room (10.6 minutes vs. control 10.6 minutes) nor perception of time in the room for physicians (9.4 minutes vs. 9.8 minutes) or patients (13.1 minutes vs. 13.5 minutes).”
A few thoughts:
1. This is a clever study.
2. The nudge worked: more docs sat (and patient satisfaction improved).
3. And the nudge was decidedly low tech and inexpensive.
4. The authors note several limitations, including that the study was performed “in a single county hospital with single occupancy rooms, thus our findings may be less generalizable to other hospitals.”
5. This isn’t a serious study – after all, could physician behaviour really be influenced by a chair placement? Hmmm. Is the last laugh on us?
The full BMJ paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.