From the Editor
Who has better access to care?
This week, we have three selections. The first is a paper about inpatient ECT – an important topic. And the study – just published in The Canadian Journal of Psychiatry – has interesting findings, including that ECT is not particularly commonly performed (for just 1 out of 10 inpatients with depression). But this new paper by Dr. Tyler S. Kaster (of the University of Toronto) and his co-authors also touches on the larger issue of equity. We consider it – and the questions the study raises.
The second selection is an essay from Policy Options. Drs. Scott Patten (of the University of Calgary) and Stan Kutcher (of Dalhousie University) bemoan the state of mental health data during the pandemic. “There has been a disturbing acceptance of trivial and often misrepresented information, delivered from sub-optimal surveys and problematic interpretation of results.”
Finally, we consider an essay by Dr. Colleen M. Farrell (of Cornell University). She discusses COVID-19 – she is working in the ICU of a major New York City hospital during the pandemic – but also ties to the larger issues of public health, advocacy, and the role of medicine. “As I tend to my patients in the Covid ICU, I struggle to process reality. The attending physicians who are my teachers have few answers; this disease is new to all of us.”
Please note that there will be no Reading next week.
Selection 1: “Patient-level Characteristics and Inequitable Access to Inpatient Electroconvulsive Therapy for Depression: A Population-based Cross-sectional Study”
Tyler S. Kaster, Daniel M. Blumberger, Tara Gomes, Rinku Sutradhar, Zafiris J. Dasklakis, Duminda N. Wijeysundera, Simone N. Vigod
The Canadian Journal of Psychiatry, 2 July 2020
Depression is a leading cause of illness and disability burden worldwide. A particularly challenging clinical scenario for affected individuals is treatment-resistant depression (TRD), which is defined based on nonresponsiveness to initial pharmacotherapy or psychotherapy, affecting more than 50% of individuals with depression. Of the individuals with TRD, only 13.0% and 13.7% achieve remission after 3 and 4 trials of pharmacotherapy. Among treatment options for these individuals, electroconvulsive therapy (ECT) offers great benefits in that it achieves remission in 60% of TRD patients, with some studies finding remission rates as high as 95% for individuals with depression with psychotic features. Furthermore, ECT is extremely effective at rapidly reducing suicidality…
Despite its efficacy in TRD, ECT remains underutilized; indeed, in some regions, its use is declining, suggesting clinical practice guidelines do not always reflect real-world application of important treatments. Furthermore, previous work has pointed out disparities in access to ECT treatment, as evidenced by nonclinical factors such as being unmarried, less educated, black race, and lack of proximity to ECT treatment facilities being associated with lower probability of receiving treatment.
So begins a paper by Kaster et al.
Here’s what they did:
- “We conducted a population-based cross-sectional study in Ontario, Canada…”
- They drew on several databases, including the CIHI Ontario Mental Health Reporting System (OMHRS) that “contains mental health hospital data from all facilities with designated adult inpatient mental health beds.”
- “Using the OMHRS data set, we identified all adult (≥18 years) residents of Ontario admitted for at least 3 days to a designated psychiatric inpatient unit at an Ontario hospital between April 1, 2007, to March 31, 2017.” They focused on those with a diagnosis of major depressive episode, and used the billing code for ECT, to identify those who had this treatment.
- Different co-variables were considered, including age and education.
- Statistical analyses were done.
Here’s what they found:
- “From 75,429 unique hospital admissions for depression, 6,899 involved treatment with ECT (9.2%). This included 53,174 unique patients, of whom 5,043 (9.5%) received ECT during at least 1 admission.”
- “In univariate analyses, patients who received ECT were older, more likely to be female, married or partnered, and living in a high-income neighborhood than individuals who did not receive ECT…” People tended to older on their first admission, and were more likely to have depression with psychotic features.
- Multivariable analysis for sociodemographic factors. “Adjusted odds of ECT treatment increased with age and were also higher for individuals who were married or partnered versus never married, who had achieved any postsecondary education versus high school or less, who lived in a rural versus urban dwelling, who lived in the highest versus lowest neighborhood income quintile, and were eligible versus ineligible for public drug coverage.”
- Multivariable analysis for illness severity. “Adjusted odds of ECT treatment increased with number of prior psychiatric hospitalizations and number of outpatient visits to a psychiatrist in the year preceding hospital admission.” They found adjusted odds of receiving ECT were also higher for individuals with more severe depressive symptoms, more social withdrawal, and worse impairment in their ADLs.
A few thoughts:
- This is a good study.
- Many of the findings aren’t particularly surprising. For example, ECT is performed more often on people who have more severe illness – which makes good clinical sense (given the effectiveness of the procedure). Demographically, older patients are more likely to receive ECT – which also makes good clinical sense (given the robust data supporting this intervention in the elderly).
- Just under one in ten inpatients with a major depressive episode receive ECT. Given how incredibly effective this procedure is, are we under-treating patients?
- Is ECT inequitably available? The multivariable analysis suggests that, for example, educational level is a factor in whether or not a patient is likely to receive ECT. Wow.
The authors write: “In this study, being unmarried, less educated, and living in a lower income area (i.e. enabling resources) each independently reduced the odds that a person would receive ECT, even after accounting for clinical factors and despite all patients being treated in the common environment of a psychiatric inpatient unit in a universal health care system where ECT and all inpatient care is publicly funded. These are important findings because, when access to medical care is determined by enabling resources, as opposed to need factors (e.g., illness severity), this may indicate inequitable access to medical care…”
- How does this compare to the international literature? The authors note that their findings are consistent with a recent Danish study.
- How to explain this? The authors offer several explanations, including: “It is possible that the manner in which informed consent for ECT is obtained may not be suitable for individuals with a lower literacy level or that lower levels of education may reflect less trust in the health care system.” It goes beyond the scope of the paper to wonder how to address these inequities – but, of course, the findings raise big questions.
The Canadian Journal of Psychiatry paper can be found here:
Selection 2: “COVID-19 mental health surveys are not the stuff of effective policy”
Scott Patten and Stan Kutcher
Policy Options, 13 July 2020
The COVID-19 pandemic has produced an urgent need for policy-relevant scientific evidence in Canada, as it has in other countries. Research funding organizations, providers of health data, and the private sector have all stepped up in an effort to fulfill these needs. Mental health’s importance has not been neglected in these discussions, but from the perspective of scientifically robust knowledge generation, the efforts so far appear to have mostly missed the mark.
Some of the problems relate to a ‘one size fits all’ view of mental health. Mental health is a very broad term and encompasses many different emotional, cognitive, and behavioural states. It does not simply mean ‘feeling good all the time.’ Indeed, negative emotional states in appropriate situations are necessary to drive adaptation and are a normal component of mental health. Mental disorders often cause negative emotional states, but negative emotional states are not always due to mental disorders.
So opens an article by Drs. Patten and Kutcher.
They focus on anxiety:
“The hyperarousal response is a natural reaction to a circumstance of threat or danger. This response is universal, and in its healthy manifestations is adaptive, helping the body to prepare for a threatening or dangerous situation (“fight or flight”). Even though anxiety may be experienced as unpleasant, it reflects a healthy emotional response, and does not require treatment. On the other hand, anxiety disorders can be disabling and impairing and require professional attention.
“Determining when psychological or emotional symptoms may represent a mental disorder, adaptive failure or when they are normal responses to challenging circumstances is an important distinction necessary to develop appropriate mental health policy.”
They argue that there are problems with the current approach during this pandemic: “much of the mental health research related to the pandemic has used brief, self-reported questionnaires or scales designed to measure psychological symptoms. Such instruments are unable to make a diagnosis. By focusing on symptoms and not addressing a disorder’s presence or the presence of adaptive behaviours, the data produced from these studies cannot guide policy.”
They close with several recommendations. I highlight three:
- “Measurement must differentiate normal emotional responses to a crisis from problematic psychological states or the presence of mental disorders.”
- “A wide range of unique emotional states (both positive and negative) should be measured, preferably using instruments widely used in previous Canadian health surveys.”
- “Self-report measures of perceived mental health states should not be used, at least not in isolation.”
A few thoughts:
- This is a good essay.
- It’s also very timely. During this pandemic, there have been papers that report on anxiety in different populations (health workers, members of the public, etc.). The data can be striking but lacks a larger context.
- After all, isn’t it normal to feel not normal during stressful times?
The article can be found here:
Selection 3: “Witnessing the Pandemic From the Front Lines at New York City’s Oldest Public Hospital”
Colleen M. Farrell
The Nation, 27 July/3 August 2020
‘This will define your life,’ my attending physician said. It was the middle of an April night in the intensive care unit. Covid-19 was surging through New York City, overwhelming hospitals. Earlier that evening, another of our patients died. Our team had worked desperately to save his life. When I called his wife to give the news, she wailed into the phone in horror and disbelief.
During a rare lull in our work, my attending, a pulmonary and critical care physician, asked how I was holding up. I’m a resident physician in internal medicine, still training to practice medicine independently. I rely on my attendings to guide me through uncertainty. ‘I’m OK,’ I told him, hoping that saying it would make it true.’
So begins an essay by Dr. Farrell.
It’s intensely personal. As she explains, she is on the front-lines: “Before Covid came, I had accepted a three-year fellowship position, which begins this July, to specialize in pulmonary and critical care medicine.”
She discusses the devastation and inequity of the pandemic:
“When the Covid pandemic began, there was talk of it being a great equalizer. But as history would have predicted, that turned out not to be the case. Black and Hispanic New Yorkers 45 to 64 have died from Covid at about three times the rate of their white counterparts. Among the younger population, the disparity is even more stark: Black and Hispanic New Yorkers 18 to 44 have died at nearly five times the rate of their white counterparts. While wealthy New Yorkers have sought safe haven in home offices and vacation homes, the virus has spread rapidly through the city’s essential workplaces, jails, and homeless shelters.”
She thinks much about another public health disaster: AIDS. She had volunteered for an advocacy organization a decade ago.
“What I learned about AIDS, beginning with my time at Project Inform, added vital complexity to that formula. I learned that like a virus, neglect and oppression can kill and that like medication, activism can save lives. I realized all the medical training in the world can still leave doctors powerless in the face of disease. I came to believe that sometimes the most important work a doctor can do is to be present with her patients in their fear and sorrow.”
The essay comes back to her own experiences, tending to people at the beginning of the pandemic, a story of tears and loss.
“I find myself instead longing for the horror and devastation of this crisis to be seen and acknowledged for what it really is. I don’t want to be soothed so much as believed. During the surge, when I had a few days off, I started to question myself and what I had seen with my own eyes. Was it really that bad? Are you sure you’re not exaggerating this? And then a text from a friend working in the hospital, grieving the death of another patient, brought the visceral memories rushing back.”
A few thoughts:
- This is a good essay.
- Dr. Farrell is a beautiful writer.
- Dr. Farrell wrote a paper for JAMA describing her own illness and recovery. If you haven’t read this piece, you should. It was considered in a previous Reading, which you can find here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-dr-farrell-on-her-medical-school-days-her-depression/
The Nation essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.