From the Editor
He didn’t get better despite several medication trials. Exhausted and feeling suicidal, he chose ECT. The change was incredible. When he returned to the clinic after discharge – bright and energetic – a member of the outpatient team didn’t recognize him.
But how can we keep people like my patient well and out of hospital? How strong is the evidence supporting maintenance ECT? Dr. Anders Jørgensen (of the University of Copenhagen) and his co-authors attempt to answer these questions in a new JAMA Psychiatry paper. Drawing on a Danish national database and spanning almost two decades of data, they analyzed outcomes for nearly 20 0000 patients who began ECT, including the risk of hospitalizations. “In this cohort study involving patients who had ECT, continuing ECT was associated with a decreased risk of rehospitalization after the acute ECT series and also associated with reduced treatment costs.” We consider the paper and its implications.
In the second selection, Dr. Joel Paris (of McGill University) ponders the societal increase in psychiatric problems, arguing that social contagion may be a factor. In a new BJPsych Bulletin paper, he focuses on non-suicidal self-injurious behaviour. “When clinical symptoms or mental disorders rapidly increase in prevalence, social contagion should be considered as a likely mechanism shaping changes in the form of psychopathology.”
And in the third selection from JAMA, Dr. Julie B. Trivedi (of The University of Texas System) discusses her depression and its treatment. She notes her hospitalization – and her coming to terms with her illness, as a physician, a parent, and a person. “Today, I am focused on bringing light to topics that are stigmatized, talking about topics like mental health and burnout in health care workers that everyone wants to fix but are without an adequate solution, raising awareness of how to recognize mental health challenges among health care professionals, being an advocate for others, and reminding everyone that help is needed.”
DG
Selection 1: “Clinical Outcomes of Continuation and Maintenance Electroconvulsive Therapy”
Anders Jørgensen, Frederikke Hoerdam Gronemann, Maarten P. Rozing, et al.
JAMA Psychiatry, 18 September 2024 Online First
Electroconvulsive therapy (ECT) continues to be an important and highly efficacious treatment option in acute neuropsychiatric conditions such as severe unipolar or bipolar disorder, catatonia, and treatment-resistant schizophrenia. However, across diagnoses, the risk of relapse after a successful ECT course is high. For example, the recurrence rate after successful ECT for a depressive episode can reach 60% to 80% in the first 6 months after acute ECT if preventive measures are not taken, which will usually include pharmacological strategies.
Evidence indicates that the risk of relapse can be further reduced by continuing ECT. This can involve a gradual tapering of ECT with increasing intervals over 6 months after the acute series (continuation ECT [cECT]) or outright maintenance ECT (mECT), where ECTs are given at regular intervals to sustain remission. The clinical decision to prescribe cECT or mECT hinges on several factors, eg, previous response to ECT, nonresponse or adverse effects to pharmacological interventions, patient preference, and likely also c/mECT accessibility.
Only a few randomized clinical trials of c/mECT have been conducted, indicating a positive effect of c/mECT in the 6 to 12 months after aECT for depression (meta-analyzed in Elias et al). However, importantly, patients included in randomized clinical trials of ECT often do not mirror real-world ECT patients, who are usually severely ill and may face challenges in providing informed consent.
So begins a paper by Jørgensen et al.
Here’s what they did:
- They conducted “a cohort study that included all patients in the Danish National Patient Registry who initiated treatment with ECT from 2003 through 2022.”
- “Continuation ECT (cECT) was defined as the first occurrence of 3 or more treatments with at least 7 days and less than 90 days between adjacent treatments after an aECT series within a 180-day time frame from the first cECT.” “Maintenance ECT (mECT) started on day 181 after the first cECT if the patients continued receiving treatments with intervals of at least 7 days and less than 90 days between adjacent treatments in each session.”
- Main outcome: “The association of c/mECT with subsequent 6- to 12-month risk of hospitalization or suicidal behavior…”
- Different statistical analyses were done, including a Cox proportional hazard regression.
- They also did a cost-effectiveness analysis.
Here’s what they found:
- A total of 19 944 individuals were treated with ECT.
- Demographics. Most were women (61%), with a median age of 55 years.
- ECT experience. 7.7% received c/mECT at any time point; 5.1%, cECT only; 2.6%, mECT.
- Diagnoses. “Compared with patients receiving aECT only, c/mECT patients more frequently experienced schizophrenia (odds ratio [OR], 2.14…) and schizoaffective disorder (OR, 2.42…) and less frequently unipolar depression (OR, 0.56…).”
- Hospitalizations. “In all models, c/mECT was associated with a lower rate of hospitalization after finishing aECT (eg, 6-month adjusted hazard ratio, 0.68… 6-month incidence rate ratio, 0.51…).”
- Suicide. “c/mECT was not associated with suicidal behavior, neither in the first half year (adjusted HR, 0.68…) nor in the second half year (adjusted HR, 0.62…).”
- Cost. “Compared with the periods before the end of aECT, c/mECT was associated with a substantial reduction in total costs (hospital admission days + ECT expenses).”
A few thoughts:
1. This is a good study, addressing a practical question, offering a robust dataset, and published in a major journal.
2. The main finding in a sentence: “c/mECT was infrequently used and associated with a favorable clinical trajectory in terms of the risk of readmission after aECT.”
3. The surprise is that anyone would be surprised.
4. That said, it should be noted how infrequently continuation and maintenance ECT were done. The dataset isn’t North American, of course, but it would likely be similar here. In other words, patients did better with some element of ongoing ECT – yet few received such treatment. How can this be addressed at the system level?
5. Like all studies, there all limitations. The authors note several, including: “The observational nature of the study precludes any definitive conclusions of causality, and the decision to continue ECT after aECT will still rely on factors such as patient preference, the previous response to psychopharmacological treatments, as well as the severity and ECT responsiveness of the acute ECT-treated episodes.” Sensible.
The full JAMA Psych paper can be found here: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2823669
Selection 2: “Social contagion, the psychiatric symptom pool and non-suicidal self-injury”
Joel Paris
BJPsych Bulletin, 4 December 2024
Mental disorders and psychological symptoms can have rapid increases in prevalence over a very short time in both clinical and community populations, and this process is particularly common during adolescence. But rapid changes require an explanation. Since human genomics and neurobiology do not change over a few decades, we need to consider other possibilities.
This article will focus on mechanisms that reflect a process of social contagion. This construct describes how behaviours, emotions and other psychological phenomena spread spontaneously from one person to another within social groups. More simply, it refers to the tendency for people to mimic the behaviour of others in the same network.
So begins a paper by Dr. Paris.
He considers social contagion and other explanations. “Social contagion need not be the only mechanism leading to rapid changes in prevalence. It is also possible that, owing to stigma, some symptoms or behaviours remain hidden until they are too severe to ignore. However, this hypothesis does not account for the fact that the most severe mental disorders, such as psychoses, carry the highest level of stigma but are not associated with major changes in prevalence.” He does add that there could be other explanations, too, including “a change in exposure to risk factors, such as the frequency of psychosocial adversities, could account for increases in specific symptoms. For example, researchers have hypothesised that recent increases in depression and anxiety in adolescents could be due to the effects of social media.”
With regard to social contagion: “Psychiatric symptoms can also be variable over time. Some clinical pictures are common at specific historical periods or in specific social settings, but are later replaced by other symptoms leading to different diagnoses. Thus, ‘hysteria’ was a common diagnosis in the 19th century, but can no longer be found in any diagnostic manual, and even at its height of influence, this syndrome presented at times with sensory changes, at other times with motor symptoms and at still other times as chronic fatigue.”
He focuses on adolescence because it’s “the developmental stage at which contagion is most prominent and peer influence becomes more powerful.” He explores the concept of social contagion and its relationship to the symptom pool. “Shorter provided a strong theoretical framework that helps to account for the process of social contagion in psychiatry. His construct of a ‘symptom pool’ states that at any given historical point, societies tend to favour some symptoms over others as a way of expressing distress. These choices also need to be understood by describing multiple mechanisms of social contagion, with the crucial element deriving from peer influences. Thus, if a patient is in a social network with peers who use substances, who cut themselves… they can be more likely to develop the same symptoms. Moreover, drawing on the symptom pool can be a way of making sense out of psychological distress.”
He reviews the literature on non-suicidal self-injury:
- “A systematic review has documented an important relationship between social contagion and non-suicidal self-injury (NSSI) that suggests how social influences are shaped by a psychiatric symptom pool. NSSI usually begins in early adolescence, shortly after puberty; it is not suicidal in intent but is used to suppress or control negative emotions.”
- “Long-term follow-up studies show that most adolescents with NSSI give up self-harm over time, so that these behaviours can be described as intermittent and experimental.”
- “A large-sale epidemiological study of adolescents in the USA reported a 12-month community prevalence of 7.3% for NSSI in adolescents, and data have been quite similar in other countries.”
“Thus, NSSI is a prime example of social contagion. The internet has been a powerful medium for social contagion of psychological symptoms, and it may have increased the overall level of distress among adolescents. Those with NSSI may find validation from online friends who have the same behaviour and/or from websites that promote it. Adolescents would be less likely on their own to come up with such a way to reduce emotion dysregulation.”
A few thoughts:
1. This is an interesting, provocative, and well-argued essay.
2. When discussing the rise in psychiatric problems – a controversial but increasingly evidence-supported topic, bolstered by studies using national databases – social contagion is seldom mentioned.
3. He discusses non-suicidal self-injury. How far can we take this argument? Could social contagion apply to anxiety? Depression?
4. Is he persuasive? Readers can reach their own conclusions.
5. Dr. Paris is prolific; he has written more than two dozen books. For the record, Fads and Fallacies in Psychiatry is a must read. Your niece may be talking up a cool Lego set, but what she really wants as a stocking stuffer is that book, now in its second edition.
The full BJPsych Bulletin paper can be found here:
Selection 3: “Redefining Resilience”
Julie B. Trivedi
JAMA, 5 December 2024
This wasn’t her first rodeo with depression. It wasn’t her first time seeking out a therapist or trying antidepressants. But this time was different. She had spent the better part of her life training to be a physician, navigating married life, celebrating the birth of her 2 children but also the grieving the loss of 3 pregnancies in between. In the months leading up to her admission, she endured a painful separation and divorce and was trying to raise 2 young girls on her own…
Her Press-Ganey scores started dropping, and she couldn’t keep up with her clinic notes. She stopped socializing. She stopped eating. She could barely get herself out of bed. She thought about taking pills but couldn’t bring herself to do it for fear of the medications not working… She went to see her primary care physician for a routine follow-up visit. She knew. Her physician knew. It was time. She agreed to be admitted.
So begins a paper by Dr. Trivedi.
She notes the uniqueness of the experience. “I’d been admitted to hospitals before as a young child with severe asthma, during the birth of my children, and when I had complications after my first pregnancy. This was different… No electronics. No pens. No jewelry. No caffeine. It took time to want to eat again. Even a piece of toast seemed impossible.”
She gives herself the time and space to heal: she takes a medical leave; she enrolls in a partial hospitalization program with CBT sessions; she then transitions to intensive outpatient therapy. “Among the many issues I had to address, confronting the shame and deep-rooted stigma about mental health that had been part of the culture in which I was raised was an essential part of my healing journey.”
She speaks about being a physician with illness. “As is often the case with many other physicians experiencing depression, I was highly functioning. I always have been. When I experienced bouts of depression before, I still had straight A’s. In fact, the severity of my depression only became apparent when it affected my ability to keep up with outpatient clinic encounters. Like many colleagues, I suffered in silence behind closed doors.”
She notes the challenges in health care. “As a community, health care professionals also must focus on better recognition of depression among clinicians. If showing up to work with a smile on one’s face is the indicator by which someone’s mental health is measured, then frankly, the profession is doomed. If falling behind with outpatient clinic notes is the only evidence of burnout or depression, then the profession is woefully misguided. Discussions about mental health among physicians and other health care professionals must be normalized. How many more stories must be told about colleagues who have died by suicide? How many more stories must be heard about how wonderful Dr So-and-so was and how no one had any idea they were struggling?”
And she discusses her challenges. “For a long time, I did not want anyone to know about my mental health struggles. I feared what could happen to my medical license. I worried about what others would think of me. Julie, the strong, bright, happy person, who broke down. ‘Could I count on her to take on a project? Will she crumble again?’ Ironically, being admitted to the hospital was one of the best things that could have ever happened to me… I am learning how to be more compassionate with myself. I am learning how to be a better parent.”
A few thoughts:
1. This is a moving paper.
2. She writes well about the unique challenges of being a physician who is also a patient. This line is worth repeating: “I am learning how to be more compassionate with myself.”
3. She has pointed comments to make about resilience. “Resilience is not powering through a race with an injured leg. Resilience is not performing major surgery while recovering from major surgery. Resilience is not just changing one’s beliefs about a system when the system only knows how to take and not give back in return.”
4. I still marvel that such pieces are written. For so long, the white coat was assumed to be like Kevlar against illness, to borrow a line from Dr. David Goldbloom.
The full JAMA paper can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2827597
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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