From the Editor

We often tell our patients about the importance of exercise. But how much exercise? And is this advice really evidence based?

In the first selection from JAMA Psychiatry, Matthew Pearce (of the University of Cambridge) and his co-authors consider exercise and depression with a systematic review and meta-analysis, drawing on data from more than 190 000 people. They conclude: “This systematic review and meta-analysis of associations between physical activity and depression suggests significant mental health benefits from being physically active, even at levels below the public health recommendations.” We consider the paper and its implications.

In the second selection, we look at a new research letter by Natalia Docteur (of the Sunnybrook Research Institute) and her co-authors. In The Canadian Journal of Psychiatry, they consider passes for inpatients, wondering about the effect on length of stay and re-admissions. Interestingly, they conclude: “Overall, passes were associated with poorer post-discharge outcomes including prolonged length of stay and increased psychiatric readmissions.”

Finally, in the third selection, Dr. Amole Khadilkar (of Indigenous Services Canada) writes about his mental health problems. In a deeply personal essay, he notes the challenges of residency and warns against the culture of stoicism. “This is an important lesson to anyone who may be contemplating suicide during what seems like an irreversibly hopeless point in their life. You never know what the next day, the next month, or the next year may bring.”

Please note that there will be no Reading next week.


Selection 1: “Association Between Physical Activity and Risk of Depression: A Systematic Review and Meta-analysis”

Matthew Pearce, Leandro Garcia, Ali Abbas, et al.

JAMA Psychiatry, 13 April 2022  Online First

Prevention of depression requires effective interventions, including modification of established risk factors. Narrative reviews have concluded that physical activity can prevent future depression. One meta-analysis of prospective studies reported that compared with people with low levels of physical activity, those with higher levels had 17%… lower odds of developing depression, while another meta-analysis reported 21%… lower odds when synthesizing 106 associations from 65 studies using diverse exposure definitions. To our knowledge, no study has yet synthesized the evidence to describe the strength or shape of the association by conducting a dose-response meta-analysis using harmonized exposure estimates.

Here’s what they did:

  • They conducted a systematic review and meta-analysis that was built on a search of databases (including PubMed) up to December 11, 2020.
  • “We included prospective cohort studies reporting physical activity at 3 or more exposure levels and risk estimates for depression with 3000 or more adults and 3 years or longer of follow-up.”
  • Data extraction was done (independently) with two extractors.
  • The outcome of interest was depression, including “presence of major depressive disorder indicated by self-report, registry data, or diagnostic interviews.”

Here’s what they found:

  • Fifteen studies comprising 191 130 participants were included. 
  • “An inverse curvilinear dose-response association between physical activity and depression was observed, with steeper association gradients at lower activity volumes.” See the graphs below.
  • Some activity. “Relative to adults not reporting any activity, those accumulating half the recommended volume of physical activity (4.4 marginal metabolic equivalent task hours per week) had 18% lower risk of depression. 
  • Recommended activity. “Adults accumulating the recommended volume of 8.8 mMET hours per week had 25% lower risk with diminishing potential benefits and higher uncertainty observed beyond that exposure level.” 
  • More activity. “There were diminishing additional potential benefits and greater uncertainty at higher volumes of physical activity.”

This is a big paper published in a big journal, drawing on multiple studies. 

The clinical implications? The authors are clear about the benefits of some activity: “Accumulating an activity volume equivalent to 2.5 hours of brisk walking per week was associated with 25% lower risk of depression, and at half that dose, risk was 18% lower compared with no activity.”

The big limitation here: those individual studies relied on self-reporting of exercise.

Still, the study is consistent with other work in the area. For our patients, mention of exercise is evidence based and important. And this paper offers a specific number that we can mention (2.5 hours a week).

The full JAMA Psychiatry paper can be found here:

Selection 2: “Therapeutic Passes and Post-Discharge Outcomes in a Psychiatric Inpatient Unit: A Retrospective Study”

Natalia Docteur, Emilie Norris-Roozmon, Raphael W. Kusumo, et al.

The Canadian Journal of Psychiatry, 15 March 2022  Online First

Deinstitutionalization has shifted Canada’s mental healthcare system away from prolonged inpatient admission in favor of patient autonomy and community-based treatments. In line with this trend, therapeutic passes are utilized as a risk reduction tool prior to discharge. The rationale and administration guidelines that dictate pass use are often unstandardized, despite their ubiquity in clinical practice. Proposed justification includes testing treatment efficacy, gauging safety, observing community integration, promoting coping skills, and providing opportunities to socialize. Nonetheless, there is a lack of evidence to support the clinical utility of therapeutic passes in inpatient psychiatry. This study examined the associations between passes and patient outcomes including length of stay (LOS) in hospital, 6- and 12-month inpatient readmissions, and 6-month emergency room (ER) visits post-discharge. The secondary objective was to quantify the longitudinal contribution of passes on ER visits in patients with ≥2 admissions in one year, termed high utilizers (HUs).

So begins a research letter by Docteur et al.

Here’s what they did:

“The retrospective chart review was performed at an academic research hospital affiliated with the University of Toronto. Data were collected from January 1 to December 31, 2017, using a standardized assessment and data collection protocol. Information on passes was extracted from physicians’ notes. Participants included an undifferentiated adult psychiatric sample with a LOS spanning at least 24 h.”

Passes were coded for those during the day or the evening. Poisson regressions were used as part of the statistical analyses.

Here’s what they found:

  • There were 494 patients, accounting for 596 inpatient admission.
  • Demographics. The mean age was 40.7, and the majority were female (52.7%).
  • “Receiving ≥1 pass, daytime pass hours, and night/weekend pass hours accounted for a small but significant amount of variance in LOS.”
  • “Patients were 3.3% more likely to be readmitted after 6-months with each total pass, and 10.9% more likely to be readmitted after 12-months with each night/weekend pass.”
  • ER visits 6-months post-discharge weren’t influenced by pass factors. 

What could account for this? Are passes well intentioned but ultimately undermining care? After all, a patient on a pass isn’t attending a group session and there is greater possibility of substance misuse than had she or he stayed on the ward. 

Or is the issue that complicated admissions stretch and such patients are then offered passes? The authors used medications at discharge as a proxy measure of illness severity – “suggesting that the relationship between pass factors and LOS existed independently from disease severity.” Interesting.

The full CJP research letter can be found here:

Selection 3: “A Conversation About Suicide During Medical Training”

Amole Khadilkar

JAMA Neurology, 14 March 2022  Online First

‘Amole is a crybaby.’ These words from a grade school teacher represent the moment I learned as a young boy that it’s not okay to feel sadness, a lesson perpetuated in medical training that keeps many trainees from asking for help. Unfortunately for me, this sadness would become a lifelong struggle. In medical school, I experienced chronic depression and at times was consumed by self-doubt and the core belief that I was defective. By the time I graduated, I thought I had overcome my mental health struggles. Residency would be a fresh start, I believed, not realizing how fragile I still was.

So begins a paper by Dr. Khadilkar.

Though he has long-standing problems with mood, he describes a significant decline in mental health in residency. “Shortly after beginning my first year, I became overwhelmed with feelings of extreme worthlessness and inadequacy. I started to think about suicide all the time, but these thoughts were passive, like wishing that I would just disappear. I remembered reading a story about an elderly woman who had been hit by a bus and instantly died, and I felt guilty about wanting that for myself, yet these were distant thoughts.”

And he notes the decision that changed him: “I started pacing my living room, moving from my couch to the ledge of the balcony and back. My once-ambivalent thoughts about dying eventually changed to resolve. On little sleep and feeling completely alone, I made a split-second decision that would change my life forever: I walked to the ledge and jumped, never thinking I might survive.”

He does. “I woke in the intensive care unit, paralyzed from the chest down from a T4-level spinal cord injury I had sustained during my fall. In the years following, I struggled with dark and intense feelings of hopelessness, worthlessness, and self-loathing. I used to cry almost every day, wishing I were not alive.”

The paper also describes some recovery: “I eventually returned to medicine. The positive feedback I received from supervisors and fellow trainees was equally instrumental in my psychological transformation. I could no longer ignore the accumulating evidence that I was indeed worthy and that I had something to contribute. While I had great difficulty embracing my disability, I was also amazed at my ability to adapt and adjust to this ‘new normal…’”

He notes that there are significant problems with the culture of medicine and residency:

  • “Despite alarming rates of depression, only a minority of interns who screened positive for depression reported receiving treatment.” 
  • “Despite evidence demonstrating the biological basis for clinical depression, there is an unspoken attitude that psychiatric disorders are shameful and a sign of weakness.” 
  • “Indeed, more than half of depressed interns expressed concern about what others would think if they received mental health treatment, and 43% felt that their colleagues would have less confidence in them if they sought professional help, a reflection of the stigma associated with mental illness in medicine.” 

He wonders about what could be different. “Now during the pandemic, more than ever, residents are pushed to the limit of their capacity. In the context of a stressful work environment involving excessive work hours combined with lack of sleep, having a sense of connectedness and community serves as a key buffer against psychological and emotional distress. Physicians and trainees alike need to have a meaningful connection with 1 or more people, whether it is a therapist, friend, classmate, coworker, or family member, someone they are comfortable turning to when they are in severe anguish. It can be a lifeline. Increasing education about evidence-based mental health treatments is also necessary, to show that improvements in mood and anxiety are possible with proper intervention.”

Needless to say, this is a powerful essay. It makes a bold and personal case for change. The rawness of his disclosure is striking.

It helps when people like Dr. Khadilkar speak out – but the decision is tough. We should all be grateful that he has put the pen to paper.

The full JAMA Neurology paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.