From the Editor
Is there more mental illness than before? Or is there greater awareness?
Dr. Marco Solmi (of the University of Ottawa) and his co-authors attempt to answer these questions in a new paper for Molecular Psychiatry that focuses on schizophrenia. Drawing on 30 years of data globally, they consider prevalence (how many have the illness), incidence (the number who develop it each year), and the disability-adjusted life-years (the loss of one healthy year of life) using more than 86 000 points of data. They find: “Globally, we show that, from 1990 to 2019, raw prevalence increased by over 65%, incidence by 37.11%, DALYs by over 65%, but age-adjusted prevalence and incidence estimates showed a slight decrease, and burden did not change.” We consider the paper and its implications.
Textbooks, highlighters, and classrooms? The world of medical education is changing. Today, we have AI, sim, and e-learning. In the second selection, we look at the new Quick Takes podcast with Dr. Ivan Silver (of the University of Toronto), former vice president of education at CAMH who marvels at the potential. “This is the renaissance period for health professional education.”
And in the third selection, psychologist Darby Saxbe (of the University of Southern California) writes in The New York Times about ways to help depressed adolescents. Drawing on recent studies showing the failure of school-based psychosocial interventions, she argues for a different approach. “It’s critical to keep pace with the evidence and attend to the first principle of all health care providers: First, do no harm.”
Selection 1: “Incidence, prevalence, and global burden of schizophrenia – data, with critical appraisal, from the Global Burden of Disease (GBD) 2019”
Marco Solmi, Georgios Seitidis, Dimitris Mavridis, et al.
Molecular Psychiatry, 27 July 2023
The global burden of disease 2019 study provides estimates of the prevalence, incidence, and burden of medical disorders, including mental disorders and schizophrenia. GBD 2019 estimates disease burden (i.e., disability-adjusted life years, DALYs…) by summing up the estimated years of life lived with a disability (YLDs, non-fatal burden), and the years of life lost (YLLs, burden related with death). Previous publications have reported on the GBD estimates of schizophrenia, documenting its local or global prevalence, incidence, or burden. According to the 2010 GBD data, although schizophrenia has a lower prevalence than other mental disorders, it globally accounted for >7% of burden associated with mental and substance use disorders overall and across any age group. This result likely represents an underestimate of the real burden of schizophrenia, which would be higher if increased mortality was taken into account… A subsequent report from the GBD 2019 Mental Disorders Collaborators group, narrowing the focus to twelve mental disorders, showed that schizophrenia ranked fifth as a cause of burden in individuals aged 15–24 years, and third (after depressive and anxiety disorders which have higher prevalence) among people (both sexes) aged 25–69 years, and fourth in > 70 year-olds, respectively.
So begins a paper by Solmi et al.
Here’s what they did:
- “GBD 2019 estimates incidence, prevalence, mortality, and disability indices, including YLLs, YLDs, and DALYs associated with 369 diseases and injuries from 204 countries and territories grouped into 21 regions and seven super-regions. Data are collected from censuses, household surveys, civil registrations, and vital statistics, disease registries, health service use databases, air pollution monitors, satellite imaging, and disease notifications, among other sources (in total, 86,249 sources…).”
- “The GBD 2019 defines schizophrenia based on the DSM or the International Classification of Diseases (ICD) criteria…”
- “GBD assembles clinical informatics data, including hospital data, ambulatory (including general practitioner) visits, and health insurance claims. For each GBD cause (diseases), non-primary to primary diagnosis ratios and outpatient to inpatient care ratios are extracted from several regions. The log of the ratios is modeled by age and sex using Meta-Regression-Bayesian Regularised Trimmed (MR-BRT), the Bayesian meta-regression tool…”
Here’s what they found:
- “From 1990 to 2019, schizophrenia raw prevalence (14.2 to 23.6 million), incidence (941,000 to 1.3 million), and DALYs (9.1 to 15.1 million) increased by over 65%, 37%, and 65% respectively, while age-standardized estimates remained stable globally.” See figure below for prevalence.
- “In countries with high socio-demographic index (SDI), both prevalence and DALYs increased, while in those with low SDI, the age-standardized incidence decreased and DALYs remained stable.”
- “The male/female ratio of burden of schizophrenia has remained stable in the overall population over the past 30 years (i.e., M/F = 1.1), yet decreasing from younger to older age groups (raw prevalence in females higher than males after age 65, with males having earlier age of onset, and females longer life expectancy).”
A few thoughts:
1. This is a good and important study, drawing on many sources of data, providing international context, and published in a major journal.
2. The core findings: up, up, and up in terms of incidence, prevalence, and disability.
3. Interestingly, there was variation among countries. Of particular note: those with a low sociodemographic index actually showed a drop of incidence, suggesting continuing and significant difficulties with detection. (!) For the record, the authors compare their findings to a recent systematic review, which reported a higher prevalence of schizophrenia.
4. How to explain rising numbers? Some possibilities: the definition of schizophrenia has changed; detection may have grown better; the disease itself may have become more common. As Dr. Derek Tracy (of University College London) notes in The British Journal of Psychiatry, the topic is “contentious.”
5. The authors argue that we have historically underestimated the impact of schizophrenia. In other words, there isn’t more disease but more awareness of it.
The full Mol Psych paper can be found here:
Selection 2: “The Evolution of Medical Education”
Quick Takes, November 2023
MedEd was once under-valued; today, entire centres focus on faculty development. In this Quick Takes interview, Dr. Silver looks ahead and sees a bright future. He argues that sim and AI will be transformative. Our conversation is also personal, as he mulls his life-long interest in teaching: Dr. Silver applied to both teachers’ college and medical school at the same time.
Highlights from the discussion:
“We can hardly keep up with the innovations now that are going on with technology, both with virtual learning and the latest AI (the ChatGPT movement). It’s another game changer in terms of how we practice, how we teach, how students learn. And we’re grappling at what we need to do with it as it continues to evolve itself. It’s like a very large ball rolling down a hill.”
“I noticed just in a brief search I did recently on PubMed that in the last five months, there have been 40 peer reviewed papers on ChatGPT. I’ve never seen anything like that before in medical education. I’ve never seen the acute interest and response of the medical education community to a new technology like I have with ChatGPT.”
“The emphasis now is on anytime, anywhere.
“CPD was not until recently largely an online exercise. It is now largely an online exercise. At the hospital I worked at, it was 80% online even before the pandemic. It democratizes information. I would like to see it even more democratized… The world is getting smaller and smaller so that we understand each other. So, I would see I would like to see more of a world community of CPD than the local national focus that we have now.”
On advice to our young colleagues interested in education
“Run towards it. Say yes. If you like teaching, if you liked teaching before you went into medical school. And enjoy the interaction as you might with patients. Go for it.”
On his interests in education
“I really got my teaching chops by going to summer camp where I had the opportunity to teach younger children folk dancing. If you can engage eight- and nine-year-old’s for 45 minutes in folk dancing, you can do just about anything else.”
The above comments have been edited for length.
The Quick Takes podcast can be found here, and is just over 28 minutes:
Selection 3: “This Is Not the Way to Help Depressed Teenagers”
The New York Times, 18 November 2023
Ever since the pandemic, when rates of teenage suicide, anxiety and depression spiked, policymakers around the world have pushed to make mental health resources more broadly available to young people through programming in schools and on social media platforms.
This strategy is well intentioned. Traditional therapy can be expensive and time-consuming; access can be limited. By contrast, large-scale, ‘light touch’ interventions – TikTok offerings from Harvard’s School of Public Health, grief-coping workshops in junior high – aim to reach young people where they are and at relatively low cost.
But there is now reason to think that this approach is risky.
So begins an essay by Saxbe.
Saxbe highlights three major studies:
- WISE Teens. Students had 8-weeks of socio-emotional skill training led by psychologists “in which students learn to manage their emotions with the help of tools and principles drawn from cognitive behavior therapy and Zen Buddhism.” She notes the recently published results of 1 071 Australian teenagers. “Compared with the teenagers who got the standard education, the students in WISE Teens reported more depression, more anxiety, more difficulty managing their emotions and worse relationships with their parents. One out of every eight WISE Teens participants appeared clinically depressed after completing the program, compared with one out of every 13 participants who did the regular health classes.”
- MYRIAD. “An even larger study of a school-based mindfulness program, which looked at more than 8,000 British teenagers in more than 80 schools, found that the program did not improve mental health – and in fact led to worse anxiety and emotional problems, and lower levels of mindfulness skills.”
- Climate Schools. “Yet another study published last year, which included some 2,500 Australian teenagers, also found that a mental health program made students more distressed.”
How to explain the results? “The WISE Teens researchers suggest, convincingly, that the teenagers weren’t engaged enough in the program and might have felt overwhelmed by having too many tools and skills presented to them without enough time to master them.”
But the author offers three other explanations.
“By focusing teenagers’ attention on mental health issues, these interventions may have unwittingly exacerbated their problems. Lucy Foulkes, an Oxford psychologist, calls this phenomenon ‘prevalence inflation’ – when greater awareness of mental illness leads people to talk of normal life struggles in terms of ‘symptoms’ and ‘diagnoses.’ These sorts of labels begin to dictate how people view themselves, in ways that can become self-fulfilling.”
Wrong place, wrong people
“They were provided in the wrong place and to the wrong people. The structure of school, which emphasizes evaluation and achievement, may clash with practicing ‘slow’ contemplative skills like mindfulness. And many of the skills taught in these programs were developed for people coping with severe mental illness, not everyday stresses. These tools might not feel applicable to teenagers who aren’t deeply struggling – and on the flip side, their wide-scale adoption might make them seem too generic and watered-down to teenagers who are truly ill.”
Highlighting the problem, not fixing it
“These interventions offered enough information to highlight a problem, but not enough to fix it. As research has repeatedly shown, the most effective therapies involve not just learning skills but also developing meaningful relationships. Even the most structured cognitive behavioral approaches recognize the value of a strong working therapeutic alliance between therapist and client.”
The author offers a way forward:
“The hard truth is that soaring rates of teenage depression and anxiety present a structural problem requiring structural solutions, including the training of a much larger work force of therapists. In school settings, creating more opportunities for young people to build relationships with adults through smaller class sizes and greater access to traditional guidance counselors might move the needle more than specialized mental health curriculums can. Other, more prosaic-seeming changes like starting school later to encourage sleep, decreasing the homework burden and creating more opportunities for play, exercise, music, arts and community engagement are all empirically supported…”
A few thoughts:
1. This is a well-written essay.
2. As I’ve noted before, school-based interventions are trendy. But the task is harder than it seems. The New York City initiative introducing five-minutes of mindfulness daily is unlikely to achieve much.
3. Her comments on prevalence inflation are particularly interesting. “It’s generally a sign of progress when diagnoses that were once whispered in shameful secrecy enter our everyday vocabulary and shed their stigma. But especially online, where therapy ‘influencers’ flood social media feeds with content about trauma, panic attacks and personality disorders, greater awareness of mental health problems risks encouraging self-diagnosis and the pathologizing of commonplace emotions…”
4. School-based interventions have been considered in past Readings, including one that look at MYRIAD. You can find it here:
The full NYT essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.