From the Editor
He presented for the appointment with his dog. He told me that getting the chocolate lab – who had been trained by a national, not-for-profit organization – was the best single thing to help him. For the record, the dog was beautiful.
More and more of our patients are turning to animal interventions. But is there evidence to support this trend? In a new The British Journal of Psychiatry paper, Emily Shoesmith (of the University of York) and her co-authors look at dog-assisted interventions (DAIs), describing a review involving 33 papers. “DAIs may show promise for improving mental health and behavioural outcomes for those with mental health or neurodevelopmental conditions, particularly for conditions requiring social skill support. However, the quality of reporting requires improvement.” We discuss the paper and its clinical implications.
In the second selection, John F. Kelly (of Harvard University) reviews the successes of drug decriminalization in Portugal and its failures in British Columbia. In a new Editorial for JAMA Psychiatry, he notes key differences in their approaches. He also mulls the importance of such public-policy experimentation. “As demonstrated in Portugal, persistent, patient, thoughtful analysis, and sensitive, systemic planning is needed to ensure lives are saved and other outcomes improved.”
Finally, we explore the latest news with articles from The New York Times, The Globe and Mail, and NBC News. The topics: one firefighter’s battle with OCD, overdose deaths in North America, and a new mental-health awareness campaign.
DG
Selection 1: “Dog-assisted interventions for children and adults with mental health or neurodevelopmental conditions: systematic review”
Emily Shoesmith, Sophie Hall, Amanda Sowden, et al.
The British Journal of Psychiatry, 14 April 2025 Online First
Animal-assisted interventions (AAIs) have been receiving increasing interest as (complementary) interventions to improve health-related outcomes, especially those focused on mental health, across various age groups. In a health-focused context, AAIs intentionally include animals in health, education and social services contexts for therapeutic or other ameliorative purposes. Health-focused AAIs include animal-assisted therapy, which is goal-orientated, structured, documented and delivered by trained professionals; and animal-assisted activities, which are also goal-orientated but typically based on spontaneous interaction and delivered usually by volunteers and non-specialist trained animals. Although a variety of species (e.g. dogs, horses, small mammals, farm animals) can be involved in AAIs in research and practice, dog-assisted interventions (DAIs) are the most commonly provided and researched type of AAI…
However, DAIs are currently not based on robust evidence. Although findings from generally small randomised controlled trials (RCTs) have been reported, evidence synthesis has unanimously highlighted common methodological problems and a lack of rigour in study design. Key issues include small sample sizes and consequently a lack of statistical power, as well as an absence of manualised intervention protocols and well-designed control conditions.
So begins a paper by Shoesmith et al.
Here’s what they did:
- They conducted a systematic search across several databases including Web of Science.
- RCTs were grouped by “commonly reported outcomes and described narratively with forest plots reporting standardized mean differences and 95% confidence intervals without a pooled estimate.”
- Studies were excluded for several reasons, including if the DAIs were “primarily education interventions with educational outcomes (e.g. reading), as DAIs were only included if they were delivered for health-related and/or therapeutic purposes.”
- The quality of RCTs and DAIs reporting was assessed based on adherence to CONSORT and TIDieR guidelines.
Here’s what they found:
- The initial search identified more than 25 000 papers. After screening and applying the exclusion criteria, 33 papers were included, with 29 RCTs.
- Populations. DAIs were delivered to a variety of study populations, including individuals with dementia (n = 11), schizophrenia (5) and ADHD (2).
- Demographics. Interventions were provided to a variety of age groups, including children (n = 5), children and adolescents (5), adults (8) and older adults (11). Over half of all participants were female (54.9%). Ethnicity wasn’t consistently reported.
- Interventions. DAIs included were described as therapy (79.3%) and activities (20.7%).
- Impact. Positive impacts of DAIs were reported in 57% for social skills and/or behaviour, 50% for symptom frequency and/or severity, 43% for depression, and 33% for agitation.
- Quality. “The mean proportion of adherence to the CONSORT statement was 48.6%. The TIDieR checklist also indicated considerable variability in intervention reporting.”
A few thoughts:
1. This is an interesting study on a hot topic, published in a major journal.
2. The main finding in a sentence: “Owing to small sample sizes, heterogeneity of study quality and outcome measures, and variation in the types of DAI provided (in terms of content and delivery), it was challenging or impossible to interpret results in terms of the potential benefits of DAIs for a specific population.”
3. Even the authors are cautious: “Despite expansion of practice, inconsistencies remain in how DAIs are described, practised, and reported upon within the evidence base.”
4. Dr. Niall Boyce (of the Wellcome Trust) quips on his Substack: “evidence still ruff.”
The full British Journal of Psychiatry paper can be found here:
Selection 2: “Lessons Learned From Drug Decriminalization Remedies in British Columbia”
John F. Kelly
JAMA Psychiatry, 14 April 2025 Online First
In light of a continuing public health emergency resulting from dramatic increases in drug-related deaths during the past 25 years, the seemingly impenetrable wall of universal prohibition laws criminalizing, among other things, possession and use of psychoactive drugs (other than alcohol and cannabis) has begun to fracture as the more traditional drug policy stance has been reevaluated to try to stem a seemingly never-ending and increasing casualty rate, especially in North America, but also internationally… Beginning with Portugal’s decriminalization of all formerly illicit substances in 2001, to Oregon’s state-level emulation of the Portuguese model in the US, and more recently in the Canadian province of British Columbia (BC), a variety of new policy ideas and public health strategies have been implemented and tested with varying degrees of success.
So begins a paper by Kelly.
He details the BC experiment: “With the intention of reducing deaths and hospitalizations in BC due to opioids, stimulants, and MDMA for a 3-year period beginning on January 31, 2023, the Canadian province decriminalized personal possession (but not trafficking) and public use of up to 2.5 g of any combination of opioids, cocaine and derivatives, methamphetamine, and MDMA.”
He describes the data used to assess the experiment: “Population-based data availability through Health Canada and Statistics Canada meant that it was possible to provide estimates of the effects of decriminalization on police-reported drug incidents (eg, arrests) and hospitalizations and deaths pertaining to these substances both before and following the passing of such laws. Gaudreault and colleagues did exactly this. Because of the same type and level of data availability across the province of BC as well as the rest of Canada, where the law was not enacted, the researchers were able to conduct a naturalistic comparative interrupted time series study to examine the impact of the law in BC and compare it to changes across the rest of Canada…”
He describes the findings:
- Police-reported drug incidents. “Following decriminalization, there was a precipitous 57% reduction in drug possession incidents in BC, but no change in the rest of Canada, and there were no changes in drug trafficking incidents in BC after decriminalization (drug trafficking was not incorporated into the decriminalization law and remained a criminal offense).”
- Public health outcomes. “The study found that in the year following the implementation of the decriminalization law, there were no greater increases or decreases in opioid- or stimulant-related deaths or hospitalizations relative to the rest of Canada.”
He offers several reasons for the “disappointing public health impact.” Here, we highlight three:
The drug possession threshold may have been too low.
“Those with more severe drug use disorders who may be using and thus possessing potentially more than the 2.5-g personal use threshold limit would remain criminalized. Consequently, to the extent that criminalization – and drug-related arrests – is responsible for exacerbating health-related harms, continued arrests or anticipation of arrest and criminalization among these heavier users could have kept the overall health-harms figure higher than would have been the case had the law also decriminalized possession of higher amounts – perhaps up to 4 or 5 g per person, more typical among those who exhibit high degrees of tolerance.”
The measured outcomes may not be the best targets for assessing the beneficial effects of decriminalization law changes.
“Decriminalization law change by itself, while arguably a significant piece of the puzzle of what may be needed to resolve the drug crisis, may be too conceptually distal an indicator to associate with acute direct drug-related reductions in overdose deaths and hospitalizations. This may be especially true unless the encounter is coupled with more potent assertive linkage to harm reduction and treatment services. Decriminalization actually may have a bigger impact on helping individuals establish remission and recovery more quickly once they start their recovery journey, as the lack of any criminal felony conviction hangover means doors that would otherwise be closed because of a criminal history (eg, for employment, educational, housing opportunities) can remain open, leading to enhanced recovery optimism and greater traction when people are ready to begin recovery that may lead to better long-term outcomes.”
The BC decriminalization-associated public health procedures in the encounters were more passive than in the Portuguese model and harm reduction/treatment “system readiness” may have been insufficient.
“Without increased availability and accessibility of high-quality harm reduction, treatment, and recovery support services and more assertive linkages to them, decriminalization, while reducing criminal penalties and stigma for addicted individuals themselves, may be insufficient to produce critically important reductions in hospitalization and drug-related mortality. Unlike the successes observed in Portugal where a clinical health assessment was strongly recommended and addiction treatment linkages much more assertive, BC’s approach was much more passive, merely handing out health information without any requirements for a clinical evaluation or any treatment linkage.”
A few thoughts:
1. This is a good Editorial on a highly relevant topic, published in a major journal.
2. The author raises good points. The comment about the “passive” approach of BC is particularly strong.
3. Can Portugal’s success, in fact, be replicated elsewhere?
4. For a longer read on the Portugal model, this Washington Post essay is solid:
https://www.washingtonpost.com/world/2023/07/07/portugal-drugs-decriminalization-heroin-crack/
The full JAMA Psychiatry paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2832775
In the News
Part of an occasional series.
“The Firefighter With O.C.D. and the Vaccine He Believed Would Kill Him”
Joseph Goldstein
The New York Times, 17 April 2025
“There was always an awkward moment for Timmy Reen after the fire was out. Standing amid the smoke and steam and wet debris, the other firefighters would shut off their oxygen tanks and pull off their face masks. But not Firefighter Reen.
“The other guys ribbed him as they poked at ash and drywall, searching for embers. ‘Shut your bottle, Reen,’ they’d say, nodding to his tank.
“In the macho culture of the Fire Department of New York, showing too much concern over lingering smoke was a sure way to stand out. There’s a reason firefighters call themselves smoke eaters.”
This essay, written for The New York Times Magazine, describes in great detail OCD – how common it is, the typical symptoms, the treatments. The essay, though, really comes alive in its description of the journey of one firefighter who, despite great illness, is highly functional at work for two decades. It’s the story of someone with a mental disorder – and a deep passion for serving as a firefighter.
https://www.nytimes.com/2025/04/17/nyregion/firefighter-mental-health-ocd.html
“Overdose deaths are falling across North America. But why?”
André Picard
The Globe and Mail, 1 April 2025
“It feels like a little glimmer of hope in a long-running public health disaster: Overdose deaths, which have increased consistently over the last decade, are now falling sharply in a number of jurisdictions around Canada and the United States.
“Ontario data from December, 2024, to February, 2025, now show that overdose deaths are down 30 per cent from the same period of time a year earlier. There were ‘only’ 656 drug-related deaths reported in the province over those three months, similar to pre-COVID levels. (Overdose deaths soared in the first years of the pandemic.)”
André Picard notes that Alberta and BC numbers are better, too. “Is this a blip, or have we turned the corner on the toxic-drug crisis?”
The article weighs the different approaches of jurisdictions, including decriminalization (BC) and a push against supervised consumption sites (Alberta). It also presents a more complex and nuanced picture: deaths are down in Ontario but up in Quebec.
He wonders if those at highest risk have died already in places like BC. And he makes an important point: it’s not just about the death stats. After all, many who survive are left with long-term problems including brain injury.
The essay has good statistics and is well written. Readers can draw their own conclusions from the data. Picard concludes by noting that now is the time to continue our efforts despite the “good news” – a point that seems pretty reasonable.
“Ice bucket challenge returns with new focus on mental health”
Viola Flowers
NBC News, 19 April 2025
“The ‘Ice Bucket Challenge,’ a viral fundraising campaign that raised millions for ALS research in 2014, has been reimagined by students at the University of South Carolina to tackle a new issue: mental health awareness.
“The Mental Illness Needs Discussion (MIND) club’s #SpeakYourMIND campaign, launched on Instagram in March, adapts the challenge’s format to raise funds for Active Minds, a nonprofit whose mission is to mobilize youth and change mental health norms.Participants pour ice water over themselves, post the videos and nominate others to join – all while emphasizing the importance of speaking candidly about mental health.”
The article discusses a new fundraising campaign with a familiar idea: it borrows from the ALS campaign of a decade ago. The campaign has raised more than $100 000 (USD) and gained endorsements of star athletes. The origin of this mental-health campaign is a university student who lost two friends to suicide; he hoped to raise $500.
The feel-good story raises broader questions. For instance, do such efforts help fundraising in the long run – or are they merely fleeting?
https://www.nbcnews.com/pop-culture/viral/ice-bucket-challenge-mental-health-rcna201978
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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