From the Editor

With the pandemic dragging on, health care workers report more and more burnout; some complain of depression and anxiety.

What could help? Dr. Sam N. Gnanapragasam (of King’s College London) and his co-authors consider an app designed to provide CBT and mindfulness techniques in a new British Journal of Psychiatry paper. The RCT study involves 16 English sites with over 1000 health care workers. They conclude: “our study suggests that the app was of modest benefit with no adverse effects for a sample of HCWs in England.” We look at the paper.

How to respond to the opioid crisis? In a new analysis paper for BMJ, Dr. Robert A. Kleinman (of the University of Toronto) and his colleagues argue for a different approach to the prescribing of opioid agonist therapy, drawing on the changes made in response to the pandemic. “Embracing a more flexible model of buprenorphine-naloxone dosing would allow better alignment of prescribing practices with the needs and preferences of clients.”

And in the third selection, Dr. Devika Bhushan writes about bipolar disorder for the Los Angeles Times. The essay is very personal: the pediatrician, who serves as California’s acting surgeon general and graduated from Harvard, describes her own experiences. As she notes, during her training, she “had a secret.” Now, however, she speaks openly about her illness. “Today, I live with bipolar disorder as a chronic and manageable health condition.” 


Selection 1: “Multicentre, England-wide randomised controlled trial of the ‘Foundations’ smartphone application in improving mental health and well-being in a healthcare worker population”

Sam N. Gnanapragasam, Rose Tinch-Taylor, Hannah R. Scott, et al.

The British Journal of Psychiatry, 6 September 2022

Healthcare workers (HCWs) have faced considerable pressures during the COVID-19 pandemic. This includes work-based ones such as the risk of infection, increased workload, exposure to trauma, social challenges of isolation, increased caring demands and loss of loved ones…

Health systems and organisations have tried to support staff during the pandemic through a range of initiatives, however, most lack evidence. Smartphone applications (apps) are one type of support offered. Evidence available pre-pandemic across different population and occupational groups suggest that smartphone apps can help improve symptoms of general psychiatric morbidity, depression, anxiety and well-being with small effects (Hedge’s g 0.24–0.33), and with moderate effects for insomnia (Hedge’s g = 0.70). The studies notably highlight caution; namely, the need for robust adequately powered trials, and interventions evaluated in the context of a target population, such as HCWs, where evidence is scarce….

So begins a paper by Gnanapragasam et al.

Here’s what they did:

“We conducted a multicentre randomised controlled trial of HCWs at 16 NHS trusts… Participants were randomly assigned to the app or wait-list control group. Measures were assessed at baseline, after 4 and 8 weeks. The primary outcome was general psychiatric morbidity (using the General Health Questionnaire). Secondary outcomes included: well-being; presenteeism; anxiety; depression and insomnia. The primary analysis used mixed-effects multivariable regression, presented as adjusted mean differences (aMD).”

Here’s what they found:

  • “1002 participants were randomised (500:502), and 894 (89.2%) followed-up.” 
  • Demographics. Most participants were women (84.3%), with a mean age of 44.3 years, and were White (91.39%). The majority had a clinical job (60.85%). 
  • Primary outcome. Participants randomised to the app had a reduction in psychiatric morbidity symptoms (aMD = −1.39). See figure below.
  • Secondary outcomes. They had an improvement in well-being (aMD = 0⋅54). Insomnia also showed a reduction (adjusted odds ratio = 0.36). 
  • No other significant findings were found. (!)

“We found a statistically significant reduction in symptoms of general psychiatric morbidity and insomnia as well as an increase in mental well-being. On the other hand, we did not note any statistically significant improvement in symptoms of depression, anxiety, resilience, presenteeism and functioning.”

A few thoughts:

1. This is a timely study – dealing with the mental health of health care workers during the pandemic, and involving a tech intervention. (This paper could only be more timely if it somehow tied to the British royal family.)

2. It was done thoughtfully, with an RCT, over many sites.

3. How did the app work? “The techniques included are: relaxation (for example breathing exercises such as 4-7-8 breathing, diaphragmatic breathing, progressive muscle relaxation), working with thoughts (for example cognitive-behavioural therapy (CBT)-based cognitive restructuring, postponing worry), positive thinking (gratitude journaling on people, achievements, gratitude), mindfulness and mediation, sleep relaxations (guided audios, ambient sounds, soundscapes), working on sleep (CBT for insomnia including sleep hygiene and scheduling), physical health (healthy habits, desk exercises and physical activity programmes), or tips from the experts.”

4. How to understand the results? Well, they weren’t amazing. Consider: the lack of change with regard to anxiety and depression.

5. The authors see potential: They write: “Although the effect of the app on general psychiatric morbidity was small, its potential reach across a whole population of healthcare staff is considerable.”

6. We asked Dr. John Torous (of Harvard University) for his thoughts.

Dr. John Torous

“While the study is impressive in both the offerings by the app and the size of the sample, the use of a waitlist control makes the results very challenging to interpret. When studying app-based interventions, it is best practice to control for the digital placebo effect [1] by offering participants some simple task or activity to complete on their phones [2]. This can help control for expectations around using an app, effects due to simple distractions, or other factors. A simple waitlist is often not appropriate to use anymore, as today most people own smartphones and so can be offered digital resources and apps as part of the comparison group. Control groups need to reflect what the reality of what apps can already offer today and the concern for over-inflation of effect sizes when the digital placebo effect is not considered [3].”




The full BJP paper can be found here:

Selection 2: “Is daily supervised buprenorphine-naloxone dosing necessary?”

Robert A. Kleinman

BMJ, 16 August 2022

Guidelines in many countries, including Australia, Canada, and the United Kingdom, require clients starting buprenorphine to attend a pharmacy or clinic daily and be supervised while taking the medication. However, supervision frameworks were temporarily relaxed in many jurisdictions in response to the need to restrict contacts during covid-19. For example, in Ontario, Canada, dispensing intervals could be extended based on a clinical assessment of clients’ ability to safely manage doses at home, and doses administered at pharmacies did not need to be witnessed. These changes were welcomed by clients, who have previously described freedom from daily attendance for opioid agonist treatment as increasing their independence and sense of ‘normality’ and reducing stigma…

So begins a paper by Kleinman et al.

“Despite this better safety profile, buprenorphine supervision models in Australia, Canada, and the UK remain similar to those adopted for methadone… In Canada, the product monograph for buprenorphine-naloxone states that it ‘must be dispensed daily under the supervision of a healthcare professional, until the patient has sufficient clinical stability.’ A recent synthesis of Canada’s various provincial and national treatment guidelines recommends supervised dosing at treatment initiation and a graduated introduction of take home doses.”

They note that neither France nor the United States have such stringent requirements. They observe the advantages of that approach: “Unsupervised dosing is more convenient for clients, provides greater flexibility and ability to organise their lives, and facilitates adherence with treatment. Clients indicate that the enhanced flexibility from unsupervised dosing makes it easier to obtain work, attend school, take holidays, and manage their daily responsibilities.”

But is unsupervised dosing safe and effective? They review the literature (and we highlight three studies here):

  • Overdoses. “In Rhode Island, US, 29 of 534 deaths from opioid associated overdoses over two years involved buprenorphine or its metabolite, norbuprenorphine. An average of 5377 clients received buprenorphine treatment each month… By contrast, methadone was found in 66 of the 534 people dying from overdose, and it was the only opioid detected in 29, despite methadone being subject to more stringent dosing supervision requirements.” 
  • Buprenorphine as efficacious and effective. “In one study of 329 clients with opioid dependence treated at an emergency department in the US, buprenorphine-naloxone prescribed on discharge without supervised dosing improved treatment retention and reduced self-reported days of illicit opioid use compared with a behavioural intervention or referral.” 
  • Canadian data. “In a Canadian trial with 272 participants, clients with prescription opioid use disorder treated with buprenorphine-naloxone on a flexible supervision framework determined by the treating physician had similar reductions in opioid use to clients treated with more closely supervised methadone dosing.” 

They end with a call to action: “guidelines should emphasise a more flexible approach to supervision and dosing interval, both when starting treatment and for ongoing care. Unsupervised dosing with less frequent (eg, weekly) dispensing from treatment initiation should be recognised as a valid approach for clients who are able to store the medication safely, are not at risk of intentional overdose, are not using combinations of substances in a way that increases the risk of unintentional overdose, and do not have a high risk of diverting or misusing medications.”

A few thoughts:

1. This is a thoughtful paper.

2. Are we so cautious as to cause harm? Dr. Kleinman and his co-authors make a good case. Readers, of course, can draw their own conclusions. That said, the literature on the importance of opioid agonist therapy (OAT) is impressive. A 2021 JAMA Psychiatry paper concluded: “Our findings suggest a potential public health benefit of OAT, which was associated with a greater than 50% lower risk of all-cause mortality, drug-related deaths, and suicide and was associated with significantly lower rates of mortality for other causes.” That Reading can be found here:

3. COVID-19 has forced some service innovation. Is this the silver lining to the pandemic?

The full BMJ analysis can be found here:

Selection 3: “I am California’s acting surgeon general. And I have bipolar disorder”

Devika Bhushan

Los Angeles Times, 26 August 2022

In 2011 I was a third-year medical student at Harvard Medical School. I was on my psychiatry rotation – and I had a secret.

My attending doctors remarked on how well I supported our patients. I was grateful but felt as though my familiarity with and deep empathy for their symptoms and medication side effects were like a neon sign that at any moment could out me.

Using the words ‘bipolar disorder’ in reference to myself was brand-new to me then. The images I had of people with bipolar disorder just didn’t fit with my sense of who I was.

And I felt strong internalized shame around my diagnosis and the mood-stabilizing medications I had started taking.

So begins an essay by Dr. Bhushan. 

The pediatrician notes her first illness experience: “I first noticed mood symptoms in 2009, before starting my second year of medical school. That summer, I had worked at a health center in a Nicaraguan village, far away from those closest to me.

“When I returned to Boston, I remember standing frozen in the grocery store, completely overwhelmed by the vegetable choices in front of me. My mind kept going over and over the options without knowing what to put in my cart.”

Though she saw a psychiatrist, she was misdiagnosed. “For more than two years I tried medication after medication, with no significant relief. The medications also layered what felt like a miserable, activated energy on top of my depression. Eventually they tripped me into mania.”

Looking back, she writes: “Having touched rock bottom and survived, I’m motivated to protect myself at all costs, to fiercely guard the boundaries and care strategies I need to stay healthy. With the right treatments and therapy in place, I hope to be well for the majority of my life.

“I’m now increasingly open about my diagnosis with colleagues and friends. I’m more authentically myself than ever before, having worked toward accepting all parts of me, flaws included. I would never have predicted this in the lowest points of my illness.” 

A few thoughts:

1. Our colleague has written a great essay.

2. It’s brave to publicly disclose a psychiatric disorder as a physician; it’s very courageous to do this when holding public office.

3. A tough comment to read: “On other rotations I’d heard colleagues refer with unfounded prejudice to patients with bipolar disorder. ‘You can’t trust anything she says. She’s probably lying – she’s bipolar.’ I never wanted anyone to diminish the doctor and colleague I could be with stereotypes like these. So I went to some lengths to keep my diagnosis to myself.”

The full LA Times essay can be found here:

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