From the Editor
Even our language has changed. Last winter, we didn’t think about lockdowns and the term social distancing was confined to sociology textbooks. The world is different.
And in our new reality, we can ask: How has the pandemic affected mental health? While there have been many small surveys (and much speculation), until now we have lacked a major, large scale survey.
This week, we look at a new paper from The Lancet Psychiatry. Matthias Pierce (of the University of Manchester) and his co-authors draw on the UK Household Longitudinal Study – a large, national survey that offers us pandemic and pre-pandemic data. The good news: “Between April and October 2020, the mental health of most UK adults remained resilient or returned to pre-pandemic levels…” but they also found that one in nine people in the UK “had deteriorating or consistently poor mental health.” We consider the big study and discuss resilience with an essay by Dr. Richard A. Friedman (of Cornell University).
In the second selection, we consider an essay by Dr. David Goldbloom (of the University of Toronto) on how the pandemic has changed psychiatry. He focuses on the biggest change: that is, the embrace of virtual care. He begins: “We are all telepsychiatrists now…” He notes the advantages and disadvantages of the transformation. While some providers express ambivalence, he writes: “What counts, ultimately, is what helps our patients.”
Finally, a reader responds to our take on The New England Journal of Medicine paper on psilocybin. Dr. Craig P. Stewart (of Western University) writes: “One area I did not see mentioned in the psilocybin paper review was a discussion of confirmation bias, which I believe also should be mentioned to contextualize the results.”
Selection 1: “Mental health responses to the COVID-19 pandemic: a latent class trajectory analysis using longitudinal UK data”
Matthias Pierce, Sally McManus, Holly Hope, et al.
The Lancet Psychiatry, 6 May 2021
Marked declines in population mental health were observed in several countries after the onset of the COVID-19 pandemic. In eight countries (China, Spain, Italy, Iran, USA, Turkey, Nepal, and Denmark), relatively high rates of anxiety disorder, depression, post-traumatic stress disorder, psychological distress, and stress have been reported since the start of the pandemic. Using a random sample with pre-pandemic data, we previously reported that the prevalence of clinically significant levels of mental distress was 50% higher than before the pandemic a month after lockdown measures were introduced in the UK (April, 2020).
As the pandemic develops, interest is turning to how changing circumstances have affected people’s mental health and whether early indicators herald persistently poor mental health and subsequent increasing unmet clinical need. Studies assessing mental health trends since the beginning of the pandemic have reported symptoms of anxiety disorder, depression, and loneliness steadily improving since May, 2020. However, these studies have methodological problems relating to sampling, adjustment, and mental health measures. First, these studies used convenience samples, which means they cannot be adjusted properly for sampling bias and are thus considered poor tools for estimating population statistics. Second, many studies have considerable attrition over time, and individuals with poor mental health are more susceptible to dropout, resulting in an overoptimistic assessment of mental health trends. Third, many studies used mental health indicators that were limited to symptoms occurring only in the past week. A clinical diagnosis of anxiety disorder or a depressive episode require symptoms to be consistently present for at least the past 2 weeks – otherwise, fluctuation in psychological distress commonly seen in healthy populations might become overstated as clinical illness. Most studies do not have comparable pre-pandemic data, which is important to understand whether the acute increases in mental distress in the population returned to pre-pandemic levels after the initial shock of its onset. Furthermore, the average trajectory for the whole population could mask varied responses to the pandemic – some groups might have remained or become increasingly vulnerable.
So begins a paper by Pierce et al.
Here’s what they did:
- “This study was a secondary analysis of five waves of the UK Household Longitudinal Study (a large, national, probability-based survey that has been collecting data continuously since January, 2009) from late April to early October, 2020 and pre-pandemic data taken from 2018–19.”
- Participants were 16 and older.
- Mental health was assessed using the 12-item General Health Questionnaire (GHQ-12).
- The authors used latent class mixed models to “identify discrete mental health trajectories and fixed-effects regression to identify predictors of change in mental health.”
Here’s what they found:
- 19 763 adults participated.
- Demographics: the majority of participants were women (58.1%) and minority ethnic groups represented 17.5%.
- “Mean population mental health deteriorated with the onset of the pandemic and did not begin improving until July, 2020.”
- “Latent class analysis identified five distinct mental health trajectories up to October 2020.” Most participants had either consistently good mental health (39.3%) or consistently very good mental health (37.5%). And there was a recovering group – 12.0% of participants who had worsened mental health but returned to pre-pandemic levels.
- There were two groups that fared less well. One group had poor mental health throughout the observation period (4.1%); the other had a decline (7.0%). See figure below.
- “These last two groups were more likely to have pre-existing mental or physical ill-health, to live in deprived neighbourhoods, and be of Asian, Black or mixed ethnicity. Infection with SARS-CoV-2, local lockdown, and financial difficulties all predicted a subsequent deterioration in mental health.”
A few thoughts:
- This is a good study.
- While other surveys have noted that some people have struggled during this pandemic, the latent class analysis is interesting and thoughtful. Another strength of the paper: the data isn’t drawn at one point, but through the first six months of the pandemic.
- A seven-word summary: Most people did fine but not everyone.
- Are there policy implications? The authors certainly think so. They write: “Our findings have important implications for mental health policy makers and service planners. Many individuals with deteriorating mental health might be existing service users whose symptoms have been worsening over time. As the pandemic has progressed, socioeconomic effects have emerged as strongly associated with declining mental health… Therefore, socioeconomic policies should be central to post-pandemic recovery programmes to address the mental health effects seen in low-income communities and the further likely effects of school closures, financial hardship, job insecurity, and local restrictions.”
- Like all studies, there are limitations. Here’s one: “Although the GHQ-12 score is a validated measure of mental health, it is not equivalent to a clinical diagnosis.” To put this differently, they are commenting on mental health, not mental disorders.
- And the data is drawn from the UK. Would it be different in Canada, where our lockdowns have been less far reaching?
- The paper does touch on the larger topic of resilience. Dr. Richard A. Friedman writes an interesting essay in The New York Times, “You Might Be Depressed Now, but Don’t Underestimate Your Resilience.”
Dr. Richard A. Friedman
He opens on an optimistic note: “While the pandemic has undeniably caused extraordinary stress and sadness, research on human resilience suggests that people will recover from the trauma of the pandemic faster than many believe.”
Studies suggest that up to about 90 percent of Americans have experienced a traumatic event, yet the prevalence of PTSD is estimated to be 6.8 percent. So while exposure to traumatic events is common, only a small minority of people develop PTSD as a result. Follow-up studies of trauma victims with PTSD in the general population show that the symptoms decrease significantly within three months after trauma and that about 66 percent of those with PTSD eventually recover.
The essay is here:
The full Lancet Psychiatry paper can be found here:
Selection 2: “The sudden shift to online psychiatry has brought unexpected benefits”
The Globe and Mail, 6 May 2021
We are all telepsychiatrists now, connecting with patients through telephones and a variety of secure televideo links. A year ago, we were not.
The first published report of televideo psychiatry for people in underserved communities appeared in 1957. By 2017, only 7 per cent of Ontario psychiatrists used this medium to connect with patients. Then COVID-19 arrived. And while the unprecedented rapid development of multiple vaccines has been the most exhilarating scientific advance engendered by the pandemic, it has occurred against a backdrop of less dramatic but still significant changes in health care delivery. Televideo hesitancy has resolved faster than vaccine hesitancy.
So begins an essay by Dr. Goldbloom.
He notes that there is nothing new under the sun:
It constitutes the revival of the house call, for example. Such visits were an essential component of the clinical routine of my pediatrician grandfather and father, and one I occasionally incorporated into my own practice as a psychiatrist. New technology once again affords us clinicians the opportunity to see where and how our patients live, to meet their families, friends and pets, in an environment where they often feel more at ease.
And while enthusiastic about the change – he notes the advantages to patients including convenience: “their encounters with us do not demand extensive travel, time off work, child care and inevitable waiting” – he also sees drawbacks:
Patients without access to smartphones and computers can be left behind – people who are homeless, poor or live in settings without sufficient broadband access. There will always be a need for in-person services, and there will always be people who do not feel ‘connected’ through the web.
What will care look like after the pandemic?
I suspect a hybrid model will evolve, with patient choice at the centre. However stressful the pandemic has been, it has triggered radical changes in care delivery, catalyzing the uptake of opportunities that have had a long enough gestation. I have no doubt they will endure.
A few thoughts:
- This is a good essay.
- Dr. Goldbloom comments on a major change in care delivery. In the chaos of this moment, we may not fully appreciate the transformation.
- Return of the house call? Dr. Goldbloom’s makes a nice observation: that the virtual visit is, in a sense, a return to the house call. A patient story from my practice: I remember speaking to a young patient early in the pandemic who had a painting visible in the background. When I asked, the patient talked about the importance of the art (it had been a gift). There was an intimacy about the moment that would have been completely absent with an in-person visit in my (artless) office.
- Dr. Goldbloom’s new book is now out. We will be running an excerpt in the coming weeks. You can find more information here:
The essay can be found here:
Selection 3: Letter to the Editor: “Psilocybin and Confirmation Bias”
Re: “Trial of Psilocybin versus Escitalopram for Depression”
Robin Carhart-Harris, Bruna Giribaldi, Rosalind Watts, et al.
The New England Journal of Medicine, 15 April 2021
Thank you for your ongoing efforts regarding your newsletter, I read it faithfully.
Recognizing you have limited space to cover a topic exhaustively, one area I did not see mentioned in the psilocybin paper review was a discussion of confirmation bias, which I believe also should be mentioned to contextualize the results.
This was a highly curated, 59-person study screened from nearly 1 000 hopefuls, with emphasis on “hopefuls.” The researchers themselves acknowledge that the study population was drawn largely from those interested in psychedelic treatment. Exclusion criteria were extensive and included personal or family history of psychosis, health conditions per doctor, history of suicide attempts, pregnancy, experience with escitalopram (can have used psilocybin before), or a suspected pre-existing psychiatric condition that could jeopardize rapport between patient and the two mental health care givers. Then they had an interview with the psychiatrist. Certainly, the exclusion criteria in themselves mirror many studies, including pharma trials, however, the acceptance rate for participants and the selective process merit mention.
An interest additional reading that may speak to mechanism (albeit in microdosing) was generated by the same lab through a “citizen scientist” experiment, in a pro-psychedelic population showed microdosing effects may be due to placebo (https://www.imperial.ac.uk/news/216134/citizen-scientists-show-placebo-effect-explain/). Not so different from our current situation – plus ça change!
Thank you for your ongoing contributions to the psychiatric educational landscape.
Craig P. Stewart, MB BCh BAO, MA, FRCPC
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.