From the Editor
Millions of people are isolating themselves in North America, and across the world. We know that quarantine is linked to mental health problems like depression. So what advice should we be giving our patients – and our family and neighbours?
The first selection seeks to answer this question.
In The British Journal of Psychiatry, Rowan Diamond (of Warneford Hospital) and Dr. John Willan (of Oxford University Hospitals NHS Foundation Trust) provide six suggestions, drawing from the literature and taking into account our collective situation. “Dame Vera Lynn, at the age of 103, said of this pandemic that ‘even if we’re isolated in person we can still be united in spirit,’ and the sense of purpose that may be engendered in self-isolation may paradoxically lead to improvements in the mental health of some individuals who may otherwise feel that they have lost their role in society.”
How are we managing bipolar affective disorder? In the second selection, we look at a new American Journal of Psychiatry paper by Taeho Greg Rhee (of the University of Connecticut) and his co-authors, who draw on 20 years worth of data. “There has been a substantial increase in the use of second-generation antipsychotics in the outpatient psychiatric management of adults diagnosed with bipolar disorder, accompanied by a decrease in the use of lithium and other mood stabilizers.”
Finally, in the third selection, Dr. Zheala Qayyum (of the US Army) considers her time working in New York City during the pandemic. “The first thing that struck me when I stepped into the hospital in Queens was the smell that hung in the air, in these seemingly sterile hospital corridors. It was death and disease.”
Selection 1: “Achieving Good Mental Health during COVID-19 Social Isolation”
Rowan Diamond and John Willan
British Journal of Psychiatry, 4 May 2020 Online First
Attempts to contain the pandemic spread of COVID-19 infection have caused fundamental changes to the way of life of individuals around the world. The UK Government has asked that wherever possible, people should stay at home and practice social distancing, and that the most vulnerable individuals should shield themselves completely. Other countries around the world have applied even more stringent measures than these, restricting many people to their homes by law.
Governments have recognised that self-isolation has its own risks, including those of loneliness and deterioration of mental health, even in those without pre-existing mental health problems. Redundancy, furloughing, or an inability to work, as well as the associated financial issues and changes in family dynamics can exacerbate this problem. The consequences for people with severe mental health problems who are three times more likely to have a physical health problem than those in the general population are likely to be even more significant. Never has the connection between physical and mental health been so important or relevant.
So begins a paper by Diamond and Willan. Drawing on an older report and the current situation, they pull together six actions to improve people’s wellbeing.
“The acquisition of new knowledge can give a sense of achievement and reward.”
“Meaningful interaction with others can promote self-worth and a sense of identity. Whilst the social restrictions brought about by COVID-19 might seem to reduce the possibility of regular contact with others, people are likely to have increased time for letter writing, or speaking on the telephone. There are also opportunities to develop new and fulfilling ways of remote social interaction.”
“Mindfulness, or taking notice of the present moment, can improve mental wellbeing, and may be a useful technique to help deal with anxiety during the COVID-19 pandemic.”
“Some of the older people in this group will remember fondly the camaraderie of war time and the post-war period, during which the act of giving led to a strengthening of bonds within a community.” The authors note the challenges of giving with social isolation. “It is possible to connect with isolated and potentially lonely people in the community, or more widely by volunteering time or skills. This can be offered from home, perhaps by volunteering for pre-existing phone lines for elderly people (for example the Silverline telephone support scheme for older and more isolated individuals).” They also note that some are volunteering to shop for the elderly.
“Physical activity has been described by the Academy of Medical Sciences as a ‘miracle cure’, with impressive evidence of benefits to body and mind. Physical activity is safe and beneficial for almost everyone and any level of physical activity is better than none. Indeed, reducing the duration of time spent sitting, even if just standing up, is linked to improved physical health outcomes, independently of how much exercise people do.”
Though they note that the opportunities for physical activity may be reduced during the lock-down, they argue that: “exercising at home is possible for people with a range of abilities and conditions, and can be guided from readily available DVDs. There are also opportunities for people to join live classes virtually, for example using YouTube.”
Building a Routine
“Having a regular routine is important for physical and mental wellbeing and can help to ease the disturbance caused by the loss of the usual daily structures of work and school.”
This is an excellent paper. The two authors do an important job of moving past the feel-good rhetoric, and provide six practical suggestions which are worth sharing with patients.
Selection 2: “20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings”
Taeho Greg Rhee, Mark Olfson, Andrew A. Nierenberg, Samuel T. Wilkinson
The American Journal of Psychiatry, 21 April 2020 Online First
Bipolar disorder affects up to 4.5% of the adult population in the United States and can lead to significant adverse mental and physical health outcomes as well as a substantial economic burden. Traditionally, lithium was considered the treatment of choice for bipolar disorder, with evidence suggesting that lithium has a specific protective effect against suicide, even compared with other mood stabilizers.
Over the past 20 years, the pharmacological options for treating bipolar disorder have increased. Most notably, several second-generation antipsychotics received regulatory approval in the 1990s and 2000s for the treatment of bipolar disorder.
So begins a paper by Rhee et al.
Here’s what they did:
- They drew data from the National Ambulatory Medical Care Surveys (United States).
- The authors examined trends in the use of mood stabilizers, first- and second-generation antipsychotics, and antidepressants among psychiatrist visits for bipolar disorder.
- Statistical analyses were done.
Here’s what they found:
- Mood stabilizers. “Visits for bipolar disorder that included prescriptions for any mood stabilizer decreased from 62.3% in the 1997–2000 period to 26.4% in the 2013–2016 period.”
- Antidepressants. “The prescription rate for any antidepressant was 47.0% of visits for bipolar disorder in the 1997–2000 period and 57.5% of visits in the 2013–2016 period…”
- Psychotherapy. “Among visits for which bipolar disorder was listed among the primary diagnoses, the use of psychotherapy decreased from 50.9% in the 1997–2000 period to 35.7% in the 2013–2016 period…”
This is an excellent and important paper, drawing on a large database.
How to interpret the findings? The paper provides good data, though the context of individual patient experiences isn’t possible. The view from 30,000 feet, however, is clear.
Consider the use of lithium. Many believe that this mood stabilizer is the best overall medication for bipolar. Rhee et al. found: “a decrease in use of lithium from 30.4% to 17.6%.” Not good.
The use of antidepressants in people with bipolar is controversial, but it’s a non-controversial comment to say that enthusiasm for such combinations has cooled in recent years. Yet the study results suggest a sharp rise in use of these medications, including the prescription without the use of mood stabilizers (possibly increasing the risk of manic episodes). The authors write: “the prescribing patterns in community practice nevertheless suggest a possible need for quality improvement initiatives to educate and provide feedback for practicing psychiatrists.” Not good.
Psychotherapy? Down in use – despite the robust evidence for psychoeducation and CBT (for the depressive phase of the illness). Not good.
The authors wonder if the use (or misuse) of psychotropics in bipolar is a public health problem.
The data is for American patients seeing US doctors. What would prescribing patterns be like on the rugged side of North America? This paper obviously doesn’t ask that question. But Canadian data also indicates a problem. As an example, in a recent research letter (considered in a past Reading), Patten et al. analyzed lithium prescribing, finding that it was infrequent.
Treating bipolar disorder is challenging on both sides of the border, and we can wonder if practice draws well from the current evidence.
Selection 3: “I Served In New York City As An Army Reserve Doctor. Here’s What I Saw”
wbur, 21 May 2020
Lately I’ve found myself giving people directions to the hospital morgue.
It’s not what I expected to do as a physician. I’m a highly trained Boston-area psychiatrist, recently called to active duty by the Army Reserves, to fight the COVID-19 pandemic in New York. But in my new role – as an emergency room psychiatrist at a hospital in Queens – I get stopped in the hallways and asked, ‘which way?’
So begins an essay by Dr. Qayyum.
As a psychiatrist here, I feel like a soldier in the trenches, part of something too big to comprehend, even as this first acute phase of carnage wanes. I understand only fragments of what swirls around me.
She writes about the hospital and the neighbourhood:
Nearly half the patients I’m assigned to care for have tested positive for COVID-19. Some have serious mental health issues, largely untreated since the pandemic began. Others have lost family members to the disease and are now sick themselves. Suicides are on the rise in this neighborhood, as people struggle with grief and loss.
And she writes about the people she is working with:
One young adult patient I was treating lost his father to the virus a few weeks ago. When I saw him, his mother had just been taken off the ventilator; there was no hope for her recovery. He had been working on finding his mom a safer place to live, but now she wouldn’t be coming home. He looked so utterly lost. All he could say is that he wouldn’t allow anyone to see him cry. I could do little but stand beside him, as he got the definitive word of his mother’s death. He looked at me, tears rolling down his cheeks.
This essay is hard to read – moving and sad. As someone in mental health, I can immediately relate to the author (she is, after all, a psychiatrist).
What impact does all this have on the author? She speaks to this, writing: “As a psychiatrist here to help, I have to muffle my own sense of helplessness and fear.”
More and more, we are discussing how to handle the aftermath of the pandemic, when the physical illness grows less common, but the mental health sequelae continues. Tying back to the excellent paper by Vigo et al. (considered in last week’s Reading), we will need to think about different sub-populations. Obviously some essential workers – people like Dr. Qayyum and her colleagues working on the front lines – will require mental health services given everything that they have seen.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.