From the Editor
Prenatal depression affects two: the mother and her fetus. But how to effectively address depressive symptoms?
In the first selection, from JAMA Psychiatry, Benjamin L. Hankin (of the University of Illinois at Urbana-Champaign) and his co-authors consider a focused psychotherapy for that population. In a RCT involving 234 participants, they find that IPT was helpful. “Brief IPT significantly reduced prenatal depression symptoms and MDD compared with EUC [enhanced usual care] among pregnant individuals from diverse racial, ethnic, and socioeconomic backgrounds recruited from primary OB/GYN clinics.” We look at the paper and its clinical implications.
In the second selection, Caroline King (of the Oregon Health & Science University) and her co-authors consider buprenorphine for opioid use disorder with a focus on adolescent residential treatment. In a JAMA research letter, they report the findings which included every identified facility in the United States. “In contrast to the standard of care, only 1 in 4 US facilities offered buprenorphine and 1 in 8 offered buprenorphine for ongoing treatment.”
And, in the third selection, former AMA president Dr. Patrice A. Harris (of Columbia University) and her co-authors argue that physicians should know more about addiction treatment. In a Washington Post essay, they argue for more robust training. “Opioid use disorder is treatable, and medicines are readily available. But doctors cannot learn to help patients by taking a weekend course alone.”
DG
Selection 1: “Effect of Brief Interpersonal Therapy on Depression During Pregnancy: A Randomized Clinical Trial”
Benjamin L. Hankin, Catherine H. Demers, Ella-Marie P. Hennessey, et al.
JAMA Psychiatry, June 2023
Depression is common and contributes to disability and disease burden. Approximately 17% of pregnant individuals meet criteria for major depressive disorder (MDD) diagnosis, and up to 37% report elevated symptoms during pregnancy. Prenatal maternal depression confers intergenerational risks, including preterm birth as well as developmental delays, and enhanced vulnerability to psychopathology in offspring. The Perinatal Depression Task Force of the American College of Obstetricians and Gynecologists highlighted the need for early screening of depression and intervention during pregnancy. Still, most published work and current health care policy has emphasized preventing postpartum depression with scant attention focused on reducing prenatal depression…
The US Preventive Services Task Force (USPSTF) showed that current interventions exhibit significant but small effects to prevent perinatal depression (defined broadly including pregnancy through 12 months post partum). This recent USPSTF systematic review summarized perinatal counseling interventions and noted several limitations of the literature. They advocated for larger-scale effectiveness trials that use good-quality design, assess depression repeatedly throughout pregnancy with dimensional symptom measures, and focus on individuals at elevated risk for depression recruited from general primary obstetrics and gynecology (OB/GYN) care.
So begins a paper by Hankin et al.
Here’s what they did:
- “A prospective, evaluator-blinded, randomized clinical trial, the Care Project, was conducted among adult pregnant individuals who reported elevated symptoms during routine obstetric care depression screening in general practice in obstetrics and gynecology (OB/GYN) clinics.”
- “Participants were recruited between July 2017 and August 2021.”
- “Pregnant participants were randomized to IPT or EUC and included in intent-to-treat analyses.” The intervention involved 8 sessions of IPT. “Intervention focuses on psychoeducation and interpersonal skill building to decrease interpersonal conflict and increase interpersonal support and competence. Individuals are educated about the link between feelings and interpersonal interactions and learn strategies to resolve interpersonal conflicts contributing to depression symptoms…”
- Main outcome: “Two depression symptom scales, the 20-item Symptom Checklist and the Edinburgh Postnatal Depression Scale, were assessed at baseline and repeatedly across pregnancy.” Participants also had structured interviews at the beginning and end.
Here’s what they found:
- “Of 234 individuals, 119 were allocated to EUC and 115 assigned to IPT (106 of whom received intervention, and 9 participated in no intervention sessions).”
- Demographics and depression. The mean age was 29.8 years. In terms of ethnicity, 4.3% were Asian; 9%, Black; and 43.2%, White. The median annual household income was $50 000; about half of participants were on Medicaid. About 37% of participants met criteria for current MDD at the start of the study.
- Retention. Retention rates were 88% in IPT and 87% in EUC.
- Symptom Checklist. “The 20-item Symptom Checklist scores improved from baseline over gestation for IPT but not EUC (d = 0.57…).”
- Edinburgh Postnatal Depression Scale. “IPT participants more rapidly improved on Edinburgh Postnatal Depression Scale compared with EUC (d = 0.40…).”
- Depression. MDD rate by had decreased significantly for IPT participants; 6.1% versus 26.1%, down from 37% in both groups. (!!) See figure below.
A few thoughts:
1. This is a good paper with much to like: an RCT involving two sites, with diverse participants, published in a major journal, and featuring a focused, practical intervention (bonus: strong retention rates).
2. Wow.
3. The paper summarized in a sentence: “Study findings demonstrated that a safe, prenatal intervention (MOMCare, brief IPT) substantially reduced depression symptoms and led to a considerable reduction in MDD diagnosis relative to pregnant individuals receiving EUC from general OB/GYN clinics.”
4. Like all studies, there are limitations. The authors note several, including: “inclusion of only English-speaking participants limits generalizability.”
5. Would it be possible to scale this up? There is great potential here.
6. IPT therapists were doctoral-level clinicians in the study. Would there be a role for less trained therapists, say, for less ill patients?
The full JAMA Psychiatry paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2803843
Selection 2: “Treatments Used Among Adolescent Residential Addiction Treatment Facilities in the US, 2022”
Caroline King, Tamara Beetham, Natashia Smith et al.
JAMA, 13 June 2023
An unprecedented number of adolescents were identified as having an opioid use disorder (OUD) in 2021. Residential treatment facilities are part of the American Society for Addiction Medicine’s levels of care for adolescents with OUD, yet little is known about treatment facility practices. Buprenorphine is the only OUD treatment approved by the US Food and Drug Administration for use in adolescents aged 16 years or older; the Society for Adolescent Health and Medicine states that medications for OUD, including buprenorphine, should be offered with behavior therapy (eg, family-based therapy) to all adolescents with OUD, although adolescents who do not pursue behavior therapy should not be denied medications for OUD. Despite this, buprenorphine treatment is limited among adolescents…
So begins a research letter by King et al.
Here’s what they did:
“We adapted a ‘secret shopper’ approach to simulate calls inquiring about treatment to all identified facilities in the US from October to December 2022.5 We identified facilities using the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Locator and SpyFu, a website that captures Google advertising data. We called as the aunt or uncle of a 16-year-old with a recent nonfatal fentanyl overdose to make calls more plausible if we did not have all requested information about the adolescent. Four investigators called facilities in random order and asked to speak to someone about residential treatment. We called facilities up to 7 times on different days. We asked specific questions about buprenorphine use and open-ended questions about other available treatments.”
Here’s what they found:
- “We identified 354 facilities, reached 327 (92.4%), and confirmed that 160 (45.2%) provided residential treatment to patients younger than 18 years.”
- Buprenorphine. “Of 160 facilities, 39 (24.4%) offered buprenorphine, including through partnership with outside clinicians, which varied by US region (18.0% in the West to 40.0% in the Northeast).”
- Treatment. “Twelve facilities (7.5%) offered buprenorphine initiation but discontinued before discharge, 17 (10.6%) initiated buprenorphine and offered ongoing treatment, and 3 (1.9%) offered buprenorphine for ongoing treatment only.”
- Depot medication. “Four facilities (2.5%) offered long-acting injectable buprenorphine.”
- Those that didn’t offer. “Among the 121 facilities that did not offer buprenorphine or were unsure, 57 (47.1%) indicated that adolescents who were prescribed buprenorphine by their own clinician could continue receiving it, at least temporarily, although some facilities indicated they would discontinue it before discharge, and 27 (22.3%) required adolescents to not be receiving buprenorphine at admission.”
A few thoughts:
1. This is a good research letter.
2. Ouch.
3. What does it mean for a parent of a patient? “The average parent would need to call 9 facilities on the SAMHSA Treatment Locator list to find one that offered buprenorphine and 29 to find one for an adolescent younger than 16 years.” (!)
4. They focused on buprenorphine, but other evidence-based treatments were lacking, including CBT, offered at just 32.5% of facilities. (!!)
5. Opioid agonist therapy – which, of course, includes buprenorphine – has been considered in past Readings. A 2021 JAMA Psychiatry systematic review and meta-analysis concluded: “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 paper can be found here:
The JAMA research letter can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2805916
Selection 3: “Addiction can be treated. Doctors need to learn how.”
Patrice A. Harris, Josiah D. Rich, Joshua M. Sharfstein
The Washington Post, 13 June 2023
Given the size of the U.S. overdose crisis – the number of annual deaths topped 100,000 again in 2022 – it is astonishing how few Americans who need medical addiction treatment receive it. Buprenorphine and methadone, highly effective drugs for opioid use disorder, are provided to fewer than 1 in 6 people who would benefit from them. A major reason for this failure is that not enough doctors have been trained in their use.
Surprising as it might seem, most U.S. medical schools and residency programs do not provide a full set of training for treating addiction. This needs to change.”
So begins an essay by Harris et al.
They note the historic reason for the omission. “Addiction medicine has been left out of the system because it was historically frowned upon. In the early 20th century, federal authorities operating under the draconian Harrison Narcotics Tax Act arrested thousands of doctors for treating patients with substance use disorder. Many physicians understandably but unfortunately kept their distance from such patients, adding to the stigma of both addiction and its treatment.”
The absence of education is felt. “Only about half of U.S. medical schools provide teaching sessions during clinical years in the treatment of substance use disorders, and fewer than one-third provide clinical experiences related to addiction early in medical school, according to a survey by the Liaison Committee on Medical Education.” Residency education also lacks much focus on substance, though they note that the US Accreditation Council for Graduate Medical Education requires all programs to teach residents to “provide instruction and experience in pain management for the specialty, including the recognition of the signs of substance use disorder.” They are cool to this requirement since “[p]ain management… is only a facet of what is needed.”
Hands on experience with medications? “[A]bout 15 percent, have ‘experiential training’ using medications to treat opioid use disorder, a 2021-2022 survey found. Fewer than half of the programs in emergency medicine, family medicine, internal medicine and obstetrics provide this critical education.”
“This is especially unfortunate because many teaching hospitals are located in or near Black and Hispanic communities, which often have inadequate access to effective addiction treatment and are experiencing substantial increases in overdose deaths.”
They note that federal legislation recently required eight hours of training, but they feel more is needed, and they close with a call for action: “The training needs to be part of their foundational education. All physicians should emerge from medical school and residency able to give this lifesaving care.”
A few thoughts:
1. The authors raise good points.
2. The central argument – that medical training hasn’t kept up with the substance use needs of our patients – is thoughtful.
3. They focus on the United States. A similar argument could be made here: many Canadian physicians lack adequate training in medications for the treatment of substance disorders. A 2015 paper reported that, of 119 Ontario family physicians, only five doctors felt comfortable prescribing pharmacotherapies for alcohol and opioid use disorder. The overwhelming barrier identified: lack of knowledge. That paper can be found here:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0124402
4. In terms of psychiatry training in Canada, residents are required to do a rotation (one month), but Bahji et al. note great variability among programs:
“Some residency training programs meet the requirement through a distinct one-month rotation in addiction psychiatry, while others offer a longitudinal experience equivalent to one month. Timing and setting also vary. Some programs use a residential treatment setting for the experience early in psychiatric training to meet the requirements. In contrast, others integrate addiction psychiatry training with other core clinical rotations, such as consultation-liaison psychiatry, emergency psychiatry, inpatient psychiatry and outpatient–community services, meaningful to future clinical practice.”
That CMEJ paper can be found here:
https://journalhosting.ucalgary.ca/index.php/cmej/article/view/69739
The full Washington Post essay can be found here:
https://www.washingtonpost.com/opinions/2023/06/13/doctors-medical-school-addiction-buprenorphine/
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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