From the Editor
This week, we have three selections.
With the legalization of cannabis, many big claims haven been made about the medicinal aspects of this drug – including by industry. Cannabidiol, or CBD, is often touted as being helpful yet non-addictive (in contrast to THC, the more famous cannabis molecule). In the first selection, UBC’s Jairo Vinícius Pinto and his co-authors consider cannabidiol in the treatment of mood disorders, reviewing the existing literature. Does CBD help? “The methodology varied in several aspects and the level of evidence is not enough to support its indication as a treatment for mood disorders.”
In the second selection, the University of Michigan’s Paul N. Pfeiffer and his co-authors try to improve depression treatment outcomes by combining a cutting-edge psychotherapy (CBT, delivered by computer) with a not-so-cutting edge approach (peer support). They conclude that the intervention “should be considered as an initial treatment enhancement to improve effectiveness of primary care treatment of depression.”
And in the third selection, we look at the work of artist Daniel Regan, which is featured on the front cover of February issue of The Lancet Psychiatry. He notes: “I really think if I hadn’t gone on to study photography, I wouldn’t be here.” Featured above is “Abandoned,” part of a series of photos from Victorian-era asylums in the UK.
Selection 1: “Cannabidiol as a Treatment for Mood Disorders: A Systematic Review”
Jairo Vinícius Pinto, Gayatri Saraf, Christian Frysch, Daniel Vigo, Kamyar Keramatian, Trisha Chakrabarty, Raymond W. Lam, Márcia Kauer-Sant’ Anna, and Lakshmi N. Yatham
The Canadian Journal of Psychiatry, 13 December 2019 Online First
The plant Cannabis sativa contains more than 600 compounds, among which 100 share similar structures and are known as cannabinoids. Cannabidiol is one of these phytocannabinoids; preclinical and clinical studies have suggested its therapeutic utility in brain disorders. While Δ-9-tetrahydrocannabinol (THC), the main active component of the plant, is related to psychotomimetic effects, inducing anxiety and psychotic symptoms, cannabidiol can reverse these effects due to its impact on CB1 and 5-hydroxytryptamine (5-HT1A) receptors. Recent clinical studies have shown the anticonvulsant, antipsychotic, and anxiolytic properties of cannabidiol; preclinical studies have also shown antidepressant-like effects in several animal models of depression. Acting in the endocannabinoid system, cannabidiol has a unique pharmacological profile with promising results in neuropsychiatric disorders.
Here’s what they did:
- They searched databases (including PubMed) for terms including
- “The inclusion criteria were double-blind randomized clinical trials (RCTs) with and without placebo conditions, open-label clinical trials, observational studies (longitudinal or cross-sectional), or case series that evaluated the effect of pure cannabidiol or cannabidiol mixed with other cannabinoids on affective symptoms.”
- Gray literature wasn’t searched.
Here’s what they found:
- 16 papers were included in the final sample.
- “Seven papers were clinical studies that used cannabidiol to treat other medical and psychiatric conditions but assessed mood symptoms as an additional outcome. Five studies tested medical cannabis, nabiximols, or other blends of cannabinoids that included cannabidiol in the treatment of medical or psychiatric conditions and assessed affective symptoms as secondary outcomes.”
- “We did not find any published clinical trial investigating the efficacy of cannabidiol in patients with mood disorders.”
- “In other health conditions, there were no studies that examined affective symptoms as a primary outcome, although 10 clinical studies evaluated affective symptoms, mainly depressive, as secondary outcomes.”
- “In general, these studies showed a good safety profile of cannabidiol, without inducing dysphoria, anxiety, or psychotic symptoms and with few adverse effects. However, regarding the mood symptoms, the results were conflicting, showing both significant improvements in depressive symptoms and absence of significant differences.”
- “Our review revealed considerable heterogeneity and methodological variations among the trials in several aspects.”
The paper closes by calling for more research.
The findings of the paper are a marked contrast from the claims of industry. That said, a note of caution: these are early days. Though this paper is well conceived and executed, there is a general dearth of research in the area – in fact, there are no published clinical trials, as the authors note. (!)
The authors aren’t dismissive of CBD. “An important potential advantage of testing cannabidiol in mood disorders is its well-known effect on anxiety, including physiological anxiety, social phobia, and even anxiety associated with heroin abstinence. It can be useful for populations with mood disorders, since 45.7% of patients with MDD and 34.7% of patients with bipolar disorder have a comorbid diagnosis of anxiety disorder and many more have anxiety symptoms associated with depressive episodes.”
Selection 2: “Effectiveness of Peer-Supported Computer-Based CBT for Depression Among Veterans in Primary Care”
Paul N. Pfeiffer, Brooke Pope, Marc Houck, Wendy Benn-Burton, Kara Zivin, Dara Ganoczy, H. Myra Kim, Heather Walters, Lauren Emerson, C. Beau Nelson, Kristen M. Abraham, and Marcia Valenstein
Psychiatric Services, 14 January 2020 Online First
Computer-based psychotherapy has the potential to address many of the barriers to in-person treatment, given its relatively low marginal costs, accessibility, and privacy. Meta-analyses of data from randomized trials have demonstrated the effectiveness of computer-based cognitive-behavioral therapy (cCBT) for depression. Studies have also found that providing human support to individuals referred for cCBT results in greater engagement and increased effectiveness, compared with cCBT without human support.
Mental health clinicians, technical support personnel, and volunteers have provided support for cCBT. Support of cCBT by peer specialists—individuals with mental health challenges who have been trained and employed to support others in their recovery—has not previously been studied. However, peer specialists may improve engagement in cCBT and complement its effectiveness by decreasing social isolation and sharing successful self-management strategies. In meta-analyses, peer support improved depression symptoms, compared with usual care.
So beings a paper by Pfeiffer et al.
Here’s what they did:
- They ran the study from 2015 to 2018 at three midwestern U.S. Department of Veterans Affairs (VA) medical centers.
- Study participants were selected if they had a new diagnosis of depression, a significant score on a depression scale (i.e., a PHQ-9 score above 10), and computer skills.
- The intervention: “PS-cCBT participants received access to the online cCBT program Beating the Blues (BtB) for 3 months. BtB consists of eight CBT modules for depression and anxiety and includes video vignettes of program users, interactive assignments, and symptom self-monitoring with the PHQ-9…” Participants were then connected with a peer supporter who “conducted approximately weekly phone calls and occasional in-person visits with participants to discuss progress and barriers to completing cCBT modules and to provide general peer support for managing depression.”
- The outcomes included a decline in mood symptoms.
Here’s what they found:
- 163 participants were assigned to the usual care; 167, to PS-cCBT.
- Demographics: the mean age was 52 years; 80% were male; 71% were white.
- Adjusted analysis: “we found response rates (a 50% reduction in depression symptoms from baseline) at 3 months to be 20.0% in the PS-cCBT group, compared with 6.4% for enhanced usual care (p=0.002, NNT=7.3); at 6 months, response rates were 25.3% and 16.4% (p=0.11), respectively… At 3 months, we found remission rates (QIDS-SR score ≤5) of 14.0% for PS-cCBT participants and 6.3% for EUC participants (p=0.046, NNT=13.0); at 6 months, remission rates were 21.8% and 11.0% (p=0.03, NNT=9.3), respectively.” See the figure below.
We found that PS-cCBT as an enhancement to usual primary care treatment for depression was associated with greater improvements in depression symptoms, quality of life, and mental health recovery at 3 months, compared with usual care alone.
There is much to like in this paper. The intervention makes sense – pairing a low-cost computer program with peer support. And it did seem to help, though the overall improvement in QIDS scores was – by the description of the authors – “modest,” as were changes on secondary outcomes.
We are enthusiastic about new technology but the ability to bring these interventions to clinic and achieve material results have often proven elusive – the gap between the cool paper in a journal and the not-so-cool real-world experience. This paper suggests that peer support could be useful, helping to better engage our patients.
On a slight pivot, the study authors focus on the impact of the intervention. But it’s striking how poorly patients did regardless of whether or not they received the peer supported computer therapy. Indeed, the vast majority of patients remained symptomatic. Depression is a challenging illness to treat, particularly in the primary care setting.
Selection 3: Cover
The Lancet Psychiatry, February 2020
Selections for the Reading of the Week have included everything from political speeches to book chapters. In this final selection, we focus on a journal cover.
The work of artist Daniel Regan is worth noting. He is the photographer behind this journal cover (a collaboration facilitated by the Bethlem Gallery). He is also a person with lived experience.
In a Guardian article, he discusses his mental health journey and his photography. The story can be found here: https://www.theguardian.com/society/2019/jul/20/without-photography-i-wouldnt-be-here-daniel-regan.
Regan talks about the importance of photography in his life and healing. His subjects are diverse, and include his own self-harm.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.