From the Editor
Complementary and alternative medicines are trendy – but are they helpful?
“Depressed patients… often perceive CAMs [complementary and alternative medicines] as safer, accessible, more tolerable, and easily acceptable compared to pharmaceuticals. It has been estimated that 10% to 30% of depressed patients use CAM therapies, often in tandem with conventional treatments and frequently without the knowledge of their physician. This percentage is even higher amongst those with bipolar disorder (up to 50%) and in clinic populations (up to 86%).”
So writes Dr. Arun V. Ravindran (of the University of Toronto) and his co-authors in a new Canadian Journal of Psychiatry paper. That study – our first selection this week –considers the use of one type of CAM: yoga. They find that it “may be helpful as an adjunctive intervention.”
In the second selection, writing in JAMA, Dr. Linda Brubaker (of the University of California, San Diego) considers gender and roles in medicine. While she is careful not to over-generalize, she notes that: “As a group, women physicians spend proportionately more time on home and family care activities.” With the disruptions of COVID-19, she wonders what must be done to support all physicians. “Women and men physicians should be able to share the joy and the work of their lives equally.”
And, in the third selection, University of Toronto psychiatry resident Dr. Erene Stergiopoulos considers masks – and humility – in a time of COVID-19. In a personal essay that turns on a split-second decision, she notes: “These days it’s hard to remember a time before masks. And some days, it’s just as hard to imagine a future without them.”
Selection 1: “Breathing-focused Yoga as Augmentation for Unipolar and Bipolar Depression: A Randomized Controlled Trial”
Arun V. Ravindran, Martha S. McKay, Tricia da Silva, Claudia Tindall, Tiffany Garfinkel, Angela Paric, and Lakshmi Ravindran
The Canadian Journal of Psychiatry, 17 July 2020 Online First
Yoga was born out of the centuries-old sociocultural tradition of India but now accepted as a secular practice worldwide. Modern Western yoga disciplines usually focus on three main components – asanas (postures), pranayamas (breathing exercises), and dhyana (meditation). Forms of yoga differ in their degree of focus on one or more of these components but usually incorporate all three.
Several randomized controlled trials (RCTs) and open studies have found yoga to be beneficial in treating unipolar depression. On its own or as an adjunct to medication, yoga has been shown to alleviate symptoms of mild to moderate depression. Preliminary evidence suggests that it may even benefit more severe depression and even alleviate suicidal ideation. It is noted to be well tolerated, with only mild and infrequent adverse events linked to physical fitness being reported, and evidence for sustained benefit 3 to 6 months postintervention. In contrast, the role of yoga in the treatment of bipolar depression is significantly understudied. Preliminary observations suggest that yoga improves psychological, physical, and cognitive function warranting further investigation.
Although early results are promising, their reliability and generalizability are limited by the paucity of studies and methodological constraints, including small sample sizes, variations in clinical measurements, blinding methods, and patient selection…
So begins a paper by Ravindran et al.
Here’s what they did:
- “The investigation was a 16-week, single-blind, randomized, controlled, rater-blinded, crossover study…”
- “Patients were randomized to receive 8 weeks of yoga, followed by 8 weeks of psychoeducation, or 8 weeks of psychoeducation, followed by yoga for equal duration. Treatment sessions were conducted twice a week for 1.5 hours per session.”
- Yoga “focused on cyclical breathing and breathe control (pranayamas).” The psychoeducation incorporated education on symptoms and treatments, as well as coping strategies and community resources.
- Patients needed to meet criteria for major depression, dysthymia, or bipolar, and had a score on the Montgomery-Åsberg Depression Rating Scale (MADRS) of between 12 and 24.
- Statistical analyses were done. “We conducted an intent-to-treat (ITT) analysis assessing mean changes (MC) from baseline to 8 weeks for each intervention and mean differences (MD) between yoga and psychoeducation on all primary (MADRS)…”
Here’s what they found:
- “Seventy-two participants (age range 18 to 70 years) were enrolled in the study (bipolar, N = 17; unipolar, N = 55). Nine participants were considered screen failures, and 29 participants withdrew or were lost to follow up for several reasons during the first 8 weeks of the study…”
- “The majority of participants (90.3%) were receiving psychotropic medication for the treatment of a mood disorder.”
- “At 8 weeks, 37% of participants were considered to be responders as defined by our protocol (≥50% decrease in MADRS score), while 27.9% of participants were in remission (MADRS score of ≤10).”
- “The ITT analysis revealed a significant decrease in MADRS-rated depressive symptoms after yoga… but not after psychoeducation… However, there was no significant difference in MADRS scores between yoga and psychoeducation at Week 8…”
“We did not find a significant difference in MADRS scores between interventions at 8 weeks posttreatment, which is contrary to the initial hypothesis. There were, however, positive changes in well-being over time for both interventions, as determined by other clinician- and self-rated measures. This was especially true for yoga.”
A few thoughts:
- This is an interesting study on a timely topic.
- In the end, the intervention was something of a bust – at least in terms of the primary outcome measure. The authors conclude: “Findings suggest that yoga, similar to psychoeducation, may be helpful as an adjunctive intervention in reducing symptoms and improving function in depression of mild to moderate severity.”
- The limitations? The authors note several, including the design. “[I]t employed a crossover design in which patients served as their own controls with maximum benefits obtained if they completed both arms of the study. This design is somewhat inflexible and presented unique recruitment and attendance challenges for this patient population, which likely contributed to the high dropout rate.”
- Clinical take-away: this paper doesn’t offer a re-think of CANMAT recommendations.
The CJP article can be found here:
Selection 2: “Women Physicians and the COVID-19 Pandemic”
JAMA, 31 July 2020
Despite the complexity and challenges inherent in the US health care system and the unprecedented demands in and disruptions of clinical practice created by the coronavirus disease 2019 (COVID-19) pandemic, it remains a privilege to be a physician. This privilege comes with many responsibilities, including a responsibility to reflect on the profession and address the entrenched dysfunctional ways of the work involved in medicine. The medical profession has missed opportunities to establish reasonable demands and expectations for physicians. Instead, physicians are often asked to do more that moves them away from the deep thinking that is needed for patient care. This has led to a loss of professional fulfillment and a moral crisis for an increasing number of physicians.
Even before the COVID-19 pandemic, physicians have been affected by systemic issues that foster unhealthful work environments, with expectations of 24/7 availability and a persistent life-work imbalance. While some younger physicians are making intentional changes to their personal and professional lives, far too few physicians have effectively prioritized commitments to the personal roles they value. These preferences and other human factors that each physician brings to their vocation in medicine are framed by their personal experiences. This mix of personal attributes and professional skills can keep physicians healthy and thriving.
So begins a paper by Dr. Brubaker.
She notes the diversity of characteristics of female doctors: “There is no appropriate stereotype for a woman physician.” She continues: “Some are just starting their professional careers. Some are older, nearing retirement. Some are partnered, others are solo. Some are childless, others are parents. Family care responsibilities vary with some caring for their children, their aging parents, or both. Practice parameters and settings vary, including business owners, health care executives, academic physicians, and employees of hospitals and group practices.”
There may be diversity but a common thread running through their collective experience: “Since their entry into medicine, women physicians have often been held to different standards and judged by different metrics than their male peers.”
“As a group, women physicians spend proportionately more time on home and family care activities. The COVID-19 pandemic has disrupted common activities, such as meal planning and preparation, family and social activities, exercise or sport, spiritual practices, shopping, and leisure. Many of these changes disproportionately affect women, who often are leading efforts to find an acceptable new normal.”
And she writes more about the pandemic: “The COVID-19 pandemic has raised the level of personal sacrifice as many physicians have experienced an increase in the duration and intensity of their work.”
A few thoughts:
- This is a good essay.
- With COVID-19, we have spent much time considering the impact on patients – obviously. The author focuses on physicians and particularly the female experience, making this an important essay.
- As we attempt to deal with the new normal, how can we better adjust roles and responsibilities? How can we address inherent gender biases?
The JAMA paper can be found here: https://jamanetwork.com/journals/jama/fullarticle/2769140
Selection 3: “Masking Reality”
UofTMed Magazine, Summer 2020
Every morning when I enter the hospital I receive a soft blue mask the moment I step through the door. I sanitize my hands, flash my badge, don the mask and confirm a 14-item list of statements about being COVID symptom-free.
The ritual is seamless and these days it’s habit. It’s amazing how quickly the routine started to feel normal, as if the hospital was always that way. What was once terrifying and new is now entirely mundane.
I remember when all of this felt strange. I remember early in the pandemic, in April, when I worked on the palliative care team as a first-year resident at a downtown Toronto hospital.
On a busy afternoon, I was seeing a patient with end-stage cancer. As part of the palliative care team, I was to speak with her about her eventual end-of-life care.
Each day I saw this patient, she asked me to take off my mask. She said she couldn’t understand my words through the mask, no matter how loudly I spoke or how close I got.
After a few days, when we started to speak frankly about her end-of-life plans, she asked me again to take off my mask, but this time she begged.
So begins a short, compelling essay by Dr. Stergiopoulos.
The physician considers her situation: “There’s an intense visceral feeling that comes with providing care in a way you feel is inadequate. It’s called ‘moral distress’ — the feeling of being stuck between doing the ‘right thing’ according to your values and the ‘right thing’ according to the rules. I knew I wasn’t supposed to take off my mask in a patient room.”
But she does, only to experience the nightmare scenario: “They swabbed her for COVID. In the very last email, the attending doctor confirmed that the patient tested positive.”
“I had no gown, no gloves, no face shield – not even the mandatory mask. I kept trying to recall the exact distance between us at every point in the conversation, every surface I had touched in that room and at what moment I had washed my hands. What did this mean for going to work the next day? Did I need to self-isolate? Was the chest tightness I was feeling a symptom of anxiety, or was it COVID?”
Fortunately, the story has a happy ending with a negative swab.
A few thoughts:
- This is a well written essay.
- The author makes good points about the new normal – and how quickly we adapt to new situations.
- Of course it was the wrong decision to take off the mask, and yet who doesn’t feel the moral distress? And who doesn’t feel good about the future of our profession with people like Dr. Stergiopoulos in our ranks?
The UofTMed Magazine article can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.