From the Editor
Postsecondary education can be incredibly stressful for students – and, not surprisingly, mental health problems may surface. Is it possible to inform (and thus empower) students with a simple intervention?
In the first selection, Yifeng Wei (of the University of Alberta) and her co-authors consider a trial of Transitions, a program that includes both mental health literacy and comprehensive life skills resources “for those transitioning from secondary to postsecondary education.” In a new Canadian Journal of Psychiatry paper, they describe a study involving nearly 2 400 students across five institutions. “Students in the intervention significantly improved mental health knowledge, decreased stigma against mental illness, increased positive attitudes toward help-seeking, improved help-seeking behaviours, and decreased perceived stress compared to the control group.” We review the paper.
In the second selection, Christine Timko (of Stanford University) and her co-authors consider benzodiazepine use. In a new Psychiatric Services paper, they note: “This study’s findings suggest that challenges remain in discontinuing long-term benzodiazepine use among patients who are older than 45 years, White, taking higher doses for longer, and diagnosed as having anxiety, PTSD, bipolar disorder, or psychosis.”
And finally, in a new section, we consider some recent news items relevant to those of us in mental health care. Our aim: not simply to draw from interesting reports, but to include those that our patients may read and bring up. This week: the focus (and TikTok videos) on the vagus nerve, the Freud who hated Freud, and ADHD in adults.
Selection 1: “The Impact of Transitions, a Mental Health Literacy Intervention With Embedded Life Skills for Postsecondary Students: Preliminary Findings From a Naturalistic Cohort Study”
Yifeng Wei, Stan Kutcher, Erin Austen, et al.
The Canadian Journal of Psychiatry, June 2022
Many young people may head off to postsecondary institutions, leaving home for prolonged periods of time. These new circumstances create normal existential stresses, which may exacerbate existing mental disorders or demand coping strategies not yet developed. Concomitantly, young people may not realize that the difficulties they are experiencing could be due to a mental disorder rather than simply a reaction to life changes. Thus, they may not seek appropriate assistance with the result that early intervention and effective treatment do not occur expeditiously. Alternatively, young people may misinterpret the normal negative emotional states occurring as a result of these new challenges as a mental disorder requiring professional intervention. Therefore, providing information about mental health and mental illness in the context of other important issues that characterize this transition period may both enhance support to young people during this critical period and improve their ability to cope with these stresses, identify a mental disorder if it is on-setting and to seek help appropriately if needed.
So begins a paper by Wei et al.
Here’s what they did:
“Students from five Canadian postsecondary institutions were assigned to the intervention or the control group and were administered a survey at baseline, postintervention, and at 2-month follow-up (September 2017 to February 2018). We applied generalized linear mixed effects (PROC Mixed procedure) to test the between-group difference in the post – pre/follow-up – pre and to determine the predicted least-square mean values.”
Here’s what they found:
- “Out of 2,397 students, 1,768 students were assigned to the intervention group and 629 students as controls…”
- 49% completed both pretest and posttest; 40% did the 2-month follow-up surveys.
- Demographics. Most participants were female (55.3%), had not had previous mental health education (74.9%) and had no previous mental health treatment (55.3%).
- Knowledge. “The intervention group estimate was 1.878… higher post follow-up compared to the control group.”
- Stigma. “A multivariate analysis demonstrated that the LS mean estimate in stigma was 1.22… greater for the intervention group compared to the control. There was no statistically significant difference between intervention and control at baseline, 0.114.”
- Help-seeking attitudes and behaviours. “A multivariate analysis demonstrated that the intervention group had an LS mean difference estimate of post–pre score 1.287… compared to 0.77… in the control group.”
- General health. “A univariate analysis showed no statistically significant association between post and prechange in general health with the study groups (P = 0.762) implying that the intervention did not influence the general health outcome among participants.”
A few thoughts:
1. This is a good study.
2. The key finding in three words: the intervention worked. (Though it didn’t change health – as measured at 2 months.)
3. The intervention itself was centred on a readable workbook; institutions added in seminars or more. #Scalable.
4. Perspective: it wasn’t an RCT. Still, the study design was clever and they had an impressive number of participants: “over 2,000 students, representing ∼11% of the first-year university/college student population between 2017 and 2018 in these provinces, a quite large sample although it may not represent the whole student population in Canada.”
5. At the same time, the actual approach to recruitment varied greatly by school. “Each institution made its own decision on whether it would recruit students for both intervention or control groups or just for one study group depending on its contexts. Each institution designated specific staff to recruit participants.” In one school, psychology students were enrolled; at another, they were picked by administrators. How many of these participants were motivated to learn more about mental health?
The full CJP paper can be found here:
Selection 2: “Long-Term Benzodiazepine Use and Discontinuation Among Patients in the U.S. Veterans Health Administration”
Christine Timko, Katherine J. Hoggatt, Aryan Esmaeili, et al.
Psychiatric Services, 3 May 2022 Online First
Benzodiazepines are a class of central nervous system depressants with anxiolytic, hypnotic, muscle relaxant, anticonvulsant, and sedative effects and are approved for treating anxiety, insomnia, seizures, alcohol withdrawal, and other conditions. They are relatively safe to use for 2–4 weeks or for acute as-needed use, but side effects (e.g., falls, sedation, and confusion) are amplified among older adults, and prolonged use leads to physiological dependence. Although clinical guidelines recommend that longer-term (>30 days) use of benzodiazepines should be avoided, a systematic review estimated the prevalence of long-term benzodiazepine use (ranging across studies from 1 month to several years) to be 3% in the general population. The mean relative proportion of persons using benzodiazepines long term was 24%.
So begins this paper by Timko et al.
Here’s what they did:
“The study used nationwide electronic health record data for all VHA-enrolled patients (age ≥18) from fiscal year (FY) 2019 (N=6,032,613). The primary outcome, benzodiazepine discontinuation, was defined as no prescription refill for 120 days.”
Here’s what they found:
- “In FY2019, of 6,032,613 veterans enrolled in VHA health care, 4.9% were prescribed any kind of benzodiazepine as outpatients, for any length of time.”
- “The most common benzodiazepines prescribed were clonazepam (33.1% of veterans prescribed any benzodiazepine), lorazepam (22.4%), and alprazolam (20.0%).”
- “3.5% were prescribed benzodiazepines as outpatients long term…”
- “One-third of veterans prescribed long-term benzodiazepines discontinued use.”
- “Continuation was more likely among patients who were older, not Black, taking benzodiazepines longer, and taking higher doses.”
- “When demographic factors were controlled, patients who continued long-term use were more likely to have a diagnosis of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or psychosis and less likely to have depression or an alcohol or drug use disorder.”
A few thoughts:
1. This is a good paper.
2. It is also relevant: “Benzodiazepine use among adults in the United States is common and increasing… One in 10 U.S. adults reported past-year use of prescribed benzodiazepines.” And there is evidence that benzodiazepine use is trending up in Canada, as well. So… though this paper draws on American data, it’s relevant for clinicians here, too.
3. The data suggests a serious problem: long-term use, yes, and with a population that shouldn’t be using long term – that is, older people.
4. The clinical implications? When encountering patients on benzodiazepines, it’s important to start a conversation about reducing use, especially for long-term users.
The full Psychiatric Services paper can be found here:
The New York Times has an article on the vagus nerve. “In recent years, the vagus nerve has become an object of fascination, especially on social media. The vagal nerve fibers, which run from the brain to the abdomen, have been anointed by some influencers as the key to reducing anxiety, regulating the nervous system and helping the body to relax.”
The article notes the incredible attention on social media: “TikTok videos with the hashtag ’#vagusnerve’ have been viewed more than 64 million times and there are nearly 70,000 posts with the hashtag on Instagram. Some of the most popular ones feature simple hacks to ‘tone’ or ’reset’ the vagus nerve, in which people plunge their faces into ice water baths or lie on their backs with ice packs on their chests. There are also neck and ear massages, eye exercises and deep-breathing techniques.”
Though techniques to improve your vagus nerve “tone” are much discussed, evidence of improvements with mood (or anything else) are scant at best. TikTok, after all, is a great source for cat videos; health information, not so much.
The New York Times has an obituary for Sophie Freud.
“Sophie Freud, who fled the Nazi onslaught in Europe and escaped to the United States, where, as a professor and psychiatric social worker, she challenged the therapeutic foundation of her grandfather Sigmund’s theories of psychoanalysis, died on Friday at her home in Lincoln, Mass. The last surviving grandchild of Sigmund Freud, she was 97.”
The article details her life – and profound skepticism of her grandfather’s work.
“‘I’m very skeptical about much of psychoanalysis,’ she told The Boston Globe in 2002. ‘I think it’s such a narcissistic indulgence that I cannot believe in it.’”
It seems that the historical divides in psychiatry have been seen in the Freud family itself. The article doesn’t mention awkwardness at holiday gatherings for this clan.
The Globe and Mail has an article about adult ADHD with a catchy opening paragraph:
“Looking back, Pippa Boyd can see the telltale signs – like frequently getting in trouble in grade school for moving around too much, and needing an organizational system that relied heavily on cue cards to make it through nursing school – but only recently has she started to think she has ADHD.”
The article notes some anecdotal evidence of “an influx of Canadian adults” who are interested in diagnosis and treatment: a Burnaby, BC, clinic reports a 25% increase of referrals for adults who think they may have ADHD and a tripling of members for a Toronto, ON, support group.
The article goes on to quote experts who remind us that many may be undiagnosed. Fair points, all – though inattention during an uninteresting task isn’t necessarily the same thing as a disorder, as some patients may be inclined to believe. Dr. Google is a popular doc but of dubious clinical judgment, after all.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.