From the Editor
Many in high-income nations don’t receive needed mental healthcare. Moreover, problems run deeper in countries like India, where only about 4% of patients with depression receive minimally adequate treatment, due to the higher prevalence of stigma and the limited number of providers.
Could anti-stigma campaigns make a difference? Could technology be leveraged to reach those at high risk? In the first selection, Dr. Pallab K. Maulik (of the University of New South Wales) and his co-authors seek to answer these questions in a new paper for JAMA Psychiatry. They report the findings of a major study involving 44 primary health centres and nearly 10 000 participants across the states of Haryana and Andhra Pradesh in India. The interventions included both anti-stigma campaigns and an app designed to guide and prioritize care. “There was a significant difference in mean depression scores between intervention vs control groups at 12 months, with lower scores in high-risk cohort.” We discuss the paper and its implications.
In the second selection, Dr. Neil Krishan Aggarwal (of Columbia University) bemoans global conflicts and wonders about the role of psychiatry in a Viewpoint for JAMA Psychiatry. Noting that psychiatry helped create a less formal type of diplomacy, called Track II, he questions what role psychiatry might play in the future. “Mental health professionals can encourage dialog among foreign policy elites to reduce the possibility for military conflict.”
And in the third selection from Schizophrenia Bulletin, Constanza Morén (of the University of Barcelona) writes about her father who was a “magnificent person.” He was also an individual with schizophrenia. She discusses his journey and his challenges he faced within the healthcare system. “Patients live with their own voices, but, in a way, they need the rest of us to also give them a voice.”
DG
Selection 1: “Mental Health Care Support in Rural India: A Cluster Randomized Clinical Trial”
Pallab K. Maulik, Mercian Daniel, Siddhardha Devarapalli, et al.
JAMA Psychiatry, 14 August 2024 Online First
Mental illness, behavioral disorders, and self-harm account for about 16% of all disability adjusted life-years (DALYs) worldwide. In India, the National Mental Health Survey estimated the lifetime prevalence of any mental disorder among adults is 15%, with nearly 150 million people in need of treatment and a doubling of disease burden since 1990…
Given limited trained mental health professionals, alternative solutions that involve delivery of mental health care by upskilling primary care physicians and community health workers holds promise. The Indian government contracts village-based community health workers known as Accredited Social Health Activists (ASHAs), with one ASHA servicing a population of about 1000 individuals… ASHAs are provided basic training in health services delivery supporting the government maternal and child health programs on a part-time (2 to 3 hours per day) contractual basis… The potential benefits of an electronic decision support system in managing different health conditions, including mental health, have been demonstrated mainly in high-income countries; however, few studies demonstrated improvements in clinical outcomes.
So begins a paper by Maulik et al.
Here’s what they did:
- They conducted “a parallel, cluster randomized, usual care-controlled trial” with blinded follow-up assessments at 3, 6, and 12 months.
- High risk group. They defined those at high risk as having high scores on the Patient Health Questionnaire-9 item (10 or greater), a Generalized Anxiety Disorder-7 item (10 or greater), or the self-harm/suicide risk question on the PHQ-9 (2 or greater). There was also a second cohort: adults who were selected randomly from the remaining screened population.
- The anti-stigma intervention included all participants and consisted of pamphlets and posters, as well as “videos of people with mental disorders and their caretakers talking about their illnesses and a local celebrity emphasizing treatment for mental disorders…” There was also a digital mental health intervention for those at high risk. “Physicians were trained in identification and clinical management of [common mental disorders] using an app, based on recommendations from WHO’s mhGAP guidelines. The physicians used psychoeducation, brief counseling (talk therapy), and, where indicated, medication treatment…” Patients could be referred to a specialist if the algorithm suggested it.
- Primary outcomes: mean PHQ-9 scores in the high-risk cohort and mean behavior scores in both cohorts (using the Mental Health Knowledge, Attitude, and Behavior scale).
Here’s what they found:
- 9 928 participants were recruited.
- Demographics. 3 365 were at high risk and 6 563 not at high risk. 57% were female with a mean age of 43 years.
- Follow up. 91.2% followed up at 12 months.
- PHQ-9. “Mean PHQ-9 scores at 12 months for the high-risk cohort were lower in the intervention vs control groups (2.77 vs 4.48; mean difference, −1.71…).”
- Remission rate. “The remission rate in the high-risk cohort (PHQ-9 and GAD-7 scores <5 and no risk of self-harm) was higher in the intervention vs control group (74.7% vs 50.6%; odds ratio [OR], 2.88…).”
- Behavior scores. “Across both cohorts, there was no difference in 12-month behavior scores in the intervention vs control group (17.39 vs 17.74; mean difference, −0.35…).”
A few thoughts:
1. This is a good study with a practical approach, involving an impressive number of people across two states in India, and published in a major journal.
2. The main finding in two sentences: for those at risk, “there were large reductions in risk of depression, anxiety, and self-harm risk with a 3-fold increase in odds of remission (effect size 0.6).” But “[f]or the total adult population, the intervention did not demonstrate improvements in behavior scores at 12 months.”
3. Patients appeared to have benefitted because of non-pharmacological management; only about 10% received meds. (!)
4. Though large and ambitious, the study didn’t employ a particularly remarkable digital intervention. What could things look like in the future with AI triaging patients? Or chatbots delivering psychoeducation and CBT in real time?
5. Of course, the interesting work here didn’t involve an app; it was the upskilling of community health workers. Are there lessons for other low- and middle-income countries? What lessons might there be for nations like Canada?
6. Why didn’t the anti-stigma campaign work?
7. Like all studies, there are limitations. The authors note several, including that scaling up beyond India may not be possible given the uniqueness of that country and its mental health needs.
8. Global psychiatry has been considered in past Readings, including one that summarized a podcast interview with Dr. Vikram Patel (of Harvard University). Dr. Patel discussed his work in Goa and the use of laypeople to deliver mental healthcare. You can find it here:
The full JAMA Psych study can be found here:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2822020
Selection 2: “Roles That Psychiatrists Can Play in International Negotiations to Reduce Conflict”
Neil Krishan Aggarwal
JAMA Psychiatry, 12 June 2024 Online First
The Israel-Palestine and Russia-Ukraine military conflicts have prompted members of the health care community to consider ways of reducing the risks of nuclear war. Some have suggested that scientists educate government policymakers about war’s drastic consequences. Others recommend that health professionals join organizations that are campaigning for nuclear de-escalation. To supplement these laudable initiatives, this Viewpoint discusses how mental health professionals can encourage dialog among foreign policy elites to reduce the possibility for military conflict.
So begins a Viewpoint by Dr. Aggarwal.
He argues that psychiatrists “have contributed to the science of international negotiations for decades.” He highlights Track II diplomacy – “defined as unofficial meetings among people with access to government policymakers – to supplement official Track I diplomacy among currently serving officials.” The concept was first proposed by psychiatrist William Davidson and American diplomat Joseph Montville who were “realistic about Track II’s goals, writing that, ‘Political psychological analysis will not eliminate such concrete problems as territorial boundary disputes or allocation of water and mineral sources. But it can help illuminate human barriers to the resolution of human problems.’”
“Psychological concepts have helped diplomats understand their defense mechanisms, sources of their worldviews, leader-follower relationships, transference dynamics among negotiating teams, and large-group identities.”
He notes that after Egyptian President Anwar Sadat addressed the Israeli Knesset in 1977, the “American Psychiatric Association convened Egyptian, Israeli, and Palestinian psychiatrists, psychologists, and diplomats for Track II negotiations from 1979 to 1986.” He also writes about his own role. Working with Amarjit Singh Dulat (who once served as Special Director of India’s Intelligence Bureau) and Asad Durrani (who had served as Director General of Pakistani’s Military Intelligence), he organized several videoconferences that explored different themes, including the psychology of spycraft, their transitions into peacemaking, and cultural, ethnic, and religious similarities or differences between Indian and Pakistani people. (Remember: these two countries have had several wars over the years.)
He forwards several suggestions, in part based on these conversations:
Medical conferences offer rare opportunities for people in hostile countries to interact because scientific developments that affect all humans are emphasized over partisan political agendas.
He notes that governments often send delegations, including people from the intelligence and military communities. Thus, “organizations such as the World Psychiatric Association, the Global Psychology Alliance, and the World Health Organization are ideal venues for mental health professionals to facilitate peace-building initiatives among people whose governments are in conflict.”
Mental health professionals who moderate negotiations can draw on the psychological concept of the frame to clarify each stakeholder’s roles and responsibilities and the problems that interfere with sessions.
“Helpful ground rules include all participants interacting civilly, listening with respect, not interrupting one another, and allowing each person to present views comprehensively. For negotiations to be successful, participants must try empathizing with the other government’s positions rather than simply repeating their own.”
Mental health professionals may be asked to propose solutions to specific issues after parties reach an impasse.
“Clarifying the sources of an impasse are vital, as individuals may be reacting to situations based on personal defense mechanisms or worldviews, social pressures from others (such as political leaders), and official policies. Mental health professionals can help participants explore their individual reactions and social pressures.”
A few thoughts:
1. This is a timely Viewpoint.
2. The role of psychiatry in the development of Track II negotiations is interesting and well described.
3. To play the Devil’s advocate: is the author overly hopeful about the potential role of psychiatry in conflict and conflict resolution? Is the author right in his suggestion that the problem with, say, Ukraine-Russia negotiations is the lack of psychiatrists pushing their respective leaders on (psychoanalytic) defense mechanisms?
The full JAMA Psych Viewpoint can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2819862
Selection 3: “Let’s Give a Voice to Schizophrenia”
Constanza Morén
Schizophrenia Bulletin, 9 June 2024
My father was a magnificent person and the best dad a girl could have. My first memories with him are blurred. I remember him tying my shoelaces with a calmness that hypnotized me, and comforting me while I cried desperately watching my pinky gush blood as I held it up. When my parents separated, I was 5 years old, and he continued to be a father like no other. He made me the best French omelet in the world, he still walked me to school every day holding my hand, and he patiently taught me and my two sisters to ride bicycles, and later to drive… He worked his entire life, had a great sense of responsibility, and was a good contributor to our public system. My father also had paranoid schizophrenia, officially diagnosed in his thirties, which accompanied him until the spring of 2023, when he finally became free. However, as you can see, this was only one of the facets of his wonderful persona.
So begins an essay by Morén.
She starts by discussing herself. “I could have inherited some genetic risk factor from him, but, overall, I inherited the stubbornness that allowed me to complete a PhD in biomedicine. Over the years, I have specialized in neurosciences and I am currently coordinating the first monographic schizophrenia research lab in Spain…” Despite significant scientific breakthroughs, Morén notes: “our society still does not know to deal, at least not appropriately, with people like my father.”
She describes her father’s struggles. “My father experienced hallucinations and, in the last years of his life, he could barely move due to the extrapyramidal effects (motor symptoms) derived from the haloperidol, a drug developed more than 60 years ago that still remains a symptomatic treatment of choice. Nineteen years ago my father decided to stop the medication and deal with his monsters, bareback. Like him, a large number of patients are not able to maintain adherence to treatment. This is not surprising, since current drugs stop delusions but are not really effective against the disease and are associated with serious adverse events. In short, my father had become a persecuted person who could not run away, physically or mentally, from his enemies.”
Yet, his resilience was palpable. “It was luck, or maybe the love from his daughters and sisters, that made it possible for my father to far exceed, at 79, the average life expectancy of schizophrenia patients, who usually die prematurely due to the high suicide rate or the lack of correct continuous medical follow-up.”
Morén then pivots to discuss how “we never knew how to help him.” In his last years, despite speaking with numerous institutions and healthcare professionals, “the only way out was to disqualify my father, to incapacitate him, to take him to court, and remove his autonomy, his freedom. The public system’s solution was to ‘betray’ him…” Her realization is disheartening: “He would have lost trust in the handful of people whom he could already hardly trust. We moved heaven and earth yet were unable to help my father because, neither he nor the system made it easy for us.”
She further illustrates the lack of support from the healthcare system. “My father spent his last weeks between the hospital and a nursing home. There he had to let himself be cared for by unknown people. That must have been stressful for him like dropping a newborn baby on a parachute.”
Morén feels that there are more compassionate approaches and likes the concept of a Reserved Therapeutic Space – which prioritizes giving hospitalized patients with mental illness a voice and attending to their needs in a “private space, in a personalized way, with respect and empathy.” Morén concludes with an important call to action, for an improved system, and for “more humanity and research in favor of schizophrenia patients and their families.”
A few thoughts:
1. This is an impactful essay.
2. Regardless of your views on the practicality of ideas like Reserved Therapeutic Space, we can all agree that legal systems are poorly equipped to deal with the realities of chronic mental illness.
3. The first line was particularly beautiful and worth repeating. “My father was a magnificent person and the best dad a girl could have.”
The full Schizophr Bull paper can be found here: https://academic.oup.com/schizophreniabulletin/advance-article/doi/10.1093/schbul/sbae091/7690203
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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