From the Editor
Mindfulness is trendy. It’s offered at your local YMCA. There are mindfulness techniques in popular apps. Corporations offer sessions over the lunch hour.
But is it helpful? Millions of North Americans struggle with anxiety disorders. Could mindfulness help them? Is it an alternative for those who don’t want to take medications? In the first selection, Dr. Elizabeth A. Hoge (of Georgetown University) and her co-authors try to answer these questions. Their results have just been published in JAMA Psychiatry. In an RCT, they compare a form of mindfulness to the use of an SSRI. They write: “Our prospective randomized clinical trial found that MBSR was noninferior to escitalopram for the treatment of anxiety disorders.” We consider the paper and its clinical implications.
In this week’s second selection, we look at a new Quick Takes podcast interview with CAMH’s Stephanie Sliekers and Dr. Petal Abdool (of the University of Toronto). They discuss simulation in mental health education, noting the potential. They also talk about their innovative work in this area. “We can create an environment that’s safe, predictable, consistent, standardized, and reproducible.”
In this week’s third selection, Dr. Srijan Sen (of the University of Michigan) writes about physician burnout. In a Perspective paper published in The New England Journal of Medicine, he argues that separating burnout from depression is problematic. He writes: “Expanding reform efforts to encompass depression and mental health more broadly will not reduce the urgency of reforming our health care system. Rather, it will increase the likelihood that physicians who are struggling can access the spectrum of available evidence-based individual interventions.”
Selection 1: “Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial”
Elizabeth A. Hoge, Eric Bui, Mihriye Mete, et al.
JAMA Psychiatry, 9 November 2022 Online First
Effective treatments for anxiety disorders exist and include medications and cognitive behavioral therapy, but not all patients have access to them, respond to them, or are comfortable seeking care in a psychiatric setting. For example, nearly one-third of people surveyed in 1 study believed that psychiatric medication would interfere with daily activities, and about one-fourth believed it is harmful to the body…
Mindfulness-based interventions (MBIs) may be seen as a more acceptable option given that mindfulness meditation has recently become more popular. For example, in the US, approximately 15% of the population has tried meditation. Mindfulness meditation has been found to help reduce anxiety; a recent meta-analysis of trials with anxiety disorders found a significant benefit with mindfulness meditation compared with treatment as usual.
So begins a paper by Hoge et al.
Here’s what they did:
- They conducted an RCT with a noninferiority.
- Patients were recruited between June 2018 and February 2020.
- “The outcome assessments were performed by blinded clinical interviewer at baseline, week 8 end point, and follow-up visits at 12 and 24 weeks.”
- “Participants were 1:1 randomized to 8 weeks of the weekly MBSR course or the antidepressant escitalopram, flexibly dosed from 10 to 20 mg.”
- About the course: “MBSR is a manualized 8-week protocol with weekly 2.5-hour long classes, a day-long retreat weekend class during the fifth or sixth week, and 45-minute daily home practice exercises.”
- The primary outcome: anxiety levels as assessed with the Clinical Global Impression of Severity scale (CGI-S).
Here’s what they found:
- Participants were randomized to MBSR (n = 136) or escitalopram (n = 140).
- Demographics. Participants tended to be in their 30s (mean age of 33); the majority were female (75%); most were White (59%).
- Baseline. “Baseline mean (SD) CGI-S score was 4.44 (0.79) for the MBSR group and 4.51 (0.78) for the escitalopram group in the per-protocol sample and 4.49 (0.77) vs 4.54 (0.83), respectively, in the randomized sample.”
- Change. “At end point, the mean (SD) CGI-S score was reduced by 1.35 (1.06) for MBSR and 1.43 (1.17) for escitalopram.” See figure below.
- Adverse effects. “Of patients who started treatment, 8% dropped out of the escitalopram group and none from the MBSR group due to adverse events. At least 1 study-related adverse event occurred for 110 participants randomized to escitalopram (78.6%) and 21 participants randomized to MBSR (15.4%).”
A few thoughts:
1. This is a good study.
2. It adds nicely to the literature. As the authors note: “this is the first study comparing a standardized evidence-based MBI with a first-line medication for anxiety disorders.”
3. There is much to like here: a standardized approach to mindfulness, a trial across multiple sites, an RCT, a good follow-up period. Nice.
4. To summarize the results in five words: MBSR was non-inferior to escitalopram.
5. Like all studies, there are limitations, and the authors note several including: “Treatments in this study were not matched for time and attention, as participants in the MBSR group spent more time engaged in treatment-related activities than those in the escitalopram group, and this design allowed only for single-blinding procedures. However, this comparative effectiveness trial was designed to inform clinical decision-making in the real world rather than test the theoretical efficacy of 2 time-matched arms…”
6. From a clinical perspective, this study suggests a thoughtful, evidence-based alternative to medications. But, to be clear: MBSR involved more than a participant downloading an app and listening to actor Matthew McConaughey reading bedtime stories (as the Calm app offers); in addition to the classes, people committed to 45 minutes a day of mindfulness.
7. Mindfulness has been considered in past Readings. For instance, we looked at a paper by Breedvelt et al. comparing antidepressants and psychotherapies for relapse prevention, finding: “The sequential delivery of a psychological intervention during and/or after tapering may be an effective relapse prevention strategy instead of long-term use of antidepressants.” That Reading can be found here:
The full JAMA Psychiatry paper can be found here:
Selection 2: “Sim”
Petal Abdool and Stephanie Sliekers
Quick Takes, November 2022
Forget the traditional approach to med education – a world of textbooks, highlighters, and classrooms. In today’s episode of Quick Takes (part of our innovation series), we focus on simulation-based education in mental health. I speak with Dr. Petal Abdool and Stephanie Sliekers.
We highlight from the podcast.
Dr. Petal Abdool, Medical Director of the CAMH Simulation Centre, and Stephanie Sliekers, Manager of Simulation and Digital Innovation at CAMH
What is sim?
Stephanie Sliekers: “It’s a form of learning, and in our context health professional learning, where you’re doing more than just receiving knowledge, you’re actually applying knowledge and learning through experience… We actually try and recreate the world of clinical practice in various forms. We can do it with actors, in virtual reality or with mannequins. And we do this with the hope of actually creating change in the real world of clinical practice.”
Sim and opioids
Petal Abdool: “So we’re actually brainstorming about the content for an opioid overdose virtual reality scenario. Ideally, the patient will be unconscious and the goals: how to reverse and how to manage a patient who has overdosed.”
Petal Abdool: “VR sounds exciting, but it’s costly and resource intensive, needing the headset or desktop to use (and the headsets run at a cost thousands of dollars). So you see that there are limiting factors…”
Evaluation of sim
Stephanie Sliekers: “A number of ways that we evaluate our simulation education offerings are to do pre- and post-evaluations of improvements in knowledge, skills and attitude, as well as intention to change practice. So we are trying to examine not only the satisfaction or interest and enjoyment of a learning experience, but actually how has their participation in that potentially contributing to their practice change.”
The above answers have been edited for length.
The podcast can be found here, and it’s 13 minutes long:
Selection 3: “Is It Burnout or Depression? Expanding Efforts to Improve Physician Well-Being”
The New England Journal of Medicine, 3 November 2022
Awareness of physician burnout in the United States has increased dramatically. So far in 2022, there have been 10 times as many published scholarly articles on burnout as there were 20 years ago, and the National Academy of Medicine and the U.S. Surgeon General’s office have recently published reports on clinician burnout. This growing attention has helped to reduce the stigma associated with burnout, highlighting the health care system, rather than the individual, as the primary driver of the problem.
However, this progress in stigma reduction has largely been limited to burnout – to the exclusion of mental health conditions such as anxiety, suicidality, and, most notably, depression. In fact, efforts to destigmatize burnout have often emphasized a strong distinction between burnout and depression, in the hope of clarifying that burnout is not the result of individual weakness.
So begins a paper by Dr. Sen.
He argues that the distinction is problematic. “Although this framing is attractive in its simplicity, it is inconsistent with the preponderance of research. Furthermore, it has the unintended consequence of perpetuating misunderstandings and stigma associated with depression and deters us from fully utilizing the tools that have been developed for preventing and treating depression in our efforts to improve clinician well-being.”
He draws from the literature:
- “Part of the confusion stems from the varying definitions of burnout employed by various studies. One review identified 142 different definitions of physician burnout in 182 studies.
- “Among the tools for diagnosing and assessing burnout, the most commonly used is the Maslach Burnout Inventory… The core component, emotional exhaustion, actually has a stronger correlation with depressive symptoms than it does with the other two components of burnout.”
“[D]espite the conceptualization of burnout as being unique as a work-related phenomenon, work-related stress is the primary driver of depression among physicians. A stark illustration of this dynamic is the fact that the prevalence of depression among training physicians before they enter residency is similar to that among young adults in the general population, but depression rates quintuple immediately after residency begins. This dramatic increase indicates that the conditions of practicing medicine, rather than individual factors, are driving depression among physicians.”
He continues: “Furthermore, the specific work-related factors (e.g., workload and workplace environment) and non–work-related factors (e.g., personality traits and mental health history) that predict the development of depression are almost identical to those that predict the development of burnout. Overall, the relative importance of work-related factors and non–work-related factors is similar for depression and for burnout. Although researchers should continue to assess whether burnout is meaningfully distinguishable from depression, the argument that depression and burnout are caused by fundamentally different precipitants is unsupported by the evidence to date.”
He then suggests implications for care and organization.
A few thoughts:
1. This is an interesting and well-written essay.
2. Is it persuasive? The author links burnout with depression, and he rightly notes the overlap between them. To play the Devil’s advocate: is the connection overstated? Consider that in a recent CMA survey, roughly half of the doctors reported having burnout. Are half of all doctors in Canada really struggling with major depressive disorder? Dr. Sen seems to suggest that they are, or at least they are at very high risk of developing depression.
3. A line worth repeating: “So far in 2022, there have been 10 times as many published scholarly articles on burnout…” #Progress
4. Burnout has been considered in past Readings. In December, we looked at a Quick Takes podcast with Dr. Jillian Horton (of the University of Manitoba). She commented on medical culture: “We’re taught to disembody. We are taught to work through our fatigue, our hunger, our intense emotions. We’re not really taught to be mindful about those things and learn to coexist with them. We’re taught to ignore them, to bury them deep.” That Reading can be found here:
The full NEJM paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.