From the Editor
He diagnosed himself. My patient suspected something was wrong, did some reading, and then completed a PHQ-9 survey (which he found on a website). But, like many, he struggled to get care.
The story is too familiar. Access to care is deeply problematic. Not surprisingly, then, low-cost interventions are of interest, with much work focused on CBT. What about mindfulness? In the first selection, Clara Strauss (of the University of Sussex) and her co-authors attempt to answer that question with direct comparison of mindfulness and CBT. In a new JAMA Psychiatry paper, they find: “practitioner-supported [mindfulness] was superior to standard recommended treatment (ie, practitioner-supported CBT) for mild to moderate depression in terms of both clinical effectiveness and cost-effectiveness.” We consider the paper and its implications.
In the second selection, Keith Humphreys (of Stanford University) and Chelsea L. Shover (of the University of California, Los Angeles) look at overdose deaths in older Americans for JAMA Psychiatry. Drawing on a database, they find a quadrupling between 2002 and 2021. “Even though drug overdose remains an uncommon cause of death among older adults in the US, the quadrupling of fatal overdoses among older adults should be considered in evolving policies focused on the overdose epidemic.”
And in the third selection, Dr. Ethan L. Sanford (of the University of Texas) writes about the loss of his infant daughter. In a deeply personal essay for JAMA, he describes her illness and death – and his re-evaluation of his career. “I sometimes wish every physician could understand the loss of a child. I wish they could understand how I miss Ceci achingly, how I miss her in my bones.”
Selection 1: “Clinical Effectiveness and Cost-Effectiveness of Supported Mindfulness-Based Cognitive Therapy Self-help Compared With Supported Cognitive Behavioral Therapy Self-help for Adults Experiencing Depression: The Low-Intensity Guided Help Through Mindfulness (LIGHTMind) Randomized Clinical Trial”
Clara Strauss, Anna-Marie Bibby-Jones, Fergal Jones, et al.
JAMA Psychiatry, 22 March 2023
Depression has a lifetime prevalence of 10.8% worldwide. It is often recurrent and has significant personal and economic consequences. Despite this, there is a well-established treatment gap whereby most people with depression do not have access to evidence-based treatments…
To widen access, cognitive behavioral therapy self-help (CBT-SH) supported by a trained practitioner is recommended in the treatment of mild to moderate depression in national treatment guidelines. CBT for depression explores and evaluates the interrelationships between thoughts, feelings, physical sensations, and behaviors in the maintenance of depression, along with the historical antecedents of unhelpful thinking patterns. The effectiveness of specialist CBT for depression offered by highly trained CBT therapists is well established; however, CBT-SH appears less acceptable, with higher rates of dropout…
Mindfulness-based cognitive therapy (MBCT) is an in-person group program recommended in national treatment guidelines for depression. Mindfulness involves deliberately bringing nonjudgmental awareness to present-moment experiences (eg, thoughts, feelings, physical sensations, behavioral urges), and this skill can be cultivated through mindfulness practice. In MBCT, daily mindfulness practice supported by verbal guidance and therapist-led discussion is combined with CBT for depression… Practitioner-supported MBCT-SH is one solution to widen access… A randomized clinical trial (RCT) with students found that unsupported-MBCT-SH was superior compared with waitlist in reducing depression symptom severity, and another RCT found practitioner-supported MBCT-SH superior in reducing depression symptom severity compared with usual care for adults experiencing residual symptoms of depression.
So begins a paper by Strauss et al.
Here’s what they did:
“This was an assessor- and participant-blinded superiority randomized clinical trial with 1:1 automated online allocation stratified by center and depression severity comparing practitioner-supported MBCT-SH with practitioner-supported CBT-SH for adults experiencing mild to moderate depression. Recruitment took place between November 24, 2017, and January 31, 2020. The study took place in 10 publicly funded psychological therapy services in England (Improving Access to Psychological Therapies [IAPT])… Participants met diagnostic criteria for mild to moderate depression. Data were analyzed from January to October 2021.” In terms of the intervention: “Participants received a copy of either an MBCT-SH or CBT-SH workbook and were offered 6 support sessions with a trained practitioner.” The primary outcome was measured by Patient Health Questionnaire (PHQ-9) score at 16 weeks.
Here’s what they found:
- 600 were eligible and 410 were randomized.
- Demographics. 255 (62.2%) were female with a median age of 32. The vast majority were White British or White Irish (85%+) and employed (75%).
- Depressive symptoms. At 16 weeks, there was “statistically significant superiority in favor of MBCT-SH (mean [SD] PHQ-9 score, 7.2 [4.8] points vs 8.6 [5.5] points; between-group difference, −1.5 points…).” See figure below.
- Cost effectiveness. “The probability of MBCT-SH being cost-effective compared with CBT-SH exceeded 95%.”
- Adverse events. “There were 3 serious adverse events (1.5%) in the MBCT-SH arm and 0 in the CBT-SH arm. All serious adverse events were deemed unrelated to the intervention by the independent clinical reviewer.”
A few thoughts:
1. This is a good study and there is much to like here: it’s an RCT, across multiple sites, published in a big journal, and the intervention is practical and thoughtful.
2. A three-word summary of the main finding: “the intervention worked.”
3. A two sentence summary: “The primary hypothesis was supported: practitioner-supported MBCT-SH was superior to practitioner-supported CBT-SH in reducing depressive symptom severity at postintervention follow-up. In addition, PWP [Psychological Well-being Practitioner]-supported MBCT-SH was found to be cost-effective compared with PWP-supported CBT-SH due to significantly lower total costs alongside similar QALY outcomes.”
4. Nice touch: people with lived-experience were involved in the study design and helped train the therapists.
5. What are the clinical implications? The authors see great potential in offering this form of therapist-supported self-help in the United Kingdom. The relevance in North America: we are looking for low-cost interventions here too, of course.
6. Like all studies, there are limitations. The authors note several, including “Confidence in findings is limited by study dropout.” They do note that drop-out rates tend to be high in self-administered psychological interventions.
The full JAMA Psychiatry paper can be found here:
Selection 2: “Twenty-Year Trends in Drug Overdose Fatalities Among Older Adults in the US”
Keith Humphreys and Chelsea L. Shover
JAMA Psychiatry, 29 March 2023
US opioid overdose deaths have been concentrated in the working-age population, but older adults may be at increasing risk as the baby boom generation ages. Approximately 2.0% of Medicare enrollees 65 years or older meet diagnostic criteria for a substance use disorder (SUD), and half of enrollees take 4 or more prescription drugs daily. Both factors may raise risk of intentional and unintentional overdose in individuals with and without SUD. We therefore assessed 20-year trends in drug overdose among older adults in the US.
So begins a brief report by Humphreys and Shover.
“Using the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) database, we calculated the annual overdose death rate from 2002 to 2021 for all US adults 65 years or older and contribution of overdose to all-cause mortality. For the most recent year (2021), we compared demographic characteristics, specific drug involvement, and manner of death (unintentional, intentional, or undetermined).”
Here’s what they found:
- “The rate of fatal drug overdoses among people 65 years and older quadrupled from 3.0 per 100 000 population (1060 deaths) in 2002 to 12.0 per 100 000 (6702 deaths) in 2021… with highest rates among non-Hispanic African American individuals (30.9 per 100 000).”
- “The share of all-cause mortality attributable to drug overdose increased 359% from 0.06% to 0.27% during this period… By 2021, 1 in 370 deaths among those 65 years and older was caused by an overdose.”
They close with some recommendations: “Safer prescribing initiatives (eg, addressing opioids and benzodiazepines) underway in many health care systems may help reduce the risk of overdose among older adults who have a high level of polypharmacy utilization. The Veterans Health Administration approach of developing algorithms to judge when a patient being prescribed an opioid is at high risk of an overdose and to provide that patient and family with the overdose rescue drug naloxone is a useful strategy that deserves adoption in other health care systems.”
A few thoughts:
1. This is interesting data.
2. Overdoses in this population remain rare – but the surge is clear. Substance is casting a larger shadow over our society and we see that in many ways, including overdoses in the elderly.
3. The policy recommendations make sense.
The full JAMA Psychiatry research letter can be found here:
Selection 3: “Losing Ceci”
Ethan L. Sanford
JAMA, 6 April 2023 Online First
Ceci died on December 5, 2022, and Terry died on November 11. Ceci was my daughter and Terry was my patient.
As a pediatric anesthesiologist and critical care physician, I had sometimes contemplated scenarios of my own children dying, particularly when patients I cared for died. My brain would put up defenses with vague thoughts like, ‘I can’t imagine.’ Grieving Ceci’s death has indeed been something I could not have imagined. The immense sadness that devolved into endless loops of ‘what-ifs,’ the sorrow melting into an overwhelming sense of failure, and the loss of my professional identity – these are all things I could not have imagined.
So begins an essay by Dr. Sanford.
He describes the death of his daughter as sudden but notes her health problems over the weeks preceding it: “We noticed progressive weakness in her right leg when she was 9 months old. On Ceci’s first birthday, she could not pull to stand or crawl. Every movement appeared to be a futile battle against gravity. After several visits to various physicians and physical therapists, Ceci underwent magnetic resonance imaging (MRI) on Halloween to rule out any structural abnormalities… There was a mass involving the nerves exiting Ceci’s lumbar and sacral spine.”
Her health deteriorated. “She underwent an 8-hour surgical biopsy with partial laminectomy. However, the type of tumor was never fully elucidated, despite extensive pathological testing including multiple external reviews.”
“After a scheduled outpatient follow-up MRI 5 weeks after her tumor was initially discovered, Ceci woke up cheerful as before. She came home, played, ate, went down for a nap, and never woke up.” He tried to resuscitate her but couldn’t.
Around that time, he started to take care of a young patient. “Terry drowned in a swimming pool during a family gathering on Labor Day and was brought to the pediatric intensive care unit (PICU). Although his heart had been revived, Terry’s brain suffered irreversible injury. His parents, Johnathon and Kathryn, struggled to understand the concept of brain death and felt the clinical team’s assessment was rushed. Wracked with sorrow, they turned to their Christian faith for guidance.”
Because of his daughter’s illness, he stepped away from Terry’s care. “We cried together and Johnathon prayed.” A short time later, Terry died.
As he dealt with his loss, he reached out. “One evening, I locked myself in our bedroom’s walk-in closet, which had been Ceci’s room – where she slept and where she died – and called Johnathon. I told him of my shame. I felt I had failed as a father and lost my identity as a doctor. My job as a physician was to save children, yet I couldn’t protect Ceci or save her life. Johnathon explained that I had misidentified myself. Yes, medicine is my job, but my identity is centered on who I am, not what I do. Johnathon told me that in all our time together in Terry’s room, he never expected I would save his son’s life. Rather, he saw me as a companion who might offer guidance and comfort.”
He concludes: “I wish every physician could understand – without going through the unimaginable – that our success in this profession isn’t defined by achieving external validation metrics but rather by our ability to care for and about our patients. I feared losing Ceci would untether me from life, from myself, from my profession, from any possibility of joy or meaning. With time, it has only intensified my appreciation for being a father and husband and for helping others to heal.”
A few thoughts:
1. What a beautiful essay.
2. I had a brief exchange with Dr. Nina Sanford, the wife of Dr. Sanford and Ceci’s mother. She commented that they had pored over the piece, examining “every word and comma.” The writing reflects that.
3. But the more remarkable aspect of the writing: it’s candor and rawness.
4. This sentence is worth repeating and thinking about: “Yes, medicine is my job, but my identity is centered on who I am, not what I do.”
5. Every doctor should read this essay.
The full JAMA paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.