From the Editor
Can a sleep intervention reduce suicidal thoughts in those with depression and insomnia?
When seeing people with depression, we often tend to focus on the Big Problem: that is, the major depressive disorder itself. But should we also consider trying to provide early symptomatic relief, with, say, a sleep medication?
In the first selection, we look at a new paper from The American Journal of Psychiatry. Dr. William V. McCall of the Medical College of Georgia at Augusta University and his co-authors write about the REST-IT study, a randomized controlled trial of zolpidem-CR for those with MDD and insomnia. “The results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia…”
Sleeping Like a Baby: Fewer Suicidal Thoughts?
In the second selection, the University of Western Ontario’s Rebecca Rodrigues and her co-authors consider involuntary psychiatric admissions and ethnic minority groups in the context of early psychosis. Spoiler alert: “African and Caribbean groups were the most likely to experience an involuntary admission…”
And in the third selection, phyisician Jill Halper wonders: is depression like cancer? “My rabbi said that my husband, like a dying cancer patient, had been in hospice care. We just didn’t realize it.”
Selection 1: “Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT): A Randomized Clinical Trial”
William V. McCall, Ruth M. Benca, Peter B. Rosenquist, Nagy A. Youssef, Laryssa McCloud, Jill C. Newman, Doug Case, Meredith E. Rumble, Steven T. Szabo, Majorie Phillips, Andrew D. Krystal
The American Journal of Psychiatry, 20 September 2019 Online First
In the United States, there have been recent reductions in mortality related to medical illness, but mortality rates from suicide steadily increased from 12.5 to 15.0 per 100,000 annually between 2001 and 2015. Insomnia has been identified as a risk factor for suicidal ideation, suicidal behavior, and suicide death (hereafter collectively termed ‘suicide’), but thus far there have been no randomized clinical trials examining whether targeted pharmacologic treatment of insomnia would reduce the risk of suicide. It is reasonable to hypothesize that hypnotic medication might reduce the risk of suicide because changes in insomnia symptoms precede suicidal ideation. Patients with insomnia and survivors of suicide attempts show poorer performance on standardized measures of interpersonal problem solving compared with psychiatric patients who have not made a suicide attempt, as well as poorer performance in attention, working memory, and executive function. Thus, the impaired problem solving associated with insomnia could play a role in suicide. Hypnotic medication might reduce suicidal ideation, but the possibility of benefit from hypnotics must be balanced against the risks of suicide associated with hypnotics.
To examine the effect of treatment of insomnia on suicide risk, we conducted the randomized clinical trial Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT) to study the effects of placebo relative to a bedtime dose of controlled-release zolpidem (zolpidem-CR), a hypnotic medication, on suicidal depressed outpatients with insomnia who were receiving open-label selective serotonin reuptake inhibitors (SSRIs). Our hypothesis was that the addition of zolpidem-CR would result in greater reduction of suicidal ideation.
So begins a new paper by Dr. McCall and his co-authors.
Here’s what they did:
- The study was an 8-week double-blind parallel-group randomized controlled trial of zolpidem-CR compared with placebo across multiple sites (including Duke University and the University of Wisconsin).
- Participants were 18- to 65-year-olds and with major depressive disorder (confirmed with a SCID), insomnia, and suicidal ideation.
- Exclusion criteria included a positive urine drug test.
- Suicidal ideation was the main outcome, measured first by the Scale for Suicide Ideation and second by the Columbia–Suicide Severity Rating Scale (C-SSRS).
Here’s what they found:
- 103 participants were randomly assigned to receive zolpidem-CR (n of 51) or placebo (52).
- “The majority of participants were women, and 39% of the sample represented minorities. Generalized anxiety disorder and posttraumatic stress disorder were present in 40% and 28% of the participants, respectively, at baseline.”
- “The zolpidem-CR group immediately showed more improvement in Insomnia Severity Index scores compared with the placebo group, with a significant advantage during the period of randomized treatment.”
- “No significant treatment effect was observed on the Scale for Suicide Ideation…” But “improvement in insomnia was significantly positively related to improvement in insomnia after accounting for the effect of other depression symptoms.”
- The C-SSRS indicated that zolpidem-CR had a significant treatment effect.
In other words, the results were mixed.
The authors conclude: “Although the results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia, they suggest that coprescription of a hypnotic during initiation of an antidepressant may be beneficial in suicidal outpatients, especially in patients with severe insomnia.”
Taking a step back: the trial didn’t work, at least in terms of showing improvement with the Scale for Suicide Ideation. That said, the final conclusion seems reasonable if somewhat unexciting.
Selection 2: “Risk of involuntary admission among first-generation ethnic minority groups with early psychosis: a retrospective cohort study using health administrative data”
Rebecca Rodrigues, Arlene G. MacDougall, Guangyong Zou, Michael Lebenbaum, Paul Kurdyak, Lihua Li, Salimah Z. Shariff and Kelly K. Anderson
Epidemiology and Psychiatric Sciences, 15 October 2019 Online First
International evidence has demonstrated notably higher rates of involuntary admission among some ethnic minority groups, with the largest risk observed among Black-Caribbean and Black-African patients compared with White patients, and moderate risk for South Asian patients. Early studies on ethnic differences in involuntary admission in the context of first-episode psychosis did not tend to find these differences, leading to the theory that this excess develops over time as a result of repeated negative interactions with mental health services. Subsequent larger-scale studies have provided evidence that disparities among Black-Caribbean and Black-African patients are evident at the first episode – findings supported by recent meta-analytic evidence showing no subgroup differences between the risk of first involuntary admission v. readmission. Less evidence exists regarding involuntary admission among other ethnic minority groups with early psychosis, given that these groups tend to be underrepresented in prior studies.
These disparities in service experiences among ethnic minority groups early in the course of psychotic illness may have long-term consequences.
So begins a paper by Rodrigues et al.
Here’s what they did:
- Drawing on administrative databases, including the Ontario Mental Health Reporting System (OMHRS), they “constructed a retrospective cohort (2009–2013) of people with first-onset non-affective psychotic disorder aged 16 – 35 years.”
- They considered the first involuntary admission and the risk of involuntary admission for first-generation migrant groups to the general population.
- Comparisons were made (using country of birth) for the risk of involuntary admission among ethnic minorities to a European reference.
Here’s what they found:
- 15 844 incident cases of psychotic disorder with 19% first-generation migrants (n of 3049).
- The majority were male in most groups.
- The risk of involuntary admission was higher than the general population in five of seven ethnic minority groups.
- “African and Caribbean groups were the most likely to experience an involuntary admission, with a 52% and 58% increased risk of involuntary admission, respectively.” See table below.
Ouch. What explains the findings? Certainly, several ideas come to mind. Drawing from the literature, the authors mull various explanations, including social isolation (“the absence of someone to facilitate help-seeking”), more severe clinical presentation, and “racial discrimination in which Caribbean patients are more likely to be perceived as violent or threatening.”
What are the policy implications? “Taken together with previous Canadian evidence similarly revealing inequities in mental health service use in early psychosis, our findings highlight the need for policy initiatives aimed at improving pathways to care in first-generation ethnic minority groups with early psychosis – particularly in Caribbean and African communities.”
This is a good and important study.
Selection 3: “When Depression Is Like a Cancer”
The New York Times, 26 September 2019
Depression is not cancer. It’s a completely different disease. Yet when I look back on my husband’s depression and death by suicide three years ago, it sure looks a lot like cancer to me.
As an adolescent medicine physician in Los Angeles, I have cared for many patients with depression and mental illness, and as a pediatric resident in training, I also cared for many children with cancer. But the difference in how people view these illnesses is astounding.
So begins an essay by Dr. Halper.
She describes her husband’s illness, comparing it to the course that a person may have with cancer.
After his first suicide attempt, he successfully went through intensive treatment of his disease – comparable to the radiation and chemotherapy phase of cancer treatment – and his disease went into remission. He did everything a cancer patient would have done to prevent a recurrence: He faithfully checked for the earliest signs of the disease returning, and minimized his risk factors.
Just as cancer may go into remission but still kill in the end, depression is a chronic disease that may ultimately prove fatal even with state-of-the-art care and resources. Not all cancers can be cured. Nor can all depressions. With the strong foundation of our love and his excellent care, my husband had almost 20 years of remission before succumbing to his disease.
Depression isn’t cancer, of course, but she raises good points. We tend to see major depressive disorder as episodic – but for many of our patients, the illness is chronic, often returning years even decades after the first episodes. It is also a life-threating illness.
The essay describes well the challenges of caring for a loved one with mental illness – even for a physician.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.