From the Editor
He cut himself out of frustration with a break-up. She came to the ED with suicidal thoughts after losing her job.
Some patients need help with ongoing self-harm and suicidal thoughts – but access to care is challenging, particularly for dialectal behavioural therapy. Could a simple intervention help? Could it be delivered virtually?
In the first selection, Dr. Gregory E. Simon (of Kaiser Permanente Washington Health Research Institute) and his co-authors detail a pragmatic randomized trial that evaluated two low-intensity outreach programs, aiming to reduce risk of self-harm and suicidal behaviour. In this new JAMA study, they conclude: “Compared with usual care, offering care management did not significantly reduce the risk of self-harm, and offering brief online dialectical behavior therapy skills training increased the risk of self-harm among at-risk adults.” We look at the study.
In the second selection, Thomas McLellan (of the University of Pennsylvania) and his co-authors note the failings of substance treatment and then mull a way forward: considering the approach to diabetic care and the concept of prediabetes. Should we embrace preaddiction? They write: “the diabetes example shows that an early intervention approach can work given a comprehensive, sustained effort.”
And in the third selection, Dr. Norman R. Greenberg (of Yale University) contemplates his patient’s psychosis and his approach. Drawing on an old Hasidic tale, this resident of psychiatry stops debating with his patient; he chooses to listen to him instead. He writes: “I may not always be able to convince others of my perspective, I hope that I am able to convince others that we share similar goals and that I care about them.”
Selection 1: “Effect of Offering Care Management or Online Dialectical Behavior Therapy Skills Training vs Usual Care on Self-harm Among Adult Outpatients With Suicidal Ideation: A Randomized Clinical Trial”
Gregory E. Simon, Susan M. Shortreed, Rebecca C. Rossom, et al.
JAMA, 15 February 2022
In studies including more than 80 000 people attempting or dying by suicide, greater than 60% had health care contacts in the prior 3 months. Self-report questionnaires or algorithms using electronic health record (EHR) data have been shown to accurately identify people at increased risk…
Prevention of suicidal behavior will require effective interventions scalable to the large population of people at risk. Structured psychotherapies such as dialectical behavior therapy (DBT) and cognitive behavior therapy have reduced suicide attempts in people accepting treatment after recent self-harm or hospitalization. Collaborative care and care management interventions may be associated with improved treatment adherence and symptom outcomes in people initiating treatment for specific mood and anxiety disorders. However, these effective clinical interventions have not been tested in broader populations, including those less likely to seek or accept treatment. Interventions limited to recent survivors of suicide attempt or others at highest risk cannot reach most people who attempt or die by suicide. Broad population-based suicide prevention programs are supported by before-after comparisons but not by randomized trials…
So begins a paper by Simon et al.
Here’s what they did:
“Pragmatic randomized clinical trial including outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at 4 US integrated health systems. A total of 18 882 patients were randomized between March 2015 and September 2018, and ascertainment of outcomes continued through March 2020… Patients were randomized to a care management intervention (n = 6230) that included systematic outreach and care, a skills training intervention (n = 6227) that introduced 4 dialectical behavior therapy skills (mindfulness, mindfulness of current emotion, opposite action, and paced breathing), or usual care (n = 6187). Interventions, lasting up to 12 months, were delivered primarily through electronic health record online messaging and were intended to supplement ongoing mental health care.”
Here’s what they found:
- A total of 18 644 patients were included in the analysis.
- Demographics. 48% were aged 45 years or older; most were female (67%).
- Self harm. A total of 540 participants had a self-harm event, including 45 deaths attributed to self-harm and 495 nonfatal self-harm events over 18 months following randomization.
- By arm. 3.27% in care management, 3.92% in skills training, and 3.27% in usual care.
- “Risk of fatal or nonfatal self-harm over 18 months did not differ significantly between the care management and usual care groups (hazard ratio [HR], 1.07…) but was significantly higher in the skills training group than in usual care (HR, 1.29…). For severe self-harm, care management vs usual care had an HR of 1.03… skills training vs usual care had an HR of 1.34.”
A few thoughts:
1. This is a solid study.
2. A quick summary: the interventions didn’t work.
3. There is much to like here: an RCT across multiple sites, 3 arms, practical interventions. One of the interventions was DBT skills – a focused version of the evidenced-based therapy.
4. Alas, see 2.
5. What to make of this RCT? Barbara Stanley and Dr. Lisa Dixon (both of Columbia University) weigh in with an accompanying editorial, “Health System–Based Low-Intensity Interventions to Prevent Self-harm Among Patients With Suicidal Ideation Disentangling the Effects of Implementation Strategies and Interventions.”
They make several points, including that “the choice of the study population should be considered.” They write: “An inclusion criterion of frequent suicidal ideation seems reasonable if the goal is preventing suicidal behavior. However, the vast majority of individuals with suicidal ideation never engage in self-harm behavior. In a 2008 report, Nock et al found that among 84 850 adults, the estimated lifetime prevalences of suicidal ideation, suicide planning, and suicide attempts were 9.2%, 3.1%, and 2.7%, respectively. Importantly, these authors also found that among those who had suicidal ideation, the probability of ever making a suicide attempt was 29.0% and was only 15.4% among those without a suicide plan. These observations were borne out in the data reported in Simon et al, which indicated that only 2.5% (n = 47) of their sample had a history of self-harm… Therefore, the majority of patients enrolled in this clinical trial never engaged in self-harm prior to enrollment and are likely never going to engage in this behavior. In other words, the study was likely underpowered to detect the self-harm outcome despite the power calculations reported.”
That editorial can be found here:
6. Low-intensity interventions are attractive, offering something for patients at a low cost. But we must be careful: some DBT for many might ultimately prove to be too little psychotherapy for those who actually need it.
7. Since the start of the pandemic, our interest in virtual therapies has grown, but this study offers a cautionary note: just because it’s online doesn’t mean it’s helpful.
The full JAMA paper can be found here:
Selection 2: “Preaddiction – A Missing Concept for Treating Substance Use Disorders”
Thomas McLellan, George F. Koob, Nora D. Volkow
JAMA Psychiatry, 6 July 2022
Despite decades of federal funding to develop and deliver treatments for individuals with serious addictions, treatment penetration rates are less than 20%. Facing a similar situation, the diabetes field increased treatment penetration and impact by identifying and intervening with early-stage diabetes, termed prediabetes. We use this example to illustrate the essential elements of this strategic clinical approach and discuss the changes that will be required within the substance use disorder (SUD) field to implement an analogous strategy. We suggest the DSM-5 diagnostic categories mild to moderate SUD as a starting operational definition for the term preaddiction, a commonly understood, motivating term that could engender broader clinical efforts to effect that strategy.”
So begins a paper by McLellan et al.
“In 2001, the American Diabetes Association strategically suggested the term prediabetes, operationally defined by elevated scores on 2 laboratory tests: impaired glucose tolerance and impaired fasting glucose. The term was purposely chosen to capitalize on public motivation to avoid serious diabetes. Advertising campaigns followed to raise public awareness and advocate for policy change. Partnerships with health care organizations and insurers led to creation and testing of new medications and interventions more appropriate to early-stage cases.”
They make several points, two of which are summarized here:
- “The diabetes field already had easy-to-use, insurance-reimbursed laboratory tests to define and detect prediabetes. No such objective tests are yet available in the SUD field, but efforts are underway to better characterize the neurofunctional domains indicating predisposition to addiction and its clinical course… The criteria defining mild to moderate SUD are one reasonable starting point for operationally defining preaddiction until more objective measures are developed.”
- “Importantly, the diabetes field did not simply prescribe insulin for those with prediabetes. Instead, they developed specially designed prediabetes medications and behavioral interventions. In the SUD field, screening, brief intervention, and referral to treatment and a computerized version of cognitive behavioral therapy for SUD both have potential as preaddiction interventions. However, a much broader range of medications and social support interventions are needed for those with early-stage SUD to arrest impaired control and/or to reduce the motivational properties of substances.”
A few points:
1. This is a good Viewpoint paper.
2. Drawing from the diabetes-prediabetes field is interesting. A focus on intervening early is attractive for substance use disorders.
3. But things are more complicated in mental health. Diagnosing prediabetes involves blood testing. We don’t have clear biomarkers for substance, of course. The focus on mild and moderate SUD is interesting – is it persuasive?
The full JAMA Psychiatry paper can be found here:
Selection 3: “When We Are the Delusional Ones”
Norman R. Greenberg
Academic Psychiatry, June 2022
‘So how do I know that you don’t have psychosis?’
I stood stunned for a moment after my patient David, as I’ll call him, asked me that question.
‘You are right. You don’t,’ I answered.
For several days, that exchange occupied my thoughts. David arrived on the inpatient psychiatric unit two weeks earlier, presenting with delusions and disorganized behavior. In speaking to him and hearing his history, it became clear that he was experiencing a psychotic episode and he believed that he was completely fine. My medical school lectures prepared me well for this diagnosis. But for several days, I struggled to find a way to convince David that he had an illness, and that we were there to help him.”
So begins an essay by Dr. Greenberg.
He then “drafted a note for his chart and checked off, ‘Insight: Poor’ from the dropdown menu.”
Unable to connect with patient after several attempts, he remembers an old Hasidic tale that he had read as a child:
“A king heard news of a new crop in the kingdom which gave the people a strange case of psychosis. The king consulted his top minister, who advised that they hoard some of the old crop for the king and the minister to maintain their sanity until the strange illness subsides. The king remarked, ‘But then we will be the only ones who do not eat from the new crop, and then we will be the delusional ones.’ The king decided that he and his minister would eat from the new crop, contract the delusional disorder, and mark each other’s foreheads. ‘When we see each other, we will be reminded that we are delusional.’”
He tries a different approach:
“I decided to stop mentioning his diagnosis of psychosis. Instead, I took an interest in his life, his hobbies, and his interests. Rather than attempting to change his beliefs, I tried to show David that we shared a common goal of getting him home safely. Eventually, our team was able to build a trust with him, even if he initially rejected any mention of psychosis. With the newfound trust, David took his medications, attended group therapy, and eventually was discharged.”
He thinks on the case:
“I realized that many of the challenges I faced with David were not limited to my time on the wards. I thought back to other encounters – like political debates or personal disagreements –when I could not convince others to agree with me. In those moments, I found it tempting to dismiss others as misguided or even delusional, ignoring that I too have my own biases and preconceptions, with my own ‘mark on my forehead.’”
A few thoughts:
1. This is a good essay.
2. Who hasn’t been in a situation of debating with a patient over a diagnosis – when time could have been better spent connecting with that individual?
3. Dr. Greenberg is a resident of psychiatry. His future is bright.
The full Academic Psychiatry can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.