From the Editor

Our patients tell similar stories about their experiences with depression: of strained and lost relationships, of job opportunities that didn’t work out, of the pain of the illness itself.

Could all this be avoided? The attractiveness of prevention is obvious. In the first selection, Willem Kuyken (of the University of Oxford) and his co-authors describe a program focused on those 11 to 16 years of age. In this new EBMH paper, they use mindfulness training. The intervention is randomized, involving 84 schools. They conclude: “In a fully powered, rigorous, cluster randomised controlled trial we found no support for our hypothesis that school-based mindfulness training is superior in terms of mental health and well-being compared with usual provision over 1 year of follow-up in young people in secondary schools.” We consider the paper and its implications.

In the second selection from Psychiatric Services, Gregory M. Smith (of the Allentown State Hospital) and his co-authors analyze Pennsylvania’s move to eliminate seclusion and restraint events. Drawing on nine years of data, they conclude: “The findings of this study provide compelling evidence that uses of seclusion and restraints can be reduced or eliminated in both civil and forensic populations, with benefits to both the persons being served and their support staff.”

And, in the third selection, lawyer Helen Morrison considers mental illness and stigma. In this essay for CBC First Person, she notes her own journey and her fears about how people would react to her having bipolar disorder. She finds support with her faith group and others. She writes: “I want people to know that being diagnosed with a mental illness need not be earth-shattering. Faulty brain chemistry should be seen as just another chronic medical condition.”


Selection 1: “Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial”

Willem Kuyken, Susan Ball, Catherine Crane, et al.

EBMH, August 2022

Mental health problems commonly have their first onset in adolescence. Of all mental health disorders that emerge during adolescence, depression has the largest impact on health throughout the life span in terms of years lost to disability. Preadult onset is associated with poorer lifetime mental health outcomes, greater impairments in social, emotional and occupational functioning, and reduced quality of life… There have been many calls to develop programmes for adolescents to reduce risk of mental ill-health and promote well-being. Because schools play a central role in the lives of children and families, they provide an opportune setting for promoting mental health and preventing mental health problems…

Our premise was that skills in attention and social-emotional-behavioural self-regulation underpin mental health and well-being across the full spectrum of well-being. As such, we suggest the need for a training method that focuses on teaching these skills, instead of focusing on reducing pathology-specific patterns of negative thinking and unhelpful behaviour. Our programme aims to examine one such method, school-based mindfulness training (SBMT), which is specifically designed to address those processes and can be used by young people across the spectrum of mental health.

So begins a paper by Kuyken et al.

Here’s what they did:

“MYRIAD was a parallel group, cluster-randomised controlled trial. Eighty-five eligible schools consented and were randomised 1:1 to TAU or SBMT, stratified by school size, quality, type, deprivation and region… SBMT comprised 10 lessons of psychoeducation and mindfulness practices. TAU comprised standard social-emotional teaching. Participant-level risk for depression, social-emotional-behavioural functioning and well-being at 1 year follow-up were the co-primary outcomes. Secondary and economic outcomes were included.”

Here’s what they found:

  • “Forty-three schools (3678 pupils) delivering SBMT, and 41 schools (3572) delivering TAU, provided primary end-point data.”
  • Demographics. Many were female (54.9%); most were White (75.7%); the mean age was 12.2.
  • “Analysis of 84 schools found no evidence that SBMT was superior to TAU at 1 year.”
  • “Standardised mean differences were: 0.005… for risk for depression; 0.02… for social-emotional-behavioural functioning; and 0.02 for well-being.”
  • “SBMT had a high probability of cost-effectiveness (83%) at a willingness-to-pay threshold of £20 000 per quality-adjusted life year.”
  • “No intervention-related adverse events were observed.”

A few thoughts:

1. This is an impressive study.

2. To summarize the results: school-based mindfulness training wasn’t superior to treatment as usual.

3. There is much to like here, including multiple sites and an impressive number of participants. The core idea, prevention, is very attractive. So, too, is the approach of a universally applied program avoiding stigma and reaching many.

4. In terms of the mindfulness, the first author has established himself in recent years as an exceptional thinker and researcher. Not surprisingly, the school-based mindfulness was thoughtful: “The intention is to introduce young people to a range of skills (eg, attentional control, self-regulation of thoughts, feelings and behaviours) and they were encouraged to use these in their everyday lives. There are resources to support SBMT teachers (course booklets) and worksheets and online mindfulness practices for students. Because implementation affects both reach and outcomes, all schools allocated to SBMT were supported through: information provision to school leadership teams, SBMT teacher selection and training, and support of at least one round of teaching the MT curriculum prior to teaching study students…”

5. Alas, see 2.

6. Is the problem the study design? Is mindfulness simply not practical in terms of depression prevention? Pim Cuijpers (of the Vrije Universiteit Amsterdam) writes an accompanying perspective paper, “Universal prevention of depression at schools: dead end or challenging crossroad?”

“We seriously have to consider that universal prevention of mental health problems in schools is not effective. It could, for example, be the case that the intervention, mindfulness, is not effective and that other interventions are effective, or that interventions aimed at students should be embedded in a broader package of school-wide measures to improve mental health problems, as is happening in other areas. Maybe the ‘usual care’ interventions are so good in high-income countries that a universal intervention has no additional effects… However, it is at least as probable that universal interventions in schools simply do not work or do not work enough to have a public health impact. The idea of teaching young people skills that they can use when they will develop mental health problems may simply not work.”

7. Mindfulness has been considered in past Readings, including another paper by Kuyken. Zen versus Zoloft can be found here:

The full EBMH paper can be found here:

Selection 2: “Effects of Ending the Use of Seclusion and Mechanical Restraint in the Pennsylvania State Hospital System, 2011–2020”

Gregory M. Smith, Aidan Altenor, Roberta J. Altenor, et al.

Psychiatric Services, 20 July 2022  Online First

The Pennsylvania Department of Human Services, Office of Mental Health and Substance Abuse Services (OMHSAS), was an early pioneer in reducing and ending the use of seclusion and restraint in its state hospitals and forensic centers. This renaissance in the care of people with mental illness has spread worldwide, with seclusion and restraint no longer viewed as treatments, but rather as treatment failures. Since 1990, members of past and present OMHSAS leadership teams have monitored the impact of seclusion and restraint reduction on safety and quality of care.

Despite concerns that ending the use of seclusion and restraint in mental health facilities would lead to increased assaults and injuries, the experience has been the opposite. Even though successful treatment approaches have been proven safe and effective in reducing seclusion and restraint, these containment procedures continue to be used at numerous facilities worldwide. Additionally, the use of containment procedures and forced medication continues to raise concerns about patient and staff safety worldwide.

So begins a paper by Smith et al.

Here’s what they did:

“This study examined data from adults ages ≥18 years civilly committed to the Clarks Summit, Danville, Norristown, Torrance, Wernersville, and Warren State Hospitals in Pennsylvania and those criminally committed to the Regional Forensic Centers at Norristown and Torrance State Hospitals between January 1, 2011, and December 30, 2020. These facilities provide acute and subacute levels of care to people in their geographic service areas.”

Here’s what they found:

  • Data included 3,989 adults committed to psychiatric hospitals and 3,548 adults committed to forensic hospitals.
  • Mechanical restraint and seclusion. “During the study, mechanical restraint was used 128 times and seclusion four times.”
  • Physical restraint. “Physical restraint use decreased from a high of 2.62 uses per 1,000 days in 2013 to 2.02 in 2020… The average length of time a person was held in physical restraint was reduced by 64%, from 6.6 minutes in 2011 to 2.4 minutes in 2020.”
  • “All safety measures improved or were unchanged.”
  • Focusing on non-forensic patients. Seclusion was used just three times; the last time: in July 2013. Mechanical restraint was applied 118 times; the last time: September 2015. Physical restraint use decreased from a high of 2.62 uses per 1,000 days in 2013 to 1.9 per 1,000 days in 2020.

A few thoughts:

1. This is an impressive study.

2. Seclusion and mechanical restraint use were sharply reduced. (!!) Wow.

3. The effort is impressive: covering multiple hospitals with different populations. Though the Pennsylvania experiment may not be applicable to every inpatient setting, it suggests that restraint and seclusion events can be reduced.

4. How did they achieve this? The authors note several factors including: “Pennsylvania’s ongoing emphasis on staff training, deescalation techniques, psychiatric emergency response teams, and the multipronged approach… contribute to a person-centered approach to care and treatment with significant benefits to staff and patients. Marked reduction in aggression, patient-to-patient and patient-to-staff assaults, and instances of self-injurious behaviors in the civil hospitals and forensic centers during this period all reinforce the utility of this approach.”

The Psychiatric Services paper can be found here:

Selection 3: I kept quiet about my mental illness, fearing how others would see me

Helen Morrison

CBC First Person, 5 July 2022

In squabbles with my siblings, we would casually toss out insults like ‘you’re crazy’ or ‘you’re a psycho.’ None of us actually knew anything about mental illness but we had the notion that people put in ‘loony bins’ were misfits and outcasts.

Much to my horror, I actually ended up being one of those ‘crazy’ people. I was committed to a psych ward twice in my thirties. I was initially misdiagnosed with postpartum psychosis after the birth of my daughter. I didn’t even know what a psychotic break was before I had one – basically it felt like I was dreaming while awake. But the magical thinking is all too real.

So begins an essay by Morrison.

She writes about her diagnosis: “Five years later, the diagnosis was bipolar disorder and, for me, earth-shattering. It was one thing to have a one-off humiliating experience but quite another to have a lifelong chronic mental illness… My initial reaction was bewilderment and disbelief because my self-image would not allow me to comprehend how I could possibly have a mental illness. I was a well-educated and capable professional and the mother of an adorable little girl. I was not one of those ‘crazy’ people!”

She hesitates to tell people. “For a long time, I only shared my diagnosis on a need-to-know basis and envied people who had physical illnesses and could be more readily open about their experiences. I saw how they received lots of sympathy, went to support groups, and were prayed for in church. I didn’t even talk about my mental illness with family as I had the sense I would be mostly seen as an embarrassment and a burden.”

She notes her decision to speak about her experiences with people in her faith group, starting with a retreat in 2003. She was surprised by the warmth of the reception. Since then she has continued to speak out. And while noting that people are more willing to talk about depression and anxiety, work needs to be done. “I still don’t hear much understanding or compassion for those of us who swim in the deep end of the pool. I fear the risk of reputational harm and automatically being considered as unstable by neighbours and acquaintances. Or being labelled as ‘crazy’ or a ‘psycho’ behind my back.”

A couple of thoughts:

1. This is a moving essay.

2. She makes good points. This line is particularly haunting: “[I] envied people who had physical illnesses and could be more readily open about their experiences.”

3. Stigma has faded – but it still exists. The decision of people like Morrison to speak out is very important.

The full CBC essay can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.