From the Editor
How to reduce alcohol consumption? That question is more relevant than ever, given evidence of increased use in Canada during the pandemic. Recently, Scotland has experimented with minimum unit pricing (MUP) – unlike a tax increase that raises the cost of all alcohol, MUP disproportionally affects low-cost wines and ciders, more likely to be consumed by heavy drinkers.
In the first selection, Grant M. A. Wyper (of the University of Glasgow) and his co-authors consider the Scottish data. In a new paper for The Lancet, they do an impressive analysis, with a controlled interrupted time series, looking at time before and after the MUP, and contrasting Scottish and (non-MUP) English data. They find: “The implementation of MUP legislation was associated with significant reductions in deaths, and reductions in hospitalisations…” We look at the paper and its implications.
In the second selection, George Musgrave (of the University of London) and his co-authors consider the connection between musicians and mental health. In a Comment for The Lancet Psychiatry, they note: “Great advances have been made in the field of musicians’ mental health.” But they argue that “further dialogue between all major stakeholders is needed if, collectively, we are to shape this emerging intervention landscape to serve the target population effectively, both the musicians themselves and the teams around them.”
And in the third selection, from the pages of the Daily Mail, Dr. Liz O’Riordan describes her career as a surgeon – and her secret battle with depression. In a personal essay, she talks about her decision to speak out. “I’ve got better at asking for help and looking after myself. But I’m not ashamed of depression. It’s part of me, and that’s OK.”
Selection 1: “Evaluating the impact of alcohol minimum unit pricing on deaths and hospitalisations in Scotland: a controlled interrupted time series study”
Grant M. A. Wyper, Daniel F Mackay, Catriona Fraser, et al.
The Lancet, 22 April 2023
Harmful alcohol consumption is a leading risk factor of the global disease burden. In 2021, the highest number of deaths from alcohol-specific causes on record were reported for the UK. Within the UK, health harms from alcohol are disproportionately higher in Scotland…
As part of a comprehensive strategy to reduce levels of alcohol consumption and related harms, Scotland became one of very few countries in the world to implement minimum unit pricing (MUP), of £0.50 per unit, for alcoholic drinks sold directly to the public. The legislation was introduced on May 1, 2018… [F]ollowing 3 years of MUP legislation, alcohol sales in Scotland were estimated to have reduced by 3%. Whether the legislation led to reductions in alcohol-attributable deaths and hospitalisations at a population level is not known.
So begins a paper by Wyper et al.
Here’s what they did:
“Study outcomes, wholly attributable to alcohol consumption, were defined using routinely collected data on deaths and hospitalisations. Controlled interrupted time series regression was used to assess the legislation’s impact in Scotland, and any effect modification across demographic and socioeconomic deprivation groups. The pre-intervention time series ran from Jan 1, 2012, to April 30, 2018, and for 32 months after the policy was implemented (until Dec 31, 2020). Data from England, a part of the UK where the intervention was not implemented, were used to form a control group.”
Here’s what they found:
- “In the 32 months following the implementation of MUP legislation, the policy was associated with a significant 13.4% decrease (p=0·0004) in deaths wholly attributable to alcohol consumption compared with what would have been observed in the absence of MUP legislation…”
- “On average, and after 32 months, the implementation of alcohol MUP legislation was associated with a 4·1% decrease (p=0·064) in hospitalisations wholly attributable to alcohol consumption…”
- “Effects were driven by significant improvements in chronic outcomes, particularly alcoholic liver disease.”
A few thoughts:
1. This is a good paper, with a robust dataset, published in a major journal, and addressing a significant public policy issue. Nice.
2. How to understand MUP? It’s clever, targeted pricing intervention focused on cheap alcohols that tend to be misused by those who have alcohol use disorders. Think boxes of wine, not pricey bottles of chardonnay. In Scotland, they imposed a minimum price of 50 pence per alcohol unit – about $0.84, meaning that a can of beer (2.4 units) would cost at least $2. MUP is increasingly of interest across the Atlantic, with experimentation in Scotland, and also Wales and Ireland. Though the roots of the MUP can be found in Saskatchewan, Canadian provinces have cooled to the idea.
3. The results in a sentence: “Our findings indicate that the implementation of alcohol MUP legislation in May, 2018 in Scotland led to significant reductions in deaths, and reductions in hospitalisations, wholly attributable to alcohol consumption.” Good.
4. In terms of health inequities: “Exploratory analyses indicated that the largest reductions were estimated in the 40% most socioeconomically deprived areas in Scotland, indicating that the implementation of MUP has had a positive impact in tackling deprivation-based health inequalities in alcohol health harms.” Very good.
5. As with all studies, there are limitations. The authors note several, including timing – “During this period, restrictions on the purchasing of alcohol were imposed for on-trade premises (eg, pubs and restaurants).”
6. Recently, the Canadian Alcohol Policy Evaluation, led by the University of Victoria, considered “policies proven to reduce harm from alcohol use.” In a report released in May, they gave a failing grade to all provinces. Among their recommendations: meaningful minimum unit pricing. That report can be found here:
The full Lancet paper can be found here:
Selection 2: “Mental health and the music industry: an evolving intervention landscape”
George Musgrave, Charlie Howard, Amy Schofield, et al.
The Lancet Psychiatry, May 2023
Professional musicians in the popular music industries seem to have increased mental health difficulties relative to the general population, however, the reasons for this are poorly understood. From Janis Joplin to Avicii, high-profile deaths from suicide and drug misuse by musicians in the public eye are part of our collective cultural history. Such losses have engendered growing concern, as well as academic and clinical interest, in the mental health of people who pursue music as a career. Public debate around musicians’ mental health has often been depicted problematically, from the pathologisation of artistry to the romanticisation of suffering and trauma.
So begins a Comment by Musgrave et al.
“Questions of causality in this area have been approached from two distinct – though not mutually exclusive – perspectives.” They describe the first perspective: “a career in music selects people with a particular personality structure or life history, which might engender important benefits such as increased creativity and the capacity to push boundaries, but also exposes particular vulnerabilities.”
“The second perspective adopts a psychosocial focus on the systems within which musicians function. Underpinning this perspective is the idea that the working conditions of the music industries and the processes involved in building a musical career are inherently stressful.”
They note a new interest in helping musicians by major record companies, for instance; it takes the form of “dedicated helplines, industry-specific workshops on continuing professional development, therapeutic retreats, peer support groups, therapists accompanying musicians on tour, charters of best practices, and a range of therapeutic interventions.” While they appreciate the goodwill of the different individuals involved – from counsellors to psychiatrists – “they work in different ways, commonly without systematic monitoring of the effects of their work.”
“[W]e suggest changes to this landscape are required if it is to meet the diverse needs of its target population, with a need for greater regulation, accountability, and evidence-based expert care. Specifically, we propose that psychological interventions and the provision of mental health support are most likely to elicit positive change when the work is undertaken by specialised, appropriately qualified, and highly trained professionals, underpinned by comprehensive formulation and understanding, which takes into consideration a broad array of both individual and systemic factors.”
They also suggest for more understanding of musician patients. “Research, as well as our combined clinical experience, highlights a need to understand musicians and the multiple systems in which they are embedded, from their personality and developmental history, to their social and professional networks, and the wider sociopolitical context in which they exist. Only then can interventions be targeted at the correct level.”
A few thoughts:
1. This is an interesting Comment.
2. More and more employers are recognizing mental health problems. The paper suggests that the music industry is doing this. (!) In Canada, progress has been made in several sectors, including banking and telecom.
3. The Comment does weigh whether musicians are more prone to mental health problems. Some, like Kay Redfield Jamison (of Johns Hopkins University) in An Unquiet Mind, argue that creativity ties to mental disorders.
4. The call for “comprehensive formulation and understanding” sounds reasonable for musician patients – and, for that matter, all patients.
The full Lancet Psychiatry Comment can be found here:
Selection 3: “A month before this photo was taken, I was on the brink of suicide after battling severe depression most of my life”
Daily Mail, 1 July 2023
I want to talk about something I’ve kept hidden for years. Even though I’ve shared every detail of my breast cancer journey – I’ve had it twice, and written about it extensively in The Mail on Sunday and on social media – shame and embarrassment stopped me revealing anything about this, until now… I’ve lived with severe depression for most of my life.
I was well aware that, in recent years, many high-profile people in showbiz and politics have been open about their mental health struggles, but I was scared to discuss my own, even to people I knew well. What would my patients think of me if they found out?
So begins an essay by Dr. O’Riordan.
She mentions the decision to speak out. “I’ve now retired from medical practice – radiotherapy treatment affected my left arm and I could no longer operate. I think it’s about time I told my story.”
“My journey with depression started in my 20s, in my fourth year of medical school in Cardiff. My days were packed with lectures in pharmacology and pathology. The stress of revising was getting to me and everything seemed like a huge effort. Some days it was a struggle just to get out of bed… I felt like I was living in a thick black cloud. I wasn’t sleeping well and my appetite disappeared. I’d start crying for no reason and pretend I had a migraine to avoid going out with friends.”
She spoke to her family doctor, who started her on medications. This initially helped, but she then grew worse. “I was becoming manic. I started spending money I didn’t have on things I didn’t need. Euphoric with lack of sleep after night shifts… My drinking got out of hand – I’d be the life and soul of the party, out drinking and dancing until three in the morning. Alcohol gave me confidence, made me feel invincible, but I didn’t know when to stop.”
She was referred to a psychiatrist. “He told me to try to forget I was a doctor and answer his questions without thinking too much.” She tries a period without medications. “That was horrific. It took six months, weaning myself off slowly by reducing the dose by a quarter of a tablet at a time. I felt jittery all the while.”
She describes struggling with lower mood for years. But then things again took a turn for the worse, this time after landing a good surgery job close to home. “But instead of getting better, things got worse.”
“I’d imagined that reaching the pinnacle of my career would give me authority in the operating theatre, with my own ladies to look after and a chance to develop my skills as a reconstructive breast surgeon.” But, instead, she describes how poorly she was doing. “I started to dread going into work. I began to question my own judgment about how to manage patients, if colleagues had different opinions. I increasingly struggled to get my voice across and became less and less confident.”
“The antidepressants kicked in without any issues, and I was lucky to be able to see a therapist through work in a matter of weeks.”
She also describes her suicidal thoughts. “As things improved I made a ‘safety plan’ using a website called Staying Safe. This involves writing down the things which make you happy and the numbers of people to call if you start to struggle. You can download the plan on to your phone, so it’s there if you need it.”
Unfortunately, she rushes back to work, only to have a setback. She then takes a period of time off, working with her psychologist and healing. She eventually returns to work – though is soon diagnosed with breast cancer.
A few thoughts:
1. This is a moving and raw essay.
2. It’s interesting that for so long she felt comfortable telling people that she has struggled with cancer – but, until recently, hesitated on disclosing her mental health problems. Progress with cancer is clear but still lags with mental disorders – even in the eyes of doctors.
3. Safety planning works – including for physicians.
4. Past Readings have considered lived experience and depression. In a Psychiatric Services paper, Dr. Rebecca E. Barchas writes about her career as a psychiatrist, and then her late-life depression and treatment with ECT. That paper can be found here:
The full Daily Mail essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.