From the Editor
Though many years have passed, he clearly remembers his first depressive episode, which occurred before his 18th birthday. My patient often wonders how things could have been different had he been offered care earlier. School-based initiatives are much discussed – indeed, they are having a moment. Public schools, for example, in New York City, offer students a few minutes daily of teacher-led mindful breathing. Such efforts are unlikely to yield significant results, in part because they lack focus.
What if we offered psychotherapy skills to interested high school students? Could it help alleviate symptoms of mood and anxiety? Would it be cost effective? June Brown (of King’s College London) and her co-authors address these questions in a new study just published in The Lancet Psychiatry. They report on a randomized controlled trial involving 900 UK adolescents who self-referred and received CBT or treatment-as-usual. “[T]he DISCOVER intervention is modestly clinically effective and economically viable and could be a promising early intervention in schools.” We consider the paper and its implications.
In the second selection, drawing on US data, Hefei Wen (of Harvard University) and co-authors examine hospital readmissions in the United States for mental health. In this new research letter published in JAMA Psychiatry, they find that rural readmissions – historically lower than urban ones – now exceed their urban counterparts. “This reversal and worsening of rural and urban gaps in mental health readmission was primarily concentrated in schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, and depressive disorders.”
And in the third selection from the Los Angeles Times, Dr. Jillian Horton (of the University of Manitoba) discusses time, aging, and resilience in a personal essay. Our internist colleague touches on the debate over the US president and his health but focuses on the story of her sister, who faced major problems after neurosurgery. She notes that her sister was able to “beat the odds” many times, until she couldn’t. “[W]e can’t change the reality of what comes next.”
DG
Selection 1: “Clinical effectiveness and cost-effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents (BESST): a cluster randomised controlled trial in the UK”
June Brown, Kirsty James, Stephen Lisk, et al.
The Lancet Psychiatry, 14 May 2024
More than half of adult mental health conditions have first onset before the age of 15 years, and almost three-quarters by the age of 18 years… The most recent government report on mental health of children and young people in England showed that the proportion of those aged 17–19 years with a probable mental health condition increased from 17.4% to 25.7% between 2021 and 2022. Although data are not available specifically for 16-18-year-olds, it is estimated that 60% of children and young people with a diagnosable mental health condition do not receive any care through specialist child and adolescent mental health services (CAMHS) in the UK. Barriers to accessing formal support for young people include concerns about stigma and confidentiality and the limited capacity (and stringent eligibility criteria) of specialist mental health services, restricting access to effective evidence-based therapies…
So begins a paper by Brown et al.
Here’s what they did:
- They conducted a multicentre, cluster randomized controlled trial in UK schools “to evaluate clinical effectiveness and cost-effectiveness of a brief CBT workshop (DISCOVER) compared with treatment-as-usual.”
- The CBT was offered on a self-referral basis, aiming for 60 schools and 900 adolescents.
- “Participants were included if they were 16-18 years old, attending for the full school year, seeking help for stress, and fluent in English and able to provide written informed consent.”
- “Schools were randomised in a 1:1 ratio for participants to receive either the DISCOVER workshop or treatment-as-usual, stratified by site and balanced on school size and index of multiple deprivation.”
- The primary outcome: depression symptoms were measured with the Mood and Feelings Questionnaire (MFQ) at 6-month follow-up.
Here’s what they found:
- A total of 111 schools were invited to participate in the study; after screening and consent, 57 schools were involved with 900 adolescents. 443 students were in the DISCOVER group.
- Demographics and past care. Most of the participants were White (52%) and female (71%) with a mean age of 17.2 years. Only 20% had sought help from their general practitioner for their mental health problems. (!)
- Primary analysis. There was an adjusted mean difference in MFQ of –2.06 (Cohen’s d=0.17…) at the 6-month follow-up, “showing a significant reduction in depressive symptoms in the DISCOVER group versus the control group.”
- Secondary outcomes. There was found a significant improvement in the DISCOVER group versus treatment-as-usual for wellbeing (adjusted mean difference, 1.77; Cohen’s d=0.20); anxiety (adjusted mean difference –2·21; Cohen’s d=–0.17); and resilience (adjusted mean difference, 1.23; Cohen’s d=0.16).
- Cost-effectiveness. “The probability that DISCOVER is cost-effective compared with treatment-as-usual ranged from 61% to 78% at a £20 000 to £30 000 per quality-adjusted life-year threshold.”
- Adverse events. There were 23 adverse events reported, with nine in the DISCOVER group compared with 14 in the treatment-as-usual group.
A few thoughts:
1. This is a good study, with solid data, published in a major journal.
2. The main finding in a sentence: “the brief CBT DISCOVER intervention was modestly clinically effective for reducing depressive and anxiety symptoms among adolescents.”
3. Additionally, when looking at subgroup analysis, those who had higher depressive scores at baseline (MFQ >27) tended to benefit more.
4. This study contributes significantly to the growing literature on school-based initiatives. As opposed to those efforts offered to everyone (and coloured by low engagement) and those that are focused (and may thus be stigmatizing), CBT was provided on a universal but self-referral basis – a third way that is appealing.
5. And this approach is particularly appealing for adolescents, allowing them care while maintaining autonomy. Of note, the initiative reached students who, historically, have been harder to reach. For instance, 46% self-identified as being Black, Asian, Mixed or of another group – a point highlighted in the accompanying Comment by Deborah M. Caldwell (of the University of Bristol). As well, 80% hadn’t sought support from their family physician. (!)
6. Like all studies, there are limitations. The follow-up period was only six months.
7. More significantly, scalability would require significant resources – as the intervention was done by professionally trained staff, more costly and complicated than, say, the light training offered to NYC public school teachers for mindfulness.
The full Lancet Psych paper can be found here:
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00101-9/fulltext
Selection 2: “Rural and Urban Trends in Mental Health Readmissions”
Hefei Wen, Alyssa Halbisen, Kenton J. Johnston, et al.
JAMA Psychiatry, 5 June 2024 Online First
Hospitalization for mental health conditions in the US increased at a higher rate than that for other health conditions in the early 2010s. Serious mental illness consistently ranked among the top 20 principal diagnoses for frequent and costly hospital readmissions throughout the 2010s. Recent evidence suggests a more rapid deterioration of the timeliness and quality of postdischarge follow-up mental health care in rural areas than in urban areas. Therefore, it is important to use the most up-to-date, nationally representative data to assess rural and urban mental health readmission trends to inform policy and practice.
So begins a research letter by Wen et al.
Here’s what they did:
- They conducted a cohort study drawing data from the Nationwide Readmissions Database “which encompasses nearly the universe of all-payer inpatient records from community hospitals to generate national readmission estimates…”
- They analyzed rural versus urban counties and principal diagnoses.
- Primary outcomes: “weighted rates and costs of 30-day all-cause and same-cause readmissions.” Readmissions were defined as another inpatient stay within a month of hospital discharge.
Here’s what they found:
- Readmission trends. “Rural and urban inpatient readmission trends were stable between 2016 and 2020.”
- Mental health. “For index mental health stays, rural and urban readmission rates trended in opposite directions: the 30-day all-cause readmission rate increased from 14.74 per 100 index stays in 2016 to 16.17 in 2020 for rural mental health stays (relative 9.70% change…), whereas it decreased from 16.96 per 100 index stays to 15.75 during the same period for urban mental health stays (relative −7.13% change…).” See figure below.
- All-cause readmissions. “A similar pattern was observed for 30-day all-cause readmission costs and for 30-day same-cause readmission rates and costs.”
A few thoughts:
1. This is a good research letter, analyzing solid US data and published in a good journal.
2. The main finding: “Although the rural mental health readmission rate has been historically lower, we observed that it surpassed the urban rate for the first time in 2020, which may signal suboptimal discharge planning and care coordination and inadequate postdischarge follow-up community care.”
3. Ouch.
4. The authors note limitations, including “the incomplete capture of readmissions from a hospital in a participating state to a nonparticipating state.” Still, they drew on data from states “with approximately 60% of US residents and of all hospitalizations.”
5. In recent years, with the rise of technology, some have hoped that historical inequities (like urban vs. rural outcomes) might get better. Though this research letter focuses on just one metric, it suggests that some of that optimism may not have been realized.
The research letter can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2819408
Selection 3: “Even the toughest fighters eventually lose the battle with time. Biden is no exception”
Jillian Horton
Los Angels Times, 11 July 2024
A flashbulb memory from the archives of my life: It is the summer of 1997, and we are moving my disabled sister, Wendy, into a care home. She is in her bedroom in my parents’ house. She is a woman in her 30s who requires 24-hour care, and my aging parents can no longer provide it. Her life is being dismantled around her – her ornaments gingerly packed away for transport, the cords of her precious stereo unplugged and set aside in a snake-like tangle. My sister cannot understand what is happening. She looks up at me from the floor where she is sitting and shouts angrily: ‘Why? Why do things have to change?’
This memory keeps coming back to me in recent weeks – ever since the U.S. presidential debate. Superficially, nothing about Wendy would remind us of President Biden’s life story – she never had a chance to play politics or run a country – but the more I see Biden caught in the gears of time, or doing his best not to face it, the more I realize he’s fighting in the same war my sister waged for decades. We are all eventually called up to those front lines, where we all, eventually, lose.
So begins an essay by Dr. Horton.
She notes that her sister had “defied many odds,” and lived to 52. “In so many ways, she was the beating heart of our family. I always had the sense that her life told the story of the kind of people we were.”
“At some point, ‘beating the odds’ stories can turn tragic, beginning in microscopic ways. The line between hope and delusion thins, and in the moment, sometimes it is difficult to know when you or your family are crossing it. Some people will never walk again. Some brains will never heal. You also can’t beat odds that are unequivocal. Those aren’t even ‘odds,’ really, because the hoped-for outcome isn’t possible. One of my toughest jobs as a doctor is helping patients and their families face the moment when those odds are ushering them toward an inevitable truth, one we are all tempted to resist.”
She notes some medical parallels between the president and her sister (both had neurosurgery). But there is a key difference: “Biden may be the author of his own narrative of triumph, but in my sister’s case, that story came from the people who loved her.”
She describes the decline of her sister. “In those early years, every time she almost died, she did appear to bounce back. But it was also true that as the years went on, with each new medical challenge, she was like a basketball with a little less air in it. She no longer bounced. Deflated, she slowly began to disappear. Her brain, vulnerable after surgery and subsequent seizures, had no reserve to mop up new injuries. If she had nine lives, then she also suffered enough for nine lifetimes. By the time she died, she was a husk of her former self.” She observes Biden’s decline. “Biden, too, seems deflated, a husk of the scrappy, inspiring career politician he once was. His seeming lack of insight into the public’s concern for his health is an alarming symptom on its own.”
She comments on decline and a family’s tendency to minimize. “Even when someone is struggling with a simple act such as making toast, our long record of confidence in their powers can blind us to what is happening in real time. Even when not just the toaster but the whole house has caught on fire, for families who have seen their loved one pull back from the brink time and time again, it is hard for them to believe they won’t see that same magic trick once more, just in the nick of time.”
She closes: “Time. Isn’t that what it all boils down to? Not so much the nick of time as time’s nicks: death by a thousand little cuts. The story of our lives cannot rewrite the story of life. Things have to change. Sometimes we cannot understand why, and it hurts.”
A few thoughts:
1. Wow. This is a beautifully written essay. Dr. Horton is a truly gifted writer.
2. This line is worth repeating: “The story of our lives cannot rewrite the story of life.”
3. Should Biden withdraw? Is Trump the better pick for president? Is it time for a serious look at a third-party candidate? Let’s leave politics for others to debate but mull Horton’s excellent insights into resilience and time.
4. Dr. Horton’s work has been featured in past Readings, including one highlighting a Quick Takes podcast interview which you can find here:
The full LA Times essay can be found here:
https://www.latimes.com/opinion/story/2024-07-11/joe-biden-age-health
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
Recent Comments