From the Editor

He walked into our emergency department late one night. He told me that he felt overwhelmed – not just by his university studies, but by everything. Even getting out of bed was challenging. Like many, his depression began in late adolescence, just as he was starting his engineering program.

What are the experiences of university students with mental health problems? And what can be done to improve them? Nathan King (of Queen’s University) and his co-authors try to answer these questions in a new paper published in The Canadian Journal of Psychiatry. They surveyed more than 4 000 Queen’s students over a five-year period, and did both qualitative and quantitative analyses. They found 30% reported a lifetime mental disorder and 23% had a history of self-harm, yet only 15% accessed care. They make several recommendations including: “Student-tailored mental health literacy may be a sustainable approach to address the attitudinal and practical barriers identified.” We consider the paper and its implications.

In the second selection, Dr. Markku Lähteenvuo (of the University of Eastern Finland) and his colleagues discuss semaglutide and sister drugs for alcohol use disorder in a JAMA Psychiatry brief report. Drawing on Swedish databases, they compared individuals who took the glucagon-like peptide-1 receptor (GLP-1) agonists to those who didn’t. “Among patients with AUD and comorbid obesity/type 2 diabetes, the use of semaglutide and liraglutide were associated with a substantially decreased risk of hospitalization due to AUD.”

In the third selection, an op ed published in the Toronto Star, Nick Kerman and Dr. Vicky Stergiopoulos (both of the University of Toronto) consider the Ontario government’s plan to end homeless encampments in Canada’s largest province. They suggest an alternative. “Let’s leverage a housing-first intervention, a proven way to get people the housing and support they need.”

The Reading of the Week is going on holidays for the next weeks (or, at least, I am). The next Reading will be 16 January 2025. All the best in the holiday season.

DG

Selection 1: “Access to University Mental Health Services: Understanding the Student Experience”

Nathan King, William Pickett, Kurtis Pankow, et al.

The Canadian Journal of Psychiatry, December 2024

Over the past decade, there has been an increase in the reported prevalence of common mental health disorders in the general population of young people and in university students in Canada and other western countries. In parallel, universities have reported progressive increases in demand for mental health support, outpacing increases in enrolment, and straining resources. Universities acknowledge they have an important role to play in ensuring a welcoming learning environment that promotes student well-being, as well as providing accessible student-tailored well-being promotion and support for common mental health concerns. An important challenge for universities is to determine what scope of mental health support is feasible and appropriate to provide and how best to collaborate with community mental health for students who require more intensive specialized services and may not be connected to local health care.

Authoritative papers and standards have recommended a combination of complementary whole-university and student-tailored services targeting common mild to moderate mental health concerns rationalized in accordance with a stepped care framework. There is recognition that the university should not attempt to duplicate community or specialized mental health services, but rather focus on developing, evaluating, and continually improving integrated, evidence-based well-being promotion and early intervention services.

There is a paucity of Canadian research informing access to university mental health support, barriers to access, and support gaps from the student perspective.

So begins a paper by King et al.

Here’s what they did:

  • They conducted a multiple-cohort study using self-report data from undergraduate students who completed the U-Flourish Well-Being Survey.
  • Students at Queen’s University (in Kingston, Ontario) were invited to participate at the start and end of their first year, encouraged with coffee vouchers.
  • Surveying was done from 2018 to 2023. 
  • “The survey incorporated validated measures of mental health symptoms, barriers to care, and open-text questions about the mental health care experience and perceived gaps.” 
  • “Quantitative analyses summarized utilization patterns and barriers. An interpretive qualitative analysis identified common themes about support services and opportunities for improvement from the student perspective.”

Here’s what they found: 

  • 4 138 first-year students completed the survey.
  • Demographics. The average age of the respondents at entry to university was 18.2 years and 74% identified as female. 
  • Mental illness. A lifetime history of diagnosed mental illness was reported by 30%; one-third reported having a first-degree relative with a diagnosed mood, anxiety, psychotic, or substance use disorder. 43% of students screened positive for clinically significant symptoms of anxiety (35%) and/or depression (32%), and over one-fifth (23%) reported a lifetime history of self-harm. (!)
  • Accessing care. 15% reported accessing services over first year.
  • Student experience. “Just over one-half of the students who accessed services reported they were easy to access (45%–69%), while about one-quarter reported they were difficult to access (11%–38%).”
  • Stigma. “The most common stigma barriers reported included ‘concerns about what my family might think, say, or feel’ (27%), ‘feeling embarrassed or ashamed’ (27%), and concern that ‘people I know may find out’ (19%).”
  • Qualitative analyses. “Within the mental health support theme, the two major subthemes identified were accessibility (i.e., accessing services, booking appointments, and being seen on a timely basis/long wait times) and gaps in services (i.e., need for longer-term support, increased capacity across services, access to psychotherapy in addition to short-term supportive counselling, and more flexible provision).”

A few thoughts:

1. This is a nice study, focused on practical questions in an understudied population, and published in a solid journal.

2. The main finding in a sentence: “Over 40% of students screened positive for anxiety or depressive symptoms and a substantial proportion reported a lifetime mental disorder and/or self-harm/suicidal thoughts or behaviours at university entry, but only 15% accessed university mental health support over their first year.”

3. Many people needed care and yet didn’t receive it. Ouch.

4. Though stigma has faded in our society, it still lingers – even in a generation who tends to be open-minded. Many felt embarrassed about accessing services.

5. A nice touch in this paper: drawing on the participants’ responses, they offer suggestions. Among them: “In addition to short-term problem-focused counselling, findings suggest that investment needs to be made in evidence-based individual and group psychological therapies and a multidisciplinary mental health team embedded in a university primary care practice. Furthermore, the student journey through different services could benefit from being more integrated (e.g., having shared electronic records), interactive, and collaborative (offered jointly by health promotion, disability, student health, and counselling services). Incorporating digital tools is one approach to facilitating information sharing across university services and providing a more joined-up and engaging student mental health support journey.” Thoughtful.

6. Like all studies, there are limitations. The authors note several including the lower response rate during the peak of the pandemic.

The full CJP paper can be found here:

https://journals.sagepub.com/doi/full/10.1177/07067437241295640

Selection 2: “Repurposing Semaglutide and Liraglutide for Alcohol Use Disorder”

Markku Lähteenvuo, Jari Tiihonen, Anssi Solismaa, et al.

JAMA Psychiatry, 13 November 2024

According to the World Health Organization, harmful use of alcohol is accountable for 5.1% of the global burden of disease. Psychosocial treatments are the cornerstone of alcohol use disorder (AUD) treatment, but pharmacological treatments are also beneficial, although underused.

Glucagon-like peptide-1 receptor (GLP-1) agonists are approved for clinical use to treat diabetes and obesity. Preclinical studies in rodents and monkeys, as well as human case reports, have shown that GLP-1 agonists can reduce alcohol consumption. In humans, genetic variation in GLP-1R has been shown to be associated with increased risk of AUD. A recent registry study from Denmark has also shown that use of GLP-1 agonists has been linked to transient (3-month) reduced risk of subsequent alcohol-related events.

So begins a brief report by Lähteenvuo et al.

Here’s what they did:

  • They conducted a cohort study using Swedish data from January 2006 to December 2023.
  • They drew on several databases covering “inpatient care, specialized outpatient care, sickness absence, and disability pension.”
  • Participants were residents aged 16 to 64 years who had a diagnosis of an alcohol use disorder.
  • “The primary exposure was use of individual GLP-1 agonists (compared with nonuse of GLP-1 agonists), and the secondary exposure was medications with indication for AUD.”
  • Outcome: “AUD hospitalization analyzed in a Cox regression within-individual model.”

Here’s what they found:

  • There were 227 866 individuals with AUD.
  • Demographics & experience. 63.5% were male with a mean age of 40.0 (15.7) years; 85% were born in Sweden. Median follow-up time was 8.8 years. 58.5% experienced an AUD hospitalization. 
  • Meds & hospitalizations. Semaglutide was associated with the lowest risk (AUD: adjusted hazard ratio [aHR], 0.64; any SUD: aHR, 0.68) and use of liraglutide with the second lowest risk (AUD: aHR, 0.72; any SUD: aHR, 0.78) of both AUD and SUD hospitalization. Use of any AUD medication was associated with a modestly decreased risk (aHR, 0.98). 
  • Other hospitalizations. Semaglutide and liraglutide (aHR, 0.79; 95% CI, 0.69-0.91) use were also associated with decreased risk of somatic hospitalizations.

A few thoughts:

1. This brief report presents interesting if early data.

2. The main finding in a sentence: “In this nationwide register-based study, the GLP-1 agonists semaglutide and liraglutide, but not other GLP-1 agonists, were associated with a markedly reduced risk of AUD- and SUD-related hospitalizations as well as somatic hospitalizations.”

3. Needless to say, the brief report has caused a stir, including on social media. Some have suggested that since GLP-1 agonists target reward systems in the brain (as well as metabolic ones), they may reduce cravings for alcohol.

4. Perspective is important: this is an observational study.

5. As the authors note: “GLP-1 agonists, and especially semaglutide and liraglutide, may be effective in the treatment of AUD. Randomized clinical trials are urgently needed to confirm whether GLP-1 agonists could be used to treat AUD and SUDs.”

6. Of course, we are all keen for new treatments for alcohol. This brief report isn’t exactly persuasive – but it may spark interest in further studies.

7. GLP-1 agonists have been considered in a past Reading. A JAMA Psychiatry paper focused on the implications for psychiatry. You can find it here:

https://davidgratzer.com/reading-of-the-week/reading-of-the-week-effectiveness-of-omega-3-the-new-schiz-bulletin-paper-also-weight-loss-meds-in-psychiatry-the-latest-in-the-news/

The full JAMA Psych brief report can be found here:

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2825650

Selection 3: “Ford government’s encampment crackdown will have people cycling through shelters and jails. There’s a better way”

Nick Kerman and Vicky Stergiopoulos

Toronto Star, 13 December 2024

Homeless encampments have become a regular fixture in cities across Canada. Unsheltered homelessness, including people staying in encampments, rose 88 per cent across the country from 2018 to 2022, according to the last national point-in-time count.

In Ontario, advocates, clinicians, researchers, mayors, and city councillors, in addition to people experiencing homelessness, have been sounding the alarm, calling on the provincial government to act. Last week, Premier Ford responded to those calls by signalling that he would introduce legislation to provide municipalities with ‘enhanced legislative powers’ to dismantle encampments.

Then on Thursday, the government introduced new legislation giving police more power to punish drug use in public parks, and penalties for those who continually ‘trespass’ in parks and other properties. These changes are all part of the Ford government’s plans to address encampments.

So begins an essay by Kerman and Stergiopoulos.

They note that the province promised $75.5 million for shelters and affordable homes. And while they describe it as “a much-needed investment,” they offer a cautionary note: “building sufficient affordable housing will take time and additional resources.” 

“Where will encampment residents go in the meantime?”

They are cool to the approach. “The government’s approach to dismantling encampments in effect puts forward three potential paths for residents: shelter, jail, or hospital. These options, known for decades as the institutional circuit, do not resolve the primary unmet need of encampment residents: rapid access to housing with supports. Moreover, shelter, jail, and hospitals represent the most expensive types of services where you can find people experiencing homelessness.”

 “A U.S. simulation study found that involuntary displacement, such as encampment dismantlement, produces additional overdose deaths. Involuntary displacement also results in more hospitalizations as well as reduced initiation of medications for opioid use disorder, the first-line treatment for this condition.”

Instead, they champion housing first which “involves the provision of a rent supplement along with community-based mental health and addiction supports to help those with serious mental illness, substance use disorders, and chronic medical conditions immediately access permanent housing.” They review the literature:

  • At Home/Chez Soi. They note that in this, the largest randomized controlled trial of the housing-first approach conducted anywhere, the authors found that “the intervention is effective in housing 80-90 per cent of people experiencing long-term homelessness.” 
  • Follow-up research. “Follow-up research conducted in Toronto showed that these outcomes were sustained as many as six years later.”
  • Houston. “In 2011, the city had approximately 8,500 people who were homeless. A decade later, they had reduced that by 61 per cent. Unsheltered homelessness is also down 33 per cent in the last four years. Houston’s approach? Housing first.”

“This approach is not only more fiscally prudent for taxpayers, it is a more sustainable solution for improving access and safety in our parks and other public spaces.”

A few thoughts:

1. This is a thoughtful essay.

2. Housing first has evidence in the literature – and the real world. For those interested in understanding more about the Houston experiment, The New York Times had a long and fascinating essay on the topic:

https://www.nytimes.com/2022/06/14/headway/houston-homeless-people.html

3. For the record, the Houston results are incredible.

4. Homelessness has been considered in past Readings. In the spring, we focused a whole Reading on the topic, including an excellent review paper by Nick Kerman and Vicky Stergiopoulos. You can find it here:

https://davidgratzer.com/reading-of-the-week/reading-of-the-week-the-homeless-who-are-they-how-can-we-help-them-also-shannon-jones-on-her-son-his-homelessness/

The full Star essay can be found here:

https://www.thestar.com/opinion/contributors/ford-governments-encampment-crackdown-will-have-people-cycling-through-shelters-and-jails-theres-a-better/article_68540d28-b8cd-11ef-bb43-f337cc908976.html

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