From the Editor
In terms of depression treatment, do people with substance use problems get worse care than those without?
The answer should be a resounding no. In the first selection, we consider a new paper, just published in The American Journal of Psychiatry, which suggests otherwise. Lara N. Coughlin (of the University of Michigan) and her co-authors draw on Veterans Affairs data involving more than 53,000 patients. “In this large national sample, we found that patients with comorbid depression and substance use disorders receive lower quality care than those with depression but without substance use disorders.”
In the second selection, we consider a Canadian Journal of Psychiatry research letter. Dr. Peter Giacobbe (of the University of Toronto) and his co-authors surveyed senior residents, asking about their familiarity and comfort with first line recommendations for the treatment of depression. Spoiler alert: just one in four felt that they had achieved competency in ECT.
Finally, in the third selection, we look at a new essay by journalist Abby Goodnough. With many Americans (and Canadians) struggling with substance problems, she writes about contingency management – that is, rewarding substance users with cash and prizes for sobriety. The concept has evidence in the literature, but lacks political support. She quotes a patient: “Even just to stop at McDonald’s when you have that little bit of extra money, to get a hamburger and a fries when you’re hungry. That was really big to me.”
Note: there will be no Reading next week.
Selection 1: “Quality of Outpatient Depression Treatment in Patients With Comorbid Substance Use Disorder”
Lara N. Coughlin, Paul Pfeiffer, Dara Ganoczy, Lewei A. Lin
The American Journal of Psychiatry, 29 October 2020 Online First
Depression commonly co-occurs with substance use disorders and contributes to poor outcomes, including increased substance use, more severe illness trajectories, higher rates of suicide, fatal overdoses, and overall mortality. Antidepressants and psychotherapy are both effective, empirically supported treatments for depression; however, depression remains undertreated, with, on average, one-third of patients experiencing a major depressive episode receiving no treatment at all. To ensure guideline-concordant depression treatment, initial treatment and continuation of treatment are critical for optimizing effectiveness and mitigating these poor outcomes, especially among patients with comorbid substance use disorders.
So begins a paper by Coughlin et al.
Here’s what they did:
- They conducted a retrospective cohort study with US veterans.
- Inclusion criteria: a new diagnosis of depression (in 2017), and an elevated score on a PHQ scale (2 or 9).
- The veterans also had a substance use disorder diagnosis.
- Outcomes included the use of antidepressants and/or psychotherapy.
- Statistical analyses were done.
Here’s what they found:
- “The study cohort included 53,034 patients diagnosed with a new episode of depression during fiscal year 2017; 28,081 (52.9%) of these patients received any antidepressant treatment, and 18,484 (34.9%) received any psychotherapy for depression within 90 days following their diagnosis.”
- “Of this cohort, 7,516 (14.2%) had a substance use disorder diagnosis in the year before the depressive disorder diagnosis. Despite patients with substance use disorders having more visits in mental health and primary care settings in the year following the depression diagnosis (an average of 14.1 visits… compared with 10.2 visits… among those without substance use disorders), providing more opportunity for depression treatment, patients with substance use disorders received less guideline-concordant depression treatment across all metrics.”
- “Patients with substance use disorders had lower odds of receiving guideline-concordant care, including lower odds of receiving adequate acute and continuation phases of antidepressant and psychotherapy treatment (antidepressant: acute phase, adjusted odds ratio=0.79… continuation phase, adjusted odds ratio=0.74… psychotherapy: acute phase, adjusted odds ratio=0.87… continuation phase, adjusted odds ratio=0.81…”
A few thoughts:
- This is a good paper.
- There isn’t good news to be found in this paper. “Depression remains vastly undertreated with observed rates of guideline-concordant depression care in the present study ranging from 66.2% of patients without substance use disorders receiving adequate acute-phase antidepressant treatment to 32.2% of these patients receiving adequate continuation of psychotherapy.” Though this paper focuses on veterans in the United States, the findings remind me of the Canadian paper by Patten et al. showing that only about half of people with depression get care. Would we tolerate such standards with cancer?
- And those with substance use disorders? They were less likely to receive depression care. The authors mull a variety of explanations, from those related to the patient (complexity) to a variety of system issues. I highlight one: care that focuses on one diagnosis (like a depression clinic) may fall short for those patients who have more than one problem (like depression and substance).
- How to think of this result in terms of practice? Those with a comorbid substance use disorder need more attention and effort. Just as physically complex patients need a fuller plan, these mentally complex patients are at risk of falling through the cracks of care.
The full AJP paper can be found here:
Selection 2: “Interventional Psychiatry: An Idea Whose Time Has Come?”
Peter Giacobbe, Enoch Ng, Daniel M. Blumberger, et al.
The Canadian Journal of Psychiatry, 5 October 2020 Online First
In a similar vein to cardiology or radiology, the term interventional psychiatry has been proposed to describe treatments that are more procedural and invasive than general medical care within that specialty. Descriptions of approaches that fall within interventional psychiatry have emphasized anatomically-guided direct-to-brain treatments for major depressive disorder (MDD) such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS). There has been a veritable explosion of interest in interventional psychiatry in the last decade, but the rate of competency of trainees to deliver these treatments is understudied.
This study aims to assess the self-reported experience, knowledge, and efficacy of a representative national sample of physicians who have completed or are nearing completion of their psychiatry residency programs and to administer evidence-based treatments (EBTs) for MDD including ECT and rTMS.
So opens a research letter by Giacobbe et al.
Here’s what they did:
- Participants were senior residents attending the 2019 P. Chandarana London Psychiatry Review Course at Western University in London, Ontario.
- “Participants were asked about their self-efficacy, satisfaction, and degree of exposure to recommendations from the 2016 MDD CANMAT guidelines that received 1st-line recommendations.”
- “Multiple logistic regression was used to model levels of experience administering ECT with odds of self-reported competence.”
Here’s what they found:
- “In this study, 162 participants completed the survey (73.3% of all attendees; 162/221), including 57.5% (119/207) of the PGY-5 psychiatry residents in the country.”
- “The majority of people completing the survey were female (61.5%), graduated from a Canadian medical school (66.7%), attended a Canadian psychiatry residency program (90.1%), and anticipated working in a hospital setting (53.7%).”
- “The majority of participants felt that familiarity with ECT (91.3%) and rTMS (56.5%) should be required for licensure in psychiatry; however, only a small percentage were able to achieve competency during their training (ECT: 24.3%; rTMS 3.1%).”
A few thoughts:
- This is an excellent research letter.
- One in four senior residents felt that they have received adequate teaching in rTMS, and fewer than one in ten felt that their supervision was adequate. Ouch.
- What to make of the ECT findings? “The rates of competency in ECT have been stagnant over the past 3 decades. Given the established efficacy of ECT as the gold-standard approach in treating acute depression, perceived ECT competency in just under a quarter of the emerging psychiatric workforce is particularly concerning. The results of this study suggest a way forward from the learners’ perspective, with more opportunities to receive supervision being especially valued. ” Ouch. “Only 18% of respondents reported that they feel completely competent administering ECT.” Ouch.
- The authors write about interventional psychiatry. Regardless of the term used, training seems to fall short; the ECT problem is long standing, unfortunately. Is a new approach needed?
The research letter can be found here:
Selection 3: “This Addiction Treatment Works. Why Is It So Underused?”
The New York Times, 27 October 2020
Steven Kelty had been addicted to crack cocaine for 32 years when he tried a different kind of treatment last year, one so basic in concept that he was skeptical.
He would come to a clinic twice a week to provide a urine sample, and if it was free of drugs, he would get to draw a slip of paper out of a fishbowl. Half contained encouraging messages – typically, ‘Good job!’ – but the other half were vouchers for prizes worth between $1 and $100.
‘I’ve been to a lot of rehabs, and there were no incentives except for the idea of being clean after you finished,’ said Mr. Kelty, 61, of Winfield, Pa. ‘Some of us need something to motivate us – even if it’s a small thing – to live a better life.’
So begins a news article by Goodnough.
“A number of clinical trials have found it highly effective in getting people addicted to stimulants like cocaine and methamphetamine to stay in treatment and to stop using the drugs. But outside the research arena and the Department of Veterans Affairs, where Mr. Kelty is a patient, it is nearly impossible to find programs that offer such treatment – even as overdose deaths involving meth, in particular, have soared.”
The article considers reasons why contingency management isn’t widely adapted:
- “The fact that no public or private insurer will pay for contingency management, except in a few pilot programs, is a major challenge to expanding it; the biggest obstacle is that offering motivational rewards to patients has been interpreted as violating the federal anti-kickback statute.”
- “A group of treatment experts recently asked the Department of Health and Human Services to waive the statute for two years as it pertains to contingency management, but the agency refused, saying programs that provide rewards need to be evaluated on a case-by-case basis.”
Yet, there is evidence: “A 2018 meta-analysis of 50 clinical studies of interventions for cocaine and amphetamine addiction, for example, found contingency management combined with an intervention called the community reinforcement approach was the most effective.”
What enlivens the essay is that the reporter interviews patients. Jodi Waxler-Malloy of Toledo, for example, tried contingency management treatment after more than a dozen treatment programs for cocaine, heroin and meth. She found the approach particularly helpful during the first month of sobriety. “It was enough to buy cigarettes or grab something to eat. Maybe I was going to the appointments and meetings for the wrong reason at that time, but it helped me in the long run – helped me meet people, have a support group.”
A few thoughts:
- This is a good essay.
- If something works, shouldn’t we use it?
- Behavioural economics has been discussed in past Readings. The core idea – that people can be “nudged” to a certain behaviour – is compelling, particularly with difficult problems like substance use. Results to date have been mixed. That said, the essay makes a persuasive case.
The full New York Times essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.