From the Editor

In her autobiography, psychiatrist Linda Gask writes about her struggles with depression and the moment she realized that she was better: she started to hear the birds chirping again. For many of our patients, the songs of the birds remain elusive. Antidepressants work but some patients don’t respond, and others are cool to the idea of medication management. CBT is effective but difficult to access. What about Transcranial Direct Current Stimulation (tDCS) – an intervention that could be done at home?

Dr. Lucas Borrione (of the University of São Paulo) and his co-authors try to answer that question in a new JAMA Psychiatry paper. They report on a randomized clinical trial including 210 Brazilian adults with a major depressive episode who were offered tDCS and a digital intervention; the study featured two sham interventions. “The findings indicate that unsupervised home use tDCS should not be currently recommended in clinical practice.” We consider the paper and its clinical implications.

Would tDCS have helped?

Artificial intelligence is having a moment. Not surprisingly, many are seeing the possibilities for mental health care, from better therapy to reduced paperwork. In the second selection, from Psychiatry Research, Charlotte Blease (of Uppsala University) and her co-authors report on the findings of a survey of 138 psychiatrists with both qualitative and quantitative data. “The foremost interest was around the potential of these tools to assist psychiatrists with documentation.”

And in the third selection, Dr. Daniel Gorman (of the University of Toronto) writes about the struggles of taking a child to Disney World in JAMA. Any parent – or aunt or cousin or older sib – can relate. But Dr. Gorman notes the particular challenges that he faces: he’s a child psychiatrist. “Sometimes I fantasize about sharing with parents my doubts about parenting strategies, but the risks always seem too great – the risk of discrediting myself and my profession and the risk of robbing parents of agency and hope.”


Selection 1: “Home-Use Transcranial Direct Current Stimulation for the Treatment of a Major Depressive Episode: A Randomized Clinical Trial”

Lucas Borrione, Beatriz A. Cavendish, Luana V. M. Aparicio, et al.

JAMA Psychiatry, April 2024

Transcranial direct current stimulation (tDCS) is a noninvasive brain stimulation modality that is moderately effective for major depression. It involves the application of low currents through 2 or more electrodes placed over the scalp, thereby modulating underlying neuronal excitability and neuroplasticity. Unlike transcranial magnetic stimulation and electroconvulsive therapy, tDCS is portable, straightforward, inexpensive, and has minimal adverse effects. However, tDCS needs to be applied daily, and when performed at the clinic, can pose dislocation burdens and is limited by the working hours of the staff.

Therefore, home-use tDCS could greatly increase scalability and enable its widespread adoption. A small, open-label trial showed promising therapeutic results for depression, with satisfactory feasibility and safety profiles. Nonetheless, despite the development and adoption of several portable devices, their efficacy has not been confirmed in rigorously controlled clinical studies.

So begins a paper by Borrione et al.

Here’s what they did:

  • They conducted a double-blinded, sham-controlled, randomized clinical trial.
  • Inclusion criteria: participants were aged 18 to 59 years, had a diagnosis of an acute depressive episode of at least moderate severity – that is, a score above 16 on the Hamilton Depression Rating Scale. 
  • Exclusion criteria included other psychiatric disorders (except for anxiety).
  • There were three arms: (1) home-use tDCS plus a digital psychological intervention (double active); (2) home-use tDCS plus digital placebo (tDCS only), and (3) sham home-use tDCS plus digital placebo (double sham). tDCS was administered in 30-minute prefrontal sessions for 15 consecutive weekdays and twice-weekly sessions for 3 weeks. 
  • Antidepressant dosing was unchanged.
  • The study was conducted between April 2021 and October 2022.
  • Main outcome: change in HDRS-17 score at week 6.

Here’s what they found:

  • Of 1 604 prescreened and 837 individually screened volunteers, 210 participants were enrolled.
  • Randomization. Participants were allocated to double active (n = 64), tDCS only (n = 73), or double sham (n = 73).
  • Demographics. Most participants were female (86%) with a mean age of 38.9 years. Most were Black (72%). The majority (57%) had a personal monthly wage of $1300 or less.
  • Change. The mean (SD) change in HDRS-17 scores from baseline was 8.2 in double active, 8.5 in tDCS only, and 7.7 in double sham – not statistically significant.
  • Ease of use. All groups considered the interventions to be very easy to use.
  • Adherence. The overall rate of adherence to home-use tDCS was 97.5% in double active, 97% in tDCS only, and 96.3% in double sham.

A few thoughts:

1. This is a good study with much to like: a double-blinded, randomized clinical trial with sham interventions, published in a big journal. 

2. Also, it’s a negative trial with participants from a middle-income nation. (Not so long ago, such studies didn’t appear in our journals.)

3. The result in a sentence: tDCS wasn’t superior to sham for treatment of depression. Interesting. 

4. How does this study differ from past ones? “Compared to previous trials, here we had more participants with recurrent depression and longer depressive episodes, which have been associated with greater treatment resistance.” That’s an important point.

5. Like all studies, there are limitations. The authors note several, including: “A 6-week treatment course might have been too short to induce clinical effects. This time frame was also used in 2 large-scale tDCS randomized clinical trials that yielded negative results, while significant tDCS effects were observed in a study that spanned 22 tDCS sessions over 10 weeks.”

6. This study comes on the heels of the Burkhardt et al. study, published in The Lancet, which looked at adding tDCS to SSRI treatment of adults with MDD, also showing no superiority to sham.

That Reading can be found here:

7. Two studies – both impressive – point in a similar direction: for those who are more ill, tDCS isn’t effective.

The full JAMA Psych paper can be found here:

Selection 2: “Psychiatrists’ experiences and opinions of generative artificial intelligence in mental healthcare: An online mixed methods survey”

Charlotte Blease, Abigail Worthen, John Torous

Psychiatry Research, March 2024

Since the launch of OpenAI’s ‘ChatGPT’ in November 2022, considerable attention has been focused on advances in chatbots in healthcare… Previous research demonstrates that documentation and administrative tasks remain a leading source of burnout among all clinicians including psychiatrists who seek help, including from the assistance of AI. LLM-powered chatbots such as OpenAI’s GPT-4, and Google’s Bard are potentially well suited to these tasks. Notably, for example, these tools have strengths in writing responses in a requested style, literacy level or tone, suggesting potential to help write clinical notes. Further support comes from preliminary evidence that LLM-powered chatbots can assist with writing empathic documentation. Emerging research shows that ChatGPT may improve documentation by creating more comprehensive and organized clinical histories…

However, LLM tools also carry significant limitations and invite new problems, although a study by Walker et al. found that ChatGPT-4 provided medical information of comparable quality to that offered by searches of static internet information. Notwithstanding, risking the epithet of ‘garbage-in, garbage-out’, these tools are unable to discriminate the quality of the information upon which they are trained. Responses can be inconsistent, clearly wrong, and more disturbingly, subtly false, and in many documented instances have generated harmful responses…

So begins a paper by Blease et al.

Here’s what they did:

  • Participants did an online survey about AI that focused on their experience with chatbots, their thoughts on how practice will be affected by AI in the future, and their reflections on patients’ use of chatbots.
  • Participants were recruited from members of the APA registered for an informational session, “AI in Psychiatry: What APA Members Need to Know” which took place on August 16, 2023.
  • There were both quantitative and qualitative responses and participants were given three minutes to complete the full survey.

Here’s what they found:

  • Of the 811 who received email invitation, 138 completed the survey (18%). 41 partially completed responses were excluded from the analysis. 
  • Demographics. Of 138 respondents, 54% identified as male, and most were mid-career. 
  • Clinical questions. Four in ten survey respondents (43%) reported using OpenAI’s GPT-3.5 to assist with answering clinical questions. See figure below.
  • Documentation. 7 in 10 somewhat agreed/agreed “documentation will be/is more efficient” with these tools.
  • Diagnoses. About half (45.2%) “will/already does improve diagnostic accuracy.”
  • Education. 8 in 10 agreed “clinicians need more support/training in understanding these tools.”
  • Patient experience. Most (55%) felt that patients will “better understand their health.”
  • “Respondents expressed divergent opinions on the benefits and harms of chatbots.” The largest theme was the perceived impact of generative AI to “help with documentation and reducing admin burden.” One participant believed it will “relieve administrative burdens on overworked psychiatrists.” Many were optimistic that these tools “will revolutionize healthcare” and “make a huge change in our mental health services.” Some were more apprehensive and noted the need for education – “We need to understand these tools” and “Would love to get training in it ASAP.

A few thoughts:

1. This is an interesting study.

2. A summary of the results: physicians tended to be optimistic, seeing a role in reducing paperwork and improving diagnoses.

3. Of course, this data set needs to be taken with a grain of salt. After all, these psychiatrists had signed up for an AI-related course. Still the paper offers some numbers on AI and psychiatrists. 

4. Our AI future may be very different. A Danish proverb reminds us: “It is difficult to make predictions, especially about the future.” How much could AI change mental health care? For example, could AI help us predict relapses of depression or those at risk of readmission to hospital?

The full Psychiatry Res paper can be found here:

Selection 3: “I Am Your Father”

Daniel A. Gorman

JAMA, 9 February 2024

‘I want to kill you!’ The words were shouted in my face as the fists pelted me like hail.

We were at Disney’s Hollywood Studios theme park, and my just-turned 6-year-old son was having a meltdown. After a day at Animal Kingdom and a day at Magic Kingdom, this was the day that he was really excited about. The reason: Star Wars. He had watched only a few of the movies, and he ran out of the room scared during the iconic scene where Darth Vader tells Luke Skywalker: ‘No, I am your father.’ But his advanced reading skills owed much to Star Wars books, and he loved wielding a light saber and explaining to his clueless dad the intricacies of the saga and its myriad characters.

So begins an essay by Dr. Gorman.

He discusses the challenges of the Disney visit. “My son was having a blast, and his dad – a Disney skeptic and never a huge Star Wars fan – was touched by the power of the Force. It was now time for the third and best Star Wars ride: ‘Star Wars: Rise of the Resistance.’ Sadly, no amount of planning, money, or app wizardry could get around the 2-hour line required to get on.” Dr. Gorman goes on to describe an ill-fated trip to the washroom. “More than once I shouted in frustration and hurled punishments that I knew I wouldn’t follow through on. I even lay on the ground, letting him punch me and then telling him I was dead. A terrible parenting move, no doubt, but my desperate reasoning was that maybe he just needed to discharge his aggression and achieve his Oedipal objective…”

He confesses to his supposed expertise. “I should tell you that I’m a child psychiatrist. I even specialize in disruptive behavior disorders. I frequently supervise medical students and residents, and I used to be a program director tasked with training the next generation of child psychiatrists.” He adds: “I have counseled countless parents and taught countless trainees on how to manage unruly, obstreperous children. Yet with my own stubborn son, none of the strategies I recommend to others was working, and I committed the cardinal sin of losing my cool. I felt defeated.”

“‘Imposter syndrome’ is common among physicians, but child psychiatrists who are parents can carry the double burden of feeling like an imposter both at work and at home. I have also experienced what might be called ‘charlatan syndrome,’ as I secretly doubt whether the parenting strategies we recommend truly work for parents and children in the real world, no matter what the experts and the research may say. Over and over, I hear from parents who are doing their best to follow our advice, but the improvements are modest or fleeting if they occur at all. They keep trying to do the same strategies better, or they try different strategies, or they work with another therapist and then another. But things don’t get better, until usually they do, and when that happens the reason often seems to be something else entirely.”

He mulls what is important in parenting. “In my final months as program director, one of the residents, himself a new father, asked me for my insights about how to be a good parent. This came at a time when my son’s meltdowns were getting worse, and I was becoming increasingly unraveled by daily morning battles over putting on his socks or brushing his teeth as I rushed to get him and his sister out the door. I hardly felt in a position to impart wisdom about parenting, and any talk of strategies, approaches, or philosophies would have felt disingenuous.” He notes that parents often become disengaged from challenging children. “So I told the resident to be present as a parent, to throw yourself into the struggle, to embrace the messiness of meltdowns – both your child’s and yours – and to keep trying to do better.” 

He, then, engages. “No accidents, no whining, no meltdowns.” Finally, it’s their turn. “Even for a Disney skeptic, ‘Star Wars: Rise of the Resistance’ is magnificent. More of an immersive movie experience than a traditional ride, it casts the riders in the role of recruits for a secret mission… My son was beaming, our previous battle eclipsed by this shared adventure. As we exited the ride hand in hand, he looked up at me and said, ‘Dad, that was a real experience.’”

A few thoughts:

1. This essay is humorous and real.

2. Charlatan syndrome is particularly humorous.

3. I suspect that our colleagues in child psychiatry can relate – and, in fact, all of us in mental health.

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