From the Editor
When the pandemic started in 2020, the webcam sitting on my desk had barely been used. Of course, over the following days, it became an indispensable part of my outpatient practice as terms like “lockdown” and “Zoom fatigue” entered the common lexicon.
As we move past the pandemic, questions arise. Who benefits from telepsychiatry? And who is better served with in-person visits? Katsuhiko Hagi (of the Sumitomo Pharma Co.) and co-authors attempt to answer these questions with a new systematic review and meta-analysis, just published in The British Journal of Psychiatry. They analyzed 32 papers, involving 3 600 people, across 11 mental illnesses. “Telepsychiatry achieved a symptom improvement effect for various psychiatric disorders similar to that of face-to-face treatment. However, some superiorities/inferiorities were seen across a few specific psychiatric disorders, suggesting that its efficacy may vary according to disease type.” We consider the paper and its implications.
In the second selection, Kwok Ying Chan (of Grantham Hospital) and his co-authors discuss palliative care. In a Viewpoint paper for JAMA Psychiatry, they note that some patients with severe mental illness could benefit from palliative care – yet such care is less available to those with mental disorders than the general population. They highlight challenges and then outline “a more sustainable model for the collaboration between palliative care and psychiatric teams.”
And in the third selection, health care executive Joe Kemp writes about his struggles with suicidal thoughts and substance misuse. In a deeply personal essay for the New York Post, he talks about turning around his life. “I can’t deny my drug-addled past, or that I’m a survivor of two suicide attempts. But I can proudly show the man I am today as someone who has dignity and self-respect; I’ve acquired the most important things to live a happy life. I just followed a different path to get here.”
Selection 1: “Telepsychiatry versus face-to-face treatment: systematic review and meta-analysis of randomised controlled trials”
Katsuhiko Hagi, Shunya Kurokawa, Akihiro Takamiya, et al.
The British Journal of Psychiatry, 1 September 2023 Online First
The pandemic caused by the novel coronavirus disease 2019 (COVID-19) has transformed healthcare significantly… Telemedicine is a viable option to reduce COVID-19 infection among both healthcare providers and patients while allowing access to medical care. Although the COVID-19 pandemic posed unprecedented challenges to healthcare delivery systems, it also prompted the rapid adoption of telemedicine, which has revolutionised healthcare delivery… Psychiatry is probably the most suitable field of medicine for the use of videoconferencing, as diagnoses and symptom assessments are completed by conversing with patients and the use of laboratory tests is limited…
The advantages of psychiatric telemedicine are manifold. Telepsychiatry increases access to psychiatric care. It can be a necessity for patients living in underserved areas and those for whom visiting hospitals/clinics is difficult because of physical difficulties and/or psychiatric symptoms. Telepsychiatry can also lead to early intervention and can simplify the coordination of treatment involving multiple healthcare providers. On the other hand, the potential disadvantages of telepsychiatry include a negative impact on doctor–patient rapport, drop out from long-term treatment, the cost of infrastructure, the possibility of misdiagnosis/maltreatment, essential proficiency in operating web conferencing systems, and limited availability owing to financial and IT skills/ability issues.
Here’s what they did:
“A comprehensive meta-analysis comparing telepsychiatry with face-to-face treatment for psychiatric disorders. The primary outcome was the mean change in the standard symptom scale scores used for each psychiatric disorder. Secondary outcomes included all meta-analysable outcomes, such as all-cause discontinuation and safety/tolerability.”
Here’s what they found:
- They identified 32 RCTs with 3 592 participants.
- Primary outcome. “Of the 10 psychiatric disorders analysed, no significant difference in symptom score improvement was found between telepsychiatry and face-to-face treatment for 8 disorders (chronic tic disorders, OCD, PTSD, insomnia, disruptive behaviour disorder, substance misuse, mild cognitive impairment (MCI) or mild dementia, and multiple disorders).”
- Depression and eating disorders. “Telepsychiatry was significantly more effective than face-to-face treatment for improving depressive symptoms (k = 6, n = 561…). On the other hand, for eating disorders, face-to-face treatment was significantly more effective than telepsychiatry for improving symptoms, based on one study (n = 128…).”
- Combined. “No significant difference was seen between telepsychiatry and face-to-face treatment when all the studies/diagnoses were combined (k = 26, n = 2290…).” See figure below.
- Discontinuation. “Telepsychiatry had significantly fewer all-cause discontinuations than face-to-face treatment for mild cognitive impairment (k = 1, n = 61; risk ratio RR = 0.552…), whereas the opposite was seen for substance misuse (k = 1, n = 85; RR = 37.41…).” But they note: “Telepsychiatry was similar to face-to-face treatment in terms of study discontinuation when all the diagnoses were combined (k = 27, n = 3341…).”
A few thoughts:
1. This is a good study.
2. The paper is practical and highly relevant to our times. What care should be moved back to in person? What care should stay virtual?
3. The main finding in two sentences: “The results of our meta-analysis suggest that telepsychiatry is mostly equivalent to face-to-face treatment in terms of both efficacy and study completion rate when a wide range of common psychiatric disorders, including depressive disorders, PTSD, insomnia and eating disorders, are considered collectively. When all studies examining all diagnoses were combined, no significant differences in 27 of the 29 outcomes, including the primary outcome, were found between telepsychiatry and face-to-face treatment.”
4. But diagnosis matters. In particular, those with depressive disorders did better with the virtual option.
5. Like all studies, there are limitations. The authors note several, including: “the number of studies and the sample size per study were mostly small: except for PTSD and depressive disorders, most of the diseases had only one RCT.” They also note the lack of long-term data. Over time, more research in this area will be needed.
6. Virtual care has been considered in past Readings, of course. Late last year, we looked at a Canadian Journal of Psychiatry paper focused on primary care for those with schizophrenia, finding: “There were substantial decreases in preventive care after the onset of the pandemic.” That CJP paper can be found here:
The full BJP paper can be found here:
Selection 2: “Rethinking Palliative Care in Psychiatry”
Kwok Ying Chan, Desmond Y. H. Yap, Harinder Singh Harry Gill
JAMA Psychiatry, 13 September 2023
Severe mental illnesses (SMI) are long-term and recurring conditions that interfere with daily activities and demand long-term therapy. Schizophrenia, bipolar disorder, and severe depression are the most common diagnoses. In the US, the prevalence of SMI is estimated to be 4.2%. People with SMI have a higher risk of chronic illnesses that are more severe and are discovered later in life (including 2 to 3 times the risk of diabetes and 5 times the risk of metabolic syndrome compared with the general population)… Palliative care is regarded as appropriate for this population due to the care complexity associated with SMI along the illness trajectory and toward the end of life. However, the rate of receipt of palliative care in patients with SMI was only 0.5%, compared with 1.72% of the general population.
So begins a Viewpoint by Chan et al. They focus on three areas:
Difficulties Associated With SMI in Palliative Care
“Distinguishing feature of palliative care in SMI is that, unlike patients with fatal illnesses, such as cancer or heart disease, patients with SMI must cope with 2 distinct issues: lifelong SMI treatments and management of fatal medical conditions.”
They highlight unique challenges:
- Suicide. “Palliative care teams may lack competence in caring for suicide and self-harm for patients with SMI. Unlike traditional palliative care for people with terminal illnesses, care for patients with SMI and medical comorbidity should include a preventive component to lower the likelihood of future suicidal attempts.”
- Spirituality. “Bringing spirituality to patients with SMI can be challenging at times. While spiritual faith workers are recognized to play an important role for people with conditions, such as cancer, their work for people with SMI can be difficult at times since some patients have religious delusions or hallucinations.”
- Family. “The role of the family in palliative care for patients with SMI is likely to be distinct.”
Rethinking Palliative Care Strategy in Psychiatry
“We endorse the expanding use of palliative care specialists’ best practices, notably in the treatment of major physical symptoms. In fact, both professions strive for continuity of care, the best psychosocial management (whether delivered by nurses, social workers, support groups, or psychotherapy) and the ability to predict future needs in order to avoid crises. A lack of advance care planning and late referral remain significant barriers to palliative care delivery for patients with SMI, just like other serious medical disorders. According to current research, a respective proportion of consultation liaison and geriatric psychiatrists already have some general palliative care proficiency and understanding (symptom management/advance care planning/end-of-life system issues were included in 70% to 80% of fellowship training programs). This generalist plus specialist palliative care concept may be more sustainable…”
The Way Forward
“Close collaboration between psychiatrists and palliative care professionals can gradually improve patients’ quality of life. A tiered approach may entice patients with SMI to participate in palliative care.”
A couple of thoughts:
1. This is a good Viewpoint paper, and on a topic that is not often discussed.
2. As is the case with physical health problems for those with severe mental disorders, palliative care is difficult to access.
The full JAMA Psych Viewpoint can be found here:
Selection 3: “This Suicide Prevention Week, I hope I can spare others the pain I went through”
New York Post, 11 September 2023
It should have been my last glance at the outside world, but I took little notice of the cloudless sky or the plush green trees in my parents’ backyard.
I pulled my bedroom window shut, dropped the metal blinds and turned my focus to a dimly lit end table.
There, I had a small pile of heroin, and I was determined to shoot up enough to kill me. I was 17.
Suicide was something that I had contemplated for a few years, but until that day, I always managed to resist the urge to follow through.
So begins an essay by Kemp.
“When it finally swelled so large that it began to overwhelm my heart and lungs, physically weighing me down, I quietly decided it was time to go… So there I was: alone in my room, planning an overdose – what would appear nothing more than a sad accident – to be the last page of my life story. That moment of despair, now more than 25 years ago, may seem extreme to many.”
He notes the statistics: “those between the ages of 10 and 24 account for about 15% of all suicides, which have become the second leading cause of death for that age group in the country.” Fortunately, his outcome was different. “A friend unexpectedly walked into my room just after I collapsed.”
The road to recovery was long. “There would be a similar failed suicide attempt a couple of years after I dropped out of high school and grew tired of bouts of homelessness, hunger, violence and incarceration. But then something happened when I was 20 – two close friends overdosed and died in quick succession. I was devastated by the loss, but also deeply ashamed.”
He talks about his changes. “My last high was just days before my second friend’s funeral. I walked to the grave behind a long line of people, all of them completely broken that young Jimmy – a son, a brother and a friend to so many – was gone forever. When his casket was put in the ground, I realized that I had one more chance to make my life mean something, even if it was just for the sake of those who never got the chance. That’s when I suddenly found the will to live.”
He discusses his career. “I worked as a reporter and editor for more than a decade, often covering tragedies laced with drug addiction and suicide. If only my colleagues knew my personal experience on those subjects; if they only knew I was writing about the lives that I once lived.”
“Today, I have more meaning in my life than I ever imagined. I’m happily married, raising three beautiful young daughters in the city and working as a publicist for a leading health care provider. My job every day is to communicate how health care professionals are saving people or improving their quality of life. Nothing has been more satisfying than having a small role in how my organization creates impact in the communities it serves. The irony is not lost on me. I’m also currently pursuing an MBA at Columbia Business School, the first in my family to attend – or to even imagine attending – an Ivy League institution.”
A few thoughts:
1. This is a tough essay to read – personal and raw.
2. I’ll repeat a comment made in past Readings: it’s great to read such honest accounts of mental health problems, further evidence of fading stigma.
3. He recovers and chooses a career in health care. Lucky us.
The full NYP essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.