From the Editor

Is mental health becoming too technical (and forgetting patients as a result)?

The future of us clinicians?

This is the second Reading in a two-part series considering the future of mental health – not in terms of distant developments like biomarkers and genetically-tailored drugs – but rather by looking at measurement-based care and the evolution of the field.

Last week, measurement-based care.

This week, the end of the art of care?

This week, we look at an editorial The British Journal of Psychiatry that warns against physicians becoming “well treated skilled workers.”

And, continuing the consideration of ‘the future,’ we also consider a new paper that has received much attention. Can a web-based intervention help with insomnia? Spoiler alert – as The New York Times reported last week, “more than half of chronic insomniacs who used an automated online therapy program reported improvement within weeks and were sleeping normally a year later.”


Practice and its Future

“Uncertainty principles in medicine and mental healthcare”

Kamaldeep Bhui

The British Journal of Psychiatry, October 2016

The medical consultation requires that the doctor listens, takes account of the patient’s individual biography, profile of risk and protective factors, the social and economic contexts in which the patient lives, and carefully marshals good practice guidance and research evidence. All of this information is applied to recommend treatments suited for the individual person. This should be a thoughtful, creative, and humanistic form of evidence-based practice, rather than a technical and impersonal industrialisation of healthcare. While undertaking this layered and labyrinthine process, there is much uncertainty that must be managed, in terms of the patient’s anticipated apprehension about diagnosis and treatment, but also in terms of the evidence base if it does not fully cover the individual circumstances of a particular person’s dilemmas.

The assessment of risk is an example of where such expertise and evidence need critical interpretation, especially in order to assess and prevent serious consequences.

Kamaldeep Bhui

So begins an editorial from The British Journal of Psychiatry. According to that journal’s website, this piece is one of the most read of the year.

Dr. Bhui – a psychiatrist and editor of The British Journal of Psychiatry – argues that:

Doctors seem to be resisting the status of well-treated skilled workers instead of being a profession. Skilled workers make use of checklists and algorithms, following uniform, linear, and sometimes inflexible guidelines to deliver consistent and predictable outcomes, during a fixed time allocation, for all patients.

Dr. Bhui expands his argument:

· Suicide prevention requires clinical judgment. “In order to reduce uncertainty, the assessment of suicide risk is often a ritual progression through a series of checklist questions (skilled worker rather than professional). Organisational (provider, state, and profession) defences against uncertainty require such measures, but the task of the doctor and any health professional must include far more than actuarial evaluations.”

· PTSD. Again, he notes the importance of judgment. “As we grapple with evidence on the most appropriate interventions, the diagnostic status of PTSD is still to be reconciled with emerging evidence… Professional judgement is made in this context of evolving diagnostic systems, but also where established interventions may not work as well for specific groups of patients, or individuals exposed to particularly adverse experience…”

He concludes by tapping quantum mechanics:

Heisenberg’s uncertainty principle suggests fundamental limitations to the precision of measuring the properties of particles. Similarly, uncertainty and judgement are inherent in healthcare, although we must still battle to provide better knowledge of what works, for whom, but also where and when.

A few thoughts:

1. This is a well-argued editorial.

2. Let me repeat a point I made last week: the two papers in this two-part series are from two different journals. Dr. Bhui isn’t responding to the paper on measurement-based care. In some ways, though, he is suggesting that there is more to clinical work than scales and the interpretation of scales.

3. Of course, the two papers aren’t necessarily contradicting each other. We can favour measurement-based care but also recognize that mental health clinicians need to practice the art of care delivery.

CBT and the Internet

“Effect of a Web-Based Cognitive Behavior Therapy for Insomnia Intervention With 1-Year Follow-up: A Randomized Clinical Trial”

Lee M. Ritterband, Frances P. Thorndike, Karen S. Ingersoll, Holly R. Lord, Linda Gonder-Frederick, Christina Frederick, Mark S. Quigg, Wendy F. Cohn, Charles M. Morin

JAMA Psychiatry, 1 November 2016


Insomnia is a significant public health problem with substantial medical, psychiatric, and financial ramifications. Simply defined, insomnia is difficulty falling asleep or maintaining sleep, and it is one of the most common health concerns today. Approximately 35% to 50% of the general adult population experience insomnia symptoms, with 12% to 20% meeting criteria for insomnia as a disorder. Insomnia is highly comorbid with medical and psychiatric disorders. The combined direct and indirect costs associated with insomnia exceed $100 billion in the United States alone. Given the high prevalence and detrimental effect of insomnia, finding effective, accessible, and affordable treatment is critical.

Cognitive behavior therapy (CBT) and pharmacotherapy are the only 2 treatments with sufficient empirical support to be recommended for treating chronic insomnia (>1 month). While medication use is readily accessible and effective in the short term, CBT for insomnia (CBT-I) has longer-lasting benefits, with fewer adverse effects. It is now recommended as a first-line treatment. Most important, CBT-I addresses the problematic thoughts and behaviors believed to have developed in response to acute insomnia or a short-term sleep problem (days or weeks).

Although there is strong empirical support for CBT-I, the lack of trained clinicians and expense, while cost-effective, limits access. To overcome these barriers, innovative methods of delivering CBT-I have been developed, and initial evidence supports their feasibility and efficacy. To date, internet-based trials with published outcomes have been small, homogeneous, and limited in their generalizability and have excluded individuals with insomnia co-occurring with medical and psychiatric disorders.

The present study was designed to address several limitations that exist within the internet-delivered CBT-I literature.

Lee M. Ritterband

So begins a new paper just published in JAMA Psychiatry. Internet-delivered CBT-I was also considered in a summer Reading (for the prevention of depressive episodes). This JAMA Psychiatry paper reports on six-month and 12-month follow-ups for insomnia – offering us new, important data. This paper has received much attention; it seems reasonable that a series on the Future of Psychiatry include discussion of this paper.

Here’s what they did:

· Essentially, this study was a randomized clinical trial for people with insomnia, looking at “the efficacy of a fully automated internet-delivered cognitive behavior therapy for insomnia intervention compared with an insomnia patient education website with respect to the primary sleep outcomes of Insomnia Severity Index” and two other measures.

· Participants were randomized into an intervention group and a patient education group. The intervention: “Sleep Healthy Using the Internet (SHUTi) is a fully automated, interactive, and tailored web-based program that incorporates the primary tenets of face-to-face CBT-I, including sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention.” The PE group received information on insomnia from a website.

· Different measures were used, including ISI, “a 7-item global index of self-reported insomnia symptom severity.”

· Inclusion criteria included needing more than 30 minutes to fall asleep. Exclusion criteria included shift work and pregnancy.

· Participants were recruited online, with post-assessment data collection done after the assessment period, then at 6 and 12 months. Participants were given financial incentives to complete the post-assessments (gift certificates at 6 months for $50 and $100 at 12 months)

· Statistical analysis was done, including the calculation of effect sizes (Cohen d).

Here’s what they found:

· 1,212 people filled out the online form; 303 were enrolled.

· 151 were randomized to SHUTi; 152 to the PE group.

· The demographics: on average, participants were white (83.8%), female (71.9%), and well educated (77.6% had college or more). In terms of insomnia, they had a mean of nine years of sleep difficulties most nights.

· Participants in the SHUTi group did better than the PE group in terms of ISI (see graph below).

· “An evaluation of clinical significance also demonstrated the superiority of SHUTi, with 52.6% (70 of 133) of the SHUTi group deemed treatment responders (defined by a reduction of >7 points on the ISI) from baseline to postassessment compared with only 16.9% (24 of 142) of the PE group.”

· On secondary measures – sleep efficiency, number of awakenings, sleep quality – the SHUTi group did better, but not with overall sleep time.

The authors conclude:

This randomized clinical trial is the first to evaluate the long-term efficacy of a fully automated internet-delivered CBT-I intervention to improve sleep in a heterogeneous sample of adults with chronic insomnia. The SHUTi group experienced significant improvements in ISI, SOL, and WASO—the 3 primary sleep outcomes. With all participants averaging in the moderate severity insomnia range of 15 to 21 on the ISI at baseline, those in the SHUTi group had a mean ISI of less than 8 (denoting no insomnia) at the 1-year follow-up, whereas the PE group was in the subthreshold insomnia range of 8 to 14.

A few thoughts:

1. This is an interesting paper, and does include 12-month data.

2. As we consider access issues, it’s useful to look to non-traditional ways of delivering care. SHUTi offers what few family medicine or mental health clinics offer – an evidence-based psychological intervention to address insomnia. As Andrew D. Krystal and Aric A. Prather note in an accompanying editorial, “Internet-based CBT-I is an attractive solution to challenges of scalability.”

3. I’m a bit tempered in my interpretation of the results. The completion rate was 60.0% (for all completing all six “cores” of the program) – and that’s with financial incentives for people to complete, in a group that almost surely was motivated to start with (remember people responded to an online ad). New York Times reporter Benedict Carey in his article on the study quotes National Jewish Health’s Jack Edinger: “These results suggest that there are a group of patients who can benefit without the need of a high-intensity intervention… We don’t know yet exactly who they are – the people who volunteer for a study like this in first place are self-motivated – but they’re out there.”

4. As we consider ways to reform mental health services across this country, we should think about e-mental health. We shouldn’t oversell – many patients require face-to-face care.

Further Reading

The editorial can be found here:

The NYT article can be found here:

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