From the Editor
At the start of the pandemic, the shift to virtual care was important and necessary, allowing us to reach our patients during the lockdowns. As we slowly move past COVID-19, there are big questions to ask. What’s lost in the virtual world? What’s right and what’s to be done?
In the first selection, Ellen Stephenson (of the University of Toronto) and her co-authors look at patients with schizophrenia. In a new paper just published in The Canadian Journal of Psychiatry, they analyze different aspects of care, including prevention. They find: “There were substantial decreases in preventive care after the onset of the pandemic, although primary care access was largely maintained through virtual care.” We consider the paper and its clinical implications.
In the second selection, David B. Yaden (of Johns Hopkins University) and his co-authors weigh in on the enthusiasm and criticism of psychedelics. In this Viewpoint for JAMA Psychiatry, they argue that interest has reached a “hype bubble.” They make a call for action: “As scientists and clinicians, we have an ethical mandate to dispute claims not supported by available evidence. We encourage our colleagues to help deflate the psychedelic hype bubble in a measured way…”
And in the third selection, K. J. Aiello – who has lived experience – writes about mental illness and stigma in an essay for The Walrus. While noting some progress in the acceptance of mental disorders, the writer wonders how much has really changed. “Even as the stigma around mental illness has faded, it has become clear that this compassion and effort extend only so far, and that they are not available to everyone. Often those fault lines appear around class – and around the type of mental illness.”
Selection 1: “Disruptions in Primary Care among People with Schizophrenia in Ontario, Canada, During the COVID-19 Pandemic”
Ellen Stephenson, Abban Yusuf, Jessica Gronsbell, et al.
The Canadian Journal of Psychiatry, 30 November 2022 Online First
The COVID-19 pandemic upended healthcare systems around the world. One of the key changes has been a rapid and now sustained increased use of telemedicine and virtual care, particularly in primary care settings…
Ontario experienced a rapid decrease in in-person primary care visits and a concomitant increase in virtual visits. Prior to the pandemic, there were 110 in-person office visits for every 1 virtual visit in primary care in Ontario; after the pandemic onset, virtual visits outnumbered in-person office visits at a rate of 2.5:1…
A recent study from the United States showed decreases in mental health outpatient visits, emergency department use and medication dispensing among people with serious mental illness (schizophrenia, schizophrenia-related disorders and bipolar I); this study did not describe changes in the quality of care provided and was not focused on primary care.
So begins a paper by Stephenson et al.
Here’s what they did:
“This cohort study was performed using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN), a network of > 500 family physicians in Ontario, Canada. Data were collected during primary care visits from 2643 patients living with schizophrenia. Rates of primary care health service use (in-person and virtual visits with family physicians) and key preventive health indices indicated in antipsychotic monitoring (blood pressure readings, hemoglobin A1c, cholesterol and complete blood cell count [CBC] tests) were measured and compared in the 12 months before and after onset of the COVID-19 pandemic.”
Here’s what they found:
- A total of 2643 patients with schizophrenia met criteria for inclusion; 82.8% of patients were included in both time periods (that is, before and after the start of the pandemic).
- Demographics. Most were male (53.75%), with a median age of 49.7. Many lived in lower income neighbourhoods. Chronic illnesses were common: diabetes, 22.74%; hypertension, 25.92%.
- Care. “Access to in-person care dropped substantially in the first year of the pandemic with only 39.5% of patients having at least one in-person visit with their family physician compared to 81.0% the year before.” And with regard to virtual care: “38.5% of patients had only virtual visits during the first year of the pandemic.”
- Types of antipsychotics. In-person visits were more common for those prescribed injectable antipsychotics (versus those prescribed oral or no antipsychotic medications).
- Preventative care. “The proportion of patients who did not have recommended tests increased from 41.0% to 72.4% for blood pressure readings, from 48.9% to 60.2% for hemoglobin A1c, from 57.0% to 67.8% for LDL cholesterol and 45.0% to 56.0% for CBC tests during the pandemic.”
A few thoughts:
1. This is a good study.
2. It’s also highly relevant, offering solid data on virtual care.
3. The good news: primary care shifted and – in terms of measures like proportion of patients with visits – people with schizophrenia continued to have access.
4. But preventive care suffered. Blood pressure readings were, not surprisingly, less commonly done with heavier reliance on virtual care. The authors write: “Given the increased risk of cardiovascular disease among people with schizophrenia, it is concerning that the completion of blood pressure readings after the onset of the pandemic dropped by >50%.”
5. The implications for care? They argue: “Although there were some encouraging findings related to access and intensity of care, overall this demonstrates the detrimental effects of the COVID-19 pandemic… These results demonstrate the importance of developing and evaluating proactive approaches to primary care management of people with schizophrenia, to optimize the primary prevention of cardiovascular disease.”
6. Like all studies, there are limitations. The authors note several, including: “Primary care EMRs contain incomplete data on patients’ health conditions such that diagnostic status can sometimes be difficult to determine…” A larger question: how generalizable are these findings based on Toronto academic family practices with robust EMRs?
7. Virtual care has been considered in past Readings. In recent months, we looked at a JAMA Psychiatry Viewpoint paper written by Dr. Carlos Blanco (of the National Institute on Drug Abuse, United States) and his co-authors. They comment that 39% of mental health care in the US is now virtual, creating opportunities and challenges. That Reading can be found here:
The full CJP paper can be found here:
Selection 2: “Preparing for the Bursting of the Psychedelic Hype Bubble”
David B. Yaden, James B. Potash, Roland R. Griffiths
JAMA Psychiatry, 1 October 2022
Psychedelic research currently appears to be trapped in a hype bubble driven largely by media and industry interests. We believe that it would benefit the field of psychedelic research if this bubble were to be systematically deflated by researchers and clinicians using good science communication practices.
The term bubble is often applied to something of value that has become overvalued in popular perception. As a society, we are familiar with the term as it has been applied to, for example, the internet (the dot-com bubble of the 1990s) and the value of housing (the housing bubble of the early 2000s). In terms of psychedelics, headlines have turned from presenting alarmist, extremely negative views of the drugs (approximately 1960s to 2000s) to acknowledging their positive potential (2006 to the present). However, in the past few years, a disturbingly large number of articles have touted psychedelics as a cure or miracle drug as well as mentioned the investment potential of psychedelics reaching billions of dollars.
So begins a paper by Yaden et al.
They make a few comments:
State of Evidence
“The superenthusiasts are incorrect in believing that psychedelics pose no risks because those risks are well established. Furthermore, the treatment potential of psychedelics is real but is less impressive than expected, as shown in a recent trial comparing psilocybin with a gold-standard treatment of depression. On the other hand, the skeptics are incorrect in thinking that the short-term subjective effects of psychedelics consist of a psychotic-like state of delirium; well-replicated findings have shown these effects to be challenging yet positive and highly meaningful, with persisting favorable effects for most people.”
The Hype Cycle
Drawing on the Gartner Hype Cycle, they argue that a period of “inflated expectations” can be followed by a “trough of disillusionment.” They authors warn of potential “blowback” because “although some people are unfortunately harmed by any number of effective treatments, the visibility of psychedelic use means that such cases will be widely reported, often without the context of how clinical trials contribute to scientific progress.”
Ethical Obligations for Science Communications
“Overly hyped claims fall into 2 main categories: clinical and social. Clinically, psychedelics are not a cure for mental disorders. We have not found evidence for this claim, and it increases the risk of inflated patient expectations. Socially, psychedelics do not solve major issues such as racism and war. Such claims risk trivializing the complexities of the issues and resources needed to make real progress. That said, we need to be on guard for equally extreme negative claims that are likely just over the horizon.”
A few thoughts:
1. This is a cleverly written paper.
2. The core point: we should be careful about both over-enthusiasm and under-enthusiasm for psychedelics.
3. Is their argument particularly controversial?
4. Psychedelics have been discussed in past Readings. The latest NEJM paper on the topic (psilocybin for treatment-resistant depression) was considered last month. You can find it here:
The full Viewpoint can be found here:
Selection 3: “Who Gets to Be Mentally Ill?”
K. J. Aiello
The Walrus, 2 December 2022
A little while ago, I saw a post in my Toronto neighbourhood Facebook group about a man with ‘mental issues’ hovering around a local park. The post also reminded us to ‘stay safe.’ My neighbours said thanks for this warning, but my heart sank. I wondered who that man was and what had happened to him, about the events in his life that had led him to wander a public park with outward symptoms of mental illness. Maybe his gestures were sharp and pointed, his mind mired in what can only be assumed to be psychosis.
I wondered what my neighbours would think if they knew that I too had experienced severe mental health crises. I’d heard things that weren’t there, believed things that weren’t true, and lived with one foot in a semidelusional existence. Given the right mix of life events, I could have been that person wandering the park.
So begins an essay by Aiello.
While there has been progress, the author doesn’t feel that it applies to all with mental health problems. “People who are perceived as productive members of society, who have jobs and who rent or own their homes, are, in some cases, allowed to be anxious, down, or depressed. Meanwhile, mental illnesses like schizophrenia, bipolar disorder, and substance use disorder, which result in behaviours that can be perceived as destructive and sometimes even violent, are not discussed as freely.”
The author continues: “In mental health discourse, there is a strong underlying message that mental health is one’s own responsibility (self-care, expensive therapy, psychiatric intervention, and so on) and that mental unwellness – including mental illness – is something to be overcome, followed by a return to productivity within a capitalist world. And yet this is hardly ever unpacked within wider advocacy, such as #BellLetsTalk and CAMH’s 2020 campaign Not Suicide, Not Today. Instead, positivity campaigns are exclusive. They don’t include people that aren’t going to fit into an aspirational persona. Would #BellLetsTalk be open to having an unhoused person on its website, for example?”
The essay includes the author’s reflections on illness and hospitalization, including disclosure of an overdose and an admission. “In that hospital, I learned who I really was. I wasn’t just a person who’d failed their second semester at university and was marched out of their dorm room accompanied by two police officers while students watched. I wasn’t a person who was terrified of what was happening to them. I was the Other, the sick, the deranged.”
A few thoughts:
1. This essay is provocative and well argued. It’s also beautifully written.
2. Has stigma faded – but only for some and for certain illnesses? Aiello seems to think so, and points to a few things, including positivity campaigns. Perhaps, though, the glass is both half full and half empty, and significant progress has been made.
3. The summary here doesn’t quite capture the nuances and cleverness of the essay, which also includes a thoughtful review of the history of mental health services.
The full Walrus essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.