Lam et al. have published a study this month in JAMA Psychiatry (http://www.ncbi.nlm.nih.gov/pubmed/26580307 ) in which they show that people with non-seasonal major depressive disorder may have improvements in their mood with daily use of a light box alone. Previously, light boxes have been used mainly in the treatment of seasonal depression or "SAD."
One of the reasons light therapy is attractive is that it is not a medication: it is far less likely to cause side effect problems, and therefore it could have a much broader appeal, especially among people who are not comfortable using psychotropic medications.
In the study, there were four groups:
1) 10 000 Lux light box exposure for 30 minutes as soon after waking as possible (the standard regimen of using light therapy), plus a placebo medication.
2) A "sham" or "placebo device" condition of sitting in front of a buzzing box (an inactive ion generator), plus a placebo medication
3) 20 mg/day of fluoxetine + placebo device
4) 20 mg/day fluoxetine + 10 000 Lux light box
The treatment duration was 8 weeks.
At the end of the study period, there were no significant differences between the fluoxetine+placebo device and the placebo medication+placebo device groups. We could conclude from this that monotherapy with 20 mg/d of fluoxetine for 8 weeks had no benefit for treating major depression in this cohort!
The light box+placebo medication group showed much more improvement (about twice as much change from baseline as the placebo-placebo group), with response rates typical for effective antidepressant therapies. The combination group did best of all, with a response rate of 76% and a "remission rate" of 59%.
So this study supports the use of a light box alone as a viable therapy for depression, even if the depression does not have a seasonal pattern.
However, here are a few possibly cynical queries about this study:
1) while people in the study had to be medication-free for 2 weeks before the study commenced, I would suspect that many people in the study had tried other antidepressants. This was not clearly documented. By far the most common antidepressants that they would have tried would have been SSRIs. Obviously, any SSRI trial would not have led to satisfactory improvement in these people, otherwise they wouldn't still be depressed! In general there is not a lot of evidence that one SSRI is very different from any other, in terms of effectiveness. Therefore, the study would have been biased against the medication group, in favour of the outcome which I presume the authors desired (which is to show that "light therapy is good"). If the authors wanted to control more powerfully for this factor, it would be necessary for them to assemble a cohort of depressed patients who had no prior history with antidepressants.
2) it is not hard to imagine that bright light could be a healthy, wholesome way to start the day. It is much harder to imagine that sitting in front of a buzzing dark box could be beneficial. The study demonstrated that the "expectancy scores" were the same for each of the four groups, i.e. that people in each of the 4 groups had a similar belief that the treatment they were receiving could be beneficial. Yet, I question how compelling it would be for a modern person to believe that sitting in front of a buzzing box daily for 8 weeks would lead to a positive mood change or health benefit.
Furthermore, the treatments were absolutely not "blinded." It would be obvious to the person sitting in front of the light box that they were receiving light therapy! The person sitting in front of the buzzing box would be fully aware of not receiving light therapy!
3) people in the study were apparently told not to "spend an excessive or unusual amount of time outside" during the study! If you are told not to go outside, do you not think that you might benefit even more from bright light indoors? What if the effect of time outside exceeds the effect of the light box?! In this case, how about prescribing that people just go outside for a half-hour in the morning after sunrise? I'd be curious to see a study comparing a half hour walk outside with a half hour sitting in front of a light.
Is a commercial 10 000 Lux light box really necessary? How well can a person tell the difference between light intensities? In various prior studies, the "sham" light therapy was a dim red light. Here again, such a "device placebo" is not truly blinded! Being stuck in front of a dim red light for half an hour sounds depressing just to think about!
The most interesting study I have come across looking at some of these questions was published by Riemersma-van der Lek et al in JAMA in 2008. http://www.ncbi.nlm.nih.gov/pubmed/18544724
They had different lighting levels in nursing homes, followed for over a year. People living in the homes could not guess accurately whether they were in the bright light condition or not (the intensities were approximately 1000 Lux vs 300 Lux, all day). The brighter light seemed to cause some positive effects, and also eliminated negative effects caused by nightly melatonin administration.
To have a truly blinded study, we would need to use a light box of the same size, with the same colour of light, but with a lower intensity (for example, 5 000 Lux), but such that the person exposed to this light would not be able to guess the intensity level correctly. That is, if you sat in front of the lower intensity light box, you wouldn't be able to tell that you were in the "dim light" group. This is reasonable to expect, since the visual system adjusts remarkably to different lighting conditions, causing wide ranges of measured illumination to be perceived similarly unless they are contrasted directly with each other at the same time.
It would also be useful to more carefully assess the relationship, if any, between light therapy duration and intensity with clinical symptom changes. What about 20 minutes vs. 30 minutes? Or 7 000 Lux vs 10 000 Lux? I suspect that the 10 000 Lux, 30 minute regimen is more arbitrary than one might expect.
I have little doubt that bright light first thing in the morning is beneficial for mood--it seems like an obviously wholesome thing, which could also help regulate behaviour and sleep-wake patterns etc. It could also be an opportunity to structure a type of meditative or study time in the morning.
But is a commercial product really necessary? A typical "light box" costs about $200. The electrical components inside are probably worth no more than perhaps $20-40. It is just a fluorescent light!
It would be reasonable to conduct studies with "home made" light therapy, including just turning on a few extra lamps, or even just sitting in front of a bright east-facing window! While the 30-minute treatment could be enjoyable and meditative for some, or a time to start the day with a bit of reading, it may be that the sedentary nature of light box exposure could be unhelpful for at least some people. For these others, perhaps they could use that 30 minute time more healthily to get outside for a walk, instead of sitting in front of a box.
One of the other applications for a light box that I have recommended to people is to help with morning sleep habits. Many people have trouble waking and getting up out of bed at a regular hour (this regularity being a cornerstone of healthy sleep habits!). Using a light box next to the bed, connected to a timer circuit which turns it on at the same hour each morning, could be used to help consolidate a regular sleep routine. It would be like an "artificial sunrise." (Of course, a natural sunrise would be much better still, but in our modern indoor world, it is hard to arrange this; also in a northerly latitude, the sun rises very late during the winter months, which is most likely a factor in causing seasonal mood and sleep changes). So, using bright light as an "alarm clock" could be an idea worth trying, especially in the winter months.
Monday, January 11, 2016
Thursday, January 7, 2016
Omega-3 supplements: update
A number of negative studies have come out in the past year or two, regarding various types of supplements.
I think it is good to be wary of claims about supplements, just as we should be wary of biases related to pharmaceutical marketing or to therapists touting particular styles of psychotherapy.
Here is a review of some recent research regarding omega-3 supplementation:
I think it is good to be wary of claims about supplements, just as we should be wary of biases related to pharmaceutical marketing or to therapists touting particular styles of psychotherapy.
Here is a review of some recent research regarding omega-3 supplementation:
A simple 12-week study by Fristad et al (2015), published in the Journal of Child and Adolescent Psychopharmacology, showed that omega-3 supplements, given over 12 weeks, had a modest antidepressant effect in children with bipolar-spectrum symptoms. The effect size was greater than placebo, but less than that of "psychoeducational psychotherapy."
In a very recent meta-analysis by Cooper et al (2016), it is concluded that omega-3 supplements given to children with ADHD do not cause large symptom improvements. But there is enough evidence, including from high-quality studies, to believe that omega-3 supplementation could lead to small improvements in emotional lability and oppositional behaviour.
http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.jad.2015.09.053
Bos et al (2015) compared omega-3 supplements (650 mg/day EPA+DHA) with placebo, in a 16-week study of 79 boys with ADHD. They found improved parent-rated attention scores in the omega-3 group. The effects they report appear to be clinically significant. http://www.ncbi.nlm.nih.gov/pubmed/25790022
Widenhorn-Muller et al (2014) showed an improvement in working memory in children with ADHD given 720 mg/day of omega-3 supplements for 16 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.plefa.2014.04.004In a JAMA article by Chew et al (2015), the authors show that omega-3 supplements, given daily over 5 years, do not slow down the rate of cognitive decline in elderly people.
http://www.ncbi.nlm.nih.gov/pubmed/26305649
For a recent review, Mischoulon and Freeman's 2013 chapter in Psychiatric Clinics of North America is a good contribution.
Gonzales et al (2015) showed that omega-3 supplements, given to rats, led to "increased adaptive coping with stressful events."
http://www.ncbi.nlm.nih.gov/pubmed/?term=10.1016%2Fj.bbr.2014.11.010
In this interesting article by Bondi et al, they suggest from their findings that omega-3 deficiency, continued over several generations, can cause "impairment in cognitive and motivated behaviour" in adolescent rats. This may speak to the importance of the dietary quality through the entire lifespan, as a factor in psychological resilience. The typical western diet is often described as progressively omega-3 deficient.
Conclusion
I continue to recommend omega-3 supplementation. It is a reasonable supplement for those with symptoms of depression, ADHD, or bipolar disorder. The dose to aim for is between 1 and 2 grams per day of EPA+DHA combined, usually with the EPA:DHA ratio at least 3:2.
I base this recommendation on the fact that there is reasonable evidence of a slight improvement, not only in measures of psychological health, but also in various other aspects of physical health (such as inflammatory diseases).
I think the magnitude of any improvement due to omega-3 supplements is likely to be very slight. But in combination with other factors, such as healthy lifestyle and responsible use of medication, it could be a component of balanced, holistic health care, particularly if continued regularly for long periods of time.
One of the weaknesses of many of these studies is the lack of consideration for other lifestyle elements. Considering diet alone, it is unlikely that omega-3 supplements would help very much if the rest of a person's diet is unhealthy. A healthy, balanced, "Mediterranean" style diet, with lots of vegetables, healthy oils (such as olive), fish, and nuts, with minimal processed foods, minimal sugar, minimal simple carbs, is likely to be much more important in terms of nutritional care of mood, compared to any supplement alone. However, omega-3 supplements could be a safe and possibly useful adjunct to an already healthy diet.
Parenting & Psychotherapy
There are many books out there about how to be a better parent. The fact that this genre is popular is, in my opinion, a good sign of societal health: perhaps part of parenting well is being interested in learning about ways to parent well! It speaks to a cultural change as well, in which quality of parenting is considered important as a societal theme.
Demographics have changed over the centuries, in a way which bodes well for the earth's future:
At this point, there is about 1.1% of population for each year of age, up to 1.6% per year for people in their 50's (the baby-boomers), then declining gradually for elderly. In general, the population pyramid now looks more like a "solid bar" rather than a triangle, indicating that people of all ages are more equally represented in the population, rather than young children being most common.
This means that each family with children, on average, can invest more time, attention, and resources, with each individual child.
What is the evidence about the merits of different styles of parenting?
Here we have the very surprising finding that differences in "shared family environment" have a much smaller impact on most phenomena, such as personality traits, intelligence, and mental illnesses, compared to differences "non-shared environment" (i.e. the environmental factors unique to the individual) and to differences in genetics.
Yet, these findings refer to population averages. It is obvious that extremes of environmental experience will obviously influence outcomes much more. An atmosphere of severe abuse and neglect is likely to have a damaging effect, while smaller differences in home environment within the "average" range in the society are much less likely to have significant effects.
People tend to focus excessively on the "smaller differences" side of things, with respect to parenting and home environment. Provided that the home is secure, safe, relatively stable, with access to reasonable social and educational resources, it is probably true that variations within one or two standard deviations of the mean of parenting style are unlikely to make very much difference, in terms of subsequent illnesses, intellectual achievement, or overall well-being among children who grow up in such family environments. The key thing is the avoidance of extreme negatives such as abuse or neglect.
Is there any other parenting variable that clearly matters?
I believe it is simply time, involvement, and availability. Better parenting does not necessarily require parent education groups, expanded community resources and collaboration, better activity groups for the children, more efficient time-management strategies, etc.
Rather, better parenting simply involves being joyously, affectionately present for your children!
Presence and availability alone are not enough. The availability has to be provided with a spirit of joy and delight. Child-rearing cannot merely be a chore or a technical skill -- it must be nurtured as a joy of life. Children who see that their parents actually enjoy parenting, enjoy laughing and playing and working together, are much better off than those whose parents spend equal amounts of time, but with a spirit of stress, negativity, or conflict.
I wish to make an analogy between parenting and psychotherapy. I know it is an imperfect comparison, in many cases at least. Some patients do not desire or need any such dynamic with a therapist, and it could be intrusive or presumptuous for the therapy relationship to have some kind of unwelcome "parental" quality. For other patients, there is a more overt "parental" dynamic in therapy frames. In any case, I think that there is a direct analogy between optimal "parenting strategy" and optimal "psychotherapeutic strategy."
Most of us, examining evidence of psychotherapy, emphasize technical differences in the therapy style or actions (e.g. using CBT vs. psychodynamic approaches). Yet, evidence about relative advantages of one technique vs another is actually very minimal.
I do think there are technical elements which are important. For example, I think principles of behavioural therapy must be called upon for management of any condition or problem -- it is like prescribing exercise to strengthen a muscle -- all the talking in the world cannot replace the need to actually practice something actively to become stronger or more skilled. Similarly, a parent does need to literally teach a child to speak, to throw a ball, to ride a bike, to read, etc. Time and togetherness alone are not usually enough to help a child acquire these skills.
However, the biggest factor of all, in psychotherapy, is just like with parenting: it is all about being available, and offering time and attention. But just like with parenting, time and attention are not enough: the time and attention must be provided with a spirit of joy, interest, and engagement, and with stable, healthy, safe boundaries.
Nowadays, we have pressures upon medical and mental health care which seek to "optimize" care delivery. Evidence is gathered about efficiency of care. This tends to push medical and psychotherapeutic practice towards shorter visits, less frequent visits, limited numbers of visits (for example, 6 month limits on courses of therapy), and indirect visits (e.g. through video links). Most of the evidence supporting such methods is short-term.
Imagine instructing a parent to become "more efficient," encouraging briefer interactions with children, less frequently, and for no more than 6 months at a time, particularly if it was found that the children's "symptom scores" had reached a particular threshold.
Optimal psychotherapeutic care requires time, patience, and availability. In a setting of impoverished resources, there may be less time and availability to be shared. But sometimes, such as in Canada, we do not actually have an impoverishment of resources. It is "pseudo-impoverishment." If it is difficult to access resources, the solution does not need to involve spartan rationing or obsessing about "efficiency." It may mean that it is worth considering, for society as a whole, that it is good to invest more of our nation's vast wealth to offer personalized, patient, ongoing empathic care to those who desire or need it.
Thursday, December 17, 2015
Antidepressants in Pregnancy: Autism Risk?
On December 14, 2015, Boukhris, Sheehy, Mottron, and Berard published a paper in JAMA Pediatrics which described their study of the association between autism-spectrum disorders and exposure in utero to antidepressants.
They looked at all women who had pregnancies in Quebec between 1998 and 2009. These 186 165 women have been followed prospectively in the Quebec Pregnancy Cohort (QPC). The authors looked only at those infants born at full term; all antidepressant exposure was recorded, and there was up to 11 years of follow-up.
They found that 3.2% of all infants born to this cohort were exposed to antidepressants in utero. Of those infants who had this exposure, 46 later received a diagnosis of an autistic-spectrum disorder (1 %). More specifically, among those exposed in the second or third trimester, there were 31 autistic-spectrum diagnoses (1.2 %). Among those infants with no in utero antidepressant exposure, 1008 later received an autistic spectrum disorder diagnosis (0.7 %).
When the diagnoses were restricted to those made by a neurologist or psychiatrist, the findings remained positive, but with reduced statistical confidence.
Other factors, such as maternal history of psychiatric disorders, mother living alone, maternal gestational diabetes or hypertension, were also positively correlated with the infant later having an autistic-spectrum disorder diagnosis.
A major weakness of the study was that it did not have a detailed analysis or discussion of autistic-spectrum symptoms (even subsyndromally) in the parents or other relatives of the infants. They state "although our sample size is large, the size decreased substantially in stratified analysis on family history of ASD, which led to decreased statistical power." And they observe that "those using [antidepressants] were...more likely to have had another child with ASD than those not using ADs", but did not expand on this finding. The most likely contributing factor towards autism-spectrum phenomena would be the presence of these same phenomena in the family, which would be heritable. It is possible that the presence of this hereditary factor could have been an underlying cause for the heightened risk which they observed. This same risk factor could theoretically have contributed to the mothers using antidepressants more frequently during the pregnancy.
Another weakness of the study concerns the use of the "autism spectrum disorder" diagnostic label. The use of this label is more frequent nowadays. The degree to which it is appropriately considered a "disorder" could be subject to debate about criteria or severity. For example, with the "autism spectrum quotient" questionnaire, criteria such as "I don't like reading fiction," "I am fascinated by numbers," and "I would rather go to a library than a party" increase the score towards an autism diagnosis! It seems much more important to restrict such a label to some kind of marked social, behavioural, or communicative problem, rather than intellectual or recreational preferences. Enjoyment of libraries should not lead to a DSM label!
Another related confounding factor could be that someone who has taken antidepressants might be more likely to have their children assessed by someone able to "diagnose." It could be that if an autism questionnaire was administered to every child in the cohort, then 1.2% (rather than 0.7%) of the entire cohort could meet some "autism spectrum" threshold. Perhaps the increased incidence in the group who had taken antidepressants is simply due to these mothers having a higher likelihood of asking for their children to be assessed. In order to determine whether this is true, we would have to ensure that every child in the cohort received the same type of assessment, including the same questionnaires (such as the "autism spectrum quotient"). But in this study, this was certainly not the case.
While the authors find that SSRIs in particular were associated with increased ASD incidence, with minimal associations from other antidepressant classes, it is notable that there were far too few cases of non-SSRI antidepressant exposure to make any reliable statement at all about non-SSRI antidepressants. Therefore, they should remove the implied message that only SSRIs are involved with the association.
Nevertheless, it is an important study with a very large cohort. We must be vigilant about the possibility of risks for giving any medications, particularly in pregnancy.
If, in future studies, this difference in autism incidence is found to be directly caused by antidepressant exposure, the evidence here shows that the risk increases from 0.7% to 1.2%. Posed differently, the probability of not having an autism-spectrum diagnosis changes from 99.3% to 98.8%.
In some cases, the risk of severe depression in pregnancy could outweigh the risk of a treatment causing harm, but this would need to be carefully evaluated and discussed. A question to ask in this situation would be whether the antidepressant is specifically required for treatment of the depression. In some cases, it might indeed be very helpful, with a much higher likelihood of depressive symptoms, and various adverse outcomes for mother and child, without it. But in other cases, despite high depressive severity, the antidepressant might not clearly be an imperative component of the therapy. Perhaps in some cases other treatment modalities could be sufficient, at least during the pregnancy. It depends on the specific case or situation.
I am bothered by the author's concluding remarks in their abstract; the remarks assert causation, despite the findings really being associative: they say "use of antidepressants...increases the risk of ASD in children." It would be more appropriate for them to have said, as they were more careful to do elsewhere in the body of the paper, that "there is an association between antidepressant exposure in utero and subsequent ASD diagnosis."
In any case, it is not controversial to assert that all possible non-medication strategies should be optimized in the treatment of depression, particularly in pregnancy. This includes promotion of healthy lifestyle factors, careful attention to social and community support, and psychotherapy.
They looked at all women who had pregnancies in Quebec between 1998 and 2009. These 186 165 women have been followed prospectively in the Quebec Pregnancy Cohort (QPC). The authors looked only at those infants born at full term; all antidepressant exposure was recorded, and there was up to 11 years of follow-up.
They found that 3.2% of all infants born to this cohort were exposed to antidepressants in utero. Of those infants who had this exposure, 46 later received a diagnosis of an autistic-spectrum disorder (1 %). More specifically, among those exposed in the second or third trimester, there were 31 autistic-spectrum diagnoses (1.2 %). Among those infants with no in utero antidepressant exposure, 1008 later received an autistic spectrum disorder diagnosis (0.7 %).
When the diagnoses were restricted to those made by a neurologist or psychiatrist, the findings remained positive, but with reduced statistical confidence.
Other factors, such as maternal history of psychiatric disorders, mother living alone, maternal gestational diabetes or hypertension, were also positively correlated with the infant later having an autistic-spectrum disorder diagnosis.
A major weakness of the study was that it did not have a detailed analysis or discussion of autistic-spectrum symptoms (even subsyndromally) in the parents or other relatives of the infants. They state "although our sample size is large, the size decreased substantially in stratified analysis on family history of ASD, which led to decreased statistical power." And they observe that "those using [antidepressants] were...more likely to have had another child with ASD than those not using ADs", but did not expand on this finding. The most likely contributing factor towards autism-spectrum phenomena would be the presence of these same phenomena in the family, which would be heritable. It is possible that the presence of this hereditary factor could have been an underlying cause for the heightened risk which they observed. This same risk factor could theoretically have contributed to the mothers using antidepressants more frequently during the pregnancy.
Another weakness of the study concerns the use of the "autism spectrum disorder" diagnostic label. The use of this label is more frequent nowadays. The degree to which it is appropriately considered a "disorder" could be subject to debate about criteria or severity. For example, with the "autism spectrum quotient" questionnaire, criteria such as "I don't like reading fiction," "I am fascinated by numbers," and "I would rather go to a library than a party" increase the score towards an autism diagnosis! It seems much more important to restrict such a label to some kind of marked social, behavioural, or communicative problem, rather than intellectual or recreational preferences. Enjoyment of libraries should not lead to a DSM label!
Another related confounding factor could be that someone who has taken antidepressants might be more likely to have their children assessed by someone able to "diagnose." It could be that if an autism questionnaire was administered to every child in the cohort, then 1.2% (rather than 0.7%) of the entire cohort could meet some "autism spectrum" threshold. Perhaps the increased incidence in the group who had taken antidepressants is simply due to these mothers having a higher likelihood of asking for their children to be assessed. In order to determine whether this is true, we would have to ensure that every child in the cohort received the same type of assessment, including the same questionnaires (such as the "autism spectrum quotient"). But in this study, this was certainly not the case.
While the authors find that SSRIs in particular were associated with increased ASD incidence, with minimal associations from other antidepressant classes, it is notable that there were far too few cases of non-SSRI antidepressant exposure to make any reliable statement at all about non-SSRI antidepressants. Therefore, they should remove the implied message that only SSRIs are involved with the association.
Nevertheless, it is an important study with a very large cohort. We must be vigilant about the possibility of risks for giving any medications, particularly in pregnancy.
If, in future studies, this difference in autism incidence is found to be directly caused by antidepressant exposure, the evidence here shows that the risk increases from 0.7% to 1.2%. Posed differently, the probability of not having an autism-spectrum diagnosis changes from 99.3% to 98.8%.
In some cases, the risk of severe depression in pregnancy could outweigh the risk of a treatment causing harm, but this would need to be carefully evaluated and discussed. A question to ask in this situation would be whether the antidepressant is specifically required for treatment of the depression. In some cases, it might indeed be very helpful, with a much higher likelihood of depressive symptoms, and various adverse outcomes for mother and child, without it. But in other cases, despite high depressive severity, the antidepressant might not clearly be an imperative component of the therapy. Perhaps in some cases other treatment modalities could be sufficient, at least during the pregnancy. It depends on the specific case or situation.
I am bothered by the author's concluding remarks in their abstract; the remarks assert causation, despite the findings really being associative: they say "use of antidepressants...increases the risk of ASD in children." It would be more appropriate for them to have said, as they were more careful to do elsewhere in the body of the paper, that "there is an association between antidepressant exposure in utero and subsequent ASD diagnosis."
In any case, it is not controversial to assert that all possible non-medication strategies should be optimized in the treatment of depression, particularly in pregnancy. This includes promotion of healthy lifestyle factors, careful attention to social and community support, and psychotherapy.
Monday, December 14, 2015
Changes in Psychiatric Culture -- Wait Lists, "Efficiency," and Superficial Care
Psychiatrists are more commonly offering the following services:
1) "Assessment": This is a single 1-hour interview, yielding an obligatory report with diagnostic label, and treatment advice. In some places, this single interview is all the psychiatric input that is offered.
The single assessment has rich prececents in other areas of medicine. For example, a visit to a dermatologist could yield a very accurate and fruitful diagnosis of a specific type of chronic skin disease, leading to a clear set of instructions for safe and effective treatments. In many cases, it would not be necessary to see the dermatologist regularly after this assessment, unless the treatment regime was going very poorly.
But psychiatry and dermatology are quite different! Despite our attempts to have a reductionistic and medicalized diagnostic scheme in psychiatry (e.g. the DSM-V), we see that two different people with the exact same diagnosis frequently do not follow the same pathway of symptom progression. Identical treatments do not work in identical ways with different people.
Furthermore, I believe it is an act of significant hubris to assume that one can effectively "diagnose" someone, with respect to issues touching on a person's entire history of self, character, emotion, and intellect, following a single one-hour visit. The "first impression" from a first interview can be very important to understand a person's life and problems, but as we all know, first impressions can very, very often be inaccurate or incomplete. For some people, it could take weeks, months, or even years, to share their story.
Yet, this pattern of assessments may, on paper, appear to be very efficient. One could "manage" wait lists much more quickly. The problem is that a single assessment is actually not very useful, despite yielding an official-looking report which appears useful. Offering single assessments only is similar to a teacher offering a single day of school to each of 4 000 students, rather than a whole year of daily teaching for a classroom of 20. Another insidious consequence of the apparently "efficient" pattern of doing multiple "assessments" is that the therapist, or teacher, who may have a great joy and talent for deeply helping people in an ongoing collaborative relationship, may instead not really get to help anyone very much, leading to sinking morale and rising cynicism. Burnout would probably follow, much more often. But the paycheque would not go down -- it would actually be higher (in psychiatry, the fees for assessments are about 25% higher than for spending the same length of time offering a follow-up therapy appointment).
Many of the patients I have seen have had an incredible, audible sigh of relief, when they have discovered that I am actually going to make time to see them regularly! There is often some sense of surprise that I do not focus on diagnostic labels. The experience of mental health care, for many, has been one of shuttling between various short-term groups, superficial courses of CBT in a sort of group lecture format, brief one-on-one followup which ends just as a deeper sense of trust is forming, and medication trials with primary care doctors.
2) "Medication management visits": In many cases, psychiatrists do not offer what could be called "psychotherapy." Instead, patients are seen for a few minutes, to discuss medication doses. These visits could possibly be more frequent if the patient is not doing as well. It is understandable to have such visits, for people who are wishing to take medication. In clinics serving those who have major mental illnesses, who are taking complex medication combinations, this type of service is undeniably important. Other types of psychotherapy or health care may be happening elsewhere. But if this is the only style of visit which psychiatrists are offering, it creates a frame in which medication use is implied as a norm. Why would you have a "medication management visit" if you didn't want or need medication? From the psychiatrist's point of view, why discuss other matters, such as relationships, goals, dreams for the future, etc. unless it pertains to the medication management plan? The frame leads to an atrophy of therapeutic skill. I think it is a serious problem if psychiatric visits are framed with an expectation of medication management, particularly when we know what an incredibly, strongly loaded set of biases exist around medication use and marketing. The medication management visit framework is surely designed to "optimize" the use of psychiatry, in a setting of long wait lists and shortages of care, but in setting things up this way we are inviting a possible massive deterioration in the quality of care. I note again, that psychiatrists using the provincial fee schedule receive a large financial gain by seeing larger numbers of patients for briefer, more superficial, medication-oriented visits. The decrement in the quality of care may tragically not be noticed in the short term, because wait lists would be shorter, appearing to be beneficial.
Also, "improved" wait list management may cause an external observer to assume that the system has been "fixed," therefore delaying more substantive systemic changes.
In a further sort of game-theoretical analysis of these evolving trends, I believe that there are even more adverse consequences: because of the changing culture of the type of psychiatric practice which is considered a norm, the profession itself will attract those who are most comfortable offering this style of service. Those wishing to do more psychotherapeutic work, or having more skepticism about medicalized psychiatry, would feel ever more part of an eccentric minority, and might choose not to enter a psychiatry residency in the first place. So psychiatry would become even more "medicalized" with time, in a form of evolutionary selection process.
Ideas for Positive Change:
1) Wait list management.
a) The public health system in Canada, and possibly private insurers elsewhere in the world, could simply fund private non-medical psychotherapists. Therapy visits with a psychologist or other counselor could be covered under the public medical services plan. This could reduce psychiatry wait lists dramatically, while also helping the many psychotherapists who are ironically struggling to make a living, despite there being a massive population need for their services. For a large institution such as a university, if there were extra funds to spend on mental health, these funds could be spent on providing service availability with local therapists, personal trainers, music & art therapists, pet therapists, gym memberships, etc., rather than spending money on expensive new buildings and other infrastructure. People help people. Buildings don't help people much, despite appearing to do so.
b) Non-medical psychotherapists could be allowed to prescribe medication, at least in a very limited way. I am not meaning to suggest this as a way to increase medication use! I suggest this to defuse the power dynamic which currently exists among psychiatrists and other physicians. The basics of psychiatric medication prescription do not require many years of medical education to understand and manage safely. In fact, the many years of education may simply consolidate a culture of medication use as an often unnecessary norm. If there would be less pressure on psychiatrists and other physicians as the sole prescribers of medication, then there could be an opportunity for psychiatrists to be less focused on medication, and therefore more focused on therapeutic alliance.
2) Style of Practice
Here, I think it is very simple: make time for people! Doctors, make time for your patients! Be willing to see them! I am less concerned about what style of psychotherapy or other tactics. I am more concerned about being present, collaborative, empathic, and available. We should be well-informed about medications, and about therapy styles such as CBT, but we should focus most of our attention on very basic matters of building rapport, trust, and working alliance, without fear of the relationship being cut off.
1) "Assessment": This is a single 1-hour interview, yielding an obligatory report with diagnostic label, and treatment advice. In some places, this single interview is all the psychiatric input that is offered.
The single assessment has rich prececents in other areas of medicine. For example, a visit to a dermatologist could yield a very accurate and fruitful diagnosis of a specific type of chronic skin disease, leading to a clear set of instructions for safe and effective treatments. In many cases, it would not be necessary to see the dermatologist regularly after this assessment, unless the treatment regime was going very poorly.
But psychiatry and dermatology are quite different! Despite our attempts to have a reductionistic and medicalized diagnostic scheme in psychiatry (e.g. the DSM-V), we see that two different people with the exact same diagnosis frequently do not follow the same pathway of symptom progression. Identical treatments do not work in identical ways with different people.
Furthermore, I believe it is an act of significant hubris to assume that one can effectively "diagnose" someone, with respect to issues touching on a person's entire history of self, character, emotion, and intellect, following a single one-hour visit. The "first impression" from a first interview can be very important to understand a person's life and problems, but as we all know, first impressions can very, very often be inaccurate or incomplete. For some people, it could take weeks, months, or even years, to share their story.
Yet, this pattern of assessments may, on paper, appear to be very efficient. One could "manage" wait lists much more quickly. The problem is that a single assessment is actually not very useful, despite yielding an official-looking report which appears useful. Offering single assessments only is similar to a teacher offering a single day of school to each of 4 000 students, rather than a whole year of daily teaching for a classroom of 20. Another insidious consequence of the apparently "efficient" pattern of doing multiple "assessments" is that the therapist, or teacher, who may have a great joy and talent for deeply helping people in an ongoing collaborative relationship, may instead not really get to help anyone very much, leading to sinking morale and rising cynicism. Burnout would probably follow, much more often. But the paycheque would not go down -- it would actually be higher (in psychiatry, the fees for assessments are about 25% higher than for spending the same length of time offering a follow-up therapy appointment).
Many of the patients I have seen have had an incredible, audible sigh of relief, when they have discovered that I am actually going to make time to see them regularly! There is often some sense of surprise that I do not focus on diagnostic labels. The experience of mental health care, for many, has been one of shuttling between various short-term groups, superficial courses of CBT in a sort of group lecture format, brief one-on-one followup which ends just as a deeper sense of trust is forming, and medication trials with primary care doctors.
2) "Medication management visits": In many cases, psychiatrists do not offer what could be called "psychotherapy." Instead, patients are seen for a few minutes, to discuss medication doses. These visits could possibly be more frequent if the patient is not doing as well. It is understandable to have such visits, for people who are wishing to take medication. In clinics serving those who have major mental illnesses, who are taking complex medication combinations, this type of service is undeniably important. Other types of psychotherapy or health care may be happening elsewhere. But if this is the only style of visit which psychiatrists are offering, it creates a frame in which medication use is implied as a norm. Why would you have a "medication management visit" if you didn't want or need medication? From the psychiatrist's point of view, why discuss other matters, such as relationships, goals, dreams for the future, etc. unless it pertains to the medication management plan? The frame leads to an atrophy of therapeutic skill. I think it is a serious problem if psychiatric visits are framed with an expectation of medication management, particularly when we know what an incredibly, strongly loaded set of biases exist around medication use and marketing. The medication management visit framework is surely designed to "optimize" the use of psychiatry, in a setting of long wait lists and shortages of care, but in setting things up this way we are inviting a possible massive deterioration in the quality of care. I note again, that psychiatrists using the provincial fee schedule receive a large financial gain by seeing larger numbers of patients for briefer, more superficial, medication-oriented visits. The decrement in the quality of care may tragically not be noticed in the short term, because wait lists would be shorter, appearing to be beneficial.
Also, "improved" wait list management may cause an external observer to assume that the system has been "fixed," therefore delaying more substantive systemic changes.
In a further sort of game-theoretical analysis of these evolving trends, I believe that there are even more adverse consequences: because of the changing culture of the type of psychiatric practice which is considered a norm, the profession itself will attract those who are most comfortable offering this style of service. Those wishing to do more psychotherapeutic work, or having more skepticism about medicalized psychiatry, would feel ever more part of an eccentric minority, and might choose not to enter a psychiatry residency in the first place. So psychiatry would become even more "medicalized" with time, in a form of evolutionary selection process.
Ideas for Positive Change:
1) Wait list management.
a) The public health system in Canada, and possibly private insurers elsewhere in the world, could simply fund private non-medical psychotherapists. Therapy visits with a psychologist or other counselor could be covered under the public medical services plan. This could reduce psychiatry wait lists dramatically, while also helping the many psychotherapists who are ironically struggling to make a living, despite there being a massive population need for their services. For a large institution such as a university, if there were extra funds to spend on mental health, these funds could be spent on providing service availability with local therapists, personal trainers, music & art therapists, pet therapists, gym memberships, etc., rather than spending money on expensive new buildings and other infrastructure. People help people. Buildings don't help people much, despite appearing to do so.
b) Non-medical psychotherapists could be allowed to prescribe medication, at least in a very limited way. I am not meaning to suggest this as a way to increase medication use! I suggest this to defuse the power dynamic which currently exists among psychiatrists and other physicians. The basics of psychiatric medication prescription do not require many years of medical education to understand and manage safely. In fact, the many years of education may simply consolidate a culture of medication use as an often unnecessary norm. If there would be less pressure on psychiatrists and other physicians as the sole prescribers of medication, then there could be an opportunity for psychiatrists to be less focused on medication, and therefore more focused on therapeutic alliance.
2) Style of Practice
Here, I think it is very simple: make time for people! Doctors, make time for your patients! Be willing to see them! I am less concerned about what style of psychotherapy or other tactics. I am more concerned about being present, collaborative, empathic, and available. We should be well-informed about medications, and about therapy styles such as CBT, but we should focus most of our attention on very basic matters of building rapport, trust, and working alliance, without fear of the relationship being cut off.
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