Barnhill-Hubbard and Hawks of CAHOOTS attend to a man who needs help, later taking him to a local sobering station. Credit: Thomas Patterson

Oct. 29: This Week in Mental Health Research

This is the third installment of a new weekly column reviewing recent mental health research and reports. The articles cited are chosen from the peer-reviewed literature, prioritizing reports that can inform policy or new directions in research.  This column does not claim to be comprehensive nor does it promote the science cited.  It will appear on the MindSite News website and will be sent to subscribers of our Research Roundup newsletter. You can sign up for our newsletters here

By Tom Insel, MD

Responding to a Mental Health Emergency: Cops, Clinicians, or Both?

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CAHOOTS team members in Eugene, Oregon attend to a man. Photo: Thomas Patterson

Can police be removed from mental health crisis response? As states grapple with the national mandate to create a national hotline – 988 – for people to call in the event of mental health emergencies, Margaret E. Balfour MD, PhD and colleagues have published an important paper that addresses the composition of response teams and the need for collaboration across systems.

The current 911 number elicits a police response, often resulting in use of force, arrest or drop-off to an emergency room. The problem is profound: people with serious mental illness represent a fourth of all police shootings and account for more than 2 million jail bookings each year. Emergency room boarding – in which people with mental illness linger for days in ERs, taking up beds – has become a national crisis.

988 will offer a new number to call, but without a different kind of response team and better alternatives than jails or hospital ERs, it won’t be able to deliver better outcomes on its own. An alternative approach would dispatch a team using some combination of nurses, social workers, EMTs, behavioral health technicians and peers, rather than armed officers in a patrol car.

Dr. Balfour’s paper, based on her experience in Tucson, seeks to define a new role for police in mental health crisis response – not by removing them completely but by clarifying when and how they should be involved. She argues for a collaborative model in which a civilian mobile team responds to a mental health crisis. Police would join only when the crisis appears to involve a safety risk. While only a small fraction of mental health emergencies involves such risks, without a collaborative strategy to respond to these complex situations, 988 will not avert further tragedies.

This paper argues for an inclusive planning process as communities roll out 988 call centers. “Stakeholders will need to collaborate closely to ensure adequate planning, financing, accountability, data collection, and oversight, including ongoing assessment of racial bias and health inequities,” Balfour writes.

With less than nine months before the mandated implementation of 988, this paper is timely. It reminds us that changing from 911 to 988 will not by itself reduce police shootings, incarceration, and emergency room boarding. We need not only “someone to call” but “someone to come” and “someplace to go.” That “someone to come” should be a health team that coordinates with a public safety team. Clinicians or cops? This report says we’ll need both, but not always responding together.

Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies  Psychiatric Services, Oct 20, 2021

Covid-19’s Global Impact on Depression and Anxiety: ‘Inaction Should Not Be an Option’

Ever since the World Health Organization predicted a second pandemic from the mental health fallout of Covid-19, scientists have been tracking rates of distress and mental disorders. With loss of loved ones, lockdowns, social isolation and economic concerns, there was every reason to fear a global surge in mental health concerns. Even before the pandemic, the Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD study) found depression and anxiety among the top 25 leading causes of health-related “burden” worldwide, without any evidence of reduction since the study began in 1990.

Now GBD2020 is giving us a first view of the global impact of the pandemic on depression and anxiety across 204 countries. The authors estimate that COVID-19 has led to an additional 53.2 million cases of major depressive disorder globally (an increase of 27.6%) and an extra 76.2 million cases of anxiety disorders (an increase of 25·6%). Increases were greatest in areas with the highest prevalence of Covid-19 infections, the lowest levels of mobility, and generally were more evident in women and young people. 

The GBD study generates a single number, the Disability Adjusted Life Year (DALY), which many health ministers and policy makers use to rank death and disability from medical disorders. The authors note the striking increase in DALYs for depression and anxiety in 2020, which rose from 38.7 million to 49.4 million globally for depression and from 35.5 million to 44.5 million globally for anxiety disorders. “Tackling this increased mental health burden will present immediate challenges in most nations, but it is also an opportunity for countries to broadly reconsider their mental health service response,” the authors conclude. “Taking no action in the face of the estimated impact of the COVID-19 pandemic on the prevalence and burden of major depressive disorder and anxiety disorders should not be an option.”

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Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic  The Lancet, Oct 8, 2021

Men and Guns: A Riskier Combination

Suicide deaths in the US vary by age, geography, sex, and race but two factors loom large: More than half are carried out using a firearm and males are at much higher risk of dying from suicide. That’s according to the CDC’s National Vital Statistics System, which just reported data on firearm-related deaths from 2019 based on race, ethnicity, and sex.

In 2019, the age-adjusted, firearm-related suicide rate was 12.3 per 100,000 for males and 1.8 per 100,000 for females. The comparable rates of homicide were 7.7 per 100,000 males and 1.4 per 100,000 females. Firearm-related suicide rates were highest for white males (15.8 per 100,000) and Native American males (11.2 per 100,000). For homicides, death rates were highest for Black males (34.9 per 100,000), a rate five-fold higher than suicide in this population.

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Deaths per 100,000 population are age-adjusted to the 2000 U.S. standard population, with 95% confidence intervals indicated with error bars. In 2019, the age-adjusted rate of firearm-related suicide was 12.3 per 100,000 population for males and 1.8 for females.

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Deaths per 100,000 population are age-adjusted to the 2000 U.S. standard population, with 95% confidence intervals indicated by error bars. In 2019, the age-adjusted rate of firearm-related homicide was 7.7 per 100,000 population for males and 1.4 for females.

The lower death rate in women is notable. Compared to men, women are far more likely to report suicidal ideation and more likely to attempt suicide. But because they are less likely to use lethal means, their overall death rate is considerably lower – just one-fifth the rate of men, according to this report. And that’s a pretty clear sign that suicide deaths could be reduced by ensuring that men at risk don’t have ready access to firearms.

QuickStats: Age-Adjusted Rates* of Firearm-Related Suicide, by Race, Hispanic Origin, and Sex — National Vital Statistics System, United States, 2019

QuickStats: Age-Adjusted Rates of Firearm-Related Homicide, by Race, Hispanic Origin, and Sex — National Vital Statistics System, United States, 2019.

Strong Results Seen in Magnetic Stimulation Study for Depression

Researchers searching for ways to help patients who don’t respond to medication or psychotherapy have been working for decades to use electrical or magnetic stimulation to influence brain circuitry and reduce the symptoms of depression or other mental disorders. Regional transcranial magnetic stimulation (rTMS) has been approved by the FDA, but most studies show modest benefit even after weeks of daily treatments. Several groups have tried to improve the efficacy of rTMS by increasing the dose, bunching multiple stimulation sessions into a single day, or personalizing the stimulus based on imaging a patient’s neural circuits. Now an approach that combines all these modifications has shown strong results in a new study in the American Journal of Psychiatry.

This approach, called SNT, was developed and patented by Nolan Williams, director of the Stanford Brain Stimulation Lab, who has licensed the technology to a company, Magnus Medical. Williams and his colleagues tested the effects of SNT in people who had moderate to severe depression after being treated with an average of five different antidepressants. Half of the patients received SNT and half received sham stimulation over five days of intensive treatment.  The study was designed for 60 patients but was halted after an interim analysis of the first 30 patients showed significant effects.

At the end of treatment and for the subsequent four weeks, patients in the SNT group showed markedly lower levels of depression. At some point during the four-week follow-up, symptoms were reduced to below the threshold for clinical depression in 79% of participants in the SNT group, compared with 13% in the sham treatment group. At the end of four weeks, 69% of the patients in the SNT group had at least a 50% reduction in depression ratings and 46% met the clinical criteria for remission. For the sham group, just 7% had that level of response and none showed remission.

The numbers are small (14 patients in the SNT group and 15 patients in the sham group) but the effects are large, much larger than reported with traditional rTMS or virtually any pharmacological treatment. These results will undoubtedly create excitement as a potential breakthrough treatment for a form of depression that has not responded to other therapies. But before we declare victory, it’s important to remember that psychiatric research has a long history of reported breakthroughs that appear less effective on replication.

Previous attempts to alter the dose or the schedule of rTMS delivery have resulted in only modest improvements. Adding personalized targeting may make the SNT approach different; the need now is for an independent replication by a group without a financial stake in the results. The need is real – as many as 30% of patients with major depressive disorder don’t respond to current treatments. They need something better.

Stanford Neuromodulation Therapy (SNT): A Double-Blind Randomized Controlled Trial American Journal of Psychiatry Oct. 29 2021

Schizophrenia by Any Other Name?

Swiss psychiatrist Eugene Bleuler first proposed the term “schizophrenia” to the German Psychiatric Association in 1908 to replace the diagnosis “dementia praecox” or precocious dementia. From intensive observations of patients at an asylum in Rheinau, Bleuler believed the problem was not early dementia but a “splitting of the mind,” a loss of the unity of the self. While the term “schizophrenia” has been adopted globally over the past century, recently critics have begun asking whether this diagnosis does more harm than good.

In a new paper in Schizophrenia Research, Raquelle I. Mesholam-Gately from Harvard Medical School joins with colleagues from across the country (including the editor of Schizophrenia Research) to examine attitudes towards the term. Of 1190 U.S. respondents, including a broad array of community stakeholders, most favored a name change (74.1%) and found the name stigmatizing (71.4%).

So what would be better? In this survey, new names with the most support included “Altered Perception Syndrome,” “Psychosis Spectrum Syndrome,” and “Neuro-Emotional Integration Disorder,” although none of these received overwhelming endorsement.

Renaming schizophrenia is hardly a new idea. In Japan, the current term is “togo shitcho sho” which translates to “integration disorder.” In South Korea, “johyeonbyung” or “attunement disorder” replaced schizophrenia. These changes were intended to reduce the stigma associated with a label that was viewed as sentencing someone to an irreversible illness. Some evidence suggests that these name changes resulted in better communication and more engagement in care.

But the renaming efforts in Japan and South Korea and some of the names proposed in this new article continue to miss what psychiatrists call the heterogeneity or diverse nature of the diagnosis. The DSM5 – psychiatry’s diagnostic bible – recognizes the risk of clustering a range of disorders under a single label and shifted from “schizophrenia” to “schizophrenia spectrum,” a pivot that reflects the emerging scientific evidence that the singular term “schizophrenia” has been applied to several biologically distinct disorders. 

While nearly three-fourths of those surveyed voted for a name change, the question remains: Would changing the name improve outcomes any more than the change from dementia praecox to schizophrenia? Would it alter attitudes or accuracy? This new survey will add to the debate.

 See: Are we ready for a name change for schizophrenia? A survey of multiple stakeholders. Schizophrenia Research.  October 20, 2021

New Numbers from the National Survey of Drug Use and Health

The National Survey of Drug Use and Health (NSDUH) is an annual door-to-door interview across all 50 states and the District of Columbia collecting data on substance use and mental health. Originally begun by the federal government in 1971, the current survey, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) launched in 2002, with the sampling technique updated in 2014 and questionnaires updated in 2015. The 2020 data released this week were handicapped by the absence of face-to-face interviews during much of the year, so it can’t be directly compared with previous years. Nevertheless, SAMHSA has given us lots of useful information on substance use and mental illnesses, including estimates of service utilization.

A few quick stats from NSDUH2020 data on adults 18 and over:

  • 52.9M (21%) have “any mental illness”
  • 14.2M (5.6%) have “serious mental illness”
  • 42.4M (16.9%) have received mental health treatment
  • 7.0M (49.7%) of those with “serious mental illness” describe unmet needs

The stats on adolescents (ages 12 to 17) continue to show an increase in major depression episodes (MDE), a trend that began about a decade ago. While the 2020 data may be affected by differences in methodology (online vs face to face), they appear to be following the same trend.

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Overall, the picture that emerges from NSDUH2020 is a continuing increase in the prevalence of mental disorders, especially among young people. More than half of these young people are not in treatment, including those with a “severe impairment.” In 2020, 1.3 million youth made plans for suicide and 629,000 made an attempt.

This face-to-face survey is extensive – typically including nearly 70,000 people in the sample. It has become the basis for many commonly referenced statistics, such as that “one in five people have a mental illness” or “one in twenty have a serious mental illness.” While the numbers reflect rising incidence of mental illness, they are likely an undercount, especially in terms of serious mental illness. The survey does not include people experiencing homelessness who do not use shelters, residents of institutional group quarters such as jails, nursing homes, mental institutions, and long-term care hospitals, all settings with a high prevalence of people with serious mental illness.  Remarkably, there is no national survey that captures the prevalence or the unmet needs of those with the most disabling forms of mental illness. 2020 data released October 25, 2021

ECT:  Does it Save Lives?

Electroconvulsive Treatment (ECT) may be the most underused treatment in psychiatry. Although it’s eligible for reimbursement by Medicare, approved by the FDA (based on evidence from 60 randomized clinical trials) and has been in use for 80 years of practice, only 6% of facilities offer it and less than 1% of patients who might benefit actually receive it. Today the individuals most likely to receive ECT are elderly, hospitalized, and severely depressed. People in this group are at a higher risk of dying after discharge from a variety of causes especially suicide. Does ECT increase or reduce “all-cause mortality”? Does it reduce the risk of suicide?

Taeho Greg Rhee and colleagues from several universities followed Medicare-insured psychiatric inpatients age 65 or older who received ECT (n = 10,460) or other treatments (n = 31,160). For the year following discharge from the hospital, those treated with ECT had nearly a 40% reduction in risk of dying from conditions including circulatory disorders, diabetes-related illness, smoking-related conditions, and cancer. They were also less likely to die by suicide during the first 90 days after treatment, but that association waned over time and was not significantly different for the full year.

How to explain ECT’s apparent protective effect against both medical and psychiatric causes of mortality? This study is observational, so mechanisms can only be inferred. For instance, it is possible that elderly patients with more severe medical issues were not referred for ECT. Or that those receiving ECT were wealthier with fewer lifestyle stressors. While this study can’t define the mechanism, the finding that ECT is associated with lower “all-cause mortality” and reduced likelihood of suicide in the period of highest risk provides a compelling case that this treatment should be available to older patients with depression.

Why this treatment remains so little used is worth exploring. Before the development of medical and psychological treatments in the mid-twentieth century, ECT was used not too little but too much, a blunt instrument that was used often for disorders for which it didn’t work and forced on patients without their consent. This legacy of misuse, captured in films like One Flew Over the Cuckoo’s Nest, have left many skeptical or terrified.

There remains something mysterious about a treatment whose workings aren’t understood but that appears to “reboot the brain.” The treatment has changed dramatically so that today, it looks nothing like the Hollywood version. It now is done under anesthesia and causes no visible seizure. Side effects like headache and memory loss still occur but are far less severe. Like shocking the heart for an arrhythmia, ECT is a safe, effective medical procedure. And this new paper suggests that it may save lives.  

See: Am J Psychiatry Oct, 2021

Tom Insel, MD, is a psychiatrist, neuroscientist, and former director of the National Institute of Mental Health (NIMH). He is a donor to MindSite News and chair of its Editorial Advisory Board. Dr. Insel’s financial conflict of interest statement, which includes equity and advisory roles in several early-stage mental health technology companies, can be found here.

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