The Power of the Lay Person
March 25, 2022
By Tom Insel, MD, and Matthew Hirschtritt, MD, MPH
Good morning, Research Roundup readers. Last week we promised to find some good news from the research literature. Drum roll… A new report on task sharing documents the power of using lay therapists for scaling up psychological treatments for depression. And more good news: Sleep may be a powerful intervention for postpartum depression. On the other hand, the emerging news on the mental health consequences of Covid-19 and the evidence for the impact of social isolation during the pandemic are sadly not the good news stories we wanted. However, they are important for you to see. Also, we report findings from the journal Nature, which looks at the challenge of finding reproducible results with MRI. Let us know what we missed.
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Task Sharing: Psychological Treatment for the Masses
What can be done when there aren’t enough mental health practitioners to provide care to people with depression or other mental health conditions? In the developing world, a strategy has emerged in recent years called task sharing. The idea is deceptively simple: Train lay people – interested community members – to deliver brief psychological interventions to people in need.
Much of the work done in this area has provided care to people with mild to moderate depression. Community members are trained to deliver cognitive behavior therapy or similar approaches. The hope is that this new workforce – with weeks of training instead of years of schooling – will be able to help people with depression who would otherwise not receive treatment.
A meta-analysis including individual patient data from over 4,000 participants across 11 studies has now been published by a large team of scientists led by Vikram Patel of the Harvard School of Public Health. The results are compelling. The team included only studies that compared the outcome of care delivered by nonspecialists (such as lay counselors, health workers, or peers) to outcomes for people in control groups who received standard care.
They found that participants who received psychological treatment through task sharing were roughly twice as likely to experience a 50% drop in their symptoms (odds ratio 2.11) or to have their symptoms fall below the cutoff for diagnosis of mild depression (odds ratio 1.89), as measured by outcomes on a PHQ-9 assessment of depression. Each of the studies differed in key aspects, like the setting for treatment and the exact nature of the control condition used as a comparator. One general finding across the studies was that patients who had what clinicians call “psychomotor retardation” – a slowing-down of thinking or physical movement – had better responses to the treatments provided by the lay workers.
These positive results with task sharing are notable not only because of the effect sizes, which are similar to results with antidepressants in studies from higher-income countries, but because this approach offers the potential to vastly increase the provision of psychological treatments in both developing and more developed countries.
Although interventions provided by mental health professionals are effective in treating depression and are recommended as a first-line treatment by the World Health Organization, there may never be enough providers with graduate degrees to meet the need. Task sharing could effectively meet this need by training nonspecialists to provide effective psychological treatments and reduce the suffering of people with mild-to-moderate depression.
Association of Task-Shared Psychological Interventions With Depression Outcomes in Low- and Middle-Income Countries: A Systematic Review and Individual Patient Data Meta-analysis JAMA Psychiatry, March 23, 2022
Neuroimaging: Small Findings Need Big Samples
When magnetic resonance imaging (MRI) provided the first detailed images of brain structure three decades ago, there was every reason to believe that this technique would reveal the brain changes associated with mental illness and transform clinicians’ ability to make a diagnosis. Yet remarkably, MRI is still not a standard tool for psychiatry, except to rule out a brain injury.
Scott Marek from Washington University and colleagues recently took a close look at the MRI literature to understand why this powerful imaging tool has still not yielded findings that are clinically actionable. They note that MRIs have helped identify the functions that certain structures of the brain perform and can be useful for following the progress of individual patients over time. But brain structure is so variable between people that studies comparing individuals have generally been too small to find reproducible differences.
Marek’s group wanted to determine the minimum number of subjects needed to provide meaningful, reproducible imaging results. They plumbed three large datasets of brain MRIs with a total sample size of around 50,000 people and drilled down into much smaller subsamples. Even though most published MRI studies report findings from less than 100 subjects, Marek and his team found that reports based on hundreds of subjects yielded inflated group differences and could not be replicated.
Based on their research, they contend that sample sizes need to be in the thousands to provide useful, reproducible data. They balance this sobering finding a bit by noting that smaller studies that combine a specific type of imaging known as functional MRI (fMRI), which looks at brain oxygen consumption as a measure of function, and studies that add other data such as cognitive testing, appear to provide more robust comparisons between groups.
These findings are similar to those in genomics, where scientists have needed large samples to find small effects. These studies remind us that individual variation in both genes and brains, like individual variation in personality, is part of the human condition. Finding consistent differences requires narrowing the focus to very small changes that may only be detectable with huge samples.
If MRI requires thousands of subjects to find reproducible differences, it seems unlikely that this can be a reliable clinical tool to guide decisions for diagnosing or treating an individual patient. The technique is still important for ruling out structural lesions and fMRI continues to hold promise for research. But the promise of 30 years ago has not been realized. Thankfully, electroencephalography (EEG), cognitive testing, new kinds of behavioral assessment, and clinical interviews continue to offer the possibility of greater diagnostic precision.
Reproducible brain-wide association studies require thousands of individuals Nature, March 16, 2022
Goodnight to Postpartum Depression
A simple, low-tech solution may be a big help for women with postpartum depression: sleep.
Every year, about one in ten women with no previous history of depression experience postpartum depression. The impacts can be profound: Postpartum depression can impair a woman’s ability to parent, interfere with the bonds of attachment between a mother and infant, cause a mother physical illness and death, and even, in extreme cases, lead to infanticide. For women who have a personal history of depression, trauma, or poor social support – or those who have a family history of depression – the rate of postpartum is even higher.
Two years ago, the FDA approved the first medication specifically indicated for postpartum depression. The medication, brexanolone, was hailed as a revolution in the treatment of postpartum depression because of its rapid and substantial antidepressant effect. But administration of this drug is an intensive, hospital-based procedure: Patients need to stay in the hospital for three days while the medication is slowly administered intravenously, and they can’t breastfeed for seven days after.
In a recent editorial, Nicole Leistikow of the University of Maryland and colleagues highlight a consistent finding from the brexanolone trials – both the treatment group and the placebo group got better. The common element that seemed to help all the study participants was good-quality sleep. The women were temporarily freed from nighttime breastfeeding and were able to sleep through the night.
Treatments for postpartum depression are similar to those recommended for garden-variety depression: talk therapy, antidepressants, lifestyle changes, and a supportive home environment. But good-quality sleep has received less attention as a treatment tool.
New moms often find it challenging – if not impossible – to prioritize sleep when caring for a newborn. The demands of breastfeeding can make a hard job even harder. As the authors write, “just telling a mother to sleep is as ridiculous as telling her to fly.” So Leistikow and colleagues recommend clinicians help women put sleep first with a few concrete approaches:
- Change the narrative. The prevailing sentiment holds that women must sacrifice their own wellbeing for the health of their infant. Instead, the message should read, “meeting a mother’s needs allows her to better care for her family.”
- Consolidate sleep. Finding ways to have two chunks of sustained sleep of three to four hours each is critical.
- Make it a team approach. Solicit help from a partner or others to help with nighttime feeding.
- Pump and use formula. Pumping breastmilk during the day allows a partner or others to help with nighttime feeding; some women may also be comfortable taking a mix-and-match approach with breastmilk and formula.
Implementing this sleep prescription will require changes at multiple levels: better training for clinicians, more support for mothers from their partners and employers, not to mention financial assistance (to help mom hire a night nanny, for example). Given the dire consequences of untreated postpartum depression, this low-risk intervention deserves our attention.
Prescribing Sleep: An Overlooked Treatment for Postpartum Depression. Biological Psychiatry, March 16, 2022.
– Matthew Hirschtritt
More Severe COVID-19 Brings Worse Mental Health Outcomes
The COVID-19 pandemic has taken a heavy toll on global mental health. According to a recent WHO report, the first year of the pandemic saw a dramatic 25% jump in global rates of anxiety and depression compared with the year before. There’s also mounting evidence that hospitalization for COVID-19 is associated with high rates of depression, anxiety, and insomnia – especially in the first few months after being discharged from the hospital.
But what about the mental health of the many COVID-19 patients who didn’t need to be hospitalized? A new study, drawing data from several countries, demonstrates the relationship between COVID-19 severity and mental health outcomes.
A research effort called the COVIDMENT Collaboration recruited adults from six countries – Iceland, Sweden, Denmark, Norway, Estonia, and Scotland – from March 2020 to August 2021, and then followed them for up to 16 months. Among the 247,249 adults, 4% (9979) were diagnosed with COVID-19.
At each wave of data collection, the researchers asked participants about their depression and anxiety symptoms, levels of COVID-19 distress (as measured by PTSD symptoms), and sleep quality. They also examined the change in these symptoms before and after a COVID-19 diagnosis.
Adults with COVID-19 had about an 18% higher prevalence of significant depression and 13% higher prevalence of poor sleep quality compared with adults who didn’t have COVID-19; the rates of anxiety and COVID-19-related stress didn’t differ between the two groups.
But interesting patterns emerged when the researchers divided the COVID-19-infected group into two severity levels based on how many days (if any) they were bedridden. Among adults who were bedridden because of COVID-19 for more than a week, their rates of depression were persistently about 61% higher than among adults without COVID-19 , and rates of anxiety were about 43% higher. In contrast, looking at adults with COVID-19 who were never bedridden, their rates of depression and anxiety were about 17% and 23% lower than adults who didn’t have COVID-19.
It’s intuitive that more severe COVID-19 would lead to worse mental health outcomes. But it’s more challenging to explain why the less severely affected COVID-19 patients would have better mental health outcomes than adults without COVID-19. The authors suggest that mildly affected but recovered COVID-19 patients may have been able to visit in person with others sooner than non-infected adults because they didn’t have to fear infecting others. Another possibility is that adults with less severe COVID-19 symptoms may have had better mental health compared with the uninfected and severely affected groups at baseline. And yet another, not raised by the authors, is that uninfected adults may have experienced greater anxiety about contracting COVID-19 than those who’d already been infected.
Two clear takeaways do emerge: 1) COVID-19, even without hospitalization, leads to worse mental health outcomes compared with uninfected adults. 2) Disease severity matters. This study adds nuance to our growing appreciation of the myriad and prolonged impacts of COVID-19.
Acute COVID-19 severity and mental health morbidity trajectories in patient populations of six nations: an observational study. Lancet Public Health, March 14, 2022.
– Matthew Hirschtritt
Dying of Loneliness During the Pandemic
It’s well-known by now that Covid-19 was especially deadly to elderly people living in long-term care facilities. Now new results show that residents who didn’t have personal contact with friends or family were at higher risk of dying.
Rachel D. Savage of Women’s College Hospital in Toronto and colleagues scoured death records and found that about 2% of long-term care residents had no contact with friends or family, either in person or virtually, during the early months of the pandemic. This subgroup had a 35% increased mortality rate that could not be explained by baseline age, physical function, or dementia.
Loneliness has long been associated with a higher risk of mortality. For the socially isolated elders in this study, was that the key factor contributing to excess mortality, or was it the absence of someone to advocate for their care? Most likely, it was a combination of the two. Either way, the results show that social contact was literally a matter of life or death for long-term care residents during the pandemic.
If you or anyone you know is considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255. And if you’re a veteran, press 1.
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.
Matthew Hirschtritt, MD, MPH, is a clinical psychiatrist with the Permanente Medical Group, Inc., a mental health services researcher with the Division of Research, Kaiser Permanente Northern California, and assistant program director of the Kaiser Permanente Oakland Adult Psychiatry Training Program. His current research focuses on identification and treatment of patients with first-episode psychosis, as well as implementation of a telehealth-based mental health evaluation and referral program.
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