This is the second 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
Covid-19 and Depression: It’s Getting Worse
It’s hardly news that Covid-19 has been bad for mental health. After reporting a three-fold increase in depressive symptoms during the pandemic’s early months (March to April, 2020), Catherine K. Ettman and her colleagues at Boston University took another look a year later (March to April, 2021) using the same nationally representative sample of 1161 U.S. adults.
Their findings are not comforting – and don’t suggest a shift toward resilience, as many hoped. In 2021, 32.8% of people reported elevated depression symptoms – up from the 27.8% a year earlier. And once again, the psychological impact of the pandemic appears greatest in younger adults, with 43.9% of people in the 18-39 age group reporting symptoms of depression.
The CDC has focused on pre-existing medical risk factors for Covid complications, but what are the risk factors for the mental health consequences? Ettman and her colleagues report that poverty is a major risk factor for depression during the pandemic, and the gap between people at different income levels continued to widen as the pandemic wore on. In 2021, people with low incomes were 7 times more likely to have increased depressive symptoms, up from 2.3 times the year before. In the lowest-earning group (less than $19,999 a year), a full 58.1% of people reported an increase in such symptoms.
This pattern of enduring and worsening depressive symptoms is without precedent. The mental health impacts of natural disasters like Katrina and traumatic events like 9/11 tend to ebb with time, with a small fraction of people suffering persistent symptoms. These new findings may reflect the persistence of the pandemic and its attendant stressors, especially for people with low-incomes and more limited options for health and support. And sadly, there is no reason to assume we have seen the peak. While we have clearly improved our responses to Covid’s medical complications, the psychological fallout may be more intractable.
See: Persistent depressive symptoms during COVID-19: a national, population-representative, longitudinal study of U.S. adults. The Lancet: Americas. October 2021
Do Psychosocial and Psychological Treatments Reduce Relapse in People with Schizophrenia?
Most young people with schizophrenia will relapse, with one in four requiring re-hospitalization within the first year after treatment for a psychotic episode. Medication reduces the risk of relapse, but many people stop taking their medication, usually because of side effects and sometimes because their symptoms have resolved. Psychological treatments, including cognitive behavior therapy and family interventions, have also been recommended to prevent relapse, but their effectiveness has been debated.
Irene Bighelli of the Technical University of Munich and colleagues from research centers in Catania, Barcelona, Bern, Kyoto, and Verona have done a massive meta-analysis to look at the efficacy of psychological interventions to prevent relapse in people with schizophrenia. In total, the team compared the results of 72 studies of 20 different psychological interventions with over 10,000 patients. In most studies, these interventions were combined with medication.
Looking at results after one year, several psychological treatments were better than standard care alone in preventing relapse, although some of the effects were modest. These treatments include family interventions, family psychoeducation, cognitive behavioral therapy, patient psychoeducation, integrated interventions, and relapse prevention programs. Assertive community treatment, which includes home visits and intensive case management, was effective at 6 months but not later in follow-up. Other interventions, such as social skills training, acceptance and commitment training, and case management, did not appear to reduce relapse.
While this analysis doesn’t provide a clear picture of who benefits from psychological treatments or explore how specific interventions should be tailored to individual needs, the overall picture is hopeful. Engaging families and focusing on cognition as well as treating symptoms with medication can improve outcomes for people with serious mental illness. Translating this basic insight from 72 studies into routine practice remains a major challenge, however. Figuring out how to ensure that a person who has a first episode of psychosis won’t have a second one remains the Holy Grail for managing an illness like schizophrenia.
See: Psychosocial and psychological interventions for relapse prevention in schizophrenia: a systematic review and network meta-analysis Lancet Psychiatry, Oct 12, 2021
Recovering from Serious Mental Illness – with a Little Help from Friends and Family
For the mental health recovery movement, empowering people with serious mental illness (SMI) is seen as a vital way to help them recover. Yet empowerment – the idea of helping someone rediscover their identity and agency – is rarely a goal of treatment and almost never measured in people. Resource Groups were developed nearly 20 years ago in Sweden to focus on empowerment, essentially by having the person with SMI create a support team of family and friends, along with a social worker, caregiver or other professional that would meet with them regularly. These kinds of psychosocial interventions are often developed as pilots, but too often fail to get developed at scale because there isn’t enough evidence that they’re effective.
Now a carefully designed, randomized clinical trial from the Netherlands has tested the value of Resource Groups (RGs) for individuals with SMI. Cathelijn Tjaden from the Trimbos Institute working with colleagues across the Netherlands followed 158 patients with SMI who were randomized to receive flexible assertive community treatment (consisting of case management, peer support, and medication monitoring) either with or without the addition of an RG. The RG, nominated by the patient to include professionals as well as family members and friends, met quarterly to help the patient set and meet specific recovery goals.
At both 9 and 18 months, individuals in both groups showed reductions in symptoms but those with using a Resource Group showed greater empowerment (measured on scales for confidence and purpose, self-management, connectedness, social support, professional help, and caring community). They also showed greater improvement on measures of recovery, quality of life, and general functioning. In this study, some of these differences were of “moderate” effect size, meaning that they were clinically important, not just statistically significant.
These findings add to a literature supporting the value of including families and social networks in the treatment of people with serious mental illness. Clinicians in Sweden and the Netherlands, recognizing the importance of this approach, have championed it. As Tjaden and colleagues note, rolling out the Resource Groups was still “challenging” as 21 of the 80 patients selected for a Resource Group were never able to convene a meeting. Still, these new findings from a randomized clinical trial demonstrate that structured social support in the form of a Resource Group can improve recovery outcomes for many people with SMI.
See: Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness. JAMA Psychiatry, Oct 13, 2021
People with Serious Mental Illness Have 10 Times the Risk of Being Injured by Police
Daniel Prude, Ricardo Munoz, Juston Root – these are just three of the people with mental illness who were killed by police over the past two years during a mental health crisis. Largely because of tragedies like these, Congress last year mandated the creation of a new 988 line for crisis calls involving a mental health emergency. The intent of 988 is to shift such calls from the 911 line that summons armed police officers to a mental health crisis service using trained mental health responders.
While there has been no shortage of stories about individual tragedies, there has been little scientific research assessing the magnitude of police use of force against people with serious mental illness (SMI). Until now. Ayobami Laniyonu of the University of Toronto and Phillip Atiba Goff of Yale University reviewed data from nine police departments with over 28,000 police “use of force” events from 2011 to 2017. Police departments in all nine cities had implemented training to improve police interaction with people with mental illness.
Although people with SMI represented only 1% to 3% of the population in these cities, they were nearly 20% of those experiencing “use of force” or injury from interactions with police.
The results varied across police departments and precincts, but overall, people with SMI were 12 times more likely to experience “use of force” by police and 10 times more likely to be injured by police than those without SMI.
To put these numbers in context, Laniyonu and Goff looked at racial disparities using the same approach. They found that Black residents were about three times more likely and Latinx residents slightly more likely than white residents to experience “use of force” or injury by police. In terms of disparities, people with SMI – irrespective of race – were at far greater risk of injury from police than Black or Latinx citizens without SMI.
In December 2015, the Treatment Advocacy Center estimated that people with untreated mental illness were 16 times more likely to be killed during a police encounter. These new data provide the first detailed, precinct-level assessment of the disparities in outcomes when people with SMI in a mental health crisis encounter police.
See: Measuring disparities in police use of force and injury among persons with serious mental illness. BMC Psychiatry. Oct 12, 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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