Childhood Trauma and Abuse is the Smoking of Psychiatry

Annals of Internal Medicine 2013; 158(3): 179-190

Childhood trauma and abuse is the smoking of psychiatry. As a risk factor for mental illness it is comparable to how smoking a pack of cigarettes per day increases the risk of lung cancer and heart disease.

As an adult psychiatrist I see the consequences of poor starts to life and do my best to manage the consequences. However, doing my best often isn’t that effective or proves to be only a temporary solution. So the real question at hand is - what if we could do something to prevent child abuse from happening?

This is the question addressed in a systematic review published in the Annals of Internal Medicine in February this year. The authors update the US preventive services task force recommendations from 2004 on the prevention of child abuse and neglect. They reviewed the literature up until the middle of 2012 and found 11 randomised controlled trials which tested different interventions to prevent child abuse.

However, they only included English language studies and didn’t search outside MEDLINE, PsycINFO or the Cochrane Central Register of Controlled Trials which means non-English language studies were likely to be missed. (It seems strange that systematic reviewers ignore non-English language studies – is the implication that they are somehow less “good” than English language papers or that we can’t learn from “foreign” countries?).

The authors found one study in a paediatric clinic (although in other countries this would more likely be a family physician practice) which sought to identify and then refer those children up to age 5 at high risk of abuse and neglect. The program found that the intervention produced a significant reduction in child protective service reports up to four years after the child was seen. The evidence was less clear cut for various forms of home visits by nurses or “trained laypersons” up to three years after birth.

The conclusion of the review is that risk assessment and behavioural interventions in paediatric clinics reduced abuse and neglect for young children, but the evidence is inconsistent for home visitation programs. Plus, of course, it’s clear that additional research is needed.

This seems to be one of those areas where there is the choice between focusing on those at high risk or trying to address abuse at a population level – the classic Geoffrey Rose problem first articulated over salt and hypertension. Providing leadership through the development of infant mental health services may be one way forward.

Antipsychotics Not the Answer for Treatment Resistant Depression

PLOS Med 2013; 10(3): e1001403

The so called atypical antipsychotics are no more effective than the older ones but the neuromuscular adverse effects have been replaced by metabolic ones.

One exception to this broad generalization is their use as an adjunctive treatment for treating depression, although there is a suspicion that this is a sign of “indication creep” for drugs which may be coming off patent. To address this, a systematic review raises its head in the March PLOS Medicine on-line Journal.

The authors identified 14 trials (all funded by drug manufacturers) where patients with depression who were “treatment resistant” were randomized to receive either an antipsycotic or placebo. The trials were short term studies ranging from 4 to 12 weeks and included aripriprazole, an olanzapine/fluoxetine combination, quetiapine and risperidone.

All four drugs had significant effects on remission and response (except the olanzapine/fluoxetine combination which did not affect response rates). However the effect was small with a mean difference of about 2.5 on the Montgomery-Asberg Depression Rating Scale. Additionally, on measures of quality of life the drugs had no or very small effect (with the exception of risperidone which had a small to moderate effect). Numbers needed to treat for remission compared to placebo were 9 for aripiprazole, quetiapine and risperidone and 19 for the olanzapine/fluoxetine combination.

Treatment was associated with weight gain, akathisia, sedation and abnormal metabolic laboratory results.

So would I have an antipsychotic if I had treatment resistant depression? Probably not and if I did I'd want to stop it pretty quickly.

Association between Depression and Hospital Outcomes among Older Men

Canadian Medical Association Journal; 185.2 (Feb. 5, 2013) p117. 

It is a little known fact that the Canadian Medical Association Journal ranks at number 8 in the list of the world’s top medical journals as judged by impact factor. So to emphasize yet again that there is no health without mental health and the global nature of healthcare, in February the Journal published a cohort study of over 5400 Australian men.

These men were over 65 years old and were enrolled in the “Health in Men study” where they were assessed for depression at baseline on the Geriatric Depression Scale.  Two years later of the 339 men who scored more than 7 on the rating scale 152 (44.8%) had at least one non-psychiatric emergency hospital admission compared to 1164 of 5072 (22.9%) non depressed men.

The depressive symptoms also predicted whether these men were admitted to hospital (for non-psychiatric conditions), the number of admissions and the total length of stay. The system of separating mental health care from other aspects of health care is anachronistic and can no longer be supported by the evidence. Once funders recognize that taking into account the whole person improves quality and reduces costs this separation will increasingly be seen to be out of date and a sign of organizational stigma.

Discrimination against Depression

Lancet 2013; 381(9860)55-62

Maintaining the theme of having “global” in the title of every paper it publishes The Lancet produced a paper in January on discrimination experienced by people with depression around the world. The authors surveyed 1082 selected people with depression in 35 countries and found that four out of five experienced some form of discrimination.

The most common areas where people reported discrimination was by family members, friendships, marriage or divorce and keeping a job. Three quarters of people wished to conceal their depression from other people (in the medical profession I would suspect this figure would be higher).

It’s not entirely clear what the point of this paper is as the participants were not randomly selected but were approached by local research staff so the numbers are hard to generalize and should be taken with a pinch of salt. Nor did the authors report discrimination by country which would have been interesting to see how they stack up and might have generated ideas about how to address stigma.

Perhaps for clinicians reading this the take home message is to ask the question “Have you ever been discriminated against because of your depression or do you anticipate any discrimination”. I would guess the most likely areas this would apply would be at work or at the hands of the health system where discrimination against people with mental illness is rife.

Putting Alzheimer’s on Ice?

New England Journal of Medicine 2013; 368:107-116

Iceland is not renowned for its contribution to medical science, being a small country in between the North Atlantic and the Arctic Ocean. However, that seems about to change as an Icelandic team scored two major papers and an editorial in the New England Journal of Medicine in January. The fuss was all about TREM2 which is a receptor on brain cells which is involved in clearing away damaged tissue and inflammation associated with the damage.

What the Icelandic team has shown is that people with later onset dementia have a higher risk of the gene that codes for this receptor having a mutation. The mutation results in less TREM2 and therefore more brain inflammation.

All very interesting but clearly not the whole picture as the prevalence of the abnormal gene that codes for TREM2 in the general population is less than 1% so it cannot account for the 20% plus rate of Alzheimer’s in the older population. Also the odds ratio for the increased risk was less than 3 so hardly a massive rise. So not much in this for jobbing clinicians but watch this space for the development of drugs acting at the TREM2 receptor…

The Global Burden of Disease Study

Lancet 2012;380:2224-2260

These days it is difficult to find a paper published in The Lancet which doesn't have the word global in the title. However the Christmas edition of this journal surpasses itself by devoting all its content to the latest findings from the global burden of disease project. It is the first time the Journal has devoted an entire issue to one study.

This project is an excellent example of big teams answering big questions – and we are talking a big team here with 486 authors from 302 institutions in 50 countries contributing to the papers. The principal findings can be summarized as fewer people are dying but more people are living with disability with chronic disease such as musculoskeletal disorders, mental health disorders and injuries the commonest causes.

One paper is the dauntingly titled “A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010” and that’s before the colon in the title. Why is this important for psychiatrists working at the coal face? Well one of the reasons for justifying increased funding in mental health services is the often quoted prediction that depression will result in the second biggest disease burden in the future. What this paper does is turn the question around and look at what risk factors are important in causing disability rather than what diseases.

What the authors conclude is that high blood pressure, tobacco smoking and alcohol use are the three leading risk factors for global disease burden. This clearly is important for substance use services and should inform policy development and funding in those areas. What about other mental health problems? The way the authors did the study was to pair up risk factors with outcomes. Most of the risk factors were traditional, some would say 19th century, items such as occupational exposure to chemicals paired with specific outcomes. The authors did not look at poverty, social class or inequality as risk factors which I think is a serious omission.

What they did look at was childhood sexual abuse and intimate partner violence paired with depression and self-harm. They found that globally intimate partner violence rated the 23rd most important risk factor and childhood sexual abuse 33rd out of the 43 factors they looked at - however for North America intimate partner violence was 22nd whilst childhood sexual abuse rose to 21st. This illustrates the importance at a population level of managing these risk factors and at an individual level asking about sexual abuse and partner violence. Not doing so is like a cardiologist not asking someone about smoking.

The other six papers in this issue by the same group look at a variety of other measures of global burden of disease. These include global death rates where self-harm (that is suicide) is the 13th most common cause of death globally contributing about 5% of deaths in adults aged 15 to 49. In another paper looking at disability life years lost, globally depressive disorders were the 11th most common cause of disease burden (up from 15th in 1990).

Cognitive Behavioural Therapy as an Adjunct to Pharmacotherapy for Primary Care Based Patients with Treatment Resistant Depression

Lancet, Early Online Publication, December 7, 2012 doi:10.1016/S0140-6736(12)61552-9

Also available online in the Lancet is the result of the CoBaLt trial which was a trial of cognitive behaviour therapy in people who had failed to respond to antidepressants in primary care in England. Failure to respond to antidepressants is the norm with only a third of people responding fully to antidepressants. The authors recruited 469 patients into the trial with 235 randomized to usual care and 234 to cognitive behaviour therapy plus usual care. To get into the trial participants had to have been on antidepressants for longer than six weeks, have a BDI score greater than 13, be aged 18-75 and meet ICD 10 criteria for depression.

Most people in the trial had received treatment for depression for over a year. One year after starting the trial 95 participants in the intervention group (46%) met criteria for response versus 46 (22%) in the usual care group. This means that about four people need to be treated with CBT for 12 to 18 sessions to get one extra person better after one year compared to usual care. One of the most noticeable aspects of this trial is that it demonstrated the acceptability of psychological treatments with 99% of patients invited for baseline assessment agreeing to participate. This is in contrast to the flawed STAR*D trial where only a quarter of participants were willing to be randomised to CBT.

The context for this trial is the introduction of IAPT in England where IAPT stands for “improving access to psychological therapies” which is a £ 500 million project to train providers in cognitive behaviour therapy for depression and anxiety. This is an attempt to address the difficulty that clinicians always encounter when recommending CBT in that there is limited access to CBT therapists.

One obvious way to alleviate this is to massively increase the number of CBT therapists which is what they are doing in England. However criticisms of IAPT are that:

• it treats people who previously would not have had treatment and who would have got better without any intervention (just the passage of time);


• IAPT workers do not manage risk so anyone who is remotely suicidal gets booted up the system paradoxically increasing waiting times in mental health service;


• the system is protocol driven with little flexibility; and


• there is no system for the introduction of new therapies (that is therapies other than CBT).

Another way to manage the lack of CBT resources is to provide computerised therapies with mental health coaches to help people progress through them. We are planning on trying the second approach in Ottawa but a few more therapists would not go amiss – one approach would be to use consumer peers who get brief training in CBT but close supervision from fully trained therapists.