Assessing 2022: What’s the Prognosis in Psychiatry?

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Psychiatric issues continued to take center stage as the world stepped out of the depths of the COVID-19 pandemic. Was progress made, or did we stall? Psychiatric Times™ looked at some of the most pressing topics in psychiatry and mental health care as featured on our covers and asked leaders in the field to be the judge.

SDOMH: Time to Walk the Walk

What is the most important issue in mental health? In an online Psychiatric Times™ poll, 30.7% of respondents felt that social determinants of mental health (SDOMH) were the top issue of 2022. Notably, SDOMH landed on the first cover of the year and were a focus of discussion during the 2022 American Psychiatric Association (APA) Annual Meeting in May. Have things changed?

“As we reported in our January article, the Royal College of Psychiatrists [United Kingdom] has established a funded component to address the need for better education to address the impact of adverse [SDOMH], and in the US both the professional organizations for pediatrics and family medicine have advocated for urgent and concerted action,” Allan Tasman, MD; and Kenneth Thompson, MD, told Psychiatric Times™ in revisiting the subject. “These make it even more difficult to understand the hesitancy of the APA to do anything substantial on this issue.”

Tasman and Thompson shared that the APA eventually supported the formation of a SDOMH caucus, and the APA Assembly separately formed a SDOMH committee. However, the 2 doctors feel that these initiatives, although important, do not have enough meaningful financial support and must rely on the work of volunteer psychiatrists.

“Lack of attention to the role that adverse social determinants play in the etiology and subsequent treatment of psychiatric disorders has led to insufficient change in our treatment outcomes in spite of multiple new medications and psychotherapies,” Tasman and Thompson said.

This topic is sure to remain of utmost importance to mental health care for years to come. Research suggests that addressing poverty, food security/nutrition, neighborhood/community impacts, trauma, and racism has significant positive benefits for children and adolescents¹; this may be a good place upon which to build.

Psychedelics: A Real Solution?

On the February cover, and later in a supplement to the September issue, psychedelics, the controversial treatment turning heads, took center stage. On the one hand, clinicians are eager for a promising new treatment. On the other, there is some skepticism about a treatment that has its roots in drugs of abuse. Thus, data are essential in determining psychedelics’ potential place in the psychopharmacological armamentarium.

To support that thirst for information, Psychiatric Times™ also featured psychedelics among the many session topics at the 2022 Annual Psychiatric Times™ World CME Conference in August. Explained John J. Miller, MD, editor in chief of Psychiatric Times™ and cochair of the meeting, “We were honored to have 2 experts update us on the current status of [the pertinent] trials. David B. Yaden, PhD, presented a detailed overview of psilocybin’s history and current research status. Corine de Boer, MD, PhD, provided a well-needed overview on MDMA [3,4-methylenedioxy-methamphetamine] and how it is being studied in patients with severe posttraumatic stress disorder (PTSD).

“Both psilocybin and MDMA are steadily moving forward in phase 2 and 3 FDA registration trials to determine their efficacy and safety for various treatments, especially for conditions with unmet needs such as treatment resistant depression and severe PTSD,” Miller added.

Most recently, a randomized, controlled, double-blind phase 2b study showed that a single 25-mg dose of psilocybin could improve symptoms in patients with treatment-resistant depression.²

“You can be sure we at Psychiatric Times™ will continue to provide timely, accurate, and comprehensive updates as these 2 drugs move forward in the FDA approval process,” Miller said.

Stigma: Psychiatrists Are People, Too

Amid the talk of increasing burnout, how do you care for yourself? Research shows that clinician reluctance to seek mental health care may begin as early as college and medical school, with 25% to 56% of medical students reporting depression and anxiety.³

Fortunately, there are those taking a stand and fighting the stigma. In the March issue, Jake Goodman, MD, opened up about his own mental health.

“One year ago, I posted about taking medication for my mental health to millions of people online. As a resident doctor, especially one who treats mental illness, this was extremely taboo. I hope my post was able to move the culture in a healthier and more compassionate direction.

“Today, I am still taking medication for my mental health. I still go to therapy for my mental health. I still have some bad days, but overall my mental health is in a really good place. Seeking treatment for depression was one of the best decisions I’ve ever made. Posting about it on social media, and letting others know that they are not alone, is one of my proudest moments. After that post, I received thousands of messages and comments from people around the world thanking me for making them feel seen and less alone.

“One year later, I’m still Dr Jake. I’m still a resident doctor who treats mental illness, and I still take medication for my mental health. By the way, I’m still proud of it.”

Much like Goodman, approximately 25% of practicing physicians in the US have depression.⁴ But an anonymous survey found less than half those who reported depressive symptoms sought treatment.⁴ By being open and honest not just with patients, but with colleagues as well, we can make strides to tamp down stigma in the mental health profession.

Telehealth: Getting Plugged In

Like it or not, thanks to COVID-19, telehealth is here to stay, as we reported in the April issue.

“As a field, we have to now accept that new skill sets have to be developed: one skill set for seeing [patients] in person, and one for virtual. The art of psychiatry will have to evolve to include a distinction of who would benefit from which modality and how/when to switch modalities,” said Psychiatric Times™ Editorial Board Member Nidal Moukaddam, MD, PhD.

The highest rates of telehealth visits were among patients with Medicaid (29.3%) and Medicare (27.4%), Black individuals (26.8%), and those earning less than $25,000 a year (26.7%).⁵ But is telehealth actually helping underserved communities? Moukaddam has doubts.

“I worry this area may be a mixed bag of findings,” she said. “There [are] also data that indicate individuals with broadband connectivity disparities—only a data plan on their phone, no home internet—cannot fully benefit from virtual services because access is not guaranteed.”

War and Trauma: The Ripple Effect

On February 24, 2022, Russia invaded Ukraine, causing a worldwide ripple effect of mental health trauma as Ukrainians chose to seek refuge abroad or stay to defend their home. In September, the United Nations Human Rights Monitoring Mission reported that 14,059 civilians had been killed or injured since the invasion, although numbers are predicted to be much higher.⁶

Peter Kowalski, MD, reported to us from the front lines for the May cover. Here is the update he shared exclusively with Psychiatric Times™:

“The horror waged by Russia against Ukraine continues. Ukraine pushed the Russians out of Kherson, the gateway to lands that Russia claims. The president of Ukraine asserted ‘this is the beginning of the end’ of the war. But this war is not over. Putin threatens nukes. Winter is here, and the brutal wind slices through the broken plain. Fuel and food are scarce. Refugees may need to leave their homes again.”

Although some volunteers have moved on, they have not forgotten what they saw in Ukraine. War grinds a people down. This should not be happening in the 21st century. Coordinated mental health care is mandatory after the bullets stop flying. As mental health professionals, we can lend expertise and assistance to help put a shattered country together again,” Kowalski said.

“The world continues to engage in multiple armed conflicts with dire consequences in places like Ukraine, Yemen, Syria, Burma, and the Middle East,” Omar Reda, MD, told Psychiatric Times™. “I refuse to preach despair, though; I remain full of hope and I am a strong believer that humans can hurt and also heal each other… We psychiatrists should strive to be the source of light and hope for everyone around us, starting with those we love, and not forgetting to nurse our own wounds in the process of healing others.”

Valeriia Palii, PhD, president of the National Psychological Association of Ukraine, shared her own update with Psychiatric Times™: "Not only will we not break down, but we will also become stronger because the enemy shows its true face every time, destroying everything. People die in hospitals without electricity, schools cannot fully function because it is cold, we cannot cook for ourselves because we depend on resources. But we know that by capitulating, we will live even worse than now."

Competitive Sports: Are the Kids OK?

With young athletes admitting mental fatigue (or worse) during the 2022 Winter Olympics, in Beijing, China, all eyes turned to the field of youth competitive sports.

In June, new research indicated the type of sport may affect a child’s mental state. The more intense the sport, the bigger the mental health impact. Hoffmann et al published results on the association between sports participation and mental health difficulties among US youth.⁷ Although they found that those who participated in team sports had fewer mental health problems than those who did not participate, youth involved with individual sports were more likely to have mental health problems such as increased anxiety, depression, withdrawal, social problems, and attentional problems.

“Unlike in team sports, an athlete who competes in individual sport is constantly faced with the realization that they are solely responsible for success or failure. This can take a toll on one’s mental health, particularly at a young age if one has not yet developed the coping skills to deal with this type of pressure or if one is not receiving the necessary support from others to manage the situation,” Matt D. Hoffmann, PhD, told Psychiatric Times™.

Fortunately, the pleas for help have not gone entirely unanswered. Large athletic groups may be taking the first steps to combat this issue. In October, USA Gymnastics unveiled a new program that expands mental health coverage for athletes and coaches alike. Eight annual mental health provider visits will be covered for eligible national team members, and eligible coaches will be covered for 4 visits. Although the previous program provided mental health services during events such as training camps or meets, the new model will reimburse athletes/coaches up to $125 per visit when they return home.⁸

Suicide Hotline: Calling for Help

Three digits had the mental health care community talking this year: 988. The new toll-free dialing code, which routes callers to the National Suicide Prevention Lifeline (now known as the 988 Suicide & Crisis Lifeline) has been active since July. Although there was a lot of trepidation at its rollout, how has it worked so far?

According to data from the US Department of Health and Human Services, there was a 45% increase in overall usage volume and 152,000 more calls, chats, and texts answered compared with August 2021. Furthermore, the average answer speed across all contacts decreased from 2.5 minutes to 42 seconds.⁹ Despite these increases, data also indicate overall contacts are slowing slightly; phone calls fell by 7% the following month.¹⁰ Could this be due to a lack of awareness? Results of a recent survey of 2000 US adults found 56% reported they had heard “nothing at all” about 988.¹¹

Adding insult to injury, there have been a few viral social media posts warning not to call 988. Why? Posters listed potential police involvement, involuntary treatment in emergency departments/psychiatric hospitals, and the possible emotional and financial toll.¹²

Shootings: Perception and Prevention

Since our August issue, at least 12 more school shootings have occurred in the US.¹³ The violence of school shooters persists, as has the media’s erroneous focus on “psychopathological” shooters.¹⁴

“There is a common misperception that has been perpetuated by the mainstream media that mental illness is the primary, if not sole, factor in mass shootings. It is a very simplistic way of looking at a complex problem,” Alan D. Blotcky, PhD, exclusively told Psychiatric Times™. “The truth is that mass shootings are a complicated, multifactorial problem that is not easily described or researched, much less understood by the citizenry. What is crystal clear is that very few mass shooters have a major mental illness, such as schizophrenia.”

Blotcky does believe, however, that shooters are more likely to have externalizing disorders (ie, antisocial personality, substance use, and other impulsive and aggressive disorders). According to a 2-stage study from 2021, 10.1% to 24.3% of students met criteria for an externalizing disorder.¹⁵ “In my opinion, the obsession with mental illness as the culprit in mass shootings is a way of avoiding the harsh reality that firearms are too plentiful and too easily obtained,” Blotcky added.

Perhaps the bigger discussion should fall on prevention, and some progress has been made. In June 2022, President Joe Biden signed into law the first major gun safety legislation passed in decades, which includes funding for school safety. California, New York, and other states also have passed new laws to regulate untraceable ghost guns and strengthen background checks.¹⁶ According to an early 2022 study, such legislation might reduce gun deaths, as states with weaker gun laws had higher rates of homicides, suicides, and accidental killings using a gun.¹⁷

Moving Forward

Overall, the experts seem to agree that psychiatry has made steps toward dealing with the issues in 2022, but more needs to be done. Psychiatric Times™ readers seem to agree, according to results of a recent online survey (Table).

Table. Top Critical Issues in Psychiatry According to a Psychiatric Times™ Survey

In addition, there are ongoing factors, such as prior authorization and managed care struggles, the debate over how to address incomplete recovery and residual symptoms, and the need for additional resources and clinicians.

How will 2023 fare?

We want to hear from you! Was progress made in psychiatry in 2022? What story was most impactful to you?
What are some lingering issues you want to see addressed? Write to us at PTEditor@mmhgroup.com

References

1. Abraham A, Walker-Harding L. The key social determinants of mental health: their effects among children globally and strategies to address them: a narrative review. Pediatr Med. 2022;5:7.

2. Kuntz L. A single dose of psilocybin for treatment-resistant depression. Psychiatric Times. November 4, 2022. https://www.psychiatrictimes.com/view/a-single-dose-of-psilocybin-for-treatment-resistant-depression

3. Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry. 2008;32(1):44-53.

4. Brower KJ. Professional stigma of mental health issues: physicians are both the cause and solution. Acad Med. 2021;96(5):635-640.

5. Karimi M, Lee EC, Couture SJ, et al. National survey trends in telehealth use in 2021: disparities in utilization and audio vs. video services. Assistant Secretary for Planning and Evaluation; Office of Health Policy. February 1, 2022. Accessed November 8, 2022. https://aspe.hhs.gov/sites/default/files/documents/4e1853c0b4885112b2994680a58af9ed/telehealth-hps-ib.pdf

6. Ukraine: more than 14,000 casualties to date but ‘actual numbers are likely considerably higher.’ United Nations. September 9, 2022. Accessed November 8, 2022. https://news.un.org/en/story/2022/09/1126391

7. Hoffmann MD, Barnes JD, Tremblay MS, Guerrero MD. Associations between organized sport participation and mental health difficulties: data from over 11,000 US children and adolescents. PLoS One. 2022;17(6):e0268583.

8. USA Gymnastics expands mental health services for athletes. AP News. October 10, 2022. Accessed November 8, 2022. https://apnews.com/article/sports-health-mental-gymnastics-57baecee03219f54c3726e91866cb30c

9. HHS Secretary: 988 transition moves us closer to better serving the crisis care needs of people across America. Substance Abuse and Mental Health Services Administration. September 9, 2022. Accessed November 8, 2022. https://www.samhsa.gov/newsroom/press-announcements/20220909/hhs-secretary-988-transition-moves-closer-to-better-serving-crisis-care-needs

10. 988 Lifeline performance metrics. Substance Abuse and Mental Health Services Administration. Updated October 31, 2022. Accessed November 8, 2022. https://www.samhsa.gov/find-help/988/performance-metrics

11. Lopes L, Kirzinger A, Sparks G, et al. KFF/CNN Mental Health in America Survey. KFF. October 5, 2022. Accessed November 8, 2022. https://www.kff.org/report-section/kff-cnn-mental-health-in-america-survey-findings/

12. Social media posts warn people not to call 988. Here’s what you need to know. NPR. August 25, 2022. Accessed November 8, 2022. https://www.npr.org/sections/health-shots/2022/08/11/1116769071/social-media-posts-warn-people-not-to-call-988-heres-what-you-need-to-know

13. School shootings this year: how many and where. EducationWeek. Updated October 31, 2022. Accessed November 8, 2022. https://www.edweek.org/leadership/school-shootings-this-year-how-many-and-where/2022/01

14. Norrholm SD, Blotcky AD. Most mass shooters are terrorists, not mentally ill. Psychiatric Times. May 31, 2022. https://www.psychiatrictimes.com/view/most-mass-shooters-are-terrorists-not-mentally-ill

15. Danielson ML, Bitsko RH, Holbrook JR, et al. Community-based prevalence of externalizing and internalizing disorders among school-aged children and adolescents in four geographically dispersed school districts in the United States. Child Psychiatry Hum Dev. 2021;52(3):500-514.

16. Tucker E. These are the gun control laws passed in 2022 so far. CNN. July 30, 2022. Accessed November 8, 2022. https://www.cnn.com/2022/07/30/us/gun-control-laws-2022/index.html

17. Gun safety policies save lives. Everytown. Updated January 19, 2022. Accessed November 8, 2022. https://everytownresearch.org/rankings/