Wellness Check: Mental Health

2 Minute Medicine is pleased to announce that we are launching Wellness Check, a new series dedicated to exploring new research evidence focused on wellness. Each week, we will report on articles examining different aspects of wellness, including (but not limited to) nutrition, sleep, reproductive health, substance use and mental health. This week, we explore the latest evidence-based updates in mental health.

Cognitive behavioral therapy may improve outcomes in children and adolescents with prolonged grief disorder

1. In this randomized control trial, individualized cognitive behavioral therapy (CBT) for prolonged grief disorder was superior to supportive therapy in reducing symptoms at both 6- and 12-month follow-up.

2. Participants in the CBT Grief-Help group also demonstrated decreased symptoms of depression, post-traumatic stress disorder (PTSD), and lower levels of internalizing problems compared to the supportive therapy group.

Evidence Rating Level: 2 (Good)

Prolonged grief disorder occurs following bereavement and is typically treated with CBT in adults. Treatment practices for children and adolescents commonly include supportive counselling; the current literature does not address whether CBT is effective for prolonged grief disorder in this population.

This randomized control trial compared an individualized CBT program, CBT Grief-Help, with supportive therapy in children and youths in prolonged grief disorder. The primary outcome was participant Inventory of Prolonged Grief for Children (IPG-C) score at 3-, 6-, and 12-month follow-up. Secondary outcomes included Children’s Depression Inventory (CDI), Child PTSD Symptom Scale (CPSS), and Child Behavior Checklist (CBCL) scores. Participants included were between 8 and 18 years old, had lost a close relative, and were experiencing distressing/disabling prolonged grief disorder symptoms. Participants with a history of concurrent psychological or psychopharmacological treatment as well as those with a previous diagnosis of intellectual disabilities, developmental disorders, or severe conduct disorders were excluded.

134 participants were randomly allocated to either the supportive counselling group (n=60) or the CBT group (n=74). Participants in the CBT and supportive group showed 78.6% and 60% improvement of IPG-C scores, respectively, at 12-month follow-up as compared to pre-treatment measurements. Additionally, there was a greater reduction in CDI, CPSS, and CBCL scores in the CBT group. However, this study had several limitations. For instance, multiple therapists were used to administer the therapies and no independent ratings of treatment integrity occurred. Additionally, the home environment and level of caretaker support for participants were not accounted for. The results of this study suggested that CBT may be superior to supportive therapy in treating prolonged grief disorder in children and adolescents.

Half of Ontario, Canada psychiatric emergency patients not previously seen in outpatient mental health

1. In this cohort study, almost half of the psychiatric presentations to the emergency department (ED) had not received outpatient mental health care in the previous 2 years.

2. Male patients who presented with substance use disorder from rural communities were less likely to have previously received psychiatric outpatient care.

Evidence Rating Level: 2 (Good)

Despite the increase in Psychiatric ED visits, emergent care may not be appropriate for all presentations. Outpatient settings, for instance, are both better suited for patients who require long-term follow-up and have connections to key support services. Additionally, proper outpatient support may prevent acute psychiatric events requiring emergent care.

This cohort study analyzed psychiatric ED visits in Ontario, Canada to investigate how many patients over the age of 16 had received outpatient psychiatric care in the preceding 2 years. Patients 16 years or older who presented to the ED for the first time with mental health complaints between 2010 and 2018 were included. Non-Ontario residents and those without Ontario health insurance plan (OHIP) eligibility were excluded. The primary outcome was a first-contact ED visit without visiting outpatient care in the previous two years. Additionally, sociodemographic and admission data were used to identify factors associated with lack of previous outpatient care.

Among the 659,084 patients included in this study, 45.4% had not received psychiatric outpatient care preceding their ED visit. Patients who were male, from a rural community (<10,000 residents), immigrants, not followed by a primary care physician, and who presented with substance use disorder were more likely to present without 2-year history of outpatient care. One limitation of this study was that there were no controls for external mental health programs that patients could have accessed previously, such as privately funded programs or utilization of social workers. Nonetheless, this study’s results are significant and reinforce that improved outpatient care and mental health screening may reduce progression of mental illness, number of psychiatric ED visits, and outcomes for disproportionately impacted populations.

Smoking cessation may result in improved mental health outcomes and reduced stress   

1. In this meta-analysis, smoking cessation was associated with reduced symptoms of anxiety and depression.

2. Smoking cessation was also associated with lower stress, increased positive affect, and improved psychological quality of life as compared to individuals who continued smoking.

Evidence Rating Level: 2 (Good)

For some, smoking cigarettes is a form of stress reduction. Previous studies have found that for these individuals, the concern is that with smoking cessation, their stress levels will increase and thereby negatively affect their mental health. Furthermore, this effect can be exacerbated by nicotine withdrawal symptoms, which include agitation and changes to mood.

The purpose of the present meta-analysis was to summarize the literature on mental health outcomes and wellbeing following smoking cessation. A search of literature published up to January 2020 was conducted. Studies were included if they were randomized control trials or longitudinal cohort studies that recruited adults who smoked tobacco and were assessed for smoking cessation at follow-up. Studies that did not analyze mental health outcomes by smoking status or ineligible outcomes were excluded. Primary outcomes were change in depression symptoms, anxiety symptoms, or mixed depression and anxiety symptoms from baseline to follow-up.

A total of 102 studies with over 169,500 participants were included. With respect to primary outcomes, participants who underwent smoking cessation were less likely to have symptoms of anxiety, depression, and mixed anxiety and depression, Furthermore, participants who were successful in smoking cessation reported reduced stressed, increased positive affect, and improved psychological quality of life without reduction in social of life. The authors noted that there was high risk of bias in some of the included studies as well as heterogeneity in the measurement tools used to assess symptoms of anxiety and depression. Nonetheless, the results of the present study suggest that smoking cessation may not negatively impact mental health or stress levels and may improve quality of life.

Decreased wellbeing of first-year university students during the initial COVID-19 lockdown

1. First year university students in the United States reported sustained behavioral, emotional, and attention problems during the COVID-19 pandemic.

2. Participants who engaged in a university wellness program experienced fewer attention problems during the spring 2020 COVID-19 lockdown.

Evidence Rating Level: 2 (Good)

The COVID-19 pandemic has resulted in school closures and online learning at the majority of post-secondary institutions in North America during the spring 2020 semester. Further, because the majority of first year undergraduate students are in their late adolescence, they are especially vulnerable to experience neurodevelopmental disruption. This prospective study was the first to explore the emotional and behavioral impact of a global pandemic in this population. Students between the ages of 18- to 25-years-old enrolled in their first year at the University of Vermont at the beginning and end of their spring semester in 2020 were included. Exclusion criteria included students with phones that were incompatible with the questionnaire application. Assessments included a questionnaire on student responses to the COVID-19 pandemic, daily wellness assessments, and the Brief Problem Monitor (BPM) which evaluated attention as well as likelihood to internalize problems.

576 participants completed both baseline and follow-up BPM and COVID-19 response assessments. Approximately 67% of participants were enrolled in a university wellness program. Students who were confident in the government’s response to COVID-19 (31.6%) were more likely to be older or enrolled in a university wellness program. At follow-up assessment, students reported an increase in attention problems and externalizing problems. Participants enrolled in a wellness program were also less likely to experience increased attention problems at follow-up. This study was subject to limitations which should be taken into consideration. For example, it did not account for selection bias, extent of involvement in wellness programs, and did not have an age-matched control group. Nonetheless, the results of the present study suggest that university student behavioral and emotional wellbeing was impacted by the COVID-19 pandemic, which may be partially mitigated with the support of university wellness programs.

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