AuthorDavid Gratzer

Reading of the Week: Cannabis in America (and Canada) – the New JAMA Psychiatry Paper with Commentary

From the Editor

It’s legal. Are people using more? And has cannabis use disorder become more common?

This week, we look at a new paper considering cannabis legalization and use. The authors draw on American data where legalization is increasingly found across different states though not as extensively as in Canada; to date, 11 US states have legalized recreational cannabis, with 33 (and D.C.) having legalized medical marijuana.

In a new JAMA Psychiatry paper, Magdalena Cerdá and her co-authors use the National Survey on Drug Use, a major survey involving more than half a million participants, considering marijuana use, frequent use, and cannabis use disorder. What effect does legalization have? They find that cannabis use disorder is more common in adolescents after legalization and for adults who are 26 years of age and older, use, frequent use, and substance use are all up.

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We consider the paper. We also discuss the commentary that accompanies it. Finally, with an eye closer to home, we ask: are the findings relevant here in Canada?

DG

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Reading of the Week: Cannabis for Mental Illness: Popular and Promoted by Industry – But Evidenced? The New Lancet Psychiatry Paper

From the Editor

“It’s the only thing that helps with my anxiety.”

It’s closing in on midnight, and the ED patient I’m seeing is adamant that cannabis has helped him with his generalized anxiety disorder. My day has been long, but I choose to push a bit. Why cannabis? He notes how challenging it was to access mental health care. When he finally did see a psychiatrist, he feels he was offered a prescription after only a few minutes, and the trial of sertraline left him feeling more anxious. Cannabis, in contrast, helps him sleep and takes an edge off the anxiety.

More and more, our patients are talking up cannabis. Google “medical marijuana,” and there are over 166 million hits. And, yes, industry has noticed. There are a half a dozen cannabis dispensaries within a 10-minute walk from the CAMH ED, where I work. In the spring, a former prime minister joined the board of Acreage Holdings, a marijuana company, explaining that he was excited by the potential of cannabis to treat PTSD.

But is any of this evidence based?

This week, we look at a new paper from The Lancet Psychiatry. University of New South Wales’ Nicola Black and her co-authors do a systematic review and meta-analysis. Considering a variety of psychiatric disorders including depression, they draw on the literature to try to understand the effectiveness and safety of cannabinoids. “There is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, post-traumatic stress disorder, or psychosis.”

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We consider this big paper on the hot topic.

We also discuss the comment paper that accompanies this study. Yale University’s Deepak Cyril D’Souza writes: “The process of drug development in modern medicine is to first demonstrate efficacy and safety in clinical trials before using the drug clinically. With cannabinoids, it seems that the cart (use) is before the horse (evidence).” For the record, I don’t think Acreage Holdings will be distributing either paper to shareholders.

Please note that there will be no Reading next week.

DG

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Reading of the Week: Are the Pills Safe? JAMA Psychiatry on Antidepressants, NICE on Withdrawal Symptoms

From the Editor

They are popular, but are they safe?

It’s the question that patients often ask about antidepressants. Though SSRIs have been on the market for decades – and older antidepressants for much longer – people continue to question their overall safety. Online forums relate stories of problems; news articles have linked them to suicidal thoughts in youth and other issues; regulatory agencies have acted on their doubts – the FDA, as an example, issued a black box warning for SSRIs use in adolescents.

This week, in our first selection, we consider a new paper from Linköping University’s Elena Dragioti and her co-authors. In this JAMA Psychiatry paper, the authors use a systematic umbrella review, drawing on meta-analyses of observational studies. “This study’s findings suggest that claimed adverse health outcomes associated with antidepressants may not be supported by strong evidence and may be exaggerated by confounding by indication; no absolute contraindication to the use of antidepressants was found to be currently supported by convincing evidence.”

We discuss the paper and the methodology.

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In the second selection, we draw from the recently revised UK NICE guideleines, which provide advice on withdrawal symptoms and tapering strategies. “There is substantial variation in people’s experience…”

DG

 

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Reading of the Week: More Sleep, Fewer Suicidal Thoughts? New AJP Paper; Also, Is Depression like Cancer (NYT)? Admissions & Ethnic Minorities (EPS)

From the Editor

Can a sleep intervention reduce suicidal thoughts in those with depression and insomnia?

When seeing people with depression, we often tend to focus on the Big Problem: that is, the major depressive disorder itself. But should we also consider trying to provide early symptomatic relief, with, say, a sleep medication?

In the first selection, we look at a new paper from The American Journal of Psychiatry. Dr. William V. McCall of the Medical College of Georgia at Augusta University and his co-authors write about the REST-IT study, a randomized controlled trial of zolpidem-CR for those with MDD and insomnia. “The results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia…”

sleeping-babySleeping Like a Baby: Fewer Suicidal Thoughts?

In the second selection, the University of Western Ontario’s Rebecca Rodrigues and her co-authors consider involuntary psychiatric admissions and ethnic minority groups in the context of early psychosis. Spoiler alert: “African and Caribbean groups were the most likely to experience an involuntary admission…”

And in the third selection, phyisician Jill Halper wonders: is depression like cancer? “My rabbi said that my husband, like a dying cancer patient, had been in hospice care. We just didn’t realize it.”

DG

 

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Reading of the Week: When Physical Medicine Met Mental Health; New Papers from General Hospital Psychiatry and JAMA Neurology

From the Editor

In my last hospital job, an afternoon might involve seeing a gentleman with poorly controlled diabetes, a woman who wasn’t participating in her post-hip physiotherapy, and an ICU patient with multiple problems. The common thread: they all had psychiatric diagnoses (PTSD, depression, and delirium, respectively).

Patients with physical and mental health problems can be costly and complicated. They also pose a challenge for a health care system that is designed for the simplicity of tackling one problem at a time.

This week, we look at a couple of papers on this interface between mental and physical health.

In the first paper, the University of Rochester’s Mark A. Oldman and his co-authors wonder if proactive psychiatric consultations can reduce hospital length of stay. With a systematic review, they conclude: “Our review indicates that proactive models of CL psychiatry whose screening is enriched by clinical expertise in mental health care and that deliver enhanced, proactive mental health services appear to reduce LOS, with preliminary cost-benefit analyses reporting favorable returns on investment that more than offset the increased costs of providing this level of enhanced care.”

hospitalGood Hospital, Good CL Service?

In the second paper, the University of Toronto’s Matthew J. Burke, a neurologist, considers patients who present with symptoms unexplained by medical disease. “The irony of ‘it’s all in your head’ is that although this phrase is often used inappropriately and dismissively, it is technically correct.”

DG

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Reading of the Week: Should Medical Education Stay in Its Lane? Drs. Zaheer and Berkhout Respond

From the Editor

Should medical education “stay in its lane?”

Two weeks ago, we discussed an essay by the University of Pennsylvania’s Dr. Stanley Goldfarb who warns that: “Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.”

This week, we feature two letters to the editor responding to this essay, both original content for the Reading of the Week, and both from physicians affiliated with the University of Toronto.

Drawing on the medical literature and her life experience, Dr. Juveria Zaheer wonders what makes a medical expert or a physician scientist. “Being a medical expert or a physician scientist isn’t just about learning about biology – it’s about committing to the creation of a society where every life is worth living.”

Looking at medicine and philosophy, Dr. Suze G. Berkhout questions the basic assumptions of Dr. Goldfarb’s argument. “Goldfarb misrepresents the place of values in shaping scientific and medical knowledge.”

2012_canada_highwayoftears_0Staying in Your Lane: Good for Drivers, not Med Ed?

Both letters are thoughtful and worth reading.

DG

 
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Reading of the Week: Postsecondary Students & Mental Illness (CJP), a New Podcast (CAMH), and Bipolar & Social Media (NYT)

From the Editor

Social media. An uncertain job market. Increasing academic demands.

Is life for our postsecondary students harder than ever? And are we seeing a surge in mental health disorders as a result?

In the first selection, we consider a new Canadian Journal of Psychiatry paper on postsecondary education and mental illness. While many have opinions on this topic, the University of Toronto’s Kathryn Wiens and her co-authors seek to add data to the discussion. Drawing on the Canadian Community Health Survey, they find: “The results do not imply the emergence of a mental health crisis among postsecondary students.”

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In the second selection, we look at a new podcast considering technology and education. I interview some accomplished educators, including the University of Toronto’s David Goldbloom. “This is about challenging our own norms, values and expectations as clinicians.”

And in the final selection, we consider a New York Times essay on bipolar and social media. “Facebook snitched our big family secret: Roland, the literary prodigy, the tenderhearted musician, the Ivy League grad, was bipolar.”

DG

 

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Reading of the Week: Should Medical Education Stay in Its Lane? Goldfarb Argues Yes; Also, Problems in Youth (BJP) & Medical Memoirs (Lancet Psych)

From the Editor

What’s the best way of training future doctors?

Medical education has changed much over the years – schools across the country embraced the McMaster model, then cooled to it; efforts have been made to revisit core curriculum topics and add in more timely ones.

In the first selection, the University of Pennsylvania’s Dr. Stanley Goldfarb – a former associate dean of curriculum at the Perelman School of Medicine – bemoans the state of medical education. Controversially, he argues in The Wall Street Journal: “Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.”

Is he right? We discuss the essay and responses to the essay.

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In the next selection, we look at a new British Journal of Psychiatry paper. Drawing on a large dataset, the University College London’s Jessica Deighton and her co-authors study the rate of psychiatric problems among youths. “Findings reported here indicate the scale of mental health problems in children across many schools in England is much higher than previous estimates…”

And in the third selection, Dr. Linda Gask, a British psychiatrist, considers autobiographies written by physicians. “These stories can, in turn, inspire, impress, inform, engage, and even shock through the sharing of personal conflict and confessions…”

DG

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Reading of the Week: PTSD – More Common in High-Income Countries? The New BJP Open Paper; Also, the Trauma of 911 & Torrey on His Sister

From the Editor

Is there more PTSD in countries like Norway and Canada?

The question seems odd since we typically don’t associate major mental illness with affluence (though, of course, not everyone in an affluent society is affluent). Yet there is a literature suggesting that high-income countries may have more PTSD.

This week, we look at a new paper on the topic. The University of Oslo’s Trond Heir and co-authors consider PTSD in Norway. Drawing on a survey, they find significant rates of PTSD, higher than found in low-income countries. “A possible explanation may be that high expectations for a risk-free life or a happy life can lead to a low threshold for perceiving adverse events as life-threatening or as violating integrity.”

norway-aurlands-fjordenNorway: High incomes, universal health care, many fiords, and more PTSD?

In the next selection and continuing on the topic of PTSD, New York Times reporter James Barron writes about the other victims of September 11 – those who survived, but have struggled with PTSD. As a Long Island clinician notes: “So many suffer in silence. It’s 18 years later, and to some it’s pretty new.”

And in the third selection, Dr. E. Fuller Torrey, a psychiatrist and accomplished researcher, considers his career. He notes that his sister’s psychosis pushed him to choose psychiatry, though he had originally planned to be a family doc.

DG

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Reading of the Week: Can Machine Learning Improve Psychotherapy? The New JAMA Psychiatry Paper; Also, Santa Ono on His Mental Illness

From the Editor

“Compared with treatment of physical conditions, the quality of care of mental health disorders remains poor, and the rate of improvement in treatment is slow. Outcomes for many mental disorders have stagnated or even declined since the original treatments were developed.”

Are there two sentences more disappointing to read? One in five Canadians will experience a mental health problem this year – and yet we have basic problems with quality (and access).

Could AI and machine learning help?

In the first selection, we consider a new JAMA Psychiatry paper which opens with the two sentences above. The University of Cambridge’s Michael P. Ewbankand his co-authors don’t simply bemoan the status quo but seek to change it – they “developed a method of objectively quantifying psychotherapy using a deep learning approach to automatically categorize therapist utterances from approximately 90  000 hours of [internet-delivered CBT]…” In other words, by breaking therapy down into a couple of dozen techniques and then employing machine learning, they attempt to match techniques with outcomes (patient improvement and engagement), with an eye on finding what works and what doesn’t. And, yes, you read that right: they drew on 90 000 hours of therapy. They show: “factors specific to CBT, as well as factors common to most psychotherapies, are associated with increased odds of reliable improvement in patient symptoms.”

machinelearninginmarketing-1621x1000Can computers (and machine learning) improve human therapy?

In the second selection, we consider the comments of University of British Columbia President Santa Ono about school and the stresses of school. Ono speaks about his own struggle with depression. “I’ve been there at the abyss.”

DG

 

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