CategoryReading of the Week

Reading of the Week: Prazosin for PTSD & Nightmares – No Better Than Placebo? The New NEJM Paper

From the Editor

It’s like the script of a movie: a doctor seeks a treatment for the nightmares so common in vets with PTSD. He finds an old blood pressure medication that seems to work. Then, after years of use and with some money from a not-for-profit, he does the definitive study, landing a big paper in one of the biggest psychiatric journals.

Dr. Murray Raskind had explained his interest in prazosin simply – he theorized that if he calms the brains of veterans, they would have fewer nightmares. To that end, he sought a medication that would block norepinephrine and found just one antihypertensive that did that, and crossed the blood-brain barrier. And so began a 20-year interest in an old antihypertensive.

But is there a twist in the plot? A new study just published in The New England Journal of Medicine suggests yes. “This 26-week trial involving military veterans with chronic PTSD failed to show a benefit of prazosin over placebo in reducing the frequency and intensity of trauma-related nightmares.”

And, by the way, the lead author of this study is Murray Raskind.

New pill, same old problem?

In this week’s Reading, we consider the Raskind et al. study. We also consider the accompanying Editorial that calls the results: “surprising and disappointing.”

DG

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Reading of the Week: ECT in America – Uncommon, Uneven, and Underappreciated? The New Wilkinson Paper; Also, Cope’s Challenge to Corporate Canada

From the Editor

It’s difficult not to be excited about Bell Let’s Talk. Last week’s event set a fundraising record. Pause for a moment and appreciate how far we have traveled: a major Canadian corporation is promoting mental health awareness, raising millions of dollars in the process, and gathering praise from many, including the Prime Minister. The decline of stigma is seen across the west, with talk of tackling the opioid epidemic in New Hampshire, US, and of bettering psychological interventions in Hampshire, UK.

But how accessible is evidence-based care?

In the first selection, we consider a paper just published on ECT in the United States. Drawing on a massive database, the authors of this Psychiatric Services paper find ECT is used rarely and unevenly. In this Reading, we compare the American data to Canada’s – and draw a similar conclusion.

flag_map_of_the_contiguous_united_states_1912-1959A large country with many people – but not much ECT

And speaking of Bell Canada, in our second selection, we consider a Globe article on CEO George Cope’s recent Canada Club speech. In it, Cope challenges other businesses to implement a mental health strategy. “For business leaders… here’s the call-out: The numbers are self-funding. There’s no reason not to adopt a program in your company.”

DG

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Reading of the Week: AI & Mental Health – Gordon Parker Looks Ahead; Also, Remembering Ronald Fieve

From the Editor

As artificial intelligence advances, what role will computers play in mental health care?

Today, computers touch practically every aspect of our lives – from suggesting books that may be of interest to us on Amazon to helping fly our planes to tropical destinations. But will computers soon help us with diagnosing and treating our patients? Will some parts of clinical medicine be replaced or assisted by computers?

This week, we look at a new paper from Acta Psychiatrica Scandinavica considering AI and care. University of New South Wales’ Professor Gordon Parker sees a role for computers to help humans with diagnosis – but not more. “[R]ather than seeking to develop a computer program that will have diagnostic superiority to an ace clinical psychiatrist, it may be more important to develop programs that complement the psychiatrist’s judgement.”

AI: The next great doctor – or just a pretty face?

And in the second selection, we look back, not forward, and consider the career and contributions of psychiatrist Ronald R. Fieve, who recently passed. Dr. Fieve’s work helped bring lithium to North America.

DG

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Reading of the Week: David Goldbloom on Research & Clinical Practice

 From a Contributing Editor, Colleague, and Friend of the Editor

This week’s selection is a brief paper with long implications. For all of us clinicians who turn to the peer-reviewed literature (either directly or through the filter of Reading of The Week) for guidance on how to help our patients, this paper is worth a read.

It is impossible to stay current on the treatment research results that emerge daily, and we look to those randomized controlled trials published in high-impact peer-reviewed journals for evidence of what works for people with the diagnoses that we find ourselves addressing in the office, the clinic, the ER or the inpatient unit. But who are those patients who sign consent forms to take part in these studies, and how much do they resemble the people sitting across from us?

Great clipboard but relevant to clinical work? 

– David Goldbloom, OC, MD, FRCP(C)
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Does Canada Need a Loneliness Strategy?

CBC National recently asked this question.

They note:

Britain recently appointed a cabinet minister to try and find a solution for an increasing number of people who say they’re lonely. About 200,000 seniors in the U.K. say they haven’t had a conversation with a friend or relative in more than a month.

I was interviewed in the story.

The full clip here:

http://www.cbc.ca/news/thenational/does-canada-need-a-loneliness-strategy-1.4492553

Reading of the Week: More Demand, Less Physician Care? The New Chiu et al. Paper. Also, CAMH’s Really Big Donation

From the Editor

Canadians understand more about mental health and – with declining stigma – are more interested in services. So are they using more services and how have practice patterns changed with time?

In this week’s Reading, we consider a new paper from The Canadian Journal of Psychiatry. Chiu et al. try to answer these questions by looking at outpatient family doctor and psychiatrist visits from 2006 to 2014. They also look at ED visits and hospitalizations.

8b16181v-565x422Family docs and mental health: how much care do they deliver (and are all their patients this cute)?

They find that ED visits were up for mental health, as were hospitalizations, but physicians visits went down (all in terms of rates). They write: “The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.”

Also in this week’s Reading, we consider some good news: CAMH received a $100 million gift from an anonymous donor. Good news – but is it all good news for mental health charities?

DG

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Reading of the Week: Mental Health’s Funding Problem – the New Wang Paper; Also, the Life of Jimmie Holland

From the Editor

As we start 2018, additional funding for mental health care is widely discussed.

But what are current funding levels? How have they changed over the past decade? Which provinces are funding more and which are funding less? A new paper just published by The Canadian Journal of Psychiatry attempts to answer these questions. While the paper looks at different aspects of funding, it reaches a surprising conclusion: between 2003 and 2013, “the percentage of mental health costs with respect to total provincial public health care expenditures decreased overall…”

In this Reading, we review that paper and consider the broader implications.

In the second selection, we consider the life and contributions of Dr. Jimmie Holland, who recently passed. Dr. Holland has been called the “mother” of psycho-oncology.

DG

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Reading of the Week: The Best of 2017

From the Editor

No one should feel abandoned when their child is in a mental health crisis. Yet, sadly, I’ve met with families who’ve felt like they were. I’ve met with families who have had the courage to seek help, and have been sent away. I’ve heard of cases where brave souls have come forward, but without accessible and timely [care], have taken their own lives. I know of cases where parents miss out on work to support their kids. And where 18 year olds fall through the gaps when transitioning to adulthood.

It’s an annual tradition. At the end of each year, we take stock, reviewing the best of the past year.

And this past year has been remarkable in terms of good news.

Consider:

  • Earlier this year, the federal and provincial governments agreed to big investments in mental health.
  • In December, the Quebec Minister of Health committed his province to publicly funded psychotherapy for people with depression and anxiety provided by nurses, social workers and psychologists.
  • Ontario had made a similar if smaller commitment in the fall.

And the political push for mental health reform continues. Just this past weekend, Ontario PC Leader Patrick Brown wrote the above quotation in an opinion piece for the Postmedia Network. He called for a massive infusion of money into the mental health care system above the federal commitment.

The promises are big, but paper after paper shows that there is much work to be done. Studies this year found people with schizophrenia die at a rate eight times higher than that of the general population; that ECT use is declining despite its efficacy; that the vast majority of people post-suicide attempt aren’t seen by a psychiatrist within six months.

And so, we end 2017 in an usual position – those of us in mental health who have longed for a day when funding would improve and political interest would grow can feel satisfied. We should also feel a bit anxious. We now have a remarkable opportunity. We shouldn’t waste it.

And so with an eye on the future, let’s look back at the last year. In this final Reading of 2017, there are six selections, covering everything from the effectiveness of antipsychotics to the journey of a great uncle through Ohio asylums. Enjoy.

Please note that there will be no Reading next week.

DG

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Reading of the Week: Better Pay, Better Service? The CMAJ Paper on Pay for Performance in Psychiatry. Also, a Father’s Memory

From the Editor

Does pay for performance work for psychiatry?

This week’s first selection is a paper just published by CMAJ that considers that question. Drawing on Ontario data, the authors looked at practice patterns when financial incentives were introduced for psychiatrists to take care of patients after discharge and after suicide attempts. Spoiler alert: they didn’t work.

http-i-huffpost-com-gen-1291505-images-n-free-health-care-canada-628x314Paying for Performance – Getting Performance?

In this Reading, we consider the paper and the larger debate.

We also consider a short, moving essay by radio host Charles Adler on the memory of his father – and his father’s memory. The award-winning broadcaster describes his father and his Alzheimer.

DG

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Reading of the Week: Ethics & Medical Assistance in Dying – the new Simpson Paper. Also, Exercise for the Cognitive Symptoms of Depression?

From the Editor

It may soon be the law… but is it ethical?

In 2016, Parliament passed Bill C-14, legalizing doctor-assisted suicide. The legislation represents a major change in many ways: from public policy to the practice of medicine. And, in the coming years, it’s quite possible that the scope of this legislation will be expanded, and could include those with mental illness.

In this week’s Reading, Dr. Wayne (Sandy) Simpson of CAMH weighs in on the ethics of medical assistance in dying (MAiD) and mental illness in this provocative “perspective” paper just published by The Canadian Journal of Psychiatry. He considers the nature of mental illness before concluding: “[A]cting as a partner in helping people recover as well as acting as an agent in a patient’s death is an impossible burden that is not ethically justifiable or legally necessary.”

ethics-cert

Also, this week, we consider another recent paper by The Canadian Journal of Psychiatry that considers the impact of exercise on cognition in patients with depression.

DG

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