From the Editor
In most Readings of the Week, a paper or essay is selected and then discussed. This week, we return to an older format, and look at several selections, offering an overview of a few topics.
The selections ask thought-provoking questions:
Is cannabis helpful?
Can we prevent depression?
What’s it like to be depressed – and in medicine?
Cannabis: Hype or Help?
Selection 1: “Is CBD Helpful, or Just Hype?”
Richard A. Friedman
The New York Times, 26 December 2018
Suddenly, CBD is everywhere. CBD, short for cannabidiol, a non-psychotropic component of cannabis and hemp, is being promoted as the latest miracle cure. Enthusiasts rave about its supposed anti-anxiety, anti-inflammatory, antidepressant and, well, anti-everything-you-don’t-like effects.
You can get your CBD in a cocktail (a ‘Stoney Negroni’ is being served at a Queens bar), skin creams and coffee. It’s only a matter of time before it turns up in avocado toast.
From pills to edibles, CBD is wildly popular, and it is easily available online and in stores. Indeed, sales are predicted to reach $22 billion by 2022, according to the Brightfield Group, a cannabis market research firm.
As cannabis products are more and more seen across North America, this short essay by Dr. Friedman, a Columbia University psychiatrist, is worth reading and possibly sharing with patients.
Dr. Friedman considers the possible effects of CBD in the brain, noting that it has “little direct effect on the cannabinoid receptors in the brain,” and may interfere with the breakdown of anandamide, a naturally produced cannabinoid.
He notes the paucity of evidence:
- For cannabis. “In 2017, the National Academies of Sciences, Engineering and Medicine convened a panel of experts to review the health effects of cannabis and cannabinoids. They examined more than 10,000 studies, most of which examined marijuana, not CBD. They found evidence that some cannabinoids — not including CBD — are effective for pain, nausea from chemotherapy and muscle spasms in multiple sclerosis. When it comes to CBD, the panel found only a few small randomized clinical trials, and concluded that there was insufficient evidence that CBD was effective in treating conditions like insomnia, addiction to cigarettes and Parkinson’s disease, and limited evidence in its ability to treat anxiety.”
- For CBD products. “A 2017 study in JAMA reported that only 26 of 84 samples of CBD oils, tinctures and liquids purchased online contained the amount of CBD claimed on their labels. Eighteen of them contained THC, which could lead to intoxication or impairment in some individuals. And a quarter had less CBD than advertised. The F.D.A. has likewise found many products that did not contain the amount of CBD they were claiming.”
Why the excitement over CBD? “Perhaps it’s because many people have romantic and misplaced notions about nature.” He goes on to sharply conclude: “Future studies may show otherwise, but at present CBD looks more like an expensive placebo than a panacea.”
The essay is strong, and does raise concerns at a time when some private providers seem to be pushing CBD for every mental and physical health problem. In the pages of The New Yorker, essayist Malcolm Gladwell covers similar material (including the 2017 report) though some have challenged his claims about marijuana and crime.
Dr. Friedman’s can be found here: https://www.nytimes.com/2018/12/26/opinion/cbd-cannabis-health-anxiety.html.
The Galdwell piece is here: https://www.newyorker.com/magazine/2019/01/14/is-marijuana-as-safe-as-we-think.
And here’s a blog challenging the connection between crime and marijuana: https://theincidentaleconomist.com/wordpress/a-more-thorough-analysis-of-marijuana-use-and-homicide-in-colorado-and-washington/.
Selection 2: “Prevention of depression will only succeed when it is structurally embedded and targets big determinants”
Johan Ormel, Pim Cuijpers, Anthony F. Jorm, Robert Schoevers
World Psychiatry, 2 January 2019
About 150 million people worldwide are affected with major depressive disorder (further depression) at any moment, and one in every five women and one in every eight men experience an episode of major depression over the course of their life.
Although, since the 1970s, more and more people in Western countries have received mental health care, most notably pharmacotherapy, epidemiological data do not indicate a drop in the population prevalence of depression. It is clear that the effectiveness of current therapies relative to placebo is modest, and substantial treatment quality gaps still exist. However, even with optimal treatment delivery, other approaches are necessary to address the public health burden of depression and other common mental disorders.
Prevention is a largely neglected option, but has its own complexities.
The authors note that there is strong evidence for prevention: “Recent meta‐analyses of randomized controlled trials of preventive interventions that seek to reduce the incidence of depression consistently report small to occasionally moderate effectiveness, with numbers needed to treat (NNT) around 22. Notably, these effects sizes are similar to those for the use of statins to prevent an acute myocardial infarction during a 5 year period.”
They are more pessimistic: “the large majority of prevention trials concern psychological therapies administered to motivated people with sub‐threshold symptoms.”
The paper goes on to note that there are strong proximal determinants – think poor parenting and children’s maladaptive personality traits. They note that prevention would need to start early in life. “Current prevention is that it is not structurally and socially embedded. Large‐scale, long‐term implementation and utilization of prevention can only be successful if prevention is embedded at local, district/state, and national levels.”
They go on to note:
We are facing a remarkable paradox. On the one hand, stakeholders (policy makers, consumers, insurance companies, professional organizations and researchers) consider prevention a very self‐evident idea and agree that prevention of mental disorders is their top priority. On the other hand, structural and socially embedment of preventive activities and research in mental health is minimal.
The paper calls for more research, and we can wonder if psychiatry is ready for the sort of long-term study seen in other areas (think Framingham and cardiac disease, to draw from a point made by Dr. Benoit Mulsant).
The piece can be found here:
Selection 3: “Learn from me: speak out, seek help, get treatment”
MJA Insight, 22 October 2018
I discovered CrazySocks4Docs Day – held annually on 1 June – only this year. The day aims to ‘encourage conversations about mental health and help reduce the stigma for doctors experiencing mental illness’. When I discovered the day thanks to my burgeoning Twitter obsession, I experienced an incredible and overwhelming reaction.
Almost exactly 30 years before, as an intern in the central Queensland city of Rockhampton, I had tried to kill myself. Three decades later, I am now President of a specialist college, but I had kept the entire episode to myself and tried to forget it. I am deeply ashamed of not learning from my own experience and using it to help others.
I hope it isn’t too late.
Writing for Insight, a newsletter of the Medical Journal of Australia, Dr. Steve Robson discusses his experiences with depression. Dr. Robson notes his mental health problems culminating in a plan to die.
As I reached the halfway point in my internship, I felt overwhelmed with inadequacy. I had a patient die and felt responsible. My ward work was just barely adequate. My consultants and registrars were not exactly glowing in their feedback. I had an all-pervasive sense of failure, that so many years of struggle at medical school had been a complete waste and that I was little short of dangerous. I could see no way out.
So, one night, I made careful plans to kill myself.
He notes that he was stopped when someone knocked on his door – “plain good luck.”
The piece is moving. “Doctors commonly are under pressure, are more prone to mental health problems, and often have access to the means of killing themselves. These are occupational hazards. In the same way that pilots are exposed to simulated decompression and hypoxia so they recognise the warning signs, we should recognise the warning signs and the debilitating and potentially lethal effects of psychological decompression.”
The piece can be found here: https://insightplus.mja.com.au/2018/41/learn-from-me-speak-out-seek-help-get-treatment/
I also invite you to take a look at comment 30, which suggests that it wasn’t “plain good luck” that helped save Dr. Robson’s life. (And many thanks to Dr. Mark Fefergrad for this suggestion.)
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.