From the Editor
It’s an annual Reading of the Week tradition. At the end of each year, we pause, take stock, and consider the best selections of the past 12 months.
2018 was an eventful year.
Start here: the federal government legalized the recreational use of cannabis.
We have heard so much about legalization over these past few years, that the event itself seemed almost anti-climactic. But remember: Canada is only the second country in the world to do this.
And 2018 has seen further evidence that stigma continues to fade: governments across the country have committed themselves to increased funding for mental health; more people spoke of their experiences with mental illness; more people talked about previously taboo topics, such as suicide.
And so with an eye on the future, let’s look back at the last year. In this final Reading of 2018, we look at a few memorable selections. Enjoy.
Please note that there will be no Reading for the next two weeks.
The Best Paper: Clinical Relevance
“Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis”
Andrea Cipriani, Toshi A. Furukawa, Georgia Salanti, Anna Chaimani, Lauren Z Atkinson, Yusuke Ogawa, Stefan Leucht, Henricus G. Ruhe, Erick H Turner, Julian P. T. Higgins, Matthias Egger, Nozomi Takeshima, Yu Hayasaka, Hissei Imai, Kiyomi Shinohara, Aran Tajika, John P. A. Ioannidis, John R. Geddes
The Lancet, 21 February 2018 Online First (Open Access)
Psychiatric disorders account for 22·8% of the global burden of diseases. The leading cause of this disability is depression, which has substantially increased since 1990, largely driven by population growth and ageing. With an estimated 350 million people affected globally, the economic burden of depressive disorders in the USA alone has been estimated to be more than US$210 billion, with approximately 45% attributable to direct costs, 5% to suicide-related costs, and 50% to workplace costs. This trend poses a substantial challenge for health systems in both developed and developing countries, with the need to treat patients, optimise resources, and improve overall health care in mental health.
So begins the Cipriani et al. paper on antidepressants. And they have written a Very Big Paper – involving some 500+ RCTs. They didn’t simply collect some data; they attempted to collect all the data for antidepressant trials, considering efficacy and acceptability at 8 weeks.
And the Very Big Paper comes with a Very Big Conclusion. They write: “We found that all antidepressants included in the meta-analysis were more efficacious than placebo in adults with major depressive disorder and the summary effect sizes were mostly modest. Some antidepressants, such as escitalopram, mirtazapine, paroxetine, agomelatine, and sertraline had a relatively higher response and lower dropout rate than the other antidepressants.”
The Paper I Wish Everyone Would Read
“The Name of the Dog”
The New England Journal of Medicine, 4 October 2018
It was July 1, my first day of residency, and a queasy feeling lodged in my stomach as I donned my new white coat. It was different from the previous ones I’d worn — not just longer, but heavier. I was carrying in my pockets everything I thought I needed as a freshly minted doctor: my three favorite pens, a glossy Littmann Cardiology III stethoscope, copies of studies related to my patient with cirrhosis, and of course my trusty purple Sabatine’s Pocket Medicine.
So begins a paper by Dr. Taimur Safder. In it, he discusses his training and a simple question – after a patient develops chest pain while walking his dog, his attending asks for the name of the dog.
“Four years later, I’m not sure anything I’ve carried from residency has been more useful than that question.”
The paper was written by a physician in a medical journal, but I wish everyone in health care would take a few minutes to read it.
The Best Paper: Health Services Research
“Effectiveness of Early Psychosis Intervention: Comparison of Service Users and Nonusers in Population-Based Health Administrative Data”
Kelly K. Anderson, Ross Norman, Arlene MacDougall, Jordan Edwards, Lena Palaniyappan, Cindy Lau, Paul Kurdyak
The American Journal of Psychiatry, 2 March 2018 In Advance
Rapid growth in specialized early psychosis intervention (EPI) services has occurred over the past two decades. These programs focus on early symptom detection and comprehensive, phase-specific treatment during the initial stages of psychosis. EPI programs were established on the basis of robust evidence that an extended duration of untreated psychosis is associated with poor clinical and functional outcomes. Large randomized trials suggest that EPI services reduce psychopathology and improve patients’ quality of life, vocational outcomes, treatment adherence, and satisfaction with care. There is also increased evidence that EPI services are cost-effective when compared with standard care. However, these benefits may not be sustained once patients are discharged to standard psychiatric care. Therefore, randomized trials designed to establish the optimal duration of EPI services are currently under way.
This paper shows that early psychosis interventions have an impact on service use: patients enrolled in this program in the London-area were more likely to see a psychiatrist but less likely to be seen in an ED. And there was a big effect on outcomes: “EPI service users had lower rates of all-cause mortality compared with nonusers (hazard ratio=0.24) This translates to an absolute risk reduction of 2.5% and a number needed to treat of 40…”
As we consider how to help those with mental illness, the Anderson et al. study provides an evidence-based, life-saving way forward.
The Best Paper: Health Services Improvement
“Message Framing and Engagement in Specialty Mental Health Care: A Follow-up Analysis”
Shahrzad Mavandadi, Erin Wright, Johanna Klaus, David Oslin
Psychiatric Services, 9 August 2018 Online First
Attendance rates in specialty mental health treatment are suboptimal, with many individuals neither initiating treatment nor engaging in continued mental health care. A variety of strategies to improve attendance rates have been developed and examined. For example, multicomponent care management strategies that use tailored feedback, motivational techniques, and tracking of outcomes can lead to significant improvements in initial and sustained treatment engagement. However, these strategies are both time intensive and staff intensive, and not all clinical settings have adequate resources to track and manage all patients referred to specialty mental health care. Less intensive strategies, including delivering automated prompts and appointment reminders by means of telephone, text, or postal mail, also have been shown to improve attendance rates among patients, representing potentially brief, effective, and low-cost methods of improving engagement.
In an era of VR and apps, this study isn’t particularly flashy. In it, patients were sent appointment letters that included a positive message about how treatment helps. The letters made a difference, with higher treatment attendance than those who received a routine letter with no additional message. (For the record, the p was .01.)
The Best Essay on Mental Illness
“I Solemnly Share”
JAMA, 13 February 2018
When I was a little girl, my mom or dad would tuck me in at night. I would make each parent complete the ritual of saying goodnight to my stuffed animals and dolls. There was a giant stuffed bunny whose name now escapes me and a multitude of Beanie Babies. There was my Raggedy Ann doll, and there were two plump handmade dolls named Peppermint and Tom. To me, it was essential that each of these entities be kissed and greeted every night, as a reminder that he or she was loved. I was certain the toys would feel terribly sad if neglected. Looking back, I’m sure my parents found this repetitive behavior tiresome, but they tolerated it out of love. This was the first time I remember feeling responsible for the well-being of someone else. ‘Goodnight, Peppermint,’ we would say together. ‘Goodnight, Tom. Goodnight, Raggedy Ann.’
So begins a very personal essay by this medical student, as she describes her depression, her denial about her depression, and her ultimate recovery.
This piece is honest, raw, and important.
The Big News Story of the Year
“Cannabis Day 1: How Canada greeted legalization from coast to coast”
The Globe and Mail, 16 October 2018
From St. John’s to Vancouver, from Southern Ontario to the Far North, Canada’s nearly century-old prohibition on recreational cannabis lifted on Wednesday – and in Ottawa, the Trudeau government also promised new legislation to let people convicted of simple possession apply for pardons more easily.
So begins an article from The Globe and Mail covering the big news story of the year. (You aren’t exactly surprised with this choice, are you?) Legalization marks the end of a long debate.
That week, the Reading included a round-up of major papers on the clinical implications of cannabis use.
The Best Paper: Suicide Prevention
“‘I Can’t Crack the Code’: What Suicide Notes Teach Us about Experiences with Mental Illness and Mental Health Care”
Zainab Furqan, Mark Sinyor, Ayal Schaffer, Paul Kurdyak, Juveria Zaheer
The Canadian Journal of Psychiatry, 16 July 2018 Online First
Suicide is one of the leading causes of premature death in Canada, with 4405 suicide deaths occurring in 2015. Epidemiological data and demographic characteristics of suicide attempters and decedents are often used to propose pathways to suicide. For example, empirically demonstrated risk factors for suicide, such as presence of mental disorders, past suicide attempts, and gender, have been used to substantiate the interpersonal theory of suicide. There is far less research, however, that explores the subjective experiences of people who die by suicide, yet this is critical clinical information that provides the subjective context of risk factors. Suicide notes are firsthand accounts that offer unique insight into the thought processes and emotional experiences of those who have died by suicide, information that is missed by quantitative analyses of suicide risk factors.
The Fauqan et al. paper set out to learn from these suicide notes, trying to draw clinically relevant points. To do this, they used a constructivist grounded theory approach. They attempted to find lessons in these notes, and they did. For example, “Our findings highlight the importance of exploring patients’ beliefs about their mental illness. Clinicians may want to consider specifically eliciting beliefs about agency and blame in the context of mental illness.”
Though much work is done on suicide, this study is fresh and new in its approach.
The Person of the Year
In selecting a person of the year, I consider people who have made contributions to scholarship, advocacy, or clinical care. Dr. Roger Bland did all of that, and more. He was Chair of the University of Alberta’s Department of Psychiatry, President of the Alberta Psychiatric Association, Assistant Deputy Minister of Health for Alberta, and Deputy Editor of The Canadian Journal of Psychiatry.
Dr. Bland died this July, and he leaves a rich legacy.
A past Reading considers Dr. Bland and his contributions.
Several journals have collected their best papers of the year. The editors of The American Journal of Psychiatry offer a particularly thoughtful list.
You can find it here: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.18091065.
And all the best in the holiday season.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.