TagJAMA Psychiatry

Reading of the Week: Effective Therapy for Anxious & Depressed Youth in a Peds Clinic? The New Weersing Study

From the Editor

“Anxiety and depression in youth are widely prevalent, highly impairing, and woefully undertreated.”

So writes San Diego State University’s V. Robin Weersing and her co-authors in a new JAMA Psychiatry paper. In this study, they compare a pediatric clinic-based brief behavioural treatment to referral to outpatient services for depression and anxiety. It’s a novel approach – and one with significant advantages (housing treatment in a primary care setting, to name just one).

So does this work? Spoiler alert: the brief behavioural treatment (BBT) comes out on top.

Anxiety treatment in the peds office: would Norman Rockwell approve?

As an accompanying Editorial notes: “The efficacy of BBT is particularly telling given the low response rate to treatment as usual in the control condition (57% vs 28%), especially for Hispanic populations (76% vs 7%).”

Please note: there will be no Reading next week because of the APA Annual Meeting. (I hope to see you in California.)

DG

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Reading of the Week: Can We Reduce Suicide in the Emergency Department Population? Also, Drugs & Crime

From the Editor

He presents to the Emergency Department a few days after a suicide attempt. What can we do to help keep this man safe today – and moving forward?

Emergency Departments: noisy, busy, and an opportunity for suicide prevention?

It’s a scenario that repeats itself at EDs across the country with regularity. This week, in our first selection, we consider a new JAMA Psychiatry paper that has just been published looking at suicide prevention in the ED population. The authors claim “this study is the largest suicide intervention trial ever conducted in the United States,” and they show that, with an intervention, they can reduce suicides and suicide attempts.

And, in the other selection, we look at a short New York Times essay in which economist Austin Frakt argues that substance programs pay for themselves in crime reduction.

DG Continue reading

Reading of the Week: Technology & Mental Health – Depression and Internet-based CBT; Also, Finnish e-Therapy

From the Editor

VR. e-therapies.

New technology is changing the way we think about the delivery of psychiatric services. But new isn’t necessarily better. Can care really be transformed? What does the literature say?computere-therapy: more than clever pictures of computers and stethoscopes?

In a two-part Reading of the Week, we look at technology and psychiatry.

Last week, Virtual Reality.

This week, e-therapies.

This week, we consider a new paper that has just been published. Its looks at self-guided Internet-based CBT showing that for every eight people treated, one benefits (consider this in the context of minimal cost).

And, in the other selection, we look at the Finnish experience with Internet-based CBT.

DG Continue reading

Reading of the Week: The Future of Psychiatry – Part II of II

From the Editor

Is mental health becoming too technical (and forgetting patients as a result)?

The future of us clinicians?

This is the second Reading in a two-part series considering the future of mental health – not in terms of distant developments like biomarkers and genetically-tailored drugs – but rather by looking at measurement-based care and the evolution of the field.

Last week, measurement-based care.

This week, the end of the art of care?

This week, we look at an editorial The British Journal of Psychiatry that warns against physicians becoming “well treated skilled workers.”

And, continuing the consideration of ‘the future,’ we also consider a new paper that has received much attention. Can a web-based intervention help with insomnia? Spoiler alert – as The New York Times reported last week, “more than half of chronic insomniacs who used an automated online therapy program reported improvement within weeks and were sleeping normally a year later.”

DG Continue reading

Reading of the Week: Guest Contribution – Dr. David Goldbloom on Involuntary Hospitalizations

From a Contributing Editor, Colleague and Friend of the Editor

All of us psychiatrists have exercised our responsibility for the involuntary admission of patients. Some patients (and many families) have expressed gratitude for this temporary but fundamental abrogation of civil freedoms – the freedom of movement – but for many patients it may be a source of fear and of loss of control and autonomy (even though the illnesses that they are experiencing also undermine control and autonomy). It may also reflect an upstream failure of less intrusive and earlier interventions to treat mental illness.

Involuntary admission: is there an alternative?

In an era of being patient-centred and recovery-focused, is a reduction in rates of involuntary hospitalization desirable? If you’re a human rights lawyer, the answer may be “well, yes, obviously”. If you’re a clinician, the answer may be “that depends on whether the patient ends up better or worse”. Nevertheless, there are a number of clinical initiatives in place whose goal would be to reduce the frequency of involuntary hospitalization (which does not preclude an increase in the rate of voluntary hospitalization).

So along comes a careful systematic review and meta-analysis of randomized trials to examine four categories of intervention that have, as their explicit primary or secondary outcome, a reduction in the rates of involuntary admission to psychiatric inpatient units. The interventions will seem familiar to any reader who has been involved in the care of people with severe and persistent mental illness. But the results are surprising.

– David Goldbloom, OC, MD, FRCP(C) Continue reading

Reading of the Week: Guest Contribution – Dr. David Goldbloom on Lithium and Self Harm

From a Contributing Editor, Colleague and Friend of the Editor

Sixty-seven years ago, Australian psychiatrist John Cade published his case series on manic patients treated with lithium – truly the dawn of the modern era in psychopharmacology. Two decades passed before lithium came to Canada, and almost three before it came to the United States. In the treatment of mania, it was the first significant drug alternative to the only other enduring treatment from that time – electroconvulsive therapy.

Dr. John Cade (and Lithium)

Today, however, lithium suffers from under-promotion (there is no money to be made on it by the pharmaceutical industry) and under-exposure in the training of residents despite the evidence of its benefit that continues to emerge.

Here is a new paper that looks at suicide and self-harm during maintenance treatment of people with bipolar disorder treated with lithium, valproate or the increasingly popular second-generation antipsychotic drugs. And here is an old paper that reminds us what a difference lithium had already made in the economics of mental illness by 1980.

– David Goldbloom, OC, MD, FRCP(C) Continue reading

Reading of the Week: Battling The Black Dog

From the Editor

This week, hundreds of thousands of Canadians will not go to work because of mental health problems, depression being the most common.

But despite the long shadow cast by depression on our society, it’s difficult not to feel that we fall short in terms of our active management. Many people struggle with their symptoms; even when they can beat the “black dog” – to use Winston Churchill’s term – they are at high risk for relapse.

Can we do better with the black dog?

Here are two papers that look at bettering outcomes.

In the first, the authors ask if mindfulness can prevent the relapse of depression. The second paper considers the use of statins to improve the effects of antidepressants.

DG Continue reading

Reading of the Week: Doctor-Assisted Suicide: The Dutch Experience

From the Editor

Is the practice of psychiatry about to change?

We often think of change in terms of treatment developments – new drugs and therapies. But mental health services are delivered in a larger societal context, and our work is shaped by laws and court rulings. With that in mind, Carter v. Canada has the potential to reshape our work. As you know, last year, the Supreme Court of Canada struck down the provision of the Criminal Code prohibiting doctor-assisted suicide. Later today, a special joint parliamentary committee will issue its report, guiding the drafting of legislation that will legalize doctor-assisted suicide.

How will this future legislation affect those with mental illness? What will it mean for people like us who do clinical work? Obviously, it’s not possible to comment on legislation that hasn’t been drafted yet. But it is possible to look to other countries and consider their experience. In this week’s Reading, Kim et al. consider physician-assisted suicide and euthanasia in the Netherlands. In their study of a country across the ocean, there are lessons for our patients here.

DG Continue reading

Reading of the Week: Let There Be Light

Major depressive disorder (MDD) affects at least 5% of the population, with a lifetime prevalence estimated at 14%. It is the second-ranked cause of disability worldwide and is associated with impairment in quality of life, increased risk of mortality, and societal burden. Treatments for MDD include psychotherapies and antidepressants, but remission rates remain low despite adequate treatment and more therapeutic options are needed.

Light therapy, an effective treatment for seasonal affective disorder (SAD), may also be appropriate for MDD. Bright light is a safe, well-tolerated, nonpharmacological treatment that can be used alone or combined with medications. Light can correct disturbed circadian rhythms, which have been implicated in the pathophysiology of MDD. Previous metaanalyses of light therapy for nonseasonal MDD, however, have yielded only equivocal and conflicting evidence for efficacy. Two more recent systematic reviews both concluded that the quality and methods of the identified studies were too heterogeneous to conduct a meta-analysis. They each found insufficient evidence for efficacy of bright light monotherapy, although 1 review found low-quality evidence for bright light as adjuvant treatment to antidepressants.

In summary, these systematic reviews indicate that the evidence for benefits of bright light therapy for nonseasonal MDD is inconclusive and well-designed studies are required to resolve this issue.

So begins a new paper on depression. I like these opening paragraphs and, in particular, the first paragraph (and its bluntness). For the clinicians among us, the final phrase is hauntingly true: “more therapeutic options are needed.”

This week’s Reading: “Efficacy of Bright Light Treatment, Fluoxetine, and the Combination in Patients With Nonseasonal Major Depressive Disorder: A Randomized Clinical Trial” by Dr. Raymond W. Lam et al., which was just published online (ahead of print) in JAMA Psychiatry.

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This is a big paper in a big journal with big clinical implications. It’s also very Canadian – every co-author lives north of the 49th parallel; the first author hails from Vancouver.

We know that light therapy works for those with a seasonal pattern to their depression. But could we use the light therapy for other people suffering from depression? The authors attempt to answer this question. Continue reading

Reading of the Week: Can We Prevent Depression For Those At Risk?

Depression is the leading cause of disability worldwide and commonly begins in adolescence. Prevention is one viable strategy for reducing the population burden of depression because most depressed adolescents do not receive specialty mental health treatment and because untreated depression is associated with enduring deleterious effects on interpersonal relationships, educational attainment, and occupational status.

Single-site studies have demonstrated the efficacy of an adaptation of the Coping with Depression for Adolescents intervention in preventing the onset of depression relative to usual care in adolescents with subsyndromal depressive symptoms and in those with a parental history of depression. These results were replicated in our 4-site randomized clinical trial of 316 high-risk adolescents randomly assigned to either an adaptation of the Coping with Depression for Adolescents (cognitive-behavioral prevention [CBP]) plus usual care or usual care alone, which found a lower incidence of depressive episodes at 9 and 33 months after enrollment in those who received CBP.

So begins a new paper that seeks a lofty goal: using a psychological intervention to prevent depression before it starts.

This week’s Reading: “Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents: A Randomized Clinical Trial” by Dr. David A. Brent et al., which was published in the November JAMA Psychiatry.

In this paper, Brent et al. attempt something we often dream about in psychiatry – but are so rarely able to achieve: prevention. That alone would make this paper worth considering. But there’s more: the study features an incredible follow up period (a full six years) and a consideration of the parent, not just the at-risk adolescent. Pulling it together: this is a big paper in a big journal with a big result.

Dr. David Brent

So, can we take an at risk population and, with therapy, prevent them from developing a major mental illness? This is what the study authors seek to find out. As they note early in the paper: “We hypothesized that those who received CBP would have a lower hazard of depression onsets and better developmental competence during emerging adulthood.” Continue reading