TagJAMA Psychiatry

Reading of the Week: Many Medications, Better Outcomes? Paul Kurdyak on the New JAMA Psychiatry Paper Considering Antipsychotics and Schizophrenia

From a Contributing Editor

For individuals with schizophrenia who are failed by trials of single antipsychotics, what’s next?

This week, we discuss a paper that addresses a treatment controversy. Antipsychotic polypharmacy (the use of more than one antipsychotic) is generally discouraged because the efficacy evidence is weak, and there is risk of increasing adverse events and effects with the addition of a second antipsychotic. Choosing Wisely is an initiative that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures; among their psychiatric recommendations is to avoid the use of multiple antipsychotics. The American Psychiatric Association contributed this to the Choosing Wisely initiative:

Research shows that use of two or more antipsychotic medications occurs in 4 to 35% of outpatients and 30 to 50% of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased. Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of Clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy.

 This is where this week’s selection comes in. The study, “Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia,” is from Finland by Karolinska Institutet’s Jari Tiihonen and his colleagues. This paper uses Finnish population-based health administrative data to evaluate the association between antipsychotic polypharmacy and psychiatric hospitalization. They conclude: “These results indicate that rational antipsychotic polypharmacy seems to be feasible by using 2 particular antipsychotics with different types of receptor profiles.”

kakslauttanen_aurora_augustFinland: home to big Northern Lights (and big databases)

In this Reading, we consider this paper and wonder if it should change our prescribing choices.

Paul Kurdyak, MD, PhD, FRCPC

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Reading of the Week: Can Social Connectedness Prevent Suicides? The New JAMA Psychiatry Paper on Caring Contacts in the Military

From the Editor

Social disconnectedness contributes to suicide. Past studies have tried to connect with people at risk, using simple tools like postcards.

This week, we look at a JAMA Psychiatry paper. The University of Washington’s Katherine Anne Comtois and her co-authors use a text message-based intervention (Caring Contacts) to try to reduce suicidal thoughts and behaviours in active military personal. They find: “Although the primary hypotheses were not supported, Caring Contacts was found to be a simple, scalable intervention that may be effective in reducing the occurrence of suicide ideation and attempts.”

Military man texts using smart phone in the city Suicide prevention by text: clever? Too clever?

We consider the paper and two editorials. We also consider a New York Times essay that asks: “If suicide is preventable, why are so many people dying from it?”

DG

 

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Reading of the Week: CBT for Depression – What Really Works? The New JAMA Psychiatry Paper

From the Editor

“It changed my life.”

A few years ago, a patient described to me how helpful cognitive behavioural therapy was for him. CBT wasn’t his only treatment – he had a couple of medication trials – but he found the psychotherapy to be very helpful.

Others have had a similar experience, but CBT isn’t widely available in Canada; Puyat et al. found in a Canadian Journal of Psychiatry paper that the vast majority of people with depression don’t receive any form of psychotherapy or counseling. How can we address this access gap? Could different forms of CBT work including those that are less resource intensive? What to make of self-help?

In this Reading, we consider a new paper by Vrije Universiteit Amsterdam’s Pim Cuijpers and his co-authors that seeks to answer these questions. They use a network meta-analysis to compare five treatment formats with each other and control conditions (waiting list, care as usual, and pill placebo). Their conclusion: “This study suggests that group, telephone, and guided self-help treatments are effective interventions that may be considered as alternatives to individual CBT.”

dr-aaron-beck-at-work-595048284-5af62b4dae9ab80036aca7faAaron Beck: How to deliver the CBT he has championed (and should we all wear a bow tie)?

In this Reading, we consider the big paper and its big result, and the accompanying editorial by the University of Pittsburgh’s Dr. Holly A. Swartz and Jay Fournier.

DG

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Reading of the Week: Cancer and Suicide – the New JAMA Psychiatry Paper

From the Editor

When I worked closely with cancer patients, we would often speak of that moment – the moment they were diagnosed, when they officially became cancer patients. Many recalled their first emotions: the disbelief, the shock, the anger. A few could even tell me sparkling details, like the way the doctor looked at them or what she was wearing. And, for all, that moment had been life altering.

That moment is followed by challenges, and for some, depression and even suicide.

What is the risk of suicide after the cancer diagnosis? In this week’s Reading, we look at a new JAMA Psychiatry paper. Drawing on English data, and involving 4.7 million people, Public Health England’s Katherine Henson and her co-authors look at cancer and suicide. They find: “Despite low absolute numbers, the elevated risk of suicide in patients with certain cancers is a concern, representing potentially preventable deaths.”

popepaintingBig diagnosis, big risk?

In this Reading, we consider the paper on this important topic, as well as an editorial.

DG

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Reading of the Week: VR for Phobias? The New JAMA Psychiatry Paper. Also: Lancet Psychiatry on the Potential & Pitfalls of Digital Health

From the Editor

At the end of medical school, I spent some time working with an attending psychiatrist who was keen on behavioural interventions. He asked me to see a patient with acrophobia, a fear of heights, and told me to take the patient for an elevator ride for a “real-world experience.” For the record, the patient declined. (Having had no background in behavioural interventions, I’m not sure who was more anxious about that possible elevator ride, the patient or me.)

For people with phobias, exposure can be helpful. And so, therapists have taken their patients on plane trips and to visit tall buildings, and encouraged them to sign up for public speaking classes. As technology advances, we can ask: could virtual reality, or VR, work?

In the first selection, we consider a new paper from JAMA Psychiatry. Vrije Universiteit Amsterdam’s Tara Donker and her co-authors use VR for acrophobia. They choose a very basic intervention – an app and cardboard google glasses. They find: “A low-cost fully self-guided app-based virtual reality cognitive behavioral therapy with rudimentary virtual reality goggles can produce large acrophobia symptom reductions.”

googlecardboard-580x358

The future of psychiatry? Maybe – and certainly recyclable

In the second selection, we look at a new editorial from The Lancet Psychiatry. While the authors are keen on digital psychiatry – the sort of work that Donker and her team do – they also warn about potential problems.

DG

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Reading of the Week: A Statin a Day Keeps the Doctor Away? The New Hayes et al. JAMA Psych Paper

From the Editor

Statins can help prevent MIs in people with high cholesterol. Can they also prevent psychiatric admissions for those with schizophrenia?

The question may seem odd, but there is evidence that statins can reduce symptoms in people with schizophrenia – though the evidence is light. That may not be as surprising as it seems: statins are anti-inflammatories, and a growing literature suggests neuro-inflammation is involved in major mental illness.

So should our patients receive medications like statins? The concept of repurposing common medications has gained attention.

This week, we look at a paper just published in JAMA Psychiatry. In their study, University College London’s Joseph F. Hayes and his co-authors consider the effect of statins, calcium channel blockers, and biguanides (such as metformin). Spoiler alert: they find that these medications reduce psychiatric hospital admissions and self-harm in people with serious mental illness.

statins-understandingthehypeStatins for schizophrenia?

In this Reading, we review the new paper about the not-so-new meds. We also take a quick look at another paper (on ketamine).

DG

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Reading of the Week: Prevention Works – the New JAMA Psychiatry Paper on MIs & Mortality in Patients with Schizophrenia

From the Editor

Statistically, people with major mental illness have a life expectancy that is decades shorter than those without. Not only is that gap significant, but it may be growing. In a 2013 paper, drawing on Danish data, Nielsen et al. showed that the expansion of life expectancy seen in the general population over the past 30 years hasn’t been enjoyed by those with schizophrenia.

Why the gap? And what can be done? A major new paper in JAMA Psychiatry considers the treatment of myocardial infarction. Like Nielsen et al., Aalborg University’s Pirathiv Kugathasan and his co-authors use Danish national databases. They focus on the use (or lack of use) of cardioprotective medications, like statins, after MI. Interestingly, they find that when people with schizophrenia have cardioprotective medications, they can match the outcomes of those without mental illness.

Female doctor with the stethoscope holding heartIs heart health the way to address the gap?

In this week’s Reading, we consider the Kugathasan et al. paper, as well as the accompanying editorial. Then we consider the big question: what can be done?

DG

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Reading of the Week: How to Change Docs? Send Them a Letter. The New JAMA Psychiatry Paper on Prescribing

From the Editor

How do we get doctors to practice better medicine?

Here’s a simple idea: what if we send them a sternly written letter? In this week’s Reading, we consider a paper by Columbia University’s Adam Sacarny and his co-authors who did just that. Targeting primary care physicians who were heavily prescribing quetiapine (or Seroquel), they looked at the effects of letters written by government officials, comparing prescribing habits of these physicians with their peers. The result? In the new JAMA Psychiatry paper, they find that prescriptions of quetiapine dropped markedly.

nudge

A little nudge, better care?

The core of the idea is that a nudge – that is, the behavioural economic idea of a positive reinforcement and/or an indirect suggestion – can change outcomes. In this Reading, we consider doctors and nudges (and behavioural economics). We also look at a recent study on opioid prescribing, also involving letters.

DG

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Reading of the Week: Mental Illness & Crime Victimization – the New JAMA Psychiatry Paper

From the Editor

After the mass shooting on Toronto’s Danforth, mental illness has been much in the news. The Canadian Psychiatric Association went so far as to warn against stigmatizing those with mental illness.

Despite stereotypes, studies show that people with mental disorders are more likely to be victims of violent crime rather than perpetrators. That said, the literature is light on how much crime patients experience, and the diagnoses of these patients.

This week, we look at a new paper just published by JAMA Psychiatry. Drawing on databases from Denmark, the University of New South Wales’ Kimberlie Dean and her co-authors consider crime (including violent crime) in a cohort study involving more than two million people. What do they find? Those with mental illness are much more likely to be victims than the general population.

gettyimages-126140612_superDenmark: old buildings and not-so-old data

In an accompanying editorial, Duke University School of Medicine’s Jeffrey W. Swanson and Charles M. Beldendiscuss the paper, and contrast it with American data. Their piece begins memorably: “The media-driven notion that mentally ill people pose a danger to others appears to be encrusted like a barnacle on the concept of mental illness submerged in the public mind.” They also weigh in on difference in rates of violence between Denmark and the United States.

DG

 

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Reading of the Week: Common Medications and the Link to Depression – the New JAMA Psychiatry Paper

From the Editor

“Many may be surprised to learn that their medications, despite having nothing to do with mood or anxiety or any other condition normally associated with depression, can increase their risk of experiencing depressive symptoms, and may lead to a depression diagnosis.”

JAMA Psychiatry papers rarely make international news. A new paper by the University of Illinois’ Dima Mazen Qato (who is quoted above) and her co-authors has, however. In looking at prescribed drugs like proton pump inhibitors, they find that many are linked to depressive symptoms. One online news report began with the headline: “37% of US Adults Are Using Common Meds They Don’t Realise Could Cause Depression: It’s even worse if you use several medications together.”

It’s a big study with a big result. For the record, a couple of patients have already brought up the findings with me.

statin_2819148bMany small pills, one big problem?

What to think and how should it affect patient care? In this week’s Reading, we consider the paper.

DG

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