TagKurdyak

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: Dr. Norman Doidge’s Essay on Psychotherapy, and Responses

From the Editor

Earlier this month, the University of Toronto Department of Psychiatry held a one-day conference on the Future of Psychotherapy. Speakers included Harvard University’s Dr. Vikram Patel, who has worked to expand access to care in low-income countries, and the University of Oxford’s Dr. David Clark, who has co-led the world’s largest program to improve access to evidence-based psychotherapy.

Here in Ontario, the future of psychotherapy will be influenced by several factors, including government payment. The day after the conference, when Drs. Patel and Clark were travelling home, a long essay ran in The Globe and Mail discussing a provincial government proposal to limit physician compensation for psychotherapy to 24 sessions a year; currently, there are no restrictions on the number of psychotherapy sessions billable per patient, allowing public funding of psychoanalysis. Dr. Norman Doidge, a psychoanalyst with affiliation with both the University of Toronto and Columbia University, argues strongly against the proposal. Psychiatry, he writes, will be left with “diagnose, and adios” – or worse, “diagnose, overdose, and adios.” Dr. Doidge – a bestselling author who has written on topics as diverse as the Palestinian conflict and brain plasticity, and who wrote the introduction to Jordan Peterson’s popular book – puts forward a well-crafted case.

terapia-kxsb-u11004258755405xyb-1024x576lastampa-itThe past of psychotherapy – but not its future?

In this Reading, we consider Dr. Doidge’s essay and some responses to it.

DG

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Reading of the Week: How to Improve Depression Treatment? Cuijpers in JAMA. Also, Kurdyak on Access & Goodman on Mental Health Screening for Docs

From the Editor

This week, we consider three provocative but thoughtful essays.

In the first selection, Vrije Universiteit Amsterdam’s Pim Cuijpers – a highly published researcher in depression – wonders what needs to be done to improve depression outcomes. In this JAMA paper, he notes the importance of the task: “One estimate suggests that approximately 30% of patients with depressive disorders have a chronic course with limited response to treatment.”

ketamine-a-miracle-drug-for-depression-or-not-rm-1440x810Is ketamine a possible breakthrough for depression? Cuijpers ask.

In the second selection, the University of Toronto’s Dr. Paul Kurdyak considers how to address the shortage of psychiatrists – and notes, in this healthydebate.ca essay, that the problem is more complicated than some would suggest; he argues that the supply of psychiatrists across Ontario has little impact on access because of practice styles.

Finally, in the third selection, Columbia University’s Matthew L. Goldman and his co-authors note that doctors are screened for TB. They ask: “Should physicians also be screened for mental health conditions such as depression or burnout?”

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: Mental Health Care – Doing Bad, Feeling Good? The Hayes et al. Study

From the Editor

Greetings from Ottawa. This morning, the Canadian Psychiatric Association’s 67th Annual Conference opens here. And the agenda looks great, and includes the release of the new Canadian guidelines for the treatment of schizophrenia.

It’s difficult not to feel upbeat, as people from coast to coast to coast gather to discuss new findings and new ideas on problems like refractory depression and chronic pain and, yes, schizophrenia. And this is a great time to be involved in mental health care – as stigma fades and societal recognition grows.

But how are we doing in terms of actual outcomes? This week, we look at a new British Journal of Psychiatry paper. Hayes et al. consider mortality for those with severe mental illness and the rest of us. Unfortunately, the authors find that the mortality gap has grown with time.

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Ottawa: Host city of this year’s CPA Annual Conference

In this Reading, we review the paper and an editorial, and consider the larger context.

DG

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Reading of the Week: Schizophrenia & Diabetes: The Gap in Care; Also, Swedish Health Care

From the Editor 

“The pain in my feet. It’s killing me.”

That’s what John told me when I asked him what he needed help with. It’s not quite the answer I thought he’d give – John has schizophrenia and he has significant side effects from his medications. But, like many people with mental illness, he also struggles with physical illness (diabetes and the accompanying neuropathy).

Many of our patients have both physical and mental illnesses. When faced with these twin challenges, how do they fair?

In this week’s first selection, we look at a new paper that considers people with schizophrenia and diabetes. The study authors find a significant gap between the care received by those with and without mental illness.

insulinAn old drug, an old illness, and a big problem for those with mental illness

In our second selection, drawing from a lively blog written by medical student Ali Damji, we look at Swedish health care.

DG
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Reading of the Week: Pushing Past the Headlines – Substances & Health Services, and Medically Assisted Death & Cost Savings

From the Editor

It makes sense that those with substance use problems and mental illness consume more health resources – but how much more? As Canadians opt for medical assistance in dying, what will the impact be on health spending?

Readings don’t necessarily follow a theme. But this week, we push past newspaper headlines to consider two topical issues in more detail, tapping the latest in the literature.

Pushing past the headlines

In the first paper, Graham et al. consider health costs and utilization for people with mental health and/or substance use problems. Spoiler alert: these individuals are much more likely to use health services, resulting in higher costs. That’s not exactly a surprise, but Graham et al. provide a detailed analysis in an area that has been understudied.

In the second paper, drawing from Dutch data, Trachtenberg and Manns estimate the savings from medically assisted death.

Both papers are timely. Both reach interesting conclusions.

DG Continue reading

Reading of the Week: The Best of 2016 (and a Look Ahead to 2017)

From the Editor

It’s a Reading of the Week tradition that we end the year by considering the best of the previous 12 months.

And this year we have had great material to consider. Readings were drawn from diverse publications, including journals, but also newspapers and magazines; one Reading was a speech given by the Prime Minister of the United Kingdom. (On the rich diversity of material, I made a similar comment last year.)

If once no one seemed to discuss mental illness, today these issues are being talked about.

But instead of just looking back, let’s take a moment to look ahead.

For those of us concerned about mental health services, 2017 looks like it will be a great year.

Consider:

· Though the provinces and the federal government failed to make an historic deal in 2016 that would invest in mental health services, federal and provincial ministers of health all agree that mental health needs to be a priority, and some type of deal is likely to happen.

· In 2016, Starbucks Canada made headlines for its investment in mental health benefits for employees; it’s highly likely that other companies will follow this lead in the coming months.

· In the past year, more people spoke out about their mental health problems, including a famous singer and an Olympic swimmer; in 2017, more people will find their voice and share their stories.

So – Happy New Year.

Thanks to all those who made suggestions for Readings. And thanks to Dr. David Goldbloom for his three guest contributions, as well as to my father and to my wife for their editing.

There will be no Reading next week.

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Reading of the Week: First Episode Psychosis and Access – The Anderson-Kurdyak Paper, and More

From the Editor

“If your son or daughter had cancer or diabetes, do you think it would be reasonable for them to wait? I don’t think it’s any different for mental illness.”

Access. It’s one of the biggest problems with mental health services.

How big is the access problem? What can be done about it?

This week, we consider a new paper looking at access and first episode psychosis. Dr. Paul Kurdyak, a CAMH psychiatrist and a program lead with the Institute for Clinical Evaluative Sciences, made the above comment to the CBC when discussing this new paper. In it, Kelly Anderson and Dr. Kurdyak find that 40% of patients didn’t receive physician follow-up in the month after diagnosis. Imagine – tying back to Dr. Kurdyak’s comment – if 40% of young patients with leukemia didn’t have physician follow-up in a month after their cancer diagnosis.

We also look at the discussion around a new federal-provincial accord with an op ed written by Michael Wilson, the chair of the Mental Health Commission of Canada – particularly timely as the ministers of health met this week with an eye on a new accord.

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Reading of the Week: Kurdyak’s New Paper on Access

From the Editor

As medical school classes have grown, the supply of physicians has increased across the country. Has this helped address access issues in psychiatry?

How have practice patterns changed over time?

This week’s Reading seeks to answer some basic and important questions around physician supply and access in psychiatry. Following up on a major paper written in 2014, Kurdyak et al. have written another important and relevant paper.

The long and the short of it: there are significant problems with access – and they aren’t getting any better with time.

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