TagLancet Psychiatry

Reading of the Week: Is ‘New’ Overrated? Antipsychotics in the Real World

From the Editor

Is new better?

You may be reading this on an iPhone 7, having driven to work this morning in a 2017 Hybrid Prius. So should your patients be taking a medication that became available four-and-a-half decades ago – when people drove gus-gusling eight-cylinder Oldsmobiles and smartphones didn’t even exist in science fiction novels.

This week, we look at a just-published JAMA Psychiatry paper which promises to look at the “real-world” effectiveness of antipsychotics. The authors tapped Swedish databases to consider outcomes for nearly thirty thousand people with schizophrenia.

Sweden: elaborate welfare state, beautiful historic buildings, and – yes – rich databases

Spoiler alert: new wasn’t better. That is, newer antipsychotics tended to underperform clozapine and depot medications.

We also look at similar “real-world” work drawing from a Finnish database considering treatment of depression.

DG Continue reading

Reading of the Week: The Placebo Effect and Antidepressants

From the Editor

Is the placebo effect getting stronger with time?

image001Placebo pills – greater importance?

Since the first writings of English physician John Haygarth at the turn of the 19th century, the placebo effect is something well documented and well discussed – but not well understood. How can people respond to sugar pills and the like?

Even more oddly, the placebo effect seems to be changing with time, at least in terms of antidepressant medications. In a classic paper published about a decade and a half ago, Walsh et al. found that the placebo effect was getting more pronounced over the years. Dr. Timothy Walsh joked in a Washington Post interview that “[t]hey’re making placebos better and better.” Besides being an interesting finding, there are larger issues – start with the implications to drug development. After all, if the placebo effect is rising, it becomes more challenging to develop a drug that bests it.

Have things changed since the publication of the Walsh et al. paper?

In this week’s Reading, we consider the new Furukawa et al. paper. This study, which reviewed 250 plus randomized controlled trials that involved more than 26,000 patients and included unpublished data, found that the placebo effect isn’t increasing. Also in the Reading: an editorial commenting on the Furukawa et al. paper.

Please note – there will be no Reading next week.

DG Continue reading

Reading of the Week: Guest Contribution – Dr. David Goldbloom on Locked Doors and Hospitalizations

From a Contributing Editor, Colleague and Friend of the Editor

This week’s reading is a provocative companion piece to the recent review of efforts to reduce involuntary admission to hospital. It is the environmental expression of the legal deprivation of freedom of movement: the locked door. Locked doors have a powerful symbolic meaning in psychiatry; outpatients coming for elective consultations sometimes tell me they are afraid if they “say the wrong thing” that I will “lock them up”. Asylum superintendents carried large rings of keys that embodied power and control.

Locked doors, better outcomes?

Having spent half my career working on inpatient units, I am, like almost all of you, familiar with the locked doors that distinguish our wards from all others found in a hospital. And I know the reasons for their justification: prevention of elopement by people at risk of harm to themselves and others. And that prevention is intended to serve not only the patient and family but also the clinicians and the institution in terms of risk management. And yet…people do elope. Sometimes they return and sometimes they do not. Sometimes they attempt or complete suicide and sometimes they do not.

There is, as always, a tension between safety and risk, between freedom and protection, between autonomy and control. Locks are ubiquitous but not universal on psychiatric wards. What do we know about whether they make a difference? And what would be the ethically acceptable methodology for determining it?

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