TagThe Lancet Psychiatry

Reading of the Week: Cannabis for Mental Illness: Popular and Promoted by Industry – But Evidenced? The New Lancet Psychiatry Paper

From the Editor

“It’s the only thing that helps with my anxiety.”

It’s closing in on midnight, and the ED patient I’m seeing is adamant that cannabis has helped him with his generalized anxiety disorder. My day has been long, but I choose to push a bit. Why cannabis? He notes how challenging it was to access mental health care. When he finally did see a psychiatrist, he feels he was offered a prescription after only a few minutes, and the trial of sertraline left him feeling more anxious. Cannabis, in contrast, helps him sleep and takes an edge off the anxiety.

More and more, our patients are talking up cannabis. Google “medical marijuana,” and there are over 166 million hits. And, yes, industry has noticed. There are a half a dozen cannabis dispensaries within a 10-minute walk from the CAMH ED, where I work. In the spring, a former prime minister joined the board of Acreage Holdings, a marijuana company, explaining that he was excited by the potential of cannabis to treat PTSD.

But is any of this evidence based?

This week, we look at a new paper from The Lancet Psychiatry. University of New South Wales’ Nicola Black and her co-authors do a systematic review and meta-analysis. Considering a variety of psychiatric disorders including depression, they draw on the literature to try to understand the effectiveness and safety of cannabinoids. “There is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, post-traumatic stress disorder, or psychosis.”

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We consider this big paper on the hot topic.

We also discuss the comment paper that accompanies this study. Yale University’s Deepak Cyril D’Souza writes: “The process of drug development in modern medicine is to first demonstrate efficacy and safety in clinical trials before using the drug clinically. With cannabinoids, it seems that the cart (use) is before the horse (evidence).” For the record, I don’t think Acreage Holdings will be distributing either paper to shareholders.

Please note that there will be no Reading next week.

DG

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Reading of the Week: Should Medical Education Stay in Its Lane? Goldfarb Argues Yes; Also, Problems in Youth (BJP) & Medical Memoirs (Lancet Psych)

From the Editor

What’s the best way of training future doctors?

Medical education has changed much over the years – schools across the country embraced the McMaster model, then cooled to it; efforts have been made to revisit core curriculum topics and add in more timely ones.

In the first selection, the University of Pennsylvania’s Dr. Stanley Goldfarb – a former associate dean of curriculum at the Perelman School of Medicine – bemoans the state of medical education. Controversially, he argues in The Wall Street Journal: “Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.”

Is he right? We discuss the essay and responses to the essay.

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In the next selection, we look at a new British Journal of Psychiatry paper. Drawing on a large dataset, the University College London’s Jessica Deighton and her co-authors study the rate of psychiatric problems among youths. “Findings reported here indicate the scale of mental health problems in children across many schools in England is much higher than previous estimates…”

And in the third selection, Dr. Linda Gask, a British psychiatrist, considers autobiographies written by physicians. “These stories can, in turn, inspire, impress, inform, engage, and even shock through the sharing of personal conflict and confessions…”

DG

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Reading of the Week: Your Patient’s Suicide – the New BJP Bulletin Paper; Also, Langford on Suicide and His Journey

From the Editor

It’s the phone call that we all dread – the call from the family or the coroner, explaining that your patient has died, likely by suicide.

At some point, we all receive that call.

Obviously, we think about the impact of suicide on families. But what impact does suicide have on us clinicians? In this week’s Reading, we consider the new BJP Bulletin paper on suicide and psychiatrists. Dr. Rachel Gibbons, an English psychiatrist, and her co-authors try to answer this question with a survey. Among their findings: a quarter of psychiatrist has considered a career change after a patient’s suicide.

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In this week’s other selection, in a Lancet Psychiatry paper, Dr. Alex Langford, also an English psychiatrist, talks about the impact that suicide has had on his life.

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.”

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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: ECT & Dementia – the New Lancet Psychiatry Paper

From the Editor

It’s effective but is it really safe?

Electroconvulsive therapy (ECT) remains controversial 80 years after its first clinical use. At the heart of the controversy: its effects on cognition. Some wonder about the possibility that ECT could be linked to dementia.

Despite the strong concerns expressed over the years, relatively little research has been done on the possible connection between ECT and dementia. This week, we consider a new paper by the University of Copenhagen’s Merete Osler and her co-authors. In this Lancet Psychiatry study, they tap Danish national databases, finding no connection.

old-man-in-sorrow-vincent-van-goghvan Gogh’s Old Man in Sorrow – in need of ECT?

In this Reading, we look at the paper and consider some recent work on ECT.

DG

 

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Reading of the Week: MDMA for PTSD – the New Lancet Psychiatry Paper; Is the Club Drug Really a Breakthrough Drug?

From the Editor

“When it kicked in, it was like an epiphany. I could see all these things from combat I was afraid to look at before, and I had a totally new perspective. I relived the parts of me I had lost. I realized I had viewed myself as a monster, and I was able to start to have some compassion for myself. It was a turning point, and for the next year I continued to get better.”

In a recent article on MDMA (often called Molly or Ecstasy), The New York Times quotes U.S. Marine Nigel McCourry, who has PTSD, talking about his experience taking the drug. So – is there a role for MDMA in the treatment of PTSD? In a new paper published in The Lancet Psychiatry, researchers seem to find there is. In the study, therapy sessions were enhanced with MDMA; after the sessions, 68% of the patients no longer met the clinical criteria for PTSD.

The paper has gained international attention. The New York Times covered it (and quoted McCourry). So did Global News with an online article headlined: “‘Party drug’ MDMA touted as breakthrough therapy for PTSD patients.” The Independent’s story begins: “MDMA ‘cures’ sufferers’ post-traumatic stress disorder in a few weeks during study.”

mdma-pills-ecstasy-600x500MDMA: Colourful pills – helpful pills?

In this Reading, we consider the paper behind the headlines, and the Comment piece that accompanies it. We also consider what to tell patients if they ask about MDMA for PTSD.

DG

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Reading of the Week: David Goldbloom on Research & Clinical Practice

 From a Contributing Editor, Colleague, and Friend of the Editor

This week’s selection is a brief paper with long implications. For all of us clinicians who turn to the peer-reviewed literature (either directly or through the filter of Reading of The Week) for guidance on how to help our patients, this paper is worth a read.

It is impossible to stay current on the treatment research results that emerge daily, and we look to those randomized controlled trials published in high-impact peer-reviewed journals for evidence of what works for people with the diagnoses that we find ourselves addressing in the office, the clinic, the ER or the inpatient unit. But who are those patients who sign consent forms to take part in these studies, and how much do they resemble the people sitting across from us?

Great clipboard but relevant to clinical work? 

– David Goldbloom, OC, MD, FRCP(C)
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Reading of the Week: Is AVATAR Therapy a Breakthrough for Those Who Hear Voices? The New Lancet Psychiatry Paper

From the Editor

“The voices won’t leave me alone.”

A patient made this comment to me recently. And it’s an experience many patients have had. Despite medications and follow up, the voices continue to be problematic.

This week, we look at a new paper from The Lancet Psychiatry which considers a novel approach: AVATAR therapy.

In this study, patients who experienced auditory hallucinations created a computerized simulation (avatar) of the voice they most wanted to influence, including what the voice said, how it sounded, and how the “entity” with the voice looked like. Patients, working with a therapist who controlled the avatar, then had therapy sessions in which they could talk to it. Patients were compared on several measures to those who only received supportive therapy.

The paper has received significant media attention including CNN and BBC.

1124avatar2The Face of the Voice – and a Step Toward Healing?

Spoiler alert: the therapy helped – at least initially – but the results are complicated. (And, no, this isn’t “fake news,” to borrow a phrase from an American politician.)

In this Reading, we consider the paper and its findings.

DG

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Reading of the Week: Better Sleep, Less Psychosis? The Freeman et al. Study on Sleep & CBT

From the Editor

If students sleep better, are they less likely to have mental health problems like paranoia?

In this week’s Reading, we look at a new study from The Lancet Psychiatry. In this single-blind, randomized controlled trial, Oxford professor Daniel Freeman et al. consider students from 26 universities with insomnia, assigning them CBT (offered over the internet) or the usual care.

Spoiler alert: the students with CBT did better.

Sleep: good for babies, teddy bears, and students

In this Reading, we review that paper and consider the broader implications.

DG

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Reading of the Week: I Can’t Sleep – Insomnia, Part II of II

From the Editor

It’s one of the most common patient complaints: I can’t sleep.

What many of our patients aspire to…

Insomnia affects 6 to 10% of the population. It’s a common problem – and often chronic. But are we mishandling insomnia?

In a two-part, two-week series, we look at the latest in insomnia research.

Last week. Fewer Pills, More Therapy. The new Clinical Practice Guidelines.

This week. Insomnia, Is There an App for That? The GoodNight Study.

This week, turning to a new paper from The Lancet Psychiatry, we consider an online insomnia program to prevent depression relapse.

DG Continue reading