TagThe Lancet Psychiatry

Reading of the Week: Cannabis for Mental Illness (CJP)? Also, Cannabidiol for the Cannabis Use Disorder (Lancet Psych) & Love on the Police (Globe)

From the Editor

“Should I take cannabis for my mental illness?”

Our patients ask this question – in our EDs, inpatient wards, and outpatient clinics. We shouldn’t be surprised. Cannabis is now legal, and private industry pushes the medicinal benefits of cannabis. But what does the literature say?

This week, we have three selections.

The first is a new Canadian Psychiatric Association position statement that considers cannabis and mental illness. Dr. Philip G. Tibbo (of Dalhousie University) and his co-authors systematically reviewed the literature. They found 29 RCTs, including for anxiety and psychotic disorders. “Use of cannabis or a cannabinoid product should never delay (or replace) more evidence-based forms of treatment.”

marijuana-candy-sizedMany products, little evidence?

But is there emerging evidence for cannabis? Tom P. Freeman (of the University College London) and his co-authors did a phase 2a trial using CBD to address cannabis use disorder, which is written up in The Lancet Psychiatry. “In the first randomised clinical trial of cannabidiol for cannabis use disorder, cannabidiol 400 mg and 800 mg were safe and more efficacious than placebo at reducing cannabis use.”

Finally, on a pivot, in the third selection, we consider an essay from The Globe and Mail. Rebeccah Love writes about her own experiences with psychosis and her recovery. She also considers whether police should be involved in mental health crises. “The image of a police officer – often a big white man with a gun – is interpreted as a threat, an agent of death, an oppressor.”

DG

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Reading of the Week: Depression Outcomes: What Matters to Patients (Lancet Psych)? Also, NYT on Mental Health Apps and Startup Culture

From the Editor

“US Food and Drug Administration accepts only three outcome measures as primary endpoints in phase 3 studies to support an indication for major depressive disorder: the Hamilton Depression Rating Scale, the Montgomery-Åsberg Depression Rating Scale, or the Children’s Depression Rating Scale.”

The editors of The Lancet Psychiatry make this point in in the August issue of that journal. Their concern: the FDA view is very narrow and confined to these three scales.

In the first selection, we look at a new paper from The Lancet Psychiatry. Dr. Astrid Chevance (of the Center for Epidemiology and Statistics Paris Sorbonne) and her co-authors consider depression outcomes. To understand different perspectives, they draw on three groups: providers, patients, and caregivers. For the record, the resulting paper is fascinating and includes outcome measures that aren’t captured by these three scales. We consider the paper and the editorial that runs with it.

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In the second selection – also on the topic of depression – Kashmir Hill and Aaron Krolik report for The New York Times on a popular therapy app. They note that Talkspace has good marketing and a growing client base. But should you recommend the app to your patients?

DG

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Reading of the Week: COVID & Serious Mental Illness (JAMA Psych); also, Mental Health Care (Lancet Psych) and Hospital Care (Neurosci Bull)

From the Editor

In a heavy moment, a colleague of mine observed that spring is finally here, but none of us can enjoy it. This comment is one of many made over these past weeks about our new life. Our businesses are closed; our elderly are hiding; our colleagues are on the front lines and at risk. And, yes, the simple pleasure of enjoying a spring day – the warmth in the air, the song of the birds – has been lost, at least for now.

This week’s Reading has three selections, and each touches on the intersection between the pandemic and mental health care. Our new life means new challenges as we attempt to deliver mental health care services.

In the first selection, we consider a paper on COVID and serious mental illness. In a JAMA Psychiatry paper, Dr. Benjamin G. Druss (of Emory University) writes: “Disasters disproportionately affect poor and vulnerable populations, and patients with serious mental illness may be among the hardest hit.”

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What is the role of mental health care during this pandemic? In the second selection, we consider a new Lancet Psychiatry editorial. The editors write: “Although the mental health field’s interest in trauma has greatly expanded in recent decades, our scientific understanding of trauma has lagged far behind, including our understanding of its definition and aetiology, and, importantly, of how to effectively intervene.”

Finally, in the third selection, we look at a letter by Dr. Yuncheng Zhu (of Shanghai Jiao Tong University School of Medicine) and his co-authors. They discuss inpatient care and the risk and prevention of infection. “Panic is inevitable among patients and medical staff and timely mental health care for dealing with the novel coronavirus outbreak is urgently needed.”

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Reading of the Week: COVID-19 & Mental Health (Lancet Psych); Also, Depression & Online Mindfulness (JAMA Psych) and Help for Youth (Globe)

From the Editor

Earlier this week, a patient mentioned that, until recent events, he hadn’t heard of Wuhan, China. Today, it would seem, we are all familiar with this city.

Much reporting and commentary have focused on infections and deaths. But what are the psychiatric implications of the outbreak? This week, we have three selections. In the first, we look at a short and thoughtful paper from The Lancet Psychiatry that tries to answer this question. Dr. Yu-Tao Xiang (University of Macao) and his colleagues note: “In any biological disaster, themes of fear, uncertainty, and stigmatisation are common and may act as barriers to appropriate medical and mental health interventions.”

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In the second selection, we review a new study that uses an online mindfulness-based cognitive therapy aimed at patients with residual depressive symptoms, involving 460 participants. Zindel V. Segal (University of Toronto) and his co-authors find that the intervention “resulted in significant improvement in depression and functional outcomes compared with [usual depression care] only.”

And in the third selection, Drs. Pier Bryden and Peter Szatmari, both of the University of Toronto, discuss their new book. They open their Globe essay with a simple question: “What can I do to help my child?”

DG

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Reading of the Week: Is CBD Useful for Mood Disorders? The New CJP Paper. Also, Peer Support and Online CBT (Psych Services) & the Art of Daniel Regan

From the Editor

This week, we have three selections.

With the legalization of cannabis, many big claims haven been made about the medicinal aspects of this drug – including by industry. Cannabidiol, or CBD, is often touted as being helpful yet non-addictive (in contrast to THC, the more famous cannabis molecule). In the first selection, UBC’s Jairo Vinícius Pinto and his co-authors consider cannabidiol in the treatment of mood disorders, reviewing the existing literature. Does CBD help? “The methodology varied in several aspects and the level of evidence is not enough to support its indication as a treatment for mood disorders.”

In the second selection, the University of Michigan’s Paul N. Pfeiffer and his co-authors try to improve depression treatment outcomes by combining a cutting-edge psychotherapy (CBT, delivered by computer) with a not-so-cutting edge approach (peer support). They conclude that the intervention “should be considered as an initial treatment enhancement to improve effectiveness of primary care treatment of depression.”

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And in the third selection, we look at the work of artist Daniel Regan, which is featured on the front cover of February issue of The Lancet Psychiatry. He notes: “I really think if I hadn’t gone on to study photography, I wouldn’t be here.” Featured above is “Abandoned,” part of a series of photos from Victorian-era asylums in the UK.

DG

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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.

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

DG

 

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