Note from the Editor
In most Readings of the Week, a paper or essay is selected and then discussed in the commentary.
This week, we try something a bit different: a few pieces are selected and briefly discussed. We can cover more ground this way, and consider some pieces that may not have warranted a “full” Reading, but are still worthy of consideration.
Selection 1: “How to Help Save the Mentally Ill From Themselves”
Norman J. Ornstein, The New York Times, 17 November 2015
My older son, Matthew Ornstein, died at age 34 on Jan. 3 from carbon monoxide poisoning. It was accidental — he fell asleep in a tent with a propane lantern — but his death was shaped by a lack of judgment driven by a 10-year struggle with mental illness.
So begins a moving and tragic story all too familiar to us in mental health – the story of a person who is full of promise and potential, and then whose life is touched by a psychiatric disorder.
Writing in The New York Times, political scientist Norman Ornstein talks about his son’s struggle with illness and untimely death. Matthew, who had been a national high school debating champion, was different after his psychotic break: “he kept a long beard, did not cut his hair and smoked heavily.”
Like many family members of those with mental illness, Ornstein pines for a legal framework that would make it easier for such patients to get the care they need. Ornstein embraces a bill currently before Congress. The core of the Murphy-Johnson bill: empowered assisted outpatient treatment (in Canada, referred to as community treatment orders).
Ornstein doesn’t review the literature, which is mixed on AOTs. Consider the recent OCTET study published in The Lancet Psychiatry, drawing on UK data over 36 months and finding no real impact on outcomes. But stronger AOT laws, like those in North Carolina and New York, seem to be more effective, though the data set is early (Dr. Marvin Swartz presented lucidly on this at the recent IPS: Mental Health Conference in New York).
Of course, leaving aside the question of effectiveness, there is the larger question: are AOTs too coercive? Ornstein makes his case well. You can read the essay and draw your own conclusion.
The piece can be found here:
Selection 2: “Clinical Practice: Generalized Anxiety Disorder”
Murray B. Stein and Jitender Sareen, The New England Journal of Medicine, 19 November 2015
A 46-year-old married woman presents with insomnia, headaches, muscle tension, and back pain. She describes a long-term pattern of worrying about several life situations, including health, finances, and her job, and she notes increased anxiety associated with her teenager’s leaving home to attend college. She drinks alcohol daily to reduce the tension and help her sleep. In reviewing her history, you note that she has visited your office many times over the past year because of physical symptoms. What do you advise?
So begins a paper on Generalized Anxiety Disorder in The New England Journal of Medicine.
Historically, The New England Journal of Medicine hasn’t given much attention to psychiatric illness. (In essays marking its 200th anniversary, the NEJM lumped psychiatry with neurology into a short piece – the medical journal equivalent of tokenism.) That’s changing, and I note one of the most interesting psychiatric papers this year was published in this journal (“Trends in Mental Health among Children and Adolescents,” by Olfson et al., considered in an earlier Reading).
This paper gives an overview of the management of GAD. It notes the high prevalence of this disorder – “the estimated prevalence of generalized anxiety disorder in the general population of the United States is 3.1% in the previous year and 5.7% over a patient’s lifetime” and notes “particularly prevalent in primary care settings, where it occurs among 7 to 8% of patients.” The article discusses comorbidities and complicating factors, before moving into a practical approach to assessing and managing these anxiety patients.
The paper isn’t earth-shattering, but gives a solid review of the literature and offers up some useful suggestions. The article recommends psycho-education and lifestyle modifications, in addition, to pharmacology and psychotherapy. In the case of this 46 year old woman, alcohol is clearly a complicating factor and needs to be addressed. The NEJM’s Clinical Practice series is carefully edited and the writing here sparkles.
One take-away point? The authors recommend incorporating a scale into practice; to that end, they focus on the Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire “which take only minutes for the patient to complete, can be used to screen for the disorder as well as to longitudinally monitor outcomes.” Mental health clinicians are often reluctant to use scales; most clinics use scales infrequently if at all. A NEJM endorsement might give us a collective pause for thought.
The paper can be found here:
Selection 3: “Putting Housing First: The Evidence and Impact”
Paula N. Goering and David L. Streiner, The Canadian Journal of Psychiatry, November 2015
Until recently, there was little empirical evidence regarding the most effective intervention for a very vulnerable population, adults who are homeless with a mental illness. Many programs existed, but they were supported mainly by descriptive studies or nonexperimental designs. This began to change about 15 years ago, following the introduction of a novel and somewhat controversial program, Pathways to HF [Housing First]. Unlike more traditional housing approaches that first require clients to engage in treatment and stop abusing drugs and alcohol, the HF approach, true to its name, offers people who are homeless their own scattered-site apartments, without any preconditions. Since that time, there have been numerous RCTs demonstrating its effectiveness and cost-effectiveness.
So opens an editorial in last month’s The Canadian Journal of Psychiatry.
I’ve said it before and I’ll say it again: The Canadian Journal of Psychiatry is so interesting under new editor Dr. Scott Patten. This month’s issue is focused on housing and Housing First – a great topic, and one thoughtfully explored. Some of the most interesting work in the field has been done here in Canada, led by the Mental Health Commission of Canada, yet has received surprisingly little press here. (Consider that the JAMA paper by Stergiopoulos et al. was written up in the Washington Post and other newspapers, but not by a single Canadian newspaper.)
This editorial summarizes well the Canadian experimentation with Housing First. The authors note: “This study involved 2148 people in 5 cities across Canada, randomized to receive either HF plus either assertive community treatment (for those with high needs) or intensive case management (for those with moderate needs), rather than TAU.”
Goering and Streiner also touch on the backstory of this remarkable project – an external reviewer expressed hesitation on the original program design since: “very large projects rarely tap the richness of their data or publish enough papers to justify their expense.” At Home/Chez Soi has been sparked over 80 papers and a fundamental re-think of the homeless problem. Nice.
Goering and Streiner go on to explore some lessons learned. I’ll draw attention to one of their excellent points: the importance of tying economics into an analysis. For better and for worse, public policy in the 21st century is at least partly driven by dollars and cents issues. As clinicians, we often forget this.
Of course, the November issue of The Canadian Journal of Psychiatry offers more than just this editorial. The two papers on Housing First also are well worth reading. Hopefully this summary will entice you to pick up the journal.
The editorial can be found here:
With the success of Housing First, and in light of the national effort to bring in and house 25,000 Syrian refugees, this National Post essay asks if our next national effort could be ending homelessness.
By way of disclosure, I’m sometimes – though not always – impressed by the essay’s author.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.