From the Editor
This week – like last week – we pick a few interesting readings to consider.
This week’s selections: a chef and his addiction, a major new JAMA paper on resident physicians and depressive symptoms, and a big paper from BMJ comparing CBT and meds for depression.
Next week: the best of the year (the annual tradition). Suggestions are welcome for the best papers of 2015.
“Three years after his mysterious disappearance, former Langdon Hall chef breaks his silence”
Mark Schatzker, The Globe and Mail, 1 December 2015
On the night of Dec. 28, 2012, Jonathan Gushue, one of Canada’s most decorated chefs, disappeared. He finished a dinner service at Langdon Hall that included pickerel in crème fraîche with black radish and black-pepper honey, got into his car and never arrived home.
No one, including Gushue’s wife, his sous chefs and his friends, knew what had happened to the 41-year-old father of three who, just two years earlier, had put Langdon Hall, in Cambridge, Ont., on the prestigious San Pellegrino World’s Best Restaurants list. As the chef’s disappearance made headlines from coast to coast, mysterious details began leaking out – his phone was found at an upscale Toronto hotel – but nothing more.
Thirteen days later, Gushue was found and reported safe. Several months later, he left Langdon Hall, then vanished from public life.
Gushue had it all – a young family and a soaring career. He also had alcoholism.
In this interview, he talks about his struggle with addiction.
He describes the hours after the disappearance: a DUI, a binge, an impulsive decision to take a train to Montreal. And then, he reports: day after day of drinking. Gushue was a celebrity chef and his life was dominated by his addiction.
“You’re restless and irritable. It physically hurts – in your wrists, your shoulders, your elbows, your back. You wake up every single day saying, ‘I’m never going to drink again.’ By 3 p.m., you’ve changed your mind. ‘Maybe I can have just one …’”
He also talks movingly about his sobriety and recovery.
Three years ago, Gushue vanished. Today, he is very visible and on the cusp of opening up two new restaurants in Waterloo.
The piece can be found here:
“Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis”
Douglas A. Mata et al., JAMA, 8 December 2015
Studies have suggested that resident physicians experience higher rates of depression than the general public. Beyond the effects of depression on individuals, resident depression has been linked to poor-quality patient care and increased medical errors. However, estimates of the prevalence of depression or depressive symptoms vary across studies, from 3% to 60%. Studies also report conflicting findings about resident depression depending on specialty, postgraduate year, sex, and other characteristics. A reliable estimate of depression prevalence during medical training is important for informing efforts to prevent, treat, and identify causes of depression among residents.
So begins a paper on depression and depressive symptoms in residents, just published in JAMA.
Residency is a demanding time – one of stress and doubts and seemingly endless amounts of work. Is residency a time of depression? This paper seeks to answer that question
To that end, the authors looked at more than 50 papers over five decades on this topic. Their conclusion: depressive symptoms and depression are highly common among residents.
They started with more than 3,000 papers, and, using various criteria and two evaluators, drilled down to 54 articles, of which 31 were cross-sectional and 23 longitudinal. The studies covered 17,560 individuals. Many – but not all – were from North America (in fact, one study was from Africa and another from South America). Depressive symptoms were measured differently in different studies. Three studies, for example, used structured interviews; the majority used scales but the scales varied (BDI, CES-D, SDS, HANDS) and the interpretation of the scales varied, too.
The paper considered the prevalence of depressive symptoms and depression in this population (see figure below). The paper also considered level of training and evolution over time. The findings? Junior residents were no more at risk than more senior residents. Now, the bad news: over time, the problem seems to be getting worse.
The paper concludes:
In this systematic review, the summary estimate of the prevalence of depression or depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2% depending on the instrument used, and increased with time. Further research is needed to identify effective strategies for preventing and treating depression among physicians in training.
At several levels, I’m excited about this study. Start with the fact that it is published in JAMA (!) and that the whole issue is dedicated to medical education. (!) This paper asks a relevant question – how prevalent are depressive symptoms in residents? – and seeks a meaningful answer. (!!)
But I’m also a bit cautious. The authors did a vast search, covering many papers and including 17,000+ people over a huge time period. The end result: a wide range (20.9% to 43.6%); glance again at the blue squares in the above figure. Part of the issue: they drew on studies that looked at depressive symptoms (measured on scales) and depression (diagnosed on clinical interviews) – the former, obviously, is going to be more common than the latter, and the mix of the two helps explain the wide range found.
But perhaps that’s being too concrete. The Mata et al. paper does a great service, drawing attention to an issue that’s relevant to a generation of psychiatrists-in-training. As CAMH’s Dr. David Goldbloom observes: “it is a sobering reminder that the white coat is not Kevlar against the illnesses we treat, and our professional culture still has a long way to go in recognizing, accepting and supporting that we get sick, too.”
The paper can be found here:
“Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis”
Halle R. Amick et al., BMJ, 8 December 2015
Major depressive disorder is the most prevalent and disabling form of depression, affecting more than 32 million Americans. In any given year, nearly 7% of the American adult population has an episode of major depressive disorder, but only about half of these people seek care. For patients who do obtain care, only 20% receive adequate treatment. Based on available evidence based guidelines, this would include either drug therapy (at least two months of an appropriate drug for major depressive disorder plus more than four visits to any type of physician) or psychotherapy (at least eight visits with any healthcare professional lasting an average of at least 30 minutes).
So opens a new BMJ paper that considers a relevant question: meds vs. CBT for depression? (And, for the record, the “only 20% receive adequate treatment” comment is haunting.)
Noting that the majority of patients will be treated through primary care, and noting the problems of drug therapy in that clinical setting (about one in five patients don’t even fill their prescription for antidepressants), Amick et al. consider a head-to-head comparison of CBT and second generation antidepressants to better understand treatment options. Their reasoning: “primary care physicians require high quality evidence of the comparative effectiveness of the available treatments to select and manage the best options for their patients.” Some research has already been done in this area, but the authors bring something new to the table with a focus on second generation antidepressants.
They start their review with roughly 8,000 papers, and then filter down to 11 randomized controlled trials in 14 papers, covering 1,511 patients. The second generation antidepressants were: fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, citalopram, and escitalopram. CBT was defined broadly; in one study, it was problem solving therapy.
The results were considered for response (see figure below), remission and a change in HAM-D 17.
Second generation antidepressants (SGA) versus cognitive behavioral therapy (CBT): response
What did they find? They conclude:
For second generation antidepressants compared with cognitive behavioral therapies, the available evidence based on 11 randomized controlled trials with 1511 patients suggests no difference in treatment effects of second generation antidepressants and cognitive behavioral therapies, either alone or in combination, although our conclusions are tempered by small numbers and mostly low strength of evidence. Relative risks of remission and response were nearly identical for monotherapy comparisons (0.98 and 0.91, respectively) and for second generation antidepressant alone versus combination (1.06 and 1.03, respectively). Adverse event outcomes were also clinically and statistically similar for all comparisons.
This paper is smart and timely and – bonus – it comes with an excellent editorial that is worth reading. (The editorial is also very Canadian; the authors – Drs. Mark Sinyor, Mark Fefergrad, and Ari Zaretsky – are all psychiatrists working out of Toronto’s Sunnybrook Health Sciences Centre.)
There is much here to like, including comments on research and biomarkers, but this comment is particularly noteworthy:
More intriguing is the signal from some trials that CBT could be associated with a lower risk of relapse than antidepressants, once treatment stops. This finding, although statistically uncertain, aligns with the orientation of CBT towards training patients to be their own therapists. Given high rates of relapse in major depressive disorder, this is a meaningful finding that contributes to an established literature showing CBT to be an effective treatment for preventing recurrence of depression.
The paper ends by calling for more research. Many papers end with this suggestion but, given the incredible clinical relevance of the core question around the treatment of depression, this call carries great weight.
The paper can be found here:
The BMJ Editorial can be found here. Again, it’s well worth reading.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.