Author: David Gratzer

Reading of the Week: Xylazine – the New NEJM Paper; Also, Probiotics for Depression (JAMA Psych) and the New Drug Crisis (Nat Affairs)

June 29, 2023 /

From the Editor

Is xylazine the new fentanyl?

In the first selection, Dr. Rahul Gupta (of the University of Pennsylvania), who serves as the US Director of National Drug Control Policy, and his co-authors write about xylazine in The New England Journal of Medicine. They describe the emergence of this medication, intended for veterinarian uses, as a substance of abuse. They note its presentation and ask research questions. “Our goal is for the designation of xylazine as an emerging threat and subsequent actions to begin to address this threat before it worsens and undermines efforts to reduce illicit fentanyl use in the United States.” We consider the paper and its implications.

In the second selection, from JAMA Psychiatry, Viktoriya L. Nikolova (of King’s College London) and her co-authors look at probiotics – an area of increasing interest for those with mood and anxiety problems. They report on the findings of a small RCT involving people with depression who took an antidepressant but had an incomplete response. “The acceptability, tolerability, and estimated effect sizes on key clinical outcomes are promising and encourage further investigation of probiotics as add-on treatment for people with MDD in a definitive efficacy trial.”

And in the third selection, Charles Fain Lehman (of the Manhattan Institute) comments on the new drug crisis in a long essay for National Affairs. Lehman notes the rise of the synthetic agents (think fentanyl replacing heroin) and its impact on people, particularly in terms of overdoses. “Today’s drug cycle is different from previous ones, measured not just in the number of people addicted, but the number dead. Reducing the growth of that figure, now more than ever, is a vital task for policymakers to undertake.”

DG

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Reading of the Week: IPT for Depression in Pregnancy – the New JAMA Psych Paper; Also, Treating Opioid Use (JAMA) and Substance Ed for Docs (Wash Post)

June 22, 2023 /

From the Editor

Prenatal depression affects two: the mother and her fetus. But how to effectively address depressive symptoms?

In the first selection, from JAMA Psychiatry, Benjamin L. Hankin (of the University of Illinois at Urbana-Champaign) and his co-authors consider a focused psychotherapy for that population. In a RCT involving 234 participants, they find that IPT was helpful. “Brief IPT significantly reduced prenatal depression symptoms and MDD compared with EUC [enhanced usual care] among pregnant individuals from diverse racial, ethnic, and socioeconomic backgrounds recruited from primary OB/GYN clinics.” We look at the paper and its clinical implications.

In the second selection, Caroline King (of the Oregon Health & Science University) and her co-authors consider buprenorphine for opioid use disorder with a focus on adolescent residential treatment. In a JAMA research letter, they report the findings which included every identified facility in the United States. “In contrast to the standard of care, only 1 in 4 US facilities offered buprenorphine and 1 in 8 offered buprenorphine for ongoing treatment.”

And, in the third selection, former AMA president Dr. Patrice A. Harris (of Columbia University) and her co-authors argue that physicians should know more about addiction treatment. In a Washington Post essay, they argue for more robust training. “Opioid use disorder is treatable, and medicines are readily available. But doctors cannot learn to help patients by taking a weekend course alone.”

DG


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Reading of the Week: Clozapine Monitoring – the New BJP Paper; Also, Suicide Trends Among Adolescents (CJP) and Van Gogh’s Ear & Iconography (ANZJP)

June 15, 2023 /

From the Editor

“Despite its strong evidence base, clozapine remains grossly under-prescribed in clinical practice. Although reasons for this are multifaceted, a commonly cited influence is the need for mandatory haematological monitoring.” So notes Ebenezer Oloyede (of the University of Oxford) and his co-authors in a new British Journal of Psychiatry paper. Could the requirements be simplified? 

In the first selection, Oloyede et al. look at outcomes of 569 patients on clozapine when, during the pandemic, routine blood monitoring was changed. In this mirror-image cohort study, they find: “[E]xtending the haematological monitoring interval from 4-weekly to 12-weekly did not increase the incidence of life-threatening agranulocytosis in people taking clozapine.” We consider the paper and its implications.

In the second selection, Dr. Rachel H. B. Mitchell (of the University of Toronto) and her co-authors analyze Canadian data on suicide and sex differences. In this Canadian Journal of Psychiatry research article, they find that suicide rates among female adolescents aged 10 to 14 years surpassed similarly aged males in 2011. “The marked and consistent trend of rising suicide rates among adolescent females aged 10 to 14 years in Canada signals increased distress and/or maladaptive coping in this segment of the population.” 

And in the third selection, Alexander Smith (of the University of Bern) and his co-authors write about Vincent van Gogh. In an Editorial for the Australian and New Zealand Journal of Psychiatry, they describe his mental health struggles but also their commercialization. “Vincent van Gogh’s ear has generated an intrinsic cultural currency. Yet, the psychiatric vulnerabilities encompassed by his act of self-harm are not always sensitively considered or acknowledged.”

DG

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Reading of the Week: Lithium Prescribing – the New CJP Paper; Also, AI vs. Doctors (JAMA Int Med) and Bergner on Compulsory Mental Health (NYT)

June 8, 2023 /

From the Editor

For patients with bipolar disorder, lithium is an important medication, shown to reduce hospitalizations and suicides better than newer agents. But has it fallen out of fashion? International reports suggest that it has.

In the first selection, Samreen Shafiq (of the University of Calgary) and her co-authors try to answer this question with Canadian data in a new paper for The Canadian Journal of Psychiatry. They draw on a decade of Alberta prescription data with more than 580,000 lithium scripts. “This population-based study suggests that the overall number of new and prevalent lithium users is decreasing in Alberta between the years of 2009 and 2018, but the observed pattern suggests that this decrease may have stopped by the end of our study interval.” We consider the paper and its clinical implications.

In the second selection, John W. Ayers (of University of California San Diego) considers AI-generated responses to health care questions posted on social media, like the need to seek medical attention after a minor head injury with a presentation of a lump and a headache. In a JAMA Internal Medicine paper, they compare ChatGPT answers to those of physicians in terms of quality and empathy. “In this cross-sectional study, a chatbot generated quality and empathetic responses to patient questions posed in an online forum.”

The debate over coercive care is hot, with proposals to rebalance patients’ rights actively discussed in New York City, Alberta, and California. In the third selection, author Daniel Bergner writes that we should look for alternatives to medications. In a New York Times essay, he argues that antipsychotics are problematic. “By doubling down on existing methods, we’re only beckoning more failure.”

DG

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Reading of the Week: Ketamine vs. ECT – the New NEJM Paper; Also, Burnout & Depression (QT) and Rehab for Schizophrenia (Wash Post)

June 1, 2023 /

From the Editor

“Ketamine Shows Promise for Hard-to-Treat Depression in New Study”

 – The New York Times

The gold standard for treatment-refractory depression has been ECT. Last week, The New England Journal of Medicine published a new study by Dr. Amit Anand (of Harvard University) and his co-authors comparing ketamine with ECT. They did a noninferiority trial, with more than 400 people. The results have been widely reported, including in The New York Times. They write: “This randomized trial evaluating the comparative effectiveness of ketamine and ECT in patients with treatment-resistant depression without psychosis showed noninferiority of ketamine to ECT…” We discuss the paper and the accompanying Editorial.

A recent Canadian Medical Association survey found that the majority of physicians reported experiencing high levels of burnout. In the second selection, Dr. Srijan Sen (of the University of Michigan) discusses this timely topic in a new Quick Takes podcast. He talks about the definition(s) of burnout, and the overlap with depression. “Burnout has become a loose term that means different things to different people.”

And in the third selection, Dr. Thomas Insel (of the Steinberg Institute) and his co-authors discuss the life and death of New Yorker Jordan Neely. In an essay for The Washington Post, they argue for better care, in particular with a focus on rehabilitation services for those with schizophrenia. “People with other brain disorders are not abandoned to become homeless or incarcerated rather than receive medical help.”

DG

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Reading of the Week: Ethnicity, Bias, and Alcohol – the New AJP Paper; Also, Global Mental Health & AI (JAMA Psych) and Halprin on Her Mother (Globe)

May 25, 2023 /

From the Editor

He drinks heavily, but does he have a diagnosed alcohol use disorder?

Does the answer to that question tie to ethnicity and biases? In a new American Journal of Psychiatry paper, Rachel Vickers-Smith (of the University of Kentucky) and her co-authors suggest it does. Drawing on US Veterans Affairs’ data with over 700,000 people, they analyzed the scores of a screening tool and the diagnoses with ethnicity recorded in the EMR. “We identified a large, racialized difference in AUD diagnosis, with Black and Hispanic veterans more likely than White veterans to receive the diagnosis at the same level of alcohol consumption.” We look at the paper and mull its implications.

In the second selection, Alastair C. van Heerden (of the University of the Witwatersrand) and his co-authors consider AI and its potential for global mental health services in a new JAMA Psychiatry Viewpoint. They focus on large language models (think ChatGPT) which could do several things, including helping to train and supervise humans. “Large language models and other forms of AI will fundamentally change how we treat mental disorders, allowing us to move away from the current model in which most of the world’s population does not have access to quality mental health services.”

And, in the third selection, Paula Halprin discusses her mother’s alcohol use in an essay for The Globe and Mail. In a moving piece that touches on anger, trauma, and regret, Halprin writes about her re-examination of her mother’s life. “I now understand my mother drank not because of a weak character, but to cope with a body wearing out before its time from unremitting pregnancy and as a way to swallow her anger and disappointment. It was also a way to mourn a loss of self.”

DG

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Reading of the Week: Motor Vehicle Crashes and Mental Disorders – the New CJP Paper; Also, Psychedelics & the States, and Hogan on NYC & Coercion

May 18, 2023 /

From the Editor 

He’s not well but insists that he can still drive his car. Should you report him to the Ministry of Transportation?

As clinicians, we often struggle with such issues, which touch on clinical judgment, as well as legal requirements. In Ontario, half a decade ago, the governme­­nt changed the law, requiring mandatory reporting for several conditions, including “acute” psychosis. Yet other provinces continue to leave major decisions to the discretion of providers. What does the literature say about motor vehicle crashes and mental disorders? In the first selection, Dr. Mark J. Rapoport (of the University of Toronto) and his co-authors do a systematic review for The Canadian Journal of Psychiatry, drawing on 24 studies. “The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder.” We consider the paper and its implications.

In the second selection, Dr. Joshua S. Siegel (of Washington University in St. Louis) and his co-authors look at US state legislation for psychedelic drugs in a new JAMA Psychiatry Special Communication. They note a sharp uptick in legislative activity and draw comparisons to cannabis. “After decades of legal restriction, US states have been swiftly moving toward increased access to psychedelics.”

And in the third selection, Michael F. Hogan (of Case Western Reserve University) writes about coercion and mental health care in JAMA Psychiatry. He considers the proposals of New York City Mayor Eric Adams which would expand efforts to hospitalize those with several, persistent mental illness. “Mayor Adams’ proposal for a more vigorous police response leading to inpatient care is well intended but incomplete. It would be preferable for New York to implement comprehensive crisis programs, including intensive care options that reduced the burden on police.”

DG

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Reading of the Week: Polypharmacy & Health – the New AJP Paper; Also, Melatonin Gummies (JAMA) & Mehler Paperny on Involuntary Care (Globe)

May 4, 2023 /

From the Editor

When it comes to antipsychotics, polypharmacy (the use of more than one antipsychotic) has fallen out of fashion – the psychopharmacological equivalent of bell bottoms. Providers worry about side effects and the long-term physical health implications. Are the concerns overstated? In the first selection, Heidi Taipale (of the University of Eastern Finland) and her coauthors analyze Finnish data for The American Journal of Psychiatry. The study includes almost 62,000 patients with schizophrenia with a median follow up period of more than 14 years, and they find that the use of more than one antipsychotic isn’t linked to poorer health outcomes. “The results show that antipsychotic monotherapy is not associated with a lower risk of hospitalization for severe physical health problems when compared with antipsychotic polypharmacy.” We consider the paper and its clinical implications.

Melatonin is a popular recommendation for sleep, but what’s the quality like? In the second selection from JAMA, Dr. Pieter A. Cohen (of Harvard University) and his co-authors try to answer that question with a focus on melatonin gummy products, looking at 30 brands. “The great majority of melatonin gummy products were inaccurately labeled, with most products exceeding the declared amount of melatonin and CBD.”

Gummy melatonin: colourful but what’s the quality?

In the third selection, in an essay for The Globe and Mail, journalist Anna Mehler Paperny writes about the push for more coercive care by different governments. Drawing on her personal experiences, she notes potential problems. “There is a role for coercive care. It’s arguably necessary for some people, sometimes. But used injudiciously, it can sour people on care and set them up for failure.”

There will be no Reading next week.

DG

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Reading of the Week: Bipolar & Med Adherence – the New Journal of Affective Disorders Study; Also, Sleep (QT) and Sheff on Involuntary Treatment (NYT)

April 27, 2023 /

From the Editor

You wrote a prescription, but did he actually take the medications? For those with bipolar disorder, pharmacotherapy is an essential part of care. Studies have noted poor adherence. 

To date, though, there hasn’t been a big cohort study. And there are good questions to ask: what drugs are more linked with adherence? Who is more likely not to take the medications? In a new paper just published in the Journal of Affective Disorders, Dr. Jonne Lintunen (of the University of Eastern Finland) and his co-authors attempt to answer these questions. They draw on Finnish data, covering more than three decades and including over 33 000 patients. “The majority of patients with bipolar disorder do not use their medications as prescribed.” We consider the paper and its clinical implications.

In the second selection, Dr. Michael Mak (of the University of Toronto) comments on sleep in a new Quick Takes podcast interview. In this sleep “update,” we talk about meds, CBT, and the mobile apps that he recommends to patients and their families. We also explore the history of sleep medicine and mull the growing role apps and wearables are playing in both diagnosis and therapy. “The lines between sleep, health, and mental health in general are blurred.”

In the third selection, author David Sheff talks about his son’s addiction and recovery – and involuntary treatment. In a New York Times’ essay, he notes the challenges of engaging those with substance problems. He sees several ways forward, including involuntary treatment. “Many people in the traditional recovery world believe that we must wait for people who are addicted to hit bottom, with the hope that they’ll choose to enter treatment. It’s an archaic and dangerous theory.”

DG

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Reading of the Week: Mindfulness Self-Help for Depression? The New JAMA Psych Study; Also, Elderly Overdoses (JAMA Psych) and Sanford on Loss (JAMA)

April 20, 2023 /

From the Editor

He diagnosed himself. My patient suspected something was wrong, did some reading, and then completed a PHQ-9 survey (which he found on a website). But, like many, he struggled to get care.

The story is too familiar. Access to care is deeply problematic. Not surprisingly, then, low-cost interventions are of interest, with much work focused on CBT. What about mindfulness? In the first selection, Clara Strauss (of the University of Sussex) and her co-authors attempt to answer that question with direct comparison of mindfulness and CBT. In a new JAMA Psychiatry paper, they find: “practitioner-supported [mindfulness] was superior to standard recommended treatment (ie, practitioner-supported CBT) for mild to moderate depression in terms of both clinical effectiveness and cost-effectiveness.” We consider the paper and its implications.

In the second selection, Keith Humphreys (of Stanford University) and Chelsea L. Shover (of the University of California, Los Angeles) look at overdose deaths in older Americans for JAMA Psychiatry. Drawing on a database, they find a quadrupling between 2002 and 2021. “Even though drug overdose remains an uncommon cause of death among older adults in the US, the quadrupling of fatal overdoses among older adults should be considered in evolving policies focused on the overdose epidemic.” 

And in the third selection, Dr. Ethan L. Sanford (of the University of Texas) writes about the loss of his infant daughter. In a deeply personal essay for JAMA, he describes her illness and death – and his re-evaluation of his career. “I sometimes wish every physician could understand the loss of a child. I wish they could understand how I miss Ceci achingly, how I miss her in my bones.”

DG

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