Author: David Gratzer

Reading of the Week: High Tech and Low Tech Opportunities for Mental Health Care

September 30, 2021 /

From the Editor

Social media. Bots. VR.

When I applied to psychiatry residency programs in my last year of medical school at the University of Manitoba, none of these were mentioned when we talked about mental health care. But technology is changing our world. We are seeing a digital boom in mental health care – or is it really a digital mirage?

In the first selection, we move past the big rhetoric with a thoughtful paper by Dr. John Torous (of Harvard University) and his co-authors. In World Psychiatry, they review the literature and make insightful comments about the potential and reality of digital mental health care. “It now seems inevitable that digital technologies will change the face of mental health research and treatment.” We discuss the paper and its implications.

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Woebot: Too cool to be clinical?

If the first selection considers cutting-edge technology for bettering patient care, the second is very different. Dr. Thomas E. Smith (of Columbia University) and his co-authors study “the strength of associations between scheduling aftercare appointments during routine psychiatric inpatient discharge planning and postdischarge follow-up care varied by level of patient engagement in outpatient psychiatric care before hospital admission” in a paper for Psychiatric Services. Spoiler alert: there are no chatbots mentioned. “Discharge planning activities, such as scheduling follow-up appointments, increase the likelihood of patients successfully transitioning to outpatient care, regardless of their level of engagement in care prior to psychiatric inpatient admission.”

DG

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Reading of the Week: Suicidal Ideation in a 37-Year-Old Woman – A NEJM Case; Also, Goldbloom on Innovation (QT) and Purdy on Her Brother (CMAJ)

September 23, 2021 /

From the Editor

She presents with suicidal thoughts and had a challenging course with COVID-19.

She could be a patient in your afternoon clinic. In fact, she was seen and treated at Massachusetts General Hospital. And her case was discussed at psychiatry grand rounds, and then written up for The New England Journal of Medicine.

In our first selection, Dr. Carol S. North (of the University of Texas Southwestern) and her co-authors consider this patient’s story. They detail her history and course in hospital. They also note the complexities: “This case highlights the importance of attending to the intricate, multilevel, systemic factors that affect the mental health experience and clinical presentation of patients, especially among patients such as this one, who identified as Latina.”

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Dr. David Goldbloom (of the University of Toronto) joins me for a Quick Takes podcast interview. We discuss his new book about innovations in mental health care. “I wrote the book because like so many people who work in our profession, so many people who are on the receiving end of care, and for the families who support those individuals, there is a shared sense that the status quo isn’t good enough.”

In the third selection, Dr. Kaylynn Purdy (of the University of Alberta), a resident of neurology, writes about her brother and his illness in the pages of the CMAJ. He develops schizophrenia and becomes homeless in Vancouver. She talks about his life and death. “When you meet somebody living on the streets, remember my brother.”

DG

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Reading of the Week: Telepsychiatry – the Reality, the Potential, the Problems

September 16, 2021 /

From the Editor

Just a handful of months ago, mental health work didn’t require a webcam or a lighting ring, and no one talked about Zoom fatigue. The world is different now, obviously. With COVID-19, telepsychiatry is very much part of our clinical work.

This week, we consider three papers focused on telepsychiatry and our new world.

How widespread is the adoption of telepsychiatry in this pandemic era? In the first selection, Jonathan Cantor (of the RAND Corporation) and his co-authors draw on a big American database to answer that question. In Psychiatric Services, they write: “During the COVID-19 pandemic, the percentage of outpatient mental health and substance use disorder treatment facilities offering telehealth has grown dramatically. However, our analyses also indicated that considerable proportions of mental health and substance use disorder treatment facilities still did not offer telehealth as of January 2021…”

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In the second selection, John C. Fortney (of the University of Washington) and his co-authors consider two different types of care: with psychiatrists directly involved in patient care (through televideo) or indirectly, by providing support to primary care. In a JAMA Psychiatry study, they do a comparison. Spoiler alert: both approaches were effective, suggesting great potential, especially for those in rural areas.

Of course, not everyone is enthusiastic about telepsychiatry. In our third selection, Dr. J. Alexander Scott (of the University of Michigan), a resident of psychiatry, describes his ambivalence. His Academic Psychiatry paper starts memorably: “Admittedly, I’ve never liked telemedicine.” He outlines some of the problems with our digital world.

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Reading of the Week: Cardiovascular Diseases & Mental Disorders – The New AJP Paper; Also, Systematic Racism & Depression (JAMA Psych)

September 9, 2021 /

From the Editor

When people with mental health problems have physical illness, how does their care measure up?

Not surprisingly, we worry about their access and follow up. Evidence suggests poorer outcomes. But how do people with mental disorders fare on an international basis?

In the first selection, Dr. Marco Solmi (of the University of Padua) and his co-authors try to answer that question, focusing on cardiovascular diseases (CVD). In a new American Journal of Psychiatry paper, they conduct a systematic review and meta-analysis, drawing on the data of more than 24 million people. (!) They find: “People with mental disorders, and those with schizophrenia in particular, receive less screening and lower-quality treatment for CVD. It is of paramount importance to address underprescribing of CVD medications and underutilization of diagnostic and therapeutic procedures across all mental disorders.” We discuss the paper and its clinical implications.

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In the second selection from The American Journal of Psychiatry, Drs. Nathalie Moise and Sidney Hankerson (both of Columbia University) consider structural racism and depression care, using a clinical vignette. Rather than just seeing the patient’s experience in terms of genetic loading and medications, they describe a person who has struggled with various forms of racism. They argue: “Mental health professionals need to recognize the effect of structural, individual, and internalized racism on individuals with depression symptoms.”

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Reading of the Week: Is ECT Really Safe? The New Lancet Psychiatry Paper; Also, Antrim on His ECT (New Yorker)

August 26, 2021 /

From the Editor

Is it safe?

The first treatment of electroconvulsive therapy (ECT) was administered in 1938. Yet decades later, people still debate the safety of this treatment; a study found that one in five patients reported fear of death as a major concern. (And, yes, so many of our patients have seen that movie.)

In our first selection, we consider a new and important paper on this topic, just published in The Lancet Psychiatry. Dr. Tyler S. Kaster (of the University of Toronto) and his co-authors attempt to answer the safety question by comparing those who received ECT with those who didn’t in the context of depression and inpatient care. “In this population-based study of more than 5000 admissions involving electroconvulsive therapy for inpatients with depression, the rate of serious medical events within 30 days was very low among those exposed to electroconvulsive therapy and a closely matched unexposed group (0.5 events per person-year vs 0.33 events per person-year), with those who received electroconvulsive therapy having a numerically lower risk of medical complications.” We look at the big study, with an eye on clinical implications.

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In the other selection, we look at a new essay from The New Yorker. Writer Donald Antrim – an accomplished novelist and a MacArthur fellow – discusses his depression, his suicidal thoughts, and his decision to opt for ECT. He notes that after treatment: “I felt something that seemed brand new in my life, a sense of calm, even happiness.”

DG

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Reading of the Week: Which Antipsychotics are Patients Less Likely to Discontinue? The New AJP Paper; Also, Dr. Lawrence on Mental Health (Guardian)

August 12, 2021 /

From the Editor

Is new really better?

With several new antipsychotic medications on the market, this question is very relevant clinically. For the patient in your office, should you opt for a new antipsychotic or something older?

In the first selection, Dr. Mark Weiser (of the Stanley Medical Research Institute) and his co-authors draw on a large database – and the experience of tens of thousands of people – to compare antipsychotics. “Among veterans with schizophrenia, those who initiated antipsychotic treatment with clozapine, long-acting injectable second-generation medications, and antipsychotic polypharmacy experienced longer episodes of continuous therapy and lower rates of treatment discontinuation.” We consider this paper, and the clinical implications.

new-2Is new better – or just eye catching?

In the other selection, Dr. Rebecca Lawrence, a practicing psychiatrist, writes for The Guardian. In her essay, she distinguishes between mental health and mental illness, noting that they are not the same thing, and worrying that we are increasingly as a society focused on the former at the expense of the latter. She thinks about her work as a physician: “As a doctor, I can talk with someone and give them pills, but I can’t easily get them any help with losing weight or trying to exercise. I can tell them it would be good for them, but I don’t necessarily have any practical ways to help.”

DG

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Reading of the Week: Does Opioid Agonist Treatment Save Lives? Also, the Problem with Decriminalization of Illicit Drugs (CJP)

August 5, 2021 /

From the Editor

Methadone was invented in the 1930s. The first legal injection site opened its doors nearly two decades ago. Yet our challenges with opioids seem to have only worsened with time. Consider, for example, that in a new, two-year study, the authors found that opioid-related deaths rose almost 600% between 2015 and 2017 in Canada.

What can we do? This week, we consider two selections.

In the first, Thomas Santo Jr (of the University of New South Wales) and his co-authors do a systematic review and meta-analysis for opioid agonist treatment for those with opioid dependence. They write in JAMA Psychiatry: “Our findings suggest a potential public health benefit of OAT, which was associated with a greater than 50% lower risk of all-cause mortality, drug-related deaths, and suicide and was associated with significantly lower rates of mortality for other causes.” We consider the big paper and its implications.

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And in the other selection, Benedikt Fischer (of the University of Toronto) and his co-authors weigh the recent interest in decriminalizing illicit drug use. In a new Canadian Journal of Psychiatry commentary, they note their hesitation, writing: “while ‘decriminalization’ proposals for illicit drug use are popular and largely well-intended, their overall merits require cautious analysis and scrutiny.”

DG

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Reading of the Week: Canada Day – With Papers on Cannabis, Chatbots, Depression, Nutraceuticals and Benzodiazepines in Pregnancy

July 1, 2021 /

From the Editor

It’s Canada Day.

Let’s start by noting that not everyone has a day off. Some of our colleagues are working – perhaps in hospitals or vaccine clinics. A quick word of thanks to them for helping our patients on a holiday.

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Appropriately, this week’s selections will focus on Canadian work.

What makes a paper “Canadian” for the purposes of this review? That is, how do we define Canadian? Things could get complicated quickly when considering journal papers. Does the second author order “double double” at Tim Hortons? Has the senior author eaten poutine for breakfast? Is the journal’s action editor hoping that the Canadiens bring the Cup home?

Let’s keep things simple: all the papers selected this week have been published in a Canadian journal and the papers are clinically relevant for those of us seeing patients in Canada.

There are many papers that could have been chosen, of course. I’ve picked five papers – a mix of papers that have been featured previously in past Readings, and some new ones. All but one of the selected papers are recent.

Please note that there will be no Readings for the next two weeks.

DG

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Reading of the Week: Suicide and Schizophrenia – Across Life Span; Also, Transgender-Inclusive Care (QT), and the NYT on Chatbots

June 10, 2021 /

From the Editor

This week, we have three selections.

In the first, we consider suicide and schizophrenia. In a new JAMA Psychiatry paper, Dr. Mark Olfson (of Columbia University) and his co-authors do a cohort study across life-span, tapping a massive database. They find: “the risk of suicide was higher compared with the general US population and was highest among those aged 18 to 34 years and lowest among those 65 years and older.” The authors see clear clinical implications: “These findings suggest that suicide prevention efforts for individuals with schizophrenia should include a focus on younger adults with suicidal symptoms and substance use disorders.”

In the second selection, we consider transgender-inclusive care, looking at a new Quick Takes podcast. Drs. June Lam and Alex Abramovich (both of the University of Toronto) comment on caring for members of this population. “Trans individuals are medically underserved and experience, poor mental health outcomes, high rates of disease burden – compared to cisgender individuals.”

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Finally, in our third selection from The New York Times, reporter Karen Brown writes about chatbots for psychotherapy, focusing on Woebot. The writer quotes psychologist Alison Darcy about the potential of these conversational agents: “If we can deliver some of the things that the human can deliver, then we actually can create something that’s truly scalable, that has the capability to reduce the incidence of suffering in the population.”

DG

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Reading of the Week: Suicide and Gender in Canada; Also, Access and Immigrants (CJP), and Chok on Variations on a Theme (CMAJ)

June 3, 2021 /

From the Editor

This week, we have three selections; all are from Canadian publications.

Suicide rates have been declining in this country. In the first selection, Sara Zulyniak (of the University of Calgary) and her co-authors look at suicide by age and gender, drawing on almost two decades’ worth of data. In their analysis, there is a surprising finding: “The suicide rates in females aged 10 to 19 and 20 to 29 were increasing between 2000 and 2018. In comparison, no male regression results indicated significantly increasing rates.” This research letter, just published in The Canadian Journal of Psychiatry, is short and relevant.

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In the second selection, also from The Canadian Journal of Psychiatry, Joanna Marie B. Rivera (of Simon Fraser University) and her co-authors consider access to care. They focus on immigrants and nonimmigrants, noting differences in the way care is provided for those with mood disorders. “People with access to team-based primary care are more likely to report mental health consultations, and this is especially true for immigrants. Unfortunately, immigrants, and especially recent immigrants, are more likely to see a doctor in solo practice or use walk-in clinics as a usual place of care.”

Finally, in our third selection from CMAJ, Dr. Rozalyn Chok (of the University of Alberta), a pianist who is now a resident of paediatrics, describes a performance at a mental hospital. “I still hear exactly how it sounded on that tinny upright piano. I feel the uneven weighting of the keys, remember how difficult it was to achieve the voicing – the balance of melody and harmony – I wanted.” She reflects on the piece she played, and its impact on a patient.

DG

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