CategoryReading of the Week

Reading of the Week: Smoking Cessation – Doing Bad, Feeling Good? Also, Ethnicity & Opioids (JAMA Psych) and Dr. Freedman on Lunches (Acad Psych)

From the Editor

We ask our patients about cannabis. We inquire about illicit drugs. But are we forgetting tobacco? A new paper in Psychiatric Services helps answer that question – and, perhaps, raises other questions, including about how we could do better. 

In the first selection, Sarah A. White (of Johns Hopkins University) and her co-authors draw on American data to look at smoking cessation medications in a new Psychiatric Services paper. Among more than 55,000 smokers (many of whom have mental illness), they find that: “Cessation pharmacotherapy for smokers remained vastly underprescribed across all groups. At least 83% of smokers with or without mental illness did not receive varenicline, NRT, or bupropion during the 14-year study period.” We consider the paper and its clinical implications.

In the second selection, Huiru Dong (of Harvard University) and her co-authors look at buprenorphine treatment and demographics in the United States. Their JAMA Psychiatry research letter, which was just published, finds a growing gap. “The observed heterogeneity in buprenorphine treatment duration among racial and ethnic groups may reflect disproportionate structural barriers in treatment retention for Opioid Use Disorder.”

In the third selection, Dr. David Freedman (of the University of Toronto) writes about resident lunches for Academic Psychiatry. Dr. Freedman, who is a resident, notes that in-person lunches shifted to virtual ones for more than two years because of the pandemic – something that was necessary but unfortunate. He argues that the gatherings are important. “Yet, as a collective of residents munch on the last bites of their sandwiches, say goodbye, and return to work, I am struck by the camaraderie. Funded resident lunches nurture the professional identities of psychiatry trainees – an essential element of medical education.”

DG

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Reading of the Week: Mindfulness for Anxiety? The New JAMA Psychiatry Paper; Also, Sim in Med Ed (QT) and Dr. Sen on Burnout & Depression (NEJM)

From the Editor

Mindfulness is trendy. It’s offered at your local YMCA. There are mindfulness techniques in popular apps. Corporations offer sessions over the lunch hour.

But is it helpful? Millions of North Americans struggle with anxiety disorders. Could mindfulness help them? Is it an alternative for those who don’t want to take medications? In the first selection, Dr. Elizabeth A. Hoge (of Georgetown University) and her co-authors try to answer these questions. Their results have just been published in JAMA Psychiatry. In an RCT, they compare a form of mindfulness to the use of an SSRI. They write: “Our prospective randomized clinical trial found that MBSR was noninferior to escitalopram for the treatment of anxiety disorders.” We consider the paper and its clinical implications.

In this week’s second selection, we look at a new Quick Takes podcast interview with CAMH’s Stephanie Sliekers and Dr. Petal Abdool (of the University of Toronto). They discuss simulation in mental health education, noting the potential. They also talk about their innovative work in this area. “We can create an environment that’s safe, predictable, consistent, standardized, and reproducible.”

In this week’s third selection, Dr. Srijan Sen (of the University of Michigan) writes about physician burnout. In a Perspective paper published in The New England Journal of Medicine, he argues that separating burnout from depression is problematic. He writes: “Expanding reform efforts to encompass depression and mental health more broadly will not reduce the urgency of reforming our health care system. Rather, it will increase the likelihood that physicians who are struggling can access the spectrum of available evidence-based individual interventions.”

DG

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Reading of the Week: Psilocybin for Treatment-Refractory Depression – the New NEJM Paper

From the Editor

“Severe depression eased by single dose of synthetic ‘magic mushroom’”

– CNN, 3 November 2022

For its proponents, psilocybin could be the breakthrough we have been waiting for in depression treatment. For its critics, psilocybin lacks evidence.

What to make of psilocybin? Dr. Guy M. Goodwin (of the University of Oxford) and his co-authors attempt to answer that question with a phase 2 double blind trial focused on those with treatment-resistant depression, offering participants psilocybin at three different doses, in addition to therapy. The resulting paper was just published in The New England Journal of Medicine and has received much attention (including, yes, coverage by CNN). They find: “participants with treatment-resistant depression, psilocybin at a single dose of 25 mg, but not 10 mg, reduced depression scores significantly more than a 1-mg dose over a period of 3 weeks but was associated with adverse effects.” 

The future of depression treatment?

We discuss the big paper and the review the accompanying Editorial by Bertha K. Madras (of Harvard University). We also have comments from Dr. Ishrat Husain (of the University of Toronto), one of the study co-authors.

So does psilocybin offer a breakthrough? Read on and decide for yourself.

(Note that there will be no Reading next week.)

DG

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Reading of the Week: Are Involuntary Admissions on the Rise? The New CJP Paper; Also, Telepsychiatry (JAMA Psych) and Dr. Oh on Suicide (Acad Psych)

From the Editor

A recent New York Times article notes that adolescents are increasingly looking for information on mental health and turning to TikTok. Such is life at a time when stigma fades: people are curious, though not necessarily going to the best places for information.

But are we reaching people earlier in their illness experience? We hope that the answer is yes – a new paper with British Columbian data, however, suggests that police apprehensions are more common, as are involuntary admissions, indicating that more people are in crisis. In the first selection from The Canadian Journal of Psychiatry, Jackson P. Loyal (of Simon Fraser University) and his co-authors draw on administrative databases and find a major shift: “While roughly half of the people hospitalized for mental health and substance use disorders were admitted voluntarily in 2008/2009, by 2017/2018 this fell to approximately one-third.” We look at the paper and its clinical implications.

British Columbia: a province of rivers, whales, and involuntary admissions

In the second selection, Dr. Carlos Blanco (of the National Institute on Drug Abuse, United States) and his co-authors consider the rise of telepsychiatry, noting that 39% of mental health care in the US is now virtual. In this new JAMA Psychiatry Viewpoint, “Expansion of telepsychiatry creates new opportunities to increase treatment access, while it poses overlapping challenges to multiple stakeholders…”

And in the third selection, Dr. Nicholas Zhenwei Oh (of the Ministry of Health Holdings, Singapore) writes personally and thoughtfully about the loss of a patient by suicide. He goes into detail on his own experience during training. “Patient suicide is possibly the great equaliser amongst psychiatrists, psychiatry trainees, and perhaps any other clinician who has experienced a patient’s suicide. My own experience came suddenly and unexpectedly, and it will likely leave a psychological scar as a grim reminder of one of the lowest points of my career.”

DG

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Reading of the Week: Lithium & Renal Health – the New Lancet Psych Paper; Also, COVID & Suicides (ANZJP)

From the Editor

After starting lithium in the hospital, his life was transformed. My patient didn’t have another hospitalization, and he went back to excelling at his job and raising his young family.

There are many lithium success stories. But how safe is it for our patients’ kidneys? Though lithium has been used for decades, there is still controversy. We know that lithium can affect the kidneys, but how much renal change is naturally occurring (aging), due to psychiatric illnesses (like bipolar), or the medication itself?

In a new paper just published in The Lancet Psychiatry, Filip Fransson (of King’s College London) and his co-authors attempt to answer these questions with a cross-sectional cohort study drawing on 2,200 people from Sweden. They review kidney function over time for the general population, those with schizoaffective disorder and bipolar, and compare them to those on lithium. They find a significant connection between lithium and renal decline, but only after a decade of use. We consider the paper and its clinical implications.

In the second selection, Dr. Nick Glozier (of The University of Sydney) and his co-authors consider suicide rates during the pandemic in a new research article for the Australian & New Zealand Journal of Psychiatry. They note the dire predictions – of a “suicide epidemic” – that weren’t realized, and consider why, noting several factors, including that the economic downturn was mitigated by government action. Ultimately, though, they write: “suicide is an inherently difficult (stochastic) event to predict.”

DG

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Reading of the Week: Twitter & Suicide – the New ANZJP Paper; Also, Crystal Meth Use (Quick Takes) and Patients and Physicians’ Names (JAMA Net Open)

From the Editor

More and more, people use social media to debate current events, share personal experiences, and maybe enjoy a cat video or two. But if people are disclosing much, are they discussing suicidal thoughts? Could certain social media posts encourage people to get help?

In the first selection, Dr. Thomas Niederkrotenthaler (of the Medical University of Vienna) and his co-authors attempt to answer these questions with a new paper just published in the Australian & New Zealand Journal of Psychiatry. Drawing on more than 7.15 million tweets (from Twitter) and employing a machine learning approach, they divide content into several categories, then review volumes of calls to a suicide hotline and completed suicides. “This is the first large-scale study to suggest that daily volume of specific suicide-prevention-related social media content on Twitter corresponds to higher daily levels of help-seeking behaviour and lower daily number of suicide deaths.” We mull the paper and its implications.

Social media: more than cat videos?

In this week’s second selection, we consider a new Quick Takes podcast interview with Dr. David Castle (of the University of Toronto). Dr. Castle discusses crystal methamphetamine, a drug used more and more in Canada. Drawing on his Australian experience and noting the rise in use here, he comments: “it’s highly prevalent, highly available, highly pure and highly destructive.”

Finally, in the third selection, Dr. Jamison A. Harvey (of the Mayo Clinic) and her co-authors take a look at communication between patients and their physicians. Drawing on nearly 30,000 email messages, they consider the way patients address their physicians in a new JAMA Network Open research letter. “This is the first study to objectively identify patterns of addressing physicians through electronic messaging and may reveal potential bias. We found that women physicians… and primary care physicians were addressed by their first name more frequently.”

DG

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Reading of the Week: rTMS – the New JAMA Psych Paper; Also, Opioid Overdoses (JAMA Net Open) and Green on Peak Mental Health (NYT)

From the Editor

She’s an accomplished person who had succeeded in business and then writing, all the while raising three children; she also has an amazing smile and lights up the room when talking about her kids. But in my office, sick with depression, she can only focus on her losses and failings; the smile is absent.

Depression is common and disabling. Those who are affected in late-life are particularly challenging to treat. Is there a better way? In the first selection from JAMA Psychiatry, Dr. Daniel Blumberger (of the University of Toronto) and his co-authors consider theta burst stimulation, a newer form of rTMS which has shown promise in earlier work. Their study is a randomized noninferiority trial, directly comparing the two versions of rTMS in elderly patients with depression. The result? “We showed that bilateral TBS was noninferior to standard bilateral rTMS in improving depression, and similarly well tolerated, in a real-world sample of older adults with TRD [treatment resistant depression]…” We review the paper and its clinical implications.

In the second selection, Lori Ann Post (of Northwestern University) and her co-authors draw on CDC data to look at opioid overdoses in the United States with a focus on geography. In a JAMA Network Open research letter, they find: “Overall, opioid-involved overdose deaths rates increased steadily in counties of every urbanicity type, although there were distinct temporal wave patterns by urbanicity.”

And in the third selection, Huw Green (of the University of Cambridge) wonders about mental health and mental illness – and worries that the terms are becoming blurred together. Writing in The New York Times, the psychologist concludes: “When we move away from a focus on psychological problems and toward ‘mental health’ more broadly, clinicians stumble into terrain that extends beyond our expertise. We ought to be appropriately humble.”  

This month, the Reading of the Week enters its ninth year. A quick word of thanks for your ongoing interest.

DG



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Reading of the Week: Anxiety Screening for Adults – Helpful or Not? Also, Bram on His Depression & His Chatbot (NYT)

From the Editor

“A panel of medical experts on Tuesday recommended for the first time that doctors screen all adult patients under 65 for anxiety, guidance that highlights the extraordinary stress levels that have plagued the United States since the start of the pandemic.”

So reports The New York Times late last month with news of the US Preventive Services Task Force’s draft recommendation. The article quotes panelist Lori Pbert (of the University of Massachusetts): “Our only hope is that our recommendations throw a spotlight on the need to create greater access to mental health care – and urgently.”

In the first selection, we look at the recommendation. In making it, the USPSTF reviewed the literature and weighted the advantages and disadvantages of screening. If finalized, the recommendation would have implications on primary care in the United States – and beyond. “The USPSTF concludes with moderate certainty that screening for anxiety in adults, including pregnant and postpartum persons, has a moderate net benefit.” Is this a step in the right direction? Is this well intentioned but problematic?

In the second selection, Barclay Bram writes about his experiences with a therapist bot, working with the Woebot app. In a long New York Times essay, he talks about his depression and his therapy bot. He writes: “Using Woebot was like reading a good book of fiction. I never lost the sense that it was anything more than an algorithm – but I was able to suspend my disbelief and allow the experience to carry me elsewhere.”

DG

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Reading of the Week: Psychiatrists & Patient Suicide – the New CJP Paper; Brain Wellness Spas (JAMA Psych) and Dr. Heidari on Her Mantra (NEJM)

From the Editor

It’s the call we dread, perhaps from a relative or the family doctor. The news catches us by surprise: the patient has died and suicide is suspected.

In the first selection from The Canadian Journal of Psychiatry, Dr. Zainab Furqan (of the University of Toronto) and her co-authors consider psychiatrists’ experiences with patients who die by suicide. In this qualitative analysis drawing on 17 interviews, they explore the emotional response. They conclude: “patient suicide is often associated with grief, shock, anxiety and guilt; emotions which are mediated by physician, patient, relational and institutional factors and have important ramifications on psychiatrists’ well-being and clinical practice.” We consider the paper and its implications.

In this week’s second selection, Anna Wexler and Dominic Sisti (both of the University of Pennsylvania) write about the potential and problems of off-label use for psychedelic drugs in light of likely FDA approval. In a JAMA PsychiatryViewpoint, they note: “With high public enthusiasm, extremely bullish investors, and hundreds of newly established brain wellness clinics, all the pieces are now in place for expansive off-label promotion and use of psychedelics to quickly mushroom beyond what is safe.”

Finally, in the third selection from The New England Journal of Medicine, Dr. Shireen N. Heidari (of Stanford University) notes the incredible challenges of working during the pandemic – and the psychological toll. She describes her decision to seek care and her own recovery: “A year after making the decision to talk to my family and my doctor, I know that advocating for my own mental health was the best decision I could have made.”

DG

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Reading of the Week: African Nova Scotian Youth & Stigma; Also, Engaging Health Care Workers (Psych Services) and Therapy & Psychiatry (Psych Times)

From the Editor

Many with mental disorders don’t engage in psychiatric care or, if they do, it is after significant delays – problematic for obvious reasons. Some groups are less likely to engage, including young Black individuals with psychosis.

Why the hesitation? What are the concerns of these patients and their larger communities? In the first selection, a paper just published by the Canadian Journal of Psychiatry, Ingrid Waldron (of McMaster University) and her co-authors take a qualitative interpretive narrative approach, to engage African Nova Scotians – including those in a first episode psychosis program – attempting to answer these questions and more. Among their key findings: “barriers include a lack of trust in health care services and a dearth of African Nova Scotian service providers.” We discuss the paper and its implications.

In this week’s second selection, Dr. Doron Amsalem (of Columbia University) and his co-authors aim to improve health care workers treatment seeking; in a paper for Psychiatric Services, they describe an RCT for a brief video intervention, finding positive results. They write: “This easily administered intervention could increase the likelihood of care seeking by proactively encouraging health care workers with mental health challenges to pursue treatment.”

Finally, in the third selection, Mark L. Ruffalo (of the University of Central Florida College of Medicine) and Dr. Daniel Morehead (of the Tufts Medical Center) consider psychotherapy and psychiatry. In an essay for Psychiatric Times, they argue that this is “the great divorce that never happened.” They write: “For decades, critics and leading psychiatrists have worried that psychotherapy among psychiatrists will one day die out and be forgotten. Yet for decades, reports of its demise have been greatly exaggerated.”

DG

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