From the Editor
What can we do for those with severe mental illness?
Homelessness: can we do better?
This week, we look at a series of excellent essays that have run on mental illness in The New England Journal of Medicine. They are well written and insightful. We particularly focus on the first of the three essays, which considers treatment and rights.
From the Editor
What’s new in depression treatment?
The new guidelines
This week, we look at the new CANMAT guidelines. Published in September in The Canadian Journal of Psychiatry, the papers – six in all – speak to the latest in depression management.
What should you think about the new antidepressants? What alternatives are there to CBT? What to do when everything else fails? Spoiler alert: this week’s Reading answers all these questions and more.
From the Editor
Will they cut a deal?
Ontario Minister of Health and Long-Term Care Eric Hoskins speaks during a health ministers’ meeting last week in Toronto
It’s the question that will be discussed for weeks to come.
But for those of us in mental health, a possible deal is more than an item on the evening news. After all, a new federal-provincial accord could be important, with more money for mental health services. And let’s remember: right now, just 7 cents on every dollar of health spending goes to mental health (in the UK, by contrast, spending is 12 cents on the dollar).
But we hope for more than just a new deal. We hope for a smart new deal – one that will help improve mental health services.
What are steps the federal government could take?
This week’s Reading considers the new report issued by the Canadian Alliance on Mental Illness and Mental Health (or CAMIMH), an alliance of sixteen member organizations, including the Canadian Psychiatric Association, the Canadian Medical Association, and the College of Family Physicians of Canada. This thoughtful document lays out a five-point plan for bettering mental health services from coast-to-coast-to-coast. Spoiler alert: the plan calls for more spending, yes, but also efforts to improve access, better measurement of the system, and a targeted basic income to help less affluent Canadians.
Also in this reading – tying back to the UK – we look at an article from The Guardian about making mental health services stronger across the Atlantic.
The two pieces offer a strong contrast: about where our debate is in this country – and where mental health services could be with some needed reforms.
From the Editor
“If your son or daughter had cancer or diabetes, do you think it would be reasonable for them to wait? I don’t think it’s any different for mental illness.”
Access. It’s one of the biggest problems with mental health services.
How big is the access problem? What can be done about it?
This week, we consider a new paper looking at access and first episode psychosis. Dr. Paul Kurdyak, a CAMH psychiatrist and a program lead with the Institute for Clinical Evaluative Sciences, made the above comment to the CBC when discussing this new paper. In it, Kelly Anderson and Dr. Kurdyak find that 40% of patients didn’t receive physician follow-up in the month after diagnosis. Imagine – tying back to Dr. Kurdyak’s comment – if 40% of young patients with leukemia didn’t have physician follow-up in a month after their cancer diagnosis.
We also look at the discussion around a new federal-provincial accord with an op ed written by Michael Wilson, the chair of the Mental Health Commission of Canada – particularly timely as the ministers of health met this week with an eye on a new accord.
From the Editor
Readings in recent weeks have drawn from several journals and a major autobiography.
Recognizing that mental health is increasingly part of our public and private conversations, we draw from newspapers and news sites this week.
Starbucks: fraps, breakfast sandwiches, and psychotherapy (for employees)
The decision of Starbucks to expand employee coverage for psychotherapy leads this week’s lineup.
We also consider the first Parliamentary speech of an Australian politician and a new British exhibit of old art – from asylums.
From the Editor
What’s new in psychotherapy?
Psychotherapy is an area of psychiatry transformed over the past years.
Dr. Aaron Beck: not a Freudian
Last week, we looked at a major new paper on IPT. This week, we return to Dr. Paul Garfinkel’s book – the source of two past Readings – for an excellent chapter on psychotherapy.
Last week. A major new review of IPT.
This week. An overview of psychotherapy developments.
This chapter describes the evolution of psychotherapy, and its importance. It also notes the excellent opportunity for the mental health field – to embrace evidence-based treatments and to offer better care for our patients.
From the Editor
What’s new in psychotherapy?
If there is one area of psychiatry that seems to have been transformed in recent years, it’s psychotherapy. Not surprisingly, then, past Readings have looked at the expanded role of short-term, evidenced-based therapies – in particular, Cognitive Behavioural Therapy, or CBT.
Today’s psychotherapy: a long way from Freud
Over the next two weeks, we’ll look in more detail at new developments in psychotherapy.
This week. A major new review of IPT.
Next week. An overview of psychotherapy developments.
This week, we consider a new paper published in The American Journal of Psychiatry on Interpersonal Therapy, or IPT. This paper is clear, lucid, and worth reading.
Is there evidence for IPT? Yes – and more than just for depression.
From the Editor
As medical school classes have grown, the supply of physicians has increased across the country. Has this helped address access issues in psychiatry?
How have practice patterns changed over time?
This week’s Reading seeks to answer some basic and important questions around physician supply and access in psychiatry. Following up on a major paper written in 2014, Kurdyak et al. have written another important and relevant paper.
The long and the short of it: there are significant problems with access – and they aren’t getting any better with time.
From a Contributing Editor, Colleague and Friend of the Editor
This week’s reading is a provocative companion piece to the recent review of efforts to reduce involuntary admission to hospital. It is the environmental expression of the legal deprivation of freedom of movement: the locked door. Locked doors have a powerful symbolic meaning in psychiatry; outpatients coming for elective consultations sometimes tell me they are afraid if they “say the wrong thing” that I will “lock them up”. Asylum superintendents carried large rings of keys that embodied power and control.
Locked doors, better outcomes?
Having spent half my career working on inpatient units, I am, like almost all of you, familiar with the locked doors that distinguish our wards from all others found in a hospital. And I know the reasons for their justification: prevention of elopement by people at risk of harm to themselves and others. And that prevention is intended to serve not only the patient and family but also the clinicians and the institution in terms of risk management. And yet…people do elope. Sometimes they return and sometimes they do not. Sometimes they attempt or complete suicide and sometimes they do not.
There is, as always, a tension between safety and risk, between freedom and protection, between autonomy and control. Locks are ubiquitous but not universal on psychiatric wards. What do we know about whether they make a difference? And what would be the ethically acceptable methodology for determining it?
– David Goldbloom, OC, MD, FRCP(C) Continue reading
From a Contributing Editor, Colleague and Friend of the Editor
All of us psychiatrists have exercised our responsibility for the involuntary admission of patients. Some patients (and many families) have expressed gratitude for this temporary but fundamental abrogation of civil freedoms – the freedom of movement – but for many patients it may be a source of fear and of loss of control and autonomy (even though the illnesses that they are experiencing also undermine control and autonomy). It may also reflect an upstream failure of less intrusive and earlier interventions to treat mental illness.
Involuntary admission: is there an alternative?
In an era of being patient-centred and recovery-focused, is a reduction in rates of involuntary hospitalization desirable? If you’re a human rights lawyer, the answer may be “well, yes, obviously”. If you’re a clinician, the answer may be “that depends on whether the patient ends up better or worse”. Nevertheless, there are a number of clinical initiatives in place whose goal would be to reduce the frequency of involuntary hospitalization (which does not preclude an increase in the rate of voluntary hospitalization).
So along comes a careful systematic review and meta-analysis of randomized trials to examine four categories of intervention that have, as their explicit primary or secondary outcome, a reduction in the rates of involuntary admission to psychiatric inpatient units. The interventions will seem familiar to any reader who has been involved in the care of people with severe and persistent mental illness. But the results are surprising.
– David Goldbloom, OC, MD, FRCP(C) Continue reading
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