From the Editor
This week’s Reading: an excerpt from the new Goldbloom-Bryden book.
Get this book. Read it. Share it with your friends.
It’s beautifully written and important.
Category: Reading of the Week
Reading of the Week: How Successful Are We at Treating Canadians with Depression? And More
From the Editor
How successful are we at treating Canadians with depression? How could Canada’s health care system serve these patients better?
This is the ‘all Canadian’ issue of the Reading of the Week.
Readings don’t necessarily follow a theme – but we do this week. The two papers are written by Canadian authors; they tackle Canadian topics; they were published in a Canadian journal, The Canadian Journal of Psychiatry.
The first paper considers depression in Canada, looking at prevalence and treatment over a decade. The second paper champions more effective care for Canadians. Both are readable and relevant.
Reading of the Week: Doctor-Assisted Suicide: The Dutch Experience
From the Editor
Is the practice of psychiatry about to change?
We often think of change in terms of treatment developments – new drugs and therapies. But mental health services are delivered in a larger societal context, and our work is shaped by laws and court rulings. With that in mind, Carter v. Canada has the potential to reshape our work. As you know, last year, the Supreme Court of Canada struck down the provision of the Criminal Code prohibiting doctor-assisted suicide. Later today, a special joint parliamentary committee will issue its report, guiding the drafting of legislation that will legalize doctor-assisted suicide.
How will this future legislation affect those with mental illness? What will it mean for people like us who do clinical work? Obviously, it’s not possible to comment on legislation that hasn’t been drafted yet. But it is possible to look to other countries and consider their experience. In this week’s Reading, Kim et al. consider physician-assisted suicide and euthanasia in the Netherlands. In their study of a country across the ocean, there are lessons for our patients here.
Reading of the Week: Euthanasia, Psychiatry, and the Thienpont et al. paper
The Belgian Euthanasia Law (2002) defines euthanasia as the physician’s “act of deliberately ending a patient’s life at the latter’s request,” by administering life-ending drugs.In Europe, psychological suffering stemming from either a somatic or mental disorder is acknowledged as a valid legal basis for euthanasia only in Belgium, the Netherlands and Luxembourg.In the Netherlands and Luxembourg, the term ‘assisted suicide’ is used when the life-ending drugs are taken orally, but in Belgium, the term ‘euthanasia’ is used whether the drugs are received orally or intravenously.
So begins a new paper on euthanasia in Belgium.
The topic is fascinating and it’s also highly relevant in Canada. As you will recall, Carter v. Canada – the Supreme Court ruling made earlier this year – speaks directly to the right to doctor-assisted suicide. (I’ll return to this point in a moment.)
This week’s Reading: “Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study” by Dr. Lieve Thienpont et al., which was just published online at BMJ Open.
Though much has been written about Belgium and euthanasia (a June Reading considered a New Yorker essay on the topic), little data has been analyzed. And that’s what makes the Thienpont et al. paper interesting. A quick summary: in a first-of-it-kind paper, the authors consider 100 psychiatric patients requesting euthanasia – from their diagnosis to their final outcome. It should be noted that the first author is a leading proponent of euthanasia and was actively involved in the care and decision making of these patients.
Reading of the Week: Depression and Measurement-Based Care (Depression: Week 1 of 3)
Major depression is common, leading to marked suffering for patients and families and causing physical and mental disability, with a substantial economic burden. Although major depression is prevalent across different cultures and effective pharmacological and psychosocial interventions are available, low remission rates in clinical practice are discouraging. Poor outcomes are related to inadequate dose and duration of pharmacotherapy, poor treatment adherence, high dropout, and frequent as well as unnecessary medication changes. In addition, inconsistency of treatment strategies among clinicians is common. Even in current, guideline-driven practice, there are often wide variations in clinicians’ behaviors, resulting in practice bias rather than a tailored and individualized treatment algorithm.
So opens a new paper that has a large goal: trying to reduce that “wide variation” and improve patient care.
This week’s Reading: “Measurement-Based Care Versus Standard Care for Major Depression: A Randomized Controlled Trial With Blind Raters” by Tong Guo et al., just published online (and ahead of print) by The American Journal of Psychiatry.
Find the paper here:
http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.14050652
Here’s a quick summary: big study, big journal, and big implications for depression management (and, yes, your patients). In a head-to-head comparison, patients did better when depression management included an algorithm for medications rather than regular psychiatrist care. Continue reading
Reading of the Week: Insomnia and Its Treatment
Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent treatment package that usually includes stimulus control, sleep restriction, and cognitive therapy and has emerged as the most prominent nonpharmacologic treatment for chronic insomnia. Previous meta-analyses have found that CBT-I improves sleep parameters and sleep quality at post treatment and follow-up for adults and older adults. Most of these studies selected individuals with primary insomnia, excluding patients with co-morbid psychiatric and medical conditions. However, patients with insomnia who present to internists and primary care physicians are likely to report comorbid conditions associated with the sleep disturbance. Furthermore, insomnia was previously conceptualized as a symptom arising from the comorbid disorder and treatment was targeted at the underlying disorder. However, accumulating evidence indicates that insomnia can have a distinct and independent trajectory from the comorbid disorder, thus indicating a need for separate treatment from the comorbid condition.
So begins this week’s Reading, which considers CBT-I for people with insomnia. Here’s a quick summary: big study, big journal – and big relevance to your patients.
This week’s Reading: “Cognitive Behavioral Therapy for Insomnia Comorbid With Psychiatric and Medical Conditions: A Meta-analysis” by Jade Q. Wu et al. was just published in JAMA Internal Medicine. Find the paper here.
Wu et al. consider a very common problem: insomnia. Many patients – whether they have mental health issues or physical health issues – struggle with insomnia. Boston University health economist Austin Frakt has written about his insomnia for The New York Times. He notes that he decided to receive treatment when:
One weekend afternoon a couple of years ago, while turning a page of the book I was reading to my daughters, I fell asleep. Continue reading
Reading of the Week: Depression: Is There an App for That?
Depression is a serious, common, and recurring disorder linked to diminished functioning, quality of life, medical morbidity, and mortality. There has been a 37.5% increase in health life years lost to depression over the past two decades. Depression was the third-leading cause of global burden of disease in 2004 and the leading cause of burden of disease in high- and middle-income countries. It is projected to be the leading cause globally in 2030. While effective treatments for depression are available, they are underused. Barriers to treatment include geography, socioeconomic status, system capacity, treatment costs (direct and indirect), low mental health literacy, cultural beliefs, and stigma. A 2010 study found that 75% of primary care patients with depression in urban areas could identify more than one structural, psychological, cultural, or emotional barrier to accessing behavioral treatments. The rate was substantially higher in rural areas.
So begins a new paper that considers an old problem – the difficulty of patients accessing mental health care.
But this paper is different. It considers a modern approach to access: smartphone and tablet applications (or apps) for depression. And it’s not just the topic that is so modern with this week’s Reading. Consider: the paper was published in a new journal, JMIR mHealth and uHealth, available only on-line, and focused on the very modern topic of mobile health. (This journal is a spin-off of JMIR, the Journal of Medical Internet Research, itself a relatively new journal, which boasts an impact factor of 4.7 in 2013.)
This week’s Reading: “Finding a Depression App: A Review and Content Analysis of the Depression App Marketplace” by Nelson Shen et al. In it, the authors seek to shed light on a poorly studied area. As they note early in the paper, despite the incredible popularity of apps, only one recent systemic review looked at depression apps, and included just 4 papers. And so, Shen et al. consider apps for depression, drawing out common characteristics and purposes.
This is, then, an important topic. The potential here is great: with so many of our patients empowering themselves with apps, those with depression could potentially access good information, screening tools and even treatments such as CBT.
What did Shen et al. find in their paper? It’s best summarized by the old Roman phrase caveat emptor (let the buyer beware). Continue reading
Reading of the Week: The New Yorker Essay on De Troyer (and Carter v. Canada)
In her diary, Godelieva De Troyer classified her moods by color. She felt “dark gray” when she made a mistake while sewing or cooking. When her boyfriend talked too much, she moved between “very black” and “black!” She was afflicted with the worst kind of “black spot” when she visited her parents at their farm in northern Belgium. In their presence, she felt aggressive and dangerous. She worried that she had two selves, one “empathetic, charming, sensible” and the other cruel.
She felt “light gray” when she went to the hairdresser or rode her bicycle through the woods in Hasselt, a small city in the Flemish region of Belgium, where she lived. At these moments, she wrote, she tried to remind herself of all the things she could do to feel happy: “demand respect from others”; “be physically attractive”; “take a reserved stance”; “live in harmony with nature.” She imagined a life in which she was intellectually appreciated, socially engaged, fluent in English (she was taking a class), and had a “cleaning lady with whom I get along very well.”
So begins this week’s reading, an essay by writer Rachel Aviv that was just published in The New Yorker.
It’s a moving and tragic story of a woman who struggles with low mood. If she dreams of fluent English and a cleaning lady, her life takes a turn for the worse: after a breakup, she “feels black again.” Loss and estrangement replace hope and love. After years of struggling, the near elderly woman ultimately chooses to end her life. But she doesn’t die by her own hand; she dies in a clinic at the hands of a physician. To us Canadians, this is a story that is both familiar – involving psychiatry and medications – and unfamiliar – euthanasia and state-sanctioned doctor-assisted suicide.
De Troyer’s life and death occurs an ocean away, in Belgium. But, in light of a recent Supreme Court of Canada ruling in Carter v. Canada, a question to ask: how will doctor-assisted suicide reshape psychiatry in this country? Continue reading
Reading of the Week: My lovely wife in the psych ward
There’s no handbook on how to survive your young wife’s psychiatric crisis. The person you love is no longer there, replaced by a stranger who’s shocking and exotic. Every day I tasted the bittersweet saliva that signals you’re about to puke. To keep myself sane I hurled myself at being an excellent psychotic-person’s spouse. I kept notes on what made things better and what made things worse. I made Giulia take her medicine as prescribed. Sometime this meant watching her swallow, then checking her mouth to confirm that she hadn’t hidden the pills under her tongue. This dynamic led us to become less than equals, which was unsettling.
I’ve been a physician now for nearly a decade and a half. Much of everything has become routine. It wasn’t always like this. I remember the first night on call as a medical student doing my Internal Medicine rotation – the angst and confusion, as I received page after page. As a resident, I remember my first few “observed” psychiatric interviews, with the entire team present, so many people watching me. I remember the first few months of being an attending, trying to pace myself and navigate everything from dictations to the parking lot. But those days are behind me. Practicing day after day, week after week, year after year, routine sets in.
For patients and their families, though, health care is so often not routine – and that’s especially true with mental illness. It’s a world of first appointments, unexpected side effects and complications, recovery and relapse. Continue reading
Reading of the Week: The Best of 2014
As one year draws to a close and the next begins, it’s an annual Reading of the Week tradition to weigh in on the best of the past 12 months.
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