CategoryUncategorized

Reading of the Week: Let There Be Light

Major depressive disorder (MDD) affects at least 5% of the population, with a lifetime prevalence estimated at 14%. It is the second-ranked cause of disability worldwide and is associated with impairment in quality of life, increased risk of mortality, and societal burden. Treatments for MDD include psychotherapies and antidepressants, but remission rates remain low despite adequate treatment and more therapeutic options are needed.

Light therapy, an effective treatment for seasonal affective disorder (SAD), may also be appropriate for MDD. Bright light is a safe, well-tolerated, nonpharmacological treatment that can be used alone or combined with medications. Light can correct disturbed circadian rhythms, which have been implicated in the pathophysiology of MDD. Previous metaanalyses of light therapy for nonseasonal MDD, however, have yielded only equivocal and conflicting evidence for efficacy. Two more recent systematic reviews both concluded that the quality and methods of the identified studies were too heterogeneous to conduct a meta-analysis. They each found insufficient evidence for efficacy of bright light monotherapy, although 1 review found low-quality evidence for bright light as adjuvant treatment to antidepressants.

In summary, these systematic reviews indicate that the evidence for benefits of bright light therapy for nonseasonal MDD is inconclusive and well-designed studies are required to resolve this issue.

So begins a new paper on depression. I like these opening paragraphs and, in particular, the first paragraph (and its bluntness). For the clinicians among us, the final phrase is hauntingly true: “more therapeutic options are needed.”

This week’s Reading: “Efficacy of Bright Light Treatment, Fluoxetine, and the Combination in Patients With Nonseasonal Major Depressive Disorder: A Randomized Clinical Trial” by Dr. Raymond W. Lam et al., which was just published online (ahead of print) in JAMA Psychiatry.

image001

This is a big paper in a big journal with big clinical implications. It’s also very Canadian – every co-author lives north of the 49th parallel; the first author hails from Vancouver.

We know that light therapy works for those with a seasonal pattern to their depression. But could we use the light therapy for other people suffering from depression? The authors attempt to answer this question. Continue reading

Reading of the Week: Can We Prevent Depression For Those At Risk?

Depression is the leading cause of disability worldwide and commonly begins in adolescence. Prevention is one viable strategy for reducing the population burden of depression because most depressed adolescents do not receive specialty mental health treatment and because untreated depression is associated with enduring deleterious effects on interpersonal relationships, educational attainment, and occupational status.

Single-site studies have demonstrated the efficacy of an adaptation of the Coping with Depression for Adolescents intervention in preventing the onset of depression relative to usual care in adolescents with subsyndromal depressive symptoms and in those with a parental history of depression. These results were replicated in our 4-site randomized clinical trial of 316 high-risk adolescents randomly assigned to either an adaptation of the Coping with Depression for Adolescents (cognitive-behavioral prevention [CBP]) plus usual care or usual care alone, which found a lower incidence of depressive episodes at 9 and 33 months after enrollment in those who received CBP.

So begins a new paper that seeks a lofty goal: using a psychological intervention to prevent depression before it starts.

This week’s Reading: “Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents: A Randomized Clinical Trial” by Dr. David A. Brent et al., which was published in the November JAMA Psychiatry.

In this paper, Brent et al. attempt something we often dream about in psychiatry – but are so rarely able to achieve: prevention. That alone would make this paper worth considering. But there’s more: the study features an incredible follow up period (a full six years) and a consideration of the parent, not just the at-risk adolescent. Pulling it together: this is a big paper in a big journal with a big result.

Dr. David Brent

So, can we take an at risk population and, with therapy, prevent them from developing a major mental illness? This is what the study authors seek to find out. As they note early in the paper: “We hypothesized that those who received CBP would have a lower hazard of depression onsets and better developmental competence during emerging adulthood.” Continue reading

Reading of the Week: Mindless Psychiatry?

Recently, a psychiatric study on first episodes of psychosis made front-page news. People seemed quite surprised by the finding: that treatment programs that emphasized lower doses of psychotropic drugs, along with individual psychotherapy, family education and a focus on social adaptation, resulted in decreased symptoms and increased wellness.

So begins a thoughtful essay considering the state of psychiatry.

This week’s Reading: “Psychiatry’s Mind-Brian Problem” by Dr. George Makari, which was published recently in The New York Times.

You can find the article here:

http://www.nytimes.com/2015/11/11/opinion/psychiatrys-mind-brain-problem.html?src=me

In this short essay, Dr. Makari, a professor of psychiatry at Weill Cornell Medical College, opens by contemplating the new American Journal of Psychiatry paper by Dr. John M. Kane et al., which shows that first-episode psychosis patients treated with more than just medications – individual psychotherapy and family education and a focus on social adaptation in the study – did better than those treated with just meds.

The real surprise… was that this was considered so surprising.

Continue reading

Reading of the Week: Psychiatry’s Dirty Little Secret?

Stigma has repeatedly been identified as a major barrier to help seeking for mental health problems across various disorders and across the lifespan. Stigma is also an obstacle to community reintegration and rehabilitation in people suffering from severe mental illness. Moreover, people with psychiatric diagnoses suffer the effects of discrimination in health care settings. Not only do people with mental illness have diminished access to primary care, there is evidence to suggest that physicians perform fewer physical examinations and laboratory investigations, provide less preventive health care, and undertake fewer therapeutic interventions in this population. Researchers are increasingly framing the problem of stigma as a public health issue.

So begins a new paper that considers stigma and mental health.

This week’s Reading: “Explicit and Implicit Attitudes of Canadian Psychiatrists Toward People With Mental Illness” by Dr. Layla Dabby et al., which was just published in The Canadian Journal of Psychiatry.

This paper shows that members of the public demonstrated relatively negative explicit attitudes towards mental illness. In fact, Canadians reported a desire for greater social distance from the patient with schizophrenia as opposed to the patient with diabetes, even though the study describes the patient with schizophrenia as well-controlled by medication. Wow.

Except here’s the twist in the tale. The paper actually didn’t look at the public. The paper looked at psychiatrists and residents of psychiatry. In other words, the relatively negative explicit attitude wasn’t from the uninformed small businessman in Edmonton or the teacher in Halifax; it reflects the biases of people like… me.

Is this psychiatry’s dirty little secret? Continue reading

Reading of the Week: Ending Revolving Door Justice?

More than 10 million people are currently in prison worldwide, and substantially larger numbers of ex-prisoners are living in society. Despite reported decreases in violence in many countries, repeat offending remains high across many high-income and middle-income countries. In the USA and UK, more than a third of released prisoners are reconvicted for a new crime within 2 years, and more than half within 5 years. Furthermore, about 70% of those convicted in the USA are repeat offenders. In England and Wales, this figure is estimated at 90%, and the proportion of individuals convicted who have had 15 or more previous offences has been increasing since 2008.

So begins a new paper that considers Swedish prisoners and the likelihood of reoffending with a particular focus on those with mental disorders. This opening paragraph well describes our incredible success at crime reduction – historical lows across the west – and our incredible failure – those who do end up in jail often are convicted again (and again and again).

This week’s Reading: “Psychiatric disorders and violent reoffending: a national cohort study of convicted prisoners in Sweden” by Zheng Chang et al., which was just published in The Lancet Psychiatry.

Zheng Chang

This paper may not seem immediately relevant – it draws on European data and was published in a British journal. In fact, it is. First, Canada’s prison population has a high rate of mental illness (an International Journal of Law and Psychiatry study found that a third of people entering Canadian penitentiaries met criteria for mental illness.). Second, there is growing interest in prisoners and mental health, both in Ottawa and beyond. Chang et al. helps shed light on this important issue – and perhaps even points the way to more sensible public policy. Continue reading

Reading of the Week: Marijuana Use and Misuse

In the United States, laws and attitudes toward the use of marijuana are changing. Twenty-three states now have medical marijuana laws, and marijuana use is higher in states with such laws than in other states. Four of these states have also legalized marijuana for recreational use. More Americans now favor legalization of marijuana use than in previous years. Further, fewer Americans view marijuana use as risky, although studies have shown that use or early use of marijuana is associated with increased risk for many outcomes, including cognitive decline, psychosocial impairments, vehicle crashes, emergency department visits, psychiatric symptoms, poor quality of life, use of other drugs, a cannabis-withdrawal syndrome, and addiction risk. Further, marijuana use disorders (abuse or dependence) are associated with substantial comorbidity and disability and are consequently of substantial public health concern.

So begins a new paper looking at an old question: how does drug legalization affect use and misuse?

This week’s Reading: “Prevalence of Marijuana Use Disorders in the United States Between 2001-2002 and 2012-2013” by Deborah S. Hasin et al., just published online (and ahead of print) by JAMA Psychiatry.

You can find the paper here:

http://archpsyc.jamanetwork.com/article.aspx?articleid=2464591

Columbia University’s Hasin and her co-authors have picked a timely topic. Here’s a quick summary: as laws and public attitude have shifted, looking at U.S. survey data, they conclude that marijuana use has sharply increased. Continue reading

Reading of the Week: Psychiatry and West Africa

KPOVÉ, Togo — The church grounds here sprawled through a strange, dreamlike forest. More than 150 men and women were chained by the ankle to a tree or concrete block, a short walk from the central place of worship. Most were experiencing the fearsome delusions of schizophrenia. On a recent visit, some glared, while others slept or muttered to themselves. A few pushed to their feet and gestured wildly, their cries piercing the stillness.

Until this year, Koffi Gbedjeha, 45, a carpenter and father of four, was one of them — a resident of the Jesus Is the Solution prayer camp here, shackled like the others, his family and camp staff members said. For more than two years, his youngest sister, Akossiwa, 27, tended to him. Rising early each morning, she walked along a cool red-earth path to the human forest; each day, amid the stirring bodies and clinking chains, she emptied her brother’s chamber pot, swept the ground and cooked his meals over a charcoal fire.

So begins a series of articles on mental illness in West Africa.

This week’s Reading: “The Chains of Mental Illness in West Africa” by Benedict Carey, which was published earlier this month in The New York Times.

The selection may seem a bit unusual – Readings, after all, usually draw from journals, not from the Sunday paper. But Carey’s reporting is unusually lucid. If you haven’t read his article, I invite you to read it; if you saw this before, it’s worth re-reading.

You can find the article here:

http://www.nytimes.com/2015/10/12/health/the-chains-of-mental-illness-in-west-africa.html?hp&action=click&pgtype=Homepage&module=photo-spot-region&region=top-news&WT.nav=top-news&_r=0

Benedict Carey Continue reading

Reading of the Week: Of Pills and Placebo – The Pecina et al. paper

High rates of placebo responses are consistently reported across medical conditions, notably mood disorders, Parkinson disease, and pain, but also schizophrenia, substance use disorders, and surgical procedures. Placebo response rates in antidepressant trials average 31% to 45% compared with approximately 50% responses to antidepressants, and they have increased over the last 30 years. The failure of antidepressant responses to separate from placebo has contributed to the reduction or discontinuation of research on new treatments for depression and other neuropsychiatric illnesses, hindering the development of novel neuropsychiatric treatments.

So begins a new paper considering the relationship between placebo and depression treatment.

This week’s Reading: “Association Between Placebo-Activated Neural Systems and Antidepressant Responses Neurochemistry of Placebo Effects in Major Depression” by Dr. Marta Peciña et al., which was just published “online first” by JAMA Psychiatry.

Dr. Marta Peciña

Here’s a quick summary: this is a big paper in a big journal that seeks to better understand the placebo effect and antidepressants, and taps neuroimaging to do so. There is, however, a catch: the number of patients involved is small. Continue reading

Reading of the Week: The Silence of Prozac

In the 1980s, historian of pharmacology Mickey Smith wrote that new blockbuster medicines enter society by a three-step process. First, a wild popular embrace, driven by overestimation of the drug’s potential, leads to overuse; next, the sudden discovery of “problems” with the drug leads to a backlash; and finally, a state of equilibrium is reached, in which the drug is used judiciously, its real benefits and limits seen clearly at last. Smith called these three stages the “law of the wonder drug.”

I remembered Smith’s formula not long ago, while talking to an old friend on a summer ramble around New York City. The substance of our conversation was that antidepressants – a topic we’d bandied back and forth together for almost 20 years, in various states of using them ourselves and not – had begun to seem quaint. Maybe even a little retro, like lava lamps or tube socks.

So begins a short, cutting essay on antidepressants.

The piece is timely: once considered miracle drugs for depression, this medication class has come under sharp criticism, and yet has gained wide acceptance. In my clinical work, I’m surprised by the large number of patients – particularly younger patients – who hesitate about these medications; I’m also surprised by the large number of patients – particularly younger patients – who are on these medications.

This week’s Reading: “The silence of prozac” by author and essayist Katherine Sharpe, which was just published in The Lancet Psychiatry.

Katherine Sharpe

Continue reading

Reading of the Week: Dr. Linda Gask’s New Book (Depression: Week 3 of 3)

This is a story about overcoming depression and also about coming to terms with loss. The two are closely related to each other. I know about this not just from my personal experience, but because I am a psychiatrist. I have specialised in treating those who suffer from the same problems which have afflicted me throughout my adult life. I’ve survived and come through it, and I know others can too.

So opens a new book by Dr. Linda Gask, a British psychiatrist. This Week’s Reading: an exclusive excerpt from The Other Side of Silence: A Psychiatrist’s Memoir of Depression, which was just published by Summersdale Publishers Ltd.

otherside

This Reading is the third part in a three-part series on depression.

Two weeks ago: a look at better psychopharmacological management.

Last week: consideration of better treatment in the primary care setting.

This Week: a look at the burden of illness on the patient and the psychiatrist.

(And this isn’t Mad Men Season 4. Miss a week and you aren’t lost.)

Dr. Gask has had a remarkable career. Beyond clinical work, she’s had a sparkling academic career, with a focus on mental-health policy and practice. She’s published papers and book chapters; she’s trained residents; she’s lectured all over the world. She was a Harkness Fellow at the Group Health Research Institute in Seattle, Washington. And she has also worked as a consultant for the World Health Organization and with the World Psychiatric Association.

GaskDr. Linda Gask

Continue reading