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Reading of the Week: Augmentation in the Elderly with Depression – the New NEJM Study; Also, Dr. Simpson on Violence (Globe)

April 13, 2023 /

From the Editor

“Approximately 30% of patients treated for depression do not have a response to selective serotonin-reuptake inhibitors (SSRIs).” So notes an Editorial in The New England Journal of Medicine. And for those who don’t respond, what’s the next step? 

Unfortunately, though many elderly struggle with depression, this population is understudied. In a new paper published in the same journal, Dr. Eric J. Lenze (of the Washington University in St. Louis) and his co-authors attempt to answer that question with a two-step intervention. “In older adults with treatment-resistant depression, augmentation of existing antidepressants with aripiprazole improved well-being significantly more over 10 weeks than a switch to bupropion and was associated with a numerically higher incidence of remission. Among patients in whom augmentation or a switch to bupropion failed, changes in well-being and the occurrence of remission with lithium augmentation or a switch to nortriptyline were similar.” We look at the study and its clinical implications, as well as the accompanying Editorial.

And, in the other selection, Dr. Sandy Simpson (of the University of Toronto) considers the violence seen on public transit in Canada’s largest city. In an essay for The Globe and Mail, he mulls several factors and points a way forward, including by advocating a guaranteed basic income. “We are seeing now that we have failed to create a compassionate society, and that security and safety needs to extend to all people. To achieve this, we need a change in heart, and expenditure.”

DG

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Reading of the Week: Mental Health Tsunami? The New BMJ Study on COVID; Also, Burnout & Professionalism (JAMA Health) and Buprenorphine (CMAJ)

April 6, 2023 /

From the Editor

How has COVID-19 impacted mental health? What to make of the forecasts of a mental health tsunami?

In a new BMJ paper, Ying Sun (of the Jewish General Hospital) and her co-authors do a systematic review and meta-analysis to try to answer these questions. Drawing on 137 studies, they consider mental and the pandemic. They find: “Most symptom change estimates for general mental health, anxiety symptoms, and depression symptoms were close to zero and not statistically significant, and significant changes were of minimal to small magnitudes…” We look at the paper and its clinical implications.

In the second selection, Dr. Dhruv Khullar (of Cornell University) writes about burnout and professionalism for JAMA Health Forum. He argues that burnout is common and costly, and points a way forward, in part by reducing clerical tasks. “A better path is one that strenuously removes the obstacles to physician and patient well-being and that actively promotes the deep work of doctoring.”

In the third selection, Dr. Ari B. Cuperfain (of the University of Toronto) and his colleagues consider extended-release buprenorphine, a subcutaneous monthly depot injection used to treat opioid use disorder in a short CMAJ paper. They make several observations about titration, effectiveness, and safety.

DG

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Reading of the Week: Amphetamines & ED Visits – the New CJP Paper; Also, Psilocybin for Depression (QT) and Anti-NMDAR Encephalitis (CMAJ)

March 30, 2023 /

From the Editor

Agitated, excited, violent – when intoxicated. But my patient is also pleasant and engaging when not using substance (crystal methamphetamine).

Amphetamine use seems more and more common. What does the data show? In a new paper for The Canadian Journal of Psychiatry, James A. G. Crispo (of the University of British Columbia) and his co-authors look at amphetamine-related ED visits in Ontario. Drawing on administrative databases, they find a sharp rise over time: a 15-fold increase between 2003 and 2020. They write: “Increasing rates of amphetamine-related ED visits in Ontario are cause for concern.”

In the second selection, Dr. Ishrat Husain (of the University of Toronto) comments on psilocybin and depression in a new Quick Takes podcast. He goes into detail on the new NEJM study – which he co-authored. Dr. Husain discusses the literature and unanswered research questions. “It’s not necessarily all sunshine and rainbows.”

And in the third selection, Dr. Candace Marsters (of the University of Alberta) and her colleagues consider the unusual presentation of young adult with first-episode psychosis in a new paper for CMAJ. With time and diagnostic testing, they conclude that she has anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, and offer observations about that diagnosis and the limitations of testing. “Anti-NMDAR encephalitis is a rare but important differential diagnosis of first-episode psychosis among young adults.”

DG

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Reading of the Week: The Cutting Edge – Pharmacotherapy for Depression, Apps for Mental Health & AI for Everything (or Maybe Not)

March 9, 2023 /

From the Editor

He’s been depressed for years and you are considering augmentation. Should you choose an antipsychotic? Which one?

These are good questions, especially when treating patients with treatment-resistant depression. In the first selection, Drs. Manish K. Jha (of the University of Texas) and Sanjay J. Mathew (of Baylor College of Medicine) look at four antipsychotics in an American Journal of Psychiatry paper. They review the literature for augmentation, including the use of cariprazine, which has just received FDA approval for this purpose. They find evidence, but “their long-term safety in patients with MDD is not well established, and they are potentially concerning regarding weight gain, metabolic dysfunction, extrapyramidal symptoms, and tardive dyskinesia.” We consider the paper and its clinical implications.

In the second selection, S. E. Stoeckl (of Harvard University) and her co-authors consider the evolution of mental health apps in a new paper for the Journal of Technology in Behavioral Science. Looking at hundreds of apps, they analyze data on updates, including new features. They find: “This study highlights the dynamic nature of the app store environments, revealing rapid and substantial changes that could present challenges for app selection, consumer safety, and assessing the economic value of apps.”

And in the third selection, Dr. Dhruv Khullar (of Cornell University) writes for The New Yorker about AI and mental health. In a long essay that touches on chatbots for therapy and screening tools for suicide prevention, he wonders if AI can help clinicians (and non-clinicians) overcome issues around access. “Can artificial minds heal real ones? And what do we stand to gain, or lose, in letting them try?”

Note: there will be no Readings for the next two weeks.

DG

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Reading of the Week: Peer Support – the New Psych Services Paper; Also, BMJ on Dr. Smith & Drs. Stergiopoulos and Hwang on TTC Violence (Tor Star)

March 2, 2023 /

From the Editor

Anxiety provoking. That’s how a patient recently described the first few days of hospitalization in an unfamiliar environment and feeling unwell. Would peer support have helped?

In the first selection, Cecilie Høgh Egmose (of the University of Copenhagen) and her colleagues conduct a systematic review and meta-analysis for Psychiatric Services. In this study, they analyzed 49 RCTs involving more than 12,000 participants and with different types of services and peer support. They find: “peer support interventions generally but only slightly improve outcomes of personal recovery and slightly reduce symptoms of anxiety among individuals with any mental illness.” We look at the paper and its clinical implications.

In the second selection, writer Adele Waters interviews the incoming president of the UK’s Royal College of Psychiatrists in a front cover article for The BMJ. Dr. Lade Smith’s new position is like a British combination of two Canadian presidencies: of the Royal College of Physicians and Surgeons and of the Canadian Psychiatric Association. She has had a big career as an educator, clinician, and researcher. And Dr. Smith is clear in her advocacy: “The chronic underfunding of mental health care must be tackled urgently. We have the evidence to make the case. Investing in mental healthcare is cost effective, saves lives, and enhances our economy.”

And in the third selection, Drs. Vicky Stergiopoulos and Stephen Hwang (both of the University of Toronto) mull violence and Toronto’s transit system. In an essay for the Toronto Star, they push past the headlines and suggest that we address core issues. They write: “Simply adding police officers and security guards on the TTC will not be sufficient. This is not a TTC problem but, rather, a whole system problem.”

DG

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Reading of the Week: Delirium in the ICU – the New NEJM Paper; Also, Admissions and COVID (CJP) and Dr. Boulay on Our Own (NEJM)

February 23, 2023 /

From the Editor

Is there a role for haloperidol in the treatment of delirium in ICU settings? That may seem like an unusual question since many patients receive this medication, perhaps half. But evidence is light.

In the first selection, Dr. Nina C. Andersen-Ranberg (of the University of Southern Denmark) and her co-authors consider ICU delirium with a new RCT, published in The New England Journal of Medicine. In this elegant study, half of the patients were randomized to receive haloperidol (in the IV form) and the other half received a placebo. They find: “Among patients in the ICU with delirium, treatment with haloperidol did not lead to a significantly greater number of days alive and out of the hospital at 90 days than placebo.” We consider the paper.

In the second selection, Dr. Scott B. Patten (of the University of Calgary) and his co-authors analyze hospital admissions and psychiatric diagnoses before and after the start of the pandemic. In this Canadian Journal of Psychiatry paper, they draw on Alberta data. Noting an existing literature on eating disorders, they also find an increase in patients with personality disorders being admitted. “[T]he increase was more pronounced than the widely reported increase in admissions for eating disorders.”

And, in the third selection, Dr. Richard M. Boulay (of St. Luke’s University Health Network) weighs in on physician mental health. In this highly personal New England Journal of Medicine paper, the gynecologic oncologist describes the problems of a second-year surgery resident who almost dies by suicide. He feels that she was failed by her program and medical culture itself. He writes: “[S]olutions are available. It’s time we began looking after our own.”

DG

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Reading of the Week: RCTs & Mental Health – the New CJP Paper; Also, AI and Discharge Summaries (Lancet DH), and Mehler Paperny on Action (Globe)

February 16, 2023 /

From the Editor

How has psychiatric research changed over time?

In the first selection, Sheng Chen (of CAMH) and co-authors attempt to answer this question by focusing on randomized controlled trials in mental health in a new paper for The Canadian Journal of Psychiatry. Using the Cochrane Database of Systematic Reviews, they look at almost 6,700 RCTs published over the past decades. They find: “the number of mental health RCTs increased exponentially from 1965 to 2009, reaching a peak in the years 2005–2009,” and observe a shift away from pharmacologic studies.

RCTs: the gold standard of research

In the second selection, Sajan B. Patel (of St Mary’s Hospital) et al. consider ChatGPT and health care in a new Lancet Digital Health Comment. Noting that discharge summaries tend to be under-prioritized, they wonder if this AI program may help in the future, freeing doctor to do other things. “The question for the future will be how, not if, we adopt this technology.”

And in the third selection, writer Anna Mehler Paperny focuses on campaigns to reduce stigma in a hard-hitting essay for The Globe and Mail. She argues that action is urgently needed to address mental health problems. She writes: “We need more than feel-good bromides. Every time someone prominent utters something about how important mental health is, the follow should be: So what? What are you doing about it? And when?”

DG

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Reading of the Week: Dr. Scott Patten on ChatGPT

February 9, 2023 /

From the Editor

Having only written four papers, the author wouldn’t seem particularly noteworthy. Yet the work is causing a buzz. Indeed, JAMA published an Editorial about the author, the papers, and the implications.

That author is ChatGPT, who isn’t human, of course – and that’s why it has made something of a splash. More than a million people tried this AI program in the week after its November launch, utilizing it to do everything from composing poetry to drafting essays for school assignments. 

What to make of ChatGPT? What are the implications for psychiatry? And for our journals?

To the last question, some are already reacting; as noted above, last week, JAMA published an Editorial and also updated its Instructions to Authors with several changes, including: “Nonhuman artificial intelligence, language models, machine learning, or similar technologies do not qualify for authorship.”

This week, we feature an original essay by Dr. Scott Patten (of the University of Calgary) for the Reading of the Week. Dr. Patten, who serves as the Editor Emeritus of The Canadian Journal of Psychiatry, considers ChatGPT and these three questions, drawing on his own use of the program.

(And we note that the field is evolving quickly. Since Dr. Patten’s first draft, Microsoft has announced a chatbot for the search engine Bing.)

DG

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Reading of the Week: Mental Health & Recidivism – the New CJP Paper; Also, Virtual Care in Canada (CIHI) and Dr. McKenzie on Health Service (Tor Star)

February 2, 2023 /

From the Editor

He explained to me that he has often been in the “system” – in and out of correctional institutions (and hospitals and shelters) – since he was first diagnosed with schizophrenia in his late adolescence, with charges like failure to appear. The story is too familiar. 

How common is recidivism with those who have mental disorders like my patient? What’s a way forward? In the first selection, Michael Lebenbaum (of the University of Toronto) and his co-authors try to answer these questions in a new paper for The Canadian Journal of Psychiatry. Drawing on Ontario administrative databases, they conducted a population-based cohort study with a sample of almost 46 000 people. They find: “Despite a high risk of recidivism and acute MHA [mental health and addiction] utilization post-release, we found low access to MHA outpatient care, highlighting the necessity for greater efforts to facilitate access to care and care integration for individuals with mental health needs in correctional facilities.” We consider the paper and its clinical implications.

In the second selection, the authors detail different aspects of mental health services and the rise of virtual care in recent years. This new CIHI report highlights physician services. They note the general increase of virtual care with the start of the pandemic: “in 2019–2020, virtual services accounted for 4% of mental health services provided by physicians, while in 2020–2021, they accounted for 57%.” They also consider income (by analyzing neighbourhood data) and geography. 

And in the third selection, Dr. Kwame McKenzie (of the University of Toronto) writes about the health care system in a new Toronto Star essay. While many focus on public versus private provision, Dr. McKenzie sees this debate as a diversion from more fundamental issues. He argues: “If we do not focus on right-sizing the health service and building in redundancy, it is only a matter of time before we see the system crashing.”

DG

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Reading of the Week: CBT for Depression – the Latest Evidence; Also, Digital Mental Health (World Psych) and Dr. Castro-Frenzel on Her Cancer (JAMA)

January 26, 2023 /

From the Editor

Cognitive behavioural therapy is widely used for the treatment of depression – but the last significant meta-analysis was published a decade ago. What’s the latest evidence? 

In the first selection, Pim Cuijpers (of the Vrije Universiteit Amsterdam) and his co-authors try to answer this question with a new meta-analysis including more than 400 randomized trials with almost 53 000 patients (yes, you read that correctly). In this World Psychiatry paper, they compare the therapy with controls, other therapies, and medications. They write: “We can conclude that CBT is effective in the treatment of depression with a moderate to large effect size, and that its effect is still significant up to 12 months.” We consider the paper and its clinical implications.

Beck: the father of CBT

In the second selection, Dr. John Torous (of Harvard University) and his co-authors look at digital mental health. Despite widespread use of smartphones – perhaps 80% of the world’s population now has access to one – “digital mental health is not transforming care.” In this Editorial for World Psychiatry, they wonder why. They also point a way forward: “Developing a new generation of digital mental health tools/services to support more accessible, effective and equitable care is the true innovation ready to be stoked today by each person who becomes empowered to connect, set up, engage, start/stop, and demand more from mental health technology.”

Finally, in the third selection, Dr. Karla Castro-Frenzel (of the University of Central Florida) writes about a patient with advanced lung cancer. As it turns out, she’s that patient. In this personal essay published in JAMA, she writes about being a doctor and a patient. “My ultimate hope… is that we can create space for illness as well as wellness. In helping our colleagues feel safe and supported when they become patients, we rehumanize our environments and our very selves.”

DG

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