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Reading of the Week: On D-Day, Three Papers on Shell Shock, One by Dr. Charles Myers

June 6, 2019 /

From the Editor

Today is the 75th anniversary of D-Day.

Ceremonies are planned across the country, and across Europe; Prime Minister Justin Trudeau is in France. During these anniversaries, people comment on the importance of the moment. US President Barack Obama noted: “much of the progress that would define the 20th century, on both sides of the Atlantic, came down to the battle for a slice of beach only six miles long and two miles wide.” And people speak of the loss of life. US President Ronald Reagan, on a past anniversary, talked about “the boys of Pointe du Hoc” who had tried to take “these cliffs” off the beaches, noting that the majority were killed.

But the damage of war is not only in the loss of life.

In this week’s Reading, we consider shell shock and PTSD starting with the first paper on the topic, written by Dr. Charles S. Myers for The Lancet, published just over a century ago. Dr. Myers writes about three cases of shell shock, noting the similarities in their presentations.

La pointe du Hoc en Normandie (Calvados, Basse-Normandie, France)

We also consider a recent paper, published in JAMA Internal Medicine, discussing a more modern presentation – but perhaps not a profoundly different presentation. Finally, we consider a summary of recent published guidelines.

DG

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Reading of the Week: Dr. Farrell on Her Medical School Days & Her Depression

May 30, 2019 /

From the Editor

It’s been 19 years since I finished medical school. Though almost two decades have passed, medical schools are very similar today – the anatomy lessons, the white coat ceremony, the Hippocratic Oath.

But things appeared different then. No one seemed to have struggled with depression or anxiety. Except, of course, that people did – they struggled quietly, and with shame.

This week’s selection is short and moving, and was just published in JAMA. Dr. Colleen Farrell, a resident of internal medicine at NYU, writes about her depression during her med school days – and the lessons she has learned.

premednav_sinai_white_coat-jpg__750x325_q85_crop_subsampling-2_upscaleA white coat ceremony: 1 in 5 adults has a mental health problem – even here

This week, we consider Dr. Farrell’s essay.

DG

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Reading of the Week: Many Medications, Better Outcomes? Paul Kurdyak on the New JAMA Psychiatry Paper Considering Antipsychotics and Schizophrenia

May 23, 2019 /

From a Contributing Editor

For individuals with schizophrenia who are failed by trials of single antipsychotics, what’s next?

This week, we discuss a paper that addresses a treatment controversy. Antipsychotic polypharmacy (the use of more than one antipsychotic) is generally discouraged because the efficacy evidence is weak, and there is risk of increasing adverse events and effects with the addition of a second antipsychotic. Choosing Wisely is an initiative that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures; among their psychiatric recommendations is to avoid the use of multiple antipsychotics. The American Psychiatric Association contributed this to the Choosing Wisely initiative:

Research shows that use of two or more antipsychotic medications occurs in 4 to 35% of outpatients and 30 to 50% of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased. Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of Clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy.

 This is where this week’s selection comes in. The study, “Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia,” is from Finland by Karolinska Institutet’s Jari Tiihonen and his colleagues. This paper uses Finnish population-based health administrative data to evaluate the association between antipsychotic polypharmacy and psychiatric hospitalization. They conclude: “These results indicate that rational antipsychotic polypharmacy seems to be feasible by using 2 particular antipsychotics with different types of receptor profiles.”

kakslauttanen_aurora_augustFinland: home to big Northern Lights (and big databases)

In this Reading, we consider this paper and wonder if it should change our prescribing choices.

Paul Kurdyak, MD, PhD, FRCPC

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Open for Business: Chatbots, E-therapies, and the Future of Psychiatry

May 19, 2019 /

While not offering a solution for every patient in every circumstance, digital psychiatry may even be attractive to a subset of patients who would prefer a digital interaction to a human one, whether for financial and other pragmatic considerations (e.g., a single parent of 3 children, on public assistance, for whom getting to an office appointment is a major logistical problem and even financial hardship) or for more psychological and interpersonal reasons (e.g., someone with autism spectrum disorder for whom the lack of human connection with a chatbot may be helpful).

I’ve just edited an “in review” series for The Canadian Journal of Psychiatry considering digital psychiatry.

With my colleague Dr. David Goldbloom, I’ve co-written an editorial to open the series.

cpaaugcover2017

You can find our paper (which is open access) here:

https://journals.sagepub.com/doi/full/10.1177/0706743719850057

The Andersson et al. paper is here:

https://journals.sagepub.com/doi/full/10.1177/0706743719839381

The Vaidyam et al. paper is here:

https://journals.sagepub.com/doi/full/10.1177/0706743719828977

Reading of the Week: Can Social Connectedness Prevent Suicides? The New JAMA Psychiatry Paper on Caring Contacts in the Military

May 16, 2019 /

From the Editor

Social disconnectedness contributes to suicide. Past studies have tried to connect with people at risk, using simple tools like postcards.

This week, we look at a JAMA Psychiatry paper. The University of Washington’s Katherine Anne Comtois and her co-authors use a text message-based intervention (Caring Contacts) to try to reduce suicidal thoughts and behaviours in active military personal. They find: “Although the primary hypotheses were not supported, Caring Contacts was found to be a simple, scalable intervention that may be effective in reducing the occurrence of suicide ideation and attempts.”

Military man texts using smart phone in the city Suicide prevention by text: clever? Too clever?

We consider the paper and two editorials. We also consider a New York Times essay that asks: “If suicide is preventable, why are so many people dying from it?”

DG

 

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Reading of the Week: Ramadan and Mental Health Care – What are the Clinical Considerations?

May 9, 2019 /

From the Editor

For some patients, it carries deeply religious meaning. For others, it will be a time for reflection. And for us clinicians, it must be thought of in terms of patients’ management.

As our Muslim patients begin Ramadan, there are implications for care. About 80% of Muslims in North America will fast. Should medication times change? Would sleep be disrupted? Are patients on lithium at greater risk of toxicity? In a new paper, Dr. Zainab Furqan – a resident in the University of Toronto’s Department of Psychiatry – joins co-authors from three countries in considering Ramadan and care. They note that several groups are exempt from fasting but “many people who are exempt from fasting due to illness choose to fast during this month due to the spiritual significance of Ramadan for Muslim communities.”

They write: “It is important for clinicians not to undermine the importance of this spiritual practice for their patients.”

newmoon11A small moon and big challenges for care?

In this week’s Reading, we consider their new paper.

And an invitation: the Reading of the Week series invites guest contributions. If this is of interest, please let me know.

DG

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Reading of the Week: How Do University Students Use Cannabis? Also, the Life and Legacy of Richard Green, and Scott Gottlieb on E-Cigs

May 2, 2019 /

From the Editor

I don’t quite remember when I changed my interview questions, but at some point – more than a decade ago – I stopped assuming that if I asked about street drugs, patients would tell me about cannabis. Long before legalization, people stopped seeing cannabis as illicit. Today, not only is cannabis legal for recreational use, many see it as a drug to be taken for their health.

In a new Canadian Journal of Psychiatry paper, the authors write about cannabis use for medicinal purposes among Canadian university students. Drawing on a survey, they find wide use – but not exactly the use that follows the guidelines.

We also consider two other pieces: an obituary for Dr. Richard Green, a prominent psychiatrist who challenged the DSM’s inclusion of homosexuality, and an interview with Dr. Scott Gottlieb, the outgoing FDA Commissioner, who worries about e-cigarettes.

508221091 Use – but medicinal use?

Enjoy these selections.

And an invitation: the Reading of the Week series invites guest contributions. If this is of interest to you, please let me know.

DG

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Reading of the Week: CBT for Depression – What Really Works? The New JAMA Psychiatry Paper

April 25, 2019 /

From the Editor

“It changed my life.”

A few years ago, a patient described to me how helpful cognitive behavioural therapy was for him. CBT wasn’t his only treatment – he had a couple of medication trials – but he found the psychotherapy to be very helpful.

Others have had a similar experience, but CBT isn’t widely available in Canada; Puyat et al. found in a Canadian Journal of Psychiatry paper that the vast majority of people with depression don’t receive any form of psychotherapy or counseling. How can we address this access gap? Could different forms of CBT work including those that are less resource intensive? What to make of self-help?

In this Reading, we consider a new paper by Vrije Universiteit Amsterdam’s Pim Cuijpers and his co-authors that seeks to answer these questions. They use a network meta-analysis to compare five treatment formats with each other and control conditions (waiting list, care as usual, and pill placebo). Their conclusion: “This study suggests that group, telephone, and guided self-help treatments are effective interventions that may be considered as alternatives to individual CBT.”

dr-aaron-beck-at-work-595048284-5af62b4dae9ab80036aca7faAaron Beck: How to deliver the CBT he has championed (and should we all wear a bow tie)?

In this Reading, we consider the big paper and its big result, and the accompanying editorial by the University of Pittsburgh’s Dr. Holly A. Swartz and Jay Fournier.

DG

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Reading of the Week: Dr. Norman Doidge’s Essay on Psychotherapy, and Responses

April 18, 2019 /

From the Editor

Earlier this month, the University of Toronto Department of Psychiatry held a one-day conference on the Future of Psychotherapy. Speakers included Harvard University’s Dr. Vikram Patel, who has worked to expand access to care in low-income countries, and the University of Oxford’s Dr. David Clark, who has co-led the world’s largest program to improve access to evidence-based psychotherapy.

Here in Ontario, the future of psychotherapy will be influenced by several factors, including government payment. The day after the conference, when Drs. Patel and Clark were travelling home, a long essay ran in The Globe and Mail discussing a provincial government proposal to limit physician compensation for psychotherapy to 24 sessions a year; currently, there are no restrictions on the number of psychotherapy sessions billable per patient, allowing public funding of psychoanalysis. Dr. Norman Doidge, a psychoanalyst with affiliation with both the University of Toronto and Columbia University, argues strongly against the proposal. Psychiatry, he writes, will be left with “diagnose, and adios” – or worse, “diagnose, overdose, and adios.” Dr. Doidge – a bestselling author who has written on topics as diverse as the Palestinian conflict and brain plasticity, and who wrote the introduction to Jordan Peterson’s popular book – puts forward a well-crafted case.

terapia-kxsb-u11004258755405xyb-1024x576lastampa-itThe past of psychotherapy – but not its future?

In this Reading, we consider Dr. Doidge’s essay and some responses to it.

DG

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Reading of the Week: Cancer and Suicide – the New JAMA Psychiatry Paper

April 11, 2019 /

From the Editor

When I worked closely with cancer patients, we would often speak of that moment – the moment they were diagnosed, when they officially became cancer patients. Many recalled their first emotions: the disbelief, the shock, the anger. A few could even tell me sparkling details, like the way the doctor looked at them or what she was wearing. And, for all, that moment had been life altering.

That moment is followed by challenges, and for some, depression and even suicide.

What is the risk of suicide after the cancer diagnosis? In this week’s Reading, we look at a new JAMA Psychiatry paper. Drawing on English data, and involving 4.7 million people, Public Health England’s Katherine Henson and her co-authors look at cancer and suicide. They find: “Despite low absolute numbers, the elevated risk of suicide in patients with certain cancers is a concern, representing potentially preventable deaths.”

popepaintingBig diagnosis, big risk?

In this Reading, we consider the paper on this important topic, as well as an editorial.

DG

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