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Reading of the Week: Physician, Heal Thyself: Residents and Depression, and More

December 17, 2015 /

From the Editor

This week – like last week – we pick a few interesting readings to consider.

This week’s selections: a chef and his addiction, a major new JAMA paper on resident physicians and depressive symptoms, and a big paper from BMJ comparing CBT and meds for depression.

Next week: the best of the year (the annual tradition). Suggestions are welcome for the best papers of 2015.

DG

Selection 1

“Three years after his mysterious disappearance, former Langdon Hall chef breaks his silence”

Mark Schatzker, The Globe and Mail, 1 December 2015

On the night of Dec. 28, 2012, Jonathan Gushue, one of Canada’s most decorated chefs, disappeared. He finished a dinner service at Langdon Hall that included pickerel in crème fraîche with black radish and black-pepper honey, got into his car and never arrived home.

No one, including Gushue’s wife, his sous chefs and his friends, knew what had happened to the 41-year-old father of three who, just two years earlier, had put Langdon Hall, in Cambridge, Ont., on the prestigious San Pellegrino World’s Best Restaurants list. As the chef’s disappearance made headlines from coast to coast, mysterious details began leaking out – his phone was found at an upscale Toronto hotel – but nothing more.

Thirteen days later, Gushue was found and reported safe. Several months later, he left Langdon Hall, then vanished from public life.

Jonathan Gushue

Gushue had it all – a young family and a soaring career. He also had alcoholism. Continue reading

Reading of the Week: A Father Mourns His Son, and More

December 10, 2015 /

Note from the Editor

In most Readings of the Week, a paper or essay is selected and then discussed in the commentary.

This week, we try something a bit different: a few pieces are selected and briefly discussed. We can cover more ground this way, and consider some pieces that may not have warranted a “full” Reading, but are still worthy of consideration.

DG

 

Selection 1: “How to Help Save the Mentally Ill From Themselves”

Norman J. Ornstein, The New York Times, 17 November 2015

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My older son, Matthew Ornstein, died at age 34 on Jan. 3 from carbon monoxide poisoning. It was accidental — he fell asleep in a tent with a propane lantern — but his death was shaped by a lack of judgment driven by a 10-year struggle with mental illness.

Continue reading

Reading of the Week: Let There Be Light

December 3, 2015 /

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.

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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?

November 26, 2015 /

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?

November 19, 2015 /

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?

November 11, 2015 /

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?

November 5, 2015 /

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

October 29, 2015 /

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