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Reading of the Week: Psychiatry and West Africa

October 22, 2015 /

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

October 15, 2015 /

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

October 8, 2015 /

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: Euthanasia, Psychiatry, and the Thienpont et al. paper

September 30, 2015 /

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.

Continue reading

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

September 24, 2015 /

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

Reading of the Week: Depression and Primary Care (Depression: Week 2 of 3)

September 17, 2015 /

Depression is a common psychiatric disorder and a major contributor to mortality and morbidity worldwide. Over the past decade in Sweden, work absence because of mental ill health has risen markedly and depression is a major factor. Substantial societal costs are associated with the disorder, which affects up to 15% of the population at any one time and tends to be recurrent. There are compelling reasons to investigate alternative treatments for depression. Although effective treatments exist, most people with the disorder never seek professional help. Among those that do, only half appear to benefit. Adherence with medication is often poor and waiting times for cognitive–behavioural therapy (CBT) can be lengthy, resulting in more entrenched symptoms and a worse long-term prognosis. As general medical practitioners are frequently the main care providers for depression, treatment options that are non-stigmatising, have few side-effects and can readily be prescribed in community healthcare settings are needed.

So begins a new paper that considers depression treatment in Sweden. These issues sound very familiar. Reading over this list of problems – the burden of illness, the inaccessibility of care, etc. – we could replace Sweden with Canada. And that’s why this paper is so relevant to us.

This week’s Reading: “Physical exercise and internet-based cognitive–behavioural therapy in the treatment of depression: randomised controlled trial” by Mats Hallgren et al., which was just published in the British Journal of Psychiatry.

Mats Hallgren

A quick summary: this is a smart paper seeking ways to improve the treatment of depression in the primary care setting. How to achieve better results? Hallgren et al. consider exercise and Internet-based CBT, and compare such interventions to the usual care. Continue reading

Reading of the Week: Depression and Measurement-Based Care (Depression: Week 1 of 3)

September 10, 2015 /

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: Immigration and Psychosis (and Canada)

September 3, 2015 /

Meta-analytic reviews suggest that international migrants have a two to threefold increased risk of psychosis compared with the host population, and the level of risk varies by country of origin and host country. This increased risk may persist into the second and third generations. Incidence rates are not typically found to be elevated in the country of origin; therefore it is believed that the migratory or postmigration experience may play a role in the etiology.

The migration-related emergence of psychotics disorders is a potential concern in Canada, which receives 250,000 new immigrates and refugees each year. However, there is a notable lack of current epidemiological information on the incidence of psychosis among these groups.

So begins a new paper that seeks to answer a basic question: are there certain migrant groups more at risk of psychotic disorders in Canada?

This week’s Reading: “Incidence of psychotic disorders among first-generation immigrants and refugees in Ontario” by Kelly K. Anderson et al., which was published in the CMAJ in June.

Kelly K. Anderson

Of course, studying the incidence of psychotic disorders in immigrant populations isn’t exactly novel – there is a rich literature in this field. And the Canadian angle isn’t novel either – as the paper points out, previous studies have considered B.C. hospital admission rates for schizophrenia in European migrants in the early 1900s.

But this paper aims to consider recent data and Canadian data – relevant in a country that takes in 250,000 migrants a year. The paper focuses on Ontario, where first generation migrants constitute almost a third of the population.

Continue reading

Reading of the Week: Is CBT Losing Its Effectiveness? The Johnsen and Friborg Paper

August 27, 2015 /

Depressive disorders (DDs) can be highly disabling and are ranked third in terms of disease burden as defined by the World Health Organization, and first among all psychiatric disorders in terms of disability adjusted life years. In addition, DDs seem to be rising globally, and a 20% annual increase in its incidence has been predicted. Improvements in treatment methods and prevention measures, and the availability of community psychiatric services are, therefore, as important as ever before.

So begins, without much controversy, this week’s Reading – which happens to be one of the most controversial papers of the year.

This meta-analysis has been mentioned in newspapers and blogs. No wonder – in 22 pages, it raises questions about the effectiveness of a major psychiatric treatment: cognitive behavioural therapy.

The Reading: “The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis” by Tom J. Johnsen and Oddgeir Friborg, recently published in the prestigious Psychological Bulletin.

The full paper can be found here:

https://uit.no/Content/418448/The%20effect%20of%20CBT%20is%20falling.pdf

Tom J. Johnsen

A quick summary: analyzing data from 70 studies over nearly four decades, Johnsen and Fribourg find CBT to have become less effective at reducing depressive symptoms. Continue reading

Reading of the Week: Housing First and At Home/Chez Soi

August 20, 2015 /

Homelessness is a significant social problem in Toronto, Canada’s largest and most ethnically diverse urban center, where approximately 29,000 individuals use shelters each year and roughly 5,000 people are homeless on any given night.

So opens this week’s Reading. The sentence is simple and direct; the facts conveyed are haunting. But this week’s Reading is ultimately a good news story. Actually, it’s a very good news story.

The Reading: “Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial” by Vicky Stergiopoulos et al., which has just been published in PLOS ONE.

Dr. Vicky Stergiopoulos

Here’s a quick summary: offer the homeless housing, and they not only gain housing stability but end up drinking less and are hospitalized less. Continue reading