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Reading of the Week: NEJM and Smoking Cessation

June 18, 2015 /

More than 50 years after the release of the first Surgeon General’s report on the harmful effects of smoking, national policies, behavioral programs, and pharmacologic approaches have helped reduce smoking rates in the United States. However, the need for new approaches is clear because smoking remains the leading cause of preventable illness and death.

So begins a big paper from The New England Journal with a simple aim: getting people to butt out. It raises two important questions: If we are serious about promoting smoking cessation, are we willing to put ‘our money where our mouth is’ – literally? And how could we do this?

“Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation” by Dr. Scott D. Halpern et al. is this week’s Reading; it has just been published.

Though other papers have been written on this topic, the Halpern et al. paper is clever and interesting – and the results are surprising.

And, don’t tell the editors of The New England Journal of Medicine: the results are also disappointing. Continue reading

Reading of the Week: Choosing Wisely and Psychiatry

June 11, 2015 /

The routine use of antipsychotics, like Zyprexa (olanzapine) and Seroquel (quetiapine), should not be used to treat primary insomnia in children, adults or the elderly, say Canadian psychiatrists. This information is part of a series of 13 evidence-based recommendations made by the Canadian Psychiatric Association (CPA) and its working group partners, the Canadian Academy of Child and Adolescent Psychiatry (CACAP) and the Canadian Academy of Geriatric Psychiatry (CAGP), for the Choosing Wisely Canada campaign.

Choosing Wisely Canada (CWC) is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures, and to help physicians and patients make smart and effective choices to ensure high-quality care.

So begins the press release announcing the 13 recommendations made jointly by these three bodies as part of Choosing Wisely Canada.

The full list is this week’s Reading, and “Thirteen Things Physicians and Patients Should Question” can be found here:

http://www.choosingwiselycanada.org/recommendations/psychiatry/

Choosing Wisely is a good campaign – thoughtfully done and executed. It ultimately aims to better patient care. It’s also important within the context of the larger system itself. Continue reading

Reading of the Week: The Case For Publicly Funded Therapy

June 4, 2015 /

It’s 4:30 on a Friday afternoon at her Sherbrooke, Que., clinic and Marie Hayes takes a deep breath before opening the door to her final patient of the day, who has arrived without an appointment. The 32-year-old mother immediately lists her complaints: She feels dizzy. She has abdominal pain. “It is always physical and always catastrophic,” Dr. Hayes will later tell me. In the exam room, she runs through the standard checkup, pressing on the patient’s abdomen, recording her symptoms, just as she has done almost every week for months. “There’s something wrong with me,” the patient says, with a look of panic.

Dr. Hayes tries to reassure her, to no avail. In any case, the doctor has already reached her diagnosis: severe anxiety. Dr. Hayes prescribed medication during a previous visit, but the woman stopped taking it after two days because it made her nauseated and dizzy. She needs structured psychotherapy – a licensed therapist trained to bring her anxiety under control. But the wait list for public care is about a year, says Dr. Hayes, and the patient can’t afford the cost of private sessions.

Meanwhile, the woman is paying a steep personal price: At home, she says, she spends most days in bed… Dr. Hayes does her best, spending a full hour trying to calm her down, and the woman is less agitated when she leaves.

But the doctor knows she will be back next week.

So begins an article from The Globe asking a simple question: should we publicly fund psychotherapy? In this week’s Reading, “The case for publicly funded therapy,” Erin Anderssen argues yes.

http://www.theglobeandmail.com/life/the-case-for-publicly-funded-therapy/article24567332/

Anderssen’s piece opened the The Globe and Mail’s excellent new series on mental health, which covers everything from the potential of technology to the search for biological markers. Continue reading

Reading of the Week: The Kids are Alright – The New England Journal of Medicine and Childhood Mental Health Disorders

May 28, 2015 /

The rate of severe mental illness among children and adolescents has dropped substantially in the past generation, researchers reported Wednesday, in an analysis that defies public perceptions of trends in youngsters’ mental health.

So begins The New York Times’ front-section coverage of a big paper in a big journal with a big result.

This paper, just published by The New England Journal of Medicine, considers the rate and treatment of childhood mental health impairment. In contrast to other surveys, this paper didn’t find a rise in the rate of mental illness. (Contrast this finding with the comment of a former president of the American Psychiatric Association that such illnesses are “an epidemic hidden in plain view” – that is, obviously there but underreported historically.)

Explains the lead author, Dr. Mark Olfson:

The finding is robust and real and challenges the prevailing stereotype that young people are somehow more vulnerable to mental problems.

Dr. Mark Olfson

How common is mental impairment among children and adolescents? How has this changed in recent years? How are patients being treated? Are we prescribing more than in the past? Olfson et al. seek answers to these important questions in “Trends in Mental Health Care among Children and Adolescents” – this week’s Reading. Continue reading

Reading of the Week: Dr. Gawande and ‘Low-Value Care’

May 21, 2015 /

It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful.

So begins Dr. Atul Gawande’s recent essay in The New Yorker, which I have chosen as this week’s Reading.

It asks a simple question: what can we do about this?

Dr. Atul Gawande

Dr. Gawande, a general surgeon at Brigham and Women’s Hospital, is a prolific writer; he is a frequent contributor to The New Yorker and has penned several bestselling books, including Being Mortal and The Checklist Manifesto.

In this piece, Dr. Gawande focuses on overtreatment. Indeed, the title is a good summary: “Overkill.” Continue reading

Reading of the Week: Depression and Employment

May 14, 2015 /

I want to get back to work… I want to get back to my life.

A patient recently made this comment to me. Before his depression, he had thrived at a government job and taken great pride in his work. (He showed me iPhone pictures of an event he had helped organize which was keynoted by the premier.) But in the cloud of depression, he left his job, and worried that he would never have another one.

This raises a simple question: how do you get patients like this back to work?

It seems like an obvious question to ask – and very relevant one. After all, many people with depression are off work, or have left the workforce altogether. A Towers Watson report considered disability in North America; mental health issues (typically “depression, anxiety and stress”) contribute to 78% of short-term and 67% of long-term disability claims in Canada. Let’s put that in perspective: for short-term disability, cancer was well under half that.

Yet if the burden of illness is great, little has been written about interventions to get patients with depression back to work. A 2008 Cochrane review identified only 11 randomized controlled trials (RCTs) on interventions aimed at reducing work disability in workers with major depressive disorder (and just four studies including work functioning as an outcome measure). A more recent Cochrane review considered 13 randomized controlled trials; only three studies, for example, looked at antidepressant therapy.

That’s why this week’s Reading is so interesting. “Gains in employment status following antidepressant medication or cognitive therapy for depression” by Jay C. Fournier et al. compares drug management with psychological interventions (CBT). Continue reading

Reading of the Week: Economics and Mental Illness

May 7, 2015 /

For John Mooney, it was a career highlight. In March the Irish cricketer took a crucial catch that gave his team the victory in a World Cup match and eliminated the higher-ranked Zimbabwe. But afterwards the Zimbabwe Herald, a daily paper with links to Zanu-PF, the thuggish ruling party, claimed that Mr. Mooney had lied when he said that his foot had not been touching the boundary, meaning the catch should have been disallowed. The article cited previous interviews in which the sportsman had spoken frankly about his long battles with drink, depression and suicidal thoughts. Under pressure, it claimed, a “man of such a character” could not be trusted to have “the honesty, let alone the decency” to tell the truth.

John Mooney, cricketer, Ireland “player of the year” (2010), and a man with depression

So begins this week’s Reading.

The essay provides an excellent summary of the impact of mental health on our society and our economy. It also notes reasons for hope. Indeed, Mr. Mooney’s story is moving: after the Zimbabwe Herald attack, fearing that others may be reluctant to talk about their mental illness in light of his harassment, Mr. Mooney chose to publicly speak about his battle with depression. The article notes:

The reaction was heartening. Messages and thanks are still coming in.

This essay is readable and concise. “Out of the shadows: The stigma of mental illness is fading. But it will take time for sufferers to get the treatment they need” is a must read. Here’s the surprise: it was published in an economics magazine.

Welcome to 2015, where thoughtful analysis on mental health issues isn’t just for the psychiatry journals anymore. Continue reading

Reading of the Week: Zen or Zoloft? Mindfulness vs. Meds for Relapse Prevention in Depression

April 30, 2015 /

Depression typically has a relapsing and recurrent course. Without ongoing treatment, individuals with recurrent depression have a high risk of repeated depressive relapses or recurrences throughout their life with rates of relapse or recurrence typically in the range 50–80%.

So begins this week’s Reading (which is attached). As is so often the case, the journal writing is understated.

50-80%. Wow.

Having been in practice for some years, many stories come to mind when considering this statistic.

Here’s one: a young woman with a challenging childhood who pulled her life together, kept an unplanned pregnancy, and then tried to do everything right for herself and her daughter. In her late 20s, she fell into a deep depression, attempted suicide, and had a long admission. And, after work on the inpatient unit and in the outpatient department, she returned to her life: free of symptoms, working full time, raising her daughter. Feeling well, she stopped her citalopram, and became sick again (and with an employer keen on her termination because – and this sounds like a 19th century novel – “she told me I look dead on the outside”).

It’s easy to say that she should have stayed on her medications. But many of our patients don’t. The reasons vary – the side effects are too strong, the concept of medications is unappealing, etc. – but the end result is so often the same.

What then are non-medication options for maintenance in patients with depression? This week’s Reading offers an interesting answer: mindfulness-based cognitive therapy.

Continue reading

Reading of the Week: Can Crowdsourcing Treat Depression?

April 23, 2015 /

Social networks aspire to connect people, which is a noble but naive goal. When we uncritically accept connection as a good thing, we overlook difficult, important questions: Are some forms of virtual communication more nourishing than others? Might some in fact be harmful? Is it possible that Facebook, for instance, leaves some people feeling more lonely? No one knows for sure. We tend to build things first and worry about the effects they have on us later.

Robert Morris is taking the opposite approach. Starting with the desired effect of helping people deal with depression, he developed Panoply, a crowdsourced website for improving mental health.

So begins this week’s Reading.

This is not your typical selection. Though the disease discussed is depression, the treatment involves social networks, not sertraline. The article is well written, but it doesn’t appear in the pages of World Psychiatry but Wired. The article details therapy, but with a focus on apps, not Adler. CBT is important, but crowdsourcing is talked about more than cognitive distortions.

Welcome to psychiatry in the 21st century.

Continue reading

Reading of the Week: Dr. Kurdyak’s Paper on Psychiatry and Practice

April 16, 2015 /

A few months ago, a patient walked into my office and immediately broke down. He explained that he had waited so long to see a psychiatrist that he was overwhelmed to finally meet me. For the record, he had never spoken to me before and knew nothing about me – except that I was a psychiatrist and that he needed to see one.

The surprise is that anyone would be surprised by such a story.

Patients often face long wait lists in our health care system. The wait for psychiatric care seems particularly long. But here’s the question: do we have a shortage of psychiatrists in Ontario – or do we have a shortage of creative thinking on how psychiatrists practice in Ontario? The week’s Reading asks this important question, with a surprising conclusion: “increasing psychiatrist supply will have little impact on patients’ access.” Continue reading