From the Editor
He survived a terrible car accident and recalls his worst memory: being pinned for hours in his Honda as rescuers attempted to free him, eventually with the Jaws of Life. The mental recovery proved more complicated than the physical one, with flashbacks and nightmares and the resulting substance misuse. He tried different therapies, but would he have benefitted from alternative treatments?
Dr. Michael Hollifield (of George Washington University) and his co-authors look at acupuncture for PTSD in a new JAMA Psychiatry study. They did an impressive randomized clinical trial involving 93 combat veterans with PTSD who received either verum or sham acupuncture. “[V]erum acupuncture had a large pretreatment to posttreatment effect and was statistically superior to sham needling for reducing PTSD symptoms and enhancing fear extinction.” We consider the paper and its clinical implications.
Across North America, there are more people than ever before who are chronically homeless. Who are they? What psychiatric problems do they have? How can we help them? In the second selection, Dr. Vicky Stergiopoulos (of the University of Toronto) considers those who are chronically homeless in a podcast interview for Quick Takes. “The problem is visible. It’s in our streetcars and buses, our subways, our streets, and it’s hard to ignore.”
And in the third selection, Dr. Suzanne Koven (of Harvard University) writes about mentorship in The New England Journal of Medicine. She discusses how a mentor’s advice transformed her career and then considers what makes for good mentorship. “A mentor is someone who has more imagination about you than you have about yourself.”
DG
Selection 1: “Acupuncture for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial”
Michael Hollifield, An-Fu Hsiao, Tyler Smith, et al.
JAMA Psychiatry, 21 February 2024
Posttraumatic stress disorder (PTSD) involves reexperiencing aspects of an incident event, avoidance of event reminders, aversive thoughts and feelings, and hyperarousal…
Efficacious interventions for PTSD include pharmacotherapy and psychotherapy (ie, cognitive behavior therapies and mindful or spiritual approaches). Effectiveness is limited by nonadherence and high withdrawal… Complementary and integrative therapies are desired by the public. The first published randomized clinical trial of acupuncture for PTSD showed efficacy equivalence between acupuncture and group cognitive behavior therapies and superiority to a wait-list control on self-reported symptom reduction, with effect retention for 3 months. This led to broader adoption of and more research about acupuncture for PTSD, which has generally shown efficacy with persisting methodological limitations.
So begins a paper by Hollifield et al.
Here’s what they did:
- The authors conducted a “2-arm, parallel-group, prospective blinded randomized clinical trial hypothesizing superiority of verum to sham acupuncture.”
- The study was done at one site in California. Recruitment was from April 2018 to May 2022, followed by a 15-week treatment period.
- Exclusion criteria included “characteristics that are known PTSD treatment confounds, might affect biological assessment, indicate past nonadherence or treatment resistance, or indicate risk of harm.”
- The interventions: “verum and sham which were provided as 1-hour sessions, twice weekly, and participants were given 15 weeks to complete up to 24 sessions.” In terms of the verum, they did standard needling and retention, drawing on “traditional Chinese medicine diagnostic patterns.” In contrast, the sham was done “2 cm lateral or medial to reference points, which were not expected to affect PTSD symptoms…”
- Main outcome: the primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale-5 (CAPS-5). The secondary outcome was change in the fear-conditioned extinction, assessed by fear-potentiated startle response.
Here’s what they found:
- 601 people were referred. 436 were excluded for a variety of reasons, including a lack of combat deployment. 165 were enrolled, but 72 were excluded (about half didn’t meet the diagnostic criteria). 93 were then randomized.
- Demographics. Most were male (91%) with a mean age of 39.2 years and about half being White (47.4%). The majority graduated high school or did some college. In terms of the incident leading to PTSD, the vast majority listed direct combat (77.4%).
- Intervention effects. “There was a large treatment effect of verum (Cohen d, 1.17), a moderate effect of sham (d, 0.67), and a moderate between-group effect favoring verum (mean Δ, 7.1…) in the intention-to-treat analysis. The effect pattern was similar in the treatment-completed analysis: verum d, 1.53; sham d, 0.86; between-group mean Δ, 7.4…” See figure below.
- Startle during extinction. “There was a significant pretreatment to posttreatment reduction of fear-potentiated startle during extinction (ie, better fear extinction) in the verum but not the sham group and a significant correlation (r = 0.31) between symptom reduction and fear extinction.”
- Retention. This was similar for both groups: 90.7% for verum acupuncture and 84.2% for sham after 1 or more treatment sessions.
- Adverse events. None.
A few thoughts:
1. This is a solid study with much to like – a randomized clinical trial with an intervention and a sham intervention, published in a major journal.
2. The main finding in a sentence: acupuncture worked.
3. Note the strong placebo effect: patients who received the sham showed improvement, too.
4. A nice touch: they measured the change in fear-conditioned extinction, not just a change in CAPS-5, allowing for a study of the biological and clinical effects of acupuncture.
5. Like all studies, there are limitations. Obviously, there are questions about generalizability for most people with PTSD given that the majority in this study had specifically combat-related PTSD. As well, the sample was treatment seeking – again, creating problems when mulling generalizability.
6. Acupuncture, yoga, mindfulness – treatments that were once considered “alternative” have become decidedly mainstream in recent years.
7. Past Readings have considered the treatment of PTSD, including a JAMA Psychiatry study that compared written exposure therapy, an emerging psychotherapy, to prologued exposure therapy. That Reading can be found here:
The full JAMA Psych paper can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2814938
Selection 2: “Chronic Homelessness”
Vicky Stergiopoulos
Quick Takes, February 2024
In this episode of Quick Takes, I speak with Dr. Vicky Stergiopoulos, an internationally recognized expert on chronic homelessness and a former Physician-in-Chief of CAMH. Dr. Stergiopoulos has a passion for serving this population. In our interview, she shares stories from her clinical work. She also discusses playing an integral part in the biggest RCT on Housing First to date, At Home/Chez Soi.
I highlight from the discussion:
On working with those who are chronically homeless
“This is what keeps me going. That’s what, paradoxically, gives me hope. I learn a lot from the population. It’s an opportunity to hear heartwarming stories of compassion, of camaraderie. I work currently in the shelter hotels, the Bond Hotel and the Toronto Plaza, and some of the individuals that I meet are just remarkable – both in terms of the patient that I see, but also the staff who work in these settings.”
On the psychiatric problems of those who are chronically homeless
“When I started 22 years ago or so, I would see a lot of people with psychosis at the shelter system. These days, what I see: addictions and trauma. I do see some people with psychosis, but by far the majority are people with severe addictions.
“If we look at the international literature, we know that up to 75% of individuals who are homeless meet criteria for a current mental disorder. And we know that the rates of psychotic disorders have stayed stable over time, but we’ve seen increases in rates of depression, personality disorders, trauma, and addictions.”
On substances
“When I started 22 years ago, it was a lot of alcohol. Then, a few years later, crack. And now, it’s fentanyl and crystal meth primarily – over 90% of the people that I see misuse these substances.”
On clinical care
“They want timely services. They want comprehensive services. They want one-stop shopping. And they want providers that understand the realities of homelessness. And they work from a trauma-informed perspective.
“They want providers that they can see as a friend. And I know it’s hard to keep the boundaries clear that they’re professional. And at the same time, they want somebody they can trust as a friend and who relates to them at that level. And it’s not an easy thing to do…”
On Housing First
“We need to talk about Housing First, not just at the program level, but at the system level, because where we’ve seen success in decreasing rates of homelessness, it’s when Housing First has been adopted, not just a program but as a policy. And I’ll cite an example: Finland adopted Housing First as a policy ten years ago and has seen significant reductions in the rates of homelessness. They hope to end homelessness in the next several years.”
On her plans to continue working with this population
“As long as I can.”
The above answers have been edited for length.
The podcast can be found here, and is just over 24 minutes long:
Selection 3: “What Is a Mentor?”
Suzanne Koven
The New England Journal of Medicine, 17 February 2024
A few weeks into my medical internship, decades ago, I realized that I didn’t want to pursue the neurology residency I was scheduled to begin the following year. In retrospect, I think I made a common error: mistaking what interested me for what I wanted to spend my career doing. As a medical student, I’d been drawn to the nervous system’s fascinating anatomy and pathophysiology. But what I found I loved most during my internship wasn’t anatomy or pathophysiology. Like most interns, I enjoyed solving diagnostic puzzles and managing complex acute problems; great cases excited me. What thrilled me more, though, was seeing patients after their crises had passed. My favorite part of internship was the part most of the other interns liked least: outpatient clinic.
So begins an essay by Dr. Koven.
The writer focuses on a major career decision early in her residency training: whether or not to transfer out of neurology. She considered what she like to do: “I delighted in seeing people I’d followed in the hospital come into the clinic, dressed in regular clothes. Sometimes they even dressed up to see their doctor – me! I liked it even better when they returned to the clinic again and again for visits during which I learned about their lives, their work, their families, and how all these things affected and were affected by their health.” She worried that neurology wouldn’t offer that type of follow up. But she also notes her hesitation. “Confident as I was in this realization, I dreaded acting on it. How could I renege on my commitment to the highly selective neurology residency to which I’d matched, backing out of a position I’d taken from someone who truly wanted it?”
She sought out the advice of the dean of students at the medical school she graduated from. “What he said to me during our brief conversation that day changed my life.”
Dr. Koven notes how important mentorship can be. How to define it? She describes the thinking of her and her peers. “We considered whether a mentor is a teacher, a coach, an advisor, a patron, a role model, a wise friend, a parental figure, a sponsor, an advocate – or some combination of all of these. None seemed quite right…” She notes the roots of the word itself. “The word ‘mentor,’ after all, derives from The Odyssey. Mentor is Athena, the goddess of wisdom, disguised as an old man who assures young Telemachus that he’s more capable than he realizes of managing his father Odysseus’s chaotic household while Odysseus is journeying home from the Trojan War.”
She describes different types of mentorship. “With some I’ve had decades-long relationships, and others have mentored me effectively in a single meeting – or even with a single comment. Most have been older than me but, more and more recently, several have been younger. What they all have in common is genuine empathy and firm ego boundaries – qualities not dissimilar to those that make someone a good friend, teacher, parent, or clinician… they’ve understood that mentorship is about the mentee, not the mentor.”
She also cautions against finding mentors just because they have similar interests to yours. She thinks of one mentor in particular: “He meant to be helpful, but he spent most of our meeting telling me which opportunities to avoid rather than which to pursue, what I couldn’t accomplish rather than what I could. No matter how perfect the alignment seems, if you leave a meeting with a mentor feeling like your possibilities have narrowed rather than broadened, you know you’ve got the wrong mentor.”
She closes with some advice:
“A good mentor makes you feel the way I felt leaving the office of my old dean, nearly 40 years ago, crossing the street from the medical school back to the hospital: more grounded than before we’d spoken, and also lighter than air.”
A few thoughts:
1. This is an excellent paper – well written and thoughtful, but also practical in its advice.
2. I’ll confess my bias: a mentor transformed my career several years ago. I’ve thanked him – but I’m not sure he fully appreciates how grateful I am.
3. Dr. Koven touches on different types of mentorship. Writing in JAMA Internal Medicine, Dr. Vineet Chorpa (of the University of Colorado) and his co-authors suggests four types. Yes, they write about the traditional mentor, but also: the coach, the sponsor, and the connector. You can find the paper, which I strongly recommend, here:
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2664070
The full NEJM paper can be found here:
https://www.nejm.org/doi/pdf/10.1056/NEJMp2313304
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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