From the Editor
Better PTSD symptom control, less diabetes? How do we talk to our patients about cannabis (and cannabis use disorder)? Who was Dr. Ruth Kajander?
This week, there are three selections. The first two deal with timely and relevant topics: the intersection of physical and mental health and the use of cannabis post-legalization. The third reminds us of the youth of our field.
In the first selection, Saint Louis University School of Medicine’s Jeffrey F. Scherrer and his co-authors consider PTSD and diabetes, asking if improvement with the mental health disorder results in a lower risk of type 2 diabetes. Drawing on Veterans Health Affairs data involving nearly 1 600 people, they find that “clinically meaningful reductions in PTSD symptoms are associated with a lower risk of type 2 diabetes.”
In the second selection, we draw on a podcast interview with the University of Toronto’s Dr. Leslie Buckley, the chief of addictions division at CAMH, on cannabis. What advice would she give clinicians about cannabis use? “Try to have that long conversation with [patients] about their use and make sure that they know the harms – because I feel like most people don’t.”
Finally, with an eye on yesterday and not today, we look at the recent Globe obituary for Dr. Ruth Kajander, a psychiatrist who served in many roles, and was a member of the Order of Canada.
Selection 1: “Association Between Clinically Meaningful Posttraumatic Stress Disorder Improvement and Risk of Type 2 Diabetes”
Jeffrey F. Scherrer, Joanne Salas, Sonya B. Norman, Paula P. Schnurr, Kathleen M. Chard, Peter Tuerk, F. David Schneider, Carissa van den Berk-Clark, Beth E. Cohen, Matthew J. Friedman, Patrick J. Lustman
JAMA Psychiatry, November 2019
Posttraumatic stress disorder (PTSD) is a chronic condition that affects up to 12% of civilians and up to 30% of the veteran population and is associated with increased risks for multicomorbidity. Completion of evidence-based psychotherapy is associated with clinically meaningful reductions in PTSD symptoms and can result in improvement in psychiatric comorbidities and perceived health. Improvement in PTSD is associated with parallel improvements in depression and general emotional well-being, sleep, blood pressure, general physical concerns (eg, back pain, headache, and cough), and perceived health.
So begins the Scherrer et al. paper.
Here’s what they did:
- Drawing on Veterans Health Affairs data, they did a retrospective cohort study.
- They considered people who used a PTSD specialty clinic between 2008 and 2012, and had follow up care through 2015.
- Participants had 1 or more scores of 50 or higher on the PTSD Checklist (PCL), as well as another score within 12 months.
- Participants were found to have diabetes if they were coded with a diabetic diagnosis or they filled a script for related medications.
- Statistical analyses were done.
Here’s what they found:
- There were 1 598 patients.
- Demographics: mean age was 42; most were male (84.3%) and white (66.3%).
- Age-adjusted cumulative incidence of diabetes: 2.6% in the group with clinically meaningful improvement of PTSD, 5.9% in the group without clinically meaningful improvement.
- Adjusting for confounding factors: 0.51 hazard ratio.
In this large cohort of VHA patients with PTSD, a clinically meaningful PCL score decrease (defined as a decrease in PCL score ≥20 points) compared with less than a clinically meaningful decrease was significantly associated with a lower risk of incident T2D. This result was independent of numerous demographics and psychiatric and physical comorbidities. The association was also independent of the number of PTSD psychotherapy sessions used, suggesting that a healthy adherer effect, or a general orientation to improve health, is unlikely to explain our observations.
This is a good paper. Of course, we can wonder about unmeasured cofounding variables – though the results are pretty robust.
And the results aren’t so surprising. The separation between physical and mental health is at best artificial. The authors didn’t do an economic analysis, but we could speculate that better PTSD care may be a cost-saver given the heavy health costs associated with diabetes.
Selection 2: “What all physicians need to know about cannabis use and how to talk to our patients about it”
David Gratzer & Leslie Buckley
Quick Takes, November 2019
It’s legal – but how do we speak to our patients about cannabis use?
In a Quick Takes podcast, I join Leslie Buckley, Chief of Addictions Division at CAMH, for a discussion about cannabis.
I highlight some of her comments:
On motivational interviewing and core principles.
One of the most important things to think about when you are doing motivational interviewing is autonomy. That was probably the biggest change when motivational interviewing came out in the ’80s. And the principle is that somebody likes to feel part of the team, not told what to do. So as a person who’s working with somebody in motivational interviewing, you’re thinking about their autonomy, you’re thinking about their reasons for use. Somebody is going to change because of the reasons that they think they should change, not the reasons that their physician thinks. So, it’s really you trying to pull out of somebody the reasons that they might want to change – and trying to build discrepancy. The discrepancy is between the way things are now, and the way things could be.
On the difference between THC and CBD.
THC is the component of cannabis that is psychoactive and it’s the part that is the cause of dependence and use disorders. It has increased in recreational cannabis from 4% over the last couple of decades to 15%. THC is very high in recreational cannabis and any cannabis that you would also buy in a store. It is the substance that we’re most concerned about versus CBD. CBD actually may counteract the THC. And there are no significant findings in terms of it being psychoactive in a way that is rewarding – so it doesn’t really create addiction.
On the problem with edibles.
When you’re taking an edible, it takes one-and-a-half to two hours to get the impact, to feel different. Versus smoking, which is about 10 minutes. So, the worry that we have is that people will be waiting for that response, and that feeling, and it doesn’t come. So they take more…
On helping patients stop using.
Never forget insomnia. One of the toughest things during withdrawal from cannabis is insomnia. So, if you can provide sleep medication for that time, and maybe carrying on, depending on if [the insomnia] resolves or not, that can be a really big help.
The full interview runs just over 17 minutes – and, yes, we touch on Martha Stewart. There is also a bonus podcast featuring a motivational interview role-play. Spoiler alert: I play the college student with a cannabis problem (and a full head of hair).
Selection 3: “Psychiatrist Ruth Kajander was a pioneer in schizophrenia treatment”
The Globe and Mail, 24 November 2019
In her 80s, Ruth Kajander took two of her grandchildren to visit the Eiffel Tower. They could have taken an elevator to the top, her grandson Robin Fiedler recalled, but Dr. Kajander had no interest in taking the easy way. She climbed the stairs, keeping up with her then-teenage grandsons.
‘I think part of it was wanting to prove to herself and to her younger grandkids that that’s something she was still capable of doing,’ Mr. Fiedler said.
Dr. Kajander proved her mettle on that trip, as she did throughout her long, extraordinary life, which saw her graduate from medical school in post-war Germany and eventually become a trailblazer in the field of psychiatry and a member of the Order of Canada.
So begins a colourful piece on the life of Dr. Kajander by Wendy Leung.
The article outlines how she came of age in Germany during the war (her father was shot as a member of the resistance). After her training – first in Germany, and then here – it notes her interest in chlorpromazine, which was found to be calming for surgical patients.
After her one-year internship, she got a job as a resident at the London Psychiatric Hospital, where she sought the medical superintendent’s permission to use chlorpromazine on an experimental basis, to see how it would work…. They tried the drug on an agitated patient, for whom no other interventions seemed to have an effect.
Despite the result, she didn’t get credit:
Although the young female doctor was the first to use the drug on psychiatric patients in Ontario, credit for this ground-breaking contribution to the field went to psychiatrist Heinz Lehmann, who, unbeknownst to her, was experimenting with the drug in Montreal around the same time.
The obituary notes the many achievements of her career. She was a president of the Ontario Psychiatric Association and had an active role in the Ontario Medical Association. She was also a member of the Order of Canada. And she was the founding director of the Port Arthur Mental Health Clinic.
She lived a good and long life, passing at the age of 95 in Thunder Bay. And, for the record, though in her 80s, Dr. Kajander did climb the Eiffel Tower with her grandchildren.
As an aside, it’s striking when reading this essay to consider that the use of antipsychotics is relatively new to psychiatry (Dr. Kajander’s experiments were 66 years ago), a gentle reminder that psychopharmacology is not an ancient tradition.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.