From the Editor

During the first wave, alone and isolated, he started to drink significantly more. Now, many months later, he continues to struggle with an alcohol use disorder. This patient’s journey – as he told me in the ED last week – is a familiar story that we as clinicians have heard many times in these past few years. What can be done to help? Could we better reach those who are misusing alcohol?

In JAMA Psychiatry, Dan I. Lubman (of Monash University) and his co-authors describe an intervention that is very relevant. In this Australian RCT, some participants received 4-6 sessions of telephone-provided, manualized cognitive and behavioural intervention that included mindfulness. They found that: “this randomized clinical trial did not find superior effectiveness of this telephone-based cognitive and behavioral intervention compared with active control.” We discuss the paper and its clinical implications.

Dr. David Goldbloom has had a storied career: senior medical advisor at CAMH, professor at the University of Toronto, former chair of the Mental Health Commission of Canada, former editor of The Canadian Journal of Psychiatry. And tomorrow, he adds another title to that long list: retiree. This week’s second selection is a new Quick Takes podcast interview with him in which he comments on career and retirement and more. “I’m not an entirely gloomy or nihilistic person, either by temperament or based on what I’ve witnessed over the last 40 years.”

Finally, in the third selection, Dr. Robert A. Kleinman (of the University of Toronto) and his co-authors argue that “against medical advice” is a dated term. In Annals of Internal of Medicine, they argue for a new approach: “Shifting away from the ‘AMA’ terminology and toward more collaborative approaches to these discharges would improve the treatment of patients who are too often stigmatized by the clinicians and health systems that are meant to care for them.”


Selection 1: “Effectiveness of a Stand-alone Telephone-Delivered Intervention for Reducing Problem Alcohol Use: A Randomized Clinical Trial”

Dan I. Lubman, Jasmin Grigg, John Reynolds, et al.

JAMA Psychiatry, November 2022

Alcohol consumption is a leading cause of preventable morbidity and mortality globally, resulting in 5.3% of all deaths (3 million) and 5.1% of all disease burden in 2016. Alcohol use disorders are estimated to affect 5.1% of the adult population worldwide. Yet, the magnitude of alcohol consumption and attributable harms remains in sharp contrast to the low rates of treatment use, with the treatment gap attributable to a range of structural (eg, treatment coverage, distance to services) and individual (eg, readiness for change, fear of shame or stigma) barriers… Telehealth has the potential to overcome many of the individual and structural barriers to accessing treatment for alcohol problems…

Although there is an expansive literature demonstrating the effectiveness of low-intensity alcohol interventions delivered in primary care settings, multiple barriers to their implementation remain (eg, lack of time, training, and confidence). A comparatively small body of literature provides evidence for the benefits of telephone-delivered interventions in reducing substance use problems, although there is strong evidence for their effectiveness in promoting smoking cessation. Telephone-delivered interventions have been shown to be comparable to in-person treatment in reducing alcohol consumption and to enable experiences of therapeutic alliance, and there is growing evidence that they are filling a gap in service provision for health inequity groups (eg, women, people living in regional and remote areas)…

So begins a paper by Lubman et al.

Here’s what they did:

  • They conducted a double-blind, randomized clinical trial; they recruited participants with an Alcohol Use Disorders Identification Test (AUDIT) score of greater than 6 (for female participants) and 7 (for male participants) from across Australia.
  • “Telephone assessments occurred at baseline and 3 months after baseline…”
  • The intervention: “The telephone-based cognitive and behavioral intervention comprised 4 to 6 telephone sessions with a psychologist. The active control condition comprised four 5-minute telephone check-ins from a researcher and alcohol and stress management pamphlets.”
  • Primary outcome: change in alcohol problem severity, measured with the AUDIT score.

Here’s what they found:

  • There were 344 participants, 173 participants randomized to the intervention group, and 171 participants to the active control group.
  • Demographics. Most participants were male (51.5%), some were culturally and linguistically diverse participants (8.1%), with a mean age of 39.9. In terms of alcohol treatment: “Less than one-third of participants (29.4%) had previously sought alcohol treatment.” (!)
  • Alcohol use. Mean baseline AUDIT score: 21.5.
  • “For the primary intention-to-treat analyses, there was a significant decrease in AUDIT total score from baseline to 3 months in both groups (intervention group decrease, 8.22; control group decrease, 7.13…), but change over time was not different between groups (difference, 1.08…).”

A few thoughts:

1. This is a good study in so many ways – RCT, clear intervention, measurable outcome, active control – except, of course, the result. (!)

2. To summarize the core finding in four words: the intervention didn’t work (at least in terms of the primary outcome).

3. Did the telephone intervention help any sub-population? It was effective in reducing hazardous alcohol use at 3-months. The authors write: “That the intervention group showed a greater reduction in AUDIT hazardous use relative to the active control group is an important finding.”

4. It’s also true that this intervention was able to reach people with significant alcohol use who typically aren’t reached by other programs. “Most participants were new to alcohol treatment, despite high baseline alcohol problem severity, with two-thirds having scores indicative of alcohol dependence.” The authors write: “Findings demonstrate the potential benefits of this highly scalable telehealth model of alcohol treatment, with potential to reduce the treatment gap for problem alcohol use.”

5. Readers may choose to temper the authors’ enthusiasm with the negative result.

The full JAMA Psychiatry paper can be found here:

Selection 2: “On his retirement, on his career, and on psychiatry”

David Goldbloom

Quick Takes, 14 December 2022

In this interview, I speak with Dr. David Goldbloom. In our half-hour podcast – not nearly enough time to cover his many insights – we discuss research, stigma, his optimism for the future of psychiatry, and, yes, his retirement plans (spoiler alert: he’s thinking about writing a book and no mention of golf).

I highlight from the discussion:

On retirement

“[I did] a fair amount of thinking about what would be the right time for me, not for everybody, but for me personally. And I had a kind of moment of epiphany, if you will, when I realized that absent a prescribed retirement age, my only options were too early and too late when it came to retirement. And given that forced choice, my preference was very strongly in the ‘too early’ category, based on the old Broadway adage of always leave them wanting more. And frankly, when I thought about how I would want my colleagues to react, I thought better they should express surprise and disappointment than a sigh of relief.”

On the profession

“Our profession is in better shape than it was when I started, attracting lots of talented and smart and passionate and committed people to work in it in greater numbers than ever before. The human factor in terms of who chooses psychiatry is critical. I’ve seen a significant shift among younger psychiatrists towards a sense of care for and responsibility for the needs of people with severe and persistent mental illness, a return to hospital-based work with the most severely ill.”

On stigma

“I’m not so Pollyannaish to think that we will entirely eliminate stigma. Now it is probably a little easier to eliminate the discrimination that flows from stigma, but those sort of very core beliefs on a set of illnesses that profoundly disrupt or have the potential to disrupt those elements of our being that are integral to our individuality, our moods, our thoughts, our behaviours are very, very different than a broken leg.”

On advice for younger colleagues

“Keep reading. The danger is that you just stop reading after you’ve got your shingle. And the explosion in our professional literature means that you require aggregating sites or filters or thoughtful editors to help guide you in your reading. But trying to stay current and stay stimulated is important.”

On the biggest career highlight

“I would say probably the opportunity to work at CAMH.”

(The above answers were edited for length.)

The podcast can be found here, and is just over 29 minutes long:

Selection 3: “Retiring the ‘Against Medical Advice’ Discharge”

Robert A. Kleinman, Thomas D. Brothers, Nathaniel P. Morris

Annals of Internal Medicine, 29 November 2022

Most clinicians are familiar with the following scenario: A patient hospitalized with a serious illness asks to leave. The patient’s illness would likely improve with further treatment, but despite entreaties from the clinical team, the patient wishes to go. Following hospital policy, a clinician asks the patient to sign a form describing the risks of leaving, and the patient scribbles a signature. The team completes discharge paperwork and indicates that the discharge was ‘against medical advice,’ or ‘AMA.’ We believe it is time to retire the ‘AMA’ designation.

So begins a paper by Kleinman et al.

They note how commonly such discharges occur.

  • “In 2019, there were 502 970 AMA discharges from U.S. hospitals, representing 1.4% of all inpatient discharges. The proportion of discharges labeled as ‘AMA’ was 2.6% among people with Medicaid and 4.3% among people without insurance coverage for the hospital admission.”
  • “These discharges were also more frequent among people admitted with complications of unhealthy substance use, with 10.6% of U.S. hospital discharges for alcohol-related admissions and 18.0% of discharges for opioid-related admissions designated as ‘AMA’.”

They argue that the term is problematic, offering three reasons:

“First, the terminology has been criticized as stigmatizing and non–person-centered language. Clinical documentation around AMA discharges may shape health professionals’ attitudes toward patients and clinical decision making by, for example, making patients with ‘a history of multiple AMA discharges’ seem difficult or irresponsible. Second, the terminology places responsibility for the decision on the patient while neglecting other factors, such as clinician attitudes and health system policies, that may contribute to a patient leaving the hospital. Many factors influence these decisions, including undertreated withdrawal symptoms and pain, stigma and discrimination, an inability to smoke on smoke-free hospital campuses, reminders of past incarceration, and other personal factors beyond the hospital. Third, and perhaps most important, the ‘against’ component of the AMA designation implicitly describes an antagonistic interaction between patients and clinicians rather than encouraging a collaborative approach to promoting patient health when these situations arise.”

They champion an alternative: “before medically advised.” They argue that there are advantages, including that the new term is “nonjudgmental and is not antagonistic.”

“Whereas a patient who wants to leave ‘against’ medical advice may be treated dismissively, describing the situation as ‘before medically advised’ promotes curiosity about why a patient wants to leave and whether anything can be done to address the underlying factors… [It] can be understood by clinicians based on a literal understanding of each word. It continues to highlight for clinicians that such a discharge may increase a patient’s risk for adverse outcomes.”

A few thoughts:

1. This is a thoughtful paper.

2. They raise good points. Medical terms, after all, should be free of judgment.

3. Are you persuaded? Readers should draw their own conclusions.

The full Annals paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.