From the Editor

Our patients increasingly use cannabis, and we worry about the impact on their mental health. But what about the impact on their physical health?

In the first selection, Abra M. Jeffers (of Harvard University) and her co-authors consider cannabis and cardiac health. In a new paper for the Journal of the American Heart Association, they analyzed cardiac outcomes, drawing on survey data and involving more than 400 000 participants, some of whom used cannabis. “Cannabis use is associated with adverse cardiovascular outcomes, with heavier use (more days per month) associated with higher odds of adverse outcomes.” We review the paper and its implications.

In the second selection, Nina A. Sayer (of the University of Minneapolis) and her co-authors look at burnout in a new paper for JAMA Network Open. In a cohort study involving 165 therapists and almost 1 300 patients, they note a connection between provider burnout and PTSD outcomes. “These findings suggest that interventions to reduce therapist burnout might also result in more patients experiencing clinically meaningful improvement…”

Dr. Mary Seeman (of the University of Toronto), who died in late April, had a storied career as a psychiatrist. She had major roles, including the Tapscott Chair in Schizophrenia at the University of Toronto. In a 2003 paper for The American Journal of Psychiatry, she reflects on her work with a patient. This essay – the third selection this week – notes the decades-long connection between doctor and patient. “Her faith in me keeps me coming into work each morning, often tired and achy, sometimes trying unsuccessfully to remember the comforting word I want to be able to say.”

DG

Selection 1: “Association of Cannabis Use With Cardiovascular Outcomes Among US Adults”

Abra M. Jeffers, Stanton Glantz, Amy L. Byers, and Salomeh Keyhani

Journal of the American Heart Association, 28 February 2024

Cannabis use is increasing in the US population. From 2002 to 2019, past‐year prevalence of US adult cannabis use increased from 10.4% to 18.0%, whereas daily/almost daily use (300+ days per year) increased from 1.3% to 3.9%… At the same time, perceptions of the harmfulness of cannabis are decreasing. National surveys reported that adult belief in great risk of weekly cannabis use fell from 50% in 2002 to 28.6% in 2019. Despite common use, little is known about the risks of cannabis use and, in particular, the cardiovascular disease risks…

There are reasons to believe that cannabis use is associated with atherosclerotic heart disease… Tetrahydrocannabinol, the active component of cannabis, has hemodynamic effects and may result in syncope, stroke, and myocardial infarction. Smoking, the predominant method of cannabis use, may pose additional cardiovascular risks as a result of inhalation of particulate matter…

So begins a paper by Jeffers et al.

Here’s what they did:

  • The authors conducted a population based, cross-sectional study, and assessed the association of cannabis use with self‐reported cardiovascular outcomes.
  • They used the Behavioral Risk Factor Surveillance Survey (BRFSS) – “a telephone survey that collects data from a representative sample of US adults on risk factors, chronic conditions, and health care access.” 
  • They did the analysis for those with and without tobacco use; they also considered gender, age, and other factors.
  • The main outcome: the association of cannabis use with self-reported cardiovascular outcomes (coronary heart disease, myocardial infarction, stroke, and a composite measure of all 3).

Here’s what they found:

  • There were 434 104 respondents to the survey. 4% used cannabis daily; 7.1% used nondaily.
  • Demographics and use. Most cannabis consumption was by smoking (73.8%). About half were women (51.1%) and the majority were White (60.2%), with a mean age of 45.5 years.
  • Cardiovascular outcomes. Daily cannabis use was associated with higher odds of coronary artery disease (1.16), myocardial infarction (1.25), stroke (1.42), and a composite of the three (1.28). For nondaily users, there were proportionally lower odds.
  • Never-tobacco smokers. Daily cannabis use was not associated with coronary heart disease, but was associated with higher odds of myocardial infarction (1.49), stroke (2.16), and a composite of the three (1.77).
  • Gender. Relationships between cannabis use and cardiovascular outcomes were similar for men <55 years old and women <65 years old at risk of cardiovascular events.
  • Risk factors. There was higher tobacco use and daily alcohol use among adults who use cannabis, but fewer risk factors including less obesity and diabetes. (!)

A few thoughts:

1. This is a good study – practical and relevant and published in a major journal. 

2. The main finding in seven words: use was associated with adverse cardiovascular outcomes.

3. To offer more details: “Cannabis use is associated with increased risk of myocardial infarction and stroke, with higher odds of events associated with more days of use per month, controlling for demographic factors and tobacco smoking.”

4. The main finding isn’t surprising, but how often do we talk to patients about heart health who use cannabis?

5. Needless to say, the authors see clinical implications. They advocate that patients be screened for cannabis use and advised to avoid using cannabis to reduce their risk of premature cardiovascular disease and cardiac events.

6. Like all studies, there are limitations. The authors note several, including that the study is based on a self-reporting. They also acknowledge that reverse causality could be a factor (that is, the patient started to smoke after his MI).

The full JAHA paper can be found here:

https://www.ahajournals.org/doi/10.1161/JAHA.123.030178



Selection 2: “Clinician Burnout and Effectiveness of Guideline-Recommended Psychotherapies”

Nina A. Sayer, Adam Kaplan, David B. Nelson, et al.

JAMA Network Open, 17 April 2024

Burnout among US health care professionals is an epidemic that preceded and has been exacerbated by the COVID-19 pandemic. The toll of burnout includes physical and mental health symptoms as well as the intention to leave the profession, potentially worsening workforce shortages. Burnout may also affect the quality of care that clinicians who remain in the workforce provide. Clinicians experiencing burnout self-report lower quality of care, poorer communication with patients, and more medical errors. However, burnout is not consistently associated with evidence of poorer quality of care or worse outcomes…

The association of burnout on patient care may be particularly evident for interventions that require a high level of clinician empathy and interpersonal engagement, such as psychotherapy.  Yet there has been surprisingly little research on patient outcomes associated with burnout among mental health professionals.

So begins a paper by Sayer et al.

Here’s what they did:

  • They conducted a prospective cohort study for licensed therapists working at the US Veterans Affairs Health Care System.
  • The therapists, who provided trauma-focused psychotherapies, responded to an online survey in 2019. Therapists also completed a burnout survey reported burnout, a 5-point validated measure taken from the Physician Worklife Study.
  • Their patients also did a survey (in 2020). 
  • The primary outcome: patients’ clinically meaningful improvement in PTSD symptoms (according to the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders).

Here’s what they found:

  • 165 therapists participated and 1 268 patients.
  • Demographics and experience. Most therapists were female (53.9%). Many were psychologists (55.8%) or social workers (40.6%). Two-thirds (63.6%) had been treating veterans with PTSD for at least 5 years. 
  • Burnout. 35.2% of the therapists reported burnout (3 or more on the burnout measure). 
  • Improvement. One third of patients met criterion for clinically meaningful improvement.
  • Burnout and care. Clinically meaningful improvement in PTSD symptoms was experienced by 28.3% seen by therapists who reported burnout and 36.8% patients seen by therapists without burnout. “Burnout was associated with lower odds of clinically meaningful improvement (adjusted odds ratio [OR], 0.63…). The odds of clinically meaningful improvement were reduced for patients who dropped out (OR, 0.15…) and had greater session spacing (OR, 0.80…).”

A few thoughts:

1. This paper offers valuable insights into burnout and therapy, presenting an intriguing perspective.

2. The main finding in two words: burnout mattered.

3. To provide a bit more detail: “Among therapists who reported burnout, the odds that patients experienced clinically meaningful improvement in PTSD symptoms were reduced by approximately one-third.”

4. The authors argue that addressing burnout helps patients. “These findings suggest that interventions to reduce therapist burnout might also result in more patients experiencing clinically meaningful PTSD symptom relief from guideline-recommended psychotherapies.”

5. As with all studies, there are limitations. Here, they assessed burnout with a simple scale. As the authors note: “a stronger design would have included repeated assessments of burnout using a more comprehensive, continuous measure and evaluated how changes in burnout were associated with therapy delivery and patient outcomes.”

6. We often think about provider burnout in the context of a healthy workforce. Here, they tie the problem to patient care – excellent. 

The full JAMA Netw Op paper can be found here:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2817707

Selection 3: “Scaling Down”

Mary V. Seeman

The American Journal of Psychiatry, 1 May 2003

One of my patients, now 82, wants me to call her Kit. From someone with an originally long name who used to live in very grand style, Kit has changed into a frail person with a tiny name who lives in a miniature apartment in a home for seniors.

There is a saying among aging psychiatrists: ‘I didn’t start out as a geriatric psychiatrist [subspecializing in psychiatric problems of the elderly], but I have become one [having grown old and my patients having grown old with me].’ As a psychiatrist who is aging fast, I see fewer patients than I once did – one form of downsizing – but age sizes you down in many more ways than this.

So begins an essay by Dr. Seeman.

She describes her first meeting with Katherine Esterhazy, “a well-known hostess then, living in a suburban mansion.”

“A large woman, she and her husband could not sit in my office without knocking knees when they came for their first consultation. It was 1962, and my suite was a windowless cubicle on the sixth floor of a wing of the Toronto Western Hospital on Bathurst Street in downtown Toronto. The desk was in the corner and, with the third chair moved in to accommodate the husband, the door did not close. Katherine would not have stood for it – the shabby room, the smallness of it, my very evident junior status – if it weren’t for the fact that she was depressed.”

The patient has depression, and she isn’t eating or sleeping. “I did suggest something relatively new at the time: tranylcypromine sulfate, a monoamine oxidase…” The patient responds and they go their separate ways. “As a thank you and goodbye, a mammoth poinsettia was delivered at Christmas, too large to fit into my office.”

A decade then passes, and the patient is ill again. “Her psychiatrist had tried other tablets. Nothing worked.” She agrees to see her again. “Mr. and Mrs. Esterhazy came to my office, a more spacious room now, in the Medical Building on Leonard Avenue, just across the street from the Toronto Western.” Dr. Seeman is able to secure the medication and the patient recovers.

The patient then meets with Dr. Seeman over the ensuing years. The patient and her husband downsize to a condo. “Her life was grand – many friends, many lovers, many possessions, many travels.”

“Of course, that was her exterior life. Inside, she was tormented by memories of a sickly childhood, a father who killed himself, a stepfather who maltreated her, a mother who failed to give credit where credit was due, a stunted education, an annulled first marriage. She had the strength of personality to overcome what would have been dead ends for others. Nothing stopped Katherine. She married outside her faith and thumbed her nose at those who looked down theirs at her. She nursed her mother and stepfather as they became infirm, forgiving them the past. She somehow lived through further suicides in her family. A family who suicides was the secret burden she bore.”

Time isn’t so kind. The patient’s husband passes unexpectedly. She grows estranged from her children. Finances become an issue. “Even renting extra locker space, Kate had too many possessions to fit into her space. She began to have private sales – selling off her jewelry collection.” Fortunately, her children eventually step in. “She had lost all her money through foolish investments, but the children chipped in and arranged for an apartment in a very posh seniors’ residence. So Kit, at 82, lives in tight but elegant quarters.”

Dr. Seeman notes changes in her office and career. “In charge of a small unit, I was given a corner office with large windows on two sides and my own thermostat to control the office environment.” She is then selected as Head of Psychiatry at Mt. Sinai Hospital, Toronto, “a prestigious posting for me.” She has “[a] new office was specially constructed with built-in bookcases and a stereo sound system and very expensive furniture.” She returns to the Clarke Institute, and soon her office is divided. “And I, at 70, practice psychiatry in a very cramped office.”

She closes by reflecting on their connection. “My room is smaller. My capacity to retain things in memory has grown smaller too. The reservoir of wise counsel from which I try to draw is dwindling. The paradox for Kit is that now, as her need grows, the person she most relies on is scaling down.”

Dr. Mary Seeman

A few thoughts:

1. This is a great paper that explores aging and the passage of time and our connections to our patients, paralleling aspects of our lives.

2. I first read this paper at the start of my career, and appreciated the details on the patient. Now, two decades later, I find myself reflecting more on the changes in Dr. Seeman’s life.

3. For the record, Dr. Seeman wrote more than 300 papers, on topics ranging from psychiatry in the Nazi era to women and psychosis. This paper is worth reading – but so are many of her others.

4. Her life story was incredible. Her obituary can be found here:

https://www.legacy.com/us/obituaries/legacyremembers/mary-seeman-obituary?id=54960578

The full AJP paper can be found here:

https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.160.5.847



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