From the Editor
We ask our patients about cannabis. We inquire about illicit drugs. But are we forgetting tobacco? A new paper in Psychiatric Services helps answer that question – and, perhaps, raises other questions, including about how we could do better.
In the first selection, Sarah A. White (of Johns Hopkins University) and her co-authors draw on American data to look at smoking cessation medications in a new Psychiatric Services paper. Among more than 55,000 smokers (many of whom have mental illness), they find that: “Cessation pharmacotherapy for smokers remained vastly underprescribed across all groups. At least 83% of smokers with or without mental illness did not receive varenicline, NRT, or bupropion during the 14-year study period.” We consider the paper and its clinical implications.
In the second selection, Huiru Dong (of Harvard University) and her co-authors look at buprenorphine treatment and demographics in the United States. Their JAMA Psychiatry research letter, which was just published, finds a growing gap. “The observed heterogeneity in buprenorphine treatment duration among racial and ethnic groups may reflect disproportionate structural barriers in treatment retention for Opioid Use Disorder.”
In the third selection, Dr. David Freedman (of the University of Toronto) writes about resident lunches for Academic Psychiatry. Dr. Freedman, who is a resident, notes that in-person lunches shifted to virtual ones for more than two years because of the pandemic – something that was necessary but unfortunate. He argues that the gatherings are important. “Yet, as a collective of residents munch on the last bites of their sandwiches, say goodbye, and return to work, I am struck by the camaraderie. Funded resident lunches nurture the professional identities of psychiatry trainees – an essential element of medical education.”
Selection 1: “Smoking Cessation Medication Prescribing for Smokers With and Without Mental Illness”
Sarah A. White, Elizabeth Stone, Karly A. Murphy, et al.
Psychiatric Services, 9 November 2022 Online First
People with mental illness have a higher prevalence of tobacco smoking and smoke more frequently, compared with people with no mental illness. Rates of smoking declined significantly during the 2000s among individuals without mental illness but not among those with mental illness. Estimates show that less than 22% of individuals without mental illness smoke; however, the proportion is about 30% among those with any mental illness and over 60% among those with schizophrenia. Smokers with mental illness are also less likely to quit. One study found a 25% lower likelihood of quitting by a 2-year follow-up for those with versus those without a mental illness diagnosis. High use and low quit rates among individuals with mental illness contribute to their being at significantly greater risk of dying from tobacco-linked diseases…
Smoking cessation programs are most effective when they include pharmacotherapy and behavioral interventions, but only 4.7% of smokers receive cessation treatment that includes both. Evidence-based behavioral interventions include clinician counseling or cognitive therapy aimed at changing and managing behaviors, situations, and environmental cues associated with smoking; pharmacotherapy treatment includes three evidence-based medications approved by the U.S. Food and Drug Administration (FDA): varenicline, bupropion, and nicotine replacement therapy (NRT)… [E]stimates indicate that only 25% of specialty mental health treatment facilities offer NRT and 21% offer non–nicotine cessation medications.
So begins a paper by White et al.
Here’s what they did:
- They authors used the Medical Expenditure Panel Survey (MEPS) data, “a nationally representative longitudinal survey conducted by the National Center for Health Statistics.”
- The time period: 2005 to 2019.
- They examined cessation medication prescriptions for bupropion, varenicline, and nicotine replacement therapy (NRT) among smokers, including those with mental illness.
- “Qualitative interviews… between October and November 2017 used a semistructured guide.”
- “MEPS data were analyzed with descriptive statistics, and interviews were analyzed with hybrid inductive-deductive coding.”
Here’s what they found:
- “The MEPS sample consisted of 55,662 smokers, 18,353 with evidence of any mental illness, 7,421 of whom had evidence of serious mental illness.”
- Demographics. Most were White (79.8%), male (55.5%), and between ages 35 and 54 (41.4%).
- Prescriptions. “From 2005 to 2019, the proportion of all smokers – with any mental illness, with serious mental illness, and with no mental illness – prescribed any of the three cessation medications never exceeded 17%. The proportion receiving varenicline or NRT – frontline treatments for tobacco use disorder – never exceeded 3%.” See figure below.
- Prescriptions and mental illness. Among smokers with any mental illness, receipt of medications did change with time: varenicline – 0.4% in 2006 to 1.8% in 2019; NRT, less than 0.1% in 2005 to a peak of just under 0.4% in 2018; bupropion increased from 7.0% in 2005 to 8.4% in 2019.
- Qualitative analysis. 20 psychiatrists and 20 internists were interviewed. “Qualitative themes were consistent across general internists and psychiatrists; providers viewed cessation treatment as challenging because of the perception of smoking as a coping mechanism and agreed on barriers to treatment, including lack of insurance coverage and contraindications for people with mental illness.”
A few thoughts:
1. This is a good study.
2. To summarize the major finding: the vast majority didn’t receive smoking cessation medications. (!) Exclude bupropion, and the authors note: “nearly 98% of smokers were not prescribed varenicline or nicotine replacement therapy – first-line treatments for tobacco use disorder – a regardless of their mental illness status.” (!!)
3. Those with mental illness tended to receive fewer prescriptions.
4. There were clear barriers at the system level, including insurance coverage.
5. But what about at the provider level? Is this a case of doing bad and feeling good? Smoking rates have plummeted in recent years – but they remain stubbornly high in certain groups, including those with major mental illness. Has the larger trend led to complacency?
6. Like all studies, there are limitations. The authors note several, including: “mental illness status was determined through medical records, which may be imprecise.”
7. Smoking cessation has been considered in past Readings. Recently, we looked at a NEJM paper by Dr. Peter Selby and Laurie Zawertailo (both of the University of Toronto) that summarizes the latest in the literature. They offer solid advice for clinicians, including the following: “In a pragmatic approach regarding patients who want to quit, busy clinicians may provide very brief advice, prescribe and encourage adherence to medications, or refer the patients to a smoking-cessation program or quitline (or all these strategies).” You can find it here: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-tobacco-also-the-health-of-health-care-workers-jama/
The full Psychiatric Services paper can be found here:
Selection 2: “Racial and Ethnic Disparities in Buprenorphine Treatment Duration in the US”
Huiru Dong, Erin J. Stringfellow, W. Alton Russell, et al.
JAMA Psychiatry, 9 November 2022 Online First
Buprenorphine is used to treat opioid use disorder (OUD) and reduce overdose risk. Duration of buprenorphine treatment is a measure of quality of care; longer retention is associated with superior clinical outcomes. Racial and ethnic minority patients are more likely to discontinue buprenorphine treatment earlier than White patients. To our knowledge, no nationally representative studies have examined buprenorphine treatment duration over time across racial and ethnic groups.
So begins a research letter by Dong et al.
Here’s what they did:
- “This cohort study analyzed a random sample of buprenorphine prescriptions in IQVIA Longitudinal Prescription Data that included race and ethnicity information and were filled from January 2006 to December 2020…”
- They considered episode duration, as well as examined the percentage of buprenorphine episodes lasting at least 180 days.
- “We compared both outcome measures across racial and ethnic groups using analysis of variance.”
Here’s what they found:
- “Among 11 250 354 buprenorphine prescriptions, 866 904 treatment episodes were contributed by 240 923 patients…”
- Demographics. Patients tended to in their 30s (mean age: 37 years); the majority were male (57.2%) and White (84.1%).
- Median treatment duration. “The overall median treatment duration was 50 days… with a slightly increasing trend from 2017 to 2020. Durations differed significantly across racial and ethnic groups, with White patients consistently having the longest durations. Moreover, treatment duration among White patients increased starting in 2017 but consistently decreased among Black patients from 2014 and Hispanic patients from 2009.”
- Episodes at least 180 days. “22.8% to 26.3% of episodes were at least 180 days. Racial and ethnic minority populations consistently had fewer buprenorphine episodes of at least 180 days vs White patients. From 2011, the percentage of episodes of at least 180 days increased among all racial and ethnic groups; however, beginning in 2016, this trend reversed for Black patients.”
A few thoughts:
1. Ouch. As the authors note: “The results showed that racial and ethnic disparities in buprenorphine treatment duration increased between 2006 and 2020, particularly during more recent years.”
2. Would it be different in Canada?
3. What can be done? Even with the focus on the opioid crisis, the vast majority didn’t receive buprenorphine for 180 days or more, and the racial gap has grown in recent years.
4. Perspective: Opioid Agonist Treatments (like buprenorphine) significantly reduce mortality. In a systematic review and meta-analysis, Santo et al. found: “[OAT] was associated with a greater than 50% lower risk of all-cause mortality, drug-related deaths, and suicide and was associated with significantly lower rates of mortality for other causes.” That paper was reviewed in a past Reading which you can find here:
The full research letter can be found here:
Selection 3: “Professional Development Through Resident Lunches”
David E. Freedman
Academic Psychiatry, 22 October 2022 Online First
As I schlepped steamed bao and bánh mì to residents waiting in the hospital courtyard, the significance of in-person resident lunches was evident.
My residency program at a Toronto-based hospital supports a community-building fund at each of its teaching sites. This fund covers 1 hour of weekly protected time and $13-15 per core resident per week. The chief residents dedicate these funds to in-person resident lunches. At noon on Thursdays, up to 40 psychiatry residents gather to share food and stories on the hospital front lawn. The conversations are open-ended and unguided – chances to ask questions, commiserate, or divulge weekend plans.
Unfortunately, as many current residency reflections go, the COVID-19 pandemic prevented these in-person resident lunches from March 2020 until June 2022.
So begins a paper by Dr. Freedman.
“Despite the protected time, enthusiasm from resident leaders and staff, and gift cards for attendance, virtual resident lunches did not capture the energy of in-person lunches. All of the concrete elements were there, but not the vitality. Attendance dwindled to two to four residents per lunch, and lunches became less frequent. It felt as if videoconference fatigue absorbed the essence of resident lunches, leaving an artifact in its place.”
He notes a relevant literature:
- “Among firefighters, shared meals contribute to greater job satisfaction, cooperative behavior, and improved work performance.”
- “Recent commentaries highlighted lunchtimes in the pediatric intensive care unit and in a general practitioner practice as opportunities for healthy eating, social exchange, and community.”
- “Among anesthetic learners, peer lunches can enhance resident confidence and wellbeing.”
Is this relevant in psychiatry training? “In seeming contradiction to the nature of our work, training in psychiatry can feel isolating. Residents often work one-on-one with staff and patients, separated from co-residents. Patients may leave an emotionally laden discussion to debrief with their family while psychiatry residents return to their office to document the interaction. Resident lunches create moments for community.”
He notes some of the advantages of the lunches. He writes, for example, that: “With lunches open to everyone, there is also exposure to the diverse perspectives of our profession. Their ideas gain balance and nuance. Through this process, residents develop a broader sense of how they fit into the profession of psychiatry.” He feels that they particularly help junior residents. He even argues that it helps work life-balance, with residents exchanging travel stories. “Allegedly trivial, these conversations create bonds and encourage even the most hard-working residents to identify how to create spontaneity and play in their lives. Institutional support emphasizes that trainee wellness is an organizational priority.”
A few thoughts:
1. This is a well-written paper.
2. As life returns to normal, we can take pleasure in returning to things that were absent over these pandemic years, including – yes – lunch with colleagues.
3. To steal a line from Sarah Downey, the CEO of CAMH: “health care is a contact sport.”
The full Academic Psychiatry paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.