From the Editor
It’s a Reading of the Week tradition that we begin the New Year by reviewing the best of the past year; so, this week, we look back at 2021.
As with past annual reviews, I’ve organized papers into different categories – though there is one common thread: all the papers are clinically relevant and practical. And, yes, there is a person of the year. Spoiler alert: he was fond of bow ties and thinking outside the box.
And an observation about 2021: the quality of scholarship was very high. I’ve picked ten papers – but it would have been possible to pick scores more. Psychiatry continues to grow more sophisticated with each passing year.
The Most Relevant COVID Paper
“Ways That Mental Health Professionals Can Encourage COVID-19 Vaccination”
Noel T. Brewer and Neetu Abad
JAMA Psychiatry, 23 September 2021 Online First
“Although mental health is not the first thing that comes to mind when thinking about vaccination, strategic use of mental health professionals’ expertise could provide new opportunities to encourage COVID-19 vaccination.”
With a new variant, the pandemic is top of everyone’s mind. Those with severe mental health disorders are more likely to get COVID – and much more likely to become significantly ill from it. Our role in protecting our patients, thus, must include conversations about vaccinations and, of course, other efforts.
Noel T. Brewer (of the University of North Carolina at Chapel Hill) and Neetu Abad (of the US Centers for Disease Control and Prevention) discuss ways that we can boost the rate of vaccination of those with mental health problems. Among the practical recommendations: use motivational interviewing techniques with your patients.
The Paper I Wish Everyone Read
CMAJ, 13 September 2021
“When you meet somebody living on the streets, remember my brother.”
This is a great essay, written by a physician – and, more importantly, written by the sister of someone with major mental illness. The essay describes the life and death of her brother, who died of an overdose at just 34 after struggling with major mental illness and homelessness.
It’s a moving essay. It’s also a gentle reminder of our patients’ humanity.
Dr. Purdy closes with a call to action: “I am a doctor, with the skills to save lives, yet I couldn’t save my own brother. If death was the outcome for Blake – a person with a whole family behind him, working daily to help him – how is there any hope for people who don’t have that support? To change the outcome for people like Blake – homeless, addicted and struggling with mental illness – it will take more than just a few caring individuals; it will take every member of society doing everything in their power.”
The Biggest Paper on an Emerging Treatment
“Trial of Psilocybin versus Escitalopram for Depression”
Robin Carhart-Harris, Bruna Giribaldi, Rosalind Watts, et al.
The New England Journal of Medicine, 15 April 2021
“Tripping may be as effective as your antidepressants.” So summarized a news article on this new paper.
Robin Carhart-Harris (of Imperial College) and his co-authors received much attention. No wonder. Psilocybin is the talk of the town for the treatment of mood disorders. And Carhart-Harris et al. have published a paper in The New England Journal, no less. The big finding? The mean changes in the scores from baseline to week 6 were -8.0 in the psilocybin group and -6.0 in the escitalopram group, for a between-group difference of 2.0 points.
But the paper has its share of problems. Start here: there were only 59 participants. And there were problems with the blinding. It’s a big paper – but is it persuasive?
The Best Paper – Clinical
“Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study”
Tyler S. Kaster, Simone N. Vigod, Tara Gomes, et al.
The Lancet Psychiatry, 1 August 2021
“The clinical implication of this study is that electroconvulsive therapy is likely to be safe with respect to medical risks; considering its established efficacy in depression, the benefits of electroconvulsive therapy might outweigh its risk in this severely ill population.”
ECT was first used decades ago, yet the debate about its safety seems to be unresolved, at least in the eyes of many patients and providers. This paper adds to the literature. With hundreds of thousands of Canadians struggling with treatment refractory depression, ECT needs to be discussed more, including its safety.
The Second Best Paper – Clinical
“Maintenance or Discontinuation of Antidepressants in Primary Care”
Gemma Lewis, Louise Marston, Larisa Duffy, et al.
The New England Journal of Medicine, 30 September 2021
Our patients often ask to stop their antidepressants after their depressive symptoms resolve. This New England Journal of Medicine paper by Gemma Lewis (of University College) and her co-authors can help guide that conversation.
There is much to like with this paper. The RCT is well designed and thoughtful. And the finding is clear: “Those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current therapy.”
The Best Paper on Global Psychiatry
“Effect of Shamiri Layperson-Provided Intervention vs Study Skills Control Intervention for Depression and Anxiety Symptoms in Adolescents in Kenya: A Randomized Clinical Trial”
Tom L. Osborn, Katherine E. Venture-Conerly, Susana Arango G., et al.
JAMA Psychiatry, 9 June 2021
“To our knowledge, this is one of the first adequately powered tests in this population of a scalable intervention grounded in simple positive psychological elements.”
Drawing on a simple (and potentially scalable) intervention, the authors look at addressing mood and anxiety symptoms among Kenyan adolescents. They show a robust response. But was the study ethical?
The Best Paper on Cannabis
“Risks and Benefits of Cannabis and Cannabinoids in Psychiatry”
Kevin P. Hill, Mark S. Gold, Charles B. Nemeroff, et al.
The American Journal of Psychiatry, 8 December 2021 Online First
“Do I really need to quit cannabis?”
Patients ask this question often, in part because an industry now promotes cannabis for many problems, including mental disorders. What’s evidenced in terms of cannabis and mental disorders? With a rapidly evolving literature, it’s tough to keep up. The Hill et al. review, published in The American Journal of Psychiatry, is impressive, covering more than 800 papers.
If you are going to read one paper on cannabis, it’s this one. Dr. Kevin P. Hill (of Harvard University) and his co-authors have offered up a thoughtful review. And yes, they provide clear guidance for us clinicians:
“In general, however, prescribing clinicians should avoid initiating or recommending cannabinoid pharmacotherapy for most psychiatric patients. There are no clinical trials that support the use of cannabinoids as pharmacotherapy for mood disorders, and there is limited evidence supporting their use in PTSD. Converging lines of evidence suggest that THC-containing compounds are likely to cause harm in patients with existing psychosis or at high risk for psychosis.”
Some papers brought fresh perspectives to our work; I highlight three.
Isabelle M. Hunt (of the University of Manchester) and her co-authors consider suicide rates by ethnic group in the UK, focused on those who have had contact with mental health care. It’s an important paper – and, I hope, the start of more work that considers ethnicity and the mental health experience.
How to think about structural racism in mental health care? More importantly, how could these thoughts inform clinical practice? Drs. Nathalie Moise and Sidney Hankerson (both of Columbia University) consider structural racism and depression care in a lively and practical paper.
What’s the role of psychiatry and psychiatrists? Dr. Vicky Stergiopoulos (of the University of Toronto) offers a strong essay, touching on our history. She also notes our common purpose. “I have spent most of my professional life working with adults experiencing homelessness and mental illness, in shelters, primary care, or the streets. This work has made me a better doctor. I had to look up what Chelsea boots are, but I’m proud to be fighting for social justice alongside those who wear them.”
The Person of the Year
The fourth child of Russian Jewish immigrants. A Yale medicine graduate. A snappy dresser who loved bow ties.
In selecting a Person of the Year, I consider people who have made contributions to scholarship or advocacy or clinical work. Past selections have included a former Minister of Finance, the CEO of a major hospital, and the former chair of university department of psychiatry.
This year, I choose Dr. Aaron Beck, who died in early November.
Dr. Ari Zaretsky (of the University of Toronto) wrote about him for the Reading of the Week. In his essay, Dr. Zaretsky observes: “His life story is that of a former psychoanalyst who rejected the dogmatism of mainstream Freudian psychoanalysis during the 1950s and 1960s and in doing so permanently changed the paradigm and transformed psychotherapy.”
Interested in reading more? The Best of 2020 can be found here:
The Best of 2019, here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.