From the Editor
10.
This month, the Reading of the Week celebrates its 10th anniversary. The program has grown and evolved over this past decade but the core idea – timely summaries of the latest in the literature coupled with commentary – hasn’t changed. To mark the anniversary, over the next two weeks, we will look at some important papers that we have covered in the past ten years.
This week: ten papers that I think about often (and helped change my clinical work).
Next week: tens papers that I think about often (and helped change the way I view mental illness).
Of course, the lists of papers are hardly exhaustive. Have a favourite that I missed? Please don’t hesitate to email me.
* * *
Many of our colleagues speak enthusiastically about the influence of mentors on their lives – but how can you better incorporate mentorship into your career? What should you look for in a mentor? And what exactly is a mentor? In the second selection, we look at a new Quick Takes podcast interview with Dr. Suzanne Koven (of Harvard University). “Mentorship is especially valuable for people who are aspiring to somewhat unconventional careers, and that was certainly the case with me.”
Finally, in the third selection, a Globe and Mail editorial considers substance misuse and Canadian cities. After an episode of violence in Vancouver, they wonder what could be done and weigh more involuntary care for those with substance problems. “Involuntary care has a role to play in some cases. Getting involuntary care right, however, is difficult.”
DG
Selection 1: “Ten Papers that I Think About (and Helped Change My Clinical Work)”
September 2024
Here’s the list.
“Measurement-Based Care Versus Standard Care for Major Depression: A Randomized Controlled Trial With Blind Raters”
Tong Guo Yu-Tao Xiang, Le Xiao, et al.
The American Journal of Psychiatry, October 2015
In this RCT, participants were provided with standard care or measurement-based care. The results are striking: “Significantly more patients in the measurement-based care group than in the standard treatment group achieved response (86.9% compared with 62.7%) and remission (73.8% compared with 28.8%).”
Though published in 2015, the paper continues to spark discussion and debate. And while some argue that the results may reflect the problems of high-volume practices rather than the benefits of measurement-based care, it’s tough not to feel that incorporating scales into practice adds information with limited downside.
Clinical take-away: since reading this paper, I use more scales.
“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
Should I stay on my antidepressants?
It’s the question patients routinely ask us. This paper provides clear and practical guidance: continuation of an SRI trial prevents depressive episodes. “Relapse of depression occurred in 92 of 238 patients (39%) in the maintenance group and in 135 of 240 (56%) in the discontinuation group during the 52 weeks of the trial (hazard ratio, 2.06…).”
Though other studies have considered the risk of relapse after discontinuation, this paper is particularly elegant and lucid.
Clinical take-away: I’m more careful when talking to patients about the importance of medication compliance.
“Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis”
Andrea Cipriani, Toshi A. Furukawa, Georgia Salanti, et al.
The Lancet, 7 April 2018
No list of big papers from the past decade would be complete without this study by Cipriani et al. It is incredibly impressive: they didn’t just do a systematic review and network meta-analysis on a handful of trials, they pulled together an incredible number – published and unpublished – including 522 double-blind RCTs and 116 477 participants (yes, you read that correctly).
For the record: “Some antidepressants, such as escitalopram, mirtazapine, paroxetine, agomelatine, and sertraline had a relatively higher response and lower dropout rate than the other antidepressants.”
Clinical take-away: when starting an antidepressant, I ask myself: what would Cipriani do?
“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, February 2022
Many of our patients look to cannabis for everything from relief of their insomnia to help with their mood.
Hill et al. summarized the evidence from 850 papers and commentaries in an amazing review. Bonus: the paper is readable and clear. For the record, they conclude: “There is little data indicating that cannabinoids are helpful in treating psychiatric illness, while there is considerable evidence that there is potential for harm in vulnerable populations such as adolescents and those with psychotic disorders.”
Clinical take-away: I remain cool to cannabis for those with mental disorders, and I often mention the Hill et al. paper to patients.
“Risk of suicide death following electroconvulsive therapy treatment for depression: a propensity score-weighted, retrospective cohort study in Canada”
Tyler S. Kaster, Daniel M. Blumberger, Tara Gomes, et al.
The Lancet Psychiatry, June 2022
It’s the most controversial treatment in psychiatry. An American survey found that one in five patients identify death as a major concern with ECT.
It’s also highly effective for depression. Is it a lifesaver? In this smart study, Kaster et al. add importantly to the literature on the decades-old treatment. “1 year after discharge from a psychiatric hospital, patients with depression who were exposed to electroconvulsive therapy had a nearly 50% reduction in the relative risk of death by suicide when compared with those who had not been exposed.”
Clinical take-away: I speak more often to patients about the benefits of ECT, and I do it earlier in my care of those with depression, especially severe depression.
“Differences in Antipsychotic Treatment Discontinuation Among Veterans With Schizophrenia in the U.S. Department of Veterans Affairs”
Mark Weiser, John M. Davis, Clayton H. Brown, et al.
The American Journal of Psychiatry, October 2021
When it comes to antipsychotics, is new better?
This observational study drew on Veterans Affairs data and included more than 37 000 participants with schizophrenia. They considered different antipsychotic medications and the risk of discontinuation. All antipsychotics were not equal. “Among veterans with schizophrenia, those who initiated antipsychotic treatment with clozapine, long-acting injectable second-generation medications, and antipsychotic polypharmacy experienced longer episodes of continuous therapy and lower rates of treatment discontinuation.”
Of course, other studies have shown that clozapine has additional advantages, including its anti-suicidal properties.
Clinical take-away: despite the psychopharmacology revolution and the development of newer antipsychotics, I’m still prescribing clozapine.
“Quantifying the Association Between Psychotherapy Content and Clinical Outcomes Using Deep Learning”
Michael P. Ewbank, Ronan Cummins, Valentin Tablan, et al.
JAMA Psychiatry, January 2020
What makes therapy successful?
While many have an opinion, little of it is based on data. That’s what makes the Ewbank et al. paper so fascinating. By breaking therapy down into a couple of dozen techniques and then employing machine learning, they attempted to match techniques with outcomes (patient improvement and engagement). It’s an interesting paper. It’s also impressive: they drew on 90 000 hours of Internet-delivered CBT. The main finding: a handful of techniques – including therapeutic praise, planning for the future, and homework review – improved outcomes the most.
The writing here is a bit clunky, but it gives us a peek into how big data and AI may move us toward better and more focused psychotherapy treatments for our patients.
Clinical take-away: when I do CBT with a patient, I think more about certain things, like homework.
For the record, this paper makes me feel that the future of mental healthcare is bright.
“Anxiety-focused cognitive behavioral therapy delivered by non-specialists to prevent postnatal depression: a randomized, phase 3 trial”
Pamela J. Surkan, Abid Malik, Jamie Perin, et al.
Nature Medicine, 16 February 2024
Most of the papers on this list are written by authors in high-income nations with data from participants in such countries. But global psychiatry has evolved dramatically.
This study, done in Pakistan, attempted to prevent depression in pregnant women who had significant anxiety. That would be an ambitious goal anywhere – but especially challenging in a place with so few mental health clinicians. To address the lack of clinicians, they trained up lay people, teaching them CBT. It worked. “We found reductions of 81% and 74% in the odds of postnatal MDE and of moderate-to-severe anxiety…”
Clinical take-away: not all mental healthcare needs to be delivered by highly-trained professional in countries like Pakistan – or, for that matter, in countries like Canada.
https://www.nature.com/articles/s41591-024-02809-x
“Clinical effectiveness and cost-effectiveness of a brief accessible cognitive behavioural therapy programme for stress in school-aged adolescents (BESST): a cluster randomised controlled trial in the UK”
June Brown, Kirsty James, Stephen Lisk, et al.
The Lancet Psychiatry, July 2024
School-based interventions are popular and attractive. After all, given that mental disorders often present in adolescence, prevention would seem appropriate and focusing on schools makes sense for obvious reasons. But, to date, the literature has been hardly impressive, in part because the universality of such initiatives means that they are both expensive and unfocused. Brown et al. report on a randomized controlled trial involving 900 UK adolescents who self-referred and received CBT or treatment-as-usual. This approach offers something of a middle ground – accessible but not unfocused. “[T]he DISCOVER intervention is modestly clinically effective and economically viable and could be a promising early intervention in schools.”
Clinical take-away: therapy isn’t a panacea and not everyone benefits from it – but some do.
“Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data”
David M. Clark, Lauren Canvin, John Green, et al.
The Lancet, 18 February 2018
Back in 2007, seeking to address the lack of access to mental healthcare, the United Kingdom launched a small program offering CBT free at the point of use: Improving Access to Psychological Therapies (IAPT). The program has grown, now covering England and offering several psychotherapies; more than a half million people are served annually. Incredibly, outcomes are recorded in 98% of clinical encounters.
In this paper, IAPT co-founder David M. Clark (of Oxford University) and his co-authors evaluate the program and its metrics.
Clinical take-away: CBT is effective for mood and anxiety problems; I always mention this when discussing treatment with patients.
This paper also shows us that even very large programs can rigorously collect data. To borrow a line from Dr. Paul Kurdyak: if there was a Nobel Prize for health services, Clark would win it.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32133-5/fulltext
(Embarrassingly, I never covered this paper in the Reading of the Week though other IAPT-related studies were selected.)
Selection 2: “Mentorship”
Suzanne Koven
Quick Takes, 25 September 2024
In this episode of Quick Takes, I speak with Dr. Suzanne Koven, a Harvard-affiliated physician and Writer-in-Residence at Massachusetts General. In our interview, she shares advice on how to find a good mentor, what makes for a successful mentor/mentee relationship, and what not to look for in mentorship.
Here, I highlight several comments:
On the meaning of mentorship
“A mentor is someone who has more imagination about you than you have about yourself at any given time.”
On young docs hesitating to find a mentor
“I would want not be disingenuous or dismissive of their concerns. In order for a mentor to be effective, they have to know the mentee fairly well. To be known fairly well is to be vulnerable, and you can certainly understand that someone who is junior in the hierarchy may not feel comfortable being entirely forthcoming with a mentor or a potential mentor about challenges that they have faced, perhaps even about illnesses or disabilities that they’ve dealt with.”
On a good fit
“I am less convinced that a perfect alignment of interests or career paths or potential career paths, between mentor and mentee are important. What’s more important: a real desire to understand where the mentee is at and to supply that extra bit of imagination and confidence to get them to the next step.”
On a poor fit
“If you meet with a mentor and you leave feeling deflated, you leave feeling that your possibilities are narrower than they were when you walked in, that’s not the right mentor for you, and I don’t care how great the match was supposed to be.
On her next book
“This book is really a straight memoir called The Mirror Box. It’s about literally the week I was set to see my last patient after 32 years in primary care practice, and I had a bad injury and I became a patient myself.
“I learned a lot by being a patient. This isn’t the usual kind of turning of the tables memoir, where, you know, I learn as a patient I should have been so much more compassionate and you know the health care system is so awful. I received very compassionate care and I was treated quite well by the health care system. Of course, I’m in a great position of privilege regarding health insurance and access and much more. And yet, it was very, very difficult being a patient in all kinds of ways.”
The above answers have been edited for length.
The podcast can be found here, and is 22 minutes long:
Selection 3: “The challenges of involuntary drug treatment”
The Globe and Mail, 19 September 2024
In the political scramble to grapple with the drug overdose crisis and widespread issues of addiction, governments have deployed an array of experimental policies.
British Columbia has been a leader, from harm reduction services such as supervised drug consumption sites and prescribed opioids to expanded treatment and rehabilitation. What gets less attention is the thousands of people in B.C. each year who receive involuntary treatment, in cases where people are deemed to be a danger to themselves and to others. In 2021, the province opened the Red Fish Healing Centre, a 105-bed facility in the Vancouver suburbs. A typical stay lasts for at least six months and roughly half of the people there are involuntary patients.
There is a renewed push to expand such treatment – but tentative steps in B.C. and Alberta illustrate the challenges in figuring out the details, amid broader problems in health care and difficulties to access voluntary drug treatment.
So begins an Editorial.
They observe the politics. “The NDP’s move also shows how the seemingly divided politics of drug overdoses has far more overlap than commonly understood. Alberta Premier Danielle Smith last year promised involuntary treatment. Like Mr. Eby’s tentative steps forward, no legislation in Alberta has since emerged.”
Not everyone agrees. They note: “Critics of involuntary care – a challenge to province’s Mental Health Act is in court next spring – argue that the focus should be voluntary treatment care. There’s not enough beds available and the wait time is 35 days.”
That said, the Editorial is sympathetic to the concept: “involuntary care has a role to play in some cases.”
The authors fairly review relevant stats and literature:
- “Vancouver Police report crime is down significantly this year.”
- “[Vancouver mayor] Sim claimed violent repeat offenders were responsible for ‘a large portion’ of crime. Data shows the opposite, that mental illness and drug use drives only a small fraction of violent crime in Canada.”
- “Evidence around involuntary care is limited and mixed.”
“After record overdose deaths in 2023, the number of people dying has fallen 8 per cent this year. That’s good news but the crisis is far from over… The scale of the overdose crisis demands an array of policies and that includes involuntary care.”
A few thoughts:
1. This is a well-argued essay.
2. The authors mention Alberta and British Columbia. Reconsidering the balance between patient autonomy and societal safety is much discussed elsewhere, including New Brunswick (in Canada) and New York and California (in the United States).
3. As writer Anna Mehler Paperny has observed, “coercive care is having a moment.”
4. It’s tough to debate the final conclusion which simply calls for different policies to deal with the overdose crisis. But to play the Devil’s advocate, given that substance programs are so challenging to access presently, shouldn’t our focus be different? Shouldn’t we aspire to have more accessible care before we resort to more coercive care?
5. Readers will draw their own conclusions, of course. For those wanting to read more about substance and British Columbia, Globe columnist Marcus Gee has an excellent piece on Victoria’s Pandora Avenue in the Saturday edition.
https://www.theglobeandmail.com/canada/toronto/article-facing-victorias-pandora-avenue-problem/
The full Globe Editorial can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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