From the Editor

Three patients have recently told their stories to me. With his business failing, he turned to alcohol. When she couldn’t get hours at the restaurant because of the lockdown, she started drinking in the mornings. After a decade of sobriety, he explained that he found comfort in alcohol after his job loss.

These stories aren’t, unfortunately, surprising. With the pandemic, substance use appears to be on the rise. But what about substance-related deaths? In the first selection, we look at a new research letter from JAMA. Aaron M. White (of the National Institute on Alcohol Abuse and Alcoholism) and his co-authors examine alcohol-related deaths in the United States and the impact of the pandemic. They conclude: “The number and rate of alcohol-related deaths increased approximately 25% between 2019 and 2020, the first year of the COVID-19 pandemic.” We consider the paper and its clinical implications.

In the second selection, Dr. Tony P. George (of the University of Toronto) and his co-authors focus on the opioid crisis. In this Canadian Journal of Psychiatry commentary, they argue for a stronger approach to help those with opioid use disorder (OUD), specifically by improving the psychosocial interventions available. “While psychosocial interventions are often expensive and time consuming, they do make a difference in the lives of patients with OUD and those at risk for fatal opioid overdoses, especially when combined with broad psychosocial supports that address social determinants of health.”

And in the third selection, continuing our consideration of the first update to the DSM series in nine years, we look at a New York Times article, just published. Reporter Ellen Barry writes about prolonged grief disorder: “The new diagnosis was designed to apply to a narrow slice of the population who are incapacitated, pining and ruminating a year after a loss, and unable to return to previous activities.”


Selection 1: Alcohol-Related Deaths During the COVID-19 Pandemic

Aaron M. White, I-Jen P. Castle, Patricia A. Powell, et al.

JAMA, 18 March 2022  Online First

Research suggests that alcohol consumption and related harms increased during the first year of the COVID-19 pandemic. Studies reported increases in drinking to cope with stress, transplants for alcohol-associated liver disease, and emergency department visits for alcohol withdrawal. We examined mortality data to assess whether alcohol-related deaths increased during the pandemic as well.

So begins a paper by White et al.

Here’s what they did:

The authors drew data from two sources: the National Center for Health Statistics (for 2019 and 2020) and the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (for the first half of 2021). The authors did statistical analyses, including by age groups.

Here’s what they found:

  • Total involving alcohol. “The number of deaths involving alcohol increased between 2019 and 2020 (relative change, 25.5%), as did the age-adjusted rate (relative change, 25.9%).” (!!) See figure below.
  • All causes. “Comparatively, deaths from all causes had smaller relative increases in number (18.8%) and rate (16.6%). Alcohol-related deaths accounted for 2.8% of all deaths in 2019 and 3.0% in 2020.”
  • By age. “Rates increased for all age groups, with the largest increases occurring for people aged 35 to 44 years (39.7%) and 25 to 34 years (37.0%).”
  • By gender. Increases by gender were similar.

A one-word comment on the study: wow. Other studies have shown that drinking has increased with the pandemic, but this concise research letter demonstrates the dramatic rise of alcohol-related deaths.

In a New York Times article, the first author comments: “Stress is the primary factor in relapse, and there is no question there was a big increase in self-reported stress, and big increases in anxiety and depression, and planet-wide uncertainty about what was coming next. That’s a lot of pressure on people who are trying to maintain recovery.”

Clinically, this research letter is yet another reminder that we need to ask about substance when speaking to our patients, particularly those at greater risk of problem drinking during the pandemic (for example, those with a past history).

The full JAMA paper can be found here:

Selection 2: “Why Integrating Medications and Psychosocial Interventions is Important to Successfully Address the Opioid Crisis in Canada”

Tony P. George, Lauren Welsh, Susan L. Franchuk, Franco J. Vaccarino

The Canadian Journal of Psychiatry, March 2022

The opioid crisis continues unabated in Canada. In 2019, there were 3,923 reported deaths from opioid overdose, and 94% of these deaths were unintentional. Moreover, it appears that opioid overdose death rates have increased since the beginning of the COVID-19 pandemic. Clearly, there are multiple factors contributing to this crisis, and the limited accessibility to opioid agonist treatments (OATs), combined with a lack of utilization of psychosocial interventions (PSIs), further complicates this issue. Needless to say, the opioid crisis is a complex issue that will need nuanced solutions. We argue that while we have excellent evidence-based medication treatments for opioid use disorder (OUD), they are probably less effective when they are not appropriately combined with PSIs.

So begins a paper by George et al.

The authors note that there are several medications for opioid use disorders, including methadone, buprenorphine/naloxone, and oral naltrexone. That said: “[T]here is a clear lack of trained medical prescribers of first-line medications to meet the current needs; most provinces train only a handful of physicians and other health providers in the prescribing of OATs. Moreover, Canadians also experience significant health disparities based on where they live, and those living in rural and remote areas face further barriers to accessing OAT.”

They also note the potential of psychosocial interventions: “we have good evidence-based PSIs for OUD, including motivational interviewing (MI) and motivational enhancement therapy (MET), cognitive-behavioural therapies (CBTs), contingency management (CM), and mutual self-help (e.g., 12 steps; AA, alcohol anonymous; NA, narcotics anonymous).”

They continue: “The evidence for the efficacy of combining PSIs with OATs has been mixed, and in fact there have been very few well-controlled studies of their integration, such as ‘dismantling’ strategies that study combinations of OAT and PSIs, to OAT and PSIs alone. Notably, there is strong evidence that OAT alone (e.g., methadone without PSIs) can be very effective for detoxification of OUD, and in preventing OUD relapse.”

Still they argue: “while retention in OAT programs in Canada has historically been poor, it is known that providing evidence-based PSIs to OUD patients significantly increases treatment retention in OAT programs, which can improve other treatment outcomes from both harm reduction and abstinence perspectives.” Further, “the integration of OAT with psychosocial treatment is recommended in OUD guidelines worldwide. Thus, this lack of consistent integration of PSIs with OATs falls below established standards of care for OUD patients.” They note the importance of “targeting of symptoms, skills, and social determinants of health, to ensure optimal outcomes. We argue this is only possible by taking a holistic approach, which combines pharmacotherapies, PSIs and social supports.”

They call for a multipronged approach including:

  • “educating clinicians, patients, and families impacted by the opioid crisis about the availability of opioid medications…”
  • “We must also address issues of access to OAT, recognizing that there are enormous disparities across the country.”
  • “the provision of evidence-based PSIs to complement OATs should be considered essential, but require further study.”

This commentary isn’t earth-shattering but the multipronged approach seems very reasonable.

I’ll pick up on the second point. Access to opioid agonist treatment should be a priority. Consider: in a recent meta-analysis and systematic review of opioid agonist treatment for those with opioid dependence, Santo et al. found that “a greater than 50% lower risk of all-cause mortality, drug-related deaths, and suicide…” That JAMA Psychiatry paper was discussed in a past Reading:

The full CJP commentary can be found here:

Selection 3: “How Long Should It Take to Grieve? Psychiatry Has Come Up With an Answer”

Ellen Barry

The New York Times, 18 March 2022

After more than a decade of argument, psychiatry’s most powerful body in the United States added a new disorder this week to its diagnostic manual: prolonged grief.

The decision marks an end to a long debate within the field of mental health, steering researchers and clinicians to view intense grief as a target for medical treatment, at a moment when many Americans are overwhelmed by loss.

The new diagnosis, prolonged grief disorder, was designed to apply to a narrow slice of the population who are incapacitated, pining and ruminating a year after a loss, and unable to return to previous activities.

So begins an article by Barry.

The article notes the immediate importance of the inclusion; American insurance providers will now fund treatment of this disorder. Drug companies are doing research in the area; naltrexone is used in a clinical trial.

Dr. Paul S. Appelbaum, who chairs the APA’s committee overseeing DSM revisions, comments: “They were the widows who wore black for the rest of their lives, who withdrew from social contacts and lived the rest of their lives in memory of the husband or wife who they had lost. They were the parents who never got over it, and that was how we talked about them. Colloquially, we would say they never got over the loss of that child.”

The article outlines the evolution of thinking on this disorder:

  • “The origins of the new diagnosis can be traced back to the 1990s, when Holly G. Prigerson, a psychiatric epidemiologist, was studying a group of patients in late life, gathering data on the effectiveness of depression treatment. She noticed something odd: In many cases, patients were responding well to antidepressant medications, but their grief… was unaffected, remaining stubbornly high… Her research showed that for most people, symptoms of grief peaked in the six months after the death. A group of outliers – she estimates it at 4 percent of bereaved individuals – remained “stuck and miserable…”
  • “In 2010, when the American Psychiatric Association proposed expanding the definition of depression to include grieving people, it provoked a backlash, feeding into a broader critique that mental health professionals were overdiagnosing and overmedicating patients.”
  • “Dr. M. Katherine Shear, a psychiatry professor at Columbia University, who developed a 16-week program of psychotherapy that draws heavily on exposure techniques used for victims of trauma… By 2016, data from clinical trials showed that Dr. Shear’s therapy had good results for patients suffering from intense grief, and that it outperformed antidepressants and other depression therapies. Those findings bolstered the argument for including the new diagnosis in the manual…”

Not everyone is on side: “I completely, utterly disagree that grief is a mental illness,” comments Joanne Cacciatore, an associate professor of social work at Arizona State University.

The article concludes by discussing the grief of a few people who have struggled, including Amy Cuzzola-Kern who lost her brother suddenly, and “found herself compulsively replaying the days and hours leading up to his death, wondering whether she should have noticed he was unwell or nudged him to go to the emergency room.” She completed the 16-week program and reports feeling better.

Some will find these arguments persuasive, while others may worry about pathologizing normalcy. Either way, this news article offers good context and history to the DSM-5 revision. For those hoping to take a deeper dive into the topic, a recent JAMA Psychiatry paper co-authored by Prigerson and Shear discussed the evidence for this disorder; that paper was considered in a past Reading:”>

The full NYT article can be found here:

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