Tagcannabis

Reading of the Week: Cannabis and Inpatients – the New CJP Paper; Also, Alexander on Her Loss and Her Patient’s (JAMA)

From the Editor

First, there was decriminalization; then, legalization.

How have these major legal shifts influenced the presentation of our patients? In the first selection, we consider a new paper from The Canadian Journal of Psychiatry. Taylor McGuckin (of the University of Waterloo) and her co-authors look at cannabis use and inpatient care, drawing on databases. “This study identified a significant increase in the proportion of patients who used cannabis within 30 days of their first admission to inpatient psychiatry in Ontario, Canada, between 2009 and 2017, compared to 2007.”

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How do our biases affect the care we provide? In a moving and personal essay, Karen Alexander (of Thomas Jefferson University) discusses the loss of her baby. She thinks about another time, when a patient of hers was in a similar situation, and she mulls her own views and biases. “The weeping woman was always much more than someone who was grieving, but I never really knew her as a person until I mourned the loss of my own child.”

DG

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Reading of the Week: Cannabis, Cannabis, Cannabis – With Papers from Psychological Medicine, Psychiatric Services, and Annals of Internal Medicine

From the Editor

“It’s the only thing that works.”

So many of our patients swear by cannabis. It has become a popular choice for everything from anxiety to chronic pain. And though the literature is relatively young, now we know more about cannabis than before. This week, we focus on three new papers.

The first selection is a paper by Dr. Emmet Power (of the Royal College of Surgeons in Ireland) and his co-authors from Psychological Medicine. Does frequent and dependent cannabis use in youth affect IQ? Doing a systematic review and meta-analysis, they find seven papers. They conclude: “We found that young people who use cannabis frequently or dependently by age 18 have declined in IQ at follow up and this may be due to a decline in verbal IQ.”

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In the second selection, we consider a new paper from Psychiatric Services. Dr. Corneliu N. Stanciu (of Dartmouth College) and his co-authors did a systematic review of cannabis for several disorders. “With only eight very small studies, insufficient evidence was found for efficacy of CBD and THC to manage affective disorders, anxiety disorders, or PTSD.”

Finally, in the third selection, we look at a paper from Annals of Internal Medicine. Drs. Arthur Robin Williams (of Columbia University) and Kevin P. Hill (of Harvard University) pose 15 questions about cannabis and answer them. The authors are practical and thoughtful. The clinical bottom line: “Millions more adults now meet criteria for cannabis use disorder in a given year, and all clinicians, not just mental health professionals, have vital roles in improving clinical management, from screening and diagnosis to overseeing treatment plans.”

DG

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Reading of the Week: Yoga vs CBT – What’s Best for Anxiety? (JAMA Psych) Also, COVID & Mental Health (Lancet Psych) and Whitley on Cannabis Stigma (Van Sun)

From the Editor

Anxiety disorders are common, and often disabling to our patients. While treatments have improved, there is unmet need – and the desire to find new, scalable interventions. Increasingly, our patients look to different types of treatments, like yoga. But is trendy effective? Is yoga the not-so-new intervention we need?

Dr. Naomi M. Simon (of New York University) and her co-authors look at the treatment of generalized anxiety disorder with a sophisticated study. They compare yoga and cognitive behavioral therapy (CBT) against a psychological control condition, and against each other. So how do the treatments compare? “Kundalini yoga can reduce anxiety for adults with generalized anxiety disorder, but study results support CBT remaining first-line treatment.” We look at the big study and its big implications.

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What have we learned about COVID-19 and mental health? In the second selection, we consider a new editorial from The Lancet Psychiatry. Mulling the state of the literature after almost a year of the pandemic, they write: “The good news is that by October, 2020, mental health was top of the charts in terms of published papers and preprints on the effects of COVID-19. The bad news is that the quantity of papers is not matched by quality.”

And in our final selection, we consider an essay by Rob Whitley (of McGill University). He notes that 27% of Canadians had used cannabis in the last year, about half of them for medical reasons. He worries about the stigma around medical cannabis and champions more public education. “This can help create a climate of acceptance and inclusion for the growing number of Canadians with mental illness who use cannabis to improve their well-being.”

On another note: in a past Reading, we featured an essay by Toronto filmmaker Rebeccah Love who wrote about her mental illness. Her new film, “Parlour Love,” has its premiere this Saturday at 7 pm EST through Zoom. In this short, powerful film, she draws from her own experiences of bipolar mania and psychosis, and paints a portrait of a woman in crisis. RSVP – palmpremiere@gmail.com.

DG

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Reading of the Week: Cannabis for Mental Illness (CJP)? Also, Cannabidiol for the Cannabis Use Disorder (Lancet Psych) & Love on the Police (Globe)

From the Editor

“Should I take cannabis for my mental illness?”

Our patients ask this question – in our EDs, inpatient wards, and outpatient clinics. We shouldn’t be surprised. Cannabis is now legal, and private industry pushes the medicinal benefits of cannabis. But what does the literature say?

This week, we have three selections.

The first is a new Canadian Psychiatric Association position statement that considers cannabis and mental illness. Dr. Philip G. Tibbo (of Dalhousie University) and his co-authors systematically reviewed the literature. They found 29 RCTs, including for anxiety and psychotic disorders. “Use of cannabis or a cannabinoid product should never delay (or replace) more evidence-based forms of treatment.”

marijuana-candy-sizedMany products, little evidence?

But is there emerging evidence for cannabis? Tom P. Freeman (of the University College London) and his co-authors did a phase 2a trial using CBD to address cannabis use disorder, which is written up in The Lancet Psychiatry. “In the first randomised clinical trial of cannabidiol for cannabis use disorder, cannabidiol 400 mg and 800 mg were safe and more efficacious than placebo at reducing cannabis use.”

Finally, on a pivot, in the third selection, we consider an essay from The Globe and Mail. Rebeccah Love writes about her own experiences with psychosis and her recovery. She also considers whether police should be involved in mental health crises. “The image of a police officer – often a big white man with a gun – is interpreted as a threat, an agent of death, an oppressor.”

DG

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Reading of the Week: Apps for the Treatment of Depression (JAMA Psych)? Also, Cannabis & Driving (CJP); Oleynikova on Returning to School (Globe)

From the Editor

The world changed on March 11, the day that the pandemic was declared by the WHO. So did mental health care, with so many of our services becoming virtually delivered. But what’s effective and what should be incorporated into care moving forward?

This week, we have three selections.

The first is a new JAMA Psychiatry paper. With COVID-19, apps are becoming increasingly popular (one therapy app reports a 65% increase in clients over the spring). Can the apps be incorporated into primary care? Andrea K. Graham (of Northwestern University) and her co-authors do a RCT using apps for patients with depression and anxiety. They conclude: “In this trial, a mobile intervention app was effective for depression and anxiety among primary care patients.” But should we be so enthusiastic? And how could apps be used in care?

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Canada legalized cannabis for non-medical purposes in 2018. In a short research letter – our second selection – medical student Laura A. Rivera and Dr. Scott B. Patten (both of the University of Calgary) consider driving under the influence of cannabis, drawing on national survey data. “Public policy actions toward prevention of DUIC [driving under the influence of cannabis] appear necessary and will have the greatest impact if they are effective in the 15 to 24 age range and in males.”

Finally, in the third selection, we consider an essay from The Globe and Mail. Like many, Vera Oleynikova thinks about the return to school. She writes about her own experiences, noting a complication: she has struggled with depression. “To be sick for a long time and then to feel well again is a magical thing. You feel brand new and capable of anything. You marvel at your own capacity to do the things that for a long time were unavailable to you because of your illness. Which is why going back to school at 31 felt so right.”

DG

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Reading of the Week: Is CBD Useful for Mood Disorders? The New CJP Paper. Also, Peer Support and Online CBT (Psych Services) & the Art of Daniel Regan

From the Editor

This week, we have three selections.

With the legalization of cannabis, many big claims haven been made about the medicinal aspects of this drug – including by industry. Cannabidiol, or CBD, is often touted as being helpful yet non-addictive (in contrast to THC, the more famous cannabis molecule). In the first selection, UBC’s Jairo Vinícius Pinto and his co-authors consider cannabidiol in the treatment of mood disorders, reviewing the existing literature. Does CBD help? “The methodology varied in several aspects and the level of evidence is not enough to support its indication as a treatment for mood disorders.”

In the second selection, the University of Michigan’s Paul N. Pfeiffer and his co-authors try to improve depression treatment outcomes by combining a cutting-edge psychotherapy (CBT, delivered by computer) with a not-so-cutting edge approach (peer support). They conclude that the intervention “should be considered as an initial treatment enhancement to improve effectiveness of primary care treatment of depression.”

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And in the third selection, we look at the work of artist Daniel Regan, which is featured on the front cover of February issue of The Lancet Psychiatry. He notes: “I really think if I hadn’t gone on to study photography, I wouldn’t be here.” Featured above is “Abandoned,” part of a series of photos from Victorian-era asylums in the UK.

DG

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Reading of the Week: Better PTSD Symptom Control, Less Diabetes (JAMA Psych)? Also, Buckley on Cannabis (Quick Takes), and the Life of Kajander (Globe)

From the Editor

Better PTSD symptom control, less diabetes? How do we talk to our patients about cannabis (and cannabis use disorder)? Who was Dr. Ruth Kajander?

This week, there are three selections. The first two deal with timely and relevant topics: the intersection of physical and mental health and the use of cannabis post-legalization. The third reminds us of the youth of our field.

In the first selection, Saint Louis University School of Medicine’s Jeffrey F. Scherrer and his co-authors consider PTSD and diabetes, asking if improvement with the mental health disorder results in a lower risk of type 2 diabetes. Drawing on Veterans Health Affairs data involving nearly 1 600 people, they find that “clinically meaningful reductions in PTSD symptoms are associated with a lower risk of type 2 diabetes.”

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In the second selection, we draw on a podcast interview with the University of Toronto’s Dr. Leslie Buckley, the chief of addictions division at CAMH, on cannabis. What advice would she give clinicians about cannabis use? “Try to have that long conversation with [patients] about their use and make sure that they know the harms – because I feel like most people don’t.”

Finally, with an eye on yesterday and not today, we look at the recent Globe obituary for Dr. Ruth Kajander, a psychiatrist who served in many roles, and was a member of the Order of Canada.

DG

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Reading of the Week: Cannabis in America (and Canada) – the New JAMA Psychiatry Paper with Commentary

From the Editor

It’s legal. Are people using more? And has cannabis use disorder become more common?

This week, we look at a new paper considering cannabis legalization and use. The authors draw on American data where legalization is increasingly found across different states though not as extensively as in Canada; to date, 11 US states have legalized recreational cannabis, with 33 (and D.C.) having legalized medical marijuana.

In a new JAMA Psychiatry paper, Magdalena Cerdá and her co-authors use the National Survey on Drug Use, a major survey involving more than half a million participants, considering marijuana use, frequent use, and cannabis use disorder. What effect does legalization have? They find that cannabis use disorder is more common in adolescents after legalization and for adults who are 26 years of age and older, use, frequent use, and substance use are all up.

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We consider the paper. We also discuss the commentary that accompanies it. Finally, with an eye closer to home, we ask: are the findings relevant here in Canada?

DG

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Reading of the Week: Cannabis for Mental Illness: Popular and Promoted by Industry – But Evidenced? The New Lancet Psychiatry Paper

From the Editor

“It’s the only thing that helps with my anxiety.”

It’s closing in on midnight, and the ED patient I’m seeing is adamant that cannabis has helped him with his generalized anxiety disorder. My day has been long, but I choose to push a bit. Why cannabis? He notes how challenging it was to access mental health care. When he finally did see a psychiatrist, he feels he was offered a prescription after only a few minutes, and the trial of sertraline left him feeling more anxious. Cannabis, in contrast, helps him sleep and takes an edge off the anxiety.

More and more, our patients are talking up cannabis. Google “medical marijuana,” and there are over 166 million hits. And, yes, industry has noticed. There are a half a dozen cannabis dispensaries within a 10-minute walk from the CAMH ED, where I work. In the spring, a former prime minister joined the board of Acreage Holdings, a marijuana company, explaining that he was excited by the potential of cannabis to treat PTSD.

But is any of this evidence based?

This week, we look at a new paper from The Lancet Psychiatry. University of New South Wales’ Nicola Black and her co-authors do a systematic review and meta-analysis. Considering a variety of psychiatric disorders including depression, they draw on the literature to try to understand the effectiveness and safety of cannabinoids. “There is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, post-traumatic stress disorder, or psychosis.”

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We consider this big paper on the hot topic.

We also discuss the comment paper that accompanies this study. Yale University’s Deepak Cyril D’Souza writes: “The process of drug development in modern medicine is to first demonstrate efficacy and safety in clinical trials before using the drug clinically. With cannabinoids, it seems that the cart (use) is before the horse (evidence).” For the record, I don’t think Acreage Holdings will be distributing either paper to shareholders.

Please note that there will be no Reading next week.

DG

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Reading of the Week: Is Adult Mental Illness More Common? The New Acta Paper; Also, Hill on Cannabis & Neustadter’s Med School Experience

From the Editor

Family physician colleagues talk about how many patients now disclose mental health problems. Our EDs see more patients with mental illness than ever. Antidepressant use has doubled between 2000 and 2015 across OECD countries.

So is mental illness more common than before?

Just last week, a CBC reporter asked me this question. She noted that the rise of businesses offering mindfulness and the proliferation of mental health apps. But as stigma fades and people are more comfortable talking about mental illness, it’s also possible that more people are seeking care, but that there aren’t more people with illness.

depressionintcover0807Mental illness: more commonly discussed, more common?

In our first selection, we consider a new paper from Acta Psychiatrica Scandinavica. Dirk Richter (of Bern University of Applied Sciences) and his co-authors use a systematic review and meta-analysis to see if adult mental illness is increasing over time. “We conclude that the prevalence increase of adult mental illness is small and we assume that this increase is mainly related to demographic changes.”

In the second selection, we consider a new JAMA review of the evidence – or lack of evidence – for medical use of cannabis. Dr. Kevin P. Hill (of Harvard Medical School) writes: “Insufficient evidence exists for the use of medical cannabis for most conditions for which its use is advocated.”

In the third selection, Yale School of Medicine med student Eli Neustadter discusses a challenging patient and the connection they form. “MB and I also found time to meet weekly in a quiet room with nothing but two chairs, two guitars, and two picks.”

There will be no Readings for the next two weeks. The conversation will continue after Labour Day.

DG

 

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