Tag: CBT

Reading of the Week: Therapy = More Work + Better Income? The New Psych Medicine Study; Also, Zero Suicide & Melatonin for Kids

June 5, 2025 /

From the Editor

After completing a course of psychotherapy, he felt better and began a part-time job. The employment gave him a sense of purpose. As a physician, I could both sympathize and empathize; for many, work is a meaningful part of life, after all.

But does psychotherapy necessarily result in employment? Does therapy pay for itself with economic benefits? Otto R. F. Smith (of NLA University College) and his co-authors attempt to answer these questions in an impressive new paper in Psychological Medicine. They report on an RCT involving more than 700 Norwegian participants who were randomized to a psychotherapy program (modeled after the UK’s IAPT service) or to treatment as usual. The authors used administrative databases to analyze employment, income, and the economic benefit. “The results support the societal economic benefit of investing in IAPT-like services.” We consider the paper and its implications.

In the second selection, Dr. Calina Ouliaris (of Macquarie University) and her co-authors look at the zero suicide approach. In a Commentary for The British Journal of Psychiatry, they argue that – despite being studied and implemented in several places – it lacks evidence. “The Zero Suicide Framework is an arguably vague framework with a scant evidence base, particularly for application in healthcare settings. Despite this, the concrete goal championed… that of ‘zero suicides’, is appealing and has been widely promulgated in mental health services, ahead of evidence for the same.”

Finally, in the third selection, Dr. Chris Y. Kim (of the University of Toronto) and his co-authors weigh the use of melatonin for children and adolescents. In The Canadian Journal of Psychiatry, they are cautious, in part because of the lack of consistency of over-the-counter melatonin. “Melatonin used as a hypnotic agent for the treatment of insomnia is controversial.”

DG

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Reading of the Week: Culturally-Adapted CBT for Postnatal Depression – the New Lancet Study; Also, ADHD in Adults (JAMA Psych) and the Latest in the News

October 31, 2024 /

From the Editor

She was offered CBT through our outpatient program. Though we encouraged her to come, she didn’t even attend one session. Was the problem partly with the rigidity of our program which wasn’t tailored to her cultural background or language? Can we do better? 

Dr. Nusrat Husain (of the University of Manchester) and his co-authors attempt to answer these questions in a new RCT published in The Lancet. In their study, British south Asian women with postnatal depression were randomized to a culturally-adapted form of CBT or treatment as usual. “Participants in the [intervention] group were estimated to be almost twice as likely to have recovered at 4 months than those in the control group.” We consider the paper, the accompanying Comment, and the implications for clinical care.

In the second selection, Drs. Carlos Blanco (of the National Institutes of Health) and Craig B. H. Surman (of Harvard University) write about ADHD for adults. In a new JAMA Psychiatry Viewpoint, they argue that more needs to be done, especially given the adverse outcomes of untreated ADHD. “A tension exists between undertreatment of adults with ADHD and overuse of addictive treatments for the condition.”

Finally, we explore the latest news with recent articles from The Washington Post, The Globe and Mail, and The New York Times. The topics: ChatGPT for psychotherapy, the generosity of Bruce McKean, and the street psychiatry in LA.

DG

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Reading of the Week: Brief CBT for Suicidal Inpatients – the New JAMA Psych Study; Also, Medicaid & Access, and Dr. Yager on Turning Off the Lights

September 19, 2024 /

From the Editor

After a suicide attempt, he was admitted through our ED. The hospitalization has been helpful: we changed his medications; the family is now more understanding of his problems; he has worked on safety planning with the team. However, could more be offered? It’s a relevant question – particularly for someone like me (I’ve worked on inpatient wards for most of my career).

In the first selection from JAMA Psychiatry, Gretchen J. Diefenbach (of Yale University) and her co-authors describe a randomized clinical trial involving 200 inpatients who received either the usual care or a focused CBT, tailored for short admissions. The one common factor: all participants had had a suicide attempt in the week prior to admission or current suicidal ideation along with a suicide attempt in the past two years. “Brief cognitive behavioral therapy–inpatient reduced 6-month post-discharge suicide reattempts and rate of readmissions when added to treatment as usual.” We discuss the paper and the clinical implications.

Inpatient care: preventing suicide with CBT?

How accessible is mental healthcare in the US? In the second selection, Dr. Diksha Brahmbhatt and William L. Schpero (both of Cornell University) look at Medicaid recipients and psychiatric appointments in a research letter for JAMA. Using a “secret shopper” approach, they contacted clinicians in four cities, trying to book a psychiatric appointment for those covered by the public program. “In the largest Medicaid managed care plans across 4 of the largest US cities, only 17.8% of clinicians listed as in-network for Medicaid were reachable, accepted Medicaid, and could provide a new patient appointment.”

And in the third selection, Dr. Joel Yager (of the University of Colorado), a retired psychiatrist, writes personally in a piece for JAMA. In his later years, Dr. Yager’s father helped his older friends and neighbours with the burden of aging, including visiting them in hospitals when they were ill. Now, he is doing what his father did. “After all, someone has to be around to put out the lights.”

This month, the Reading of the Week celebrates its 10th anniversary. A quick word of thanks for the ongoing interest. I’ll reflect more in the coming weeks.

DG

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Reading of the Week: In-person vs. Remote CBT – the New CMAJ Study; Also, Treatment & Opioids in the US, and AI & Med School Exams

July 25, 2024 /

From the Editor

In the early days of the pandemic, patients connected with us virtually from their kitchens and bedrooms – and, yes, their closets and washrooms. But as COVID-19 fades, we may wonder: what care should be delivered virtually and what should be done in person?

In the first selection, Sara Zandieh (of McMaster University) and her co-authors examine remote versus in-person CBT in a new CMAJ study. They conducted a systematic review and meta-analysis with 54 randomized controlled trials and almost 5 500 participants, addressing both physical and mental problems. “Moderate-certainty evidence showed little to no difference in the effectiveness of in-person and therapist-guided remote CBT across a range of mental health and somatic disorders, suggesting potential for the use of therapist-guided remote CBT to facilitate greater access to evidence-based care.” We consider the paper and its implications.

In the second selection, Dr. Tae Woo Park (of the University of Pittsburgh) and his co-authors explore opioid use disorder (OUD) treatment. In their JAMA research letter, they compared medication and psychosocial treatments for OUD across the United States, surveying more than 17 000 facilities and analyzing the availability of evidenced-based interventions like buprenorphine and contingency management. “Substance use treatment facilities reported significant gaps in provision of effective treatments for OUD.”

And in the third selection from CNBC, Dr. Scott Gottlieb and Shani Benezra (both of the American Enterprise Institute) describe their experiment: they tasked several large language models with answering questions from the USMLE Step 3. The average resident score is 75%; four of five AI programs surpassed that benchmark. “[These models] may offer a level of precision and consistency that human providers, constrained by fatigue and error, might sometimes struggle to match, and open the way to a future where treatment portals can be powered by machines, rather than doctors.”

There will be no Reading next week.

DG

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Reading of the Week: School-based CBT for Teens – the New Lancet Psych Study; Also, Rural vs Urban Readmissions, and Dr. Horton on Fighters (and Biden)

July 18, 2024 /

From the Editor

Though many years have passed, he clearly remembers his first depressive episode, which occurred before his 18th birthday. My patient often wonders how things could have been different had he been offered care earlier. School-based initiatives are much discussed – indeed, they are having a moment. Public schools, for example, in New York City, offer students a few minutes daily of teacher-led mindful breathing. Such efforts are unlikely to yield significant results, in part because they lack focus.

What if we offered psychotherapy skills to interested high school students? Could it help alleviate symptoms of mood and anxiety? Would it be cost effective? June Brown (of King’s College London) and her co-authors address these questions in a new study just published in The Lancet Psychiatry. They report on a randomized controlled trial involving 900 UK adolescents who self-referred and received CBT or treatment-as-usual. “[T]he DISCOVER intervention is modestly clinically effective and economically viable and could be a promising early intervention in schools.” We consider the paper and its implications.

In the second selection, drawing on US data, Hefei Wen (of Harvard University) and co-authors examine hospital readmissions in the United States for mental health. In this new research letter published in JAMA Psychiatry, they find that rural readmissions – historically lower than urban ones – now exceed their urban counterparts. “This reversal and worsening of rural and urban gaps in mental health readmission was primarily concentrated in schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, and depressive disorders.”

And in the third selection from the Los Angeles Times, Dr. Jillian Horton (of the University of Manitoba) discusses time, aging, and resilience in a personal essay. Our internist colleague touches on the debate over the US president and his health but focuses on the story of her sister, who faced major problems after neurosurgery. She notes that her sister was able to “beat the odds” many times, until she couldn’t. “[W]e can’t change the reality of what comes next.”

DG

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Reading of the Week: CBT vs Mindfulness for Prolonged Grief Disorder – the New JAMA Psych Study; Also, Wildman on Her Grief, and Clozapine & MedEd

July 11, 2024 /

From the Editor

She still wears black. She mourns her partner’s death every day. Despite the passing years, she can’t seem to move forward. DSM-5-TR includes prolonged grief disorder, which has sparked controversy, but it explains well my patient’s complicated bereavement.

What’s evidenced for treatment? Is CBT superior to mindfulness? Richard A. Bryant (of the University of New South Wales) and his co-authors try to address these questions in a new JAMA Psychiatry paper. They describe a randomized clinical trial involving 100 adults offered CBT or mindfulness-based cognitive therapy. “In this study, grief-focused cognitive behavior therapy conferred more benefit for core prolonged grief disorder symptoms and associated problems 6 months after treatment than mindfulness-based cognitive therapy.” We consider the paper and its implications.

In the second selection, Sarah Wildman, a writer and editor, discusses her daughter’s death in an essay for The New York Times. She is candid about her grief. She talks about the passage of time, small things like calendars, and, yes, signs – her daughter promised that if she sees a red fox, it will be her. “I wonder if I should keep every item of clothing I can picture Orli in, I wonder what she would say about each movie I see, each book I read.”

In the third selection, Dr. Theodore R. Zarzar (of the University of North Carolina) emphasizes the importance of clozapine in the treatment of patients with schizophrenia. In his JAMA Psychiatry Viewpoint, he argues for incorporating clozapine proficiency into medical education. “Clozapine initiation can be conceptualized as the community psychiatric equivalent of a procedural skill and deserves the mentorship, knowledge acquisition, and practice that learning a procedure entails.”

DG

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Reading of the Week: Psychological Interventions for Schizophrenia – the New Lancet Psych Study; Also, Service Dogs for PTSD, and the Latest in the News

July 4, 2024 /

From the Editor

She was distressed by the voices and the paranoid thoughts. Many nights, my patient could barely sleep. She had tried several medications without much improvement. Is there a role for psychological interventions? Would CBT help? What is the evidence for this population?

In the first selection, Nurul Husna Salahuddin (of the Technical University of Munich) and co-authors attempt to answer these questions in a new systematic review and network meta-analysis, just published in Lancet Psychiatry. The analyzed 52 RCTs with 5 034 participants. “We provide robust findings that CBTp can reduce the overall symptoms of patients with treatment-resistant schizophrenia, and therefore clinicians can prioritise this intervention in their clinical practice.” We consider the paper and its clinical implications.

In the second selection from JAMA Network Open, Sarah C. Leighton (of the University of Arizona) and her co-authors describe a study involving service dogs for those with PTSD. In a nonrandomized controlled trial involving 156 military members and veterans, they examined outcomes after three months. “[C]ompared with usual care alone, partnership with a trained psychiatric service dog was associated with lower PTSD symptom severity and higher psychosocial functioning in veterans.”

Finally, we explore the latest news with recent articles from The Guardian, the Ottawa Citizen, and The New York Times. Among the topics: “honest” obituaries and the opioid crisis, antidepressants and withdrawal, and care for pregnant women with substance problems.

DG

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Reading of the Week: Cancer & Suicide & Good News – the New Transl Psychiatry Study; Also, AI & Therapy Dropouts, and Bland on Her Father & His D-Day

June 13, 2024 /

From the Editor

He was so overwhelmed by the cancer diagnosis that he didn’t eat or sleep for days. “It was my worst nightmare.” My patient isn’t alone in that devastating experience, of course – the diagnosis and treatment of cancer is a major life event. Not surprisingly, the suicide rate is roughly double that of the general population in the United States. But with increasing psychosocial interventions, how has this changed over time?

In the first selection, Qiang Liu (of the Chinese Academy of Medical Sciences) and his co-authors attempt to answer that question in a new paper for Translational Psychiatry. Drawing on 40 years of data and a major US database, they analyzed the journeys of five million cancer patients, discovering good news. “We revealed a gradual increase in cancer-related suicide rates from 1975 to 1989, followed by a gradual decrease from 1989 to 2013, and a marked decrease from 2013 to 2017.” Indeed, between 2013 and 2017, the rate dropped by 27%. We consider the paper and its implications.

In the second selection, Sakiko Yasukawa (of the Sony Corporation) and her co-authors aimed to reduce dropouts from psychotherapy using AI. In a new paper for BMJ Mental Health, they describe an RCT involving 149 people. “The results suggest that the personalised messages sent by the chatbot helped participants control their pace in attending lessons and improve programme adherence without human guidance.”

Last week marked the anniversary of D-Day with ceremonies, including in Normandy. What was the toll on those who returned home? In the third selection, an essay published in The Globe and Mail, Normanne Bland describes her father and his time in Europe. She writes about him with mixed feelings, coloured by his mental health problems, including PTSD. “I had a complicated relationship with my father. I was proud of his service but I loathed his drinking.”

There will be no Reading next week.

DG

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Reading of the Week: Preventing Postpartum Depression in Pakistan – the New Nature Med Study; Also, Deaths of Despair and ChatGPT & Abstracts

April 18, 2024 /

From the Editor

Imagine that you are asked to design a program to prevent depression in a population at risk. Would you hire psychiatrists? Look to nurses? Tap the expertise of psychologists? All three?

In the first selection from Nature Medicine, Pamela J. Surkan (of Johns Hopkins University) and her co-authors describe a study that focused on prevention. As they worked in Pakistan – a nation with few mental health providers by Western standards – they chose to train lay people, teaching them to deliver CBT. In their single-blind, randomized controlled trial, 1 200 women who were pregnant and had anxiety (but not depression) were given enhanced usual care or CBT. “We found reductions of 81% and 74% in the odds of postnatal MDE and of moderate-to-severe anxiety…” We discuss the paper and its implications.

In the second selection, Joseph Friedman and Dr. Helena Hansen (both of the University of California, Los Angeles) look at deaths of despair in the United States in a research letter for JAMA Psychiatry. Their work builds on the idea that some deaths are related to the hopelessness of a person’s social or economic circumstance; past publications focused largely on White Americans. Friedman and Hansen drew on more than two decades of data, including ethnicity, from a US database, finding a different pattern and that: “Rising inequalities in deaths of despair among American Indian, Alaska Native and Black individuals were largely attributable to disproportionate early mortality from drug- and alcohol-related causes…”

A recent survey finds that psychiatrists see AI as potentially helpful with paperwork and diagnosing patients. But could AI help you keep up with the literature? In the third selection from Annals of Family Medicine, Dr. Joel Hake (of the University of Kansas) and his co-authors used ChatGPT to produce short summaries of studies, then evaluated their quality, accuracy, and bias. “We suggest that ChatGPT can help family physicians accelerate review of the scientific literature.”

DG

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Reading of the Week: CBT for Depression – the Latest Evidence; Also, Digital Mental Health (World Psych) and Dr. Castro-Frenzel on Her Cancer (JAMA)

January 26, 2023 /

From the Editor

Cognitive behavioural therapy is widely used for the treatment of depression – but the last significant meta-analysis was published a decade ago. What’s the latest evidence? 

In the first selection, Pim Cuijpers (of the Vrije Universiteit Amsterdam) and his co-authors try to answer this question with a new meta-analysis including more than 400 randomized trials with almost 53 000 patients (yes, you read that correctly). In this World Psychiatry paper, they compare the therapy with controls, other therapies, and medications. They write: “We can conclude that CBT is effective in the treatment of depression with a moderate to large effect size, and that its effect is still significant up to 12 months.” We consider the paper and its clinical implications.

Beck: the father of CBT

In the second selection, Dr. John Torous (of Harvard University) and his co-authors look at digital mental health. Despite widespread use of smartphones – perhaps 80% of the world’s population now has access to one – “digital mental health is not transforming care.” In this Editorial for World Psychiatry, they wonder why. They also point a way forward: “Developing a new generation of digital mental health tools/services to support more accessible, effective and equitable care is the true innovation ready to be stoked today by each person who becomes empowered to connect, set up, engage, start/stop, and demand more from mental health technology.”

Finally, in the third selection, Dr. Karla Castro-Frenzel (of the University of Central Florida) writes about a patient with advanced lung cancer. As it turns out, she’s that patient. In this personal essay published in JAMA, she writes about being a doctor and a patient. “My ultimate hope… is that we can create space for illness as well as wellness. In helping our colleagues feel safe and supported when they become patients, we rehumanize our environments and our very selves.”

DG

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