Tag: CMAJ

Reading of the Week: Bipolar Disorder Drug Prescribing – Bad News? The New CJP Paper; Also, An AI Warning and Cannabis & Psychosis

September 11, 2025 /

From the Editor

There are more medication options than ever for the treatment of bipolar disorder. What are physicians prescribing? How often do we use lithium, arguably the best medication?

In the first selection, from The Canadian Journal of Psychiatry, Samreen Shafiq (of the University of Calgary) and her co-authors attempt to answer those questions in a new study. They drew on Alberta government data, including more than 130 000 individuals with bipolar disorder and more than nine million prescriptions. “Overall, we uncovered a concerning trend in the prescribing patterns for bipolar disorder treatment, with antidepressants and second-generation antipsychotics being prescribed frequently and a decline in prescribing of lithium and other mood stabilizers.” We consider the paper and its implications.

What would John Cade think?

In the second selection, Dr. Allen Frances (of Duke University) writes about AI chatbots and psychotherapy in The British Journal of Psychiatry. He notes their “remarkable fluency” and argues that there are clear benefits to AI psychotherapy. He also comments on dangers, and he doesn’t mince his words. “Artificial intelligence is an existential threat to our profession. Already a very tough competitor, it will become ever more imposing with increasing technical power, rapidly expanding clinical experience and widespread public familiarity.”

And in the third section, Sophie Li (of the University of Ottawa) and her co-authors consider psychosis and cannabis in a concise CMAJ paper. They make several points, including: “The tetrahydrocannabinol (THC) content of cannabis has roughly quintupled in the past 2 decades, from around 4% in the 2000s to more than 20% in most legal dried cannabis in Canada by 2023.”

There will be no Reading next week.

DG

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Reading of the Week: When Does Grief Become a Disorder? The Lancet Review; Also, Time to End Daylight Saving Time? And Dr. Hickey on Her Anxiety

May 8, 2025 /

From the Editor

After the unexpected loss of his spouse, my patient sank deeply into grief. He was tearful during our sessions, explaining that a part of him had died, too. Weeks turned to months. Was this a normal response to a profound loss? Or something more problematic? DSM-5 seeks to clarify the issue by recognizing prolonged grief disorder – though the disorder is controversial and has attracted much criticism. When The New York Times covered the topic in 2022, Joanne Cacciatore (of Arizona State University) commented: “I completely, utterly disagree that grief is a mental illness.”

Clare Killikelly (of the University of Zurich) and her co-authors shed light on prolonged grief disorder with a new review, just published in The Lancet. They write about the disorder, the differences from grief, its treatment, and more, drawing on 142 citations. “Grief is a universal experience. However, for a minority of individuals, grief becomes a debilitating, devastating mental health disorder with serious implications on a personal and societal level.” We examine the review, highlight four take-aways, and reflect on the broader debate.

Spring forward, fall back. Twice a year, we adjust our clocks (and our brains) to and from daylight saving time. In the second selection, Dr. David Dongkyung Kim (of the University of Toronto) and his co-authors argue that daylight saving time should be eliminated. In their JAMA Commentary, they draw on the literature. “Daylight saving time transitions cause acute disruptions in human circadian rhythm, and the medical literature shows detrimental effects for public health.”

Finally, in the third selection, Dr. Joanne Hickey (of Memorial University) discusses anxiety and her expectations. In a personal CMAJ paper, the hematologist reflects on her work – and on her own journey, including her anxiety, the decision to take medications, and her need to come to terms with her perfectionism. “Anxiety has been my life companion, though I often didn’t recognize it. It masqueraded as that internalized need to control.”

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: Visual Hallucinations & Outcomes – the New Schizophrenia Study; Also, Opioid Deaths in Canada and Dr. Roy Perlis on Antidepressants

April 25, 2024 /

From the Editor

Last week, I met a person who had deeply unsettling auditory hallucinations. I asked him the questions that we all ask: When did the voices start? How many voices do you hear? Do the voices tell you to do things? In contrast, while we know that people with psychotic illnesses can have visual hallucinations, we rarely inquire about them and if we do, it’s in a perfunctory manner, as I did with him. Clinicians aren’t the only ones to gloss over visual hallucinations; they tend to be under-researched, especially with regard to long-term outcomes.

In the first selection, Isabel Kreis (of the University of Oslo) and her co-authors look at outcomes and visual hallucinations in an impressive, new study published in Schizophrenia. They report on 184 people from Norway with first-episode psychosis, followed for ten years, with a focus on visual hallucinations and functionality, suicide attempts, and childhood trauma. “These findings highlight the relevance of assessing visual hallucinations and monitoring their development over time.” We consider the paper and its implications.

In the second selection from CMAJ, Shaleesa Ledlie (of the University of Toronto) and her co-authors report on opioid-related deaths in Canada. They drew from a national database and looked at several years of data, including over the start of the pandemic. “Across Canada, the burden of premature opioid-related deaths doubled between 2019 and 2021, representing more than one-quarter of deaths among younger adults.”

And in the third selection, Dr. Roy Perlis (of Harvard University) argues that the time has come for over-the-counter antidepressants in a STAT essay. He notes that many people with depression are untreated and that increasing the availability of these medications would be helpful. “With part of the solution hiding in plain sight, it’s time to do everything possible to give Americans another way to get treatment.”

DG

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Reading of the Week: Housing First & Mental Health Care – the new Health Affairs Paper; Also, Safe Supply & Outcomes and Antipsychotics for Delirium

February 1, 2024 /

From the Editor

With the shelter system overcrowded, my patient slept the previous four nights in the train station. “Where else was I to go?” Many major cities across North America have seen a rise in the number of those who are chronically homeless. Housing First – the idea that stable housing is needed for people to better access health care – is one option, though the concept has been increasingly criticized. Is it a good fit for our urban problems?

In the first selection from Health Affairs, Devlin Hanson and Sarah Gillespie (both of the Urban Institute) consider Housing First for a specific population: the chronically homeless population who have had frequent arrests and jail stays; most of them, not surprisingly, have major mental illness or substance problems. Hanson and Gillespie analyzed data from Denver, Colorado, where people were randomized into Housing First or a control group. “We found that within the two-year study period, people in the intervention group had significantly more office-based care for psychiatric diagnoses, fewer ED visits, more unique medications, and greater use of other health care than people in the control group.” We review the study and its implications.

Denver: mountains, fresh air, and Housing First

In the second selection, Hai V. Nguyen (of Memorial University) and his co-authors look at safe supply and opioid outcomes in British Columbia. In a JAMA Internal Medicine paper, they used data from that province, contrasting it with Manitoba and Saskatchewan, and focused on the number of prescriptions and hospitalizations. “Two years after its launch, the Safer Opioid Supply Policy in British Columbia was associated with higher rates of prescribing of opioids but also with a significant increase in opioid-related hospitalizations.”

Delirium is common in the elderly admitted to hospital, and antipsychotics are often prescribed. In the third selection, Dr. Christina Reppas-Rindlisbacher (of the University of Toronto) and her co-authors comment on use of this medication in aCMAJ Practice paper. They offer much advice, including: “They should be prescribed at the lowest effective dose for the shortest possible duration and be reevaluated at or shortly after discharge.”

DG

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Reading of the Week: Improving Self-Esteem in Youth – the New JAMA Psych Paper; Also, Black Females & Suicide and Dr. Jon Hunter on the End

December 7, 2023 /

From the Editor

Can we help youth before the onset of full disorders to build skills and avoid deeper problems? Several school-based efforts, offering DBT and mindfulness skills, have been tried without much success. Ecological momentary interventions (EMIs) – provided to patients during their everyday lives and in natural settings, giving unstructured recommendations with structured interventions – is a newer therapy that has gained attention.

But does it work? In a new paper for JAMA Psychiatry, Ulrich Reininghaus (of the University of Heidelberg) and his co-authors describe an RCT focused on youth with low self-esteem who have had past adversity, involving 174 Dutch participants. “A transdiagnostic, blended EMI demonstrated efficacy on the primary outcome of self-esteem and signaled beneficial effects on several secondary outcomes.” We consider the paper and its implications.

In the second selection, Victoria A. Joseph (of Columbia University) and her co-authors look at US suicide rates in Black females. In their American Journal of Psychiatry letter, they analyze suicides over two decades, drawing data on age and region from a national database. They conclude that: “increasing trends in suicide death among Black females born in recent years and underscores the need to increase mental health care access among Black girls and women, and to reduce other forms of structural racism.”

And in the third selection, Dr. Jon Hunter (of the University of Toronto) contemplates endings – including his ending – in a personal and moving paper for CMAJ. He notes the need to clean up his possessions. But what about his practice and the many patients that he has followed for years? “I’d rather not shy away from the uncertainty and loss of the ending, and to try to help one more time.”

DG

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Reading of the Week: Legal Cannabis at 5 – Considering Nonmedical Legalization with a CMAJ Commentary, Dr. Buckley’s Reflections and Major Papers

October 19, 2023 /

From the Editor

On Oct. 17, 2018, the government of Canada will launch a national, uncontrolled experiment in which the profits of cannabis producers and tax revenues are squarely pitched against the health of Canadians. When Bill C-45 comes into force in mid-October, access to recreational marijuana will be legal, making Canada one of a handful of countries to legalize recreational use of the drug. Given the known and unknown health hazards of cannabis, any increase in use of recreational cannabis after legalization, whether by adults or youth, should be viewed as a failure of this legislation.

 – Dr. Diane Kelsall, Editor-in-Chief, CMAJ, October 2018

On Tuesday, Canada’s experiment with the legalization of cannabis for nonmedical purposes turned five. Did use go up? What about health care utilization? Have there been benefits from justice and social justice perspectives? Is it the failure that Dr. Kelsall feared?

Now is a good time to pause and review the impact of this change. In this Reading, we try to do just that. 

We start with a CMAJ commentary just published. Benedikt Fischer (of Simon Fraser University) and co-authors look at the evidence, including studies on use and ED presentations, as well as statistics on purchases. “A consideration of the evidence 5 years after implementation suggests that success in meeting policy objectives has been mixed, with social justice benefits appearing to be more tangibly substantive than health benefits.”

Dr. Leslie Buckley (of the University of Toronto) mulls this moment with some comments about the CMAJ paper, and the larger discussion. “[T]he legal changes were enacted and resulted in positive outcomes while the preventive changes which would require more financial investment and tight regulation received less attention.”

Finally, we look at three important papers on cannabis that have been featured in this series over the past five years, and another one that we haven’t looked at before.

DG

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Reading of the Week: Mental Health Tsunami? The New BMJ Study on COVID; Also, Burnout & Professionalism (JAMA Health) and Buprenorphine (CMAJ)

April 6, 2023 /

From the Editor

How has COVID-19 impacted mental health? What to make of the forecasts of a mental health tsunami?

In a new BMJ paper, Ying Sun (of the Jewish General Hospital) and her co-authors do a systematic review and meta-analysis to try to answer these questions. Drawing on 137 studies, they consider mental and the pandemic. They find: “Most symptom change estimates for general mental health, anxiety symptoms, and depression symptoms were close to zero and not statistically significant, and significant changes were of minimal to small magnitudes…” We look at the paper and its clinical implications.

In the second selection, Dr. Dhruv Khullar (of Cornell University) writes about burnout and professionalism for JAMA Health Forum. He argues that burnout is common and costly, and points a way forward, in part by reducing clerical tasks. “A better path is one that strenuously removes the obstacles to physician and patient well-being and that actively promotes the deep work of doctoring.”

In the third selection, Dr. Ari B. Cuperfain (of the University of Toronto) and his colleagues consider extended-release buprenorphine, a subcutaneous monthly depot injection used to treat opioid use disorder in a short CMAJ paper. They make several observations about titration, effectiveness, and safety.

DG

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Reading of the Week: Amphetamines & ED Visits – the New CJP Paper; Also, Psilocybin for Depression (QT) and Anti-NMDAR Encephalitis (CMAJ)

March 30, 2023 /

From the Editor

Agitated, excited, violent – when intoxicated. But my patient is also pleasant and engaging when not using substance (crystal methamphetamine).

Amphetamine use seems more and more common. What does the data show? In a new paper for The Canadian Journal of Psychiatry, James A. G. Crispo (of the University of British Columbia) and his co-authors look at amphetamine-related ED visits in Ontario. Drawing on administrative databases, they find a sharp rise over time: a 15-fold increase between 2003 and 2020. They write: “Increasing rates of amphetamine-related ED visits in Ontario are cause for concern.”

In the second selection, Dr. Ishrat Husain (of the University of Toronto) comments on psilocybin and depression in a new Quick Takes podcast. He goes into detail on the new NEJM study – which he co-authored. Dr. Husain discusses the literature and unanswered research questions. “It’s not necessarily all sunshine and rainbows.”

And in the third selection, Dr. Candace Marsters (of the University of Alberta) and her colleagues consider the unusual presentation of young adult with first-episode psychosis in a new paper for CMAJ. With time and diagnostic testing, they conclude that she has anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, and offer observations about that diagnosis and the limitations of testing. “Anti-NMDAR encephalitis is a rare but important differential diagnosis of first-episode psychosis among young adults.”

DG

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Reading of the Week: Cannabis for Mood Disorders – the New CJP Paper; Also, Dr. Insel on Mental Health (QT) and Transgender Adolescents & Suicidality (CMAJ)

June 23, 2022 /

From the Editor

He smokes before bed to help with sleep; she finds that the edibles take an edge off from her lows.

Our patients routinely tell us about the benefits of cannabis for mood disorders. But is there any evidence in the literature? In the first selection from The Canadian Journal of Psychiatry, Dr. Smadar V. Tourjman (of the Université de Montréal) and her co-authors consider that question with a systematic review, drawing on data from 56 studies, focused on bipolar and major depressive disorders, for a CANMAT task force report. They conclude: “cannabis use is associated with worsened course and functioning of bipolar disorder and major depressive disorder.” We consider the paper and its implications.

In this week’s second selection, we look at new Quick Takes podcast interview with Dr. Thomas Insel (of the Steinberg Institute). Dr. Insel, a psychiatrist and former director of NIMH, speaks about the progress in neuroscience but the need for mental health reform. “We must think about more than just the classic medical model borrowed from infectious disease: simple bug, simple drug.”

Finally, in the third selection, Mila Kingsbury (of the University of Ottawa) and her co-authors consider the risk of suicidality among trangender and sexual minority adolescents; they draw from a nationally representative, cross-sectional survey. “Gender and sexual minority adolescents, particularly those who identify as transgender and gender-nonconforming, appear to be at greater risk of suicidal ideation and suicide attempt than their cisgender and heterosexual peers.”

There will be no Reading next week.

DG

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