Tagdepression

Reading of the Week: Better with Time? The New JAMA Paper on Stigma; Also, Dr. Steuber on Real Doctors – and Real Stigma (Academic Psych)

From the Editor

“To say that I didn’t know my great-uncle, Wolfe Levine, would understate things. I didn’t even know of such an uncle, brother of my mother’s father (a grandfather with whom I was close). In retrospect, it’s clear that my great-uncle was simply unmentionable.” In a long essay, writer Howard Husock notes that his great uncle, who suffered from mental illness, was never mentioned.

Society’s view of mental illness has changed much in recent years (good), but some stigma still exists (not so good). How have the public’s views shifted over time?

In our first selection, drawing from JAMA Network Open, we look at a new paper by Bernice A. Pescosolido (of Indiana University) and her co-authors. Reviewing attitudes and beliefs over 22 years, they find that: “this survey study found the first evidence of significant decreases in public stigma toward depression.” That said, not all the results are encouraging. We look at the paper and its clinical implications.

In the second selection, Dr. Elizabeth R. Steuber (of Johns Hopkins University) writes about the stigma faced by those in mental health care. Dr. Steuber, who is a resident of psychiatry, discusses the comments of a patient. She contemplates her work and the potential to change ongoing stigma: “I am hopeful that by leading through example on the medical floors, psychiatry trainees will continue to reshape how the field is seen by society at-large, even if it is only one patient at a time.”

DG

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Reading of the Week: Can We Prevent Depression in Older Adults? The New JAMA Psych Paper; Also, Homeless Youth and Mental Health (CJP)

From the Editor

It’s disabling and difficult to treat.

Can we prevent depression in older adults? Prevention is, of course, an important goal for any psychiatric disorder, reducing distress and health care costs. And the morbidity of major depressive disorder is great. A patient recently commented on his depressive episode: “I wouldn’t wish this on my worst enemy.”

Dr. Michael R. Irwin (of the University of California, Los Angeles) and his co-authors offer interesting data in a new JAMA Psychiatry paper. Focused on elderly adults with insomnia, they provided a form of CBT in an RCT. They find: “In this trial of older adults without depression but with insomnia disorder, delivery of CBT-I prevented incident and recurrent major depressive disorder by more than 50% compared with SET, an active comparator.” We review this big paper and its clinical implications.

unknownLess time with depression, more time for dancing

In the other selection, we consider homeless youth. In a new Canadian Journal of Psychiatry paper, Sean A. Kidd (of the University of Toronto) et al. draw on national survey data. “Youth homelessness is a wicked social problem with variable definitions, multiple determinants, corollaries, and outcomes.” They note the connection to sexual violence and make policy recommendations.

DG

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Reading of the Week: Lithium – Anti-Suicidal Qualities? Also, Dr. Tim Graham on His Illness & Recovery (CMAJ)

From the Editor

Our patients complain about the hand tremor. Some feel fatigued when they take this medication. And toxicity is always a risk.

Lithium, in other words, is tough to work with – the Callas or Pavarotti of psychotropic medications, if you will. And yet, it’s arguably the best mood stabilizer, helping people with bipolar get back their lives. Some have gone so far as to claim that all of us should take a little lithium.

Among the purported benefits of lithium: anti-suicidal effects. But does this medication really help our suicidal patients? In a new paper, Dr. Ira R. Katz (of the University of Pennsylvania) and his co-authors ask this question, armed with an impressive dataset. In a JAMA Psychiatry paper, they report the findings of a double-blinded, placebo-controlled randomized clinical trial. “The addition of lithium to usual Veterans Affairs mental health care did not reduce the incidence of suicide-related events in veterans with major depression or bipolar disorders who experienced a recent suicide event.” We consider the paper and its clinical implications.

photo-1567693528052-e213227086bbLithium: the psychotropic that’s as old as the earth

In the second selection, Dr. Tim Graham (of the University of Alberta) writes about his training and work as an ED physician, and his burnout. In a raw, highly personal essay for CMAJ, he speaks about his suicidal thoughts – and the decision to get help. He writes: “If you die tomorrow, your employer will replace you, but your loved ones cannot.” Dr. Graham also offers some practical suggestions for staying well.

DG

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Reading of the Week: Measurement-based Care – What’s the Evidence? Also, Goldbloom on the Joy of Jabbing

From the Editor

Well, he looks better.

So often our conversations about patients – in our emergency rooms, wards, and clinics – focus on soft evidence of improvement. No wonder: psychiatry lacks biomarkers. And so, while our colleagues in medicine talk about blood sugars and white blood cell counts, we often discuss other things, like how our patients look and sound.

The promise of measurement-based care: objective evidence of change (or lack thereof). The idea is having a moment, with more and more interest. But what does the literature say?

In the first selection, Maria Zhu (of the University of British Columbia) and her colleagues consider RCTs. In a systematic review and meta-analysis, they look at the efficacy of measurement-based care for depressive disorders. They conclude: “Although benefits for clinical response are unclear, MBC is effective in decreasing depression severity, promoting remission, and improving medication adherence in patients with depressive disorders treated with pharmacotherapy. The results are limited by the small number of included trials, high risk of bias, and significant study heterogeneity.” We discuss the big paper.

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The pandemic has changed much with day-to-day practice, including with the rapid virtualization of mental health care. Remember a time when you didn’t need to talk about “being on mute?” And some psychiatrists have been on the front lines of the vaccine effort. In the second selection, Dr. David Goldbloom (of the University of Toronto) writes about his experiences working in a vaccine clinic. His Toronto Lifeessay details the YouTube video he watched to remind himself of how to administer shots, his family ties to vaccinations, and his fondness for the work. “I will always be grateful to have experienced the joy of jabbing.”

DG

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Reading of the Week: Should Patients Quit Antidepressants? The New NEJM Paper; Also, the NYT Obit on Dr. Paula Clayton

From the Editor

“Can I stop my antidepressants now?”

Patients often ask that question after feeling better. Studies have looked at relapse for people with depression who go off their medications, of course, but overwhelmingly such work has focused on patients recruited from specialty care (who are, perhaps, more ill).

In the first selection, we consider a new paper from The New England Journal of Medicine by Gemma Lewis (of University College) et al. The patients have been recruited from English family practices. The study is well designed and thoughtful, adding nicely to the literature. The chief finding? “Those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current therapy.” We consider the big paper and its clinical implications.

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In the second selection, drawing from the pages of The New York Times, reporter Clay Risen writes about the life of Dr. Paula J. Clayton. This psychiatrist, who passed in September, was an accomplished researcher: “Dr. Clayton was part of a generation of clinical psychiatrists who, in the decades after World War II, revolutionized their field by applying medical rigor to the diagnosis of mental illness.” In later years, she was a strong advocate for those with mental illness.

DG

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Reading of the Week: Cardiovascular Diseases & Mental Disorders – The New AJP Paper; Also, Systematic Racism & Depression (JAMA Psych)

From the Editor

When people with mental health problems have physical illness, how does their care measure up?

Not surprisingly, we worry about their access and follow up. Evidence suggests poorer outcomes. But how do people with mental disorders fare on an international basis?

In the first selection, Dr. Marco Solmi (of the University of Padua) and his co-authors try to answer that question, focusing on cardiovascular diseases (CVD). In a new American Journal of Psychiatry paper, they conduct a systematic review and meta-analysis, drawing on the data of more than 24 million people. (!) They find: “People with mental disorders, and those with schizophrenia in particular, receive less screening and lower-quality treatment for CVD. It is of paramount importance to address underprescribing of CVD medications and underutilization of diagnostic and therapeutic procedures across all mental disorders.” We discuss the paper and its clinical implications.

heart-palpitations

In the second selection from The American Journal of Psychiatry, Drs. Nathalie Moise and Sidney Hankerson (both of Columbia University) consider structural racism and depression care, using a clinical vignette. Rather than just seeing the patient’s experience in terms of genetic loading and medications, they describe a person who has struggled with various forms of racism. They argue: “Mental health professionals need to recognize the effect of structural, individual, and internalized racism on individuals with depression symptoms.”

DG
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Reading of the Week: Is ECT Really Safe? The New Lancet Psychiatry Paper; Also, Antrim on His ECT (New Yorker)

From the Editor

Is it safe?

The first treatment of electroconvulsive therapy (ECT) was administered in 1938. Yet decades later, people still debate the safety of this treatment; a study found that one in five patients reported fear of death as a major concern. (And, yes, so many of our patients have seen that movie.)

In our first selection, we consider a new and important paper on this topic, just published in The Lancet Psychiatry. Dr. Tyler S. Kaster (of the University of Toronto) and his co-authors attempt to answer the safety question by comparing those who received ECT with those who didn’t in the context of depression and inpatient care. “In this population-based study of more than 5000 admissions involving electroconvulsive therapy for inpatients with depression, the rate of serious medical events within 30 days was very low among those exposed to electroconvulsive therapy and a closely matched unexposed group (0.5 events per person-year vs 0.33 events per person-year), with those who received electroconvulsive therapy having a numerically lower risk of medical complications.” We look at the big study, with an eye on clinical implications.

ect-1945ECT machine (cira 1950)

In the other selection, we look at a new essay from The New Yorker. Writer Donald Antrim – an accomplished novelist and a MacArthur fellow – discusses his depression, his suicidal thoughts, and his decision to opt for ECT. He notes that after treatment: “I felt something that seemed brand new in my life, a sense of calm, even happiness.”

DG

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Reading of the Week: Canada Day – With Papers on Cannabis, Chatbots, Depression, Nutraceuticals and Benzodiazepines in Pregnancy

From the Editor

It’s Canada Day.

Let’s start by noting that not everyone has a day off. Some of our colleagues are working – perhaps in hospitals or vaccine clinics. A quick word of thanks to them for helping our patients on a holiday.

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Appropriately, this week’s selections will focus on Canadian work.

What makes a paper “Canadian” for the purposes of this review? That is, how do we define Canadian? Things could get complicated quickly when considering journal papers. Does the second author order “double double” at Tim Hortons? Has the senior author eaten poutine for breakfast? Is the journal’s action editor hoping that the Canadiens bring the Cup home?

Let’s keep things simple: all the papers selected this week have been published in a Canadian journal and the papers are clinically relevant for those of us seeing patients in Canada.

There are many papers that could have been chosen, of course. I’ve picked five papers – a mix of papers that have been featured previously in past Readings, and some new ones. All but one of the selected papers are recent.

Please note that there will be no Readings for the next two weeks.

DG

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Reading of the Week: Shamiri Layperson-Provided Therapy in Kenya – Big Study, But Ethical? Also, a Reader Comments on Chatbots

From the Editor 

There are more psychiatrists of African origin in the US than in the whole of Africa. And I could actually say similar examples from the Philippines, or India, or many other countries. There is an enormous shortage of mental health resources…” 

So comments Dr. Vikram Patel (of Harvard University). Across low-income nations, mental health care services are profoundly difficult to access. Could Shamir (Kiswahili for thrive) – an intervention built on simple psychological concepts and delivered by laypersons – be part of the solution? 

This week, we look at a new paper from JAMA PsychiatryTom L.  Osborn (of Kenya’s Shamiri Institute) and his co-authors describe the results of a study involving adolescents with depression and anxiety symptoms. To our knowledge, this is one of the first adequately powered tests in this population of a scalable intervention grounded in simple positive psychological elements.” We look at the big paper. 

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 But is the work ethical? In our second selection, we consider the editorial that accompanies the Osborn et al. paper. JAMA Psychiatry Editor Dr. Dost  Öngür (of Harvard University) defends the study and his decision to publish it: “Because this trial was already conducted, we considered the obligations of the journal to be different than those of investigators and prospective reviewers. The question for us was whether there is a benefit to society by publishing the study as it was conducted.” 

Finally, in our third selection, a reader writes us. Giorgio A.Tasca (of the University of Ottawa) responds to The New York Times article by Karen Brown considering chatbots. “Is scaling up an intervention with dubious research support – that results in low adherence and high dropout (and perhaps more demoralization as a result) – worth it?” 

Please note that there will be no Reading next week. 

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Reading of the Week: Psilocybin for Depression – The New NEJM Paper

From the Editor

Is this the breakthrough we have been waiting for?

This week, we look at the new study from The New England Journal of Medicine considering psilocybin (a naturally occurring psychedelic compound found in some mushrooms) and escitalopram for depression. The paper, written by Robin Carhart-Harris (of Imperial College) and his co-authors, has received much attention. One online news source quipped: “Tripping may be as effective as your antidepressants.”

In this study, psilocybin was compared to the SSRI with a double-blind, randomized, controlled trial. Carhart-Harris et al. find: “On the basis of the change in depression scores on the QIDS-SR-16 at week 6, this trial did not show a significant difference in antidepressant effects between psilocybin and escitalopram in a selected group of patients.”

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We consider the paper and the editorial that runs with it by Dr. Jeffrey A. Lieberman (of Columbia University). We also ask Dr. Ishrat Husain (of the University of Toronto) for his thoughts. Finally, we mention other cutting-edge treatments.

DG

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