Tag: JAMA Psychiatry

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

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 PostThe 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

Continue reading

Reading of the Week: Antipsychotics – the New, the Old & the Patient Experience, with Papers from JAMA Psych, BJP and Schiz Bulletin

From the Editor

“FDA approves a novel drug for schizophrenia, a potential ‘game changer’”

– The Washington Post

“Will ‘Game Changer’ Antipsychotic Live Up to the Hype?”

– Medscape

Two weeks ago, for the first time in decades, the FDA approved an antipsychotic for schizophrenia with a novel mode of action. What does the data show for this medication, xanomeline-trospium chloride? Is it a “game changer” as some headlines suggest? 

In the first selection, Dr. Inder Kaul (of Karuna Therapeutics) and his co-authors report on a double-blind, randomized, placebo-controlled trial that was published in JAMA Psychiatry. 256 people with schizophrenia were given the antipsychotic or the placebo and followed for five weeks. “Xanomeline-trospium was efficacious and well tolerated in people with schizophrenia experiencing acute psychosis.” We consider the study and its implications.

In contrast to this week’s first selection, the second selection looks at an older antipsychotic: clozapine. Drawing on Canadian databases, Lloyd Balbuena (of the University of Saskatchewan) and his co-authors put the risks and benefits of this medication in a new light in a paper for The British Journal of Psychiatry. They analyzed data on admissions and adverse events, with almost 50 000 participants. “Clozapine was associated with lower relapse overall, but this was accompanied by higher adverse events for adults. For children/youth, clozapine was associated with lower relapse all throughout and had no difference in adverse events compared with other antipsychotics.”

And in the third selection, Susan Weiner writes about antipsychotics for Schizophrenia Bulletin. She discusses her first psychotic break, her long journey, and her ultimate recovery. In a personal essay, she also describes the connection she made with her psychiatrist and the medication that transformed her life. “The right medicine for the right person can produce sanity like a miracle drug, and all is once again bright.”

DG

Continue reading

Reading of the Week: Ten Great Papers; Also, Mindfulness’s Untapped Potential (JAMA Psych) and the FDA Approves an Antipsychotic (Nature)

From the Editor

It’s the 10th anniversary of the Reading of the Week. The program has grown and evolved over this past decade, now reaching psychiatrists and residents internationally, but the core idea – timely summaries of the latest in the literature coupled with commentary – hasn’t changed. To mark the anniversary, we look at some important papers that we have covered in the past ten years.

Last week: ten papers that I think about often (and helped change my clinical work).

This week: ten papers that I think about often (and helped change the way I view mental illness).

*      *      *

In the second selection, Jesus Montero-Marin (of the University of Oxford) and his co-authors consider mindfulness-based cognitive therapy in a new Viewpoint for JAMA Psychiatry. Noting the burden of depression, they see this therapy as being helpful, especially for those with “entrenched” depression. “By leveraging translational science, we can enhance access, engagement, and treatment outcomes for depression. This work uses MBCT as a foundational case study and delineates future research directions with the potential to profoundly impact service design and policy.”

And in the third selection, journalist Elie Dolgin reports on the new FDA-approved schizophrenia medication for Nature. He describes the novel mechanism of action and quotes Christoph Correll (of Hofstra University): “This will be a revolution of the treatment of psychosis, and I’m not saying this lightly. Now we will now be able to treat people who haven’t been helped with traditional antipsychotics.”

DG

Continue reading

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

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

Continue reading

Reading of the Week: Mental Healthcare in Rural India – the New JAMA Psych Study; Also, Conflict & Psychiatry, and Morén on Her Father

From the Editor

Many in high-income nations don’t receive needed mental healthcare. Moreover, problems run deeper in countries like India, where only about 4% of patients with depression receive minimally adequate treatment, due to the higher prevalence of stigma and the limited number of providers. 

Could anti-stigma campaigns make a difference? Could technology be leveraged to reach those at high risk? In the first selection, Dr. Pallab K. Maulik (of the University of New South Wales) and his co-authors seek to answer these questions in a new paper for JAMA Psychiatry. They report the findings of a major study involving 44 primary health centres and nearly 10 000 participants across the states of Haryana and Andhra Pradesh in India. The interventions included both anti-stigma campaigns and an app designed to guide and prioritize care. “There was a significant difference in mean depression scores between intervention vs control groups at 12 months, with lower scores in high-risk cohort.” We discuss the paper and its implications.

In the second selection, Dr. Neil Krishan Aggarwal (of Columbia University) bemoans global conflicts and wonders about the role of psychiatry in a Viewpoint for JAMA Psychiatry. Noting that psychiatry helped create a less formal type of diplomacy, called Track II, he questions what role psychiatry might play in the future. “Mental health professionals can encourage dialog among foreign policy elites to reduce the possibility for military conflict.”

And in the third selection from Schizophrenia Bulletin, Constanza Morén (of the University of Barcelona) writes about her father who was a “magnificent person.” He was also an individual with schizophrenia. She discusses his journey and his challenges he faced within the healthcare system. “Patients live with their own voices, but, in a way, they need the rest of us to also give them a voice.”

DG

Continue reading

Reading of the Week: ED Visits & Suicide Attempts – the New AJP Study; Also, Smoking Cessation, and Pappas on Her Genes & Her Olympic Drive

From the Editor

Are ED visits for suicide attempts becoming more frequent? What are the implications for care?

In the first selection from The American Journal of Psychiatry, Dr. Tanner J. Bommersbach (of the Mayo Clinic) and his co-authors attempt to answer these questions by considering US trends in ED visits for suicide attempts and intentional self-harm. Using national survey data collected over a 10-year period, they estimate that the absolute number of suicide attempts tripled to 5.3 million. “A significant national increase in emergency department visits for suicide attempts and intentional self-harm occurred from 2011 to 2020, as a proportion of total emergency department visits and as visits per capita.” We analyze this study.

In the second selection, Drs. Robert A. Kleinman (of the University of Toronto) and Brian S. Barnett (of the Cleveland Clinic) write about smoking cessation and mental illness in a Viewpoint just published in JAMA Psychiatry. They note societal progress – smoking rates are sharply down over the past five decades – yet many with mental illness still use tobacco. They argue that psychiatrists have a significant role to play in addressing this problem. “Patients who stop smoking can limit tobacco-related illness, avoid the distressing effects of nicotine withdrawal and craving, and live longer.”

Later this week, the Olympics conclude in Paris. In the third selection, former Olympian Alexi Pappas discusses her mother’s suicide and her own struggles with depression. In a deeply personal essay from The New York Times, she contemplates genes and destiny and healing. “My future – the universe where my fear lives – was never set in stone, and neither was my mom’s. I’m more than my genes, and I would not reroll the dice if given the option.”

There will be no Readings for the next two weeks.

DG

Continue reading

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)

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

Continue reading

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

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

Continue reading

Reading of the Week: Antidepressants & Discontinuation Symptoms – the New Lancet Psych Study; Also, Neuromodulation and Digital Health Technology

From the Editor

“Once I start taking them, I’m stuck.” When discussing the possible initiation of an antidepressant trial, a patient recently expressed his fear: that he wouldn’t be able to stop the medication because of discontinuation symptoms. These symptoms are debated. Some claim they are very common – though that’s not widely reported in the literature. 

How frequently do these symptoms occur? What percentage of patients experience severe symptoms? Are some antidepressants more associated with this problem than others? Dr. Jonathan Henssler (of the University of Cologne) and his co-authors attempt to answer these questions with an impressive, new systematic review and meta-analysis, published in Lancet Psychiatry. They drew on 79 studies involving more than 21 000 people. “The incidence of antidepressant discontinuation symptoms is approximately 15%, affecting one in six to seven patients who discontinue their medication.” We consider the paper and its clinical implications.

Will the stigma around ECT fade? Will ECT eventually be replaced by ketamine and MST? What’s the future of neuromodulation? We answer these questions and more in the second selection, the latest Quick Takes podcast interview. Dr. Daniel Blumberger, scientific director of CAMH’s Temerty Centre for Therapeutic Brain Intervention and professor at the University of Toronto, notes that ECT still has a unique place. “As far as medical treatments go, ECT is the safest medical procedure in all of medicine.”

And in the third selection, Dr. John Torous (of the Harvard University) and his co-authors focus on digital mental health in a new Viewpoint published in JAMA Psychiatry. They argue that we tend to both overstate and underappreciate the risks and benefits of digital mental health interventions. “Patients and clinicians should not assume wellness digital health technologies are always dangerous, nor should they assume health technologies are always safe.”

DG

Continue reading

Reading of the Week: Placebo & Mental Disorders – the New JAMA Psych Study; Also, Children Who Lost a Parent to Overdose, and the Latest in the News

From the Editor 

It’s day three of his hospitalization, and he insists that the medication trial (a low dose of an SSRI) has been transformative. It’s difficult to explain his experience pharmacologically. 

How significant is the placebo response? How much does it vary among mental disorders? These questions aren’t new. In the first selection, Dr. Tom Bschor (of the Technical University of Dresden) and his co-authors tread on a familiar path with a study just published in JAMA Psychiatry. Focusing on nine psychiatric disorders, they examined high-quality RCTs for a systematic review and meta-analysis, finding “significant improvement under placebo treatment for all 9 disorders, but the degree of improvement varied significantly among diagnoses.” We consider the study and its implications.

In the second selection, Christopher M. Jones (of the Substance Abuse and Mental Health Services Administration) and his co-authors used US databases to calculate how many children have lost a parent to drug overdoses. The resulting JAMA Psychiatry study is haunting. “We estimated that more than 320 000 US children lost a parent to drug overdose between 2011 and 2021, providing new insight into the multigenerational impacts of the ongoing overdose crisis in the US.”

Finally, we explore the latest news with recent articles from The GuardianThe Globe and Mail, and The New York Times. Among the topics: the mental health struggles of a cancer patient, the beliefs of Marshall Smith, and whether we are talking too much about mental health.

DG

Continue reading