TagJAMA Psychiatry

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: Vaccinations & Mental Disorders; Also, Nudging Patients (Psych Services)

From the Editor

By international standards, we are doing well. As a percentage of the population, more Canadians are doubly vaccinated than people in many other nations.

But let’s not be too pleased. Some Canadians haven’t received both shots – or even one. As is often the case with public health efforts (think smoking cessation and flu shots), those with mental disorders are harder to reach than the general population.

This week, there are two selections. In the first, Noel T. Brewer (of the University of North Carolina at Chapel Hill) and Neetu Abad (of the US Centers for Disease Control and Prevention) discuss ways that we can boost the rate of vaccination of those with mental health problems in a new JAMA Psychiatry paper. They recognize the unique challenges of reaching this population – and the clear opportunities for mental health professionals. “Although mental health is not the first thing that comes to mind when thinking about vaccination, strategic use of mental health professionals’ expertise could provide new opportunities to encourage COVID-19 vaccination.” We consider the paper and its clinical implications.

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In the second selection, also on the theme of nudging our patients to get better outcomes, Gabriela K. Khazanov (of Veterans Affairs) and her co-authors consider using behavioural economics. In this Psychiatric Services paper, they note that Veterans Affairs (VA) “has successfully implemented a financial incentive program aimed at improving psychiatric treatment engagement…”

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Reading of the Week: Telepsychiatry – the Reality, the Potential, the Problems

From the Editor

Just a handful of months ago, mental health work didn’t require a webcam or a lighting ring, and no one talked about Zoom fatigue. The world is different now, obviously. With COVID-19, telepsychiatry is very much part of our clinical work.

This week, we consider three papers focused on telepsychiatry and our new world.

How widespread is the adoption of telepsychiatry in this pandemic era? In the first selection, Jonathan Cantor (of the RAND Corporation) and his co-authors draw on a big American database to answer that question. In Psychiatric Services, they write: “During the COVID-19 pandemic, the percentage of outpatient mental health and substance use disorder treatment facilities offering telehealth has grown dramatically. However, our analyses also indicated that considerable proportions of mental health and substance use disorder treatment facilities still did not offer telehealth as of January 2021…”

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In the second selection, John C. Fortney (of the University of Washington) and his co-authors consider two different types of care: with psychiatrists directly involved in patient care (through televideo) or indirectly, by providing support to primary care. In a JAMA Psychiatry study, they do a comparison. Spoiler alert: both approaches were effective, suggesting great potential, especially for those in rural areas.

Of course, not everyone is enthusiastic about telepsychiatry. In our third selection, Dr. J. Alexander Scott (of the University of Michigan), a resident of psychiatry, describes his ambivalence. His Academic Psychiatry paper starts memorably: “Admittedly, I’ve never liked telemedicine.” He outlines some of the problems with our digital world.

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.

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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: Does Opioid Agonist Treatment Save Lives? Also, the Problem with Decriminalization of Illicit Drugs (CJP)

From the Editor

Methadone was invented in the 1930s. The first legal injection site opened its doors nearly two decades ago. Yet our challenges with opioids seem to have only worsened with time. Consider, for example, that in a new, two-year study, the authors found that opioid-related deaths rose almost 600% between 2015 and 2017 in Canada.

What can we do? This week, we consider two selections.

In the first, Thomas Santo Jr (of the University of New South Wales) and his co-authors do a systematic review and meta-analysis for opioid agonist treatment for those with opioid dependence. They write in JAMA Psychiatry: “Our findings suggest a potential public health benefit of OAT, which was associated with a greater than 50% lower risk of all-cause mortality, drug-related deaths, and suicide and was associated with significantly lower rates of mortality for other causes.” We consider the big paper and its implications.

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And in the other selection, Benedikt Fischer (of the University of Toronto) and his co-authors weigh the recent interest in decriminalizing illicit drug use. In a new Canadian Journal of Psychiatry commentary, they note their hesitation, writing: “while ‘decriminalization’ proposals for illicit drug use are popular and largely well-intended, their overall merits require cautious analysis and scrutiny.”

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: Suicide and Schizophrenia – Across Life Span; Also, Transgender-Inclusive Care (QT), and the NYT on Chatbots

From the Editor

This week, we have three selections.

In the first, we consider suicide and schizophrenia. In a new JAMA Psychiatry paper, Dr. Mark Olfson (of Columbia University) and his co-authors do a cohort study across life-span, tapping a massive database. They find: “the risk of suicide was higher compared with the general US population and was highest among those aged 18 to 34 years and lowest among those 65 years and older.” The authors see clear clinical implications: “These findings suggest that suicide prevention efforts for individuals with schizophrenia should include a focus on younger adults with suicidal symptoms and substance use disorders.”

In the second selection, we consider transgender-inclusive care, looking at a new Quick Takes podcast. Drs. June Lam and Alex Abramovich (both of the University of Toronto) comment on caring for members of this population. “Trans individuals are medically underserved and experience, poor mental health outcomes, high rates of disease burden – compared to cisgender individuals.”

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Finally, in our third selection from The New York Times, reporter Karen Brown writes about chatbots for psychotherapy, focusing on Woebot. The writer quotes psychologist Alison Darcy about the potential of these conversational agents: “If we can deliver some of the things that the human can deliver, then we actually can create something that’s truly scalable, that has the capability to reduce the incidence of suffering in the population.”

DG

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Reading of the Week: Zen vs Zoloft for Relapse Prevention – the New JAMA Psych Paper; Also, Grossman-Kahn on Her Patient’s Cause (NEJM)

From the Editor

He feels better and he wants to go off medications, what should you recommend?

Patients raise this question often in depression management. For some, antidepressants are rich in side effects; others simply dislike the idea of long-term medications. For years, the response was simple: outline the risks of going off medications. Depression guidelines, after all, mention the need for continued antidepressants, especially for those who have had multiple past episodes. But, more recently, several papers have suggested that certain psychotherapies reduce the risk of relapse and can rival antidepressants.

But, until now, there hasn’t been a good meta-analysis. This week, in our first selection, we consider a new JAMA Psychiatry paper. Josefien J. F. Breedvelt (of the University of Amsterdam) and co-authors do an individual data meta-analysis comparing antidepressants and psychotherapies for relapse prevention – Zen versus Zoloft, if you will. They write: “The sequential delivery of a psychological intervention during and/or after tapering may be an effective relapse prevention strategy instead of long-term use of antidepressants.” We consider the big paper and its clinical implications.

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And in the second selection, Dr. Rebecca Grossman-Kahn (of the University of Minnesota) writes about a patient encounter in Minneapolis after the murder of George Floyd. Noting his manic episode, she wonders about larger questions, including diagnosis and coercion. This resident of psychiatry writes: “Training has taught me to recognize the signs of mania and psychosis. But nothing prepared me to ask courageous protesters to put their crucial work for change on hold due to mental illness.”

DG

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Reading of the Week: Helping Healthcare Workers Seek Help; Also, Smoking Cessation for Inpatients & Priebe on Why Patients Should Be Called Patients

From the Editor

How do we connect with them?

With the worst of the third wave now behind us, we are beginning to look forward. But for some, the problems of the pandemic aren’t fading. They will continue to struggle with mental health problems.

Healthcare workers are particularly at risk. They are also, collectively, a group that is difficult to engage. In the first selection, we look at a new paper from The British Journal of Psychiatry. Dr. Doron Amsalem (of Columbia University) and his co-authors do a video intervention to increase treatment seeking. The resulting RCT is impressive. The authors write: “The high proportion of healthcare workers surveyed in this study who reported symptoms of probable generalised anxiety, depression and/or PTSD emphasises the need for intervention aimed at increasing treatment-seeking among US healthcare workers. A three-minute online social contact-based video intervention effectively increased self-reported treatment-seeking intentions among healthcare workers.”

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In the second selection, Richard A. Brown (of the University of Texas at Austin) and his co-authors look at a new approach to an old problem: high smoking rates among people with severe mental illness. Focusing on inpatient hospitalizations, they design an intervention built on motivational interviewing. We consider their JAMA Psychiatry paper.

Is the term patient antiquated? Should we use other terms, like client or service user? In a BJPsych Bulletin paper, Dr. Stefan Priebe (of Queen Mary University of London) argues that we serve patients – and that words matter. “Mental healthcare is based on shared values and scientific evidence. Both require precise thinking, and precise thinking requires an exact and consistent terminology.”

DG

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