Tag: JAMA Psychiatry

Reading of the Week: Motor Vehicle Crashes and Mental Disorders – the New CJP Paper; Also, Psychedelics & the States, and Hogan on NYC & Coercion

May 18, 2023 /

From the Editor 

He’s not well but insists that he can still drive his car. Should you report him to the Ministry of Transportation?

As clinicians, we often struggle with such issues, which touch on clinical judgment, as well as legal requirements. In Ontario, half a decade ago, the governme­­nt changed the law, requiring mandatory reporting for several conditions, including “acute” psychosis. Yet other provinces continue to leave major decisions to the discretion of providers. What does the literature say about motor vehicle crashes and mental disorders? In the first selection, Dr. Mark J. Rapoport (of the University of Toronto) and his co-authors do a systematic review for The Canadian Journal of Psychiatry, drawing on 24 studies. “The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder.” We consider the paper and its implications.

In the second selection, Dr. Joshua S. Siegel (of Washington University in St. Louis) and his co-authors look at US state legislation for psychedelic drugs in a new JAMA Psychiatry Special Communication. They note a sharp uptick in legislative activity and draw comparisons to cannabis. “After decades of legal restriction, US states have been swiftly moving toward increased access to psychedelics.”

And in the third selection, Michael F. Hogan (of Case Western Reserve University) writes about coercion and mental health care in JAMA Psychiatry. He considers the proposals of New York City Mayor Eric Adams which would expand efforts to hospitalize those with several, persistent mental illness. “Mayor Adams’ proposal for a more vigorous police response leading to inpatient care is well intended but incomplete. It would be preferable for New York to implement comprehensive crisis programs, including intensive care options that reduced the burden on police.”

DG

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Reading of the Week: Mindfulness Self-Help for Depression? The New JAMA Psych Study; Also, Elderly Overdoses (JAMA Psych) and Sanford on Loss (JAMA)

April 20, 2023 /

From the Editor

He diagnosed himself. My patient suspected something was wrong, did some reading, and then completed a PHQ-9 survey (which he found on a website). But, like many, he struggled to get care.

The story is too familiar. Access to care is deeply problematic. Not surprisingly, then, low-cost interventions are of interest, with much work focused on CBT. What about mindfulness? In the first selection, Clara Strauss (of the University of Sussex) and her co-authors attempt to answer that question with direct comparison of mindfulness and CBT. In a new JAMA Psychiatry paper, they find: “practitioner-supported [mindfulness] was superior to standard recommended treatment (ie, practitioner-supported CBT) for mild to moderate depression in terms of both clinical effectiveness and cost-effectiveness.” We consider the paper and its implications.

In the second selection, Keith Humphreys (of Stanford University) and Chelsea L. Shover (of the University of California, Los Angeles) look at overdose deaths in older Americans for JAMA Psychiatry. Drawing on a database, they find a quadrupling between 2002 and 2021. “Even though drug overdose remains an uncommon cause of death among older adults in the US, the quadrupling of fatal overdoses among older adults should be considered in evolving policies focused on the overdose epidemic.” 

And in the third selection, Dr. Ethan L. Sanford (of the University of Texas) writes about the loss of his infant daughter. In a deeply personal essay for JAMA, he describes her illness and death – and his re-evaluation of his career. “I sometimes wish every physician could understand the loss of a child. I wish they could understand how I miss Ceci achingly, how I miss her in my bones.”

DG

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Reading of the Week: Augmentation in the Elderly with Depression – the New NEJM Study; Also, Dr. Simpson on Violence (Globe)

April 13, 2023 /

From the Editor

“Approximately 30% of patients treated for depression do not have a response to selective serotonin-reuptake inhibitors (SSRIs).” So notes an Editorial in The New England Journal of Medicine. And for those who don’t respond, what’s the next step? 

Unfortunately, though many elderly struggle with depression, this population is understudied. In a new paper published in the same journal, Dr. Eric J. Lenze (of the Washington University in St. Louis) and his co-authors attempt to answer that question with a two-step intervention. “In older adults with treatment-resistant depression, augmentation of existing antidepressants with aripiprazole improved well-being significantly more over 10 weeks than a switch to bupropion and was associated with a numerically higher incidence of remission. Among patients in whom augmentation or a switch to bupropion failed, changes in well-being and the occurrence of remission with lithium augmentation or a switch to nortriptyline were similar.” We look at the study and its clinical implications, as well as the accompanying Editorial.

And, in the other selection, Dr. Sandy Simpson (of the University of Toronto) considers the violence seen on public transit in Canada’s largest city. In an essay for The Globe and Mail, he mulls several factors and points a way forward, including by advocating a guaranteed basic income. “We are seeing now that we have failed to create a compassionate society, and that security and safety needs to extend to all people. To achieve this, we need a change in heart, and expenditure.”

DG

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Reading of the Week: Can a Phone Intervention Reduce Alcohol? Also, Dr. Goldbloom on His Career & Retirement (QT) and Ending the Term AMA (Annals)

December 15, 2022 /

From the Editor

During the first wave, alone and isolated, he started to drink significantly more. Now, many months later, he continues to struggle with an alcohol use disorder. This patient’s journey – as he told me in the ED last week – is a familiar story that we as clinicians have heard many times in these past few years. What can be done to help? Could we better reach those who are misusing alcohol?

In JAMA Psychiatry, Dan I. Lubman (of Monash University) and his co-authors describe an intervention that is very relevant. In this Australian RCT, some participants received 4-6 sessions of telephone-provided, manualized cognitive and behavioural intervention that included mindfulness. They found that: “this randomized clinical trial did not find superior effectiveness of this telephone-based cognitive and behavioral intervention compared with active control.” We discuss the paper and its clinical implications.

Dr. David Goldbloom has had a storied career: senior medical advisor at CAMH, professor at the University of Toronto, former chair of the Mental Health Commission of Canada, former editor of The Canadian Journal of Psychiatry. And tomorrow, he adds another title to that long list: retiree. This week’s second selection is a new Quick Takes podcast interview with him in which he comments on career and retirement and more. “I’m not an entirely gloomy or nihilistic person, either by temperament or based on what I’ve witnessed over the last 40 years.”

Finally, in the third selection, Dr. Robert A. Kleinman (of the University of Toronto) and his co-authors argue that “against medical advice” is a dated term. In Annals of Internal of Medicine, they argue for a new approach: “Shifting away from the ‘AMA’ terminology and toward more collaborative approaches to these discharges would improve the treatment of patients who are too often stigmatized by the clinicians and health systems that are meant to care for them.”

DG

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Reading of the Week: Virtual Care & Schizophrenia – the New CJP Paper; Also, the Psychedelic Hype Bubble (JAMA Psych) and Aiello on Stigma (Walrus)

December 8, 2022 /

From the Editor 

At the start of the pandemic, the shift to virtual care was important and necessary, allowing us to reach our patients during the lockdowns. As we slowly move past COVID-19, there are big questions to ask. What’s lost in the virtual world? What’s right and what’s to be done?

In the first selection, Ellen Stephenson (of the University of Toronto) and her co-authors look at patients with schizophrenia. In a new paper just published in The Canadian Journal of Psychiatry, they analyze different aspects of care, including prevention. They find: “There were substantial decreases in preventive care after the onset of the pandemic, although primary care access was largely maintained through virtual care.” We consider the paper and its clinical implications.

Virtual care, real-world gaps?

In the second selection, David B. Yaden (of Johns Hopkins University) and his co-authors weigh in on the enthusiasm and criticism of psychedelics. In this Viewpoint for JAMA Psychiatry, they argue that interest has reached a “hype bubble.” They make a call for action: “As scientists and clinicians, we have an ethical mandate to dispute claims not supported by available evidence. We encourage our colleagues to help deflate the psychedelic hype bubble in a measured way…”

And in the third selection, K. J. Aiello – who has lived experience – writes about mental illness and stigma in an essay for The Walrus. While noting some progress in the acceptance of mental disorders, the writer wonders how much has really changed. “Even as the stigma around mental illness has faded, it has become clear that this compassion and effort extend only so far, and that they are not available to everyone. Often those fault lines appear around class – and around the type of mental illness.”

DG

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Reading of the Week: Smoking Cessation – Doing Bad, Feeling Good? Also, Ethnicity & Opioids (JAMA Psych) and Dr. Freedman on Lunches (Acad Psych)

December 1, 2022 /

From the Editor

We ask our patients about cannabis. We inquire about illicit drugs. But are we forgetting tobacco? A new paper in Psychiatric Services helps answer that question – and, perhaps, raises other questions, including about how we could do better. 

In the first selection, Sarah A. White (of Johns Hopkins University) and her co-authors draw on American data to look at smoking cessation medications in a new Psychiatric Services paper. Among more than 55,000 smokers (many of whom have mental illness), they find that: “Cessation pharmacotherapy for smokers remained vastly underprescribed across all groups. At least 83% of smokers with or without mental illness did not receive varenicline, NRT, or bupropion during the 14-year study period.” We consider the paper and its clinical implications.

In the second selection, Huiru Dong (of Harvard University) and her co-authors look at buprenorphine treatment and demographics in the United States. Their JAMA Psychiatry research letter, which was just published, finds a growing gap. “The observed heterogeneity in buprenorphine treatment duration among racial and ethnic groups may reflect disproportionate structural barriers in treatment retention for Opioid Use Disorder.”

In the third selection, Dr. David Freedman (of the University of Toronto) writes about resident lunches for Academic Psychiatry. Dr. Freedman, who is a resident, notes that in-person lunches shifted to virtual ones for more than two years because of the pandemic – something that was necessary but unfortunate. He argues that the gatherings are important. “Yet, as a collective of residents munch on the last bites of their sandwiches, say goodbye, and return to work, I am struck by the camaraderie. Funded resident lunches nurture the professional identities of psychiatry trainees – an essential element of medical education.”

DG

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Reading of the Week: Mindfulness for Anxiety? The New JAMA Psychiatry Paper; Also, Sim in Med Ed (QT) and Dr. Sen on Burnout & Depression (NEJM)

November 24, 2022 /

From the Editor

Mindfulness is trendy. It’s offered at your local YMCA. There are mindfulness techniques in popular apps. Corporations offer sessions over the lunch hour.

But is it helpful? Millions of North Americans struggle with anxiety disorders. Could mindfulness help them? Is it an alternative for those who don’t want to take medications? In the first selection, Dr. Elizabeth A. Hoge (of Georgetown University) and her co-authors try to answer these questions. Their results have just been published in JAMA Psychiatry. In an RCT, they compare a form of mindfulness to the use of an SSRI. They write: “Our prospective randomized clinical trial found that MBSR was noninferior to escitalopram for the treatment of anxiety disorders.” We consider the paper and its clinical implications.

In this week’s second selection, we look at a new Quick Takes podcast interview with CAMH’s Stephanie Sliekers and Dr. Petal Abdool (of the University of Toronto). They discuss simulation in mental health education, noting the potential. They also talk about their innovative work in this area. “We can create an environment that’s safe, predictable, consistent, standardized, and reproducible.”

In this week’s third selection, Dr. Srijan Sen (of the University of Michigan) writes about physician burnout. In a Perspective paper published in The New England Journal of Medicine, he argues that separating burnout from depression is problematic. He writes: “Expanding reform efforts to encompass depression and mental health more broadly will not reduce the urgency of reforming our health care system. Rather, it will increase the likelihood that physicians who are struggling can access the spectrum of available evidence-based individual interventions.”

DG

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Reading of the Week: Are Involuntary Admissions on the Rise? The New CJP Paper; Also, Telepsychiatry (JAMA Psych) and Dr. Oh on Suicide (Acad Psych)

November 3, 2022 /

From the Editor

A recent New York Times article notes that adolescents are increasingly looking for information on mental health and turning to TikTok. Such is life at a time when stigma fades: people are curious, though not necessarily going to the best places for information.

But are we reaching people earlier in their illness experience? We hope that the answer is yes – a new paper with British Columbian data, however, suggests that police apprehensions are more common, as are involuntary admissions, indicating that more people are in crisis. In the first selection from The Canadian Journal of Psychiatry, Jackson P. Loyal (of Simon Fraser University) and his co-authors draw on administrative databases and find a major shift: “While roughly half of the people hospitalized for mental health and substance use disorders were admitted voluntarily in 2008/2009, by 2017/2018 this fell to approximately one-third.” We look at the paper and its clinical implications.

British Columbia: a province of rivers, whales, and involuntary admissions

In the second selection, Dr. Carlos Blanco (of the National Institute on Drug Abuse, United States) and his co-authors consider the rise of telepsychiatry, noting that 39% of mental health care in the US is now virtual. In this new JAMA Psychiatry Viewpoint, “Expansion of telepsychiatry creates new opportunities to increase treatment access, while it poses overlapping challenges to multiple stakeholders…”

And in the third selection, Dr. Nicholas Zhenwei Oh (of the Ministry of Health Holdings, Singapore) writes personally and thoughtfully about the loss of a patient by suicide. He goes into detail on his own experience during training. “Patient suicide is possibly the great equaliser amongst psychiatrists, psychiatry trainees, and perhaps any other clinician who has experienced a patient’s suicide. My own experience came suddenly and unexpectedly, and it will likely leave a psychological scar as a grim reminder of one of the lowest points of my career.”

DG

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Reading of the Week: rTMS – the New JAMA Psych Paper; Also, Opioid Overdoses (JAMA Net Open) and Green on Peak Mental Health (NYT)

October 13, 2022 /

From the Editor

She’s an accomplished person who had succeeded in business and then writing, all the while raising three children; she also has an amazing smile and lights up the room when talking about her kids. But in my office, sick with depression, she can only focus on her losses and failings; the smile is absent.

Depression is common and disabling. Those who are affected in late-life are particularly challenging to treat. Is there a better way? In the first selection from JAMA Psychiatry, Dr. Daniel Blumberger (of the University of Toronto) and his co-authors consider theta burst stimulation, a newer form of rTMS which has shown promise in earlier work. Their study is a randomized noninferiority trial, directly comparing the two versions of rTMS in elderly patients with depression. The result? “We showed that bilateral TBS was noninferior to standard bilateral rTMS in improving depression, and similarly well tolerated, in a real-world sample of older adults with TRD [treatment resistant depression]…” We review the paper and its clinical implications.

In the second selection, Lori Ann Post (of Northwestern University) and her co-authors draw on CDC data to look at opioid overdoses in the United States with a focus on geography. In a JAMA Network Open research letter, they find: “Overall, opioid-involved overdose deaths rates increased steadily in counties of every urbanicity type, although there were distinct temporal wave patterns by urbanicity.”

And in the third selection, Huw Green (of the University of Cambridge) wonders about mental health and mental illness – and worries that the terms are becoming blurred together. Writing in The New York Times, the psychologist concludes: “When we move away from a focus on psychological problems and toward ‘mental health’ more broadly, clinicians stumble into terrain that extends beyond our expertise. We ought to be appropriately humble.”  

This month, the Reading of the Week enters its ninth year. A quick word of thanks for your ongoing interest.

DG



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Reading of the Week: Psychiatrists & Patient Suicide – the New CJP Paper; Brain Wellness Spas (JAMA Psych) and Dr. Heidari on Her Mantra (NEJM)

September 29, 2022 /

From the Editor

It’s the call we dread, perhaps from a relative or the family doctor. The news catches us by surprise: the patient has died and suicide is suspected.

In the first selection from The Canadian Journal of Psychiatry, Dr. Zainab Furqan (of the University of Toronto) and her co-authors consider psychiatrists’ experiences with patients who die by suicide. In this qualitative analysis drawing on 17 interviews, they explore the emotional response. They conclude: “patient suicide is often associated with grief, shock, anxiety and guilt; emotions which are mediated by physician, patient, relational and institutional factors and have important ramifications on psychiatrists’ well-being and clinical practice.” We consider the paper and its implications.

In this week’s second selection, Anna Wexler and Dominic Sisti (both of the University of Pennsylvania) write about the potential and problems of off-label use for psychedelic drugs in light of likely FDA approval. In a JAMA PsychiatryViewpoint, they note: “With high public enthusiasm, extremely bullish investors, and hundreds of newly established brain wellness clinics, all the pieces are now in place for expansive off-label promotion and use of psychedelics to quickly mushroom beyond what is safe.”

Finally, in the third selection from The New England Journal of Medicine, Dr. Shireen N. Heidari (of Stanford University) notes the incredible challenges of working during the pandemic – and the psychological toll. She describes her decision to seek care and her own recovery: “A year after making the decision to talk to my family and my doctor, I know that advocating for my own mental health was the best decision I could have made.”

DG

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