TagLancet Psychiatry

Reading of the Week: Yoga vs CBT – What’s Best for Anxiety? (JAMA Psych) Also, COVID & Mental Health (Lancet Psych) and Whitley on Cannabis Stigma (Van Sun)

From the Editor

Anxiety disorders are common, and often disabling to our patients. While treatments have improved, there is unmet need – and the desire to find new, scalable interventions. Increasingly, our patients look to different types of treatments, like yoga. But is trendy effective? Is yoga the not-so-new intervention we need?

Dr. Naomi M. Simon (of New York University) and her co-authors look at the treatment of generalized anxiety disorder with a sophisticated study. They compare yoga and cognitive behavioral therapy (CBT) against a psychological control condition, and against each other. So how do the treatments compare? “Kundalini yoga can reduce anxiety for adults with generalized anxiety disorder, but study results support CBT remaining first-line treatment.” We look at the big study and its big implications.

young-man-practice-yoga-beach-sunset_77186-348

What have we learned about COVID-19 and mental health? In the second selection, we consider a new editorial from The Lancet Psychiatry. Mulling the state of the literature after almost a year of the pandemic, they write: “The good news is that by October, 2020, mental health was top of the charts in terms of published papers and preprints on the effects of COVID-19. The bad news is that the quantity of papers is not matched by quality.”

And in our final selection, we consider an essay by Rob Whitley (of McGill University). He notes that 27% of Canadians had used cannabis in the last year, about half of them for medical reasons. He worries about the stigma around medical cannabis and champions more public education. “This can help create a climate of acceptance and inclusion for the growing number of Canadians with mental illness who use cannabis to improve their well-being.”

On another note: in a past Reading, we featured an essay by Toronto filmmaker Rebeccah Love who wrote about her mental illness. Her new film, “Parlour Love,” has its premiere this Saturday at 7 pm EST through Zoom. In this short, powerful film, she draws from her own experiences of bipolar mania and psychosis, and paints a portrait of a woman in crisis. RSVP – palmpremiere@gmail.com.

DG

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Reading of the Week: Ramadan and Mental Health Care – What are the Clinical Considerations?

From the Editor

For some patients, it carries deeply religious meaning. For others, it will be a time for reflection. And for us clinicians, it must be thought of in terms of patients’ management.

As our Muslim patients begin Ramadan, there are implications for care. About 80% of Muslims in North America will fast. Should medication times change? Would sleep be disrupted? Are patients on lithium at greater risk of toxicity? In a new paper, Dr. Zainab Furqan – a resident in the University of Toronto’s Department of Psychiatry – joins co-authors from three countries in considering Ramadan and care. They note that several groups are exempt from fasting but “many people who are exempt from fasting due to illness choose to fast during this month due to the spiritual significance of Ramadan for Muslim communities.”

They write: “It is important for clinicians not to undermine the importance of this spiritual practice for their patients.”

newmoon11A small moon and big challenges for care?

In this week’s Reading, we consider their new paper.

And an invitation: the Reading of the Week series invites guest contributions. If this is of interest, please let me know.

DG

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Reading of the Week: Is ‘New’ Overrated? Antipsychotics in the Real World

From the Editor

Is new better?

You may be reading this on an iPhone 7, having driven to work this morning in a 2017 Hybrid Prius. So should your patients be taking a medication that became available four-and-a-half decades ago – when people drove gus-gusling eight-cylinder Oldsmobiles and smartphones didn’t even exist in science fiction novels.

This week, we look at a just-published JAMA Psychiatry paper which promises to look at the “real-world” effectiveness of antipsychotics. The authors tapped Swedish databases to consider outcomes for nearly thirty thousand people with schizophrenia.

Sweden: elaborate welfare state, beautiful historic buildings, and – yes – rich databases

Spoiler alert: new wasn’t better. That is, newer antipsychotics tended to underperform clozapine and depot medications.

We also look at similar “real-world” work drawing from a Finnish database considering treatment of depression.

DG Continue reading

Reading of the Week: The Placebo Effect and Antidepressants

From the Editor

Is the placebo effect getting stronger with time?

image001Placebo pills – greater importance?

Since the first writings of English physician John Haygarth at the turn of the 19th century, the placebo effect is something well documented and well discussed – but not well understood. How can people respond to sugar pills and the like?

Even more oddly, the placebo effect seems to be changing with time, at least in terms of antidepressant medications. In a classic paper published about a decade and a half ago, Walsh et al. found that the placebo effect was getting more pronounced over the years. Dr. Timothy Walsh joked in a Washington Post interview that “[t]hey’re making placebos better and better.” Besides being an interesting finding, there are larger issues – start with the implications to drug development. After all, if the placebo effect is rising, it becomes more challenging to develop a drug that bests it.

Have things changed since the publication of the Walsh et al. paper?

In this week’s Reading, we consider the new Furukawa et al. paper. This study, which reviewed 250 plus randomized controlled trials that involved more than 26,000 patients and included unpublished data, found that the placebo effect isn’t increasing. Also in the Reading: an editorial commenting on the Furukawa et al. paper.

Please note – there will be no Reading next week.

DG Continue reading

Reading of the Week: Guest Contribution – Dr. David Goldbloom on Locked Doors and Hospitalizations

From a Contributing Editor, Colleague and Friend of the Editor

This week’s reading is a provocative companion piece to the recent review of efforts to reduce involuntary admission to hospital. It is the environmental expression of the legal deprivation of freedom of movement: the locked door. Locked doors have a powerful symbolic meaning in psychiatry; outpatients coming for elective consultations sometimes tell me they are afraid if they “say the wrong thing” that I will “lock them up”. Asylum superintendents carried large rings of keys that embodied power and control.

Locked doors, better outcomes?

Having spent half my career working on inpatient units, I am, like almost all of you, familiar with the locked doors that distinguish our wards from all others found in a hospital. And I know the reasons for their justification: prevention of elopement by people at risk of harm to themselves and others. And that prevention is intended to serve not only the patient and family but also the clinicians and the institution in terms of risk management. And yet…people do elope. Sometimes they return and sometimes they do not. Sometimes they attempt or complete suicide and sometimes they do not.

There is, as always, a tension between safety and risk, between freedom and protection, between autonomy and control. Locks are ubiquitous but not universal on psychiatric wards. What do we know about whether they make a difference? And what would be the ethically acceptable methodology for determining it?

– David Goldbloom, OC, MD, FRCP(C) Continue reading