Tag: medical education

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

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Reading of the Week: Global Burden of Schizophrenia – the new Molecular Psych Study; Also, MedEd’s Evolution & Saxbe on Helping Depressed Teens

From the Editor

Is there more mental illness than before? Or is there greater awareness? 

Dr. Marco Solmi (of the University of Ottawa) and his co-authors attempt to answer these questions in a new paper for Molecular Psychiatry that focuses on schizophrenia. Drawing on 30 years of data globally, they consider prevalence (how many have the illness), incidence (the number who develop it each year), and the disability-adjusted life-years (the loss of one healthy year of life) using more than 86 000 points of data. They find: “Globally, we show that, from 1990 to 2019, raw prevalence increased by over 65%, incidence by 37.11%, DALYs by over 65%, but age-adjusted prevalence and incidence estimates showed a slight decrease, and burden did not change.” We consider the paper and its implications.

Textbooks, highlighters, and classrooms? The world of medical education is changing. Today, we have AI, sim, and e-learning. In the second selection, we look at the new Quick Takes podcast with Dr. Ivan Silver (of the University of Toronto), former vice president of education at CAMH who marvels at the potential. “This is the renaissance period for health professional education.” 

And in the third selection, psychologist Darby Saxbe (of the University of Southern California) writes in The New York Times about ways to help depressed adolescents. Drawing on recent studies showing the failure of school-based psychosocial interventions, she argues for a different approach. “It’s critical to keep pace with the evidence and attend to the first principle of all health care providers: First, do no harm.”

DG

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Reading of the Week: Written Exposure Therapy for PTSD – the New JAMA Psychiatry Paper; Also, #MedEd & Knowledge Translation

From the Editor

How to help those with PTSD? Prolonged exposure therapy (PE) and cognitive processing therapy (CPT) are supported by good evidence but both are resource intense and often have high drop-out rates, partly because of the requirement that patients complete homework. Is there an alternative?

In the first selection, we look at a new study considering written exposure therapy (WET), an emerging therapy where patients write about traumatic events – but the therapy doesn’t demand so much from the system (in terms of resources) or patients (in terms of homework assignments). Denise Sloan (of Boston University) and her colleagues conducted a noninferiority trial, comparing this therapy with prolonged exposure therapy for US veterans with PTSD, involving 178 participants from three centres. “We found WET was noninferior to PE, a treatment that includes more treatment sessions, longer sessions, and between-session assignments.” We consider the study, an Editorial responding to it, and mull the clinical implications.

In the last selection, John W. Ayers (of the University of California San Diego, La Jolla) and his co-authors consider social media and medical education in JAMA. They argue that #MedEd is a dynamic platform with the potential to democratize medical education – but also warn of the problems of misinformation. “The potential for #MedEd to improve medical education and the health sciences is considerable, while the risks of dismissing #MedEd is potentially greater.”

DG

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Reading of the Week: Antidepressants & Bipolar – the New NEJM Paper; Also, AI & Med Ed and Humphreys on Language

From the Editor

What’s the role of antidepressants in the treatment of bipolar disorder? That question is openly debated.

In a New England Journal of Medicine paper that was just published, Dr. Lakshmi N. Yatham (of the University of British Columbia) and his co-authors try to shed light on this issue. In their study, people with bipolar depression who were in remission were given an antidepressant or a placebo and followed for a year. The study involved 209 people from three countries. “[A]djunctive treatment with escitalopram or bupropion XL that continued for 52 weeks did not show a significant benefit as compared with treatment for 8 weeks in preventing relapse of any mood episode.” We consider the paper and its implications.

In the second selection, Drs. Avraham Cooper (of Ohio State University) and Adam Rodman (of Harvard University) consider AI and medical education in The New England Journal of Medicine. They talk about previous technological advancements in history, including the stethoscope. AI, in their view, will change practice and ethics – with clear implications for training and education. “If we don’t shape our own future, powerful technology companies will happily shape it for us.”

And in the third selection, Keith Humphreys (of Stanford University) writes about words and word choices to describe vulnerable populations in an essay for The Atlantic. He notes historic disputes, such as the use of the term patient. “[M]aking these judgments in a rigorous, fact-based way would prevent experts, policy makers, and the general public from being distracted by something easy – arguing about words – when we need to focus on doing something much harder: solving massive social problems.” 

DG

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Reading of the Week: IPT for Depression in Pregnancy – the New JAMA Psych Paper; Also, Treating Opioid Use (JAMA) and Substance Ed for Docs (Wash Post)

From the Editor

Prenatal depression affects two: the mother and her fetus. But how to effectively address depressive symptoms?

In the first selection, from JAMA Psychiatry, Benjamin L. Hankin (of the University of Illinois at Urbana-Champaign) and his co-authors consider a focused psychotherapy for that population. In a RCT involving 234 participants, they find that IPT was helpful. “Brief IPT significantly reduced prenatal depression symptoms and MDD compared with EUC [enhanced usual care] among pregnant individuals from diverse racial, ethnic, and socioeconomic backgrounds recruited from primary OB/GYN clinics.” We look at the paper and its clinical implications.

In the second selection, Caroline King (of the Oregon Health & Science University) and her co-authors consider buprenorphine for opioid use disorder with a focus on adolescent residential treatment. In a JAMA research letter, they report the findings which included every identified facility in the United States. “In contrast to the standard of care, only 1 in 4 US facilities offered buprenorphine and 1 in 8 offered buprenorphine for ongoing treatment.”

And, in the third selection, former AMA president Dr. Patrice A. Harris (of Columbia University) and her co-authors argue that physicians should know more about addiction treatment. In a Washington Post essay, they argue for more robust training. “Opioid use disorder is treatable, and medicines are readily available. But doctors cannot learn to help patients by taking a weekend course alone.”

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)

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: The Resident’s Suicide – a New Paper from NEJM; Also, Help Seeking in Medical Education (JAMA Int Med)

From the Editor

“Bobby became my intern, and I was his senior resident. It was a role I cherished, and I tried to teach him all I could about caring for multiple sick patients simultaneously and navigating the systems, personalities, and politics of a large Manhattan hospital.”

Dr. Richard E. Leiter (of Harvard University) writes these words in a New England Journal of Medicine paper, this week’s first selection. He discusses loss – specifically, the death by suicide of the junior resident he was working with. On Twitter, Dr. Leiter commented that it took him six years to write about this death. Reading over the paper, we can understand why; the essay is deeply personal and moving. It also seeks to be constructive: Dr. Leiter calls for change. “Seeking to improve the lives of others shouldn’t cost our trainees their own.”

grief

Of course, the NEJM article isn’t just about Bobby; it touches on the culture of medicine. Suicide, while always tragic, is rare in health care; untreated depression and substance problems are too common. In the second selection this week, we consider a paper recently published in JAMA Internal Medicine. Dr. Erene Stergiopoulos (of the University of Toronto) and her co-authors note the mixed message of medical education: at once encouraging “wellness” but also criticizing time away. “Stigma surrounding depression is deeply embedded in medicine.” Importantly, Dr. Stergiopoulos and her co-authors makes three practical suggestions.

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On a pivot –

Since 2014, the Reading of the Week (ROTW) has been providing summaries and commentary on the latest in the psychiatric literature. Two years ago, we conducted a short survey to get your feedback. We are hoping to get more feedback to improve the Readings further.

We would invite you to join one of our online focus groups to hear your opinions and suggestions for improvement. If you are interested in participating, please email smit.mistry@camh.ca by April 12 with your preferred time slots from the following options – psychiatrists: April 21 at 4 pm or April 22 at 4 pm; residents: April 28 at 4 pm and April 29 at 4 pm. (Note: all times are in EST.) Time commitment: under an hour. If the above time slots do not work for you, please email Smit to arrange an interview time at your convenience, ideally between April 21 and April 30, 2021.

DG

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Reading of the Week: Substance Problem, Quality of Care Problem? Also, Interventional Psychiatry (CJP) and an Underused Addiction Treatment (NYT)

From the Editor

In terms of depression treatment, do people with substance use problems get worse care than those without?

The answer should be a resounding no. In the first selection, we consider a new paper, just published in The American Journal of Psychiatry, which suggests otherwise. Lara N. Coughlin  (of the University of Michigan) and her co-authors draw on Veterans Affairs data involving more than 53,000 patients. “In this large national sample, we found that patients with comorbid depression and substance use disorders receive lower quality care than those with depression but without substance use disorders.”

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In the second selection, we consider a Canadian Journal of Psychiatry research letter. Dr. Peter Giacobbe (of the University of Toronto) and his co-authors surveyed senior residents, asking about their familiarity and comfort with first line recommendations for the treatment of depression. Spoiler alert: just one in four felt that they had achieved competency in ECT.

Finally, in the third selection, we look at a new essay by journalist Abby Goodnough. With many Americans (and Canadians) struggling with substance problems, she writes about contingency management – that is, rewarding substance users with cash and prizes for sobriety. The concept has evidence in the literature, but lacks political support. She quotes a patient: “Even just to stop at McDonald’s when you have that little bit of extra money, to get a hamburger and a fries when you’re hungry. That was really big to me.”

Note: there will be no Reading next week.

DG

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Reading of the Week: Should Medical Education Stay in Its Lane? Drs. Zaheer and Berkhout Respond

From the Editor

Should medical education “stay in its lane?”

Two weeks ago, we discussed an essay by the University of Pennsylvania’s Dr. Stanley Goldfarb who warns that: “Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.”

This week, we feature two letters to the editor responding to this essay, both original content for the Reading of the Week, and both from physicians affiliated with the University of Toronto.

Drawing on the medical literature and her life experience, Dr. Juveria Zaheer wonders what makes a medical expert or a physician scientist. “Being a medical expert or a physician scientist isn’t just about learning about biology – it’s about committing to the creation of a society where every life is worth living.”

Looking at medicine and philosophy, Dr. Suze G. Berkhout questions the basic assumptions of Dr. Goldfarb’s argument. “Goldfarb misrepresents the place of values in shaping scientific and medical knowledge.”

2012_canada_highwayoftears_0Staying in Your Lane: Good for Drivers, not Med Ed?

Both letters are thoughtful and worth reading.

DG

 
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Reading of the Week: Postsecondary Students & Mental Illness (CJP), a New Podcast (CAMH), and Bipolar & Social Media (NYT)

From the Editor

Social media. An uncertain job market. Increasing academic demands.

Is life for our postsecondary students harder than ever? And are we seeing a surge in mental health disorders as a result?

In the first selection, we consider a new Canadian Journal of Psychiatry paper on postsecondary education and mental illness. While many have opinions on this topic, the University of Toronto’s Kathryn Wiens and her co-authors seek to add data to the discussion. Drawing on the Canadian Community Health Survey, they find: “The results do not imply the emergence of a mental health crisis among postsecondary students.”

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In the second selection, we look at a new podcast considering technology and education. I interview some accomplished educators, including the University of Toronto’s David Goldbloom. “This is about challenging our own norms, values and expectations as clinicians.”

And in the final selection, we consider a New York Times essay on bipolar and social media. “Facebook snitched our big family secret: Roland, the literary prodigy, the tenderhearted musician, the Ivy League grad, was bipolar.”

DG

 

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