Tag: NEJM

Reading of the Week: Psilocybin for Treatment-Refractory Depression – the New NEJM Paper

From the Editor

“Severe depression eased by single dose of synthetic ‘magic mushroom’”

– CNN, 3 November 2022

For its proponents, psilocybin could be the breakthrough we have been waiting for in depression treatment. For its critics, psilocybin lacks evidence.

What to make of psilocybin? Dr. Guy M. Goodwin (of the University of Oxford) and his co-authors attempt to answer that question with a phase 2 double blind trial focused on those with treatment-resistant depression, offering participants psilocybin at three different doses, in addition to therapy. The resulting paper was just published in The New England Journal of Medicine and has received much attention (including, yes, coverage by CNN). They find: “participants with treatment-resistant depression, psilocybin at a single dose of 25 mg, but not 10 mg, reduced depression scores significantly more than a 1-mg dose over a period of 3 weeks but was associated with adverse effects.” 

The future of depression treatment?

We discuss the big paper and the review the accompanying Editorial by Bertha K. Madras (of Harvard University). We also have comments from Dr. Ishrat Husain (of the University of Toronto), one of the study co-authors.

So does psilocybin offer a breakthrough? Read on and decide for yourself.

(Note that there will be no Reading next week.)

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)

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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Reading of the Week: Cannabis Potency & Mental Health – the New Lancet Psych Paper; Also, Legalization & Poisonings (NEJM) and Nicholson on Her Son (CBC)

From the Editor

“In the USA and Europe, the concentration of THC has more than doubled over the past 10 years…”

So notes a new paper in The Lancet Psychiatry.

Canada legalized cannabis for recreational purposes four years ago; other countries have done the same, as have almost two dozen US states. But how has cannabis itself changed over time? What are the implications for mental health disorders? And public policy? In the first selection, quoted above, Kat Petrilli (of the University of Bath) and her co-authors do a systematic review of cannabis potency and mental health and attempt to answer these questions. Drawing on 20 studies, they find: “Overall, the evidence suggests that the use of higher potency cannabis, compared with lower potency cannabis, is associated with an increased risk of psychosis, and this risk is higher in people who use cannabis daily.” We look at the paper and weigh its clinical implications.

In the second selection, using Ontario data, Dr. Daniel T. Myran (of the University of Ottawa) and his co-authors consider the effect of edible cannabis legalization on poisonings of children. Writing for The New England Journal of Medicine, they compare jurisdictions with legal sales (Alberta, British Columbia, and Ontario) with a province that hasn’t legalized that form of cannabis (Quebec). “Our data indicate that legalization was associated with marked increases in hospitalizations for cannabis poisoning in children.”

And, in the third selection, Shirley Nicholson writes about substance and stigma with a deeply personal essay. In this piece for CBC First Person, she discusses her son’s struggles and his death from an overdose. She writes: “He didn’t plan to die at 27. He was more than his addictions. He was our son, our brother, our grandson, our nephew, our cousin and we all loved him so.”

DG

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Reading of the Week: Tobacco & Cessation – the New NEJM Paper; Also, the Health of Health Care Workers (JAMA)

From the Editor

He could barely get out of bed because his depression was so severe. Yet he asked to be discharged because he wanted to smoke.

So often our patients struggle with their tobacco use disorder. But what medications have the most evidence? Do apps help? What should a clinician say during a brief encounter? This week, we consider a new paper written by Dr. Peter Selby and Laurie Zawertailo (both of the University of Toronto), just published in The New England Journal of Medicine. The authors summarize the latest in the literature, offering a relevant review that provides answers to these and other questions. And they note the devastation caused by tobacco use: “The risk of lung cancer is 25 times as high and the risk of coronary heart disease or stroke is 2 to 4 times as high among smokers as among nonsmokers.” We summarize the paper and mull its clinical implications.

And in the other selection, Dr. Lisa S. Rotenstein (of Harvard University) and her co-authors think about well-being and burnout in a JAMA paper. In recent years, this topic has gathered more and more attention. That said, Dr. Rotenstein and her co-authors don’t focus on physicians and nurses, as many authors have, but consider other health care workers. They argue: “The everyday functioning of the health care system depends on hundreds of role types. Leaders must seek to address obstacles and causes of work-related frustration not only for physicians and nurses, but also for the home health care workers, nurses’ aides, respiratory therapists, and many others who serve patients every day.” 

DG

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Reading of the Week: ECT & Suicide – the New Lancet Psych Paper; Also, Violence & Psych Trainees (Acad Psych) and Dr. Murthy on Burnout (NEJM)

From the Editor

In a recent survey, 20% identified fear of death as a major concern with ECT. One of the oldest treatments in psychiatry is also its most stigmatized and feared.

And is it also underappreciated? Is ECT a lifesaver for those who are suicidal? In the first selection, Dr. Tyler S. Kaster (of the University of Toronto) and his co-authors attempt to answer that question with a propensity score-weighted, retrospective cohort study comparing those who received ECT and those who didn’t, using Ontario data. In The Lancet Psychiatry, they write: “1 year after discharge from a psychiatric hospital, patients with depression who were exposed to electroconvulsive therapy had a nearly 50% reduction in the relative risk of death by suicide when compared with those who had not been exposed.” We consider the paper and its clinical implications.

We aren’t talking about candy

In the second selection, Dr. Victor Pereira-Sanchez (of the New York University) and his co-authors look at violence against European psychiatric trainees. In this Academic Psychiatry paper, drawing on survey data, they conclude: “Violence from patients is reported by many psychiatric trainees across countries in Europe, with very frequent verbal abuse and worrisome figures of physical and sexual assaults.”

Finally, in the third selection, Dr. Vivek H. Murthy (the US Surgeon General) writes about burnout and American health care workers. In The New England Journal of Medicine, he offers a practical plan, with an emphasis on reducing administrative burden, bettering mental health for health care workers, and changing culture to support well-being. He argues that action is needed: “we cannot allow ourselves to fail health workers and the communities they serve.”

DG

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Reading of the Week: Cancer & Suicide – the New Nature Medicine Paper; Also, Dr. Natasha Steele on Her Cancer (NEJM)

From the Editor

The big diagnosis. Even years after the fact and even in cases of good outcomes, so many still remember the exact moment when they were told that they had cancer. A patient once recalled with great detail the floor tiles in his doctor’s office (he couldn’t bear looking at his spouse or his doctor). He also remembered feeling so overwhelmed that suicide seemed like an option.

But what is the risk of suicide? In the first selection, Michael Heinrich (of the University of Regensburg) and his co-authors seek to answer that question, drawing on an impressive number of studies including more than 22 million patients. In a new paper for Nature Medicine, they report on a systematic review and meta-analysis; they found that “patients with cancer have an almost twofold increased risk of dying by suicide compared with the general population.” They write: “Despite immense progress in cancer therapy and prognosis in the past decades, suicide remains an important cause of death in patients with cancer.” We consider the paper and its clinical implications.

In the second selection, Dr. Natasha Z. Rabinowitz Steele (of Stanford University) considers her experiences in a New England Journal of Medicine paper. She writes about her cancer diagnosis and treatment, and the impact on her clinical work. She concludes: “Though all of our journeys will have beginnings and endings, our lives are what we choose to do with the precious, unpredictable, terrifying, and beautiful moments in between.”

DG


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Reading of the Week: ECT – the New NEJM Review; Also, Ethnicity & Drug Overdoses (JAMA) and Neil Seeman on His Father (CMAJ)

From the Editor

He has tried different medications, and yet he continues to struggle. The months have turned into years. When he was last well, he worked two jobs and was physically active, hoping to run the Boston marathon one day. When I saw him, he explained that he has difficulty following the plot of a TV show. Asked if he had ever considered ECT, his eyes widened. “They still do that?”

In the first selection, we look at a new review paper on ECT from The New England Journal of Medicine. Drs. Randall T. Espinoza (of the University of California, Los Angeles) and Charles H. Kellner (of the Medical University of South Carolina) provide a concise summary of the latest evidence. They conclude: “ECT is a valuable treatment for several severe psychiatric illnesses, particularly when a rapid response is critical and when other treatments have failed.” We consider the paper and the ongoing stigma associated with the treatment.

In the second selection, Joseph R. Friedman and Dr. Helena Hansen (both of the University of California, Los Angeles) draw on American data to consider overdose deaths and ethnicity. The JAMA Psychiatry paper concludes: “In this cross-sectional study, we observed that Black individuals had the largest percentage increase in overdose mortality rates in 2020, overtaking the rate among White individuals for the first time since 1999, and American Indian or Alaska Native individuals experienced the highest rate of overdose mortality in 2020 of any group observed.”

And in the third selection, Neil Seeman (of the University of Toronto) considers the life and death of his father, Dr. Philip Seeman, the celebrated scientist who studied schizophrenia. In this CMAJ essay, he comments on dopamine and his father’s life work. And he also writes about his relationship and dying. “It was that giving ice chips to my father will forever remind me of how the sensation of touch can stir love, fetch memories, and offer solace.”

DG

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Reading of the Week: E-Cigs and Cessation – the New JAMA Paper; Also, Green Space & Schizophrenia (CJP) and Dr. Jessica Gregg on Needed Care (NEJM)

From the Editor

How to help him quit?

We often speak to our patients about the dangers of smoking – with middling success, especially with those who aren’t interested in cessation. Are e-cigarettes part of the solution? In a new JAMA Network Open paper, Karin A. Kasza (of the Roswell Park Comprehensive Cancer Center) and her co-authors report on a cohort study focused on this refractory population. “In this US nationally representative cohort study of 1600 adult daily cigarette smokers who did not initially use e-cigarettes and had no plans to ever quit smoking, subsequent daily e-cigarette use was significantly associated with an 8-fold greater odds of cigarette discontinuation compared with no e-cigarette use.”

In the second selection, we consider a new Canadian Journal of Psychiatry research letter. Dr. Martin Rotenberg (of the University of Toronto) and his co-authors look at green space and schizophrenia. A connection? They find one. “We found that residing in an area with the lowest amount of green space was associated with an increased risk of developing schizophrenia, independent of other sociodemographic and socioenvironmental factors.”

Finally, in the third selection, Dr. Jessica Gregg (of the Oregon Health and Science University) writes about her experiences as a physician and as a patient. In this New England of Journal paper, she talks personally about sudden illness and unsatisfactory health care. “I knew – and know – that our system of not-care for the sick and scared is broken. I knew – and know – that our system of un-care for people affected by addiction or poverty, for those who make bad choices and those who were never offered fair choices in the first place, is even more fractured.”

DG

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Reading of the Week: Physician, Heal Thyself – the New JAMA Paper on Visits for Mental Health; Also, the History of Physician Wellness (NEJM)

From the Editor

The days have been long. As we enter the third year of the pandemic, many are feeling it. 

What has the impact been on the mental health of us physicians? We have anecdotal evidence, but data has been lacking. In the first selection, we consider a new paper by Dr. Daniel T. Myran (of the University of Ottawa) and his co-authors. Drawing on data from 34,000 Ontario doctors, the authors considered MD visits for mental health and substance (in other words, doctors visiting their doctors), finding that such appointments were up 27% during the first year of the COVID-19 pandemic. “These findings may signal that the mental health of physicians has been negatively affected by the pandemic.” We look at the paper and the invited commentary that accompanies it.

In the second selection, Agnes Arnold-Forster (of the London School of Hygiene and Tropical Medicine) and her co-authors consider the evolving understanding of physician health by looking to history. They argue that three concepts – medical exceptionalism, medicalization, and an emphasis on individual responsibility – have harmed physicians, creating “excessive commitment and complete personal sacrifice.” They suggest an alternative. “By attending to the lessons of the past, we can envision a better future for patients and their physicians.”

DG


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Reading of the Week: Should Patients Quit Antidepressants? The New NEJM Paper; Also, the NYT Obit on Dr. Paula Clayton

From the Editor

“Can I stop my antidepressants now?”

Patients often ask that question after feeling better. Studies have looked at relapse for people with depression who go off their medications, of course, but overwhelmingly such work has focused on patients recruited from specialty care (who are, perhaps, more ill).

In the first selection, we consider a new paper from The New England Journal of Medicine by Gemma Lewis (of University College) et al. The patients have been recruited from English family practices. The study is well designed and thoughtful, adding nicely to the literature. The chief finding? “Those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current therapy.” We consider the big paper and its clinical implications.

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In the second selection, drawing from the pages of The New York Times, reporter Clay Risen writes about the life of Dr. Paula J. Clayton. This psychiatrist, who passed in September, was an accomplished researcher: “Dr. Clayton was part of a generation of clinical psychiatrists who, in the decades after World War II, revolutionized their field by applying medical rigor to the diagnosis of mental illness.” In later years, she was a strong advocate for those with mental illness.

DG

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