NEJM | Dr. David Gratzer

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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.

Reading of the Week: Suicidal Ideation in a 37-Year-Old Woman – A NEJM Case; Also, Goldbloom on Innovation (QT) and Purdy on Her Brother (CMAJ)

September 23, 2021 / David Gratzer / Comments Off

From the Editor

She presents with suicidal thoughts and had a challenging course with COVID-19.

She could be a patient in your afternoon clinic. In fact, she was seen and treated at Massachusetts General Hospital. And her case was discussed at psychiatry grand rounds, and then written up for The New England Journal of Medicine.

In our first selection, Dr. Carol S. North (of the University of Texas Southwestern) and her co-authors consider this patient’s story. They detail her history and course in hospital. They also note the complexities: “This case highlights the importance of attending to the intricate, multilevel, systemic factors that affect the mental health experience and clinical presentation of patients, especially among patients such as this one, who identified as Latina.”

Dr. David Goldbloom (of the University of Toronto) joins me for a Quick Takes podcast interview. We discuss his new book about innovations in mental health care. “I wrote the book because like so many people who work in our profession, so many people who are on the receiving end of care, and for the families who support those individuals, there is a shared sense that the status quo isn’t good enough.”

In the third selection, Dr. Kaylynn Purdy (of the University of Alberta), a resident of neurology, writes about her brother and his illness in the pages of the CMAJ. He develops schizophrenia and becomes homeless in Vancouver. She talks about his life and death. “When you meet somebody living on the streets, remember my brother.”

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

May 27, 2021 / David Gratzer / Comments Off

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.”

Reading of the Week: Psilocybin for Depression – The New NEJM Paper

April 29, 2021 / David Gratzer / Comments Off

From the Editor

Is this the breakthrough we have been waiting for?

This week, we look at the new study from The New England Journal of Medicine considering psilocybin (a naturally occurring psychedelic compound found in some mushrooms) and escitalopram for depression. The paper, written by Robin Carhart-Harris (of Imperial College) and his co-authors, has received much attention. One online news source quipped: “Tripping may be as effective as your antidepressants.”

In this study, psilocybin was compared to the SSRI with a double-blind, randomized, controlled trial. Carhart-Harris et al. find: “On the basis of the change in depression scores on the QIDS-SR-16 at week 6, this trial did not show a significant difference in antidepressant effects between psilocybin and escitalopram in a selected group of patients.”

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We consider the paper and the editorial that runs with it by Dr. Jeffrey A. Lieberman (of Columbia University). We also ask Dr. Ishrat Husain (of the University of Toronto) for his thoughts. Finally, we mention other cutting-edge treatments.

Reading of the Week: A Therapy for Pandemic Loneliness? Also, Getting Digital Psychiatry Right (Lancet Psych) and the History of Vaccines (NEJM)

April 1, 2021 / David Gratzer / Comments Off

From the Editor

I saw an older patient in the emergency room recently. He described feeling overwhelmed. Fearful of the pandemic, he explained that he had rarely left his apartment since it began. “I’m so isolated.”

Many find themselves in a similar situation. What could help? In a new JAMA Psychiatry paper, Maninder K. Kahlon (of The University of Texas at Austin) and co-authors describe a focused intervention involving laypeople doing an empathy-focused program by phone. Do the calls work? They found it reduced loneliness, anxiety, and depression. They note the potential: “The use of lay callers, deliberate but brief approach on training, and the use of ubiquitous telephones made the approach easily deployable and scalable.”

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In an editorial, The Lancet Psychiatry considers our digital moment. Though they note the trendiness of the idea of digital psychiatry, they urge us to push: “Come 2 years or 20, we want to stop talking about digital psychiatry’s potential for improving public mental health and start marking its clear clinical progress.”

Finally, in our third selection, we look at a new paper from The New England Journal of Medicine. Drs. Angela Desmond and Paul A. Offit (both of the University of Pennsylvania) consider the history of vaccines, and look ahead: “With the recent authorization of mRNA vaccines, we have entered the fifth era of vaccinology.”

Please note that there will be no Reading next week.

* * *

On a pivot –

Since 2014, the Reading of the Week 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 feedback again to improve the Readings.

We would like to invite you to join one of our online focus groups to hear your opinions and suggestions. 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, preferably between April 21 and April 30, 2021.

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

March 25, 2021 / David Gratzer / Comments Off

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.”

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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.

* * *

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.

Reading of the Week: Vaccines, Vaccine Hesitation & Mental Illness, with Papers from JAMA Psychiatry and NEJM, and More

January 14, 2021 / David Gratzer / Comments Off

From the Editor:

It’s here. Less than a year after COVID-19 arrived in North America, two vaccines have been created, approved, and given (at least to some).

In the coming months, as the supply improves, people – including our patients – will have the opportunity to get a vaccine. But what are the challenges? First, some will hesitate. In a recent essay, Dr. Nadia Alam notes that: “Vaccine hesitancy is a significant issue with only 57.5% of Canadians saying they are very likely to be vaccinated for COVID-19.” And special populations will present further challenges – such as those with major mental illness.

This week, we focus on vaccinations with two papers and an article.

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In the first selection, drawing from JAMA Psychiatry, we consider a paper by Dr. Nicola Warren (of the University of Queensland) and her co-authors. They note the challenges of reaching people with serious mental illness – just one in four get a flu vaccine. “It is vital to commence planning and development of appropriate policies to ensure rapid delivery of a COVID-19 vaccine when it becomes available.”

In a New England Journal of Medicine paper, Dr. Joshua A. Barocas (of the Boston University School of Medicine) thinks about the needs of those with substance use disorders. “Officials devising vaccination strategies and allocation plans would be wise to do so from the perspective of the virus, rather than that of stigmatizing personal beliefs.”

How to speak to our patients? In the final selection, we look at a short piece by Dr. Joshua C. Morganstein (of the Uniformed Services University of the Health Sciences). His advice is very practical, and emphasizes that we should tailor our approach not by diagnosis but by patient interest in the vaccination. He also urges us to be careful in our choice of language: “Health care professionals are trained to use complex medical terminology, though more understandable and down-to-earth language often serves to enhance trust and build rapport.”

DG
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Reading of the Week: What do Google Searches Tell Us about Suicide & COVID? (CJP) Also, Bullock on Suicide (NEJM)

June 18, 2020 / David Gratzer / Comments Off

From the Editor

How will the pandemic impact mental health? Will we see more people with depression and PTSD? What about suicides?

In a recent JAMA Psychiatry paper, Mark A. Reger (of the University of Washington) and his co-authors argued that we may see a “perfect storm” with COVID-19, increasing the risk of suicide. A BMJ blog speculated that we could have a “pandemic after the pandemic,” as mental health problems grow even as the virus fades.

This week, we have two selections; the first focuses on suicide and the pandemic. Using an innovative approach – that is, considering Google searches for suicide and related terms, as a proxy for completions – the authors draw on American and international data. In a new Canadian Journal of Psychiatry paper, Dr. Mark Sinyor (of the University of Toronto) and his co-authors find surprisingly “that the initial stages of the pandemic were accompanied by a substantial reduction in searches related to suicide, anxiety, and hopelessness with no change in searches for depression.”

In the second selection, Dr. Justin L. Bullock (of the University of California, San Francisco) discusses suicide in The New England Journal of Medicine. The young doctor is very personal, describing his own struggles with mental illness. “‘I’m starting to get depressed,’ I told my sister emotionlessly. She began to cry, probably flashing back to the last time I was severely depressed, attempted suicide, and ended up in the ICU. I told her I was sad that my 2-year-old niece wouldn’t remember me. ‘Do you think I would ever let her forget you?’ she responded. We both cried.”

Reading of the Week: Physician Burnout, Interrupted (NEJM); also, COVID and Schizophrenia (Schiz Bulletin) and a Reader Responds on Inpatient Care

May 7, 2020 / David Gratzer / Comments Off

From the Editor

As we come to understand the new normal – a world of PPEs and precautions – we need to consider not just the implications of the virus on today’s work, but tomorrow’s.

In the first selection, we look at a new paper on physician burnout. In The New England of Journal, Drs. Pamela Hartzband and Jerome Groopman (both of Harvard Medical School) argue that burnout will not be remedied by offers of exercise classes and the other usual prescriptions. Drawing on organizational psychology, they call for a fundamentally different approach, built on autonomy, competence, and relatedness. At a time of COVID, “health care professionals are responding with an astounding display of selflessness, caring for patients despite the risk of profound personal harm. Our efforts are recognized and applauded.” Now, they argue, is the moment for action.

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Are people with schizophrenia at particular risk during this pandemic? In the second selection, we consider a new Schizophrenia Bulletin paper by Dr. Nicole Kozloff (of the University of Toronto) and her co-authors, who answer this question with a convincing yes. “We suggest that thoughtful consideration of the implications of COVID-19 for people with schizophrenia may not only reduce the burden of the global pandemic on people with schizophrenia, but also on the population as a whole.” They offer recommendations.

Finally, in the third selection, a reader responds to last week’s Reading. Rachel Cooper (of the University of Toronto) considers the inpatient experience. “Those of us who have spent time on psychiatric units, particularly while on forms (or held involuntarily), can speak to the immense isolation and feelings of violation of having our basic liberties removed. In this time of COVID, those with the privilege of not having had the experience of being in hospital involuntarily are getting a small taste of that isolation.”

Please note that there will be no Reading next week.

Reading of the Week: COVID & Mental Health (NEJM); also, Helping Health Workers (CMAJ) and Caring Contact for the Elderly (Globe)

April 23, 2020 / David Gratzer / Comments Off

From the Editor

This week’s Reading – like the last few – focuses on the latest in the literature on COVID and mental health care with three selections. As life with the pandemic continues, more and more journals have published about it, with some discussing the implications for mental health services.

In the first selection, we consider a paper on mental health services and the pandemic. In a NEJM paper, Drs. Betty Pfefferbaum (of University of Oklahoma Health Sciences Center) and Carol S. North (University of Texas Southwestern Medical Center) argue for an integrated and measured approach. In responding to COVID, they advocate that: “already stretched health care providers have an important role in monitoring psychosocial needs and delivering psychosocial support to their patients, health care providers, and the public – activities that should be integrated into general pandemic health care.”

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How can we help health workers? In the second selection, we consider a new CMAJ paper by Dr. Peter E. Wu (of the University of Toronto)and co-authors. They write: “Taking care of ourselves is vital so that we may continue to take care of others.”

Finally, in the third selection, we look at a news article from The Globe and Mail. Reporter Erin Anderssen describes how “caring contacts,” a psychiatric intervention, is used by volunteers to connect with the elderly. “The spontaneous initiatives expanding now are prompted more by what we instinctively know: Human contact motivated purely by compassion is essential to our well-being.”

Dr. David Gratzer

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TagNEJM

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

Reading of the Week: Suicidal Ideation in a 37-Year-Old Woman – A NEJM Case; Also, Goldbloom on Innovation (QT) and Purdy on Her Brother (CMAJ)

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

Reading of the Week: Psilocybin for Depression – The New NEJM Paper

Reading of the Week: A Therapy for Pandemic Loneliness? Also, Getting Digital Psychiatry Right (Lancet Psych) and the History of Vaccines (NEJM)

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

Reading of the Week: Vaccines, Vaccine Hesitation & Mental Illness, with Papers from JAMA Psychiatry and NEJM, and More

Reading of the Week: What do Google Searches Tell Us about Suicide & COVID? (CJP) Also, Bullock on Suicide (NEJM)

Reading of the Week: Physician Burnout, Interrupted (NEJM); also, COVID and Schizophrenia (Schiz Bulletin) and a Reader Responds on Inpatient Care

Reading of the Week: COVID & Mental Health (NEJM); also, Helping Health Workers (CMAJ) and Caring Contact for the Elderly (Globe)