Tag: NEJM

Reading of the Week: Alcohol Use Disorder – The NEJM Review; Also, Private Equity & Opioid Treatment and Gee on Refusing Help

From the Editor

When she was admitted for liver cirrhosis – the last hospitalization in her too-short life – no one visited. In her community, the stigma was great. As she grew more and more ill, I asked if she wanted me to call her family to be at the bedside. She simply smiled and said that they were all busy.

Over the years, I have seen many patients like this woman; we all have. Alcohol misuse is common. What’s the best evidence for screening and treatment? Dr. Paul S. Haber (of the University of Sydney) tries to answer that question with a sparkling review, published in The New England Journal of Medicine. His paper is clearly written and draws from more than sixty references. “Alcohol use disorder is a relapsing and remitting medical and psychological disorder that influences physical health, mental health, and social functioning, and continuing care is recommended.” We consider the review and several key take-aways.

In the second selection, David T. Zhu (of Virginia Commonwealth University) and his co-authors analyze the ownership of opioid treatment programs in the United States, with a particular focus on private equity. The research letter, published in JAMA Psychiatry, drew on government data. “This study found that 29.1% of US opioid treatment programs were owned by private equity firms, exceeding private equity penetration in other sectors of health care (range, 2%-11%).”

And in the third selection, columnist Marcus Gee of The Globe and Mail writes about mental illness and patient rights. He discusses a woman in his neighbourhood who has delusions and refuses shelter in the cold weather, convinced that she will soon be offered keys to a new home. “Surely she deserves better. Surely we can do better.”

DG


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Reading of the Week: Physician Burnout – the New NEJM Review; Also, Depression in India and Dr. Ushna Shamoon on Bias

From the Editor

I started watching the clock, thinking about how much time is left in my day. That just started getting earlier and earlier. One day, at 8:35 am, I thought: Oh boy, it feels like I’ve been here a while already.

So comments a colleague on his burnout. 

More and more, we are discussing physician burnout. But how has the concept of burnout evolved over time? How is it distinct from depression? What are evidence-based interventions? Drs. Constance Guille (of the University of South Carolina) and Srijan Sen (of the University of Michigan) seek to answer these questions in a new review for The New England Journal of Medicine. Though they note challenges, including with the definition itself, they strike an optimistic tone. “Over the past 15 years, progress has been made in raising awareness about physician well-being and improving well-being in specific populations, including physicians in training. There is a clear pathway for investing in and implementing established interventions and developing new interventions to improve well-being for all physicians.” We consider the review and its implications.

In the second selection, Dr. Felix Teufel (of Emory University) and his co-authors explore the treatment of depression in India. In a new JAMA Psychiatry brief report, they drew on a national survey, finding limited care, particularly among those living in rural areas. “Nationwide, 97% of individuals with depression were undiagnosed, and around half of individuals with diagnosed depression were untreated.”

And, in the third selection from Academic Psychiatry, Dr. Ushna Shamoon (of the University of Texas) writes about her medical school rotation in a county jail. She discusses her biases before stepping into the correctional facility. She then describes her connection to an inmate suffering from mental illness. “Though her mind was riddled with psychosis, she was not just a victim of her illness.”

Note: there will be no Reading next week.

DG

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Reading of the Week: NMS – the New NEJM Review; Also, Primary Care & Mental Health and Lucy Foulkes on Mental Health Awareness

From the Editor

I started seeing him after his psychiatrist retired. For the most part, our interactions were unremarkable: quick visits when we would talk about his walks, and then I would offer a prescription. Imagine my surprise when I heard that he had been admitted to the ICU with fever, rigidity, and decreased consciousness.

Neuroleptic malignant syndrome, what my patient developed, is rare and potentially deadly. What’s the DSM description? The differential? What are the implications for future treatment? In the first selection, Drs. Eelco F. M. Wijdicks and Allan H. Ropper (both of the Mayo Clinic Hospital) provide a concise and lucid review for The New England Journal of Medicine. They summarize the literature and offer practical suggestions. “Neuroleptic malignant syndrome is a distinctive and alarming syndrome that occurs in some persons who have been exposed to dopamine-blocking agents, particularly (but not exclusively) antipsychotic drugs.” We discuss the review and its takeaways.

How much of primary care is focused on mental healthcare? In the second selection, Avshalom Caspi (of the University of Oslo) and his co-authors attempt to answer that question, drawing on Norwegian data. In a new study for Nature Mental Health, they analyzed 350 million contacts with primary care (yes, you read that correctly) over a 14-year period. “One out of every 8 or 9 encounters that a primary care physician is for a mental-health concern.”

In the third selection, Lucy Foulkes (of the University of Oxford) writes about mental health awareness efforts. While focusing on the UK, her comments are relevant here, with campaigns by Bell Canada and others. She raises several objections, including that these efforts aren’t matched by improved access to care. “We do not have clear evidence about the impact of mental health awareness efforts. It may be that these efforts are merely a waste of time or that they are actively harmful. Or it may be that despite the above concerns, there is still a net gain that makes the efforts worthwhile.”

DG

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Reading of the Week: The Insomnia Issue with Papers from NEJM & Sleep Med, and Dr. Cannon on Her Cure for Insomnia

From the Editor

With his depressive episode, he can’t sleep. While he thinks cannabis may be worsening his anxiety, in his view, a couple of joints before bed is the only thing that seems to help with the insomnia.

My patient’s problems are common. So many of our patients struggle with insomnia. How should we assess it? What’s evidence-based care? And what can we suggest to replace that cannabis? This week, we open with the new review from The New England Journal of Medicine. Charles M. Morin (of Université Laval) and Dr. Daniel J. Buysse (of the University of Pittsburgh) provide timely advice in their paper. They consider scales that could be incorporated into practice, evidence for CBT-I, and different medications. “Recommended therapies for insomnia produce clinically meaningful reductions in insomnia symptoms, sleep-onset latency, and time awake after sleep onset.” We summarize the paper and weigh its implications.

Counting sheep may not always work

With growing evidence for CBT-I, digital options are increasingly appealing due to their convenience and accessibility. In the second selection, Jake Linardon (of Deakin University) and his co-authors report on a study looking at the effectiveness of app-based interventions for insomnia, just published in Sleep Medicine. In this meta-analysis, they drew on 19 RCTs including different treatments like CBT. “Findings suggest that stand-alone app-based interventions can effectively address insomnia and sleep disturbances, and may play an important role in the management of these symptoms.”

And in the third selection, Dr. Joanna Cannon, a UK physician and bestselling author, discusses her insomnia in an essay for The Guardian. She describes the impact on her life and her unusual way of coping. She also notes the origin of the problem: “It was when I started training as a doctor that my atypical sleeping habits became embedded.”

DG

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Reading of the Week: Acupuncture for PTSD – the New JAMA Psych Study; Also, Chronic Homelessness & Hope, and Dr. Suzanne Koven on Mentorship

From the Editor

He survived a terrible car accident and recalls his worst memory: being pinned for hours in his Honda as rescuers attempted to free him, eventually with the Jaws of Life. The mental recovery proved more complicated than the physical one, with flashbacks and nightmares and the resulting substance misuse. He tried different therapies, but would he have benefitted from alternative treatments?

Dr. Michael Hollifield (of George Washington University) and his co-authors look at acupuncture for PTSD in a new JAMA Psychiatry study. They did an impressive randomized clinical trial involving 93 combat veterans with PTSD who received either verum or sham acupuncture. “[V]erum acupuncture had a large pretreatment to posttreatment effect and was statistically superior to sham needling for reducing PTSD symptoms and enhancing fear extinction.” We consider the paper and its clinical implications.

Across North America, there are more people than ever before who are chronically homeless. Who are they? What psychiatric problems do they have? How can we help them? In the second selection, Dr. Vicky Stergiopoulos (of the University of Toronto) considers those who are chronically homeless in a podcast interview for Quick Takes. “The problem is visible. It’s in our streetcars and buses, our subways, our streets, and it’s hard to ignore.”

And in the third selection, Dr. Suzanne Koven (of Harvard University) writes about mentorship in The New England Journal of Medicine. She discusses how a mentor’s advice transformed her career and then considers what makes for good mentorship. “A mentor is someone who has more imagination about you than you have about yourself.”

DG

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Reading of the Week: Cannabis-Related Disorders – the new NEJM Paper; Also, Surgeons & Opioid Prescribing and MAiD & Mental Illness

From the Editor

Cannabis use is increasingly common. Should you be screening for misuse? What’s the role of drug testing? Do short interventions work?

In the first selection, we look at the new paper on cannabis-related disorders, published in The New England Journal of Medicine. Dr. David A. Gorelick (of the University of Maryland) comments on cannabis use disorder, offering practical suggestions, drawing on the latest in the literature (with 76 references). “Cannabis use disorder and heavy or long-term cannabis use have adverse effects on physical and psychological health.” We discuss the paper and its takeaways.

In the second selection, Jason Zhang (of the University of Michigan) and his co-authors consider surgeons and the prescribing of opioids. Given past problems, are surgeons more frugal when they reach for the prescription pad? Drawing on an impressive US database, they analyzed dispensed opioids from 2016 to 2022 in a new JAMA Network Open research letter, finding a step in the right direction – but just a step. “Despite large reductions in opioid prescribing, surgical opioid stewardship initiatives remain important.”

And in the third selection, The Globe and Mail weighs in on the recent decision to delay the expansion of medical assistance in dying, or MAiD, for mental disorders. In an unsigned editorial, the authors recognize the suffering of some, but argue that not enough has been done to define the term irremediable. “A delay is not enough.”

DG

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Reading of the Week: Catatonia – the new NEJM Review; CBD for Bipolar and Dr. Samuels on Medical Assistance in Dying

From the Editor

Catatonia has been well described but is poorly understood.

So write Drs. Stephan Heckers and Sebastian Walther (both of Vanderbilt University) in a new review. We could add: catatonia is often striking. I remember a patient who literally sat for hours in his chair with catatonia secondary to schizophrenia. His family, in some denial, had insisted that his poor eating was related to hospital food and that his lack of activity had to do with the boredom of the ward.

Drs. Heckers and Walther’s review, just published in The New England Journal of Medicine, notes: “Catatonia is common in psychiatric emergency rooms and inpatient units,” with an estimated prevalence of 9% to 30%. They describe the diagnosis and treatment. We consider the paper and its implications.

Waxy flexibility (from catatonia) in an undated photo

Interest in CBD has surged in recent years. Can it help with the tough clinical problem of bipolar depression? In the second selection, Dr. Jairo Vinícius Pinto (of the University of São Paulo) and his co-authors attempt to answer that question in a new Canadian Journal of Psychiatry paper. They describe a pilot study, with 35 patients randomized to CBD or placebo, finding: “cannabidiol did not show significantly higher adverse effects than placebo.”

And in the third selection, Dr. Hannah Samuels (of the University of Toronto) discusses medical assistance in dying in a paper for Academic Psychiatry. This resident of psychiatry describes a patient who, dealing with pain, opted for MAiD. Dr. Samuels considers the decision but her ambivalence in part stemming from her training. “I felt sad, confused, and morally conflicted. Mrs. L never faltered in her confidence that this was the right decision for her, but I could not understand it.”

DG

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Reading of the Week: Health Care Workers & Suicide – the new JAMA Paper; Also, Esketamine vs Quetiapine for Treatment-Resistant Depression (NEJM)

From the Editor

Sure, we are biased – but ours is a different type of job. Working in health care can involve life and death situations and trying to help those who are at their most vulnerable. The stakes can be high. 

But how does such work affect the workers themselves? Dr. Mark Olfson (of Columbia University) and his co-authors try to answer that question in a new paper for JAMA. In it, they analyze suicides among six different types of health care workers, including physicians, by drawing on a US data that offers a nationally representative sample from 2008 to 2019, including 1.84 million people. “Relative to non-health care workers, registered nurses, health technicians, and health care support workers in the US were at increased risk of suicide.” We consider the paper and its implications.

And in the other selection, Dr. Andreas Reif (of the University Hospital Frankfurt) and his co-authors focus on treatment-resistant depression. In this new paper published in The New England Journal of Medicine, they report on the findings from a study where 676 patients were randomized to either esketamine nasal spray or an antipsychotic augmenting agent in addition to an antidepressant. “In patients with treatment-resistant depression, esketamine nasal spray plus an SSRI or SNRI was superior to extended-release quetiapine plus an SSRI or SNRI with respect to remission at week 8.” We also look at the accompanying editorial.

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: Xylazine – the New NEJM Paper; Also, Probiotics for Depression (JAMA Psych) and the New Drug Crisis (Nat Affairs)

From the Editor

Is xylazine the new fentanyl?

In the first selection, Dr. Rahul Gupta (of the University of Pennsylvania), who serves as the US Director of National Drug Control Policy, and his co-authors write about xylazine in The New England Journal of Medicine. They describe the emergence of this medication, intended for veterinarian uses, as a substance of abuse. They note its presentation and ask research questions. “Our goal is for the designation of xylazine as an emerging threat and subsequent actions to begin to address this threat before it worsens and undermines efforts to reduce illicit fentanyl use in the United States.” We consider the paper and its implications.

In the second selection, from JAMA Psychiatry, Viktoriya L. Nikolova (of King’s College London) and her co-authors look at probiotics – an area of increasing interest for those with mood and anxiety problems. They report on the findings of a small RCT involving people with depression who took an antidepressant but had an incomplete response. “The acceptability, tolerability, and estimated effect sizes on key clinical outcomes are promising and encourage further investigation of probiotics as add-on treatment for people with MDD in a definitive efficacy trial.”

And in the third selection, Charles Fain Lehman (of the Manhattan Institute) comments on the new drug crisis in a long essay for National Affairs. Lehman notes the rise of the synthetic agents (think fentanyl replacing heroin) and its impact on people, particularly in terms of overdoses. “Today’s drug cycle is different from previous ones, measured not just in the number of people addicted, but the number dead. Reducing the growth of that figure, now more than ever, is a vital task for policymakers to undertake.”

DG

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