Tag: NEJM

Reading of the Week: Ketamine vs. ECT – the New NEJM Paper; Also, Burnout & Depression (QT) and Rehab for Schizophrenia (Wash Post)

June 1, 2023 / / 0 Comments

From the Editor

“Ketamine Shows Promise for Hard-to-Treat Depression in New Study”

 – The New York Times

The gold standard for treatment-refractory depression has been ECT. Last week, The New England Journal of Medicine published a new study by Dr. Amit Anand (of Harvard University) and his co-authors comparing ketamine with ECT. They did a noninferiority trial, with more than 400 people. The results have been widely reported, including in The New York Times. They write: “This randomized trial evaluating the comparative effectiveness of ketamine and ECT in patients with treatment-resistant depression without psychosis showed noninferiority of ketamine to ECT…” We discuss the paper and the accompanying Editorial.

A recent Canadian Medical Association survey found that the majority of physicians reported experiencing high levels of burnout. In the second selection, Dr. Srijan Sen (of the University of Michigan) discusses this timely topic in a new Quick Takes podcast. He talks about the definition(s) of burnout, and the overlap with depression. “Burnout has become a loose term that means different things to different people.”

And in the third selection, Dr. Thomas Insel (of the Steinberg Institute) and his co-authors discuss the life and death of New Yorker Jordan Neely. In an essay for The Washington Post, they argue for better care, in particular with a focus on rehabilitation services for those with schizophrenia. “People with other brain disorders are not abandoned to become homeless or incarcerated rather than receive medical help.”

DG

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Reading of the Week: Augmentation in the Elderly with Depression – the New NEJM Study; Also, Dr. Simpson on Violence (Globe)

April 13, 2023 /

From the Editor

“Approximately 30% of patients treated for depression do not have a response to selective serotonin-reuptake inhibitors (SSRIs).” So notes an Editorial in The New England Journal of Medicine. And for those who don’t respond, what’s the next step? 

Unfortunately, though many elderly struggle with depression, this population is understudied. In a new paper published in the same journal, Dr. Eric J. Lenze (of the Washington University in St. Louis) and his co-authors attempt to answer that question with a two-step intervention. “In older adults with treatment-resistant depression, augmentation of existing antidepressants with aripiprazole improved well-being significantly more over 10 weeks than a switch to bupropion and was associated with a numerically higher incidence of remission. Among patients in whom augmentation or a switch to bupropion failed, changes in well-being and the occurrence of remission with lithium augmentation or a switch to nortriptyline were similar.” We look at the study and its clinical implications, as well as the accompanying Editorial.

And, in the other selection, Dr. Sandy Simpson (of the University of Toronto) considers the violence seen on public transit in Canada’s largest city. In an essay for The Globe and Mail, he mulls several factors and points a way forward, including by advocating a guaranteed basic income. “We are seeing now that we have failed to create a compassionate society, and that security and safety needs to extend to all people. To achieve this, we need a change in heart, and expenditure.”

DG

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Reading of the Week: Delirium in the ICU – the New NEJM Paper; Also, Admissions and COVID (CJP) and Dr. Boulay on Our Own (NEJM)

February 23, 2023 /

From the Editor

Is there a role for haloperidol in the treatment of delirium in ICU settings? That may seem like an unusual question since many patients receive this medication, perhaps half. But evidence is light.

In the first selection, Dr. Nina C. Andersen-Ranberg (of the University of Southern Denmark) and her co-authors consider ICU delirium with a new RCT, published in The New England Journal of Medicine. In this elegant study, half of the patients were randomized to receive haloperidol (in the IV form) and the other half received a placebo. They find: “Among patients in the ICU with delirium, treatment with haloperidol did not lead to a significantly greater number of days alive and out of the hospital at 90 days than placebo.” We consider the paper.

In the second selection, Dr. Scott B. Patten (of the University of Calgary) and his co-authors analyze hospital admissions and psychiatric diagnoses before and after the start of the pandemic. In this Canadian Journal of Psychiatry paper, they draw on Alberta data. Noting an existing literature on eating disorders, they also find an increase in patients with personality disorders being admitted. “[T]he increase was more pronounced than the widely reported increase in admissions for eating disorders.”

And, in the third selection, Dr. Richard M. Boulay (of St. Luke’s University Health Network) weighs in on physician mental health. In this highly personal New England Journal of Medicine paper, the gynecologic oncologist describes the problems of a second-year surgery resident who almost dies by suicide. He feels that she was failed by her program and medical culture itself. He writes: “[S]olutions are available. It’s time we began looking after our own.”

DG

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

November 10, 2022 /

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)

September 29, 2022 /

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)

September 8, 2022 /

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)

August 4, 2022 /

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)

July 21, 2022 /

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)

April 7, 2022 /

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)

March 10, 2022 /

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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