Tag: opioid

Reading of the Week: Visual Hallucinations & Outcomes – the New Schizophrenia Study; Also, Opioid Deaths in Canada and Dr. Roy Perlis on Antidepressants

From the Editor

Last week, I met a person who had deeply unsettling auditory hallucinations. I asked him the questions that we all ask: When did the voices start? How many voices do you hear? Do the voices tell you to do things? In contrast, while we know that people with psychotic illnesses can have visual hallucinations, we rarely inquire about them and if we do, it’s in a perfunctory manner, as I did with him. Clinicians aren’t the only ones to gloss over visual hallucinations; they tend to be under-researched, especially with regard to long-term outcomes.

In the first selection, Isabel Kreis (of the University of Oslo) and her co-authors look at outcomes and visual hallucinations in an impressive, new study published in Schizophrenia. They report on 184 people from Norway with first-episode psychosis, followed for ten years, with a focus on visual hallucinations and functionality, suicide attempts, and childhood trauma. “These findings highlight the relevance of assessing visual hallucinations and monitoring their development over time.” We consider the paper and its implications.

In the second selection from CMAJ, Shaleesa Ledlie (of the University of Toronto) and her co-authors report on opioid-related deaths in Canada. They drew from a national database and looked at several years of data, including over the start of the pandemic. “Across Canada, the burden of premature opioid-related deaths doubled between 2019 and 2021, representing more than one-quarter of deaths among younger adults.”

And in the third selection, Dr. Roy Perlis (of Harvard University) argues that the time has come for over-the-counter antidepressants in a STAT essay. He notes that many people with depression are untreated and that increasing the availability of these medications would be helpful. “With part of the solution hiding in plain sight, it’s time to do everything possible to give Americans another way to get treatment.”

DG

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Reading of the Week: Self-stigma & Depression – the new JAD Study; Also, ChatGPT & Mental Health Care, and Dr. Catherine Hickey on the Opioid Crisis

From the Editor 

Depression is the result of character weakness. So explained my patient who had a major depressive disorder and hesitated to take medications.

Though fading, stigma about mental illness continues to exist, including self-stigma, the negative thoughts and beliefs that patients have about their own disease – as with my patient. How common is self-stigma? How does its prevalence differ around the globe? What are risk factors for it? Nan Du (of the University of Hong Kong) and co-authors attempt to answer these questions in a new Journal of Affective Disorders paper. They do a systematic review and meta-analysis of self-stigma for people with depression, drawing on 56 studies with almost 12 000 participants, and they a focus on international comparisons. “The results showed that the global prevalence of depression self-stigma was 29%. Levels of self-stigma varied across regions, but this difference was not significant.” We consider the paper and its clinical implications.

In this week’s second selection, we look at ChatGPT and mental health care. Dr. John Torous (of Harvard University) joins me for a Quick Takes podcast interview. He sees potential for patients – including making clinical notes more accessible by bridging language and knowledge divides – and for physicians, who may benefit from a more holistic differential diagnosis and treatment plan based on multiple data sets. He acknowledges problems with privacy, accuracy, and ChatGPT’s tendency to “hallucinate,” a term he dislikes. “We want to really be cautious because these are complex pieces of software.” 

And in the third selection, Dr. Catherine Hickey (of Memorial University) writes about the opioid crisis for Academic Psychiatry. The paper opens personally, with Dr. Hickey describing paramedics trying to help a young man who had overdosed. She considers the role of psychiatry and contemplates societal biases. “[I]n a better world, the needless deaths of countless young people would never be tolerated, regardless of their skin color.”

DG

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Reading of the Week: Substances, Substances, Substances – Papers from CJP & JMIR, and Dr. Devine on Our Federal Strategy

From the Editor

Creams, gummies, drinks. Cannabidiol (CBD) is increasingly popular and found in various products. Given its supposed benefits, including as an anxiolytic, could CBD be part of a harm reduction strategy?

In new paper for The Canadian Journal of Psychiatry, Lindsay A. Lo (of the University of Toronto) and her co-authors attempt to answer that question with a rapid review of 27 studies, including 5 randomized trials, covering opioids, cocaine, and polydrug use. “Low-quality evidence suggests that CBD may reduce drug cravings and other addiction-related symptoms and that CBD may have utility as an adjunct harm reduction strategy for people who use drugs.” We discuss the paper and its implications.

In the second selection, Dr. Braden O’Neill (of the University of Toronto) and his co-authors consider cannabis clinic websites. Focusing on Ontario, they find 29 clinic websites. In new paper for Journal of Medical Internet Research, they look at the claims made, and analyze the supporting literature. “The recommendation of cannabis as a general therapeutic for many indications unsupported by high-quality evidence is potentially misleading for medical practitioners and patients.”

And in the third selection, Dr. Jeremy Devine (of McMaster University) writes about federal drug policy in an essay for The Toronto Star. He feels that the current approach to the opioid crisis is flawed, with its focus on “regulation” – and he is particularly critical of safe supply programs. “The core ideological flaw in our drug policy is that it fails to recognize a hard truth: the drug user cannot have both their addiction and a free, safe, and self-determined life.”

DG

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Reading of the Week: Smoking Cessation – Doing Bad, Feeling Good? Also, Ethnicity & Opioids (JAMA Psych) and Dr. Freedman on Lunches (Acad Psych)

From the Editor

We ask our patients about cannabis. We inquire about illicit drugs. But are we forgetting tobacco? A new paper in Psychiatric Services helps answer that question – and, perhaps, raises other questions, including about how we could do better. 

In the first selection, Sarah A. White (of Johns Hopkins University) and her co-authors draw on American data to look at smoking cessation medications in a new Psychiatric Services paper. Among more than 55,000 smokers (many of whom have mental illness), they find that: “Cessation pharmacotherapy for smokers remained vastly underprescribed across all groups. At least 83% of smokers with or without mental illness did not receive varenicline, NRT, or bupropion during the 14-year study period.” We consider the paper and its clinical implications.

In the second selection, Huiru Dong (of Harvard University) and her co-authors look at buprenorphine treatment and demographics in the United States. Their JAMA Psychiatry research letter, which was just published, finds a growing gap. “The observed heterogeneity in buprenorphine treatment duration among racial and ethnic groups may reflect disproportionate structural barriers in treatment retention for Opioid Use Disorder.”

In the third selection, Dr. David Freedman (of the University of Toronto) writes about resident lunches for Academic Psychiatry. Dr. Freedman, who is a resident, notes that in-person lunches shifted to virtual ones for more than two years because of the pandemic – something that was necessary but unfortunate. He argues that the gatherings are important. “Yet, as a collective of residents munch on the last bites of their sandwiches, say goodbye, and return to work, I am struck by the camaraderie. Funded resident lunches nurture the professional identities of psychiatry trainees – an essential element of medical education.”

DG

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Reading of the Week: rTMS – the New JAMA Psych Paper; Also, Opioid Overdoses (JAMA Net Open) and Green on Peak Mental Health (NYT)

From the Editor

She’s an accomplished person who had succeeded in business and then writing, all the while raising three children; she also has an amazing smile and lights up the room when talking about her kids. But in my office, sick with depression, she can only focus on her losses and failings; the smile is absent.

Depression is common and disabling. Those who are affected in late-life are particularly challenging to treat. Is there a better way? In the first selection from JAMA Psychiatry, Dr. Daniel Blumberger (of the University of Toronto) and his co-authors consider theta burst stimulation, a newer form of rTMS which has shown promise in earlier work. Their study is a randomized noninferiority trial, directly comparing the two versions of rTMS in elderly patients with depression. The result? “We showed that bilateral TBS was noninferior to standard bilateral rTMS in improving depression, and similarly well tolerated, in a real-world sample of older adults with TRD [treatment resistant depression]…” We review the paper and its clinical implications.

In the second selection, Lori Ann Post (of Northwestern University) and her co-authors draw on CDC data to look at opioid overdoses in the United States with a focus on geography. In a JAMA Network Open research letter, they find: “Overall, opioid-involved overdose deaths rates increased steadily in counties of every urbanicity type, although there were distinct temporal wave patterns by urbanicity.”

And in the third selection, Huw Green (of the University of Cambridge) wonders about mental health and mental illness – and worries that the terms are becoming blurred together. Writing in The New York Times, the psychologist concludes: “When we move away from a focus on psychological problems and toward ‘mental health’ more broadly, clinicians stumble into terrain that extends beyond our expertise. We ought to be appropriately humble.”  

This month, the Reading of the Week enters its ninth year. A quick word of thanks for your ongoing interest.

DG



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Reading of the Week: Health Care Workers’ Mental Health – There’s an App for That; Also, Treating Opioids (BMJ) & Dr. Bhushan on Her Bipolar (LA Times)

From the Editor

With the pandemic dragging on, health care workers report more and more burnout; some complain of depression and anxiety.

What could help? Dr. Sam N. Gnanapragasam (of King’s College London) and his co-authors consider an app designed to provide CBT and mindfulness techniques in a new British Journal of Psychiatry paper. The RCT study involves 16 English sites with over 1000 health care workers. They conclude: “our study suggests that the app was of modest benefit with no adverse effects for a sample of HCWs in England.” We look at the paper.

How to respond to the opioid crisis? In a new analysis paper for BMJ, Dr. Robert A. Kleinman (of the University of Toronto) and his colleagues argue for a different approach to the prescribing of opioid agonist therapy, drawing on the changes made in response to the pandemic. “Embracing a more flexible model of buprenorphine-naloxone dosing would allow better alignment of prescribing practices with the needs and preferences of clients.”

And in the third selection, Dr. Devika Bhushan writes about bipolar disorder for the Los Angeles Times. The essay is very personal: the pediatrician, who serves as California’s acting surgeon general and graduated from Harvard, describes her own experiences. As she notes, during her training, she “had a secret.” Now, however, she speaks openly about her illness. “Today, I live with bipolar disorder as a chronic and manageable health condition.” 

DG

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Reading of the Week: Buprenorphine for Opioids – the New AJP Paper; Also, Cannabis & Hospitalizations (CJP) and Dr. Rosenberg’s Career & Illness (NYT)

From the Editor

A rise in substance use. Staff shortages and burnout. Waits for care.

The problems of the pandemic on mental health care have been clear and unfortunate. But how has care changed – and possibly improved – over the pandemic? In the first selection, Lewei Lin (of the University of Michigan) and her co-authors look at buprenorphine treatment before and during the pandemic. In a new paper for The American Journal of Psychiatry, they find a shift in care and a success story: “The number of patients receiving buprenorphine continued to increase after the COVID-19 policy changes, but the delivery of care shifted to telehealth visits…” We consider the paper and its clinical implications.

In the second selection, drawing on Canadian data, Chungah Kim (of Brock University) and her co-authors look at cannabis legalization and cannabis-related hospitalizations. In this new Canadian Journal of Psychiatry brief report, they find: “the initial legalization was followed by clinically significant increases in cannabis-related hospitalizations; however, the subsequent increase in retail stores, availability of cannabis edibles, and COVID-19 pandemic was not associated with a further increase in hospitalizations in Ontario.”

In the third selection, we consider the life and legacy of Dr. Leon E. Rosenberg with the obituary from The New York Times. Dr. Rosenberg had a storied career – a pioneer in genetics research, a dean of Yale, and the chief science officer at Bristol Myers Squibb. He’s also a person who had bipolar disorder and took lithium. “I am proof that it is possible to live a highly successful career in medicine and science, and to struggle with a complex, serious mental illness at the same time.”

Please note that there will be no Readings for the next two weeks.

DG


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Reading of the Week: Way Up – Alcohol-Related Deaths During the Pandemic (JAMA); Also, Addressing the Opioid Crisis (CJP) and the NYT on Grief

From the Editor

Three patients have recently told their stories to me. With his business failing, he turned to alcohol. When she couldn’t get hours at the restaurant because of the lockdown, she started drinking in the mornings. After a decade of sobriety, he explained that he found comfort in alcohol after his job loss.

These stories aren’t, unfortunately, surprising. With the pandemic, substance use appears to be on the rise. But what about substance-related deaths? In the first selection, we look at a new research letter from JAMA. Aaron M. White (of the National Institute on Alcohol Abuse and Alcoholism) and his co-authors examine alcohol-related deaths in the United States and the impact of the pandemic. They conclude: “The number and rate of alcohol-related deaths increased approximately 25% between 2019 and 2020, the first year of the COVID-19 pandemic.” We consider the paper and its clinical implications.

In the second selection, Dr. Tony P. George (of the University of Toronto) and his co-authors focus on the opioid crisis. In this Canadian Journal of Psychiatry commentary, they argue for a stronger approach to help those with opioid use disorder (OUD), specifically by improving the psychosocial interventions available. “While psychosocial interventions are often expensive and time consuming, they do make a difference in the lives of patients with OUD and those at risk for fatal opioid overdoses, especially when combined with broad psychosocial supports that address social determinants of health.”

And in the third selection, continuing our consideration of the first update to the DSM series in nine years, we look at a New York Times article, just published. Reporter Ellen Barry writes about prolonged grief disorder: “The new diagnosis was designed to apply to a narrow slice of the population who are incapacitated, pining and ruminating a year after a loss, and unable to return to previous activities.”

DG

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Reading of the Week: Does Opioid Agonist Treatment Save Lives? Also, the Problem with Decriminalization of Illicit Drugs (CJP)

From the Editor

Methadone was invented in the 1930s. The first legal injection site opened its doors nearly two decades ago. Yet our challenges with opioids seem to have only worsened with time. Consider, for example, that in a new, two-year study, the authors found that opioid-related deaths rose almost 600% between 2015 and 2017 in Canada.

What can we do? This week, we consider two selections.

In the first, Thomas Santo Jr (of the University of New South Wales) and his co-authors do a systematic review and meta-analysis for opioid agonist treatment for those with opioid dependence. They write in JAMA Psychiatry: “Our findings suggest a potential public health benefit of OAT, which was associated with a greater than 50% lower risk of all-cause mortality, drug-related deaths, and suicide and was associated with significantly lower rates of mortality for other causes.” We consider the big paper and its implications.

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And in the other selection, Benedikt Fischer (of the University of Toronto) and his co-authors weigh the recent interest in decriminalizing illicit drug use. In a new Canadian Journal of Psychiatry commentary, they note their hesitation, writing: “while ‘decriminalization’ proposals for illicit drug use are popular and largely well-intended, their overall merits require cautious analysis and scrutiny.”

DG

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Reading of the Week: Three Essays on Mental Illness

From the Editor

As stigma fades, we are as a society talking more and more about mental illness. And we are also writing more on the topic.

This week, the Reading features three essays that ask three provocative questions. Does naloxone access save lives? What’s it like to be depressed and in medical school? How do involuntary commitment laws affect the families of those with mental illness?

These essays are very different in part because they reflect very different perspectives on our collective experience with mental illness: the perspectives of providers, patients, and families.

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Enjoy.

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