Tagpsychiatric services

Reading of the Week: Telepsychiatry – the Reality, the Potential, the Problems

From the Editor

Just a handful of months ago, mental health work didn’t require a webcam or a lighting ring, and no one talked about Zoom fatigue. The world is different now, obviously. With COVID-19, telepsychiatry is very much part of our clinical work.

This week, we consider three papers focused on telepsychiatry and our new world.

How widespread is the adoption of telepsychiatry in this pandemic era? In the first selection, Jonathan Cantor (of the RAND Corporation) and his co-authors draw on a big American database to answer that question. In Psychiatric Services, they write: “During the COVID-19 pandemic, the percentage of outpatient mental health and substance use disorder treatment facilities offering telehealth has grown dramatically. However, our analyses also indicated that considerable proportions of mental health and substance use disorder treatment facilities still did not offer telehealth as of January 2021…”

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In the second selection, John C. Fortney (of the University of Washington) and his co-authors consider two different types of care: with psychiatrists directly involved in patient care (through televideo) or indirectly, by providing support to primary care. In a JAMA Psychiatry study, they do a comparison. Spoiler alert: both approaches were effective, suggesting great potential, especially for those in rural areas.

Of course, not everyone is enthusiastic about telepsychiatry. In our third selection, Dr. J. Alexander Scott (of the University of Michigan), a resident of psychiatry, describes his ambivalence. His Academic Psychiatry paper starts memorably: “Admittedly, I’ve never liked telemedicine.” He outlines some of the problems with our digital world.

DG

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Reading of the Week: Dr. David Goldbloom’s New Book on Innovation and Mental Health Care

From the Editor

“There’s one fact on which we all agree: people are suffering. People with mental illnesses, their families and friends, and society at large are all touched by a set of disorders that affect one in five people globally. What is also evident – to every worried parent or partner, to every citizen strolling down a busy downtown street, to every guard working in a prison, to every teacher spending the majority of children’s weekday waking hours with them – is that the status quo is unacceptable.”

Dr. David Goldbloom (of the University of Toronto), who serves as the Senior Medical Advisor at the Centre for Addiction and Mental Health, makes these comments in his new book.

Can we do better? Those with mental health problems wait for almost all care, and the quality of care is uneven. This week’s Reading is an excerpt from Dr. Goldbloom’s new book, We Can Do Better: Urgent Innovations to Improve Mental Health Access and Care. The excerpt, like the book itself, strikes an optimistic note, observing the incredible innovation already present in mental health care.

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A special word of thanks to Catherine Whiteside of Simon & Schuster Canada for making this Reading possible.

DG

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Reading of the Week: Our Pandemic Reality – How It Affected Our Patients, How It Changed Our Practice, How It Changed Us

From the Editor

A year ago this week, provinces across the country ordered the first lockdown. In the days that followed, I remember driving to the hospital and noting the eerie quiet of the streets with almost no cars or trucks on the morning commute.

Now, a year later, we can ask some questions. How has the pandemic affected our patients? How did it change our practice? How has it changed us?

This week, we have four selections that explore our pandemic reality.

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We begin by focusing on patients. In the first selection, we look at a paper from Annals of Internal Medicine. Dr. Jonathan S. Zipursky (of the University of Toronto) and his co-authors consider alcohol sales and ED visits. They find that there was an increase in alcohol sales of 38% at the start of the pandemic. They write: “Higher alcohol sales during the lockdown are worrisome because alcohol consumption can cause poor judgment, medical complications, and immune suppression.”

In the second selection, we consider an editorial from BMJ. Though some have predicated a significant increase in suicide completions, there is little evidence. Still, the authors write: “We must remain vigilant and responsive, sharing evidence early and internationally… in these evolving uncertain times.”

Then we pivot and look at providers. In the third selection, Dr. Daniel Guinart (of Hofstra/Northwell) and his co-authors report on the findings of a survey on telepsychiatry. “In this study, we report highly favorable attitudes toward telepsychiatry in its diverse forms, across a large and wide array of mental health care professionals.”

In the fourth selection, Andrea Frolic (of McMaster University) talks about the pain of the past year. After breaking a toe, she notes about the psychological injuries of our pandemic life. “As a health care leader, I am supposed to be a cheerleader, a silver-lining finder, an opportunity-seeker – a hero, not a human.”

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Some good news: the Reading of the Week was just awarded the Ivan Silver Innovation Award by Continuing Professional Development of the University of Toronto’s Faculty of Medicine. Many thanks to Drs. Rajeevan Rasasingham and Sanjeev Sockalingam for the nomination.

But I’m committed to developing this program further, not resting on our laurels – in late April, we will be conducting focus groups to better understand what works and what needs improvement. Interested in being involved? Please contact smit.mistry@camh.ca. Time commitment: under one hour.

DG

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Reading of the Week: Cannabis, Cannabis, Cannabis – With Papers from Psychological Medicine, Psychiatric Services, and Annals of Internal Medicine

From the Editor

“It’s the only thing that works.”

So many of our patients swear by cannabis. It has become a popular choice for everything from anxiety to chronic pain. And though the literature is relatively young, now we know more about cannabis than before. This week, we focus on three new papers.

The first selection is a paper by Dr. Emmet Power (of the Royal College of Surgeons in Ireland) and his co-authors from Psychological Medicine. Does frequent and dependent cannabis use in youth affect IQ? Doing a systematic review and meta-analysis, they find seven papers. They conclude: “We found that young people who use cannabis frequently or dependently by age 18 have declined in IQ at follow up and this may be due to a decline in verbal IQ.”

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In the second selection, we consider a new paper from Psychiatric Services. Dr. Corneliu N. Stanciu (of Dartmouth College) and his co-authors did a systematic review of cannabis for several disorders. “With only eight very small studies, insufficient evidence was found for efficacy of CBD and THC to manage affective disorders, anxiety disorders, or PTSD.”

Finally, in the third selection, we look at a paper from Annals of Internal Medicine. Drs. Arthur Robin Williams (of Columbia University) and Kevin P. Hill (of Harvard University) pose 15 questions about cannabis and answer them. The authors are practical and thoughtful. The clinical bottom line: “Millions more adults now meet criteria for cannabis use disorder in a given year, and all clinicians, not just mental health professionals, have vital roles in improving clinical management, from screening and diagnosis to overseeing treatment plans.”

DG

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Reading of the Week: ECT at 82

From the Editor

If you were ill with depression, would you consider electroconvulsive therapy? What if you had a manic episode?

In April 1938, the first treatment of ECT was administered in Rome. Now, 82 years later, ECT continues to be used. But, as Dr. David Goldbloom (of CAMH) notes: “ECT has the unusual status of being one of the most vilified and validated treatments in all of psychiatry and indeed in all of medicine.” The treatment has fallen out of favour, and is not even offered in certain centres.

But would you consider ECT?

In the first selection, we look at a new paper from Psychiatric Services. Dr. Rebecca E. Barchas, a retired psychiatrist, discusses her experiences with ECT – as a patient, not as a physician. She notes the depths of her depression and the decision to receive ECT, which she didn’t know much about despite many years of practice. “If reading these thoughts can help even one more patient who needs ECT accept it or help one more physician to consider recommending it when appropriate, I will have accomplished my goal of helping to destigmatize ECT.”

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In the second selection, we consider a narrative review from The American Journal of Psychiatry. ECT for patients experiencing manic episodes is used less and less often; in several recent surveys, no patient with mania received ECT. But what’s the evidence? Dr. Alby Elias (of the University of Melbourne) and his co-authors review decades’ worth of literature, from RCTs to retrospective studies, finding the treatment is safe and effective. But is it relevant in an era of pharmacology?

DG

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Reading of the Week: Should Police Respond to Mental Health Crises? Also, Apps & College Students (Psych Services) and the Life of DJ Jaffe (NYT)

From the Editor

Another tragedy, another headline.

And there have been too many. The stories differ, but there is a common thread: mental illness and a crisis, a 911 call, death. Can we do better?

In the first selection, we consider a new essay by Dr. Sally Satel (of Yale University). Dr. Satel, a psychiatrist, notes recent tragic outcomes with mental health crises. “Nationwide, a person with a psychotic illness is 16 times more likely to be killed during a police encounter than a person without such a condition.” She wonders about an alternative to police responses.

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In the second selection, we look at apps and college students. In a Psychiatric Services paper, Jennifer Melcher and John Torous (of Harvard Medical School) review the recommendations of mental health apps of several university counselling programs. They conclude: “the findings indicated that many counseling centers are suggesting apps that are inaccessible, outdated, potentially dangerous, and without research backing.”

Finally, in our third selection, we consider The New York Times obituary for D.J. Jaffe – the title is a good summary of his life: “Ad Man Turned Mental Health Crusader.” Jaffe, whose sister-in-law has major mental illness, was a strong advocate of various mental health causes, with his influence felt on state and national legislation.

DG

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Reading of the Week: ED Visits & Follow Ups – the New Psych Services Paper; Also, Antipsychotics and Brains (JAMA Psych) and Physician Biases (NEJM)

From the Editor

How accessible is urgent outpatient mental health care in Canada? Do antipsychotics affect the brain structure of people with psychotic depression? How can physician biases change cardiac care?

This week, we consider three very different selections, drawing from the latest in the literature.

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In the first selection, Dr. Lucy C. Barker (University of Toronto) and her co-authors look at follow-ups after an ED visit. As the authors note: “Urgent outpatient mental health care is crucial for ongoing assessment and management and for preventing repeat visits to the ED and other negative outcomes.” Drawing on Ontario data, they find that “fewer than half had a physician follow-up visit within 14 days of the ED visit for outpatient mental health care.” Ouch.

In the second selection, we consider a new paper by Dr. Aristotle N. Voineskos (University of Toronto) et al. In an impressive study across multiple sites, they find a connection between cortical thinning and the use of antipsychotics: “olanzapine exposure was associated with a significant reduction compared with placebo exposure for cortical thickness.” Ouch.

Finally, it’s said about health care that “geography is destiny” – so much of the patient experience is tied to her or his place of care, with incredible variations in services between, say, rural and urban centres. In an unusual research letter for The New England Journal of Medicine, Andrew R. Olenski (Columbia University) and his co-authors consider heart surgery and patient age – that is, within two weeks of a patient’s 80th birthday. They argue that numbers are destiny, with heart surgery influenced by “the occurrence of left-digit bias in clinical decision-making…” Ouch.

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

DG

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Reading of the Week: Is CBD Useful for Mood Disorders? The New CJP Paper. Also, Peer Support and Online CBT (Psych Services) & the Art of Daniel Regan

From the Editor

This week, we have three selections.

With the legalization of cannabis, many big claims haven been made about the medicinal aspects of this drug – including by industry. Cannabidiol, or CBD, is often touted as being helpful yet non-addictive (in contrast to THC, the more famous cannabis molecule). In the first selection, UBC’s Jairo Vinícius Pinto and his co-authors consider cannabidiol in the treatment of mood disorders, reviewing the existing literature. Does CBD help? “The methodology varied in several aspects and the level of evidence is not enough to support its indication as a treatment for mood disorders.”

In the second selection, the University of Michigan’s Paul N. Pfeiffer and his co-authors try to improve depression treatment outcomes by combining a cutting-edge psychotherapy (CBT, delivered by computer) with a not-so-cutting edge approach (peer support). They conclude that the intervention “should be considered as an initial treatment enhancement to improve effectiveness of primary care treatment of depression.”

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And in the third selection, we look at the work of artist Daniel Regan, which is featured on the front cover of February issue of The Lancet Psychiatry. He notes: “I really think if I hadn’t gone on to study photography, I wouldn’t be here.” Featured above is “Abandoned,” part of a series of photos from Victorian-era asylums in the UK.

DG

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Reading of the Week: Too Few Psychiatrists? Anderssen on the Gap in Access (Globe); Also, Cuijpers on Success in Depression Treatment (Expert Review)

From the Editor

After a break, the Readings are back. In the coming weeks, we will consider important papers on depression treatment, cannabis, help for the homeless, and more.

This week, there are two selections.

In the first selection, we consider the new Globe and Mail essay by reporter Erin Anderssen on the supply (or the lack of supply) of psychiatrists across Canada. This essay does a sparkling job of pulling together stories and reports, and includes an overview of the literature. It paints a familiar, if unsettling, picture of need unmatched by availability, and includes interviews and original data analysis.

She writes: “The modern psychiatrist can’t be everywhere. So they should be where Canadians need them most.”

We summarize the essay and some of the larger questions raised.

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In the second selection, the Vrije Universiteit Amsterdam’s Pim Cuijpers writes about depression and treatment. Thinking about successful care, he asks a simple question: “When patients seek treatment, is a reduction of depressive symptoms really what they want, or do patients have other goals as well?”

DG

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Reading of the Week: PTSD – More Common in High-Income Countries? The New BJP Open Paper; Also, the Trauma of 911 & Torrey on His Sister

From the Editor

Is there more PTSD in countries like Norway and Canada?

The question seems odd since we typically don’t associate major mental illness with affluence (though, of course, not everyone in an affluent society is affluent). Yet there is a literature suggesting that high-income countries may have more PTSD.

This week, we look at a new paper on the topic. The University of Oslo’s Trond Heir and co-authors consider PTSD in Norway. Drawing on a survey, they find significant rates of PTSD, higher than found in low-income countries. “A possible explanation may be that high expectations for a risk-free life or a happy life can lead to a low threshold for perceiving adverse events as life-threatening or as violating integrity.”

norway-aurlands-fjordenNorway: High incomes, universal health care, many fiords, and more PTSD?

In the next selection and continuing on the topic of PTSD, New York Times reporter James Barron writes about the other victims of September 11 – those who survived, but have struggled with PTSD. As a Long Island clinician notes: “So many suffer in silence. It’s 18 years later, and to some it’s pretty new.”

And in the third selection, Dr. E. Fuller Torrey, a psychiatrist and accomplished researcher, considers his career. He notes that his sister’s psychosis pushed him to choose psychiatry, though he had originally planned to be a family doc.

DG

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