Tag: substance

Reading of the Week: Motor Vehicle Crashes and Mental Disorders – the New CJP Paper; Also, Psychedelics & the States, and Hogan on NYC & Coercion

May 18, 2023 /

From the Editor 

He’s not well but insists that he can still drive his car. Should you report him to the Ministry of Transportation?

As clinicians, we often struggle with such issues, which touch on clinical judgment, as well as legal requirements. In Ontario, half a decade ago, the governme­­nt changed the law, requiring mandatory reporting for several conditions, including “acute” psychosis. Yet other provinces continue to leave major decisions to the discretion of providers. What does the literature say about motor vehicle crashes and mental disorders? In the first selection, Dr. Mark J. Rapoport (of the University of Toronto) and his co-authors do a systematic review for The Canadian Journal of Psychiatry, drawing on 24 studies. “The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder.” We consider the paper and its implications.

In the second selection, Dr. Joshua S. Siegel (of Washington University in St. Louis) and his co-authors look at US state legislation for psychedelic drugs in a new JAMA Psychiatry Special Communication. They note a sharp uptick in legislative activity and draw comparisons to cannabis. “After decades of legal restriction, US states have been swiftly moving toward increased access to psychedelics.”

And in the third selection, Michael F. Hogan (of Case Western Reserve University) writes about coercion and mental health care in JAMA Psychiatry. He considers the proposals of New York City Mayor Eric Adams which would expand efforts to hospitalize those with several, persistent mental illness. “Mayor Adams’ proposal for a more vigorous police response leading to inpatient care is well intended but incomplete. It would be preferable for New York to implement comprehensive crisis programs, including intensive care options that reduced the burden on police.”

DG

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Reading of the Week: Polypharmacy & Health – the New AJP Paper; Also, Melatonin Gummies (JAMA) & Mehler Paperny on Involuntary Care (Globe)

May 4, 2023 /

From the Editor

When it comes to antipsychotics, polypharmacy (the use of more than one antipsychotic) has fallen out of fashion – the psychopharmacological equivalent of bell bottoms. Providers worry about side effects and the long-term physical health implications. Are the concerns overstated? In the first selection, Heidi Taipale (of the University of Eastern Finland) and her coauthors analyze Finnish data for The American Journal of Psychiatry. The study includes almost 62,000 patients with schizophrenia with a median follow up period of more than 14 years, and they find that the use of more than one antipsychotic isn’t linked to poorer health outcomes. “The results show that antipsychotic monotherapy is not associated with a lower risk of hospitalization for severe physical health problems when compared with antipsychotic polypharmacy.” We consider the paper and its clinical implications.

Melatonin is a popular recommendation for sleep, but what’s the quality like? In the second selection from JAMA, Dr. Pieter A. Cohen (of Harvard University) and his co-authors try to answer that question with a focus on melatonin gummy products, looking at 30 brands. “The great majority of melatonin gummy products were inaccurately labeled, with most products exceeding the declared amount of melatonin and CBD.”

Gummy melatonin: colourful but what’s the quality?

In the third selection, in an essay for The Globe and Mail, journalist Anna Mehler Paperny writes about the push for more coercive care by different governments. Drawing on her personal experiences, she notes potential problems. “There is a role for coercive care. It’s arguably necessary for some people, sometimes. But used injudiciously, it can sour people on care and set them up for failure.”

There will be no Reading next week.

DG

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Reading of the Week: Bipolar & Med Adherence – the New Journal of Affective Disorders Study; Also, Sleep (QT) and Sheff on Involuntary Treatment (NYT)

April 27, 2023 /

From the Editor

You wrote a prescription, but did he actually take the medications? For those with bipolar disorder, pharmacotherapy is an essential part of care. Studies have noted poor adherence. 

To date, though, there hasn’t been a big cohort study. And there are good questions to ask: what drugs are more linked with adherence? Who is more likely not to take the medications? In a new paper just published in the Journal of Affective Disorders, Dr. Jonne Lintunen (of the University of Eastern Finland) and his co-authors attempt to answer these questions. They draw on Finnish data, covering more than three decades and including over 33 000 patients. “The majority of patients with bipolar disorder do not use their medications as prescribed.” We consider the paper and its clinical implications.

In the second selection, Dr. Michael Mak (of the University of Toronto) comments on sleep in a new Quick Takes podcast interview. In this sleep “update,” we talk about meds, CBT, and the mobile apps that he recommends to patients and their families. We also explore the history of sleep medicine and mull the growing role apps and wearables are playing in both diagnosis and therapy “The lines between sleep, health, and mental health in general are blurred.”

In the third selection, author David Sheff talks about his son’s addiction and recovery – and involuntary treatment. In a New York Times’ essay, he notes the challenges of engaging those with substance problems. He sees several ways forward, including involuntary treatment. “Many people in the traditional recovery world believe that we must wait for people who are addicted to hit bottom, with the hope that they’ll choose to enter treatment. It’s an archaic and dangerous theory.”

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: Online DBT – the New JAMA Paper; Also, Prediabetes and Preaddiction, and Greenberg on the Delusional Ones (Acad Psych)

July 14, 2022 /

From the Editor

He cut himself out of frustration with a break-up. She came to the ED with suicidal thoughts after losing her job.

Some patients need help with ongoing self-harm and suicidal thoughts – but access to care is challenging, particularly for dialectal behavioural therapy. Could a simple intervention help? Could it be delivered virtually?

In the first selection, Dr. Gregory E. Simon (of Kaiser Permanente Washington Health Research Institute) and his co-authors detail a pragmatic randomized trial that evaluated two low-intensity outreach programs, aiming to reduce risk of self-harm and suicidal behaviour. In this new JAMA study, they conclude: “Compared with usual care, offering care management did not significantly reduce the risk of self-harm, and offering brief online dialectical behavior therapy skills training increased the risk of self-harm among at-risk adults.” We look at the study.

In the second selection, Thomas McLellan (of the University of Pennsylvania) and his co-authors note the failings of substance treatment and then mull a way forward: considering the approach to diabetic care and the concept of prediabetes. Should we embrace preaddiction? They write: “the diabetes example shows that an early intervention approach can work given a comprehensive, sustained effort.”

And in the third selection, Dr. Norman R. Greenberg (of Yale University) contemplates his patient’s psychosis and his approach. Drawing on an old Hasidic tale, this resident of psychiatry stops debating with his patient; he chooses to listen to him instead. He writes: “I may not always be able to convince others of my perspective, I hope that I am able to convince others that we share similar goals and that I care about them.”

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

March 31, 2022 /

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: 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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Reading of the Week: Cannabis and Inpatients – the New CJP Paper; Also, Alexander on Her Loss and Her Patient’s (JAMA)

February 25, 2021 /

From the Editor

First, there was decriminalization; then, legalization.

How have these major legal shifts influenced the presentation of our patients? In the first selection, we consider a new paper from The Canadian Journal of Psychiatry. Taylor McGuckin (of the University of Waterloo) and her co-authors look at cannabis use and inpatient care, drawing on databases. “This study identified a significant increase in the proportion of patients who used cannabis within 30 days of their first admission to inpatient psychiatry in Ontario, Canada, between 2009 and 2017, compared to 2007.”

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How do our biases affect the care we provide? In a moving and personal essay, Karen Alexander (of Thomas Jefferson University) discusses the loss of her baby. She thinks about another time, when a patient of hers was in a similar situation, and she mulls her own views and biases. “The weeping woman was always much more than someone who was grieving, but I never really knew her as a person until I mourned the loss of my own child.”

DG

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

January 14, 2021 /

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: “The Name of the Dog” – Dr. Tafder’s Excellent NEJM Paper & More

October 25, 2018 /

From the Editor

There is something often dehumanizing about the health-care experience – the way patients can be reduced to medical-record numbers, the way lives can be summarized in disease names and a few demographic details (“a 30 year old woman with schizophrenia”).

This week, we consider two essays that are about people who happen to be patients – and the lessons that our colleagues have drawn from their stories.

In the first selection, we look at a paper written by Dr. Taimur Safder that was published in The New England Journal of Medicine. It’s about the name of a dog – and much more. During his training, Dr. Safder presents the case of a person who develops chest pain when walking his dog. When the supervisor asks the name of the dog, the physician isn’t sure. “Four years later, I’m not sure anything I’ve carried from residency has been more useful than that question.”

dy_wosjwsamveozNo, this Reading isn’t really about dogs

And, in the second selection, we consider a short essay by Dr. Lee Lu. The Texas doctor describes her experiences working with a patient with substance use problems – and wrestling with her own biases.

Finally, returning to the topic of cannabis legalization, we consider some responses to last week’s Reading, and a CMAJ editorial on the topic.

DG

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