Tag: substance

Reading of the Week: Psychological Interventions for Schizophrenia – the New Lancet Psych Study; Also, Service Dogs for PTSD, and the Latest in the News

From the Editor

She was distressed by the voices and the paranoid thoughts. Many nights, my patient could barely sleep. She had tried several medications without much improvement. Is there a role for psychological interventions? Would CBT help? What is the evidence for this population?

In the first selection, Nurul Husna Salahuddin (of the Technical University of Munich) and co-authors attempt to answer these questions in a new systematic review and network meta-analysis, just published in Lancet Psychiatry. The analyzed 52 RCTs with 5 034 participants. “We provide robust findings that CBTp can reduce the overall symptoms of patients with treatment-resistant schizophrenia, and therefore clinicians can prioritise this intervention in their clinical practice.” We consider the paper and its clinical implications.

In the second selection from JAMA Network Open, Sarah C. Leighton (of the University of Arizona) and her co-authors describe a study involving service dogs for those with PTSD. In a nonrandomized controlled trial involving 156 military members and veterans, they examined outcomes after three months. “[C]ompared with usual care alone, partnership with a trained psychiatric service dog was associated with lower PTSD symptom severity and higher psychosocial functioning in veterans.”

Finally, we explore the latest news with recent articles from The Guardian, the Ottawa Citizen, and The New York Times. Among the topics: “honest” obituaries and the opioid crisis, antidepressants and withdrawal, and care for pregnant women with substance problems.

DG

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Reading of the Week: Preventing Postpartum Depression in Pakistan – the New Nature Med Study; Also, Deaths of Despair and ChatGPT & Abstracts

From the Editor

Imagine that you are asked to design a program to prevent depression in a population at risk. Would you hire psychiatrists? Look to nurses? Tap the expertise of psychologists? All three?

In the first selection from Nature Medicine, Pamela J. Surkan (of Johns Hopkins University) and her co-authors describe a study that focused on prevention. As they worked in Pakistan – a nation with few mental health providers by Western standards – they chose to train lay people, teaching them to deliver CBT. In their single-blind, randomized controlled trial, 1 200 women who were pregnant and had anxiety (but not depression) were given enhanced usual care or CBT. “We found reductions of 81% and 74% in the odds of postnatal MDE and of moderate-to-severe anxiety…” We discuss the paper and its implications.

In the second selection, Joseph Friedman and Dr. Helena Hansen (both of the University of California, Los Angeles) look at deaths of despair in the United States in a research letter for JAMA Psychiatry. Their work builds on the idea that some deaths are related to the hopelessness of a person’s social or economic circumstance; past publications focused largely on White Americans. Friedman and Hansen drew on more than two decades of data, including ethnicity, from a US database, finding a different pattern and that: “Rising inequalities in deaths of despair among American Indian, Alaska Native and Black individuals were largely attributable to disproportionate early mortality from drug- and alcohol-related causes…”

A recent survey finds that psychiatrists see AI as potentially helpful with paperwork and diagnosing patients. But could AI help you keep up with the literature? In the third selection from Annals of Family Medicine, Dr. Joel Hake (of the University of Kansas) and his co-authors used ChatGPT to produce short summaries of studies, then evaluated their quality, accuracy, and bias. “We suggest that ChatGPT can help family physicians accelerate review of the scientific literature.”

DG

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Reading of the Week: Legal Cannabis at 5 – Considering Nonmedical Legalization with a CMAJ Commentary, Dr. Buckley’s Reflections and Major Papers

From the Editor

On Oct. 17, 2018, the government of Canada will launch a national, uncontrolled experiment in which the profits of cannabis producers and tax revenues are squarely pitched against the health of Canadians. When Bill C-45 comes into force in mid-October, access to recreational marijuana will be legal, making Canada one of a handful of countries to legalize recreational use of the drug. Given the known and unknown health hazards of cannabis, any increase in use of recreational cannabis after legalization, whether by adults or youth, should be viewed as a failure of this legislation.

 – Dr. Diane Kelsall, Editor-in-Chief, CMAJ, October 2018

On Tuesday, Canada’s experiment with the legalization of cannabis for nonmedical purposes turned five. Did use go up? What about health care utilization? Have there been benefits from justice and social justice perspectives? Is it the failure that Dr. Kelsall feared?

Now is a good time to pause and review the impact of this change. In this Reading, we try to do just that. 

We start with a CMAJ commentary just published. Benedikt Fischer (of Simon Fraser University) and co-authors look at the evidence, including studies on use and ED presentations, as well as statistics on purchases. “A consideration of the evidence 5 years after implementation suggests that success in meeting policy objectives has been mixed, with social justice benefits appearing to be more tangibly substantive than health benefits.”

Dr. Leslie Buckley (of the University of Toronto) mulls this moment with some comments about the CMAJ paper, and the larger discussion. “[T]he legal changes were enacted and resulted in positive outcomes while the preventive changes which would require more financial investment and tight regulation received less attention.”

Finally, we look at three important papers on cannabis that have been featured in this series over the past five years, and another one that we haven’t looked at before.

DG

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Reading of the Week: Fatal Overdoses & Drug Decriminalization – the new JAMA Psych Paper; Also, ChatGPT vs Residents, and Chang on Good Psychiatry

From the Editor

Does decriminalizing the possession of small amounts of street drugs reduce overdoses? Proponents argue yes because those who use substances can seek care – including in emergency situations – without fear of police involvement and charges. Opponents counter that decriminalization means fewer penalties for drug use, resulting in more misuse and thus more overdoses. The debate can be shrill – but lacking in data.

Spruha Joshi (of New York University) and co-authors bring numbers to the policy discussion with a new JAMA Psychiatry paper. They analyze the impact of decriminalization in two states, Oregon and Washington, contrasting overdoses there and in other US states that didn’t decriminalize. “This study found no evidence of an association between legal changes that removed or substantially reduced criminal penalties for drug possession in Oregon and Washington and fatal drug overdose rates.” We consider the paper and its implications.

In the second selection, Dr. Ashwin Nayak (of Stanford University) and his co-authors look at AI for the writing of patient histories. In a new research letter for JAMA Internal Medicine, they do a head-to-head (head-to-CPU?) comparison with ChatGPT and residents both writing patient histories (specifically, the history of present illness, or HPI). “HPIs generated by a chatbot or written by senior internal medicine residents were graded similarly by internal medicine attending physicians.”

And in the third selection, medical student Howard A. Chang (of Johns Hopkins University) wonders about “good” psychiatry in a paper for Academic Psychiatry. He reflects on the comments of surgeons, pediatricians, and obstetricians, and then mulls the role of our specialty. “I have gleaned that a good psychiatrist fundamentally sees and cares about patients with mental illness as dignified human beings, not broken brains. The good psychiatrist knows and treats the person in order to treat the disease.”

DG

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Reading of the Week: ADHD & Substance Outcomes – the New JAMA Psych Paper; Also, Suicide & the Impact on Psychiatrists and Foulkes on Her Anxiety & Our Times

From the Editor

Stimulants are commonly prescribed to children with ADHD. Do they protect kids against future substance misuse? Or, having been exposed early to stimulants, are these patients more likely to develop substance problems in adulthood?

Past studies have attempted to answer these questions but have been limited by study design. In a new JAMA Psychiatry paper, Brooke S. G. Molina (of the University of Pittsburgh) and her co-authors take a fresh look. In a cohort study involving 547 students, some of whom were treated with stimulants while others received behavioural therapy during the first period, Molina et al. look at outcomes when these participants are in their mid 20s. “This study found no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, marijuana, cigarette smoking, or other substances used for adolescents and young adults with childhood ADHD.” We consider the study and its implications.

In the second selection, Dr. Juveria Zaheer (of the University of Toronto) discusses patient suicide in a new Quick Takes podcast interview. Focusing on the impact on psychiatrists and residents of psychiatry, she draws from the literature, including a study she recently senior authored for The Canadian Journal of Psychiatry. She notes common reactions by psychiatrists and residents, including guilt and shock. And Dr. Zaheer talks about her own experience. “I’ll never forget when it happened.” 

And in the third selection, Lucy Foulkes (of the University of Oxford) writes about anxiety and current approaches. In a Guardian essay, she notes her own history as an “anxious teen” and wonders if life is better for today’s adolescents, with awareness campaigns but not necessarily meaningful services. “We are now in a situation where many teens know or believe they are anxious but aren’t getting the help they need to manage it.”

The Reading of the Week has formal partnerships with 14 postgraduate programs and, today, we welcome PGY1s who are joining us from across Canada.

DG

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Reading of the Week: tDCS vs Sham for Depression – the New Lancet Paper; Also, US Ketamine Seizures and Dr. Lamas on Medical Practice & AI

From the Editor

He’s tried several medications, but still struggles with his depression. The story is too familiar. Transcranial direct current stimulation (tDCS) is an option, and increasingly the focus of research. With relatively few side effects and the possibility of doing the treatment at home, the advantages of tDCS are clear.

But how do patients taking antidepressants respond? In the first selection, from the pages of The Lancet, Dr. Gerrit Burkhardt (of the University of Munich) and his co-authors report the findings of an impressive study, with a comparison against sham treatment, across eight sites, and involving triple blinding. “Active tDCS was not superior to sham stimulation during a 6-week period. Our trial does not support the efficacy of tDCS as an additional treatment to SSRIs in adults with MDD.” We consider the paper, an accompanying Comment, and the implications.

In the second selection, Joseph J. Palamar (of New York University) and his colleagues analyze data on US ketamine seizures in a Research Letter for JAMA Psychiatry. They view seizures as a measure of recreational and nonmedical use, and conclude: “These data suggest increasing availability of illicit ketamine.”

And in this week’s third selection, Dr. Daniela J. Lamas (of Harvard University), an internist, writes about AI for The New York Times. In thinking about medical practice, she sees artificial intelligence doing more and more, and ultimately helping with diagnosis. She also sees trade-offs. Still, she concludes: “Beyond saving us time, the intelligence in A.I. – if used well – could make us better at our jobs.”

Note that there will be no Reading next week.

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

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)

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)

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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