TagThe American Journal of Psychiatry

Reading of the Week: The New AJP on Alcohol & Subjective Response; Also, Remembering Philip Seeman (Globe) and Sharma on His Godmother

From the Editor

My patient could recognize the damage done by alcohol. The lost friendships. The failed marriage. The firing of her job of 15 years. And yet, she was still puzzled. “How did I get into this mess?”

In a new American Journal of Psychiatry paper, Andrea King (of the University of Chicago) and her co-authors explore the draw of alcohol with a major new study that measures the subjective response to alcohol challenges at five and ten year follow ups. “Initial stimulant and rewarding effects of alcohol predicted heavy alcohol use, and the magnitude of these positive subjective effects increased over a 10-year period in those who developed alcohol use disorder compared with those who did not develop the disorder.” We discuss this big paper.

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Dr. Philip Seeman had an extraordinary career with major achievements. Some argue that he should have shared the Nobel prize. He died on 9 January 2021 at his home. The Globe obituary is our second selection. Dr. Seeman was a generous mentor of many young scientists, and a husband, father, and grandfather. And his work was impactful: Dr. Seeman’s interest in dopamine helped change the way we practice today.

And in our final selection, we look at a new essay by Dr. Gaurav Sharma, a resident of psychiatry at the University of Toronto. The disaster of Ontario’s long term care homes has made many headlines. For this young doctor, the problems are close to home, affecting his godmother. He writes about her life and her downward turn. “In my training as a psychiatry resident, a basic principle I’ve learned is that every mental health crisis has its triggers. In Lucy’s case, the crisis that led to her hospitalization was prompted by a precarious housing situation.”

DG

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Reading of the Week: Are Benzodiazepines Misunderstood? Also, Lizotte on Mental Health Support, and The Lancet on Those Doctors Lost to COVID

From the Editor

In a recent conversation with a resident, we discussed benzodiazepines. “I’ve never prescribed one,” he explained.

This class of medications is very much out of fashion. But, after decades of overuse, have we swung to the other extreme, and forgotten an important tool in our pharmacologic toolkit? In the first selection, we consider a British Journal of Psychiatry editorial. Dr. Edward Silberman (of Tufts University School of Medicine) and his co-authors argue that benzodiazepines are underappreciated. The selection ties well into a commentary that recently appeared in The American Journal of Psychiatry. Dr. Jerrold F. Rosenbaum (of Harvard Medical School) writes: “My own son, a first-year resident in psychiatry, looks at me as if I served on the wrong side in the Spanish Civil War when I speak of benzodiazepines.” Is there a clinical takeaway here?

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In the second selection, writer and comedian Andrew Lizotte discusses the challenges of being a patient in our mental health system. He shares some jokes – but, ultimately, notes ongoing stigma and power imbalances. “We see how mental illness is portrayed in the media. We are scared of being shot by police during a ‘routine health check.’ We see the lack of empathy. Then people wonder why we don’t ask for help.”

Finally, with an eye on COVID-19, we look at a short paper in The Lancet about those doctors who have lost their lives in the pandemic. “These lives are also a reminder of the ongoing dedication and service of those who continue to care for patients at a time when COVID-19 cases and deaths are increasing in many countries.”

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: Substance Problem, Quality of Care Problem? Also, Interventional Psychiatry (CJP) and an Underused Addiction Treatment (NYT)

From the Editor

In terms of depression treatment, do people with substance use problems get worse care than those without?

The answer should be a resounding no. In the first selection, we consider a new paper, just published in The American Journal of Psychiatry, which suggests otherwise. Lara N. Coughlin  (of the University of Michigan) and her co-authors draw on Veterans Affairs data involving more than 53,000 patients. “In this large national sample, we found that patients with comorbid depression and substance use disorders receive lower quality care than those with depression but without substance use disorders.”

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In the second selection, we consider a Canadian Journal of Psychiatry research letter. Dr. Peter Giacobbe (of the University of Toronto) and his co-authors surveyed senior residents, asking about their familiarity and comfort with first line recommendations for the treatment of depression. Spoiler alert: just one in four felt that they had achieved competency in ECT.

Finally, in the third selection, we look at a new essay by journalist Abby Goodnough. With many Americans (and Canadians) struggling with substance problems, she writes about contingency management – that is, rewarding substance users with cash and prizes for sobriety. The concept has evidence in the literature, but lacks political support. She quotes a patient: “Even just to stop at McDonald’s when you have that little bit of extra money, to get a hamburger and a fries when you’re hungry. That was really big to me.”

Note: there will be no Reading next week.

DG

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Reading of the Week: Psychotherapy at a Distance; Also, Rakoff Remembered (Globe) and Horton on Her Brother (LA Times)

From the Editor

Mental health care has markedly changed since the pandemic began. What is the impact of COVID-19 on psychotherapy?

This week, we have three selections.

In the first, published in The American Journal of Psychiatry, Dr. John C. Markowitz (of Columbia University) and his co-authors write about psychotherapy and virtual care. The paper reviews the literature and also considers practical considerations. They note: “Therapists should acknowledge the crisis, and perhaps that teletherapy is a limited substitute for more direct contact.”

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In the second selection, reporter Wency Leung writes about Dr. Vivian Rakoff, who died earlier this month. In the Globe obituary, Leung writes about his various roles, including as psychiatrist-in-chief of the Clarke Institute (now part of CAMH). “To the many he inspired, he is remembered for his extraordinary intellect, kindness, sense of wonder and the agility with which he wove together ideas from a vast range of disciplines, from classic literature and philosophy to politics and pop culture.”

Finally, in our third selection, we consider an essay by Dr. Jillian Horton (of the University of Manitoba). In this LA Times essay, the internist writes about her brother and his mental illness, discussing the emotional and geographic distance of their relationship. “My brother died 40 years ago and he died in April.”

DG

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Reading of the Week: Burnout & North American Psychiatrists – the Big AJP Paper; Also, Satel on Kanye West’s Mental Illness (USA Today)

From the Editor

“Burnout is notoriously difficult to characterize.”

So comment the authors of a new American Journal of Psychiatry paper.

In recent years, we have been collectively speaking much more about physician burnout, but we often lack basic data. Using an online survey, Dr. Richard F. Summers (of the University of Pennsylvania) and his co-authors attempt to find out how common it is among North American psychiatrists. While there are many surveys of physicians, this one focuses on our specialty. What do they find? “Psychiatrists, like other physicians, have substantial burnout.”

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In the second selection, we look at a new essay by Dr. Sally Satel (of Yale University). Writing in USA Today, she discusses the presidential campaign of Kanye West and the unusual comments that he has made. “None of this is funny.” She notes that he has a history of mental illness, and wonders how journalists should have covered the story.

Please note that there will be no Reading next week.

DG

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Reading of the Week: How to Achieve Good Mental Health During Isolation (BJP)? Also, Bipolar Meds (AJP) & Qayyum on the Way to the Morgue (WBUR)

From the Editor

Millions of people are isolating themselves in North America, and across the world. We know that quarantine is linked to mental health problems like depression. So what advice should we be giving our patients – and our family and neighbours?

The first selection seeks to answer this question.

In The British Journal of Psychiatry, Rowan Diamond (of Warneford Hospital) and Dr. John Willan (of Oxford University Hospitals NHS Foundation Trust) provide six suggestions, drawing from the literature and taking into account our collective situation. “Dame Vera Lynn, at the age of 103, said of this pandemic that ‘even if we’re isolated in person we can still be united in spirit,’ and the sense of purpose that may be engendered in self-isolation may paradoxically lead to improvements in the mental health of some individuals who may otherwise feel that they have lost their role in society.”

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How are we managing bipolar affective disorder? In the second selection, we look at a new American Journal of Psychiatry paper by Taeho Greg Rhee (of the University of Connecticut) and his co-authors, who draw on 20 years worth of data. “There has been a substantial increase in the use of second-generation antipsychotics in the outpatient psychiatric management of adults diagnosed with bipolar disorder, accompanied by a decrease in the use of lithium and other mood stabilizers.”

Finally, in the third selection, Dr. Zheala Qayyum (of the US Army) considers her time working in New York City during the pandemic. “The first thing that struck me when I stepped into the hospital in Queens was the smell that hung in the air, in these seemingly sterile hospital corridors. It was death and disease.”

DG

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Reading of the Week: COVID & Mental Health Access in China (AJP); also, Transformational Care (EBMH) and Psych Wards (New Yorker)

From the Editor

What’s the latest in the literature on COVID and mental health? This week, we focus again on the pandemic with three selections.

In the first, we consider a paper on mental health services at a Chinese hospital during the pandemic. In this American Journal of Psychiatry study, Dr. Junying Zhou (of Sichuan University) and co-authors report on a survey of existing and new outpatients, finding major problems with access. Among the findings: one in five found that their mental health had deteriorated due to a lack of access to care. The authors advocate further study to “ameliorate the negative impact of viral outbreaks in the general public, especially among those vulnerable patients with mental problems.”

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Will COVID change health care once the virus has burned out? In the second selection, we consider a new EBMH editorial by Dr. Katharine Smith (of Oxford University) and her co-authors. They write: “In order to reappraise effectively our new ways of working, both in the immediate management of issues during the pandemic and also during the longer-term aftermath, we need fast-track implementation of evidence-based medicine techniques in mental health to supply the best evidence to clinicians on specific questions in real time.”

Finally, in the third selection, we look at an essay from The New Yorker. Reporter Masha Gessen argues that psychiatric wards are particularly vulnerable during the pandemic. Gessen speaks to several doctors who offer a similar if haunting story: “how a lack of testing, P.P.E., and seclusion protocols were making a difficult task – maintaining the safety of a highly vulnerable population and their care workers during a pandemic – virtually impossible.”

DG

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Reading of the Week: More Sleep, Fewer Suicidal Thoughts? New AJP Paper; Also, Is Depression like Cancer (NYT)? Admissions & Ethnic Minorities (EPS)

From the Editor

Can a sleep intervention reduce suicidal thoughts in those with depression and insomnia?

When seeing people with depression, we often tend to focus on the Big Problem: that is, the major depressive disorder itself. But should we also consider trying to provide early symptomatic relief, with, say, a sleep medication?

In the first selection, we look at a new paper from The American Journal of Psychiatry. Dr. William V. McCall of the Medical College of Georgia at Augusta University and his co-authors write about the REST-IT study, a randomized controlled trial of zolpidem-CR for those with MDD and insomnia. “The results do not support the routine prescription of hypnotic medication for mitigating suicidal ideation in all depressed outpatients with insomnia…”

sleeping-babySleeping Like a Baby: Fewer Suicidal Thoughts?

In the second selection, the University of Western Ontario’s Rebecca Rodrigues and her co-authors consider involuntary psychiatric admissions and ethnic minority groups in the context of early psychosis. Spoiler alert: “African and Caribbean groups were the most likely to experience an involuntary admission…”

And in the third selection, phyisician Jill Halper wonders: is depression like cancer? “My rabbi said that my husband, like a dying cancer patient, had been in hospice care. We just didn’t realize it.”

DG

 

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Reading of the Week: Cutting-Edge Care – Esketamine for Depression (NEJM), Digital Psychiatry for Suicide Prevention (JAMA Psych), Asylums for All (AJP)

From the Editor

This time of year, many doctors take to social media to offer advice to young colleagues as they start their specialty training (#TipsForNewDocs). Generally, the tweets give solid suggestions on everything from the importance of mentorship to doing regular exercise. For those new grads beginning psychiatry training, I offer: read more, the field is evolving. Since I started my psychiatry residency 19 years ago this month, we have seen new antidepressants placed into the drug cabinets of our patients, mental-health apps populate their smart phones, and clinical guidelines enter our practices, helping us better manage their mental illness.

This week’s Reading focuses on cutting-edge care, and there is plenty to read.

In our first selection, we consider a new paper from The New England Journal of Medicine. Written by Dr. Jean Kim and four other FDA officials, the authors discuss esketamine for depression. “The drug represents an important addition to the treatment options for patients with treatment-resistant depression.”

nasal-spray-sEsketamine: from club drug to depression care

In our second selection, Dr. John Torous (of Harvard Medical School) and Rheeda Walker (of the University of Houston) consider digital psychiatry and suicide prevention, reviewing the field with cautious optimism. The paper opens with a single sentence that puts these efforts in perspective: “Because the rates of suicide attempts and deaths have recently increased to 50-year highs,new solutions are needed.”

And, in our third selection, we look at a not-so-new editorial from The American Journal of Insanity that calls for better treatment of the poor.

Enjoy.

DG

 

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