Virtual Journal Club--Week of November 21, 2016

This is a new submission from NNCI (National Neuroscience Curriculum Initiative) which I found interesting: Modern Microglia: Novel Targets in PsychiatricNeuroscience, by Jennifer B. Dwyer and David A. Ross.

From the authors: "Neuroscience is all about neurons, right? Psychiatric neuroscience has often viewed the relative health or dysfunction of neurons as the key to mental health or disease. While we've long known about other cells in the brain, we're only now starting to appreciate their potential roles in psychiatric disorders.

Glia were classically considered the support cells of the brain, merely inert structural “glue” as their name suggests. Modern neuroscience, however, has begun to appreciate a more active, and at times critical role, for these cell types in a variety of important neural processes. Here we discuss the function and significance of microglia, particularly as they relate to mental health and disease. These hard working cells provide a new set of possible therapeutic targets and suggest that psychiatric neuroscience is about more than just neurons."

http://www.biologicalpsychiatryjournal.com/article/S0006-3223(16)32667-1/pdf

Virtual Journal Club--Dealing with Patient Suicides

The excellent Morning Report presentation by Dr. Bauer today raised two main issues: 1) the nuts and bolts of detailed suicide assessment, and 2) how do we as psychiatrists cope when despite our best efforts, a patient succumbs to their disease. Most of you have seen the DVD "Collateral Damage", discussing the impact of this event on psychiatrists at all levels of their careers. I also want to upload a very good, wrenchingly personal article from Michael Gitlin, A Psychiatrist’s Reaction to a Patient’s Suicide. I found it quite helpful in working through my first experience with this unfortunate outcome as a senior resident.

Let me also take this opportunity to encourage you all to continue to talk with one another and with your supervisors about how things are really going with your patients. This, especially the supervision time, is a time and place in which it should be safe to express doubts and fears, and OK to be wrong.

Please don't hesitate to approach me or another faculty member with your concerns.

Michael Gitlin, A Psychiatrist’s Reaction to a Patient’s Suicide.

Virtual Journal Club--Week of November 14, 2016

Some heavier reading this week, in keeping with the Milestones for somatic therapies this month.

How do you determinine if an antipsychotic medication will work? What outcome measures will you use? Is there some way to tell whether Medication A will be better than Medication B, and if so how--and how clinically meaningful is that difference.

Attached is a large randomized open trial, Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial, (René S Kahn*, W Wolfgang Fleischhacker*, Han Boter, Michael Davidson, Yvonne Vergouwe, Ireneus P M Keet, Mihai D Gheorghe, Janusz K Rybakowski, Silvana Galderisi, Jan Libiger, Martina Hummer, Sonia Dollfus, Juan J López-Ibor, Luchezar G Hranov, Wolfgang Gaebel, Joseph Peuskens, Nils Lindefors, Anita Riecher-Rössler, Diederick E Grobbee, for the EUFEST study group†.  Lancet 371: 1085-97, 2008), that asks these questions. Note too, the role of adherence and discontinuation in the outcomes. As I've often said, "the best medication for the patient is the one that they actually take".

The second article is a major metaanalysis comparing antipsychotic medications against one another (and placebo). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. (Stefan Leucht, Andrea Cipriani, Loukia Spineli, Dimitris Mavridis, Deniz Örey, Franziska Richter, Myrt. Lancet 382: 951-62, 2013) I'm simply impressed with the scope of this. Who comes out ahead, and why? The exercise is left to the reader, as they say.

Effectiveness of antipsychotic drugs... Kahn, et al.
Comparative Efficacy..., Leucht, et al.

November Milestones of the Month--PC5 and MK5

November's Milestones emphasize our knowledge and practice of somatic therapies--perhaps what most of us consider the core knowledge of psychiatry. By now you'll be pretty familiar with the gradual development of skills from Novice to Expert. Think about your last 3 or 4 medication management patients--where would you rate the complexity of your management on these scales? Would there be an opportunity to delve more deeply into mechanisms or algorithms based on the clinical problems you're trying to solve right now?  I encourage you to see each patient as an opportunity to learn and grow a little bit.