The Wayback Machine.

We suffer from a radical autonomy which too often collapses the therapeutic alliance between patient and physician into a health-care transaction between consumer and provider, a fee-for-service exchange for something far short of true health. Some ethicists and physicians are seeking a better way, by employing a virtue ethics approach in which health is seen as a distinct good and the proper end of a medical encounter. Curlin and Tollefsen's The Way of Medicine (2021) synthesizes this material into a heuristic contrasting what they characterize as the Provider Services Model and the Way of Medicine. The authors believe physicians must choose between the two models and serve, respectively, either the well-being or the health of the people they meet as patients. Between the authors' dichotomous choices, many physicians will find a middle way in virtue ethics approaches, which instead characterize health as a communal foundation to human flourishing and autonomy as serving communal as well as individual goods.

Health Equity Is No Spectator Sport: The Radical Rooting of a Post-Pandemic Bioethics.

The relationship between equality and equity has been theorized and described in many ways. Recently, this relationship has been popularly illustrated via a meme depicting three people watching a baseball game while standing on boxes. The meme's analogy, that achieving health equity is the ability to view a spectator sport, is a neoliberal account of health. The analogy defines equality at the expense of equity, characterizes health as individualistic, describes health equity as a static outcome, and implies that the bioethical questions for achieving health equity are about the distribution and redistribution of resources. As the SARS CoV-2 pandemic vividly reminded us, health equity is no spectator sport. Health equity is the intentional removal of obstacles to health and the enabling of human flourishing to assure that everyone has fair and just opportunities for health. That relational and radical account of health equity requires different analogies. This article reimagines and re-illustrates the relationship between equality and equity using an organic analogy of three plants. The analogy calls for bioethics to nurture communal relationships and engage community leaders in pursuit of communal flourishing.

Combating Contagion and Injustice: The Shared Work for Public Health and Faith Communities During COVID-19.

Faith communities are uniquely positioned for essential public health work to combat the COVID-19 pandemic and address the chronic pre-existing health disparities that have been exacerbated by COVID-19. Specifically, faith communities can (1) dialogue with public health communities, developing internal policies and meeting guidelines consistent with evidence-based recommendations and their own faith traditions, (2) bolster religious daycare and parochial school immunization policies, and (3) partner with faith-based organizations through financial support and volunteer hours. This essential work will complement governmental public health approaches and ensure faith communities can assist with future pandemics.

Questionable Agreement: The Experience of Depression and DSM-5 Major Depressive Disorder Criteria.

Immediately before the release of DSM-5, a group of psychiatric thought leaders published the results of field tests of DSM-5 diagnostic criteria. They characterized the interrater reliability for diagnosing major depressive disorder by two trained mental health practitioners as of "questionable agreement." These field tests confirmed an open secret among psychiatrists that our current diagnostic criteria for diagnosing major depressive disorder are unreliable and neglect essential experiences of persons in depressive episodes. Alternative diagnostic criteria exist, but psychiatrists rarely encounter them, forestalling the discipline's epistemological crisis. In Alsadair MacIntyre's classic essay, such crises occur in science when a person encounters a rival schemata that is incompatible with their current schemata and subsequently constructs a narrative that allows them to reconstruct their own tradition. In search of rival schemata that are in conversation with their own tradition, psychiatric practitioners can utilize alternative diagnostic criteria like the Cultural Formulation Interview, embrace an epistemologically humble psychiatry, and attend to the narrative experience of a person experiencing a depressive episode.

Alternatives to War Within Medicine: From Conscientious Objection to Nonviolent Conflict About Contested Medical Practices.

When we figure medical practice as warfare, an individual clinician may be either a dutiful combatant or a conscientious objector. The rhetorical structure of this choice means that clinicians may exercise their consciences by loyally joining or disloyally exiting the medical ranks' battle against disease. But there are alternatives to loyalty and exit, and within psychiatry, these alternatives have transformed clinical services. In the 1970s, gay activists successfully resisted the American Psychiatric Association's characterization of homosexuality as a mental illness. In the 1940s, Mennonite nonresisters created the Mennonite mental health movement as a noncoercive alternative to standard psychiatric care. These gay activists and Mennonite volunteers opened communal alternatives to violence. When clinicians pursue nonviolent conflict about contested medical practices, they practice with the integrity that develops out of engaging in moral dialogue. Medicine becomes something more than a war in which individuals serve or to which they object: instead, it becomes a prudential set of practices that advance through principled disagreements and that expand the imagination of clinicians as they respond to the vulnerability of the people they meet as patients.

The association of cannabis use on inpatient psychiatric hospital outcomes.

BACKGROUND: The associations between cannabis use and psychosis are well documented in numerous studies. There is a need to evaluate the impact of cannabis use on inpatient psychiatric utilization and outcomes. OBJECTIVES: To evaluate the impact of cannabis use on psychiatric hospital outcomes. METHODS: This study was conducted between April 20, 2015 and October 20, 2015. All patients (n = 120) admitted to Denver Health with psychotic symptoms were administered a urine toxicology screening testing for the presence of 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH, the active metabolite of cannabis). Patients with positive tests were compared to those with negative tests on several measures, including length of stay, presence or lack of 30-day readmission, Brief Psychotic Rating Scale (BPRS) score, and use of antipsychotics and/or sedatives/anxiolytics. RESULTS: There were 120 patients. Twenty nine were women and 91 were men. Patients testing positive for THC-COOH had a shorter length of stay compared to patients testing negative for THC-COOH, after adjusting for age, prior psychiatric admissions, history of a psychotic-spectrum disorder, and comorbid additional substance use (p = 0.02). There were no differences in 30-day readmissions, 30-day post-discharge presentation to the Denver Health psychiatric emergency department, BPRS scores, and medication administration. CONCLUSION: Patients presenting with psychotic symptoms and cannabis use require shorter inpatient psychiatric hospitalizations. This study is the first to quantify this observation and highlights the need for future clinical decision-making tools that would ideally correlate cannabis use with the degree of potential need for expensive and scarce mental health resources, such as psychiatric hospitalization.

Trains Departing from Different Stations: Being Mortal and Dying in the 21st Century.

While physician-writers and medical humanists both characterize contemporary deaths as train wrecks, they sometimes disagree about what causes such consistent wreckage. In Being Mortal (2014), the surgeon-writer Atul Gawande attributes the wreckage to forces that so reduce aging and dying persons' autonomy that they prevent those persons from being themselves. For the leading medical humanists in Dying in the Twenty-First Century (2015), edited by Lydia Dugdale, it is our emphasis on autonomy over interdependence that causes contemporary death and dying to go off the rails. To understand the gap between these two accounts, their implicit conversation is compared to the explicit dialogue between a previous generation's leading surgeon-writer and medical humanists: How We Die (1993) by Sherwin Nuland and Facing Death (1996), edited by Howard Spiro and colleagues.

Use and diversion of medical marijuana among adults admitted to inpatient psychiatry.

BACKGROUND: Marijuana use is associated with anxiety, depressive, psychotic, neurocognitive, and substance use disorders. Many US states are legalizing marijuana for medical uses. OBJECTIVE: To determine the prevalence of medical marijuana use and diversion among psychiatric inpatients in Colorado. METHODS: Some 623 participants (54.6% male) responded to an anonymous 15-item discharge survey that assessed age, gender, marijuana use, possession of a medical marijuana card, diversion of medical marijuana, perceived substance use problems, and effects of marijuana use. Univariate statistics were used to characterize participants and their responses. Chi-square tests assessed factors associated with medical marijuana registration. RESULTS: Of the total number of respondents, 282 (47.6%) reported using marijuana in the last 12 months and 60 (15.1%) reported having a marijuana card. In comparison to survey respondents who denied having a medical marijuana card, those respondents with a medical marijuana card were more likely to have initiated use before the age of 25, to be male, to have used marijuana in the last 12 months, and to have used at least 20 days in the past month. 133 (24.1%) respondents reported that someone with a medical marijuana card had shared or sold medical marijuana to them; 24 (41.4%) of respondents with a medical marijuana card reported ever having shared or sold their medical marijuana. CONCLUSION: Medical marijuana use is much more prevalent among adults hospitalized with a psychiatric emergency than in the general population; diversion is common. Further studies which correlate amount, dose, duration, and strain of use with particular psychiatric disorders are needed.

Does the legalization of medical marijuana increase completed suicide?

INTRODUCTION: Suicide is among the 10 most common causes of death in the United States. Researchers have identified a number of factors associated with completed suicide, including marijuana use, and increased land elevation. Colorado is an ideal state to test the strength of these associations. The state has a completed suicide rate well above the national average and over the past 15 years has permitted first the medical and, as 2014, the recreational use of marijuana. OBJECTIVES: To determine if there is a correlation between medical marijuana use, as assessed by the number of medical marijuana registrants and completed suicides per county in Colorado. METHODS: The number of medical marijuana registrants was used as a proxy for marijuana use. Analysis variables included total medical marijuana registrants, medical marijuana dispensaries per county, total suicide deaths, mechanism of suicide death, gender, total suicide hospitalizations, total unemployment, and county-level information such as mean elevation and whether the county was urban or rural. Analysis was performed with mixed model Poisson regression using generalized linear modeling techniques. RESULTS: We found no consistent association between the number of marijuana registrants and completed suicide after controlling for multiple known risk factors for completed suicide. CONCLUSION: The legalization of medical marijuana may not have an adverse impact on suicide rates. Given the concern for the increased use of marijuana after its legalization, our negative findings provide some reassurance. However, this conclusion needs to be examined in light of the limitations of our study and may not be generalizable to those with existing severe mental illness. This finding may have significant public health implications for the presumable increase in marijuana use that may follow legalization.

Enriching Spiritual Care in Medical Residents Through Cultural Humility and Courage.

Introduction: While many patients desire spiritual care, it is infrequently provided by physicians. When a model of cultural humility and courage is employed, resident physicians can be introduced to the spiritual care of patients. Methods: We developed this 90-minute, onetime session to speak directly to resident physicians about the relationships between medicine and spirituality and the nature of spiritual care. In the session, we facilitated residents in reflecting on their current posture toward spiritual care while addressing its evidence, obstacles, and timing. We also discussed the need for cultural humility and courage as we followed spiritual care to its root: guiding a person in finding meaning in their current circumstances. Results: We presented this interactive session to 35 internal medicine residents from all four training years. All residents responded to an embedded pre- and postsurvey question modeled after four attitudes towards spiritual care: rejecting, guarded, pragmatic, and embracing. Out of 22 residents who did not report embracing spiritual care in the presession survey, 10 (45%) reported a more positive attitude toward spiritual care on their postcourse surveys. Twenty-seven residents in attendance (77%) also provided feedback about presentation quality, with a mean rating of 4.7 out of 5 indicating overall satisfaction. Discussion: A single well-received session on spiritual care for medical residents models the integration of relevant spiritual care curricula into residency training. The resulting module can be modified for physicians of any specialty or seniority and complemented by other skill-based spiritual care curricula.

Implementation of dedicated social worker coaching for emergency medicine residents - Lessons learned.

Emergency medicine training is associated with high levels of stress and burnout, which were exacerbated by the COVID-19 pandemic. The pandemic further exposed a mismatch between trainees' mental health needs and timely support services; therefore, the objective of our innovation was to create an opportunity for residents to access a social worker who could provide consistent coaching. The residency leadership team partnered with our graduate medical education (GME) office to identify a clinical social worker and professionally-trained coach to lead sessions. The project was budgeted at an initial cost of $15,000 over 1 year. Residents participated in 49 group and 73 individual sessions. Post implementation in 2021, we compared this intervention to all other wellness initiatives. Resident response rate was 80.88% (n = 55/68) and median interquartile range (IQR) score of the initiative was 2 (1 = detrimental and 4 = beneficial) versus 3.79 (3.69-3.88) the median IQR of all wellness initiatives. A notable number, 22%, rated the program as detrimental, which could be related to summary comments regarding ability to attend sessions, lack of session structure, loss of personal/educational time, and capacity of the social worker to relate with them. Summary comments also revealed the innovation was useful, with individual sessions preferred to group sessions. Application of a social worker coaching program in an emergency medicine residency program appears to be a feasible novel intervention. Lessons learned after implementation include the importance of recruiting someone with emergency department/GME experience, orienting them to culture before implementation and framing coaching as an integrated residency resource.

Paliperidone palmitate for schizophrenia.

BACKGROUND: Paliperidone palmitate, a long-acting, intramuscular formulation of paliperidone, is now available for clinical use. Paliperidone is an active metabolite of risperidone and it is also available in an oral formulation for daily use. OBJECTIVES: To compare the effects of paliperidone palmitate with any other treatment for people with schizophrenia and schizophrenia-like illnesses. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Register (November 2009) and inspected references of identified studies for further trials. We contacted the manufacturers of paliperidone palmitate, the Food and Drug Administration, and authors of relevant trials for additional material. SELECTION CRITERIA: We included randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS: We independently selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate, we calculated risk ratios (RR) and their 95% confidence intervals (CI) with the number needed to benefit/harm statistic (NNB/H). We calculated mean differences (MD) for continuous data. MAIN RESULTS: Five studies with 2215 participants compared paliperidone palmitate with placebo. Fewer people left studies early if they were randomised to paliperidone palmitate (n = 2183, 5 RCTs, RR 0.76 CI 0.70 to 0.84, NNTB 9 CI 7 to 14) and those receiving any dose of paliperidone palmitate were significantly less likely to show no improvement in global state (n = 1696, 4 RCTs, RR 0.79 CI 0.74 to 0.85, NNTB 7 CI 5 to 9). People randomised to paliperidone palmitate were less likely to experience a recurrence of psychosis (n = 312, 1 RCT, RR 0.28 CI 0.17 to 0.48, NNTB 5 CI 4 to 6) than those allocated to placebo in a single trial specifically designed to study recurrence. In the other studies where recurrence was recorded only as an adverse event, we found that people who received paliperidone palmitate were also less likely to experience a recurrence of psychotic symptoms (n = 1837, 4 RCTs, RR 0.55 CI 0.44 to 0.68, NNTB 10 CI 8 to 14).  Paliperidone palmitate was associated with fewer reports of agitation or aggression (n = 2180, 5 RCTs, RR 0.65 CI 0.46 to 0.91, NNTB 39 CI 25 to 150) and of using anxiolytic medications (n = 2170, 5 RCTs, RR 0.89 CI 0.83 to 0.96, NNTB 16 CI 11 to 44). A consistent, significant elevation in serum prolactin (ng/mL) was found for both men and women receiving paliperidone palmitate, but the data were too heterogenous to sum. We found no evidence of sexual dysfunction in these short-term trials. People receiving paliperidone palmitate had a significantly greater increase in weight (n = 2052, 5 RCTs, MD 1.34 CI 0.97 to 1.70) in comparison with people who received placebo.Two studies with 1969 participants compared flexibly-dosed paliperidone palmitate with flexibly-dosed risperidone long-acting injection. The mean doses of paliperidone palmitate in these trials were 73.3 and 104.6 mg every four weeks compared with risperidone long-acting injection at mean doses, respectively, of 35.3 and 31.7 mg every two weeks. We found no differences between paliperidone palmitate and risperidone long-acting injection for leaving these studies early for any reason (n = 1969, 2 RCTs, RR 1.12 CI 1.00 to 1.25). Those receiving paliperidone palmitate were statistically no more likely to have a recurrence of psychotic symptoms than those receiving risperidone long-acting injection (n = 1961, 2 RCTs, RR 1.23 CI 0.98 to 1.53). While we found no significant difference in the occurrences of deaths in the pooled trials (n = 1967, 2 RCTs, RR 3.62 CI 0.60 to 21.89), we note that a total of six deaths occurred in these two trials, with five deaths among people who received paliperidone palmitate and one death among people who received risperidone long-acting injection. Although death is the most serious of adverse events, the small number of these events in these trials makes it unclear if this finding is meaningful. We found that participants randomised to paliperidone palmitate were significantly less likely to use anticholinergic medications in these trials (n = 1587, 2 RCTs, RR 0.67 CI 0.55 to 0.82, NNTB 13 CI 10 to 24). We found no data regarding paliperidone palmitate relating to services use, quality of life, behaviour, patient satisfaction, cognitive functioning or cost. AUTHORS' CONCLUSIONS: In short-term studies, paliperidone palmitate is an antipsychotic drug that is more efficacious than placebo. We found its adverse effects to be similar to those of its related compounds, paliperidone and risperidone, with extrapyramidal movement disorders, weight gain, and tachycardia all more common with paliperidone palmitate than placebo. While no difference was found in the incidence of reported adverse sexual outcomes, paliperidone palmitate is associated with substantial increases in serum prolactin. When flexibly dosed with a mean doses of approximately 70 to 110 mg every four weeks, paliperidone palmitate appears comparable in efficacy and tolerability to risperidone long-acting injection flexibly dosed with mean doses of approximately 35 mg every two weeks.  

The Mennonite mental health movement: discipleship, nonresistance, and the communal care of people with mental illness in late 20th-century America.

Historians typically describe the 3000 World War II conscientious objectors who served in American psychiatric hospitals and training schools in the Civilian Public Service (CPS) as "people of conscience." This phrase captures the diverse motivations of the conscientious objectors but neglects the differences among these motivations. Members of several communities served in the CPS, but half of all volunteers in mental health facilities were Mennonites. After the war, only Mennonite CPS veterans engaged their own community in a discussion about their responsibilities to people with mental illness, which led directly to the foundation of eight mental health facilities, seven of which continue to serve people with mental illness. In this review of materials published by Mennonites, we explore the difference that Mennonite religious ideology, especially the ideas of discipleship and nonresistance, made in their response to people with mental illness. Understanding these differences is critical for any attempts to replicate their success in engendering community care, in which direct conversation and encounter are critical.

"But my doctor recommended pot": medical marijuana and the patient-physician relationship.

As the use of medical marijuana expands, it is important to consider its implications for the patient-physician relationship. In Colorado, a small cohort of physicians is recommending marijuana, with 15 physicians registering 49% of all medical marijuana patients and a single physician registering 10% of all patients. Together, they have registered more than 2% of the state to use medical marijuana in the last three years. We are concerned that this dramatic expansion is occurring in a setting rife with conflicts of interest despite insufficient scientific knowledge about marijuana. This system diminishes the patient-physician relationship to the recommendation of a single substance while unburdening physicians of their usual responsibilities to the welfare of their patients.

The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives.

INTRODUCTION: Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies. METHODS: Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories. RESULTS: Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value-based care, well-being). Lastly, strategies for integrating each dyadic mission pair, including research-education, clinical operations education, and research-clinical operations, were identified. CONCLUSIONS: Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.

Held Against Our Wills: Reimagining Involuntary Commitment.

Involuntary psychiatric treatment for people with serious mental illness should focus on returning to health instead of reducing danger.

What You Need to Know About Cannabis: An Evidence-Based Crash Course for Mental Health Trainees.

Introduction: Although increasing numbers of states are legalizing cannabis for both medical and recreational purposes, health care providers and students report low comfort levels and limited knowledge regarding cannabis, highlighting current deficits in medical training. Methods: We developed a structured cannabis curriculum for a general psychiatry residency program at the University of Colorado. In constructing our curriculum, we initially surveyed advanced psychiatry residents and attending psychiatrists in the university outpatient clinic regarding attitudes and approaches to psychiatric patients using cannabis. Prior to implementation in the following year's core curriculum for first-year postgraduates (PGY 1s), pretest assessments evaluated PGY 1s' attitudes towards cannabis use and identified learning expectations, challenges, and confidence levels. After the seminars were completed, residents provided posttest assessments and general course evaluations. Utilizing initial survey information, we constructed a Marijuana and Medicine introduction curriculum for psychiatry PGY 1s. Topics included strains and formulations, pharmacokinetics, the endocannabinoid system, local Colorado laws, monitoring, evidence regarding use in psychiatric disorders, use in pregnancy, and ethical issues. These topics were covered via case-based discussion, interactive quizzes, direct instruction, and facilitated discussion. Results: Posttest assessments indicated improvement in trainees' confidence and knowledge base and requests for additional instruction on topics such as adolescent use. Discussion: The positive posttest assessments support the value of incorporating a cannabis curriculum into psychiatric training. Now in its second year, the course has been expanded to 4 hours. As cannabis is medicalized, it is increasingly important that psychiatrists be able to knowledgably counsel their patients.