H&P/ SOAP notes:
Journal Article and Summary:
The experimental effects of psilocybin on symptoms of anxiety and depression- A meta-analysis.
This article was published very recently in 2020, in Psychiatry Research, on the effects of “magic” mushrooms or psilocybin on anxiety and depression. Psilocybin is a plant alkaloid and 5-HT2A-receptor agonist, and has been looked at for treatment of anxiety, depression, and substance abuse. The authors wanted to conduct a meta-analysis of clinical trials testing psilocybin for anxiety and depression symptoms. They searched multiple databases from PubMed, PsycInfo, Scopus, Web of Science, Cochrane, recent systematic reviews, and clinicaltrials.gov. From their search a total of 864 articles were identified, however 370 were duplicates, 386 were not clinical trials, 65 did not have a relevant diagnosis, 18 did not use psilocybin, and 6 had no quantitative data. Then 19 full text articles were screened and 14 were excluded, thus only five studies (with four unique trials) were identified as eligible and included in their analysis. Across the four studies a total of 69 patients were analyzed.
One trial used a single group design and three were RCTs. Sample sizes were small (M = 29.25, SD = 19.14). Post-treatment assessment occurred on average at 3.75 weeks (SD = 2.75) and all follow-up occurred at six months. Three trials occurred in the United States and one in the United Kingdom. Risk of bias was assessed and it was found that all studies had a high risk of detection bias due to the limited blinding possible because of the nature of psilocybin. Additionally performance bias and attrition bias were found to be high in a few of the studies however reporting bias is low. Beck Depression Inventory, State-Trait Anxiety Inventory, along with other outcome measures in the studies was used to quantify effects on anxiety and depressive symptoms.
Across the four studies before and after (pre-post) effect sizes had shown a large reduction of anxiety and depression with use of psilocybin and heterogeneity was high. From the three placebo controlled studies it also indicated large reductions of anxiety and depression. Additionally at six-month follow-up for the four studies showed a large reduction in anxiety and depression. Overall the meta-analysis evaluating the effects of psilocybin with supportive behavioral intervention on anxiety and depression found reduction in anxiety and depression symptoms. However there was some risk of bias across the studies thus more studies are needed to examine the effects of psilocybin on anxiety and depression. Limitations of this meta-analysis include a small number of studies and sample size was available. This may limit the reliability of observed effects and being a small sample there are biases. Three of the four studies included individuals with terminal cancer diagnoses, which may not represent anxiety and depression generally. Limited racial/ethnic diversity reduces generalizability. In conclusion the article had some strong statistical analysis suggesting that psilocybin in combination with behavioral support may provide a safe and effective treatment option for reducing symptoms of anxiety and depression. Thus this is an area for additional careful, scientific study.
Site Evaluation Presentation Summary:
For both the mid and final evaluations, it was conducted on a group ZOOM meeting with other classmates in their Psychiatry rotation. Fortunately I had the pleasure to work with four of them in Queens Hospital Centers Comprehensive Psychiatric Emergency Program (CPEP). For the mid evaluation I presented a patient who was bipolar who presented to CPEP with bizarre behavior and suicidal ideation. Concurrently the patient also has a history of drug abuse, most notably cannabis and more recently LSD. Although the patient had a support system being his mother and therapist, patient still preferred illicit drugs to prescription drugs for control of mood symptoms. It was interesting learning how to conduct a Mental Status Exam and trying to paint the picture of the patient. It the end the patient was admitted for inpatient treatment and cognitive behavioral therapy. However a questions that arose were whether it would be considered poly substance or more so cannabis abuse, and if the patient was Bipolar or more so Major Depression disorder with psychotic features.
During the final evaluation, we met again on ZOOM where each student had to present one case and also a journal article based on one of our cases. It was interesting to hear my peers interaction, patient selection and course of treatment along with their journal articles. I had presented a disorganized, disheveled woman who was 45 but looked much older, who was missing for almost two weeks from her supportive housing, and was beaten up recently. This was one of those cases where you couldn’t get much information from the patient, whom had poor insight and impulse about her medical conditions. I had to contact her sister and her caseworker to get the full story of the patient. As she was exhibiting acute psychotic features and erratic behavior thus at risk to harm self and others she warranted admission to CPEP for observation and stabilization. My journal article was on the treatment of Catatonia with lorazepam or electro convulsive therapy (ECT) or both. It was a cohort study that looked at treatment outcomes of 6o patients who were diagnosed with Catatonia. Overall Lorazepam is a reasonable initial choice in the treatment of catatonia, with rapid consideration for ECT if there is no rapid response to lorazepam. Since about 70% of patients did not resolve their catatonic state with lorazepam and thus need ECT. It was interesting to learn from Dr. Saint Martin that although textbook may say ECT is good treatment for certain conditions, it is not readily available in New York as there are those against this treatment.
Typhon Log:
Self-Reflection:
Going into my psych rotation I was not sure what to expect. Professor Alie who is our preceptor and also works at Queens Hospital Center’s Comprehensive Psychiatric Emergency Program (CPEP) had told us great stories in class. Students have also told me their experiences and how they felt like they were in a “fish bowl” just watching the patients around them. I was lucky to work with other classmates of mine, so I always had a familiar face, also working a daytime shift was different than working an evening or night shift. It was usually busy in the morning, because all the patients would be reevaluated and a new disposition decision was made. However evening and nights would be more patient management and going on consults. Working during the day we were able to work with not only PA’s but also psychiatrists. Everyone had there own style and it was very interesting to learn how they dealt with patients, and what they found important and how that influenced their decision on medications or admission, discharge etc. From day one we learned that Psychiatry is different from other specialties in that no review of systems or physical exam is done, instead what is important is the Mental State Exam (MSE), which is an important part of the clinical assessment process in neurological and psychiatric practice. The MSE is the psychological equivalent of a physical exam that describes the mental state and behaviors of the person being seen. It includes both objective observations of the clinician and subjective descriptions given by the patient. This was what the students were tasked with and at first it was difficult because it can be subjective, but it was also entertaining to try and describe the patient. They say that a good MSE is when someone else reads it and is able to point out this patient in a crowd. Sometimes we worked in groups so it was great to see what others assessments would be of the same patient.
Having students from other programs kind of made it difficult to work with certain providers as preference or reservations were made. It was intimidating not only for the staff but us as well since there would be a total of about five to seven students working during the day, but less on weekends. Something I appreciated was that they always put safety first, being in this environment they stressed that patients may become unpredictable and that they have had horror stories before. So they always told us to buddy up with a provider or student when seeing patients. Additionally I always felt that they had us in mind when interviewing patients, ensuring our safety.
I would definitely say that with mental illness on the rise, it was definitely a worthwhile experience and a field I would consider working in. There is always a stigma in psychiatry but I feel that patients may be dealing with a lot of psychosocial stressors that may attribute to their poor health. Thus as clinicians we should not dismiss any concerns or reservations that arise and treat them as we would a medical illness. This rotation has definitely given me greater insight and appreciation for the field of psychology.
Final Mini-CAT:
Mini-Cat – Aspirin and the Prevention of Spontaneous Preterm Birth – Final
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