Richard Berlin, MD, shares poetry from Billy Collins about the death toll of the pandemic. In this poem, Collins writes the names of lost friends on the flip side of the grocery list. 

has been writing a poem about his experience of being a doctor every month for the past 23 years in

in a column called "Poetry of the Times." He is Instructor in Psychiatry, University of Massachusetts Medical School, Worcester, MA.

Videos

Poet Billy Collins writes the names of friends lost to COVID-19 on the back of his grocery list. 

Flip Side of the Grocery List

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair.” – Charles Dickens, 

The year 2020 will go down in the history books as a period of unusual and challenging times. Nevertheless, as H. Steven Moffic, MD, and our editor in chief, 

, point out in their respective articles in this issue, it was a year of opportunities, growth, bravery, and renewed commitment.

, Special Report chair, notes that despite much progress in treating the core symptoms of serious mental illness, cognitive issues sometimes get overlooked. Addressing these lingering problems improves patients’ quality of life, he adds. After all, everyone is trying to make sense of the world, even (or especially) in the year 2020. To better support you and your patients, Hartej Gill; 

, explore ways to assess and address the cognitive deficits that often accompany psychiatric illnesses.

Throughout this troubled year, we have learned so much that will allow us to improve ourselves and our world, as well as patients with psychiatric disorders. To that end, 

, shares lessons gleaned from the pandemic in hopes of helping her colleagues better assist patients as the pandemic evolves. Similarly, the Schizophrenia in the News feature offers a reminder that moving the research agenda forward has remained a priority, with a better understanding of psychiatric illnesses and novel agents to treat psychiatric disorders in the works.

Dickens’ sentiments seem to ring true, but perhaps he understood only part of it. It is not that the glass is half empty or even that it is 

. Instead, the glass is vast—and that requires us to work harder to find ways to keep it filled. At 

, our goal is to keep filling your cup of knowledge with a plethora of important, interesting, and useful clinical information to best enlighten you as you care for your patients.

With that, we wish you and yours a joyous holiday season and hopes for a happy, healthy, and fulfilling 2021! ❒

Articles

Throughout this troubled year, we have learned much that will allow us to make the world a better place. 

A Dickens of a Year

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

 is distinguished professor of Clinical Psychology at Stony Brook University, NY. He is cofounder of the Society for the Exploration of Psychotherapy Integration. He is a Past President of the Society for Psychotherapy Research and has received numerous awards and honors, including the American Psychological Association (APA) award for Distinguished Contributions to Knowledge. He has authored and co-edited several books, including the third edition of Handbook of Psychotherapy Integration (Oxford University Press, 2019, co-edited with John C. Norcross).

Dr Goldfried’s work in psychotherapy integration and common principles of change has been of great fascination to me. The central idea behind psychotherapy integration is that there are common principles, shared change processes, that transcend particular theoretical orientations in psychotherapy, and account for the effectiveness of many different psychotherapeutic interventions. I am grateful for his presence on 

, which has allowed many such as myself to be exposed to his rich ideas and his vision for a mature science of psychotherapy. As a psychiatrist with an interest in psychotherapy, I find these developments to be of great relevance to all psychiatric clinicians. 

, who introduced me virtually to Dr Goldfried, first met him when they served together, 40 years ago, on the National Institute of Mental Health (NIMH) committee that funded the early studies of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Dr Francis is convinced that the few millions of dollars spent on psychotherapy research have done far more to improve patients’ lives than all the tens of billions since spent by NIMH on neurobiological research, which has offered some fascinating insights but has yielded little of clinical benefit so far. “Marvin's career-long effort to integrate the various schools of psychotherapy, and to establish what is most essential to successful outcome, is the wave of the future in psychotherapy practice and research” (personal communication with Dr Francis, October 2020).

 that “although the field of psychotherapy has been in existence for well over a century, it nonetheless continues to be preparadigmatic, lacking a consensus or scientific core. Instead, it is characterized by a large and increasing number of different schools of thought.”

 Although you are talking specifically about psychotherapy, I feel it would not entirely be inaccurate to generalize this to the mental health professions at large. Ken Kendler described psychiatry somewhat similarly in 

: “Kuhn argues that to be considered a mature science, a field has to agree on a basic scientific paradigm. Psychiatry, by this criterion, would be in an immature ‘preparadigmatic’ state.”

 I personally find the realization that we are still in preparadigmatic state to be rather sobering. It cuts through a lot of the bravado that we see around us. I think as long as we remain in a situation where mutually antagonistic, non-interacting theoretical camps are fighting with each other for dominance and resources, we are not likely to see a maturation of the field. You have written much about psychotherapy, and we will discuss that shortly, but do you have any thoughts on the overall state of the psy-professions?

 Sociologists who studied the scientific enterprise originally thought the scientist was a totally objective and neutral being. Actual research on scientific behavior has discovered, however, that because scientists were individuals before they were scientists, strong emotions often come into play in their work. It has been clearly documented that scientists compete with each other in various ways. Publishing first is traditionally the goal. It has even been documented that citation practices are selective, and that researchers cherry-pick evidence to support their particular point of view.

Unlike fields in physical medicine, where it is clear whether somebody has a fever or not, or whether they have recovered from a major illness, psychology and psychiatry often have difficulty in agreeing upon criteria for change, ie, the criteria used to conclude that the therapy has worked. For instance, what does it mean that someone has been successfully analyzed? The criteria are often influenced by theoretical schools, and it is hard to get a consensus across theoretical orientations as to whether the treatment has worked.

, “Unfortunately, depending upon whether one is a clinician or researcher, each tends to think that his or her method of advancing the field is superior. The fact of the matter is that both are flawed, and, therefore, they both need to be complemented by the other vantage point.”

 I think there is a similar sort of a gap in psychiatry as well, albeit with its own distinct characteristics. I am reminded of something 

 wrote, “[Instead of] a dichotomy—refined research, which gets at the facts, versus anecdotes, which are often misleading—I saw a spectrum on which sit flawed efforts at objectivity.”

 What do you see as the appropriate relationship between research and clinical practice?

 Within the United States, World War II created a major shift in who delivered psychotherapy. The psychological problems manifested by soldiers required therapy, and the problem was that there were relatively few psychiatrists to meet the very large demand. Consequently, at the end of the war, the NIMH and the Veterans Administration decided that it would be appropriate to train psychologists in the practice of therapy. They had previously been trained as research scientists, with clinical applications consisting primarily of testing. The net result was the development of the scientist-practitioner model, where professional psychologists would train as both researchers and practitioners.

Although the goal of being both a scientist and practitioner was admirable, it has not often played out that way. Consequently, we have researchers who rarely see patients, and clinicians who rely on their theory and clinical experience rather than research. However, if a phenomenon is recognized by clinical observation, and it also has empirical support in the research, I think it has a greater likelihood of being true. Research methodologists call these “converging operations,” where different methods of inquiry are used to study a given phenomenon.

Philosophers of science also make a distinction between the context of discovery and the context of justification. Clinical work can be a context of discovery, where phenomena are observed subjectively, and research then becomes the context of justification, where the researcher attempts to see if the phenomenon exists under conditions of better experimental control.

 In line with the previous question, you have talked about how the gap between psychotherapy research and practice has been a long-standing source of professional distress for you. How have you navigated this gap in your own career as both a clinician and a researcher?

 I have always been dedicated to both research and clinical practice and have managed to do both throughout my career. When we established the clinical psychology program at Stony Brook University back in the 1960s, we constructed it in such a way that faculty members would not only teach and do research, but also serve as clinical supervisors. For myself, I see patients on Tuesdays and often use my clinical observations as examples on Wednesdays and Thursdays when I am working at Stony Brook.

I have experienced situations where what I observed in the clinical situation provided me with hypotheses for conducting research. For example, take the use of systematic desensitization involving both imaginal exposure and relaxation. Some research pointed out that both were necessary in order to be effective. On the basis of my clinical observation, however, some patients were finding relaxation skills alone useful. Apparently, they did not read the research literature! It turned out that in their view, relaxation was not just something that would be a passive activity. It could be used as an active coping skill as well. Consequently, I conducted some research on the issue and demonstrated that a coping skill orientation to relaxation was more effective than treating relaxation as a passive exercise.

 Your comments about clinical work providing hypothesis for research is certainly important and resonates with me a lot. I really like something you said once in 

, “Some very astute observer once noted that research ideas that are born in the literature are destined to be buried in it. Really good researchers know that informal, direct observation is the context of discovery, in which important research questions are born.”

 This remark has stayed with me ever since I read it! I am also, however, curious about the inverse relationship, the way research informs clinical practice. In your writings you have described a formative encounter with Paul Meehl during your graduate training.

 You asked him about the extent to which his clinical work was informed by research, and his unhesitant reply was “Not at all,” which left you quite disheartened. If a trainee were to ask you that question now, what do you think your response would be?

I would say that research definitely informs what I do clinically. Basic research on cognition, emotion, behavior, and social psychology tells me how individuals function. Research on psychopathology provides me with mediating and moderating variables, which I may need to attend to when working with a given patient. Therapy process research addresses the question “What did the therapist do to make an impact?” It informs me on what I can do to make an impact.

I have mixed feelings about clinical trials and have critiqued them in 

 I think the use of a medical model to conduct outcome research on interventions took a wrong turn when it targeted heterogeneous 

 disorders. I found the previous model of outcome research much more helpful, such as those studies that focused on clinical problems of as unassertiveness and procrastination.

 You have been a big proponent of moving from theoretical orientations to principles of change. At a midlevel of abstraction between theory and technique, it is possible to consider principles of change that are common to most forms of therapy, despite their very different theoretical underpinnings. Can you elaborate on what you mean by that? And can you give an example of a common principle being described differently by different orientations?

 I think the important thing about transtheoretical principles of change is that they have managed to manifest themselves despite varying theoretical orientations. Given the fact that one’s theoretical school of therapy provides a certain way of understanding a phenomenon conceptually, when a phenomenon emerges across different orientations, 

 This is much like the case of clinical phenomena that result from both clinical observation and empirical research.

One such example is the corrective experience. This can occur within the therapeutic interaction, as indicated by psychodynamic therapists, but also can occur between sessions in CBT, where patients are encouraged to expose themselves to situations that they may previously have avoided. It is of considerable interest that, early on, analysts have noticed that gradual, repeated exposure can reduce fear. This was 

 What has been the response of your colleagues to your work on common principles of change? Do you see any signs of encouragement that things are beginning to change?

 After thinking according to a particular school of thought for many years, therapists can find it difficult to think within a transtheoretical framework. Much of what they have read, and much of the training they have received, has been within a single conceptual framework, and existing habits of thought dictate how they conceptualize cases. Moreover, theoretical journals, professional networks, and conferences all serve as social and psychological contexts in which a therapist maintains his or her identity.

My sense is that the hope for the future lies with young professionals, consisting of graduate students and early career therapists and researchers. They are still struggling for their identity and forming their professional network, and I believe that we can help to change the zeitgeist within the field of psychotherapy by appealing to these individuals. This is precisely why I have decided to become involved in social media—I tweet 

—as many of these early professionals are active there. The question is whether or not they want to continue the tradition of competing schools (causing the field of psychotherapy to remain a primitive science), or do they want to move it to a greater sense of maturity?

 In your vision of psychotherapy integration, what do you see as the endgame? The 2 possibilities that come to my mind are: 1) there is an eventual assimilation of various psychotherapy traditions into a single tradition, based on an integrative, transtheoretical framework, or 2) the various psychotherapy traditions will maintain their identities, but there will be increasing cross-communication and incorporation of techniques facilitated by the language of common principles of change. I suppose this question can also be rephrased as: are we or are we not condemned to pluralism?

 I would hope we are not condemned to another century of competing schools, be they integrative or not. A mature science has an agreed-upon core as well as a cutting edge. I believe there exist some common principles/processes that cut across different schools of thought. The key question to address is: “On what can we agree?” That should be the focus of training, practice, and research. The ways of implementing these principles can vary, depending on the given case as hand.

 You have also commented on how psychotherapy research in recent decades has been more focused on outcomes and less on therapeutic processes. Can you tell us more about this?

 Much of the direction of research in psychotherapy within the United States is determined by funding priorities set forth by the NIMH. In the 1980s, they moved in the direction of viewing psychotherapy within a medical context. Psychological problems were viewed as diagnoseable mental disorders, requiring research by clinical trials, in the same way that is done to certify medications. There are lots of problems with this, some of which I have commented on.

 Along with this shift to emphasize clinical trials came a decrease in funding for psychotherapy process research.

 One of themes you bring up in your work is that there is a disconnect between past and current bodies of knowledge, an absence of common language, and new approaches often end up rediscovering and reinventing past knowledge. What are some of the reasons why this is the case? In what ways does academic culture incentivize this?

 There are various reasons why we forget what we have learned in the past. One is that we typically associate what is new with what is improved. Something that is old has some positive connotations, but also implies that it is worn out and less relevant. This may be true of the fashion world, but it is not true of science, which needs to build upon past findings.

In much the same way that drug companies often dictate what physicians do, book publishers have a comparable influence on therapy. In order for book publishers to stay in business, they need to publish books that contain new material. For example, introductory textbooks cannot contain too much old material in revisions, as they would be too unwieldy and expensive. Consequently, the past is often lost there. The existence of new information in books each year—all too often at the expense of past findings—is essential for their financial survival.

In addition, the professional the reward system depends on finding something that is new. Careers are made by making history, not knowing it. This often leads to the unfortunate practice of repackaging old concepts with new language, presenting it as new and improved. Unfortunately, many leaders in the field who do this are more interested in furthering their own careers than in furthering the field of psychotherapy.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

 is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times

Dr Aftab and Dr Goldfried have no relevant financial disclosures or conflicts of interest.

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

1. Goldfried MR. Obtaining consensus in psychotherapy: What holds us back? 

2. Kendler KS. Toward a philosophical structure for psychiatry. 

3. Goldfried MR. A professional journey through life. 

Ordinarily Well: The Case for Antidepressants

5. Stricker G, Goldfried MR. The gap between science and practice: A conversation. 

6. Goldfried MR, Wolfe BE. Psychotherapy practice and research. Repairing a strained alliance. 

7. Goldfried MR. Toward the delineation of therapeutic change principles. 

8. Brunswick D, Fenichel O. Problems of Psychoanalytic Technique. 

How can psychotherapy become a mature science? 

Integration, Common Principles, and the Future of Psychotherapy: Marvin R. Goldfried, PhD

Tools for Assessing Cognition

Slideshows

There are a number of cognitive screening tools designed to help offer timely, quality care for the elderly and those struggling with cognitive loss and dementia. 


Dr Ramtekkar is the medical director ofTele/Virtual Health and Behavioral Health at Nationwide Children's Hospital, the associate medical director of behavioral health for Partners for Kids, and clinical associate professor in the department of psychiatry and behavioral health at The Ohio State University.

Ujjwal Ramtekkar, MD, MBA, MPE, DFAACAP, discusses telehealth for what he calls 'the digital natives.' Children and adolescents are more likely to feel a sense of safety in their own environment, and therefore may be more likely to be open and engage with their mental health providers. 

The links he discussed can be found here:

is the medical director ofTele/Virtual Health and Behavioral Health at Nationwide Children's Hospital, the 

associate medical director of behavioral health

department of psychiatry and behavioral health

The pandemic revealed the potential of telepsychiatry for continuity of care in a group that perhaps needs it the most. 

Telepsychiatry in Children and Adolescents 

Major depressive disorder (MDD) is the leading cause of global disease burden.

 of MDD in the United States has continued to increase among all age groups.

 Patients with these disorders are twice as likely to suffer from a comorbid substance use disorder (SUD) compared with the general population, and the severity of the S6UD parallels that of MDD.

 The comorbidity poses treatment challenges, and patients have been found to have poor outcomes (eg, increased substance use, more severe disease burden, higher rates of suicide attempts and behaviors), as well as an overall increased mortality.

The tight association between MDD and SUD does not necessarily hint at causation, as substance use can lead to mental health symptoms and conditions; mental illness can lead to self-medicating with substance use; and both conditions may co-occur independently as in the case of overlapping predisposing genetic factors. For patients with the comorbidity treatment gaps exist. 90% of those with SUD do not get MDD treatment, and 55% of those with MDD do not get SUD treatment when addressed independently, while 33% of them get no treatment at all.

Both MDD and SUD are in the DSM-5 and hence it is our responsibility to treat them as part of our routine psychiatric practice. Treating depression and substance use independently and in isolation of each other is incongruent with 

 Guidelines recommend simultaneous and integrated treatment with pharmacotherapy and/or psychotherapy for MDD depending on disease severity.

As for how closely these guidelines are followed, no study to date has investigated whether those with the SUD comorbidity receive similar MDD care to those without SUD among the pharmacotherapy and psychotherapy-based treatment modalities, or the degree to which specific SUDs are differentially associated with the receipt of guideline-specific MDD treatment. 

 Do patients with MDD and comorbid SUD receive similar, guideline-concordant, care as those without SUD?

 of 53,034 patients in whom MDD was diagnosed in the 2017 fiscal year in the US Veterans Health Administration (VHA).

 The patients were all veterans receiving care through the US Veterans Health Administration system. They all had a diagnosis of depression made in 2017.

 Electronic medical record data was reviewed to identify patients from both inpatient and outpatient encounters who were diagnosed with depression using ICD-10 codes and Patient Health Questionnaire (PHQ) screens. The PHQ was required to have been documented within a 30-day window of the depression diagnosis in order to capture active depressive episodes. Exclusionary criteria targeted patients with a past depressive diagnosis or who had received prescription antidepressants (except trazodone) or 

 in the past 12 months prior to the index diagnosis date. Also excluded were those with positive PHQ scores documented between 30 days and 12 months before the index depression diagnosis. Patient with comorbid bipolar disorder, schizophrenia, psychosis, personality disorder or developmental disorders, or those with more than 30 days of inpatient treatment in the last year were also excluded. Patients with comorbid SUD were identified as receiving a SUD diagnosis in the year before the depression diagnosis, as identified using ICD-10 codes meant to capture alcohol, opioid, cannabis, cocaine, stimulants, and other SUDs.

The outcomes measure assessed was adherence to treatment guidelines. For this, the authors used 

Healthcare Effectiveness Data and Information Set

 (HEDIS), which is a set of performance measurement tools developed and maintained by the National Committee for Quality Assurance (

) and widely used to assess where improvements can make a difference. HEIDIS is intended to allow comparisons among various health plans, systems, as well as adherence to national benchmarks and guidelines.

Among patients who received an initial prescription for antidepressants within 90 days of the index, depressive disorders to HEDIS based measures related to pharmacotherapy were applied. These resulted in measurements of adequate acute phase treatment (receipt of an antidepressant prescription within 90 days of diagnosis that provides medication for at least 84 of the 114 days following initial prescription); adequate continuation phase treatment (continuing antidepressant for 180 of the first 231 days following initial script).

) was also examined using metrics analogous to HEDIS. Here they evaluated both acute phase treatment (psychotherapy sessions that occurred within 90 days of the index depression diagnosis), as well as continuous phase treatment (at least 3 psychotherapy sessions in the 12 weeks following the first session). Additionally, the authors considered the confounding element that psychotherapy could be delivered for both depressive disorders and SUDs hence, in the analysis-only sessions for whichdepressive disorders were the primary diagnosis were included.

The authors also aimed to adjust for patient demographics (age, gender, race, geographical locality, and distance from the VA) and clinical characteristics (comorbid mental health disorders, measured by the Elixhauser score for severity).

. Sample characteristics across all described covariates were compared between those with and without SUD. Four multivariate logistic regression models were conducted to assess the associations between the presence of a SUD diagnosis and adequate acute and continuous phase antidepressant or psychotherapy treatment. Adjustments for covariates were done for each model.

The authors estimated percentages of those receiving treatment across each of the depression care metrics (those with and without comorbid SUD) as the marginal means of balanced population based on the model. Associations of specific SUDs with depression treatment were examined via the 4 models with each SUD independently analyzed. Authors also descriptively examined the setting where patients with SUD were receiving depression treatment.

Among the 53,034 participants diagnosed with a new episode of depression during the 2017 fiscal year, 52.9% received antidepressant treatment and 34.9% received psychotherapy within 90 days following diagnosis. Of this cohort, 14.2% had a SUD diagnosis in the year prior to the depression diagnosis.

Patients with SUD comorbidity had more visits in mental health and primary care settings in the year following the depressive diagnosis (average of 14.1 visits [SD 18.1] compared with 10.2 visits [SD 10.9] among those without SUD). Unfortunately, despite this higher opportunity for depression treatment, those with SUD received significantly less guideline-concordant depressive treatment across all metrics.

Before adjusting for covariates, observed rates show acute and continuation-phase antidepressants were provided to 59.4% and 36.3% of those with SUD and MDD versus 66.2% and 44.8% of those with just MDD (

. In terms of psychotherapy, 31.6% and 26.8% of those with SUD received acute and continuation-phase treatment respectively, compared to 35.4% and 32.2% of those with just MDD (

). For those with SUD, most received treatment in metal health clinics (47% psychotherapy [N = 1117]; 59.1% antidepressants [N = 2390]); or in primary care/mental health integration clinics (42.7% psychotherapy [N = 1014] and 31.8% antidepressants [N = 1287]). A very small minority received depression treatment in SUD specialty clinics (3.5% psychotherapy [N = 83] and 2.5% antidepressants [N = 102]).

In terms of patient characteristics, those with SUD were slightly younger, male, African American, homeless, and had comorbid psychiatric conditions. Those without SUDs were more likely to be service connected, live in rural areas, and have more comorbid diagnosed medical conditions.

Patients with SUD had lower odds of receiving guideline-concordant care, specifically 21% lower odds of receiving acute antidepressant treatment, 13% lower odds of initial psychotherapy treatment, 26% lower odds of adequate continuation of antidepressant, and 19% lower odds of continuation of psychotherapy.

Based on predicted probabilities of receipt of guideline-concordant depression treatment, an estimated 55% of individuals with comorbid SUD, compared with 61% without, received adequate acute antidepressant treatment, and 27% of individuals with comorbid SUD, compared with 29% without, received initial psychotherapy. As for cotinuation of treatment, 33% of individuals with comorbid SUD, compared with 40% without, received adequate continuation of antidepressants, and 22% of individuals with SUD, compared with 25% without, received adequate continuation of psychotherapy.

In terms of specific SUDs, lower quality depression care was evident across all evaluated substance types. Alcohol and cannabis use disorders were associated with significantly lower odds of adequate continuation of antidepressants (adjusted OR 0.81, 95% CI = 0.75, 0.88, p < 0.001 and adjusted OR 0.74, 95% CI = 0.63, 0.87, p < 0.001 respectively). Alcohol and cocaine use disorders were associated with lower odds of initiation of psychotherapy for depression (adjusted OR 0.86, 95% CI = 0.81, 0.91, p < 0.001 and adjusted OR 0.78, 95% CI = 0.66, 0.92, p < 0.001 respectively). Alcohol use disorders alone were associated with lower odds of adequate psychotherapy continuation (adjusted OR 0.81, 95% CI = 0.72, 0.90, p < 0.001).

There were also several covariates associated with lower odds of guideline-concordant care. These included homelessness, racial and ethnic minority groups, those in rural areas, and those with high psychiatric disease burden living farther away from a health care facility.

This retrospective review study of patients in the Veteran Healthcare Administration system points to a treatment gap in the delivery of guideline-concordant care for depression among those with SUD compared with those without it.

This study assessed an interesting question: do patients with comorbid MDD and SUD receive different care for depression than those without SUD? Consistent with previous data

 in a large national sample of veteran patients within the VHA system, the authors found that having the comorbid SUD diagnosis is associated with lower quality of depression treatment compared with those without it.

 After accounting for various demographic, medical, and psychiatric factors, patients with SUD had lower odds of adequate acute phase treatment (21% and 13% lower for antidepressant and psychotherapy, respectively) and lower odds of adequate continuation of treatment (26% and 19% lower for antidepressant and psychotherapy, respectively) for depression. This discrepancy in guideline-concordant care for depression comes despite patients with SUD having higher health care utilization (more visits and medical encounters) and hence more opportunities for MDD treatment initiation. Knowledge of this treatment gap is important because SUD and MDD affect each other bidirectionally, and the most effective approaches involve concurrent treatment.

There are several limitations to this study. As the authors point out, this sample is limited to veterans in care within the VHA system. The generalization outside this system, and to civilians with various insurance coverages, is unknown. Additionally, the analysis does not include or account for services rendered outside the VHA system, where it is not uncommon for veterans to seek care from.

The diagnosis of MDD as well as SUD is identified here based on ICD-10 codes entered in the electronic health records, which can at times contain errors or not even be entered at all.

There is no mention of how closely providers actually adhere to the use of screening tools such as PHQ-9. It is also necessary to consider that there are other widely available tools that are not accounted for here. It is important to keep in mind that lack of training in the assessment and treatment of complex presentations such as comorbidity leads to inaccurate beliefs and stigmas, an inability to accurately identify co-occurring disorders,

 a lack of awareness of appropriate referral sources,

 and a lack of preparedness to treat co-occurring disorders.

 The providers caring for these patients are not explicitly defined here as to whether they are highly trained physicians or independently practicing nurse practitioners.

The severity of the MDD is not specifically described here via the use of any objective measure.

 Because engagement (or refusal) in treatment represents a patient-specific barrier, having a significant MDD severity, which patients with SUD comorbidity do, can lead to low motivation and lack of interest and future outlook, and hence would make it less likely for patients to be interested in and pursue treatment as well as adhere to it.

The sample selection criteria (new diagnosis of depression in fiscal year 2017 and a positive PHQ depression screen 30 days surrounding time of diagnosis) may lead to limits of generalizability of findings to the degree that these criteria may not capture most patients with depression (ie, preexisting diagnosis, noncompletion or adherence with depression screen).

Worthy of mention is that in the context of certain substances (ie, stimulant or cannabis), MDD may have psychotic features and hence require treatment with nontraditional modalities such as antipsychotics, rather than antidepressants. Within the limits of the study design it is also difficult to determine whether the MDD is due substance use or withdrawal.

The primary outcome measures here were based on the HEDIS, which has been criticized in the past for how its individual measures provide a narrow view of health care quality and interventions. There is also a question about whether attainment of their measures actually indicate better outcomes. In this study, the indicators of adequate acute and continuous phases of care (which are most often used measures of the quality of depression care) certainly do not encapsulate all features relevant to high-quality depression care. Nonetheless, HEDIS is part of NCQA’s accreditation process and attainment is globally used as incentive for many health plans and 

The data generated here is consistent with the challenges in treating patients with an SUD comorbidity and it points toward the need to better address the rapidly expanding dual-diagnosis population. From here, next steps towards improvement of delivery of care to this population should include efforts at specifically identifying barriers that account to this gap, whether clinician related, institutional or system.

is assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for 

. The author reports no conflicts of interest concerning the subject matter of this article.

1. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. 

2. McCance-Katz E. US Department of Health and Human Services. National Survey on Drug Use and Health. 2019. September 2020. Accessed November 20, 2020. 

https://www.samhsa.gov/data/sites/default/files/reports/rpt29392/Assistant-Secretary-nsduh2019_presentation/Assistant-Secretary-nsduh2019_presentation.pdf

3. Volkow N. US Department of Health and Human Services. Comorbidity: Addiction and Other Mental Illnesses. September 2020. Accessed November 20, 2020.

https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf

4. Trivedi RB, Post EP, Piegari R, et al. Mortality among veterans with major mental illnesses seen in primary care: results of a national study of veteran deaths. 

5. Watkins KE, Hunter SB, Burnam MA, et al. Review of treatment recommendations for persons with a co-occurring affective or anxiety and substance use disorder. 

Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: a clinical practice guideline from the American College of Physicians

7. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder Management of Major Depressive Disorder Working Group:. US Department of Veterans Affairs, US Department of Defense. 2016. Accessed November 20, 2020. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf

8. Coughlin LN, Pfeiffer P, Ganoczy D, Lin LA. 

Quality of outpatient depression treatment in patients with comorbid substance use disorder

9. Han B, Olfson M, Mojtabai R. Depression care among adults with co-occurring major depressive episodes and substance use disorders in the United States. 

10. Jordan N, Sohn M-W, Bartle B, et al. Association between chronic illness complexity and receipt of evidence-based depression care. 

11. Hawkins EH. A tale of two systems: co-occurring mental health and substance abuse disorders treatment for adolescents. 

12. Carey KB, Purnine DM, Maisto SA, et al. Treating substance abuse in the context of severe and persistent mental illness: clinicians’ perspectives. 

13. Foster S, LeFauve C, Kresky-Wolff M, et al. Services and supports for individuals with co-occurring disorders and long-term homelessness. 

14. Sterling S, Weisner C, Hinman A, et al. Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. 

15. Clark HW, Power AK, Le Fauve CE, et al. Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders. 

16. Blumenthal D, Gokhale M, Campbell EG, et al. Preparedness for clinical practice: reports of graduating residents at academic health centers. 

17. Office of Public and Intergovernmental Affairs. VA Grants Full Practice Authority to Advance Practice Registered Nurses. December 14, 2016. Accessed November 20, 2020. 

https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847

Are patients with depression and substance use disorder getting an appropriate level of care? Our Journal Club piece investigates.

An Inside Look at Depression Treatment Among Patients With Addictive Disorders

 of its kind, researchers discovered that young adults who combine alcohol and cannabis products experience fewer negative consequences when they avoid cannabis concentrate and consume a single kind of drink rather than multiple types of drinks.

The study examined day‐level influences of alcohol and cannabis combinations on consumption and consequences among young adults who used both. Responses from 274 college students aged 18 to 24 years who used both alcohol and cannabis were gathered using a smartphone application. About 5 short surveys per day over 54 days gathered data on types of alcohol consumed, types of cannabis, number of drinks or cannabis uses, and unwanted outcomes. Negative consequences were constituted as the following: hangover, nausea, vomiting, injury, driving under the influence, blackout, aggression, or unwanted sex.

The study honed in on 4 use categories in particular: dry cannabis leaf and beer; 2 cannabis products with 2 or more alcohol types; liquor with 2 cannabis products; and cannabis concentrate with 2 or more alcohol products. Using the statistical analysis from the gathered survey responses, researchers examined the associations and consequences of each of these combinations.

The most prevalent combination was leaf and beer, and the potentially most risky combination was 2 cannabis products with 2 or more alcohol types. Consumption of multiple alcohol products was likely to produce negative consequences though liquor was statistically riskier than wine or beer. Overall participants who combined alcohol and cannabis reported 1 or more these negative consequences on 1 in 3 study days. Those who used dry leaf and beer were unlikely to have negative consequences when compared with other combinations.

These findings suggest that shrewd choice of products may reduce potential risks.

1. Stevens AK, Aston ER, Gunn RL, et al. Does the Combination Matter? Examining the Influence of Alcohol and Cannabis Product Combinations on Simultaneous Use and Consequences in Daily Life. 

2. Research Society on Alcoholism. People who use alcohol and cannabis together may reduce risks by choosing certain products and combinations. News release. November 23, 2020. 

https://www.newswise.com/articles/people-who-use-alcohol-and-cannabis-together-may-reduce-risks-by-choosing-certain-products-and-combinations?sc=mwhr&xy=5013482

According to a recent study, certain product combinations of alcohol and cannabis may be less likely to cause negative consequences. 

Less Risky Than Believed: Alcohol and Cannabis Combinations 

How Does Your Salary Stack Up Against Your Colleagues?

is clinical director, Division of Geriatric Psychiatry and Neuropsychiatry, and associate professor of Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, Baltimore, MD.

is professor of Psychiatry and Health Policy and Director, Center for Biomedical Ethics and Society at Vanderbilt University, Nashville, TN.

FROM THE GROUP FOR ADVANCEMENT OF PSYCHIATRY

As the United States population ages, safe and effective geriatric care is needed as never before. By 2030, 20% of the population will be aged 65 years or older according to current 

s, a dramatic increase from the rate of 13% reported in the 2010 census.

 It is estimated that 14% to 20% of older adults require treatment for mental health conditions and/or substance use disorders.

 The anticipated increase in the number of older adults will place unprecedented and unrealistic burdens on our health care system, which now 

 fewer than 1400 board-certified geriatric psychiatrists.

 The current population of specialists is insufficient to meet even our present needs, and too few physicians are presently enrolled in geriatric psychiatry and geriatric medicine fellowship training to meet anticipated future needs. Because of the widening gap between the number of experts and the magnitude of patient needs, clinicians who have not had specialty training in geriatrics or geriatric psychiatry will provide the majority of mental health care for older adults.

The necessity for more geriatric mental health specialists and the urgent need to establish competencies in geriatric care for all clinicians who care for older adults were identified as national priorities in reports issued by the Institute of Medicine in 2008 and 2012.

 These goals have yet to be achieved. The Liaison Committee on Medical Education, which 

 accreditation for American medical schools, requires the undergraduate medical curriculum to “address each phase of the human life cycle,” but there is no stipulation for specific content or competencies in aging, geriatric care or geriatric mental health.

 Similarly, there are no national geriatric competency standards for nursing students, physician assistant students, or other allied health care trainees. In the absence of national competency requirements, curricula and training in aging and in geriatric care vary widely across institutions and training programs.

Inadequate recognition and management of common geriatric mental health conditions has serious consequences. Delirium, too often undetected on medical and surgical inpatient units, disproportionately affects older adults, and contributes to avoidable suffering and death.

 Aggression and other behavioral disturbances of dementias (major neurocognitive disorders) contribute to caregiver burnout and premature institutionalization.

 Late-life depression, the most frequent antecedent of suicide in older adults, is associated with potentially treatable suffering, excess disability, increased health care costs, and higher mortality.

 in older adults, is associated with falls, confusion, and preventable hospitalizations.

 Notwithstanding educational campaigns such as “

” (an initiative by the American Board of Internal Medicine Foundation

), benzodiazepines continue to be overprescribed to older adults, despite the complications associated with their excessive and chronic use.

There are 2 important reports that can help advance medical student geriatric education:

• In 2007, the American Association of Medical Colleges and John A. Hartford Foundation Consensus Conference developed the Minimum Geriatric Competencies for Medical Students. These include 26 behaviorally focused competencies nested in 8 domains: medication management; cognitive and behavioral disorders; self-care capacity; falls, balance, gait disorders; health care planning and promotion; atypical presentation of disease; palliative care, and hospital care for elders (

 Within each of these domains are listed between 2 to 5 specific skills that medical students should master before graduating medical school to ensure safe care of elders. While a number of medical schools have incorporated these competencies as objectives in creating clinical rotations for their students, wider adoption and implementation remain critical.

 a broader set of Geriatric Mental Health Learning Objectives for medical students that expands the domain of cognitive and behavioral disorders and addresses the need for specific knowledge and reasoning skills that medical students should attain in 6 key areas of normal aging, mental health assessment, psychopharmacology, depression, dementia, and delirium.

The intent of both of these reports was to establish proficiencies that delineate core material that all students should learn by the time of graduation from medical school in order to provide competent and safe care to older patients encountered during and after residency training.

The authors make the case for national education mandates from accreditation organizations and congressional support to require enhanced education of all clinicians who care for older adults.