From the Editor
Few individuals have contributed more to the evolution psychiatry, the promotion of mental health, or served as a more committed and effective advocate for the mentally ill than Dr. Roger C. Bland. He inspired us, he guided us, he mentored us and enriched us. He was a father figure to many – a voice of experience, compassion, reason and intelligence we could always count on.
Simply put, Dr. Bland was a great man.
Dr. Roger Bland had a storied career.
He was a practicing psychiatrist for decades. He also held many leadership and administrative positions over the years: Chair of the University of Alberta’s Department of Psychiatry, President of the Alberta Psychiatric Association, Vice-President International Federation of Psychiatric Epidemiology, Assistant Deputy Minister of Health for Alberta, and Deputy Editor of The Canadian Journal of Psychiatry. For his accomplishments, he was appointed to the Order of Canada. He also found time to be a father and grandfather. And he was an accomplished chef.
He passed at the end of July.
Dr. Roger Bland being invested in the Order of Canada
I had a few interactions with Dr. Bland. A couple of years ago, at the CPA Annual Conference, we started to talk about suicide prevention after a colleague’s presentation, and we ended up debating our interpretation of several papers. I remember breaking into a slight sweat as I realized that he had a near encyclopedic knowledge of the literature.
But if he could be tough in a discussion, he was an amazing collaborator. At the request of a younger colleague, I once asked Dr. Bland for input into a collaborative care project. He was generous of his time and very thoughtful. (Dr. Bland had been a founding member of the Canadian Collaborative Mental Health Initiative, which involved a dozen organizations; he testified before Parliament on the work of this Initiative.) Yet, he had no hesitation talking about how to structure a partnership with primary care and even how to think about our documentation – pro-tip: keep the notes short and focused; family doctors are busy.
In this Reading, we consider the life and contributions of Dr. Roger Bland.
I asked Dr. Scott Patten, the editor-in-chief of The Canadian Journal of Psychiatry, to write about him – his work and also what it was like to work with him. Dr. Patten also discusses some of Dr. Bland’s most important papers.
For those who wish to read more about Dr. Bland, I’ve included links to his Globe and Mail obituary. There is also a link to the University of Alberta Department of Psychiatry’s monthly newsletter where colleagues reflect on his life and legacy – the opening quotation is from Dr. Xin-Min Li, the Chair; and Dr. Bland gives an interview – his last – on his career (spoiler alert: his training included 10,000 home visits).
I first met Roger Bland at a seminar that he led as a component of our undergraduate curriculum at the University of Alberta. I was in the MD program at the University of Alberta at the time. The seminar was on geriatric psychiatry. I didn’t really know much about him at that time. To be honest, he was pretty tough on us in the seminar. I remember that a few of the medical students didn’t show up – and those of us that did got an “earful” about the lax attitude of our peers. There were no audiovisual materials or didactic commentary – it felt a little bit like being grilled over the coals. Not necessarily a pleasant experience, but I can still remember the main theme of the discussion, which was that a physician can’t really understand the circumstances of geriatric patients without having some understanding of the environment (e.g. physical conditions, social conditions) in which they live. I can’t say that there are too many medical school seminars that have left me with important messages forty years later, so maybe grilling was an effective technique.
After I moved to Calgary to pursue residency training in the 1980s, I began to be more aware of Dr. Bland’s research activities. As a first year resident at the Calgary General Hospital (last month was the 20th anniversary of this hospital’s implosion) I was beginning to develop an interest in psychiatric epidemiology. It is difficult to imagine today, but the standard psychiatry textbooks of the time could say nothing about the prevalence of mental disorders – they all reported various studies from US centres saying things like “between 10% and 20% of patients presenting to clinic X had condition Y.” You did not need to know a lot about epidemiology to know that such information was virtually useless, but this is the kind of information that people were used to hearing – and which, I suppose, in retrospect must have seemed important to physicians of that era, many of whom were not yet focused on the idea that the health of populations should be a target of their efforts. For me, it was fascinating to hear that, for the first time, estimates of prevalence would be available soon. Much of the buzz was about the ECA studies in the US (Regier et al., 1988), which were applying the still controversial DSM-III criteria in population samples. I had heard that Dr. Bland was doing the same thing in Edmonton (Bland, Newman, & Orn, 1988). We got an early view of some of his estimates when he came to Calgary in the late 1980s to make a presentation – I don’t remember many details about the estimates. What I remember most was the session’s moderator needing to intervene to quell an escalating near-shouting match between Dr. Bland and a group of cancer epidemiologists – they were arguing over the proper interpretation of odds ratios.
In my first year as a Resident, I volunteered as the Resident representative on the Alberta Psychiatric Association Board, where I recall that a discussion of billing codes went sideways when Dr. Bland sought to discourage what he viewed as inappropriate use of certain codes. I remember the response of a senior member of the Board: “go ahead, discourage me!” All of these experiences illustrate some of the key elements of Dr. Bland’s professional career. There was a whole lot of altruism there, but he often expressed it in a “hard-nosed” sort of way.
As Deputy Editor (working with three different Editor-in-Chiefs) of The Canadian Journal of Psychiatry (CJP) he was the epitome of the “senior reviewer.” Canadians have the reputation of being very polite and when Canadian academic reviewers harshly criticize a paper they will tend to counterbalance their criticisms with observations about now nicely written the text of a paper is, how the topic is very important and how the value of the manuscript might be unlocked through extensive reanalysis supplementary data collection. This sometimes creates a sense of ambiguity around the assessment of candidate papers. Trained initially as a GP in the UK and later as a psychiatrist in Canada, Dr. Bland understood this code, but I don’t think he really liked it. With a few brief comments he could decisively come down on one side or the other for every paper that he reviewed – and I should emphasize that he reviewed hundreds of papers for the CJP. He always did so promptly, and one might almost say eagerly. Right to the end of his life he engaged in his Editorial role with gusto – rejecting only a single request a few weeks before his death. The email is still in my Outlook archive: “I am in hospital and will be unable to complete any reviews at the moment.”
After completing my PhD, and then as a faculty member at the University of Calgary, our paths crossed many times. This is not surprising since Dr. Bland was involved in a dizzying array of activities. Both at the provincial level and the national level if there was a committee or task force, conference or new initiative there was a very good chance that he would be involved. At scientific conferences he tended to be one of those people in the audience that always had a question (sometimes a hard one) after hearing a presentation, but he was a personable mentor and guide for many. He enjoyed attending meetings of the Canadian Academy of Psychiatric Epidemiology (CAPE) – an organization that he helped to found and that he supported throughout his career. His pride in the sustenance and growth of the organization (which is one of the best national psychiatric epidemiology associations in the world) and the field’s ability to attract talented trainees was always evident. Every year CAPE awards the “Roger Bland Award” to one of its trainee presenters, placing his name alongside Alexander Leighton and Jane Murphy – two other “legends” of psychiatric epidemiology with Canadian connections.
Part of the respect that he was accorded was due to his pioneering contributions to the psychiatric epidemiology, through most notably (but by no means exclusively) his Edmonton Study. Along with his long-time collaborator, Dr. Stephen Newman, he also conducted some of the earliest studies of mortality in psychiatric patients (S. C. Newman & Bland, 1987, 1991). When he and his collaborators worked to extend the Edmonton study into a longitudinal investigation they were among the first to notice some of the vulnerabilities of structured diagnostic interviews to recall bias (S.C. Newman & Bland, 1998). This was based on the observation that observed incidence was not consistent with estimated prevalence and mortality and also that retrospectively reported dates of onset were often inconsistent. He and his colleagues also described examples of Berkson’s bias in psychiatric studies (Galbaud du Fort, Newman, & Bland, 1993). Berkson’s bias results from combinations of risk factors and diseases that jointly affect the probability of hospital admission, leading to bias in hospital-based case-control studies. The concept evinces the medical school seminar described above – information collected from hospitalized patients is never enough.
In addition to his major studies and the 100+ published papers, he was also a kind of 20th century medical “renaissance man” – the likes of which is not often seen in the current era. Most psychiatric epidemiologist hope that their work can influence policy – yet Dr. Bland actually worked in government for a period of time in his career, and he had the ear of policy makers long before the invention of knowledge translation. Whereas clinician-scientists seem to be an increasingly rare breed, Dr. Bland was both a very prominent researcher and highly respected clinician. While academic psychiatrists are expected to make some contributions to service and education as well as research – he was adept at all of these: a highly cited scientist, an Assistant Deputy Minister, a Department Head, a Residency Program Director and a skilled clinician. In addition, he was an advisor to all sorts of organizations and initiatives.
The relentless progress and expansion of science leads to an ever-increasing need for specialization, and this provides a certain mystique to the scholars of previous generations. They seem to have done so much. The psychiatric scholars of the current generation seem to work on much more focused problems – they specialize on individual disorders perhaps even employing a single specialized strategy. Dr. Bland collected data on prevalence at a time when the prevalence of most disorders was almost completely unknown and studied the mortality associated with psychiatric disorders at a time when this was rarely considered. It is likely that the “specialized” problems of today will similarly be magnified as they are subdivided into more and more precise questions by future generations of scholars, but this will occur on an inevitably diminishing scale. Dr. Bland’s legacy, however, will continue to have the flavor of a truly pioneering figure.
Dr. Scott Patten
Bland, R. C., Newman, S. C., & Orn, H. (1988). Period prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand, Suppl 338, 33-42.
Galbaud du Fort, G., Newman, S. C., & Bland, R. C. (1993). Psychiatric comorbidity and treatment seeking. Sources of selection bias in the study of clinical populations. J Nerv Ment Dis, 181(8), 467-474.
Newman, S. C., & Bland, R. C. (1987). Canadian trends in mortality from mental disorders, 1965-1983. Acta Psychiatr Scand, 76(1), 1-7.
Newman, S. C., & Bland, R. C. (1991). Mortality in a cohort of patients with schizophrenia: a record linkage study. Can J Psychiatry, 36(4), 239-245.
Newman, S. C., & Bland, R. C. (1998). Incidence of mental disorders in Edmonton: estimates of rates and methodological issues. J Psychiatr Res, 32, 273-282.
Regier, D. A., Boyd, J. H., Burke, J. D., Myers, J. K., Kramer, M., Robins, L. N., . . . Lucke, B. Z. (1988). One-month prevalence of mental disorders in the United States. Based on five epidemiological catchment area sites. Arch Gen Psychiatry, 45, 977-986.
For more on Dr. Bland:
The Globe and Mail obituary:
The University of Alberta Department of Psychiatry’s monthly newsletter of July/August 2018:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.