Reading of the Week: Nudging Sobriety – the New JAMA Psych Paper; Also, Torous & Topol Weigh Generative AI and Wilson on Thick Skin

July 10, 2025 / / 0 Comments

From the Editor

Substance work can be lifesaving. But it’s also challenging, as many patients continue to misuse illicit drugs or drop out of care or both. Evidence supports using incentives, including financial ones, to nudge patients toward sobriety. This approach, known as contingency management, includes tools such as vouchers and prizes.

But what forms of nudging work best? And how much of a financial incentive is needed? In a new JAMA Psychiatry paper, Carla J. Rash (of the University of Connecticut) and her co-authors attempt to answer these questions by looking at contingency management. In a systematic review, they drew on 112 protocols from 77 studies, analyzing types of nudges like vouchers (which may be exchangeable for, say, retails items) and prizes (a chance to win things like gift cards) and the amounts of money involved. The authors walk on a familiar path – the literature goes back four decades – but provide a meaningful update. “Based on these findings, weekly incentive magnitude estimates are $128/week for voucher protocols and $55/week for prize-based protocols.” We consider the paper and its implications. 

ChatGPT is the most downloaded app in history with people using it for everything from finding recipes to writing emails. How could generative AI be used for mental health? In a perspectives paper for The Lancet, Drs. John Torous (of Harvard University) and Eric J. Topol (of the Scripps Research Translational Institute) discuss this important and timely topic. “Despite considerable promise, research is still required to establish AI’s benefit and safety for promoting mental health.”

And in the third selection from Academic Psychiatry, Dr. Ariel E. Wilson, a resident of psychiatry at Kaiser Permanente Oakland, writes about patient rights, certifiability, and the weight of making good decisions. The author asks if psychiatrists need to have thick skin. “The challenge in psychiatry lies in finding a balance – creating our own semi-permeable membrane that allows us to protect ourselves from feeling the sting of every emotion we encounter, while also maintaining empathetic and trusting relationships with our patients.”

DG

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Reading of the Week: PTSD Among 9/11 Responders – the New Nature Study; Also, Therapy Isn’t Psychotherapy and Physician Vacations & Burnout

June 19, 2025 /

From the Editor

He survived the car accident that killed his partner. Although he was physically unscathed, he struggled with PTSD, lucidly describing in our sessions the nightmares and fears that dominated his life.

How long do such symptoms last? Does time heal? Frank D. Mann (of Stony Brook University) and his co-authors attempt to answer these questions with a new study, one of the largest and longest on this disorder to date. In the first selection, we examine their Nature Mental Health paper, involving 13 000 responders to the World Trade Center attack, and spanning 20 years of data. “Our findings highlight the enduring impact of PTSD among World Trade Center responders, with substantial variability in individual trajectories. Despite overall modest declines, a subset remained highly symptomatic, underscoring the need for continued treatment.” We consider the paper and its implications.

In the second selection from Psychiatric News, Dr. Steven Reidbord, a psychiatrist based in San Francisco, notes the rising popularity of therapy and how things are changing with AI. But he suggests there is a difference between “corner-cutting” therapy and real psychotherapy, which is meant for personal change. “Psychotherapists must defend quality care against the seductive fictions that pervade social media. Our own message may be less alluring, but it has the advantage of being true…”

And in the third selection, Dr. Christine A. Sinsky (of the American Medical Association) and her co-authors look at physician vacations. Drawing on a national survey of US docs, they analyzed vacations, work during these vacations, and burnout. “These findings suggest that support for taking vacation and efforts to reduce physicians’ obligations to perform patient care-related tasks while on vacation, such as providing full electronic health record inbox coverage, should be considered to prevent physician burnout.”

Note that there will be no Readings for the next two weeks. (The discussion of vacations is inspiring.)

And, on a pivot, to those completing their residency education at the end of this month: all the best in your careers. Enjoy this remarkable moment.

DG

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Reading of the Week: Suicide – with Papers from AJP and BJPsych Int; Also, O’Brien on His Brother’s Suicide & His Family

June 12, 2025 /

From the Editor

She came into our ED feeling overwhelmed. After a recent breakup, she felt suicidal; the academic demands of grade 12 further stressed her. As a clinician, this type of adolescent presentation seems to be increasingly common.

But is it? Many people have opinions. Dr. Tanner J. Bommersbach (of the University of Wisconsin) and his co-authors attempt to shed light on the state of teen mental health with a new and important paper focused on suicidal ideation, plans, and attempts. In the first selection, we examine their American Journal of Psychiatry paper, involving almost 120 000 high school students, drawing on US survey data, and covering a decade and a half. “In this nationally representative sample… significant increases occurred in the percentage reporting past-year suicidal thoughts, suicide plans, and suicide attempts from 2007 to 2021.” We consider the paper and its implications.

In the second selection from BJPsych International, Dr. Rachel Gibbons (of the Royal College of Psychiatrists) writes about suicide. In a controversial paper, she argues that we make too many assumptions about suicide, which colour our research and undermine our understanding of patients. “Embracing the complexity of suicide may not only refine prevention but also deepen our understanding of suffering, resilience, and meaning.”

And in the third selection, playwright Dan O’Brien writes about his brother’s suicide for Esquire. In a deeply personal essay, he discusses his brother’s mental health problems and his parents’ desire to hide them. He wonders what could have been. “I would like to be helpful to some who might read this, if only to deny that the suffering of mental illness is a disgrace, and to assert that such suffering is common and survivable.”

DG

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Reading of the Week: Therapy = More Work + Better Income? The New Psych Medicine Study; Also, Zero Suicide & Melatonin for Kids

June 5, 2025 /

From the Editor

After completing a course of psychotherapy, he felt better and began a part-time job. The employment gave him a sense of purpose. As a physician, I could both sympathize and empathize; for many, work is a meaningful part of life, after all.

But does psychotherapy necessarily result in employment? Does therapy pay for itself with economic benefits? Otto R. F. Smith (of NLA University College) and his co-authors attempt to answer these questions in an impressive new paper in Psychological Medicine. They report on an RCT involving more than 700 Norwegian participants who were randomized to a psychotherapy program (modeled after the UK’s IAPT service) or to treatment as usual. The authors used administrative databases to analyze employment, income, and the economic benefit. “The results support the societal economic benefit of investing in IAPT-like services.” We consider the paper and its implications.

In the second selection, Dr. Calina Ouliaris (of Macquarie University) and her co-authors look at the zero suicide approach. In a Commentary for The British Journal of Psychiatry, they argue that – despite being studied and implemented in several places – it lacks evidence. “The Zero Suicide Framework is an arguably vague framework with a scant evidence base, particularly for application in healthcare settings. Despite this, the concrete goal championed… that of ‘zero suicides’, is appealing and has been widely promulgated in mental health services, ahead of evidence for the same.”

Finally, in the third selection, Dr. Chris Y. Kim (of the University of Toronto) and his co-authors weigh the use of melatonin for children and adolescents. In The Canadian Journal of Psychiatry, they are cautious, in part because of the lack of consistency of over-the-counter melatonin. “Melatonin used as a hypnotic agent for the treatment of insomnia is controversial.”

DG

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Reading of the Week: Glucagon-Like Peptide 1 Receptor Agonists & Mental Health – the New JAMA Psych Study; Also, Innovation and Lee on His Depression

May 29, 2025 /

From the Editor

These medications are widely discussed – and, yes, our patients ask about them. But how do glucagon-like peptide 1 receptor agonists impact mental health and overall wellness? Should we hesitate before reaching for the prescription pad?

Aureliane C. S. Pierret (of King’s College London) and her co-authors attempt to answer these questions in a new paper just published in JAMA Psychiatry. In their systematic review and meta-analysis, they included more than 107 000 patients, comparing treatment with GLP1-RAs to placebo, looking at psychiatric, cognitive, and quality of life outcomes in those who are overweight, obese, or have diabetes. “Our results provide reassurance regarding the psychiatric safety profile of GLP1-RAs and suggest that GLP1-RA treatment is associated with improved mental well-being, in addition to the known physical health improvements.” We consider the paper and its implications.

When we hear innovations in mental healthcare, we tend to think of apps or wearables. In the second selection from Quick Takes, Daisy Singla (of the University of Toronto) discusses her recent study that expanded access to psychotherapy for perinatal women, reducing symptoms of depression and anxiety by drawing a page from work done in low-income countries. The key concept: training up laypeople to deliver therapy (task sharing). “It’s one of the largest psychotherapy trials in the world.”

And in the third selection, from The Globe and Mail, Joe Lee writes about his realization that he has depression and that it has affected his life for years. In a personal essay, he talks about his illness and the impact on his life. “Depression is weird like that. For some people, it sneaks in. For me, it’s always been there – like blood in my body.”

DG

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Reading of the Week: Dating Advice for Patients? The New PLOS Mental Health Paper; Also, SSRIs at 50 and Lifestyle Psychiatry

May 22, 2025 /

From the Editor

My advocacy for him included speaking with his parents, calling his landlord, and completing his insurance-related paperwork. But I rarely asked him about his relationships, and I never offered advice on dating or finding a partner. During a tearful session, he spoke at length about his profound isolation. Should I have done more?

In a new study published in PLOS Mental Health, Angelica Emery-Rhowbotham (of University College London) and her co-authors explore the problem of relationships and our patients. They report both qualitative and quantitative data from 63 providers. “Staff were willing to help service users seek an intimate relationship but may need specific training or guidance to facilitate this confidently and safely.” We consider the paper and its implications.

In the second selection, the Editors of The Lancet reflect on the fiftieth anniversary of SSRIs. They note controversies over time, including the argument that clinicians are overly reliant on this type of depression treatment. “50 years on from landmark developments in drug treatment that were the cause of so much hope, we remain a long way from providing the level of care that so many people need, and this need continues to demand the attention of the scientific and medical communities.”

And in the third selection, from World Psychiatry, Joseph Firth (of The University of Manchester) and his co-authors describe the priorities and opportunities for lifestyle psychiatry. In a letter, they present the consensus of the LifePsych Society. “As lifestyle psychiatry is poised to become an integral component of global mental health care, the LifePsych Society aims to facilitate global collaborations, establish shared priorities, and enhance the capacity for meaningful research across diverse settings.”

DG

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Reading of the Week: Lived Experience of Postpartum Depression & Psychosis – the New World Psych Paper; Also, Involuntary Treatment and Family Stress

May 15, 2025 /

From the Editor

“You are normal and then the next thing, you know, you’re crazy.”

So comments a woman about her postpartum depression. Typically, we describe this illness with a list of symptoms. But how do patients experience it? In a new World Psychiatry paper, Dr. Paolo Fusar-Poli (of King’s College London) and his co-authors attempt to answer this question with a “bottom-up” approach, looking at both postpartum depression and psychosis. “To the best of our knowledge, this is the first bottom-up review of the lived experience of postpartum depression and psychosis. Experts by experience co-designed, co-conducted and co-wrote the study, leveraging an established methodological template developed by our group to investigate the lived experience of psychosis [and] depression…” We look at the paper and its implications.

Should people with substance problems be forced into treatment? Across North America, some are proposing this idea, including governments in British Columbia and Alberta. In a new Canadian Journal of Psychiatry paper, Benedikt Fischer (of the University of Toronto) and his co-authors look at the issue and the evidence. “Involuntary treatment for severe SUD is a complex and contentious concept that requires careful in-depth consideration before its adoption.”

In the third selection, a paper written anonymously for The BMJ, the author describes the challenges for families of those with severe mental disorders. He notes his deep frustration with visits to the ward, often leaving him in tears. “Perhaps family support needs to become part of the culture on mental health wards, and we should recognise the need for help in communicating.”

DG


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Reading of the Week: When Does Grief Become a Disorder? The Lancet Review; Also, Time to End Daylight Saving Time? And Dr. Hickey on Her Anxiety

May 8, 2025 /

From the Editor

After the unexpected loss of his spouse, my patient sank deeply into grief. He was tearful during our sessions, explaining that a part of him had died, too. Weeks turned to months. Was this a normal response to a profound loss? Or something more problematic? DSM-5 seeks to clarify the issue by recognizing prolonged grief disorder – though the disorder is controversial and has attracted much criticism. When The New York Times covered the topic in 2022, Joanne Cacciatore (of Arizona State University) commented: “I completely, utterly disagree that grief is a mental illness.”

Clare Killikelly (of the University of Zurich) and her co-authors shed light on prolonged grief disorder with a new review, just published in The Lancet. They write about the disorder, the differences from grief, its treatment, and more, drawing on 142 citations. “Grief is a universal experience. However, for a minority of individuals, grief becomes a debilitating, devastating mental health disorder with serious implications on a personal and societal level.” We examine the review, highlight four take-aways, and reflect on the broader debate.

Spring forward, fall back. Twice a year, we adjust our clocks (and our brains) to and from daylight saving time. In the second selection, Dr. David Dongkyung Kim (of the University of Toronto) and his co-authors argue that daylight saving time should be eliminated. In their JAMA Commentary, they draw on the literature. “Daylight saving time transitions cause acute disruptions in human circadian rhythm, and the medical literature shows detrimental effects for public health.”

Finally, in the third selection, Dr. Joanne Hickey (of Memorial University) discusses anxiety and her expectations. In a personal CMAJ paper, the hematologist reflects on her work – and on her own journey, including her anxiety, the decision to take medications, and her need to come to terms with her perfectionism. “Anxiety has been my life companion, though I often didn’t recognize it. It masqueraded as that internalized need to control.”

DG

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Reading of the Week: Are the Kids Alright? The New JAMA Paper on Mental Disorders & Children; Also, the Remarkable Life of Dr. Mary Seeman

May 1, 2025 /

From the Editor

Are children experiencing more mental disorders than before, or are we simply getting better at screening for them? Many have opinions and there is debate among psychiatrists and within our society.

In a new JAMA paper, Janet R. Cummings (of Emory University) and her co-authors provide new data shedding light on this issue. Drawing on US government databases covering 22 states and from 2010 to 2019, they looked at diagnoses and demographics among economically disadvantaged children. “This observational study found that the percentage of publicly insured children diagnosed with any mental health or neurodevelopmental disorder increased from 10.7% in 2010 to 16.5% in 2019.” We consider the paper and the accompanying Editorial – and wonder if this reflects better screening or more illness. 

In this week’s other selection, we look at the life and career of Dr. Mary Seeman, who died in 2024. In an obituary for The Canadian Journal of Psychiatry, Dr. Robert B. Zipursky (of the University of Toronto) and his co-authors note her many contributions to psychiatry. “Although Mary was 89 years old at the time of her death, her passion, humour, curiosity, and productivity had not abated. It endures now in the legacy of her scientific work, in her teaching and clinical care and in the many people she inspired to follow her example.”

DG


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Reading of the Week: Gone to the Dogs? The New BJP Study on Dog-assisted Interventions; Also, BC Decriminalization & the Latest in the News

April 24, 2025 /

From the Editor

He presented for the appointment with his dog. He told me that getting the chocolate lab – who had been trained by a national, not-for-profit organization – was the best single thing to help him. For the record, the dog was beautiful.

More and more of our patients are turning to animal interventions. But is there evidence to support this trend? In a new The British Journal of Psychiatry paper, Emily Shoesmith (of the University of York) and her co-authors look at dog-assisted interventions (DAIs), describing a review involving 33 papers. “DAIs may show promise for improving mental health and behavioural outcomes for those with mental health or neurodevelopmental conditions, particularly for conditions requiring social skill support. However, the quality of reporting requires improvement.” We discuss the paper and its clinical implications.

In the second selection, John F. Kelly (of Harvard University) reviews the successes of drug decriminalization in Portugal and its failures in British Columbia. In a new Editorial for JAMA Psychiatry, he notes key differences in their approaches. He also mulls the importance of such public-policy experimentation. “As demonstrated in Portugal, persistent, patient, thoughtful analysis, and sensitive, systemic planning is needed to ensure lives are saved and other outcomes improved.”

Finally, we explore the latest news with articles from The New York Times, The Globe and Mail, and NBC News. The topics: one firefighter’s battle with OCD, overdose deaths in North America, and a new mental-health awareness campaign.

DG

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