From the Editor

Many with mental disorders don’t engage in psychiatric care or, if they do, it is after significant delays – problematic for obvious reasons. Some groups are less likely to engage, including young Black individuals with psychosis.

Why the hesitation? What are the concerns of these patients and their larger communities? In the first selection, a paper just published by the Canadian Journal of Psychiatry, Ingrid Waldron (of McMaster University) and her co-authors take a qualitative interpretive narrative approach, to engage African Nova Scotians – including those in a first episode psychosis program – attempting to answer these questions and more. Among their key findings: “barriers include a lack of trust in health care services and a dearth of African Nova Scotian service providers.” We discuss the paper and its implications.

In this week’s second selection, Dr. Doron Amsalem (of Columbia University) and his co-authors aim to improve health care workers treatment seeking; in a paper for Psychiatric Services, they describe an RCT for a brief video intervention, finding positive results. They write: “This easily administered intervention could increase the likelihood of care seeking by proactively encouraging health care workers with mental health challenges to pursue treatment.”

Finally, in the third selection, Mark L. Ruffalo (of the University of Central Florida College of Medicine) and Dr. Daniel Morehead (of the Tufts Medical Center) consider psychotherapy and psychiatry. In an essay for Psychiatric Times, they argue that this is “the great divorce that never happened.” They write: “For decades, critics and leading psychiatrists have worried that psychotherapy among psychiatrists will one day die out and be forgotten. Yet for decades, reports of its demise have been greatly exaggerated.”


Selection 1: “Addressing Stigma and Promoting Help-Seeking Among African Nova Scotian Youth Experiencing Psychosis and Other Mental Health Problems”

Ingrid Waldron, Brannon Senger, Jacob Cookey, et al.

The Canadian Journal of Psychiatry, 13 September 2022  Online First

In the field of early intervention for psychosis, existing research suggests that Black individuals differ from other patients in their pathways to care and help-seeking experiences. When compared to white patients, Black patients with psychosis are more likely to access EIS through referrals from emergency psychiatric services and are more likely to be brought in by police and ambulance services. Outside of emergency services, Black individuals with psychosis are twice as likely to have police involvement in their pathway to care. In the Canadian context, these trends have been suggested to be due to Black patients experiencing delayed help-seeking, which results in the exacerbation of symptoms and increased need for urgent psychiatric interventions.

So begins a paper by Waldron et al.

Here’s what they did:

“A qualitative interpretive narrative approach, using the focus group method, was employed to engage African Nova Scotians in discussions on their perceptions and beliefs about mental illnesses and help-seeking in their communities. Youth in Early Intervention services, their caregivers, youth in the community, their caregivers, community leaders, and health service providers, were recruited from four locations in the Halifax Regional Municipality. A total of 75 individuals (37 female, 38 male) participated in the study. Narrative emplotment was used to analyse data from focus groups.”

Here’s what they found: the authors identified four major themes, three of which are summarized here.

Perceptions and Beliefs About Help-Seeking Among African Nova Scotian Youth in the HRM

“Participants… discussed the beliefs that African Nova Scotian youth and the broader African Nova Scotian community hold about seeking help for and coping with mental illnesses. Multiple caregivers expressed concerns that there was a reluctance to seek help because of a lack of safe places to go. Related to this, caregivers also described mental health being neglected and help-seeking avoided out of fear that the police would become involved… Community leaders expressed concerns that instead of seeking help, youth engaged in self-medication.” 

Barriers, Opportunities and Facilitators Experienced by African Nova Scotian Youth in Seeking Help for Mental Illnesses

“Participants identified the following barriers to help-seeking among African Nova Scotian youth: lack of access to Black service providers, lack of financial resources, lack of knowledge and understanding of mental illnesses, and a cultural emphasis on personal strength and self-reliance. A youth in recovery at the NSEPP, described difficulty accessing medications as a common challenge for African Nova Scotian Youth: ‘But I think access to medication. There’s a lot of people that don’t have coverage or medical insurance to be able to afford some medication. So I think that is a barrier that needs to be tackled as well.’ 

“Reference was also made to the lack of comfort with and trust in the health system and health providers and long wait times.”

Content and Format of Educational Resources and Other Educational Activities

“Participants shared suggestions for the content and format of resources to educate youth and communities about early-stage psychosis, promote help-seeking and self-care, and reduce the stigma around mental illnesses. Youth recommended that education be delivered using virtual resources including Instagram, Twitter, videos, or through the creation of an app. They also suggested that brochures and pamphlets, educational sessions in schools and the community, and interactive group discussions be developed to engage African Nova Scotians. They suggested that the content should include information on the signs and symptoms of psychosis, stress and illness, stigma, grief, the role of trauma in illness onset, substance use and mental health, and how to support individuals in seeking help….”

A few thoughts:

1. This is an important study.

2. This type of work is novel, fresh, and overdue.

3. For the record, the analysis suggests problems with providers: “The lack of cultural competency demonstrated by mental health professionals was also a significant barrier to youth seeking help.” And institutions are criticized, as well: “One community leader noted that while there are several community initiatives that are providing young people with a safe space to share the challenges they are experiencing, the public school system has not done enough in this area…”

4. The implications? There are many. A take-away message: there is much work to be done, from the police-community relations to the need for more creative communication approaches. There are also clear clinical implications for those who practice in Nova Scotia – and beyond, a reminder of the challenges of engaging with different populations, often labelled “difficult to reach” but who could also be called “systemically oppressed” (to borrow a line from Tee Garnett of SickKids).

The full CJP paper can be found here:

Selection 2: “Brief Video Intervention to Increase Treatment-Seeking Intention Among U.S. Health Care Workers: A Randomized Controlled Trial”

Doron Amsalem, Melanie Wall, Amit Lazarov, et al.

Psychiatric Services, 13 September 2022  Online First

Health care workers, compared with the general population, have an elevated prevalence of anxiety and depression, which has intensified because of ongoing stress from the COVID-19 pandemic. Overstressed health care workers may experience burnout and lower motivation, reducing the quality of care they provide. Nevertheless, health care workers are often reluctant to seek help, and stigma toward treatment seeking creates a profound barrier to receiving mental health care. Treatment-related stigma involves perceiving care seeking as weakness, anticipating negative attitudes from colleagues, and fearing discrimination from supervisors. Feasible interventions that promote help seeking and reduce treatment-related stigma may improve the health and well-being of health care workers and their delivery of care.

So opens a paper by Amsalem et al.

Here’s what they did:

“Participants (N=1,402) were randomly assigned to view a 3-minute video in which a Black or White female nurse described struggles with COVID-19–related anxiety and depression, barriers to care, and how therapy helped, or to view a control video unrelated to mental health. Half of the participants receiving the intervention watched the same video (i.e., booster) again 14 days later. Treatment-seeking intention and treatment-related stigma were assessed at baseline, postintervention, and 14- and 30-day follow-ups.” 

Here’s what they found:

  • 1,402 health care workers completed the baseline and postintervention evaluations. 
  • Follow up. 1,171 (84%) participants completed the 14-day follow-up assessment; 1,000 (71%) completed the 30-day one.
  • Demographics. The participants were typically in their late 20s (mean age of 28.9); most were female (82%) and White (73%). Not many had experienced COVID-19 (20%) but most had a family member or friend who did (78%).
  • “Both intervention videos elicited an immediate increase in treatment-seeking intention in the intervention groups (p<0.001, effect size [ES]=21%), with similar effects among those who watched the booster video (p=0.016, ES=13%) and larger effects among those who had never sought treatment (p<0.001, ES=34%).”
  • “The increased effects were not sustained 14 days after the initial video or at 30-day follow-up.” (!!)
  • The race of the nurse in the video didn’t impact results.

A few thoughts:

1. This is an interesting study.

2. The video intervention was cleverly done: “The nurses directly described with great emotion their difficulty coping with life stressors, how they faced their anxious and depressive feelings (‘I felt helpless. . . . I couldn’t enjoy anything’), their prior mistaken assumptions about treatment (‘I was worried people might think I’m crazy’), and how they overcame these challenges. They described benefiting from social support and psychotherapy and how that support helped them cope with COVID-19–related stressors. They concluded with a supportive, encouraging statement: ‘I’m really feeling like myself again.’”

3. The intervention made a difference – but wasn’t sustainable over time. It thus offered a time-limited nudge (to use the trendy behavioural economics term).

4. Health care worker wellness has been considered in past Readings. A recent JAMA paper by Dr. Lisa S. Rotenstein (of Harvard University) and her co-authors looked beyond doctors and nurses. They noted: “In a nationwide survey of 125 717 health care workers, the highest turnover rates among all health care workers during the beginning of the pandemic (April 2020 to December 2020) were reported by health care aides and assistants, technicians, and licensed practical and vocational nurses.” This Reading can be found here:

The full Psychiatric Services paper can be found here:

Selection 3: “Psychiatry and Psychotherapy: The Great Divorce That Never Happened”

Mark L. Ruffalo and Daniel Morehead

Psychiatric Times, 23 July 2022

A frequent criticism of psychiatry is that psychiatrists do not learn, practice, or value psychotherapy. Even critics within the field routinely complain that psychiatry has ‘lost its mind,’ whereas outside critics frequently portray toxic biological psychiatrists in competition with humane psychotherapists from other disciplines. The psychiatrist, as the story goes, is interested only in diagnosing and medicating patients – not in understanding, supporting, or working psychotherapeutically with them. This story, widely reported as fact in the media, is an outdated, harmful myth – one that discounts the realities of psychiatric training, the complexity of the psychiatric treatment relationship, and the resurgence of interest in psychotherapy among psychiatry residents.

So begins an essay by Ruffalo and Dr. Morehead.

They write: “The idea that psychiatry is divorced from psychotherapy is, in fact, divorced from reality.” They forward several arguments; three are summarized here.

Psychotherapy is a part of almost all clinical interactions

“Although most psychiatrists nowadays do not offer traditional 45-minute or 60-minute psychotherapy appointments to all their patients, psychotherapy continues to be practiced in some form by most psychiatrists. From a psychodynamic perspective, every interaction between doctor and patient, even in the hospital setting, is an opportunity to relate to the patient psychotherapeutically. Sudak and Taormina have described the integration of cognitive-behavioral therapy into medication management visits, and Iannitelli et al have recently discussed the application of psychodynamic principles during psychopharmacological treatment.

“Undoubtedly, most psychiatrists engage in some supportive psychotherapy even during brief visits and even if they do not formally label or bill the sessions as such. Moreover, in their study, Tadmon and Olfson found that 47% of psychiatrists continue to offer 45-minute to 60-minute psychotherapy sessions to patients. Thus, claims that psychotherapy has simply disappeared from psychiatric practice are false.”

In the past decade, there has been a resurgence of interest in psychotherapy and psychosocial approaches among psychiatry residents.

“A 2012 survey of residents reported that 82% of them consider ‘psychotherapy to be integral to their identity as psychiatrists.’ Another survey showed that residents want more psychotherapy training rather than less. Our experience matches the results of such research. In fact, we have observed an increasing number of psychiatry residents interested in learning and practicing psychotherapy during the past decade.”

Many leading psychotherapy scholars are psychiatrists, and this has been the case for decades

“Some of the leading figures in American and global psychotherapy are psychiatrists, including Otto Kernberg, MD; Glen Gabbard, MD; and the recently deceased Aaron Beck, MD, father of cognitive-behavioral therapy. Several psychiatrists who are leading researchers in psychopharmacology have also undertaken research validating medical psychotherapy. Psychiatrists make up a significant percentage of membership of the American Psychoanalytic Association… The psychiatric profession remains integral to psychotherapy development and research.”

A few thoughts:

1. This is a well argued essay.

2. They raise good points, including the ongoing role of psychotherapy (and psychotherapeutic techniques) in clinical interactions.

3. But has the role of psychotherapy narrowed over time in the practice of psychiatrists? A recent American Journal of Psychiatry paper, using a more formal definition, observed a sharp decline in psychotherapy offered by psychiatrists: “Between 1996 and 2016, the weighted percentage of visits involving psychotherapy declined significantly from 44.4% in 1996-1997 to 21.6% in 2015-2016.” That paper was considered in a past Reading, which can be found here:

4. Is the trend good? Are psychiatrists focusing more on what they know best? Or is an important clinical offering fading? Readers can draw their own conclusions.

The full Psychiatric Times essay can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.