From the Editor

A recent CMA survey found that more than half of physicians report high levels of burnout; surveys of other health care disciplines show a similar result. Not surprisingly, burnout is much discussed. What can be done for health care workers?

In the first selection, Vincent Gosselin Boucher (of the University of British Columbia) and his co-authors consider that question, offering an app-based intervention featuring exercises that can be done at home. The resulting study, just published in JAMA Psychiatry, included 288 health care workers in an RCT. “[A] 12-week app-based exercise intervention yielded significant reductions in depressive symptoms among HCWs that became more pronounced as time progressed.” We review the paper and its implications.

In the second selection, Jonathan H. Cantor (of the RAND Corporation) and his co-authors look at mental health utilization and spending before and during the pandemic, drawing on almost 1.6 million mental health insurance claims in the US. “[U]tilization and spending rates for mental health care services among commercially insured adults increased by 38.8% and 53.7%, respectively, between 2019 and 2022.” 

Finally, in the third selection, author Maia Szalavitz writes about the decriminalization of low-level drug crimes in Portugal. In a New York Times essay, she argues that critics don’t understand what Portugal accomplished – and, in contrast, how many Americans go untreated in correctional facilities. She concludes: “Shifting priorities and funding to provide high-quality treatment and other supports for recovery like housing takes time. Our failure is a century of criminalization – not much-needed attempts to end it.”


Selection 1: “Effects of 12 Weeks of At-Home, Application-Based Exercise on Health Care Workers’ Depressive Symptoms, Burnout, and Absenteeism: A Randomized Clinical Trial”

Vincent Gosselin Boucher, Brook L. Haight, Benjamin A. Hives, et al.

JAMA Psychiatry, 9 August 2023  Online First

A segment of society particularly affected by the pandemic is health care workers (HCWs), including those directly involved in direct patient care (eg, nurses, physicians, paramedics, and allied health care professionals such as physical therapists) as well as those in supportive roles (eg, administrators, housekeeping, and security staff) who may be potentially exposed to the SARS-CoV-2 virus in health care settings. Since the start of the pandemic, HCWs have faced notable uncertainty, with increased risk of exposure to the virus compared with the general population, expanding job demands, rapidly changing protocols, and fears of spreading the virus to family members… Unsurprisingly, HCWs’ mental health problems are currently at high rates across the globe, leading to increased burnout and high staff absenteeism and turnover…

A literature review of mental health initiatives from across the globe that were developed within health care institutions and delivered to their employees to address the pandemic’s mental health impact identified 9 such programs, all of which can be categorized as psychoeducational (eg, online information for stress reduction, behavior change) or psychosocial (eg, ‘talk therapy,’ crisis lines) in nature. Behavioral approaches, including exercise, are well-evidenced as primary stand-alone strategies for the prevention and treatment of depressive symptoms.

So begins a paper by Gosselin Boucher et al.

Here’s what they did:

  • They conducted an RCT with two groups. Participants were screened from April 6 to July 4, 2022, and recruited from an urban health care organization in British Columbia, including 10 acute care and long-term care hospitals.
  • Participants completed measures before randomization and every 2 weeks after.
  • The intervention: “Exercise condition participants were asked to complete four 20-minute sessions per week using a suite of body weight interval training, yoga, barre, and running apps.” This intervention ran for 12 weeks.
  • “Wait-listed control participants received the apps at the end of the trial.”
  • Main measure: “depressive symptoms measured with the 10-item Center for Epidemiological Studies Depression Scale.”

Here’s what they found:

  • 386 potential participants expressed interest, with 326 completing screening. 288 were randomized to the exercise (49.3%) or the wait list control (50.7%).
  • Demographics. 85.4% were women. The mean age was 41.0 years. 37.2% identified as White; 19.1% as Chinese; 11.5% as South Asian; 8.3%, as Filipino.
  • Depression scale. “Effect size for depressive symptoms were in the small to medium range by trial’s end (week 12, −0.41…).” 
  • Secondary measures. “Significant and consistent treatment effects were revealed for 2 facets of burnout, namely cynicism (week 12 ES, −0.33…) and emotional exhaustion (week 12 ES, −0.39…), as well as absenteeism (r = 0.15…).” 
  • Adherence. “Adherence to the 80 minutes per week of exercise decreased from 54.9% to 23.2% participants between weeks 2 and 12.”

A few thoughts:

1. There is much to like here: an RCT of a practical intervention for a big problem (burnout). And, yes, it’s published in a major journal.

2. The result in a sentence: “Although exercise was able to reduce depressive symptoms among HCWs, adherence was low toward the end of the trial.” 

3. While offered to all health care workers, participants were overwhelmingly nurses (with very few physicians).

4. Obviously, adherence was problematic – right from the start, actually. Just 54.9% of participants did the 80 minutes of work out in the first week. The authors note: “Even though all the participants volunteered and were generally willing, ready, and able to start exercising with the apps at home (and most did so in the first few weeks), adherence was suboptimal among some participants, with older adults more likely to use the apps.”

5. The glass is half full and half empty: those who did engage showed benefit, but adherence was low.

6. If burnout is a pervasive problem, the results should be put into perspective. This study showed that a low-cost intervention helped some. The study suggests that an exercise app isn’t a panacea but perhaps part of a larger cluster of remedies.

7. Past Readings have considered burnout. Recently, we looked at an interview with Dr. Srijan Sen (of the University of Michigan) who noted the overlap between burnout and depression. That interview can be found here:

The full JAMA Psych paper can be found here:

Selection 2: “Telehealth and In-Person Mental Health Service Utilization and Spending, 2019 to 2022”

Jonathan H. Cantor, Ryan K. McBain, Pen-Che Ho, et al.

JAMA Health Forum, 25 August 2023

Telehealth service utilization expanded rapidly at the COVID-19 pandemic outset, particularly for mental health conditions. Unlike physical health conditions that may require physical examinations or laboratory testing, many mental health services can be provided virtually. Three years after the 2020 SARS-CoV-2 national public health emergency (PHE) declaration, many facets of the US health care system have returned to normal. However, trends in mental health service utilization and spending before expiration of the PHE in May 2023 are largely undocumented.

So begins a research letter by Cantor et al.

Here’s what they did:

  • “This cohort study quantified trends in mental health service utilization and spending in 3 periods: before the PHE declaration (January 1, 2019, to March 12, 2020), during the acute phase before vaccine availability (March 13, 2020, to December 17, 2020), and during the postacute phase (December 18, 2020, to August 31, 2022).”
  • They measured “trends as the number of monthly medical claims per 1000 beneficiaries and spending per 10 000 beneficiaries among approximately 7 million commercially insured adults (aged ≥18 years).”
  • Diagnoses were recorded.
  • Different analyses were done, including by month and gender.

Here’s what they found:

  • Data for 1 554 895 mental health service claims was included.
  • Acute phase and visits. “In-person visits decreased by 39.5% and telehealth visits increased roughly 10-fold (1019.3%) compared with the year prior… Jointly, this represented a 22.3% increase in overall utilization. These trends were generally consistent across conditions…” 
  • Postacute phase. “Telehealth visits stabilized at approximately 10 times (1068.3%) prepandemic levels, whereas in-person visits increased 2.2% each month over the period…” By August 2022, “overall mental health service utilization was 38.8% higher than before the pandemic.” See figures below.
  • Acute phase and spending. “Spending rates for mental health services mimicked utilization. During the acute phase, per capita expenditures were 29.5% higher… compared with the year prior.”
  • Postacute phase. “Spending for telehealth services remained stable, whereas spending for in-person care decreased to prepandemic levels.”  There was a 53.7% increase from the prepandemic phase.

A few thoughts:

1. This is good and interesting data. While the data set is impressive – including almost 1.6 million insurance claims – perspective is needed: it’s limited to Americans with private insurance.

2. A summary of utilization and spending: up and way up. 

3. Would the results be profoundly different in Canada or other countries? 

The full JAMA Health Forum research letter can be found here:

Selection 3: “Portugal Has Succeeded Where We’ve Failed With Addiction”

Maia Szalavitz

The New York Times, 29 August 2023

After Cody Bohanan, 24, was locked up on a charge related to possession of drug paraphernalia in 2021, he told the staff at Butler County Jail in Ohio that he was withdrawing from opioids. His cellmates saw him vomiting blood. They implored guards to intervene.

But outside of having his vital signs purportedly checked a few times by paramedics, Mr. Bohanan received no medication or treatment for his withdrawal. He died five days into his jail sentence. Two months later, Diann Pink, a 58-year-old grandmother arrested on a charge of drug possession and driving under the influence, died in the same jail, from the same cause: complications of opioid withdrawal.

So begins an essay by Szalavitz.

The writer notes that some have criticized decriminalization efforts. “They point to recent rises in overdoses and disorder like public drug use in Oregon, which decriminalized small amounts of drug possession in 2021, and in Portugal, which decriminalized drug possession in 2001 and was the model for Oregon’s law.” She argues that there is a misunderstanding. “People tend to assume that arrests for possession result in offers of treatment and that treatment is available for anyone in jail who wants help. Some claim that arrests help people with addictions hit bottom and choose to stop using, even without treatment. But as the Butler County cases illustrate, arrest and incarceration often block access to treatment rather than bolster it. A 2021 study by Columbia University researchers found that between 1987 and 2017, deaths from overdose, suicide and infectious disease climbed in concert with county-level incarceration rates.”

She notes that little treatment is offered in correctional facilities.

  • “[O]nly 54 percent of jails surveyed by the Department of Justice in 2019 said they provided any withdrawal treatment.” 
  • “As of 2021, only around 13 percent of correctional facilities publicly reported having some form of ongoing medication-based treatment program for people with opioid use disorder…”
  • She interviews Brandon Del Pozo, a former police chief and now an assistant professor of medicine at Brown University. “When asked what percentage of people arrested on low-level drug charges get rapid access to treatment, he said, ‘Almost none, ever.’”

She thinks that the criticisms of Portugal and Oregon are simplistic. “Critics of decriminalization have claimed that Portugal’s policy worked at first only because possession arrests were replaced by police citations that could result in forced treatment. They say that Oregon’s policy is failing because it lacks these teeth. But coerced treatment was never a fundamental aspect of Portugal’s policy. Dr. João Castel-Branco Goulão, the architect of Portugal’s drug policy, has said that treatment is ‘not mandatory,’ even with repeated citations. ‘It’s a moment to reflect.’”

She argues that Portugal has done well. “Portugal’s success in sharply reducing overdose deaths and new cases of H.I.V. among drug injectors between 2001 and 2011 was achieved largely by a huge expansion of voluntary care.”

She does note a recent uptick in overdose deaths – 74 overdose deaths in 2021 – but puts that figure in perspective: it’s below the European average and significantly below the American one. She also notes that funding for outreach and treatment was cut by 79% in 2012. (!)

A few thoughts:

1. This is a well-argued essay.

2. Despite different opinions on decriminalization, perhaps we can all agree that it’s a major problem that so few people in the United States (and Canada) have access to treatment when in prison.

3. In a less favourable review of Portugal, The Washington Post’s Anthony Faiola argues that the experiment with decriminialization has been problematic. That essay can be found here:

The full NYT essay can be found here:

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