From the Editor

He was so overwhelmed by the cancer diagnosis that he didn’t eat or sleep for days. “It was my worst nightmare.” My patient isn’t alone in that devastating experience, of course – the diagnosis and treatment of cancer is a major life event. Not surprisingly, the suicide rate is roughly double that of the general population in the United States. But with increasing psychosocial interventions, how has this changed over time?

In the first selection, Qiang Liu (of the Chinese Academy of Medical Sciences) and his co-authors attempt to answer that question in a new paper for Translational Psychiatry. Drawing on 40 years of data and a major US database, they analyzed the journeys of five million cancer patients, discovering good news. “We revealed a gradual increase in cancer-related suicide rates from 1975 to 1989, followed by a gradual decrease from 1989 to 2013, and a marked decrease from 2013 to 2017.” Indeed, between 2013 and 2017, the rate dropped by 27%. We consider the paper and its implications.

In the second selection, Sakiko Yasukawa (of the Sony Corporation) and her co-authors aimed to reduce dropouts from psychotherapy using AI. In a new paper for BMJ Mental Health, they describe an RCT involving 149 people. “The results suggest that the personalised messages sent by the chatbot helped participants control their pace in attending lessons and improve programme adherence without human guidance.”

Last week marked the anniversary of D-Day with ceremonies, including in Normandy. What was the toll on those who returned home? In the third selection, an essay published in The Globe and Mail, Normanne Bland describes her father and his time in Europe. She writes about him with mixed feelings, coloured by his mental health problems, including PTSD. “I had a complicated relationship with my father. I was proud of his service but I loathed his drinking.”

There will be no Reading next week.


Selection 1: “Trends in Cancer-related Suicide in the United States” 

Qiang Liu, Zheng Qu, Hao Dong, et al.

Translational Psychiatry, 27 May 2024

Cancer, the second leading cause of death across all age groups in the United States (US), is often accompanied by a higher risk of suicide. Suicide was the tenth leading cause of death among individuals of all ages, with 47,511 suicide cases recorded in 2019. Furthermore, suicide is recognized as a significant contributor to premature mortality. Patients with cancer face an elevated risk of suicide, primarily attributable to psychological distress, advert effects from multiple treatments, diminished quality of life, and uncontrolled and intense cancer-related pain. The shift toward a bio-psycho-social medical model has highlighted the importance of assessing and managing the risk of suicide and implementing suicide prevention strategies and psychological interventions for cancer patients.

With advancements in cancer screening and treatments and increased awareness regarding the importance of providing psychological support to patients with cancer, the trends of cancer-related suicide among patients with cancer in the US have changed. However, current evidence regarding these trends is scarce.

So begins a paper by Liu et al. 

Here’s what they did:

  • The authors conducted a retrospective cohort study.
  • They drew on data from Surveillance, Epidemiology, and End Results (SEER) – a collaboration among several agencies (the US Centers for Disease Control and Prevention, the National Cancer Institute, and regional and state cancer registries) – covering US patients diagnosed with cancer.
  • They examined the years 1975 to 2017.
  • They calculated age-adjusted rates and standardized to the US standard population (in the year 2000) and expressed per 100,000 person-years. They also calculated the annual percent change (APC) and average annual percent change (AAPC).
  • Further statistical analyses were performed for sex, age, and race.

Here’s what they found:

  • There were 4 870 410 patients diagnosed with cancer.
  • Suicide and demographics. 8 114 died by suicide. The majority were male (81.7%), Caucasian (92.8%), and aged between 50 and 79 years (72.5%).
  • Trends. There has been a decline in cancer-related suicide rates since 1989, especially in the most recent five years (AAPC, -27.3%). See figure below.
  • Sex, age, and race. The most significant declines were in male patients (AAPC, -20.4%). In terms of age, patients aged 15 to 49 years (AAPC, -16.8%), and 60-79 years (AAPC, -34.0%) had big declines. Cancer-related suicide rates among Caucasian and African Americans have also been decreasing. 
  • Comparison to population. In the general population, male and female suicide rates have been increasing since 2003 and 2000, respectively, a contrast to trends in the cancer population. Caucasian and African American suicide rates have also been increasing since 2000 and 2007, respectively. 

A few thoughts:

1. This is an important study – in the words of the authors, “the largest and most comprehensive in characterizing the profile of cancer-related suicide trends over a 40-year period.” They have good data over four decades. Nice.

2. The main finding in a sentence: cancer-related suicide rates have decreased since 1989; in contrast, the suicide rates in the US general population have increased. (!)

3. Wow.

4. Why the improvement? Cancer care itself has improved, the authors note. “As advancements were made in cancer treatment and surgical techniques, the landscape of cancer care began to change. Traditional open surgery can have several challenges and potential complications including intensive postoperative pain, significant trauma, slow healing, impacts on cardiopulmonary function, prolonged hospitalization, and high costs, which could seriously affect the quality of life of patients undergoing such procedures…”

5. Also, there is more attention paid to the psychological impact of cancer. “This period witnessed an evolving role of psycho-oncology care, palliative care, and hospice care, leading to the promotion and increased utilization of these services by patients with cancer, enhancing their overall quality of life.”

6. The way forward? Should we be focusing more on females with targeted strategies?

7. Like all studies, there are limitations. The authors write about several, including the fact that terminology has changed resulting in some challenges when comparing data over 40 years. 

8. Cancer and suicide have been considered in past Readings, including an impressive systematic review and meta-analysis published in Nature Medicine; that week, we also discussed a NEJM paper by Dr. Natasha Z. Rabinowitz Steele, a physician who writes about her diagnosis and treatment. It can be found here:

The full Transl Psychiatry paper can be found here:

Selection 2: “A chatbot to improve adherence to internet-based cognitive-behavioural therapy among workers with subthreshold depression: a randomised controlled trial”

Sakiko Yasukawa, Taku Tanaka, Kenji Yamane et al.

BMJ Mental Health, January 2024

Subthreshold depression has a high prevalence and risk for developing major depression (MDD). Depression leads to poor job performance and significant economic losses for employees… Evidence-based intervention, such as internet-based cognitive-behavioural therapy (iCBT), potentially improves the accessibility to the care of people with subthreshold depression that do not seek professional help. iCBT has been effective in reducing depressive symptoms and preventing MDD in adults including workers with subthreshold depression. Further, iCBT has the advantages of teleoperation, cost reduction and maintenance of treatment quality compared with face-to-face psychotherapy…

On the other hand, iCBT has its own challenges of low adherence and dropout, with reports of approximately 10% lower for iCBT compared with face-to-face. Approaches to increase adherence and retention need to be further studied, not only because of the insufficient effectiveness of the treatment but also because of the risk for relapse… The number of digital mental health intervention studies using chatbots has increased in recent years, and iCBT with chatbots has the advantage of promoting self-learning. The immediate responsiveness and human-like nature of chatbots may also benefit both human and automated encouragement, and we focused on the potential of chatbots to improve adherence.

So begins a paper by Yasukawa et al.

Here’s what they did:

  • “We developed a chatbot to increase adherence to an existing iCBT programme, and a randomised controlled trial was conducted…”
  • There were with two groups: one group used iCBT plus a chatbot (iCBT+chatbot group) and one group just the therapy (iCBT group). 
  • The iCBT: Resilience Training SE (Sony Edition); this app includes several components: psychoeducation (PE), behavioural activation (BA), and self-monitoring (SM).
  • The chatbot: “served as a human-like companion to participants… sending them personalised messages every morning and evening for 8 weeks.”
  • “Participants were full-time employees with subthreshold depression working in Japan…”
  • The primary endpoint: the completion rate of the iCBT programme at eight weeks.

Here’s what they found:

  • A total of 334 people were screened; 149 people were recruited; analysis was done on the data of 142.
  • Demographics and illness. The mean age was 41 years and the majority were female (52%). The mean PHQ-9 score: 6.96. There were 15 employees who scored four or less. (!)
  • Primary endpoint. The completion rate of the iCBT+chatbot group was 34.8% that of the iCBT group was 19.2%. The risk ratio was 1.81.
  • Adverse events. None (though one participant was involved in a traffic accident).

A few thoughts:

1. This is an interesting study.

2. The main finding in a few words: AI helped with dropouts.

3. Of course, there are many, many problems with the study, including that it was a non-clinical sample with no confirmation of the psychiatric condition. (Indeed, 15 people had PHQ-9 scores of four or lower – which doesn’t seem like subthreshold depression.)

4. Still, in the early days of AI, this paper suggests that there may be a role in improving low-resource psychotherapy – relevant in high-income nations where many don’t receive therapy, and very relevant in low- and middle-income nations where most don’t.

The full BMJ Ment Health paper can be found here:

Selection 3: “Dad’s life changed forever in 1944. When he died, I took his ashes to France”

Normanne Bland

The Globe and Mail, 5 June 2024

‘Were you seasick?’ I asked.

‘I was too scared to be sick,’ my dad answered.

I was asking about crossing the English Channel from Southampton to Normandy, France aboard the HMCS Prince David in the early morning of June 6, 1944. D-Day. The sea was rough. The waves, high. The stakes – even higher.

Norman Bland was 21 years old that day. He had been overseas since the beginning of the Second World War, from the age of 16. I am certain that was not permitted so his Army records must show a false birthdate. He spent time in England, Belgium, France and Holland. He likely learned to smoke and drink during this time. No doubt he charmed a few young ladies with his bright blue eyes, blond hair and impeccable manners. He also did and saw the unimaginable.

As children, we loved to hear Dad’s war stories.

So begins an essay by Bland.

She has warm memories of veterans’ events. “Our family would go to the Canadian National Exhibition in Toronto for the Warrior’s Day Parade and watch Dad march in perfect step with his mates. During cold November weekends before Remembrance Day, we gathered at the local Legion, were issued a box of poppies and dropped at some corner or storefront for an afternoon to sell poppies. I was around 11 years old and don’t recall much supervision during these outings, but there was never trouble. Just frozen fingers and toes. It didn’t matter, though. When we finally returned to the Legion, there was always hot soup and we were proud to support Dad.”

But there were other memories, too. “He would sit at our dining room table and tell us about jumping aboard the landing craft on D-Day. As the ship dipped down, the landing craft lifted up in the rough water. The jump had to be timed perfectly. Some men didn’t make the jump and were lost before they even landed on the beach. He told us how he ‘hacked his way through a human wall of flesh,’ dragging his wet equipment behind him. He could never forget the sounds from that day. The guns – TAT TAT TAT TAT TAT – all day long. He heard men crying for their mothers. He saw the sea wash up red. If we asked a question, we might get an answer. More often than not, he would say, ‘That’s enough,’ and go to bed. Sometimes, my father suffered from night terrors and would wake up screaming.”

She notes the challenges of being his daughter and the long shadow of his mental illness. “I hated the noise and booze and cigarettes.” Indeed, it wasn’t always easy. “Growing up, he tried to parent me and teach me things but would end up frustrated. I was not meticulous enough. ‘No, no, Norm,’ he would scold if I wasn’t painting or sweeping just right. If I injured myself, he would shout at me, making me cry harder. My mother used to say, ‘He’s just excited.’ Looking back, I realize he was likely anxious. Living a life with PTSD.”

She describes his decline in health and eventual death. She decides to leave her father’s ashes on the beaches of Normandy.

“The beach was quiet. The sea was calm. Thankfully, there was a breeze and with a brief goodbye, I raised the bag that held Dad’s ashes and let the wind take him away. I stayed until he settled and, as the tide came in, I knew he would be happy to spend eternity there.”

A few thoughts:

1. This is a well-written essay – personal and moving.

2. She captures well the pride of the family and their burden.

3. We often speak of those who served and didn’t return home. This essay reminds us of those who returned but were never the same.

4. Past Readings have covered PTSD, of course. A recent Reading, we considered a JAMA Psychiatry paper that compared written exposure therapy to prolonged exposure therapy, finding noninferiority.

The 75th anniversary of D-Day was noted in a past Reading which included a summary of Dr. Charles S. Myers’ original Lancet paper on shell shock. You can find it here:

The full Globe essay can be found here:

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