From the Editor

As we head into the second wave, are there lessons from the spring?

This week, we have three selections.

In the first, published in The Lancet Psychiatry, Dr. Seung Won Lee (of the Sejong University College of Software Convergence) and co-authors look at mental illness and COVID-19 in South Korea. Doing a cohort study, drawing on national databases, they wonder about diagnosis and clinical outcomes for those with mental illness. “Diagnosis of a mental illness was not associated with increased likelihood of testing positive for SARS-CoV-2.” It’s a big finding – but is it relevant on this side of the Pacific?


Can we nudge patients with depression to take medications? In the second selection, we look at a new JAMA Psychiatry research letter. Steven C. Marcus (of the University of Pennsylvania) and his co-authors offer financial incentives for medication compliance. They conclude: “In this pilot study, escalating incentives for daily antidepressant adherence significantly improved adherence compared with a control group during the critical first 6 weeks of treatment.”

Finally, in our third selection, we consider an essay by Dr. Allison Crawford (of the University of Toronto) from The Walrus. She writes about the change in mental health care with COVID-19, as virtual care has become the norm. “I take off my shoes so that I can enter softly and with an open heart. My patients can’t see my bare feet.”



Selection 1: Association between mental illness and COVID-19 susceptibility and clinical outcomes in South Korea: a nationwide cohort study

Seung Won Lee, Jee Myung Yang, Sung Yong Moon, et al.

The Lancet Psychiatry, 17 September 2020  Online First


COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide since its emergence at the end of 2019. Various risk factors for severe outcomes of COVID-19 have been elucidated. Risk factors are typically conditions that reduce general immunity and are associated with a history of chronic disease. These factors include being aged older than 65 years and having pre-existing conditions such as chronic obstructive pulmonary disease and asthma, hypertension, cardiovascular disease, chronic kidney disease, diabetes, obesity, malignancy, use of anti-inflammatory biological agents and transplantation, and chronic infection with HIV.

Mental illness adversely affects outcomes of various medical conditions. People with mental disorders are less likely to undergo screening for medical comorbidities, and have a higher mortality and a poorer prognosis when they are diagnosed with a disease than the general population. Evidence concerning whether patients with a severe mental illness have different susceptibility to infection with SARS-CoV-2 or clinical outcomes after infection is scarce.

So begins a paper by Lee et al.

Here’s what they did:

  • Drawing on South Korean national databases, they did a nationwide cohort study.
  • Mental illness was defined as having an ICD-10 diagnosis within a year.
  • People were positive for SARS-CoV-2 if they had a positive result from a publicly-funded service.
  • Different outcomes were considered.

Here’s what they found:

  • “Between January 1 and May 15, 2020, 216 418 people were tested for SARS-CoV-2, of whom 7160 (3.3%) tested positive.”
  • With the cohort propensity score matching, 3.0% of 47 058 patients without a mental illness tested positive for SARS-CoV-2; 2.9% of 48 058 with a mental illness did (adjusted odds ratio [OR] 1.00).
  • “109 (8.3%) of 1320 patients without a mental illness had severe clinical outcomes of COVID-19 compared with 128 (9.7%) of 1 320 with a mental illness (adjusted OR 1.27…).”

“We showed that people with a previous diagnosis of a mental illness had the same risk for testing positive for SARS-CoV-2 as people with no history of mental illness in a nationwide cohort from South Korea. Patients with a mental illness had slightly worse clinical outcomes of COVID-19 but the numbers were small.”

A few thoughts:

  1. This is a good paper.
  1. The authors drew on national databases and designed a cohort study. Of course, we can wonder about the completeness of the dataset, given that people may have COVID-19 without being tested. Still, it’s a solid study. There is the larger question of its relevance for clinicians in North America. After all, the South Korean experience with the virus was very confined and controlled. If there were a larger outbreak (like in Quebec), would the main finding about diagnosis hold?
  1. With regard to outcomes, they offer a reasonable policy prescription: “Patients with a severe mental illness showing acute respiratory symptoms should be prioritised for medical care. Active surveillance, monitoring, and support of people at risk for chronic stress disorders, depression, anxiety disorders, psychosis, substance use, and suicide should be put in place.”

The full paper can be found here:


Selection 2: “Effect of Escalating and Deescalating Financial Incentives vs Usual Care to Improve Antidepressant Adherence: A Pilot Randomized Clinical Trial”

Steven C. Marcus, Megan E. Reilly, Kelly Zentgraf, et al.

JAMA Psychiatry, 23 September 2020 Online First


Although antidepressant medications are efficacious for depression, nonadherence frequently undermines their effectiveness. Antidepressants have a delayed onset and therefore do not offer prompt symptom relief that would support adherence. It is unknown whether financial incentives, which encourage adherence to some but not other health behaviors, improve antidepressant adherence for depression. This randomized clinical trial compared 2 behavioral economics-based financial incentives for daily antidepressant adherence: (1) escalating incentives that leverage loss aversion because patients who initiate treatment face ever-greater lost opportunities if they discontinue medication use and (2) deescalating incentives that leverage a tendency to overweigh present benefits by providing larger rewards to overcome initial inertia concerning treatment initiation.

So begins a research letter by Marcus et al.

Here’s what they did:

  • The study involved five primary care practices in a Philadelphia, Pennsylvania.
  • People with depression were invited to participate. They weren’t taking antidepressants, but had been prescribed antidepressants in the previous ten days.
  • Participants “were randomized in equal proportion to receive 6 weeks of (1) usual care, (2) usual care and escalating daily financial incentives ($2/day, increasing by $1/week up to $7/day), or (3) usual care and deescalating financial incentives ($7/day, decreasing to $2/day) for each antidepressant-adherent day.”

Here’s what they found:

  • “Results from this analysis indicated that 26 (43%) of the 60 schools suggested apps on their Web site.”
  • “During the 6 week follow-up, the escalating group was significantly more likely to be adherent than control participants (90.7% vs 74.9%…), although the deescalating and control groups did not differ. Compared with control participants, the escalating group was significantly more likely to achieve symptom response (65.0% vs. 40.0%), remission (35.0% vs 8.6%), and adherence of 80% or more (87.5% vs 47.4%).”
  • Compared with control participants, the deescalating group was also more likely to achieve symptom response (63.2% vs 40.0%) and remission (26.3% vs 8.6%)…
  • “In post hoc analyses, the escalating group compared with the deescalating group was more likely to be have adherence of 80% of more (87.5% vs 68.4%) but was not significantly more likely to achieve symptom response or remission.”

A few thoughts:

  1. This is a good research letter.
  1. The numbers are small. That said, they do point in a direction. Behavioural economics – the attempt to nudge people in a certain direction by providing incentives – has been something of a dud in mental health, with various experiments, such as for smoking cessation. Could depression treatment be different?
  1. As is often the case, behavioural economics is promising. It’s tempting to believe that a “nudge” (like a small financial incentive) could affect outcomes. But can a few dollars a day really be the difference between compliance and non-compliance?

The full research letter can be found here:


Selection 3: Can Virtual Therapy Replace the Real Thing?

Allison Crawford

The Walrus, 21 September 2020


One day in therapy, I started crying as I recounted the time I danced in the parking lot of my mother’s long-term care facility. I had been trying to make my mother smile while she spoke to me on the phone and watched from the window above, but she waved longingly for me to come up. Her memory was deteriorating rapidly, and she didn’t understand that the precautions imposed by the pandemic would prevent me from being in her presence for months.

I was not crying copiously, but enough to reach for a tissue. Oh. I halted, hand hovering in midair as the realization caught up with me. My therapist didn’t have his tissues. Or, at least, I couldn’t access them where he was, somewhere across the city in an unfamiliar home office. For the first time in years of psychoanalysis, we were connecting by video conferencing.

I spied an almost spent roll of toilet paper near me, a few sheets stuck to the glue of the cardboard. I peeled them off, dabbing at the moisture in my eyes before it ran over. By the time this pandemic is over, I said, my mother may no longer remember me at all. So many newly distorted connections. In that moment, as I spoke with my therapist, I was a patient learning what it means to share your thoughts and feelings through a webcam.

The experience came through the looking glass with me as I faced Margo (not her real name), my next patient, later that day.

So begins an essay by Dr. Crawford.

She writes about being both a physician and a patient.

“Everything I thought I knew about virtual health has been upended as I’ve navigated relationships on both sides of the screen – as a health care provider, as a patient, and with myself. As much as I thought I’d be prepared for such a moment, I’m discovering how much there is still to know about how we display, read, mirror, and respond to emotion across digital media. What’s surprised me most over the past few months has been experiencing for myself what our research had already shown: that, even at a distance, emotional connectedness and compassionate action are still very possible. Virtual therapy at this unprecedented scale seems to be working – for now.”

Noting the rise of virtual care because of the pandemic, she describes the changes:

“Technology can distort and interrupt nonverbal communication, making it harder for us clinicians to read our patients – and for our patients to read us. Therapists haven’t yet found a way to talk about the effect of technical glitches, either in research or with their patients. I have encountered these disruptions on both sides of the screen – faces freezing in distorted emotional expressions, hearing my voice echo oddly on the other end of a bad line, the havoc of talking over each other that a slight delay can unleash, appointments interrupted in both banal and poignant moments.”

She continues:

“My ‘new normal’ in virtual health care still feels entirely strange and disorienting, but although it is ‘curiouser and curiouser,’ as Alice remarks in Alice’s Adventures in Wonderland, ‘it’s no use going back to yesterday, because I was a different person then.’ I am one of many therapists wondering how this new way of meeting contributes to their own identity and satisfaction as a therapist as well as how they can sustain their own wellness through virtual practice.”

A few thoughts:

  1. This is a good essay.
  1. Since March, mental health care has dramatically changed. Dr. Crawford explains well the changes – both as a provider and as a patient. (And the dream analysis is cool.)
  1. Past Readings have considered our virtual moment. In JAMA Psychiatry, Shore et al. posed several excellent questions: “What will the lessons of the COVID-19 pandemic be, in terms of what can vs should be done in person or through telepsychiatry or other technologies? How much virtual care is too much? Is there a virtual saturation point, at which the benefits of a virtual relationship decrease or patients request more in-person interactions? What data need to be captured now to better understand this and identify current lessons learned?”

That paper can be found here:

The full Walrus essay can be found here:


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