From the Editor

How accessible is urgent outpatient mental health care in Canada? Do antipsychotics affect the brain structure of people with psychotic depression? How can physician biases change cardiac care?

This week, we consider three very different selections, drawing from the latest in the literature.

Outpatient Sign over a Hospital Outpatient Services Entrance

In the first selection, Dr. Lucy C. Barker (University of Toronto) and her co-authors look at follow-ups after an ED visit. As the authors note: “Urgent outpatient mental health care is crucial for ongoing assessment and management and for preventing repeat visits to the ED and other negative outcomes.” Drawing on Ontario data, they find that “fewer than half had a physician follow-up visit within 14 days of the ED visit for outpatient mental health care.” Ouch.

In the second selection, we consider a new paper by Dr. Aristotle N. Voineskos (University of Toronto) et al. In an impressive study across multiple sites, they find a connection between cortical thinning and the use of antipsychotics: “olanzapine exposure was associated with a significant reduction compared with placebo exposure for cortical thickness.” Ouch.

Finally, it’s said about health care that “geography is destiny” – so much of the patient experience is tied to her or his place of care, with incredible variations in services between, say, rural and urban centres. In an unusual research letter for The New England Journal of Medicine, Andrew R. Olenski (Columbia University) and his co-authors consider heart surgery and patient age – that is, within two weeks of a patient’s 80th birthday. They argue that numbers are destiny, with heart surgery influenced by “the occurrence of left-digit bias in clinical decision-making…” Ouch.

Please note that there will be no Readings for the next two weeks.



Selection 1: “Urgent Outpatient Care Following Mental Health ED Visits: A Population-Based Study”

Lucy C. Barker, Nadiya Sunderji, Paul Kurdyak, Vicky Stergiopoulos, Alejandro Gonzalez, Alexander Kopp, Simone N. Vigod

Psychiatric Services, 24 February 2020 Online First


The emergency department (ED) is an important component of the mental health care system, acting as the gateway between outpatient and inpatient care in most settings. In the United States and other high-income countries, mental illness and addictions are the primary presenting issues for up to one in 10 adult ED visits. Whether individuals present voluntarily because of subjective distress or involuntarily (e.g., with police escort) because of acute risk, psychiatric ED visits suggest an urgent need for care. Most psychiatric ED visits do not result in hospital admission, yet mental health–related crises cannot usually be managed in a single visit. Urgent outpatient mental health care is crucial for ongoing assessment and management and for preventing repeat visits to the ED and other negative outcomes.

So begins a paper by Barker et al.

Here’s what they did:

  • Drawing on Ontario databases, they did a cohort study looking at people who presented to an ED with a primary psychiatric issue and weren’t admitted to hospital.
  • “The primary outcome was any outpatient follow-up with a physician (primary care provider or psychiatrist) for mental health care within 14 days of the index ED visit.”
  • “We measured the proportion of individuals with any follow-up visit, a follow-up visit to a primary care provider only, and follow-up care with a psychiatrist (with or without primary care).”

Here’s what they found:

  • “There were 143,662 individuals with an index psychiatric ED visit, including 31,592 (22.0%) presenting with substance use disorders and 112,070 (78.0%) whose primary presentation was not a substance use disorder. The latter group included 4,765 (3.3%) with schizophrenia, 2,222 (1.5%) with bipolar disorder, and 17,643 (12.3%) with major depressive disorder.”
  • “About 40.2% (N=57,797) of the cohort had a follow-up visit with any physician for mental health care within 14 days of ED discharge…”
  • “Those presenting with substance use disorders (N=7,974, 25.2%) were much less likely to have a follow-up visit than those who did not present with substance use disorders (N=49,823, 44.5%)…” See figure below.
  • “Only 9.4% (N=1,341) had a follow-up with a psychiatrist within 14 days”


This is a good and timely study.

And it adds to a growing literature showing that there are significant problems with access to mental health care. For us clinicians, the findings are hardly surprising; we are too familiar with the deficiencies of the system that we work in everyday. But the data presents a provincial view, and moves our concerns past the realm of anecdote. The larger questions are obvious. How should the system be better organized? Are there implications for physician compensation? What is the role (or roles) for non-physicians?


Selection 2: “Effects of Antipsychotic Medication on Brain Structure in Patients With Major Depressive Disorder and Psychotic Features: Neuroimaging Findings in the Context of a Randomized Placebo-Controlled Clinical Trial”

Aristotle N. Voineskos, Benoit H. Mulsant, Erin W. Dickie, Nicholas H. Neufeld, Anthony J. Rothschild, Ellen M. Whyte, Barnett S. Meyers, George S. Alexopoulos, Matthew J. Hoptman, Jason P. Lerch, Alastair J. Flint

JAMA Psychiatry, 26 February 2020  Online First


In their first few decades of use, antipsychotic medications were primarily administered to individuals with schizophrenia. With the introduction of atypical antipsychotics in the 1990s, evidence of efficacy led to the US Food and Drug Administration approval for use in mood disorders, including major depression, an illness with a lifetime prevalence of 10% to 15%. Antipsychotics are also increasingly prescribed off label across the life span in a range of pediatric, adult, and geriatric disorders. For example, among all drug classes, antipsychotic medications are the ones most commonly prescribed in children with autism, with nearly 20% receiving antipsychotic medication and rising. Antipsychotics are also associated with sudden death, with risk of unexpected death substantially higher in both children and elderly individuals.

With their increasing use, a better understanding of the risks and benefits of antipsychotics is important for prescribers, patients, and families.

Here’s what they did:

  • They conducted a secondary analysis of a double-blind, randomized, placebo-controlled trial at five academic centers
  • Participants were 18 to 85, and had a diagnosis of major depressive disorder with psychotic features (psychotic depression).
  • They were recruited as part of the STOP-PD II study – “The STOP-PD II was divided into 3 consecutive phases: first, up to 12 weeks of short-term open-label treatment with sertraline (target dose: 150-200 mg/d) and olanzapine (target dose: 15-20 mg/d) to attain remission; second, an 8-week stabilization phase to ensure that remission is sustained; and third, a 36 week randomized clinical trial (RCT) comparing the efficacy of sertraline plus olanzapine and sertraline plus placebo in preventing relapse of psychotic depression.”
  • “Those who consented to the imaging study completed a magnetic resonance imaging (MRI) scan at the time of randomization and a second MRI scan at the end of the 36-week period or at time of relapse.”

Here’s what they found:

  • Eighty-eight participants completed a baseline scan with 72 used for the final analyses.
  • Corticol thickness. “There was a significant treatment-group by time interaction for cortical thickness (left, t = 3.3; P = .001; right, t = 3.6; P < .001), but not surface area.”
  • “When the analyses were restricted to those who sustained remission, olanzapine exposure was associated with a significant reduction compared with placebo exposure for cortical thickness across the 36-week period in the left hemisphere… and the right hemisphere…”

This is a very complicated paper, with significant brain imaging. The above summary is at best cursory.

Still, the finding is clear and, as the authors note, consistent with animal studies. For example: “In rodents, long-term exposure to antipsychotic medication causes approximately a 10% decrease in frontal cerebral cortex volume.”

This is a very impressive study: across multiple sites, and it is a double-blind, randomized, placebo-controlled trial.

How to interpret these results? We can take a narrow view: the paper was focused on those with depression complicated by psychosis, and it only considered one antipsychotic. A broader interpretation would be that antipsychotics aren’t benign; they may cause brain changes.

The authors write: “Given that reductions in cortical thickness are typically interpreted in psychiatric and neurologic disorders as nondesirable, our findings could support a reconsideration of the risks and benefits of antipsychotics. Such reconsideration might make sense when alternatives are present (eg, antidepressants for major depression without psychosis or mood stabilizers for the maintenance treatment of bipolar disorder) or in off-label use when controlled data do not support their use (eg, for the treatment of anxiety or insomnia). Our data show that such caution may be even more important toward the end of the lifespan (and we speculate this may also be true early in the life span) when brain change is most dynamic, with heightened vulnerability.”

Given that other problems with antipsychotics are well known, including the metabolic issues, this brain-imaging paper adds to a body of evidence suggesting that we use this class of medications with thought and some caution.


Selection 3: “Behavioral Heuristics in Coronary-Artery Bypass Graft Surgery”

Andrew R. Olenski, André Zimerman, Stephen Coussens, Anupam B. Jena

The New England Journal of Medicine, 20 February 2020


Behavioral heuristics (mental shortcuts that simplify decision making) are common in medicine and can lead to cognitive biases that affect clinical decisions. Left-digit bias is the tendency to categorize continuous variables on the basis of the left-most numeric digit. Left-digit bias explains why items are often priced at $4.99 as opposed to $5.00. This bias may affect treatment decisions.

So begins a research letter by Andrew R. Olenski and his co-authors.

We hypothesized that CABG would be performed less frequently among patients admitted after their 80th birthday, despite an absence of recommendations in clinical guidelines to reduce CABG use at this age.

Drawing on US Medicare data (Medicare Provider Analysis and Review) and involving roughly 9 000 patients, they find:

Patients with acute myocardial infarction who were admitted in the 2 weeks after their 80th birthday were similar to those admitted before their 80th birthday with regard to various baseline characteristics… However, those admitted after their 80th birthday were significantly less likely to undergo CABG than those admitted before their 80th birthday (5.3% [265 of 5036 patients] vs. 7.0% [308 of 4426 patients]…), with no corresponding difference among patients who were admitted in the 2 weeks after as compared with 2 weeks before their 77th through 79th or 81st through 83rd birthdays.

They conclude:

Although we cannot completely rule out the possible influence of confounding factors, these results are consistent with the occurrence of left-digit bias in clinical decision-making, as a previous study has also shown.

It’s one thing for left-right bias to affect small things – your choice of a muffin with your morning coffee, for example – but can CABG be influenced by such tiny differences in age? The authors make a good case. The authors also cite a paper that considers ED diagnoses around a patient’s 40th birthday: “patients arriving in the emergency department just after their 40th birthday are roughly 10% more likely to be tested for and 20% more likely to be diagnosed with ischemic heart disease (IHD) than patients arriving just before this date, despite the fact that the incidence of heart disease increases smoothly with age.”

This is a research letter about cardiac surgeries in the United States… But do such biases exist in mental health in Canada?


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