From the Editor

Can we help youth before the onset of full disorders to build skills and avoid deeper problems? Several school-based efforts, offering DBT and mindfulness skills, have been tried without much success. Ecological momentary interventions (EMIs) – provided to patients during their everyday lives and in natural settings, giving unstructured recommendations with structured interventions – is a newer therapy that has gained attention.

But does it work? In a new paper for JAMA Psychiatry, Ulrich Reininghaus (of the University of Heidelberg) and his co-authors describe an RCT focused on youth with low self-esteem who have had past adversity, involving 174 Dutch participants. “A transdiagnostic, blended EMI demonstrated efficacy on the primary outcome of self-esteem and signaled beneficial effects on several secondary outcomes.” We consider the paper and its implications.

In the second selection, Victoria A. Joseph (of Columbia University) and her co-authors look at US suicide rates in Black females. In their American Journal of Psychiatry letter, they analyze suicides over two decades, drawing data on age and region from a national database. They conclude that: “increasing trends in suicide death among Black females born in recent years and underscores the need to increase mental health care access among Black girls and women, and to reduce other forms of structural racism.”

And in the third selection, Dr. Jon Hunter (of the University of Toronto) contemplates endings – including his ending – in a personal and moving paper for CMAJ. He notes the need to clean up his possessions. But what about his practice and the many patients that he has followed for years? “I’d rather not shy away from the uncertainty and loss of the ending, and to try to help one more time.”


Selection 1: “Transdiagnostic Ecological Momentary Intervention for Improving Self-Esteem in Youth Exposed to Childhood Adversity: The SELFIE Randomized Clinical Trial”

Ulrich Reininghaus, Maud Daemen, Mary Rose Postma, et al.

JAMA Psychiatry, 29 November 2023  Online First

Most mental disorders first emerge in adolescence and early adulthood and, as such, contribute substantially to disease burden. Recent years have seen a shift in focus toward transdiagnostic frameworks, which broadly posit that early clinical phenotypes are nonspecific and may result in a range of mental disorders later in life. Childhood adversity… is one of the most pervasive risk factors for various mental disorders. Although primary prevention of childhood adversity continues to be of prime importance, it remains difficult to achieve for all, and, hence, interventions targeting the negative consequences of childhood adversity in youth are a promising selective prevention strategy for adult mental disorders with tangible public health implications. One important candidate mechanism that may link childhood adversity to mental ill health is low self-esteem… 

The SELFIE intervention, a novel, transdiagnostic ecological momentary intervention (EMI), adopts a strategy that aims to transform evidence on self-esteem… EMIs offer a unique opportunity for real-time tailoring of interventions to what individuals need in a given moment and context. Consistent with an ecological interventionist causal model approach, EMIs reflect a very promising strategy for preventing adult mental disorders and/or improving well-being, resilience, and outcomes in youth already in contact with services for early mental health problems by targeting momentary self-esteem in their daily life.

Here’s what they did:

  • “This was a 2-arm, parallel-group, assessor-blinded, randomized clinical trial conducted from December 2018 to December 2022.”
  • It included youth (aged 12-16) with low self-esteem (Rosenberg Self-Esteem Scale (RSES) < 26) who had been exposed to childhood adversity.
  • The intervention: A novel, blended EMI plus care as usual, consisting of “3 face-to-face sessions (on-site or online), delivered by trained mental health professionals, 3 email contacts, and an EMI administered through a smartphone-based app for adaptive real-time and real-world transfer. The intervention was based on principles of EMIs, and a guided self-help approach using principles of cognitive behavioral therapy.”
  • “The primary outcome was RSES self-esteem at postintervention and 6-month follow-up.”

Here’s what they found:

  • Out of 425 potential candidates, 223 were assessed and 174 were included in the study, randomized to care as usual (89 youth) or the intervention (85).
  • Demographics. 89% of the participants were female with a mean age of 20.7 years, overwhelmingly White (85.6%), and in some type of schooling (70.1%). In terms of the illness experience, most were on medications (64.4%).
  • Continuation. At postintervention, 87.9% provided primary data; at six month follow-up, 80.5% did. 
  • Self-esteem. “RSES self-esteem was, on average, higher in the experimental condition (blended EMI + CAU) than in the control condition (CAU) across both postintervention and follow-up as a primary outcome (B = 2.32 … Cohen d-type effect size = 0.54).”
  • Secondary outcomes. They found small to moderate effect sizes for the intervention group with lower levels of negative self-esteem (d = -0.38), negative schematic self-beliefs (d = -0.39) and higher levels of positive self-esteem (d = 0.53) and positive schematic self-beliefs (d = 0.38).

A few thoughts:

1. This is a good and impressive study – an RCT, with an interesting approach, and published in a big journal. Even the study title, SELFIE, is excellent.

2. The findings in four words: the intervention improved self-esteem. (!!)

3. And there were improvements with the secondary measures. (!)

4. Is this a better approach to addressing problems early – away from diagnoses and focused on self-esteem? The study is compelling.

5. The authors note several limitations, including around blinding. Was the digital intervention an issue in that it created barriers to care? They argue it wasn’t: “in designing the blended EMI, we paid careful attention to ensure acceptance, adherence, and accessibility, which were found to be moderate to high.”

6. For those interested in a more detailed discussion, Dr. John Torous (of Harvard University) interviews the first author for a JAMA Psychiatry podcast. You can find it here:

The full JAMA Psych paper can be found here:

Selection 2: “Trends in Suicide Among Black Women in the United States, 1999-2020”

Victoria A. Joseph, Gonzalo Martínez-Alés, Mark Olfson, et al.

The American Journal of Psychiatry, December 2023

Suicide is a leading cause of death in the United States. Increases in suicide in the United States over the last two decades have disproportionately affected Black young women. Moreover, while the overall U.S. suicide rate decreased between 2018 and 2020, the suicide rate increased among Black female youth aged 15-24 years from 2.7 to 4.3 per 100,000 between 2013-2019, and accumulating research indicates that younger compared to older generations of Black individuals are increasingly at risk of suicide.

Recent increases in suicide deaths among young Black women in the United States warrant study of the drivers of risk unique to this population. Indeed, racial/ethnic discrimination has recently emerged as a possible driver of suicide risk among younger Black women. Assessing age, period, and cohort (APC) effects can provide additional key information about the concentration of suicide risk for specific birth cohorts, across recent time periods, and at specific ages, allowing for a more precise identification of populations in which interventions are particularly urgent.

So begins a priority data letter by Joseph et al.

Here’s what they did:

  • They drew data from the National Center for Health Statistics’ Multiple Cause of Death 1999-2020 database, which includes race, age, sex, and region.
  • “We excluded decedents aged < 15 and > 84 as suicide death counts were too low for reliable analysis.”
  • In terms of the statistical analyses: “Suicide rates by age, period, and cohort were visualized using hexagonal maps, and estimated using modified Poisson regression to address identifiability.” Additional analyses were done.

Here’s what they found:

  • Rates. “Suicide rates among Black females aged 15 to 84 increased from 2.1 per 100,000 in 1999 to 3.4 per 100,000 in 2020. Rate increases were concentrated among those aged 15-24, increasing from 1.9 to 4.9 per 100,000.”
  • Effects. “Results indicate the presence of all three effects: 1) a clear age effect, with higher rates at younger ages and lower rates at older ages, regardless of cohort and time; 2) a period effect, with rates generally increasing across time for most ages, but limited evidence of a period effect at older ages; and 3) a cohort effect, with suicide rates highest among females born after 2002 and a clustering of increased suicide rates among the youngest cohorts.”
  • Regions. “Across regions, rates were highest among those 15-24 and 25-34 years. Although population sizes were lower, rates were highest in the West, peaking at 4.8 per 100,000 among individuals 25-34 years, and deaths were concentrated in the South…” See figure below.

A few thoughts:

1. This is good and important data.

2. Ouch.

3. How to address this? The authors offer several thoughtful suggestions: “Access to help during suicidal crises is a critical component of suicide prevention efforts; however, structural racism – the ways in which values are assigned, maintained or codified in law based on racialized group membership – can reduce access to care of Black youth due to experiences of stigma and mistrust of support systems. For example, this may hinder use of police-led crisis intervention teams in the context of heightened awareness regarding police brutality toward Black individuals.”

4. Past Readings have considered interventions for specific populations. A JAMA Psychiatry paper by Zhou et al., for instance, described a tailored CBT for insomnia program for Black women. You can find it here:

The full AJP letter can be found here:

Selection 3: “The end”

Jon Hunter

CMAJ, 20 November 2023 

“It probably started with my father’s death 30 years ago. It was sudden and shocking, but life rushed back in to fill the emptiness. All was well for years, until my mother died, followed by my mother-in-law within a year. We immersed ourselves in sorting out the detritus of decades of two women who had lived alone. A fancy but cracked China plate repaired with a Band-Aid, but kept, just in case… We didn’t reflect on it much at the time, we just put our heads down and tidied, sorted, distributed, trashed, sold and donated.

“Recently, a senior doctor I know developed metastatic cancer and died. He saw his last patient 48 hours before the end. Another physician became sufficiently infirm that he ‘had’ to retire at 90 years of age. Patients he had been seeing for decades now depended on his colleagues to find them treatment.”

So begins an essay by Dr. Hunter.

He writes about his mortality. “[T]he awareness that started 30 years ago with my father’s collapse became more acute now. Death can be sudden and unexpected, but it is inevitable. It was important to start thinking about my own end.” With that in mind, and despite his own “good health,” he decides to clean up his things. “I’ll save [my colleagues] the trouble of riffling through the files of interesting papers that I will read soon, when I have the chance, many of which are more than 10 years old.”

But what about his patients? He notes a long-standing connection to some. “We call these patients ‘lifers,’ which sounds derogatory, but really isn’t. It is just a category of therapy that is distinct from someone seen with a clear expectation of an ending… All of these folks would have started with a few sessions when they were in hospital for a surgery or other procedures, but they had a scary family history of cancer and felt under threat, or the adversity in their upbringing made it hard for them to trust anyone, and so the care for their physical illness was repeatedly compromised. The problem (is it a problem?) is that the work required to sort that out meant we got really into it; we delved deep into their stories.” 

He wonders how to proceed. “I’ve tidied up my office, but what do I do with these people with whom I have longstanding intimate relationships of sorts, who despite our efforts, may not have anyone else available to them?” He talks about the difficult work. “My answer is that I take on the ending with them, right now, and without obfuscation. We need to speak of this together. That’s the way to ensure they don’t feel overlooked, without value, like something left in a dead person’s basement.” He describes mixed results. “The second person took it as me punishing them for something that had happened at the start of the session, and the third person was just completely pissed off.”

He discusses the alternative to this hard work: “[p]retending, like sticking a Band-Aid to the back of a China plate and acting as if it can be used.”

A few thoughts:

1. This is an excellent paper.

2. In medicine, we spend so much time thinking about beginnings – getting into medical school, applying for residency, setting up a practice – but rarely do we talk about endings. Should we all collectively be more like Dr. Hunter?

3. The China plate analogy is great.

The full CMAJ paper can be found here:

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