From the Editor

How has COVID-19 impacted mental health? What to make of the forecasts of a mental health tsunami?

In a new BMJ paper, Ying Sun (of the Jewish General Hospital) and her co-authors do a systematic review and meta-analysis to try to answer these questions. Drawing on 137 studies, they consider mental and the pandemic. They find: “Most symptom change estimates for general mental health, anxiety symptoms, and depression symptoms were close to zero and not statistically significant, and significant changes were of minimal to small magnitudes…” We look at the paper and its clinical implications.

In the second selection, Dr. Dhruv Khullar (of Cornell University) writes about burnout and professionalism for JAMA Health Forum. He argues that burnout is common and costly, and points a way forward, in part by reducing clerical tasks. “A better path is one that strenuously removes the obstacles to physician and patient well-being and that actively promotes the deep work of doctoring.”

In the third selection, Dr. Ari B. Cuperfain (of the University of Toronto) and his colleagues consider extended-release buprenorphine, a subcutaneous monthly depot injection used to treat opioid use disorder in a short CMAJ paper. They make several observations about titration, effectiveness, and safety.


Selection 1: “Comparison of mental health symptoms before and during the covid-19 pandemic: evidence from a systematic review and meta-analysis of 134 cohorts”

Ying Sun, Yin Wu, Suiqiong Fan, et al.

The BMJ, 8 March 2023

Concerns about covid-19 related mental health are substantial, but the sheer volume of low quality evidence has posed a barrier to evidence synthesis and decision making. Vast numbers of cross sectional studies have reported proportions of participants with scores above thresholds on easy-to-administer mental health scales as representing the ‘prevalence’ of mental health problems, without comparisons with scores before the covid-19 pandemic. These scales are not, however, intended to estimate prevalence – thresholds are typically set for screening and to identify far more people than those who have a mental disorder; thus, proportions above thresholds substantially overestimate prevalence. Nonetheless, many study authors and media stories have concluded that the world’s population is experiencing a covid-19 mental health ‘pandemic’ or ‘tsunami.’

So begins a paper by Sun et al.

Here’s what they did:

“Studies comparing general mental health, anxiety symptoms, or depression symptoms assessed from 1 January 2020 or later with outcomes collected from 1 January 2018 to 31 December 2019 in any population, and comprising ≥90% of the same participants before and during the covid-19 pandemic or using statistical methods to account for missing data. Restricted maximum likelihood random effects meta-analyses (worse covid-19 outcomes representing positive change) were performed. Risk of bias was assessed using an adapted Joanna Briggs Institute Checklist for Prevalence Studies.”

Here’s what they found:

  • More than 94 000 titles were considered with 137 unique studies from 134 cohorts reviewed. 
  • Most of the studies were from high income (77%) or upper middle income (20%) countries.
  • General mental health. “The estimated change in the general population cohorts was minimal and not significant…”
  • Anxiety symptoms. “The estimated change in the general population cohorts was not significant and was close to zero…”
  • Depression symptoms. “The estimated change in general population cohorts increased statistically significantly by a minimal amount…” Also, “The estimated change also increased significantly by minimal to small amounts among women or female participants…” Other groups with such change: older adults, university students, and people who self-identified as belonging to a sexual or gender minority groups.

A few thoughts:

1. This is a timely paper offering good data from many studies, and including high income and upper middle income nations.

2. The big finding: the pandemic didn’t have much of a mental health impact.

3. The implications? The authors write: “The lack of evidence of a large scale decline in mental health so far in the context of covid-19 could be because people are resilient and have made the best of a difficult situation. Indeed, although evidence is limited, data suggest, for example, that suicide generally declines during periods of societal conflict. War and pandemics have different characteristics, but in both there is a shared threat and common focus on collective action to tackle that threat.” Interesting.

4. Should we be a bit cautious about the results? The authors are: “High risk of bias in many studies and substantial heterogeneity suggest caution in interpreting results.” And it should be noted that many of the studies also drew on early pandemic data.

5. In an accompany Editorial, Carsten Hjorthøj and Trine Madsen (both of the University of Copenhagen) note that subpopulations may still have struggled:

“Some individuals or subgroups might experience larger deteriorations than the population mean. The authors identify women as a vulnerable subgroup for depression, anxiety, and general mental health, although deteriorations were still minimal or small on average. Media attention has often focused on the pandemic’s particular impact on young people, but this is not born out by the present study: parameters of anxiety, depression, and general mental health did not deteriorate significantly in young adults, adolescents, or children. Future updates of this systematic review, which the authors will post online as more evidence accrues, could usefully examine other subgroups, such as socially marginalised individuals.”

Carsten Hjorthøj

They also offer some perspective.

“[W]hile the present study clearly shows that we need not be overly concerned about the general population’s mental health in relation to the covid-19 pandemic, reported prevalence rates of mental health symptoms, especially among adolescents, are still concerningly high. Pandemic or not, there is a strong need to provide preventive mental health interventions for those most at risk of poor mental health outcomes.” Well said.

That Editorial can be found here:

The full BMJ paper can be found here:

Selection 2: “Burnout, Professionalism, and the Quality of US Health Care”

Dhruv Khullar

JAMA Health Forum, 24 March 2023  Online First

Physician burnout is a major threat to health care quality, patient outcomes, and the vitality of the medical workforce. More than half of US physicians report at least 1 symptom of burnout – nearly twice the rate of the general working population – and many also experience depression, anxiety, or suicidal ideation. Burnout is estimated to cost the health care system at least $4.6 billion annually, with the greatest burden attributable to turnover and work-hour reductions among primary care physicians.

Many factors have been linked to burnout, including physician age, sex, and specialty; workplace leadership and culture; and practice type and compensation model. Fundamentally, however, 3 forces drive burnout: pressure to care for too many patients in too little time and with too few resources; expectations to engage in activities felt to be rote, irrelevant, or counterproductive; and an inability to meet the medical or social needs of patients. Each assails physicians’ professionalism and threatens the delivery of compassionate, high-quality care.

So begins a paper by Dr. Khullar.

“Critics sometimes portray professionalism as a self-serving myth, an ill-defined concept used to ward off needed quality control from external entities.” Dr. Khullar dismisses this idea: “Physicians are not perfect, but they are deeply motivated to do right by patients, to improve as clinicians, and to earn the respect of their colleagues.”

He argues that the system itself is problematic, undermining professionalism with penalties and rewards. “Many physicians experience a disheartening lack of control over their time and attention, over what must be discussed with patients, and over how clinical encounters are to be structured and documented. Payers have introduced pay-for-performance programs that, in addition to increasing administrative burdens, encourage physicians to focus on a limited set of process measures (many of which are not supported by evidence) at the expense of holistic and personalized care. Meanwhile, physicians often feel disconnected from or resentful of the organizations in which they work for failing to support professional autonomy, reasonable work hours, and healthy relationships.”

The author focuses on three areas:

Reforming Payment to Increase Time With Patients

“Despite widespread agreement on the need to transition to value-based care, relative value unit–based, fee-for-service compensation remains the dominant form of payment in the US. This reimbursement model promotes excessive workloads, both for physicians who perform lucrative procedures (and feel pressure from organizations to maximize revenue) and for physicians engaged in poorly reimbursed nonprocedural work (who must maintain high visit volume to remain solvent).” He warns that the details of value-based payment are critical: “Some programs, especially those using fee-for-service payments adjusted for performance on narrow process measures, may worsen burnout by introducing administrative burdens, exacerbating health disparities, and distracting from other important aspects of care.”

Reducing the Burden of Clerical Tasks

“Time spent on meaningful work is a key predictor of professional well-being. But large-scale changes to the US health system, including the introduction of electronic health records, the pervasive use of measures that are not evidence-based, and a growing emphasis on billing and coding, have engendered a clinical environment in which many physicians spend more time engaged in clerical work than they do seeing patients. This arrangement is antithetical to their motivations for practicing medicine.”

How to reduce the burden? He offers a few examples:

  • “Recent work suggests that organizations that regularly invite clinicians to audit internal processes can remove large amounts of redundant or unnecessary work by reducing superfluous data collection, extra keystrokes, and confusing protocols.”
  • “Organizations should also rigorously examine how clinical support staff can minimize the time physicians spend on clerical work and maximize the time they spend on the work they are uniquely trained to do.”
  • “Going forward, technology may also play a role: as speech recognition and natural language processing software improve, virtual assistants could be used to document patient encounters, enter orders, engage with insurers, and retrieve and synthesize clinical data.”

Supporting Physicians in Meeting the Needs of Patients

“Physicians enter medicine to better the lives of patients, but a repeated inability to address the forces that impoverish health can lead to professional dissatisfaction and psychological distress. Although policy makers have recognized the centrality of addressing social drivers of health, they have offered inconsistent and insufficient support to help physicians in doing so. Consequently, physicians, who are already overburdened by clinical and administrative demands, have scant time and resources to tackle the root causes of illness and the social impediments to disease management.”

A few thoughts:

1. This is a thoughtful paper.

2. The paper is for an American publication on U.S. problems – though seems relevant here in Canada.

3. Burnout has been considered in past Readings. In late 2022, we looked at the Sen paper from NEJM arguing that burnout and depression are overlapping concepts. “The specific work-related factors (e.g., workload and workplace environment) and non–work-related factors (e.g., personality traits and mental health history) that predict the development of depression are almost identical to those that predict the development of burnout.” You can find it here:

The full JAMA Health Forum paper can be found here:

Selection 3: “Extended-release buprenorphine (BUP-XR) is a subcutaneous monthly depot injection used to treat opioid use disorder

Ari B. Cuperfain, Tianna Costa, and Nitin Chopra

CMAJ, 9 March 2023  

Extended-release buprenorphine (BUP-XR) is a subcutaneous monthly depot injection used to treat opioid use disorder

In 2018, Health Canada approved the only BUP-XR treatment available in Canada, under the brand name Sublocade. It is covered by all provinces and territories as part of their public drug plans, primarily for treating moderate-to-severe opioid use disorder. All prescribers across Canada must complete online training, which is required by Health Canada.

So begins a paper by Cuperfain et al

The authors make several comments in this short paper.

On initiation

“Patients can receive BUP-XR if they are stabilized on 8–24 mg of sublingual buprenorphine for at least 7 days. They can then receive BUP-XR 300 mg monthly for the first 2 months, followed by 100 mg monthly as maintenance. Therapeutic effect first occurs within 24 hours.”

On evidence

“A randomized, double-blind, placebo-controlled trial showed mean abstinence rates were 42.7% for participants taking BUP-XR, compared with 5.0% for placebo over a 24-week study period. BUP-XR has also been associated with higher treatment satisfaction, lower treatment burden and greater convenience than sublingual buprenorphine, with the main adverse effect reported being injection-site irritation.”

On safety and effectiveness

“BUP-XR can be recommended for patients with challenges adhering to daily-dosing treatments. A comparative effectiveness study showed that people who were incarcerated and maintained on BUP-XR had greater treatment retention after release from incarceration than with sublingual buprenorphine.”

A few thoughts: 

1. This is a concise paper. 

2. With opioid problems, BUP-XR is a useful tool in the toolkit.

3. A quick congratulations to the first author, who is a senior resident of psychiatry at the University of Toronto.

The full CMAJ paper can be found here:

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