From the Editor

Will there be a pandemic after the pandemic? Some have wondered about the mental health consequences of COVID-19 – speculating that, in the future, there will be significant mental health problems. In a recent JAMA paper, Simon et al. argued: “The magnitude of this [mental health] second wave is likely to overwhelm the already frayed mental health system, leading to access problems, particularly for the most vulnerable persons.” (That paper was discussed in a past Reading.)

In the first selection, we consider a new paper from Lancet Psychiatry. Kuan-Yu Pan (of Vrije Universiteit) and co-authors did a survey of people with psychiatric disorders, as well as people without. “We did not find evidence that there was a strong increase in symptoms during the COVID-19 pandemic in those with a higher burden of disorders. In fact, changes in scores from before to during the pandemic indicated increasing symptom levels in people without mental health disorders, whereas changes of symptom levels were minimal or even negative in individuals with the most severe and chronic mental health disorders.” Should we be reassured by the Pan et al. study?

Alcohol sanitizer and medical mask with copy space,Corona virus,Covid-19 prevention.Protection from physical health problems, but mental health?

In the second selection, we consider a research letter from Dr. Scott B. Patten (of the University of Calgary) and his co-authors. Drawing on survey data, they describe the pattern of use of e-cigarettes, noting that they were originally intended for harm reduction. “In 2017, 15.5% of e-cigarette users reported that they had never smoked, suggesting a de novo pattern of substance use. By 2019, this proportion had more than doubled to 36.7%.”

Finally, in the third selection, Olympian Alexi Pappas speaks about her mental health in a New York Times opinion video. The comments are very personal, and touch on her illness and recovery. “After the Olympics, I was diagnosed with severe clinical depression. And it nearly cost me my life. But it doesn’t have to be that way.”

Please note that there will be no Reading for the next two weeks. Enjoy the holidays. And if you are looking for a last-minute gift for, perhaps, Hanukkah or Christmas or a way to thank co-workers after a tough year, consider CAMH’s Pet Therapy Calendar, available for just $15 (with the promotion code). Proceeds go to a good cause: the CAMH Volunteer Resources Pet Therapy Program. The calendar is beautifully done, and features great dogs, including Toulouse (my BFF). Here’s the link:



Selection 1: “The mental health impact of the COVID-19 pandemic on people with and without depressive, anxiety, or obsessive-compulsive disorders: a longitudinal study of three Dutch case-control cohorts”

Kuan-Yu Pan, Almar A. L. Kok, Merijn Eikelenboom, et al.

The Lancet Psychiatry, 8 December 2020  Online First


Since the first confirmed case of COVID-19 was reported in the Netherlands on Feb 27, 2020, this disease has had a great impact on every aspect of Dutch society. Similar to many other countries worldwide, nationwide measures such as quarantine, lockdown, and physical distancing were launched in the middle of March, 2020, in response to the rising number of cases and deaths attributed to COVID-19. Although these measures might have mitigated the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19, they might also have negatively affected the economy, employment, and public health. With worries about future uncertainty, concern has been growing about the mental health sequelae of the COVID-19 crisis. Most evidence on the impact of the COVID-19 pandemic on mental health is based on convenience samples, without comparable prepandemic information, thus compromising the validity of this evidence…

Outcomes of the COVID-19 pandemic on mental health could differ between population groups. In particular, the emotional responses brought on by the pandemic and its management might be more substantial among vulnerable groups, such as people with pre-existing psychiatric conditions. Financial instability and small social networks are common among people with mental illness; as a result of economic recession and restricted social connectivity, the COVID-19 pandemic could present an unprecedented stressor to these individuals. Measures such as nationwide travel restrictions and quarantine, and changes in the way health-care services are provided, could interrupt access to and provision of psychiatric care. As a result, the risk of relapses or worsening of existing mental health conditions could rise during the COVID-19 pandemic…

So begins a paper by Pan et al.

Here’s what they did:

  • Online questionnaires were distributed to people involved in three long-term Dutch studies: the Netherlands Study of Depression and Anxiety, the Netherlands Study of Depression in Older Persons, and the Netherlands Obsessive Compulsive Disorder Association.
  • The surveys were sent between April 1 and May 13, 2020.
  • “The questionnaire contained questions on perceived mental health impact, fear of COVID-19, coping, and four validated scales assessing depressive symptoms, anxiety, worry, and loneliness used in previous waves during 2006-16.” Scales were used, including the Beck Anxiety Inventory.
  • Different statistical analyses were done, including linear regression.

Here’s what they found:

  • 1517 (58%) participants filled in the online questionnaire at least once.
  • Among the 1517 respondents to the online questionnaire (mean age 56.1 years; 64% women), 1181 (78%) had a lifetime mental health disorder – that is, a depressive, anxiety, or obsessive-compulsive disorder.
  • “Although people with depressive, anxiety, or obsessive-compulsive disorders scored higher on all four symptom scales than did individuals without these mental health disorders, both before and during the COVID-19 pandemic, they did not report a greater increase in symptoms during the pandemic.”
  • “People without depressive, anxiety, or obsessive-compulsive disorders showed a greater increase in symptoms during the COVID-19 pandemic, whereas individuals with the greatest burden on their mental health tended to show a slight symptom decrease.”

A few thoughts:

  1. This is a good study, with a robust data set.
  1. The major finding: the pandemic didn’t increase mood, anxiety or OCD symptoms in those with these disorders. (!)
  1. How to understand the finding? The authors offer a few explanations, including that: “staying at home could help them build a structured and fixed daily routine, which has been expressed as a preferable setting to provide a feeling of safety.”
  1. Is this a big finding or an early finding or both)? The majority of questionnaires were completed in the first month of the national lockdown. (!) Would the results have been different in the summer or fall? And the participants are all Dutch. Would the North American experience be similar?
  1. Survey data is the basis of several recent papers; surveys have been reported in the popular press (in Canada, for instance, by the Angus Reid Institute and Morneau Shepell). A word of caution: survey data gives us a snapshot in time; the pandemic and the mental health consequences of the pandemic are evolving over months. I’m also reminded of past study on PTSD symptoms after September 11th; reported symptoms were influenced by geography (proximity to downtown NYC) and time (weeks after the event). The point: early data from the Netherlands may not be so helpful in understanding the mental health needs of Canadians over time.

The full Lancet Psychiatry paper can be found here:


Selection 2: “Emerging Patterns of E-Cigarette Use in the General Population”

Scott B. Patten, Jeanne V. A. Williams, Kathryn Wiens, et al.

The Canadian Journal of Psychiatry, 26 November 2020  Online First


In recent years, e-cigarette use (or ‘vaping’) has emerged as a smoking alternative. Vaporizers can contain ingredients ranging from solvents and flavoring to drugs such as nicotine and cannabinoids. In Canada, addition of nicotine to e-cigarettes was approved in 2018, and the addition of cannabis oils became legally regulated in 2019. However, both nicotine and cannabis vaping products were widely available before these dates.

Vaping has generally been viewed as a harm-reduction strategy due to the well-known adverse effects of smoking combustible tobacco. E-cigarettes are widely used for smoking cessation and relapse prevention. In this letter, we report the emergence of an additional phenomenon: vaping as a de novo substance use pattern.

Here’s what they did:

  • They used data from the 2017 Canadian Tobacco, Alcohol and Drugs Survey (= 8,614) and the 2019 Canadian Tobacco and Nicotine Survey (= 16,349).
  • Each survey asked about e-cigarettes in the past 30 days.

Here’s what they found:

  • “A sizable proportion of e-cigarette users in both surveys reported being current smokers or former smokers, consistent with harm-reduction or smoking cessation goals. For example, in 2017, 64.5%… of e-cigarette users reported current smoking, compared to 13.5%… of nonusers.”
  • “In 2017, 15.5% of e-cigarette users reported that they had never smoked, suggesting a de novo pattern of substance use. By 2019, this proportion had more than doubled to 36.7%.”


A few thoughts:

  1. This is an interesting research letter offering unique data.
  1. Are there limitations here? The authors acknowledge several, including: “These surveys use different approaches to sampling, different modes of data collection, and there are differences in the wording of some questions. As such, the results are vulnerable to selection or measurement biases.”
  1. e-Cigarettes are often touted as an alternative for smokers. But are non-smokers attracted to this form of nicotine. Certainly the marketing and design of some products seems to target adolescents. (Think flavoured vapes.) The authors note: “The observed changes suggest that e-cigarette use can no longer be regarded exclusively as a smoking cessation or harm-reduction strategy. Rather, in 2019, e-cigarette users were equally as likely to be never smokers or current smokers, whereas a smaller proportion consists of former smokers.” Ouch.

The full CJP research letter can be found here:


Selection 3: “I Achieved My Wildest Dreams. Then Depression Hit.”

Alexi Pappas

The New York Times, 7 December 2020


I’ve always been an extremely motivated person. And that mindset took me all the way in which to the Olympics. But it didn’t prepare me for what would be the greatest challenge of my life. After the Olympics, I was diagnosed with severe clinical depression. And it nearly cost me my life. But it doesn’t have to be that way.

So opens a video on Alexi Pappas.

It’s very personal: “Shortly before my fifth birthday, my mother took her own life. I’ve always felt driven to be not like my mom.”

Depression affects her after she has accomplished “my wildest dreams” – she represented her country at the Olympics. “It began with sleeplessness. I couldn’t turn my mind off.” Initially, she made changes – switching coaches, moving to a new training program, increasing her exercise. “I was sleeping one hour a night and trying to run 120 miles a week.” The video talks about the challenges of accepting her illness and healing.

dcovpappas_vPappas gracing the cover of Sports Illustrated

Some highlights:

On coming to terms with her mental illness

When her father made her see a doctor, the physician told her: “Alexi, you have a scratch on your brain. It’s like when you fall down and get a scratch on your knee. You have an actual injury to your brain. It was like a flip of a switch for me.

“It made me feel like I could heal.”

On sports and mental health

“When it comes to sports, elite athletics only focuses on treating injuries to our bodies. When a bone breaks or a tendon tears, we know exactly what to do. There’s a process. There are resources. But in my entire experience, I’ve never had any sort of support in the way of mental health.

“What if we looked at mental health the same way we do physical health?”

On her mother

“I’ve had such misunderstanding for my own mom, and such resentment towards her. I thought she just didn’t love me enough to stay. That’s not true. She was sick… She didn’t have to die. And that’s so sad because we would have been really good friends, I think.”

A few thoughts:

  1. This video is raw and honest. It takes great courage to speak so openly – especially about a topic as personal and stigmatized as mental health.
  1. The above summary doesn’t quite capture the full impact of the video, which is beautifully produced.
  1. What should change with elite sports? Pappas talks about coaches being more vigilant, and teams hiring psychiatrists and other mental health professionals in the way that they hire physiotherapists and other physical health professionals. Good points.
  1. And, as well, it helps when elite athletes like Alexi Pappas speak out. For those of us with a few grey hairs, it’s possible to marvel at the progress – not that long ago, no elite athletes spoke about depression.

The full New York Times video can be found here:


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