From the Editor

We talk about the virus’ effects on our patients, both in terms of physical and mental health. But what has it done to us?

Health-care workers have been on the front lines of this pandemic and have experienced the psychological toll. While past studies have considered mental disorders of health-care workers, their methodology hasn’t been strong, often relying on online surveys. In the first selection, Hannah Scott (of King’s College London) and her co-authors look at mental disorders and the pandemic in a new Lancet Psychiatry paper. Importantly, they did a two-phase, cross-sectional study comprising of diagnostic interviews. They write: “The prevalence estimates of common mental disorders and PTSD in health-care workers were considerably lower when assessed using diagnostic interviews compared with screening tools.” Still, they found that about one in five met threshold for a mental disorder and “thus might benefit from clinical intervention.” We consider the paper and its implications.

In the second selection, Beatrice Webb (of Flinders University) and her co-authors look at social media and young people. In a Point of View paper for Australasian Psychiatry, they note problems with mental health including the rise in psychological distress – something tied to social media. They also observe some benefits to Instagram and other online platforms. The paper is practical and offers advice, including: “We encourage clinicians to explore social media use in the assessment of young people, due to potential impacts on depression, anxiety and self-harm.”

At this time of year, The BMJ runs its Christmas issue, meant to be light-hearted and with liberal use of British humour. In the third selection, Ryan Essex (of the University of Greenwich) considers calls to action in the medical literature. In an Editorial, he opines: “The call to action has several obvious advantages over actually acting. Making that call allows you to salve your conscience, to ‘do something’ without the hard work of actually doing something.”

There will be no Readings for the next two weeks. We will return with force (but a lack of British humour) on 12 January 2023 when we will review the best papers of the year. A quick word of thanks for your continuing interest.

All the best in the holiday season.


Selection 1: “Prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic: a two-phase cross-sectional study”

Hannah R. Scott, Sharon A. M. Stevelink, Rafael Gafoor, et al.

During the COVID-19 pandemic, health-care systems across the world have been subject to considerable strain, which in turn has stimulated global efforts to understand how this has affected health-care workers. In addition to stressors common to all, including the risk of infection, social isolation, and difficulties obtaining child care, clinical and non-clinical health-care workers have faced distinct stressors such as overwork, increased patient mortality, staffing difficulties…

This evidence is largely based on online surveys using screening tools for mental disorders. Generally, a screening tool is a brief measure that identifies so-called caseness, on the basis of mental health symptoms, characteristics, or traits… This method allows for relatively rapid and low-cost data collection with large samples. However, many of the validated screening tools widely used in mental health research favour sensitivity over specificity and therefore have low positive predictive value, and thus are likely to overestimate the true prevalence of mental disorders.

So begins a paper by Scott et al.

Here’s what they did:

“We did a two-phase, cross-sectional study comprising diagnostic interviews within a larger multisite longitudinal cohort of health-care workers (National Health Service [NHS] CHECK; n=23 462) during the COVID-19 pandemic. In the first phase, health-care workers across 18 NHS England Trusts were recruited. Baseline assessments were done using online surveys between April 24, 2020, and Jan 15, 2021. In the second phase, we selected a proportion of participants who had responded to the surveys and conducted diagnostic interviews to establish the prevalence of mental disorders… Participants were screened with the 12-item General Health Questionnaire (GHQ-12) and assessed with the Clinical Interview Schedule-Revised (CIS-R) for common mental disorders or were screened with the 6-item Post-Traumatic Stress Disorder Checklist (PCL-6) and assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) for PTSD.”

Here’s what they found:

  • The screening sample contained 23 462 participants: 2079 participants were excluded due to missing data.
  • 243 individuals participated in diagnostic interviews for common mental disorders, CIS-R; demographically, they tended to be women (76%), White (83%), and with a mean age of 42.
  • 94 individuals participated in diagnostic interviews for PTSD (CAPS-5); demographically, they tended to be women (84%), White (88%), and with a mean age of 44.
  • “Using CIS-R diagnostic interviews, the estimated population prevalence of generalised anxiety disorder was 14.3%, population prevalence of depression was 13.7%, and combined population prevalence of generalised anxiety disorder and depression was 21.5%.”
  • “Using CAPS-5 diagnostic interviews, the estimated population prevalence of PTSD was 7.9%…”

A few thoughts:

1. This is a good study.

2. There is a big gap between screening and interview results: “For common mental disorders, the screening prevalence was 52.8% whereas when using the diagnostic interview, the population validated prevalence was 14.3% for generalised anxiety disorder and 13.7% for depression.”

3. Like all studies, there are limitations. They note several, including the relatively small number of interviews.

4. Perspective: many health-care workers are struggling with mental disorders. The authors note: “we suggest that it might be helpful to provide treatment promptly for health-care workers with diagnosable mental disorders. This approach is likely to both benefit health-care workers themselves and ensure quality of care for patients by maintaining a well functioning workforce.”

5. To repeat a point made here in the past: the psychological sequelae of the pandemic may continue long after the last patient is discharged from an ICU.

The full Lancet Psychiatry paper can be found here:

Selection 2: “Point of view: Could social media use be contributing to rising rates of deliberate self-harm and suicide in Australian youth populations?”

Beatrice Webb, Jeffrey C. L. Looi, Stephen Allison

Australasian Psychiatry, December 2022

Psychological distress has been increasing in Australian youth (12–25 years old) since 2015. Rates of hospitalised deliberate self-harm increased in both males (1.1% per annum) and females (3.0% per annum) between 2008 and 2019. Rates of young women committing suicide increased 69% (aged 15–19) and 55% (aged 20–24) between 2008 and 2020, whilst suicide rates for young men increased 72% (aged 15–19) and 26% (aged 20–24) in the same time-period… Could the increased psychological distress and suicidal behaviour be related to increasing social media use amongst young people? Over the last decade, social media has become a more prominent feature in the everyday lives of many young people…

The amount of time young people spent online (including social media) in the United States (US) doubled between 2006 and 2016. Twenge and colleagues observed a marked decline in psychological well-being of US youth since 2011, in the context of rapid adoption of smartphones and the consequent shift in young peoples’ time use.

So begins a paper by Webb et al.

The authors note problems with social media, but also potential benefits.

Social media use and increased rates of self-harm

“There is a growing body of research suggesting that high levels of social media use could be associated with rising rates of depression, self-harm and suicide in young people. Among adolescents in the US, depressive symptoms, suicide-related outcomes and suicide deaths all rose during the 2010s… Adolescents who spent more time on social media were more likely to report mental health issues. Females with pre-existing mental health issues are at particular risk of increased self-harm. As in Australia, there have been rising rates of depressive symptoms, deliberate self-harm and suicidal ideation in young people despite increased service provision for youth mental health services.”

They also note the role of cyberbullying. “Cyberbullying on social media can contribute to increased rates of self-harm through hurtful online experiences, and affects females more.” As well, there are problems with basic communication: “Lower levels of visual cues such as body language and facial expression in online interactions cause people to act in a way that conveys less warmth, disinhibition and hostility, predisposing to negative or hurtful experiences.”

Potential social media benefits

“Connectedness is an essential part of adolescent life, especially for those who feel marginalised or misunderstood. For some young people, interactive media can be a form of peer support, providing opportunities to connect with others to alleviate psychological distress. Outreach therapeutic delivery, crisis support and informal support networks can be facilitated through social media, offsetting low levels of offline support, especially for those who are socially anxious or with social skills deficits, or who are harder to reach with offline service delivery. Online anonymity and a lack of visual cues can also facilitate the communication of distress, possibly reducing suicidal ideation, increasing a sense of belonging and being understood.”

They also note the availability of resources which “serve as distraction for self-harm or existing problems in people’s lives and facilitate conversations about mental health between young people.”

The paper runs with selected recommendations from the Royal College of Psychiatrists (England) on this topic. Here, we highlight three for clinicians.

  • “Be mindful of possible role of technology use in the disruption of sleep, academic performance, mood, behaviour, eating or family relationships and social interaction.”
  • “Be aware of the increased vulnerability to problematic technology use in those with existing mental health conditions such as depression or other behavioural issues.”
  • “Take time to understand individual values that may be leading young people to get locked into excessive screen time.”

A few thoughts:

1. This is a well-argued Point of View.

2. It focuses on Australian data and is published in an Australian journal. The main points are relevant there – and here.

3.  The advice is good. The last Royal College recommendation is particularly strong.

4. This topic has been reviewed in past Readings including the Abi-Jaoude et al. paper, “Smartphones, social media use and youth mental health,” which offered an impressive review of the literature. Not surprisingly, their paper is one of the most read in the CMAJ’s history. That Reading can be found here:

The full Point of View can be found here:

Selection 3: “A call to action”

Ryan Essex

The BMJ, 15 December 2022

While it is always time to act, it can be hard to know where or how to start in a world facing unprecedented crises. This can be demoralising and frustrating, but there is one form of action we can all turn to at times like these: the call to action.

So begins an editorial by Essex.

He notes: “The call to action is clearly a durable and important facet of medicine that has preoccupied doctors and researchers for decades.”

Drawing on the literature:

  • “A title, abstract, and keyword search (with no date restrictions applied) of Scopus for ‘call to action’ in October 2022 yielded over 6000 results, as did a full text search of The BMJ archive.”
  • “One of the first calls to action recorded in The BMJ was in 1913.”
  • “Looking to more recent history, calls to action have been made for many important reasons, including to prioritise patient experience in nursing practice, to reform academic global health partnerships, and to expand universal health coverage.”

Essex writes:

“The call to action can be bold and decisive without requiring extensive or time consuming collaboration with others (open letters with multiple high profile authors being the exception here). No compromise is needed, and you do not have to worry about nuances such as how to achieve or implement the action you are calling for, only about how things ought to be: we should all eat better, help refugees, and take the bus rather than driving, for example.”

The author notes that those who choose action over calls to action can do a variety of things, including donating to different charities and causes. The Editorial ends with, well, a call to action: “Observant readers will have noticed that this article is little more than a call to action calling for action to think carefully about calls to action. Ultimately, though both action and calls to action have their place in medicine and in life, and perhaps they cannot be disentangled. We should embrace the call to action and where we can, act.”

A few thoughts:

1. This is a very entertaining paper.

2. The Christmas issue of The BMJ never disappoints.

3. For the record, the 2013 research paper on chocolate, “The survival time of chocolates on hospital wards: covert observational study,” is particularly good – though Dr. Ken Little and I once had an animated discussion about the methodology. You can find it here:

The full Editorial can be found here:

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