From the Editor
He survived the car accident that killed his partner. Although he was physically unscathed, he struggled with PTSD, lucidly describing in our sessions the nightmares and fears that dominated his life.
How long do such symptoms last? Does time heal? Frank D. Mann (of Stony Brook University) and his co-authors attempt to answer these questions with a new study, one of the largest and longest on this disorder to date. In the first selection, we examine their Nature Mental Health paper, involving 13 000 responders to the World Trade Center attack, and spanning 20 years of data. “Our findings highlight the enduring impact of PTSD among World Trade Center responders, with substantial variability in individual trajectories. Despite overall modest declines, a subset remained highly symptomatic, underscoring the need for continued treatment.” We consider the paper and its implications.
In the second selection from Psychiatric News, Dr. Steven Reidbord, a psychiatrist based in San Francisco, notes the rising popularity of therapy and how things are changing with AI. But he suggests there is a difference between “corner-cutting” therapy and real psychotherapy, which is meant for personal change. “Psychotherapists must defend quality care against the seductive fictions that pervade social media. Our own message may be less alluring, but it has the advantage of being true…”
And in the third selection, Dr. Christine A. Sinsky (of the American Medical Association) and her co-authors look at physician vacations. Drawing on a national survey of US docs, they analyzed vacations, work during these vacations, and burnout. “These findings suggest that support for taking vacation and efforts to reduce physicians’ obligations to perform patient care-related tasks while on vacation, such as providing full electronic health record inbox coverage, should be considered to prevent physician burnout.”
Note that there will be no Readings for the next two weeks. (The discussion of vacations is inspiring.)
And, on a pivot, to those completing their residency education at the end of this month: all the best in your careers. Enjoy this remarkable moment.
DG
Selection 1: “A 20-year longitudinal cohort study of post-traumatic stress disorder in World Trade Center responders”
Frank D. Mann, Monika A. Waszczuk, Sean A. P. Clouston, et al.
Nature Mental Health, 27 May 2025
Post-traumatic stress disorder (PTSD) is a chronic and costly condition that can persist decades after the triggering trauma. World Trade Center (WTC) responders were exposed to extreme trauma during and after the terrorist attacks that occurred on 11 September 2001. A decade later, PTSD prevalence remained high (approximately 14%) among WTC responders and survivors. Among the police who responded to the WTC attacks, half with clinically elevated symptoms a year later persisted with elevated symptoms 4-9 years after the attacks. Although these findings underscore the severity of WTC exposures and the chronicity of PTSD, existing long-term studies of PTSD are limited by infrequent and retrospective measurement that often began years after exposure, precluding a comprehensive examination of symptom trajectories…
Longitudinal studies have examined changes in symptoms of PTSD in different trauma-exposed populations, reporting change in average symptom severity over 1-10 years. These studies have shown that changes in PTSD symptoms vary greatly from person to person. Most individuals exposed to trauma are resilient and never develop clinically elevated symptoms (stable low) but among those who do, the symptom course varies from delayed onset (increasing) to chronic (stable high) and rapid improvement (decreasing). However, it is unknown whether these broad groupings adequately capture the long-term course of PTSD symptoms. Few studies have documented the long-term course of PTSD in detail.
So begins a paper by Mann et al.
Here’s what they did:
- The authors conducted a longitudinal cohort study.
- Participants were members of the WTC Health Program Long Island Clinical Center of Excellence, which invited responders for annual monitoring visits; the Center has offered free treatment. Recruitment involved more than 50 000 phone calls and promotion through union halls.
- Different scales were used, including the PTSD checklist (PCL-S).
- The diagnoses were confirmed by interviews.
- Different statistical analyses were employed, including to plot functional impairment over time.
Here’s what they found:
- The study included 12 822 responders and 81 298 observations.
- Demographics. The mean age at exposure was 37 years. Most participants were male (90.88%) and White (75.60%). The majority were in law enforcement (63.80%).
- Symptoms. “Symptoms were stable in the short term but changed significantly over two decades, peaking over a decade after exposure and declining modestly thereafter.” See graph below. Note that participants diagnosed with PTSD are represented by the red squares.
- Demographic differences. “Demographic differences in average trajectories were small.”
- Symptom improvement. “The median time before symptoms improved was 8–10 years for PTSD cases (median = 8.88…).”
- Symptom deterioration. “Most experienced improvement after a decade but approximately 10% reported elevated symptoms two decades after trauma.”
- Functional impairment. Changes in symptoms (top decile of stratified predicted change) predicted higher functional impairments.
A few thoughts:
1. This is an impressive study with a robust dataset and published in a major journal.
2. The paper is rich in detail and analysis. The above summary is superficial.
3. The main findings: PTSD may take time to emerge and time to get better; most participants improved – but a significant minority didn’t.
4. The authors are clear: “these results imply that PTSD is a chronic condition that can last at least 20 years after initial trauma and has highly variable symptom courses that are only weakly related to demographic characteristics…”
5. They also comment on care: “This reinforces the conclusions of other long-term PTSD studies, that is, that a significant need for treatment remains decades after the trauma.”
6. On the positive side, many did get better over time. But let’s remember that some didn’t – and they all had access to treatment that was free at the point of care. (!)
7. Like all studies, there are limitations. The authors note several, including: “responders joined the program at different points throughout the two decades, and the number and length of follow-up assessments varied.” They add: “Fortunately, we found that the time of the first visit, number of visits and average interval between visits did not substantially influence trajectories, indicated by similar average trends with overlapping confidence intervals.” And, of course, we can wonder how generalizable the findings are for people who have experienced PTSD as the result of other traumas.
8. PTSD has been considered in past Readings, including a 2024 JAMA Psychiatry study that found acupuncture was “statistically superior to sham needling for reducing PTSD symptoms…” You can find that Reading here:
The full Nature Mental Health paper can be found here:
https://www.nature.com/articles/s44220-025-00419-1
Selection 2: “Therapy That Isn’t Psychotherapy”
Steven Reidbord
Psychiatric News, 29 May 2025
Never has the talking cure been so popular, at least as a topic on social media. There, psychotherapy is just ‘therapy,’ a looser term that covers services well beyond conventional treatment. In addition to fairly standard practices, licensed and unlicensed influencers tout ‘therapy’ by text message or AI chatbot, not to mention coaching, self-help, positive thinking, and much more. In the anything-goes world of social media, ‘therapy’ covers a lot of ground.
Along with expanding therapy beyond its usual margins, these voices may echo a viewpoint the public craves. They laser-focus on trauma, stress, victimhood, systemic oppression, stigma, and burnout – all factors outside the individual – and prescribe support and advocacy for the distress that results. Meanwhile, they ignore or even denigrate psychotherapy’s traditional domain: the individual’s ego strengths, intrapsychic conflicts, object relations, and sense of self. That is, character structure. None of that matters when all emotional pain is understood to originate outside the self.
To be clear, external stress and trauma surely warrant our attention. Many believe that mainstream psychiatry and psychotherapy downplay its impact, and that we’ve had too little to say about the oppression of disadvantaged groups and the exploitation of workers. But it’s quite another matter to treat these as therapy’s sole focus.
So begins an essay by Dr. Reidbord.
He argues that therapy isn’t necessarily psychotherapy: “Therapy that prizes agreement (‘validation’) over all else; therapy that absolves the patient of personal responsibility. It is therapy that valorizes empathy without even gentle challenges or interpretation, without introducing new perspectives, without helping the patient see things differently. It’s therapy that reinforces the comforting belief that the struggles patients face are not their own, that there’s nothing to change in themselves.”
He sees a clear problem with the approach. “Blaming one’s environment and disclaiming responsibility isn’t a new fad. Psychoanalytic theory calls this a form of externalization, a defense mechanism that relieves its users of the need to look within. Academic psychologists prefer other names: situational attribution or self-serving bias. However we label it, the causes of one’s distress are ‘out there’: in other people, in the world. And, as with any defense mechanism, externalization relieves anxiety – imperfectly, superficially, and at a cost. Reassuring a patient that his or her distress is ‘a normal reaction to an abnormal situation’ feels good in the moment.”
He also argues that patients lose out. “Pragmatically, it’s no help to change jobs if the individual recreates the same miserable scene in the next one. That is, if the problem isn’t just environmental.”
He sees the public’s appetite for therapy as being problematic. “Much of the public cannot distinguish bona fide psychotherapy from corner-cutting ‘therapy’ delivered by text message or AI chatbot. Even fewer realize that externalization (or self-serving bias) is not a sound treatment approach, especially when popular social media influencers insist on exactly the opposite.”
How to proceed? He argues for a return to true psychotherapy. “While we should always proceed with kindness, curiosity, and attention to environmental and social stressors, psychotherapy simply can’t feel supportive in every moment – not if it remains true to its aims of exploring the internal roots of emotional distress and empowering patients to surmount them. In fulfilling these aims, psychotherapy is often challenging. At times, we need to point out awkward or embarrassing truths, bring mixed feelings to the surface, and gently confront defenses – including externalization.”
A few thoughts:
1. This is a lively essay – and a very timely one.
2. The author does a good job of noting the rise of therapy. Today, our patients might engage with an AI chatbot or sign up for “therapy” through a website like “Seven Cups of Tea” – meeting a person who claims to provide therapy but lacks any qualifications or experience.
3. And Dr. Reidbord raises solid points. A conversation isn’t the same thing as a psychotherapy session. Fair. Most patients need more than (virtual) hand holding.
4. But is he light in his criticism of psychotherapy itself? After all, is all psychotherapy useful and helpful? It’s easy to criticize a chatbot, but what about the 5th Avenue psychoanalyst with a collection of affluent patients and no real treatment goals? Or the psychotherapist who offers CBT but strays from any standard or manualized approach, providing many sessions but few thought logs?
The full Psychiatric News essay can be found here:
https://psychiatryonline.org/doi/10.1176/appi.pn.2025.06.6.12
Selection 3: “Vacation Days Taken, Work During Vacation, and Burnout Among US Physicians”
Christine A. Sinsky, Mickey T. Trockel, Lotte N. Dyrbye, et al.
JAMA Network Open, 12 January 2024
Vacation has been shown to be an important restorative activity in the general population. Time away from work provides an opportunity to rest and recharge and is associated with benefits to both employer and employee, including improved job performance, greater productivity, enhanced creativity, greater job satisfaction, enhanced attention to personal relationships, lower absenteeism, less turnover, and lower rates of burnout. Taking vacation is also associated with improved physical and mental health, including lower risk of cardiovascular mortality, reduced cellular-level markers of stress, and fewer symptoms of depression and anxiety.
Less is known about the vacation behaviors of US physicians and the institutional policies and practices that facilitate or hinder taking vacation. A 2023 survey of a convenience sample composed of 9175 physicians in 29 specialties found that 1 in 3 physicians took 2 weeks or less of vacation each year. A 2020 study of 490 physicians found that being able to disconnect from work is associated with lower emotional exhaustion and depersonalization, the 2 key dimensions of burnout. Although variation in physician vacation behavior by gender is unknown, female physicians report worse work-life integration, spending more time on the electronic health record (EHR), including after hours, and higher and more rapidly rising rates of burnout than male colleagues.
So begins a paper by Sinsky et al.
Here’s what they did:
- They surveyed a representative sample of physicians listed in the American Medical Association Physician Professional Data, which is “a nearly complete record of all US physicians.”
- Respondents were asked about the number of vacation days taken in the last year and whether they engaged in work activities during those vacations: “time spent working on patient care and other professional tasks per typical vacation day (ie, work on vacation), electronic health record (EHR) inbox coverage while on vacation, barriers to taking vacation, and standard demographics were collected.”
- Main outcome: Burnout – as measured using the Maslach Burnout Index.
- Statistical analyses were done, including a multivariable analysis of professional and demographic characteristics of the physicians.
Here’s what they found:
- A total of 3 024 physicians participated in the study.
- Demographics and work. Most were male (62.0%), married (83.7%), and non-elderly (78.2%). 8.6% were in psychiatry. About half (48.0%) reported working between 40 and 59 hours per week.
- Vacation days. 59.6% took 15 or fewer days of vacation in the last year; 19.9% took just 5 or fewer days.
- Working on vacation. The vast majority, 70.4%, performed patient care-related tasks on vacation, with 33.1% working 30 minutes or more on a typical vacation day.
- Burnout. “On multivariable analysis, whereas spending 30 minutes or longer per vacation day on patient-related work (OR, 1.58… for 30-60 minutes; OR, 1.97… for 60-90 minutes; OR, 1.92… for >90 minutes) was associated with higher rates of burnout.”
A few thoughts:
1. This is an interesting study, offering unique data on vacation time and burnout.
2. The main finding in a sentence: “the number of vacation days taken and performing patient-related work while on vacation were associated with physician burnout.”
3. The authors see practical implications: “Our results suggest that ensuring physicians take at least 3 weeks of vacation per year and providing coverage for clinical work, including full EHR inbox coverage while physicians are on vacation, may be tangible and pragmatic organizational actions to mitigate burnout risk. Overt efforts to track, normalize, and model taking vacation would likely be helpful.” More time on the beach, less time on the laptop?
4. Like all studies, there are limitations. The authors note several, including: “the participation rate was low and response bias remains a concern.” And careful: correlation isn’t necessarily causation.
The full JAMA Network Open paper can be found here:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813914
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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