From the Editor

How has psychiatric research changed over time?

In the first selection, Sheng Chen (of CAMH) and co-authors attempt to answer this question by focusing on randomized controlled trials in mental health in a new paper for The Canadian Journal of Psychiatry. Using the Cochrane Database of Systematic Reviews, they look at almost 6,700 RCTs published over the past decades. They find: “the number of mental health RCTs increased exponentially from 1965 to 2009, reaching a peak in the years 2005–2009,” and observe a shift away from pharmacologic studies.

RCTs: the gold standard of research

In the second selection, Sajan B. Patel (of St Mary’s Hospital) et al. consider ChatGPT and health care in a new Lancet Digital Health Comment. Noting that discharge summaries tend to be under-prioritized, they wonder if this AI program may help in the future, freeing doctor to do other things. “The question for the future will be how, not if, we adopt this technology.”

And in the third selection, writer Anna Mehler Paperny focuses on campaigns to reduce stigma in a hard-hitting essay for The Globe and Mail. She argues that action is urgently needed to address mental health problems. She writes: “We need more than feel-good bromides. Every time someone prominent utters something about how important mental health is, the follow should be: So what? What are you doing about it? And when?”


Selection 1: “A Meta-Research of Randomized Controlled Trials in the Field of Mental Health: Comparing Pharmacological to Non-Pharmacological Interventions from 1955 to 2020”

Sheng Chen, Alina Lee, and Wei Wang

The Canadian Journal of Psychiatry, 6 February 2023  Online First

Since the introduction of randomized controlled trials (RCTs) in 1948, tens of thousands of such experimentations have been conducted. The ability of RCTs to control for confounding factors, reduce bias, and elucidate the direction of causation enables a robust evaluation of the efficacy and effectiveness of interventions. RCTs are regarded as the gold standard in the medical/health field and have a vital role in the development of evidence-based treatment interventions.

So begins a paper by Chen et al.

Here’s what they did:

“This study aimed to provide a general overview of mental health randomized controlled trials (RCTs) and summarize the temporal trends in terms of the number of studies, median sample sizes, and median effect sizes using data collected from the Cochrane Database of Systematic Reviews (CDSR).”

Here’s what they found:

  • After eliminating studies with missing information and duplicates, the final dataset included 6,652 RCTs in mental health and psychiatry.
  • Number. “The number of mental health RCTs reported in publications has increased almost exponentially from 1955 to 2020.” See figure below. (The drop in recent years may be due to a delay in reporting.)
  • Types of RCTs. “While pharmacological-RCT comprised a majority of mental health RCTs in the earlier years, the proportion of non-pharmacological-RCTs increased more quickly over time and markedly exceeded [the former] after 2010.”
  • By population. “The proportion of pharmacological-RCTs was more than double that of non-pharmacological-RCTs among patients with schizophrenia (71.5% vs. 28.5%) and mood disorders (69.7% vs. 30.3%). Conversely, the proportions were 33.8% for the pharmacological-RCTs and 66.2% for the non-pharmacological-RCTs for neurotic/stress-related disorders, and 18.3% versus 81.7% in all other mental disorders RCTs.”
  • Sample size. “The median sample size for all 6,652 mental health RCTs was 61… Over time, the median fluctuated, but with an overall increasing trend over the past 60+ years, from less than 50 before the 1990s to around 70 after the 2000s.”
  • Effect size. “The median of the effect size, measured by Pearson’s r, for overall RCTs was 0.18…”

A few thoughts:

1. This is a good paper.

2. The key finding in four words: more RCTs over time.

3. By focusing on this type of study, the authors provide a snapshot of the shift in psychiatry (that is, away from psychopharmacology). Non-pharmacological-RCTs, they also found, had a slightly higher effect size.

4. Like all studies, there are limitations. They drew from the Cochrane Database of Systematic Reviews and observe: “While we believe that our data are representative, they are nowhere near exhaustive.” And, as noted above, the delay in reporting seems to colour data from more recent years.

5. A big story in mental health (and medicine in general) has been the rise of non-RCTs analyses, including observational studies, sometimes drawing on vast databases. Chen et al. focused on RCTs but it would be interesting to get data on other types of analyses. Mental health research grows more sophisticated over time.

6. RCTs have been considered in past Readings. For example, we looked at a NEJM paper that outlined the history of RCTs. The Bothwell et al. paper, for the record, was unusually well written. That Reading can be found here:

The full CJP paper can be found here:

Selection 2: “ChatGPT: the future of discharge summaries?”

Sajan B. Patel and Kyle Lam

The Lancet Digital Health, 6 February 2023  Online First

ChatGPT (Open AI, San Francisco, CA, USA) has taken the world by storm. Released to the public in November, 2022, ChatGPT is based on artificial intelligence (AI) technology and trained on data from the internet written by humans, including conversations. This AI-powered chatbot has vast capabilities ranging from poem composition, essay writing, solving coding issues, and explanation of complex concepts… One potential area of ChatGPT’s application could be to generate discharge summaries. Composition of high-quality discharge summaries containing the requisite information can be time consuming, with the burden usually falling on junior doctors. Therefore, when balanced against clinical commitments, discharge summaries are often left under-prioritised resulting in delays in patients’ discharges or insufficient discharge summaries, which not only places pressure on an already stretched junior doctor workforce, but also presents potential patient safety issues in the transition of care from secondary to primary care.

So begins a Comment paper by Patel et al.

“ChatGPT allows doctors to input a brief of the specific information to include, concepts to elaborate on, and guidance to explain, outputting a formal discharge summary in a matter of seconds. Discharge summaries are an obvious choice for this technology because of their largely standardised format; this standardisation has previously been recognised through the creation of templates—eg, from the Royal College of Physicians.”

They note a couple of advantages:

  • Less time. “Automation of this process could therefore ease the work burden upon junior doctors allowing more time for the delivery of patient care and the seeking of training opportunities in often roles centered on service provision.” 
  • Better quality. “ChatGPT could also improve the quality of the discharge summaries themselves, with previous literature showing discharge summaries that are written through traditional means often missing details.”

They list several potential problems, including: “Acceptability of this technology, from patients in particular, must be considered. The concern that automation might lead to depersonalisation of care could lead to resistance to this technology. Pilot trial data is therefore necessary to gather stakeholder views and ultimately show improvements in efficiency and quality of processes…”

A few thoughts:

1. This is an interesting paper.

2. AI has caused a stir in recent days, with predictions about ChatGPT and other programs changing the way we diagnose and treat patients – ChatGPT as a modern day Aaron Beck, if you will. But is the future a bit less dramatic? ChatGPT could be used as a tool for monotonous tasks – like discharge summaries.

3. The point about patient “buy in” is a good one.

4. ChatGPT was considered in last week’s Reading, with an original essay by Dr. Scott Patten, which can be found here:

The full Lancet Digital Health Comment can be found here:

Selection 3: “On mental illness, the time to (just) talk is over”

Anna Mehler Paperny

The Globe and Mail, 3 February 2023

I’m okay. You’re okay. It’s okay not to be okay.

If you have a phone or an internet connection, you’ve seen the hashtags.

So, fine. Let’s talk.

Encouraging conversation around mental illness is good. For too long it’s been in the shadows. I’ve had people hang up on me for the temerity of mentioning mental illness. Anything that gets this psychic garbage out in the open, that normalizes its place in discourse and tells sufferers they’re not alone, is to be lauded.

But too often this discourse degenerates into trite mental-health inspo. I was lost but now am found: You can be, too. It elides the messiness inherent in these conditions. Mindfulness, ‘me-time’ and breathing exercises are great but often insufficient when you’re having a psychotic break or plunged in suicidal depths.

So begins an essay by Mehler Paperny.

She touches on her own journey: “The neat and redemptive narratives this discourse popularizes belie the often excruciating and complicated course of mental illness. This can further alienate those who haven’t found that simple wellness trajectory themselves. You can write a book about suicidality and still find yourself sucked into its grip.”

She writes about the challenges in the current system. “The facile, feel-good mental-health discourse is unforgivable when it papers over the ways our inaction fails people with mental illness. The primary treatment modalities – pharmacotherapy and psychotherapy – remain outside most public-health coverage in Canada. Waits for care stretch to months and when you fall into the crisis this inadequate preventive care almost guarantees, you’re often confronted by cops and, if you’re lucky, stuck on a plastic waiting-room chair before maybe getting a few days in hospital, then released to begin the cycle anew.”

She notes recent campaigns, including the Canadian Mental Health Association launched its Act for Mental Health campaign, calling for more federal support – and strings. She also observes the call by the mayor of Toronto for a national summit on mental health.

She sees a very practical reason for change. “Not just because it’s compassionate but because it’s cost-effective. Hospital stays are expensive. Incarceration, policing, court time are expensive. Helping someone stay in the work force, if that’s what they choose, is cheaper than supporting them once they’re shunted out of it.”

She closes by mulling a way forward.

“We need ‘universal’ health coverage that includes the universe of disorders attacking your mind. Enough with programmatic patchworks. We need ongoing, attractive, preventive care as well as compassionate, voluntary-whenever-possible-and-respectful-when-involuntary interventions for the crises we can’t prevent. We need real alternatives to cops as ‘psychiatrists in blue,’ because they are not. We need treatment breakthroughs for people whose intransigent illnesses don’t respond to what’s available now.”

A few thoughts: 

1. This is a thoughtful and important essay.

2. The author – who speaks candidly about her own experiences – is blunt in her assessment. “We coax people into disclosure, then fail them when they seek help.”

3. This comment is worth repeating: “Hospital stays are expensive. Incarceration, policing, court time are expensive. Helping someone stay in the work force, if that’s what they choose, is cheaper than supporting them once they’re shunted out of it.”

The full Globe essay can be found here:

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