From the Editor

My patient was involved in a terrible car accident. Though physically unharmed, she’s never really recovered (mentally). Her co-worker, sitting in the seat beside her, barely took off any time from work.

Why are some people resilient and others aren’t?

In The British Journal of Psychiatry, Dr. Taku Saito (of the National Defense Medical College) and his co-authors explore this question, focusing on a natural disaster. Drawing on an impressive database of first responders involved in the 2011 Japanese earthquake rescue/recovery effort, they do a seven-year prospective cohort study. They find: “The majority of first responders… were resilient and developed few or no PTSD symptoms.” Of course, some did develop mental health problems. The risk factors? Older age, personal disaster experiences, and working conditions. We consider the big paper.

In the second selection, Andrew J. Stewart (of the University of Calgary) and his co-authors analyze health spending in a new Canadian Journal of Psychiatry paper. They focus on people with schizophrenia, looking at a 10-year period. “Healthcare spending among patients with schizophrenia continues to increase and may be partially attributable to growing rates of multimorbidity within this population.”

And, in the third selection, Dr. Megan Ann Brandeland (of Stanford University) writes about her father’s death. In JAMA, she discusses his struggles and notes that – early in his career as a physician – a patient had a tragic outcome. “My hope in sharing this story is to encourage more physicians to share their own stories, to reduce the stigma around mental health, trauma, and addiction among physicians, and to honor my father’s life and the goodness he brought to the world.”

Please note that there will be no Reading next week; we will resume on 31 March 2022.


Selection 1: Risk and resilience in trajectories of post-traumatic stress symptoms among first responders after the 2011 Great East Japan Earthquake: 7-year prospective cohort study”

Taku Saito, Florentine H. S. van der Does, Masanori Nagamine, et al.

The British Journal of Psychiatry, 22 February 2022  Online First

On 11 March 2011, northeastern Japan was hit by the largest earthquake in the country’s recorded history. This earthquake caused the formation of a tsunami, which flooded a densely populated area and damaged the Fukushima Daiichi Nuclear Power Station, resulting in a release of radioactive material. This trifold disaster is known as the Great East Japan Earthquake (GEJE). In response to the GEJE, 107 000 first responders were dispatched, of which 70 000 were Japan Ground Self-Defense Force (JGSDF) personnel. First responders to major disasters are typically exposed to many potentially traumatising experiences. As such, they are at an elevated risk of developing post-traumatic stress disorder (PTSD) compared with other first responders and the general population. Previous research has found high incidences of PTSD in first responders to natural disasters such as Hurricane Katrina, man-made mass violence such as the 2001 World Trade Center (WTC) attacks and nuclear events like the Chernobyl accident… 

Even if individuals are exposed to similar traumatic events, the development and course of PTSD symptoms vary.

So begins a paper by Saito et al.

Here’s what they did:

First responders “were enrolled in this 7-year longitudinal cohort study. PTSD symptom severity was measured using the Impact of Event Scale-Revised. Trajectories were identified using latent growth mixture models (LGMM). Nine potential risk factors for the symptom severity trajectories were analysed using multinomial logistic regression.”

Here’s what they found:

  • There were 55,632 participants. 
  • Demographics. The vast majority were male (97.5%); in terms of age, about half were between 31 and 45 (46.8%). 
  • Trajectory. “The majority of individuals followed a ‘resilient’ trajectory (n = 30 476, 54.8%), experiencing few or no symptoms over the course of monitoring. Additionally, we identified a ‘recovery’ trajectory (n = 13 658, 24.6%) and an ‘incomplete recovery’ trajectory (n = 5937, 10.7%). For these trajectories, symptom severity tapered off over time, starting out higher for the incomplete recovery trajectory than for the recovery trajectory.”
  • “We also identified a ‘late-onset’ trajectory (n = 3187, 5.7%), with symptom severity starting out low and increasing over time. Lastly, we identified a ‘chronic’ trajectory (n = 2374, 4.3%), for which symptom severity was high throughout the study.”
  • Risk factors. “The main risk factors for the four non-resilient trajectories: older age, personal disaster experiences and working conditions.”

This is a good study – and one that is very relevant to our times.

The authors note several strengths, including the focus on non-Western participants. Also impressive: the size of the sample and the length of the follow up (seven years – !).

The main finding isn’t surprising: most people have resilience, even in disaster situations. The authors push further, helping to understand a bit better some of the risk factors for those who develop symptoms. Of course, the larger question: how generalizable are these findings to, say, other first responders in different circumstances? Though some interesting work has been done in the area, basic questions still need to be answered.

The full BJP paper can be found here:

Selection 2: “10-Year Trends in Healthcare Spending among Patients with Schizophrenia in Alberta, Canada”

Andrew J. Stewart, Scott B. Patten, Kirsten M. Fiest, et al.

The Canadian Journal of Psychiatry, 4 March 2022  Online First

The healthcare needs of patients with schizophrenia have major implications for health resource allocation and planning. In 2004, it was estimated that total costs for schizophrenia care in Canada (direct and indirect) exceeded $6.8 billion CAD and in 2017–2018, the estimated average cost of a hospital stay for a Canadian patient with schizophrenia was $12,971, the highest among all mental disorders. Expanding per capita healthcare costs in North America has led to an increased focus on finding efficiencies within health systems. This includes decreasing reliance on acute care services through strategies aimed at improving access to community care, early detection, and initiation of psychosis intervention programs. Further, there have been key advances in the management of schizophrenia over the past decade, which include the use of promising new antipsychotic medications. These changes in management and proposed shifts in the location of care have created a need to understand how overall, and sector-specific healthcare spending has been impacted.

So begins a paper by Stewart et al.

Here’s what they did: 

  • “We conducted a serial cross-sectional study between January 1, 2008, and December 31, 2017 (i.e., 10 years) using administrative and clinical data from the province of Alberta, Canada.”  
  • The authors considered “demographic characteristics, medical complexity, and costs among all adults (18 years or older) with schizophrenia.” 
  • They looked at total health care spending and also “sector-specific costs attributable to hospitalizations, emergency department visits, practitioner billings, and prescriptions were calculated and compared over time.”

Here’s what they found:

  • “Over the 10-year period the contact prevalence of patients with schizophrenia increased from 0.6% (n  =  16,183) to 1.0% (n  =  33,176) within the province.”
  • “There was a marked change in medical complexity with the number of patients living with 3 or more comorbidities increasing from 33.0% to 47.3%.” (!!) “The most prevalent comorbidities were depression (47.2%), hypertension (31.3%), chronic kidney disease (30.4%), alcohol misuse (27.8%), and diabetes (16.1%).”
  • “Direct annual healthcare costs increased 2-fold from 321 to 639 million CAD (493 million USD)…” They note variation in that growth: “the fastest-growing category was medication expenditures with a greater than 7-fold increase in estimated cost over time (3.6-fold increase per capita).” See graph below.
  • “When stratified by age, mean costs were highest among younger patients with schizophrenia while median costs were found to be highest among older patients.”
  • “In 2008, the five most prescribed drugs among patients with schizophrenia (in order of frequency) were: olanzapine, haloperidol, quetiapine, clozapine, and ziprasidone… However, in 2017, 18.5% of patients prescribed antipsychotics were prescribed aripiprazole injectables.”

This is a good study, and there is much to like here.

I highlight: the rise in comorbidities. The authors write: “We found the proportion of patients with three or more comorbidities increased from 33.0% to 47.3% and though prior work has shown that multimorbidity is increasing in the Canadian population, this magnitude of change combined with increasing longevity has important implications for the future management of schizophrenia.”

What’s to be done? The authors see significant policy implications: “This includes increased reliance on multidisciplinary care strategies to not only address underlying mental health concerns but the co-management of common chronic conditions such as hypertension and diabetes – particularly in younger patients.”

As noted in past Readings, the physical health needs of those with mental disorders are often neglected – siloed care is unsatisfying to many, but deeply problematic for those with mental illness. The study suggests the importance of trying to address those challenges.

The full CJP paper can be found here:

Selection 3: “The Labor of Story Telling”

Megan Ann Brandeland

JAMA, 8 March 2022

I was finishing my first year of medical school when my father died. It was Memorial Day weekend, and I had spent the evening at his house. We ate dinner together on the porch and watched one of our favorite movies, Lorenzo’s Oil. Before leaving, my dad and I made plans to have lunch together the following week. As I was driving home that night, though, I had a sinking feeling that this could be the last time I saw him. I cannot explain this intuition except to say that there was a place deep in my heart that knew that he would be leaving, that he wouldn’t survive this. He had already had 2 brushes with death in recent months. I felt like his will to live was fading.

So begins a paper by Dr. Brandeland.

She continues: 

“I told the medical examiner that my dad had a lot of medical problems, including heart failure and diabetes as well as depression and chronic pain. With hesitation, I acknowledged that he was taking opioids. I was too ashamed to admit that he had overdosed more than once in recent months.”

She wrestles with her father’s death: “The autopsy determined the cause of death to be ‘mixed drug toxicity’ with heart disease also contributing. This was the first autopsy report I read during my medical training. I remember reading it in a very academic way, trying to find some clues that would tell me he had died of some other cause. I simply did not have the words, much less the courage, to tell my friends and family the truth. The stigma surrounding addiction felt too great a burden to bear.”

She grieves: “As I began my second year of medical school, the weight of grief sat like a boulder in the pit of my stomach and echoed in the marrow of my bones. Grief colored nearly all my experiences. I remember sitting in the pathology laboratory studying a variety of diseased and injured hearts, and rather than memorizing the anatomy, I found myself thinking about the people these hearts once belonged to. This was someone’s brother, sister, father, mother. Their hearts, now torn open and exposed, not unlike my own, sat lifeless on our laboratory table.”

Dr. Brandeland also notes the role of tragedy in her father’s life: “When my father was a young physician, around my age, he experienced a tragic event that changed the trajectory of his life. Many years later, he wrote about the experience. He told the story of a pregnant patient under his care who experienced an ‘anesthesia catastrophe’ during a cesarean delivery. He had been her family medicine physician and was present as first assistant for the procedure. The patient had a cardiac arrest that resulted in severe brain injury and, several days later, was removed from life support and died. Her infant survived but had severe neurological injury.” As he was the only one left of the medical team, he needed to break the news to the family. She wonders how this tragedy coloured his life and his coping.

She notes the importance of story telling. “In sharing and receiving stories, we connect more deeply to one another: We become more real, more fully human. We feel less alone. The labor of story telling is not necessarily easy, though. It requires honesty, vulnerability, and the courage to contact the wounded places within ourselves. Sadly, these are not things that most of us are taught to do as physicians. Instead, we learn early on in medical training that it is risky to be our authentic selves, to acknowledge our imperfections, and to share our struggles. I am convinced that this has contributed to the epidemic of burnout, depression, and suicide among physicians.”

This is a beautifully written essay, about love and loss, one that is (at the same time) moving and raw. 

With regard to story telling, she makes good points. By putting the pen to paper, so to speak, we can help reduce stigma, especially among physicians, who are collectively ready to admit to successes but loathe to acknowledge human failings.

The full JAMA paper can be found here:

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