From the Editor 

Depression is the result of character weakness. So explained my patient who had a major depressive disorder and hesitated to take medications.

Though fading, stigma about mental illness continues to exist, including self-stigma, the negative thoughts and beliefs that patients have about their own disease – as with my patient. How common is self-stigma? How does its prevalence differ around the globe? What are risk factors for it? Nan Du (of the University of Hong Kong) and co-authors attempt to answer these questions in a new Journal of Affective Disorders paper. They do a systematic review and meta-analysis of self-stigma for people with depression, drawing on 56 studies with almost 12 000 participants, and they a focus on international comparisons. “The results showed that the global prevalence of depression self-stigma was 29%. Levels of self-stigma varied across regions, but this difference was not significant.” We consider the paper and its clinical implications.

In this week’s second selection, we look at ChatGPT and mental health care. Dr. John Torous (of Harvard University) joins me for a Quick Takes podcast interview. He sees potential for patients – including making clinical notes more accessible by bridging language and knowledge divides – and for physicians, who may benefit from a more holistic differential diagnosis and treatment plan based on multiple data sets. He acknowledges problems with privacy, accuracy, and ChatGPT’s tendency to “hallucinate,” a term he dislikes. “We want to really be cautious because these are complex pieces of software.” 

And in the third selection, Dr. Catherine Hickey (of Memorial University) writes about the opioid crisis for Academic Psychiatry. The paper opens personally, with Dr. Hickey describing paramedics trying to help a young man who had overdosed. She considers the role of psychiatry and contemplates societal biases. “[I]n a better world, the needless deaths of countless young people would never be tolerated, regardless of their skin color.”


Selection 1: “Prevalence, risk, and protective factors of self-stigma for people living with depression: A systematic review and meta-analysis”

Nan Du, Eddie S. K. Chong, Dannuo Wei, et al.

Journal of Affective Disorders, 1 July 2023

Stigma is an ‘attribute that is deeply discrediting’ and a ‘spoiled social identity’… At an individual level, stigma manifests itself in several ways, e.g., perceived stigma, enacted stigma, treatment stigma, and self-stigma (also known as internalized stigma)… Self-stigma is associated with a range of negative effects, such as hindering treatment and recovery, aggravating depressive symptoms, reducing help-seeking and treatment adherence, increasing the risk of suicidal behavior, that further harm the individual’s self-esteem, self-efficacy, and empowerment. Self-stigma may further compromise various aspects of the individual’s daily life. People internalizing stigma may compromise their life goals and appear withdrawn in their work and social relationships.

Regional discrepancies in the levels of self-stigma have prompted researchers to adopt a socio-cultural lens, suggesting that self-stigma is not an inherent and fixed condition but rather develops in part as a result of different contextual factors. A study comparing self-stigma related to mental illness in Japan and Australia showed Japanese evidenced a higher level of self-stigma than Australians; although living conditions in these two countries are comparable, the disparity in self-stigma might be attributable to differences in mental health care systems and cultural beliefs towards mental illness.

So begins a paper by Du et al.

Here’s what they did:

  • The authors searched major online databases to identify studies: PubMed, PsycINFO, Web of Science, and Embase. 
  • “English articles involving depression samples, assessing self-stigma or its correlates with a valid measure, and providing quantitative data on prevalence and/or correlates of self-stigma were included.”
  • “Four reviewers independently screened the literature, extracted data, and assessed the risk of bias in eligible studies.”
  • Statistical analyses were done including: “Pearson’s r was chosen as the effect size metric of risk and protective factors.” The authors also did a subgroup analysis based on geography for studies that measured depression self-stigma using the Internalized Stigma of Mental Illness Scale (ISMI).

Here’s what they found:

  • 4 168 were identified, 2 139 were excluded based on titles and abstracts. 207 were then fully screened, with 56 studies meeting criteria. 
  • Types of studies. Most included studies were cross-sectional (87.5%). “About 40% included samples with multiple diagnoses of mental disorders…”
  • Prevalence. “The pooled prevalence of self-stigma for depression was 29%, meaning that 29% of people living with depression showed moderate to high levels of self-stigma.” See figure below.
  • Demographics. “Male gender and non-White ethnicity/race were positively and modestly associated with self-stigma while having a partner or being married was negatively associated with self-stigma.” 
  • Regions. “The pooled mean of depression self-stigma measured by ISMI was 2.26, which is lower than the suggested cutoff for a moderate to high level of self-stigma. Stratified by geographical regions, a higher mean of depression self-stigma was found in Africa (2.41) and Asia (2.31), followed by North America (2.21) and Europe (2.20). However, these regional differences were not significant.” (!)

A few thoughts:

1. This is a good paper – relevant, on an important topic, and drawing on global data. And this study was built on decent studies (collectively of moderate and high quality).

2. The main findings in a sentence: just under a third of patients with depression have moderate to high levels of self-stigma.

3. The paper also shows that prevalence doesn’t really vary among regions.

4. The authors push further, and list out risk factors for self-stigma: depression symptom severityillness duration, and four different types of stigma. To be more specific – public stigma (the negative attitudes that others have about mental illness), enacted stigma (the experience of unfair treatment by others), treatment stigma (negative attitudes about treatment), and perceived stigma (beliefs about the attitudes of others). Is it surprising that people with depression who feel that they are surrounded by stigma would then have self-stigma?

5. The authors note several limitations, including the studies they drew from: “the majority of the included studies were cross-sectional, thus examining correlational rather than causal relationships.”

6. How to think about this paper from a clinical perspective? Despite the progress made, stigma continues – and many of our patients may, in fact, be experiencing self-stigma. Part of an assessment should thus include a conversation within the conversation about their thoughts on depression and its treatability. Exploring the views of their family and community may also be important. We clinicians have a bias towards diagnosis and treatment (obviously). Some of our patients may have been born and raised in an environment that has a deep skepticism of all things mental health care.

The full JAD paper can be found here:

Selection 2: “ChatGPT & mental health care”

John Torous

Quick Takes, November 2023

It’s the most downloaded app in history. ChatGPT has caused a stir. People use it to write resumes, plan dinner, and help with college term papers. What are the implications for mental health care? Will AI change our work? In this interview, I talk with returning guest Dr. John Torous, Director of the Digital Psychiatry Division at Beth Israel Deaconess Medical Center.

Highlights from the discussion:

On his impressions of ChatGPT

“Our team actually bought one of the early subscriptions to ChatGPT so we could learn about it. We’ve asked it to solve different DSM cases; the APA publishes a case-series book and we put the cases in and see what it responds. We’ve asked it to do drug-drug interactions. We’ve asked it for sleep advice. We’ve certainly played with it. 

“Overall, it’s pretty impressive.”

On hallucinations

“I think hallucinations is not a good term – being a psychiatrist – when ChatGPT gets it wrong. We should say ChatGPT makes factual errors or it lies to us about what’s happening. We put in ‘what is mindLAMP?’ (the open-source app that we built). And sometimes, it gets it right. Sometimes, it’s a piece of software but was built by different people. Sometimes, it was built in a different decade. Sometimes, it doesn’t know what mindLAMP is.”

On accuracy

“When giving information to patients in health care, we have to get it right. And if you’re going to get it wrong, even one out of 100 times, it’s not good enough.”

On ChatGPT-generated discharge summaries

“If we look at the history of innovation, sometimes it’s not the snazziest thing, right? It’s not the chatbot playing doctor and making a miraculous diagnosis. It’s the chatbot filling out a discharge summary. It’s not as glamorous, but the reality is that’s going to probably be where we start, and it’s going to make a difference. And I think if it goes well in the discharge summary, I think it can probably move up.

“If we’re being realistic, it’s going to be that kind of mundane but very important work that has to be done, and this can help.”

On whether psychiatrists should start retraining

“I think the best way to think of ChatGPT is a new modality to put together and share information – just like Wikipedia was a new modality to put together and share information. No one lost their job to Wikipedia. If anything, people were excited; Wikipedia made it easier for people to look up information. There’s always risks of misinformation on Wikipedia. People know that. But overall, it helped elevate everyone. 

“ChatGPT is a tool whose use is going to spread. It’s a new conduit and it’s exciting to have new conduits in vehicles to share information, to put data together for psychiatry.”

The above comments have been edited for length.

The Quick Takes podcast can be found here, and is just over 26 minutes:—chatgpt-and-mental-health-care-with-dr-john-torous

Selection 3: “Psychiatry in the Age of the Opioid Crisis”

Catherine Hickey 

Academic Psychiatry, June 2023

Recently, while attending a psychiatry education conference, I went for a walk downtown. As I approached a hospital, I was shocked to see a group of ten paramedics providing cardiopulmonary resuscitation (CPR) to a young Caucasian man lying on a stretcher on the sidewalk outside the emergency department. Even more shocking – albeit undoubtedly kind – was the presence of three paramedics holding sheets above the victim as the CPR was performed. I noted that the paramedics were men of color, carefully trained to deal with the gravity of the situation discretely and professionally. They were dutifully protecting the world from seeing the reality of the situation. And they were protecting the privacy of the victim. I use the word victim loosely as I hope that he was, indeed, a survivor. But after 10 minutes elapsed, I was uncertain of his status. Those gathered at the scene stated that he had overdosed on fentanyl.

Torn between declaring myself a physician to the paramedics and realizing that such a declaration would be less than helpful (I had not provided advanced cardiac life support in at least 20 years), I sat on the sidelines – unsure of what to do. On the one hand, I was a doctor, and I felt I could play some role in preventing a needless death. On the other hand, it felt too late for me and my specialty to intervene.

So begins a paper by Dr. Hickey.

In thinking about the opioid crisis, she asks: “What more could a psychiatrist do? What more could psychiatry do?”

“What does it mean to be a psychiatrist? Do we diagnose, investigate, and treat psychiatric illnesses as defined by the Diagnostic and Statistical Manual of Mental Disorders? Surely, we do all of this, but I suspect most of us do much more. Somehow, through our training and, indeed in our very constitutions, we feel a call to become advocates for social accountability. Canada has the CanMEDS role of Health Advocate, which states that physicians must be socially accountable and recognize their obligation to contribute to efforts to improve the health of their patients, their communities, and the population at large.”

“How do such roles and milestones translate into meaningful action for the psychiatrists we are and the psychiatrists we must train? Do we become the new soldiers in a war against opioids – acknowledging that this war has taken the lives of many young people across our continent and around the world? Is the call to action somehow different because the victims are more likely to be young, White, and indigenous males, rather than Black and Hispanic individuals?”

She notes the historical neglect of addition problems. “Who ‘owns’ the treatment of addictions? Addiction medicine or addiction psychiatry?… What remains at stake is the identity of the psychiatrist and the psychiatric trainee as practitioners who treat and prevent addiction in all patients who present with this complex neuropsychiatric illness… We must acknowledge our past as educators who did not place great importance on addictions education. Our efforts have been slow and obstructionist because of archaic views that addictions are the result of moral failures, that the patients who struggle with these illnesses are simply choosing unhealthy lifestyles, often against our recommendations and their best judgments.”

She argues that her biggest role is that of educator. “Through direct example, I would have taught that addiction is complex but treatable, and as with any relapsing and remitting illness, we must be strong, patient, and compassionate clinicians. I would have taught about emerging science and novel medications and that effective collaboration among specialty teams and primary care is the only way we can become accountable providers to the individuals and societies we serve.”

A couple of thoughts:

1. This is a well-written essay.

2. Is the biggest role as an educator? She makes a compelling case.

The full Academic Psych paper can be found here:

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