From the Editor

Despite what we may wish to believe, physicians are mortal. We can develop illnesses – even mental disorders. And some (too many) suicide. Past studies have shown that doctors die by suicide more than the general population. But the data wasn’t Canadian.

In the first selection, Dr. Manish M. Sood (of the University of Ottawa) and his co-authors consider suicide by Canadian physicians. In a new Canadian Journal of Psychiatry paper, they do a population-based, retrospective cohort study drawing on more than a decade and a half of data. They write: “Physicians in Ontario are at a similar risk of suicide deaths and a lower risk of self-harm requiring health care relative to nonphysicians.” We look at the paper.

In the second selection, Dr. Julia Jiyeon Woo (of McMaster University) and her co-authors review cannabis from the perspectives of clinicians and patients. In a new British Journal of Psychiatry paper, they note: “This growing discrepancy between clinicians’ and patients’ perspectives on cannabinoids can be extremely damaging to the therapeutic alliance.” They offer practical suggestions.

And in the third selection, Dr. Thomas Insel (of the Steinberg Institute) considers what’s right and what’s wrong with mental health care. As the director of NIMH, he oversaw $20 billion of funding; in his new book, excerpted in the pages of The Atlantic, he calls for mental health reform. He writes: “There are only two kinds of families in America: those who are struggling with mental illness and those who are not struggling with mental illness yet. To ensure that we serve all families well, we don’t necessarily need to know more to do better.”


Selection 1: “Suicide and Self-Harm Among Physicians in Ontario, Canada”

Manish M. Sood, Emily Rhodes, Robert Talarico, et al.

The Canadian Journal of Psychiatry, 12 May 2022

Suicide is the 13th leading cause of death, with an average of two deaths per minute worldwide. Occupation is an identified risk factor for suicide with physicians being reported to have a higher risk of suicide compared to nonphysicians despite exhibiting better measures of overall physical health. Numerous survey-based studies identify mental distress, however, there is little contemporary data on death by suicide in physicians in Canada. High levels of psychosocial stress, burnout, mental health and substance disorders, access to medications, and life-ending knowledge are proposed as putative factors. This is especially pertinent with recent reported high levels of emotional distress and elevations in mental health services among physicians with the recent coronavirus disease 2019 (COVID-19) pandemic.

Many studies reporting a higher risk of suicide among physicians predate 2000, with more recent evidence suggesting that physician suicide occurs at comparable rates to the nonphysician population. The objective of this study was to evaluate the risk of suicide and self-harm among physicians and nonphysicians in Ontario, Canada, using administrative data sources. We hypothesized that the risk of suicide in physicians would be similar to the general population in a more contemporary cohort.

So begins a new paper by Sood et al.

Here’s what they did:

“We conducted a population-based, retrospective cohort study using registration data from the College of Physicians and Surgeons of Ontario from 1990 to 2016 with a follow-up to 2017, linked to Ontario health administrative databases. Using age- and sex-standardized rates and inverse probability-weighted, cause-specific hazards regression models, we compared rates of suicide, self-harm, and a composite of either event among all newly registered physicians to nonphysician controls.”

Here’s what they found:

  • “We included 35,989 physicians and 6,585,197 nonphysicians in our study cohort.”
  • Demographics. Physicians were more likely to be male, younger, and more likely to live in higher income neighbourhoods. They also tended to be healthier (fewer medical co-morbidities).
  • Suicide. “Unadjusted suicide events (0.07% vs. 0.11%) and rates (9.44 vs. 11.55 per 100,000 person-years) were similar… Weighted analyses found a hazard ratio of 1.05…” 
  • Speciality. “Psychiatry as a medical speciality was associated with a higher risk of suicide.”
  • Self-harm. “Self-harm requiring health care was lower among physicians (0.22% vs. 0.46%; hazard ratio: 0.65…).” 

A few thoughts:

1. This is a good study.

2. A quick summary: physician rates are comparable to the general population’s.

3. And, yes, that finding is different than the data from other countries. The authors write: “Country-level physician rates of suicide relative to the general population were reported from the United States, Europe, and Australia, with consistently higher rates among physicians.”

4. Like all studies, there are limitations. The authors note several, including “our study cohort comprised newly registered physicians from 1990 onwards, thereby limiting the number of individuals over 60 years of age and potentially leading to an underestimate of the true total risk of death from suicide and self-harm.”

5. This paper offers good news. But we need to remember that suicide is just one metric for how our physicians are doing.

The full CJP paper can be found here:

Selection 2: “Cannabinoids in psychiatry: they are here to stay”

Julia Jiyeon Woo, Emma van Reekum, Sagnik Bhattacharyya, and Zainab Samaan  

The British Journal of Psychiatry, June 2022

Case vignette

A young man sits in his psychiatrist’s office. After being counselled about his diagnoses of depression and panic disorder, he is informed about first-line treatment options, including selective serotonin reuptake inhibitors (SSRIs). He replies ‘I’ve tried those medications before, and they were never as helpful as cannabis. I feel like cannabis is more natural and safer. Can’t you give me a prescription for cannabis?’ The psychiatrist states that she will not prescribe cannabis as it is not efficacious for treating mood or anxiety disorders, but the patient is adamant that it has been helpful and declines SSRIs. The psychiatrist and the patient both walk away feeling frustrated and unheard.

So begins this paper by Woo et al.

They write: “As cannabinoids become legalised and more widely available, interactions such as this are increasingly common in physicians’ offices worldwide.” 

They note the strong use among those with mental health disorders: “Cannabinoid use is widespread among the public, but even more common among people with psychiatric disorders. In the 2019 National Survey on Drug Use and Health, 35% of adults with mental illness in the USA reported using cannabinoids in the past year, compared with 14% of adults without mental illness.”

The Patient Perspective

“Legalisation has further contributed to the public perception that cannabinoids are safe and effective in improving ailments ranging from pain to anxiety, depression and insomnia. Some patients anecdotally report that cannabinoids offer fast-acting relief for their symptoms, in contrast to most psychotropic medications, which take weeks to exert their effects.” They also observe ready availability.

The Clinician Perspective

“In its 2019 position statement, the Royal College of Psychiatrists identified that there is scarce, poor-quality evidence to support cannabinoids as a therapeutic agent in psychiatric conditions.”

How to move forward? “The bottom line here is that, despite the uncertain evidence base, some of our patients will continue to use cannabinoids. Instead of providing a blanket statement that ‘cannabis is bad’, we must play an active role in educating and counselling patients.”

They make practical suggestions:

  • “Substance use history is a vital aspect of any psychiatric assessment, but one that too often turns into a checklist of closed questions.”
  • “Questions such as these could go a long way in creating an environment where patients feel understood; one in which constructive discussions and education can take place. Better understanding of our patients’ patterns and perception of cannabinoid use would allow us to shape our psychoeducation accordingly.”
  • “Perhaps more transparency and humility are also needed from clinicians. We can let our patients know with relative confidence that (a) there is limited evidence that cannabinoids are effective in treating mental illnesses and (b) there is convincing evidence to suggest harms of regular, long-term use of cannabinoids, particularly THC. Beyond that, our current knowledge of cannabinoids is quite limited.”

“The suggestions we make here all return to the basic principles of motivational interviewing: to be open, empathic and non-judgemental; to seek to understand both overt and hidden motives of behaviour; and to make patients feel heard.”

A few thoughts:

1. This is a good and thoughtful paper.

2. The authors’ suggestions are very practical.

3. Past Readings have focused on cannabis, of course. For those interested in a refresher on motivational interviewing, we considered a Quick Takes podcast on the subject which can be found here:

The full BJP paper can be found here:

Selection 3: “What American Mental Health Care Is Missing”

Thomas Insel

The Atlantic, 13 February 2022

During my last year as director of the National Institute of Mental Health (NIMH), I was in Oregon, giving a presentation to a roomful of mental-health advocates, mostly family members of young people with a serious mental illness. During my tenure as the ‘nation’s psychiatrist,’ the nickname for my role, I oversaw more than $20 billion for mental-health research, and I was eager to share evidence of the agency’s scientific success.

I clicked through my standard PowerPoint deck featuring high-resolution scans of brain changes in people with depression, stem cells from children with schizophrenia showing abnormal branching of neurons, and epigenetic changes as markers of stress in laboratory mice. We had learned so much! We were making so much progress!

While I could see heads nodding in the front row, a tall, bearded man in the back of the room wearing a flannel shirt appeared more and more agitated. When the Q&A period began, he jumped to the microphone. ‘You really don’t get it,’ he said. ‘My 23-year-old son has schizophrenia. He has been hospitalized five times, made three suicide attempts, and now he is homeless. Our house is on fire and you are talking about the chemistry of the paint.’ As I stood there somewhat dumbstruck, he asked, ‘What are you doing to put out this fire?’

So begins Dr. Insel in this excerpt of his new book.

The former director of NIMH marvels at the scientific progress – but the lack of tangible health outcomes.

  • “The scientific progress in our field was stunning, but while we studied the risk factors for suicide, the death rate had climbed 33 percent.” 
  • “While we identified the neuroanatomy of addiction, overdose deaths had increased threefold.” 
  • “While we mapped the genes for schizophrenia, people with the disease were still chronically unemployed and dying 20 years early.”

For the record, Dr. Insel is optimistic: “Hidden in this dystopian picture is an extraordinary and overlooked bright spot. For virtually all mental disorders, we have effective treatments. Medications, psychological treatments, and rehabilitative interventions (for example, supportive employment) are unequivocally helpful, on par with or better than treatments for other chronic medical conditions. Yet for treatments to be effective, they must be combined with the kind of comprehensive and continuous care that most people don’t receive. Patients must also be matched with the right treatment, which can take time and experimentation. And negative attitudes toward treatment prevent many people who would benefit from seeking help – or from doing so outside of a crisis.”

Dr. Thomas Insel

What’s the key? “As a very wise psychiatrist working in Los Angeles’s Skid Row defined recovery for me, ‘people, place, and purpose.’ In other words, finding people for support, having a place or sanctuary to heal, and discovering a purpose or mission.”

A few thoughts: 

1. This is a good excerpt.

2. The book is even better. Read it.

3. In the coming weeks, we will be featuring a podcast interview with Dr. Insel.

The full Atlantic article can be found here:

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