From the Editor

This week, we have three selections; all are from Canadian publications.

Suicide rates have been declining in this country. In the first selection, Sara Zulyniak (of the University of Calgary) and her co-authors look at suicide by age and gender, drawing on almost two decades’ worth of data. In their analysis, there is a surprising finding: “The suicide rates in females aged 10 to 19 and 20 to 29 were increasing between 2000 and 2018. In comparison, no male regression results indicated significantly increasing rates.” This research letter, just published in The Canadian Journal of Psychiatry, is short and relevant.


In the second selection, also from The Canadian Journal of Psychiatry, Joanna Marie B. Rivera (of Simon Fraser University) and her co-authors consider access to care. They focus on immigrants and nonimmigrants, noting differences in the way care is provided for those with mood disorders. “People with access to team-based primary care are more likely to report mental health consultations, and this is especially true for immigrants. Unfortunately, immigrants, and especially recent immigrants, are more likely to see a doctor in solo practice or use walk-in clinics as a usual place of care.”

Finally, in our third selection from CMAJ, Dr. Rozalyn Chok (of the University of Alberta), a pianist who is now a resident of paediatrics, describes a performance at a mental hospital. “I still hear exactly how it sounded on that tinny upright piano. I feel the uneven weighting of the keys, remember how difficult it was to achieve the voicing – the balance of melody and harmony – I wanted.” She reflects on the piece she played, and its impact on a patient.



Selection 1: “Increasing Rates of Youth and Adolescent Suicide in Canadian Women”

Sara Zulyniak, Kathryn Wiens, Andrew G. M. Bulloch, et al.

The Canadian Journal of Psychiatry, 17 May 2021  Online First


Suicide affects all age groups. The highest rates of suicide in Canada are reported in ages 45 to 59, and suicide is the second leading cause of death in ages 15 to 34. The last national analysis of Canadian suicide and self-harm trends reported a decrease in total suicide rate (using combined sex, age-standardized rates) from 1979 to 2012. However, this trend did not apply to both sexes equally, with female suicide rates remaining relatively consistent from 1979 to 2012 in comparison to decreasing male rates. Further, the prevalence of suicidality (ideation, plans and attempts) has increased among young adult females recently.These data indicate suicidality and self-harm are increasing in females and urge further analysis of trends in recent sex-specific suicide rates in Canada. This analysis examines trends in sex-specific suicide rates from 2000 to 2018.

So begins a research letter by Zulyniak et al.

Here’s what they did:

  • The authors drew on Statistics Canada mortality and mid-year population data from 2000 to 2018.
  • The number of deaths by “intentional self-harm” were calculated by 10-year age groups and gender.

Here’s what they found:

  • “For each year since 2000, the suicide rate has increased by 0.09 deaths per 100 000 females aged 10 to 19…”
  • “In females aged 20 to 29, every year from 2000, the rate of suicide has increased by 0.13 deaths…”
  • “In comparison, the data for males in ages 20 to 29 showed significantly decreasing rates…”


A few thoughts:

  1. Wow.
  1. The authors note: “These results indicate a worrisome trend among youth and adolescent females, supplementing past Canadian analyses that have observed steadying female suicide rates and decreasing rates of suicide among males.”
  1. What to make of this trend?
  1. More importantly, what to do about it? The authors argue that more research is needed: “In order to guide public health actions, further research should attempt to classify rates in relation to methods of self-harm and suicide. Prior studies have found that suffocation is an increasingly prevalent method of suicide in both males and females, in comparison to firearm use and poisoning.”

The research letter can be found here:


Selection 2: “Primary Care and Access to Mental Health Consultations among Immigrants and Nonimmigrants with Mood or Anxiety Disorders”

Joanna Marie B. Rivera, Joseph H. Puyat, Mei-ling Wiedmeyer, et al.

The Canadian Journal of Psychiatry, June 2021


Mood and anxiety disorders affect 1 in 10 Canadians aged 18 years and older and can have a major impact on basic activities and ability to work. Almost one quarter of Canadians with mood or anxiety disorders report that they did not access mental health services within the previous 12 months. Immigrants to Canada and members of racialized communities may be even less likely to access mental health services and may experience barriers including cost, language, culturally inappropriate services, lack of awareness of services, and transportation issues.

In Canada, most people with anxiety and depression access services through primary care, and primary care plays a gatekeeping role in accessing specialized mental health services. A strong, accessible system of primary care may improve access to mental health services, especially for recent immigrants, while gaps in primary care may further exacerbate challenges in accessing mental health services. Evidence suggests that patterns of primary care service use differ between immigrants and nonimmigrants in Canada. Immigrants report unmet care needs and may underuse health care services due to not knowing where to access health care services, the perception that they would receive inadequate care, transportation barriers, and language barriers. Immigrants are also less likely to have a regular doctor and more likely to visit urgent care or walk-in clinics or emergency departments for care. Furthermore, emergency departments may be viewed as a more convenient place of care, and immigrant children appear more likely to receive mental health care for the first time in the emergency department. Team-based primary care models, including community health centers (CHCs), may offer better access to mental health services through co-location of specialized mental health providers, greater capacity for referral and coordination of care, and better supports for primary care providers to manage common mental disorders.

So begins a paper by Rivera et al.

Here’s what they did:

  • They drew data from Statistic Canada’s Canadian Community Health Survey (CCHS), an annual survey, and included respondents who had been previously diagnosed with a mood or anxiety disorder.
  • They considered whether the respondent had a mental health consultation in the past year, the type of provider who did the consultation, and their access to primary care.
  • Statistical analyses were done, including “multivariable logistic regression to determine whether differences in mental health consultations between recent immigrants, longer-term immigrants, and nonimmigrants persist, adjusting for covariates…”

Here’s what they found:

  • 14,378 respondents with mood or anxiety disorders were included in the analysis.
  • “Higher percentages of recent and longer-term immigrants see a doctor in solo practice, and a higher percentage of recent immigrants use walk-in clinics as a usual place of care.”
  • “Compared with people whose usual place of care was a community health center or interdisciplinary team, adjusted odds of a mental health consultation were significantly lower for people whose usual place of care was a solo practice doctor’s office (AOR = 0.71…), a walk-in clinic (AOR = 0.75…), outpatient clinic/other place (AOR = 0.72…), and lowest among people reporting no usual place other than the emergency room (AOR = 0.59…).”
  • “Differences in access to mental health consultations by usual place of primary care were greatest among immigrants, especially recent immigrants.”

“Our findings confirm that there is a gap in access to mental health services among immigrants with mood and/or anxiety disorders compared to nonimmigrants. Even in fully adjusted models, recent and longer-term immigrants were less likely to have a mental health consultation compared with nonimmigrants. While multiple variables are associated with having reported a mental health consultation, people with access to team-based primary care are more likely to report mental health consultations, and this is especially true for immigrants. Unfortunately, immigrants, and especially recent immigrants, are more likely to receive primary care from a solo practice or walk-in clinic.”

A few thoughts:

  1. This is a good paper.
  1. We often speak about problems with access to care, but rarely do we focus on primary care. In fact, this study suggests that for many immigrants, the problem starts at this level.
  1. And access issues for immigrants are more profound. The authors note: “Findings are likely shaped by what services are publicly covered, as family doctor and psychiatrist services are available free of charge for individuals with provincial insurance in all provinces, but services from clinical counsellors, psychologists, or social workers may be more accessible through team-based primary care.”
  1. Ouch.

The full CJP paper can be found here:


Selection 3: Variations on a theme

Rozalyn Chok

CMAJ, 25 May 2021


The facility was far uptown. We all dozed off during the long ride, and by the time the train lurched into the station, we were groggy. Though we were not native New Yorkers, three years in the city was enough to develop that uncanny ability to emerge from sleep just before missing your stop. We were a motley ensemble: myself (a pianist), two dancers, a violinist and a percussionist. As Juilliard students, we received a small stipend to give performances at health care facilities such as nursing homes, hospices or, in this case, a psychiatric hospital.

On this day, I had a new piece I had just memorized and wanted to try out. It was Robert Schumann’s Geistervariationen (Ghost Variations), a work built on a central melodic theme with subsequent variations presenting it in different guises.

So begins a paper by Dr. Chok.

The pianist turned paediatric resident notes the mental health struggles of the composer:

“Schumann is best known for his piano compositions and collections of Lieder, German art song for voice and piano. Unfortunately, Schumann struggled with mental illness that began in his early twenties. He had periods of severe depression that alternated with phases of ‘exaltation,’ consistent with what we now believe was bipolar disorder. His musical productivity mirrored his mood changes. Manic periods were marked by feverish output; in 1840, the so-called ‘Year of Song,’ he composed 140 songs. In contrast, in the vice of a crippling depression, Schumann did not complete a single work in 1844…

“Schumann awoke from sleep on the night of Feb. 17, 1854, and scribbled down a melody that was ‘dictated by the angels.’ It was, in fact, a melody that Schumann himself had written and used in earlier works. The simple, hymn-like motif became the theme of the Geistervariationen. By the next morning, he was agitated, and the angelic voices turned into the ‘hideous music’ of ‘tigers and hyenas.’ In this space between lucidity and torment, Schumann composed five variations on the angelic theme. The work contains glimpses of Schumann’s brilliance, but at other points feels rudimentary in its construction… On Feb. 27, 1854, Schumann abruptly stopped working on the manuscript, left his home and attempted suicide by leaping from a bridge into the freezing Rhine.”

She then discusses the performance: “I had never been in a psychiatric hospital and wasn’t sure what to expect.”

“The audience, younger than our typical crowd, had gathered in a semicircle facing a makeshift stage. Most were dressed in baggy, beige hospital-issue clothing. Some had the repetitive lips-smacking, tongue-thrusting movements I now know as tardive dyskinesia. My eye was drawn to a woman with unkempt grey hair who looked to be in her sixties, sitting stone-like in a wheelchair, expressionless. Her eyes remained fixed straight ahead even as my group members performed a dance warm-up in front of her.”

“That’s when I noticed the silver-haired woman again. She still sat motionless, but her eyes had a sheen. A trail of tears traced its way down her wrinkled cheeks and left dark stains on her tan hospital clothing. In my memory, her eyes found mine briefly, then returned to centre. I still don’t know whether that actually happened or whether it was a figment of my desire to believe we had made some sort of connection.”

The author is left with unanswered questions:

“I wanted to know more about her life story, her diagnoses. How did she come to be trapped inside herself, human yet unable or unwilling to express the things that made her so? Could it be just coincidence that the Geistervariationen had seemingly awakened something within her? Perhaps it was a purely physiologic response – the frequency of the music setting off a cascade of synaptic firing or triggering the release of some neurotransmitter. Or perhaps a young composer’s anguish, preserved in a set of theme and variations, had somehow traversed time and space to reach a woman oppressed by emotional suffering.”

pianoDr. Rozalyn Chok

A few thoughts:

  1. This is a beautiful essay.
  1. She notes that this piece is the composer’s last. “Schumann sent the completed manuscript to Clara the day after his suicide attempt. Four days later, he voluntarily entered the asylum where he would spend the remaining two years of his life. The Geistervariationen is his last known composition.”
  1. Interested in hearing it? You can listen to Dr. Chok play the piece here:

The full paper can be found here:


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