From the Editor

This week, we have three selections.

In the first, we consider suicide and schizophrenia. In a new JAMA Psychiatry paper, Dr. Mark Olfson (of Columbia University) and his co-authors do a cohort study across life-span, tapping a massive database. They find: “the risk of suicide was higher compared with the general US population and was highest among those aged 18 to 34 years and lowest among those 65 years and older.” The authors see clear clinical implications: “These findings suggest that suicide prevention efforts for individuals with schizophrenia should include a focus on younger adults with suicidal symptoms and substance use disorders.”

In the second selection, we consider transgender-inclusive care, looking at a new Quick Takes podcast. Drs. June Lam and Alex Abramovich (both of the University of Toronto) comment on caring for members of this population. “Trans individuals are medically underserved and experience, poor mental health outcomes, high rates of disease burden – compared to cisgender individuals.”


Finally, in our third selection from The New York Times, reporter Karen Brown writes about chatbots for psychotherapy, focusing on Woebot. The writer quotes psychologist Alison Darcy about the potential of these conversational agents: “If we can deliver some of the things that the human can deliver, then we actually can create something that’s truly scalable, that has the capability to reduce the incidence of suffering in the population.”



Selection 1: “Suicide Risk in Medicare Patients With Schizophrenia Across the Life Span”

Mark Olfson, T. Scott Stroup, Cecilia Huang, et al.

JAMA Psychiatry, 26 May 2021  Online First


Suicide is a leading cause of mortality among people with schizophrenia. In contrast to the general population, in which suicide risk increases through middle age, suicide risk in schizophrenia is high in young adults. In a Finnish study, the annual suicide rate was roughly 3 times higher during the first 5 years after first hospitalization than after 10 to 16 years. A meta-analysis further found that suicide rates were approximately 3 times higher for patients with schizophrenia after illness onset than at any point during their illness. However, few studies have directly evaluated suicide risk of patients with schizophrenia across the life span to inform suicide risk surveillance and prevention by patient age.

Most research on suicide in schizophrenia has focused on young adults, and relatively little is known about suicide risk in older groups. A Danish cohort study including 5658 men and 3498 women with schizophrenia recruited as inpatients found that the suicide rate per 100 000 person-years for men declined from 883 for patients 29 years or younger to 429 for patients aged 60 to 69 years and increased to 1330 for patients aged 70 to 79 years and to 3230 for patients 80 years or older. No suicide deaths were observed among women with schizophrenia 70 years or older. A subsequent Danish study reported suicide rates per 100 000 person-years of 218 for men and women aged 50 to 69 years and 107 for men and 68 for women 70 years or older. A study from rural China that followed up 510 patients with schizophrenia for 10 years also reported declining suicide risk with advancing patient age.

Beyond uncertainty concerning suicide rates across the life span in schizophrenia, much remains to be learned about suicide risk factors at different ages.

So begins a paper by Olfson et al.

Here’s what they did:

  • They drew from Medicare data from January 1, 2007, to December 31, 2016.
  • Five national retrospective longitudinal cohorts of patients with schizophrenia were identified by age (18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older).
  • Death record information was obtained from the National Death Index.
  • Statistical analyses were done.

Here’s what they found:

  • “The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths.”
  • “The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54…).”
  • Suicide rates were significantly higher for men (aHR, 1.44).
  • By diagnosis: those with depressive (aHR, 1.32), anxiety (aHR, 1.15), and drug use disorders (aHR, 1.55).
  • By demographics: lower for Hispanic patients (aHR, 0.66) or Black patients (aHR, 0.29) than White patients; the suicide rate declined with age, from 141.95 (SMR, 10.19) for patients aged 18 to 34 years to 24.01 (SMR, 1.53) for the elderly.


A few thoughts:

  1. This is a good study.
  1. It’s also a very impressive study, involving more than 650,000 people with schizophrenia; the authors estimate that the data covers roughly half of those in the United States with this psychotic disorder. Wow.
  1. The findings aren’t surprising, and are similar to other (much smaller) studies.
  1. Like all studies, there are limitations. The authors note several, including that the diagnosis wasn’t validated but drawn from the database.
  1. Clinical implications? The authors see several: “Suicide prevention in schizophrenia might include expanding access to clozapine, treating comorbid drug use disorders, increasing availability of early psychosis detection programs, suicide risk screening in inpatient settings, and using cognitive behavioral therapy to help patients with schizophrenia resist command hallucinations and reduce their suicidal symptoms.”
  1. For those of us who see people with schizophrenia, this advice seems reasonable and evidence-based. The paper suggests: be particularly diligent when working with younger patients.

The JAMA Psychiatry paper can be found here:


Selection 2: “What every physician should know about transgender-inclusive care”

June Lam and Alex Abramovich

Quick Takes, 9 June 2021


It’s Pride Month. In this podcast, we consider transgender-inclusive care. Transgender people represent 0.5% of the population. Studies show high rates of depression and suicide in the trans community. In this episode of Quick Takes, I speak to two experts: Dr. Alex Abramovich, an independent scientist at CAMH, and Dr. June Lam, a psychiatrist at CAMH, about how to support our transgender patients.

We discuss things to be mindful of – such as asking people what pronouns they go by (not which ones they prefer) and taking accurate notes to ensure that you address your patient by their gender identity and name. We discuss “othering,” the need for inclusive data collection tools to help further research, and psychotropic medication considerations for those on hormone therapy.

I highlight from the discussion:

On pronouns

Alex Abramovich: “When you ask someone about their preferred pronouns, it sounds like you have a preference. Your preference might be he or she, but it’s not a preference. It’s what we go by. I go by he and him. I don’t prefer to go by he and him. That is what I go by.”

On definitions

June Lam: “Transgender people are people whose gender identity is different than the sex they were assigned at birth. Non-binary people are people whose gender is not part of the rigid gender binary – so they may not identify as a man or a woman; they identify outside of that binary within a spectrum. Cisgender refers to people whose gender identity is consistent with the sex they were assigned at birth.”

On outcomes

Alex Abramovich: “Research has consistently shown that trans individuals are medically underserved and experience poor mental health outcomes and high rates of disease burden – compared to cisgender individuals. So, for example, we know that trans individuals experience significantly higher rates of suicidality, substance use, depression and anxiety. And this isn’t because a person identifies as trans, but it rather has to do with social stigma, with identity-based rejection.”

On caring for transgender people

June Lam: “A first tip: introduce your own pronouns. I try to that with everyone and start by saying my name is June Lam or Dr. Lam, I’m a psychiatrist, and I use he/him pronouns. Just to signal that you can’t assume someone’s pronouns or gender just by looking at someone and to normalize that it’s OK to have conversations around pronouns… I also try to ask people about their pronouns.

“I think it’s important to validate experiences of oppression and transphobia that people experience. One main tip: if someone presents either in the acute setting or as an outpatient with depression, anxiety, and they happen to be trans, it’s important to ask what they think contributes to their mental health symptoms – and to validate those experiences.”

(The above answers were edited for length.)


The podcast can be found here, and is just over 27 minutes long:


Selection 3: “Something Bothering You? Tell It to Woebot.”

Karen Brown

The New York Times, 1 June 2021


“I understand that you’re experiencing a relationship problem, is that right?”


“Okay, I’m delighted that you want to work on this K. I’ve good and bad news for you… Which do you want to hear first?”

Good news.

“The good news is, I have very powerful skills that I can teach you! These skills have really helped a lot of people build better relationships.”

And the bad news?

“The bad news is that you would have to be willing to accept 100% of the responsibility for changing the relationship.”


“Because you’re only ever going to be able to have control over your part of it.”

This conversation may sound like a fairly typical therapist’s session, but in this case, it was directed by Woebot, a therapeutic chatbot, with the psychiatrist’s couch swapped for a smartphone screen.

So begins an article by Brown.

She notes the need for more mental health care. “At the same time, the federal government warns of a critical shortage of therapists and psychiatrists. According to the advocacy group Mental Health America, almost 60 percent of those with mental illness last year did not get treatment.”

The essay quotes the psychologist behind Woebot, Alison Darcy, as well as others.

The writer makes several points:

  • “Woebot, which was introduced in 2017, is one of only a handful of apps that use artificial intelligence to deploy the principles of cognitive behavioral therapy, a common technique used to treat anxiety and depression. Woebot aims to use natural language processing and learned responses to mimic conversation, remember past sessions and deliver advice around sleep, worry and stress.”
  • “Because cognitive behavioral therapy is structured and skill-oriented, many mental health experts think it can be employed, at least in part, by algorithm.”
  • “One advantage of an artificial therapist – or, as Dr. Darcy calls it, a ‘relational agent’ — is 24-hour-a-day access. Very few human therapists answer their phone during a 2 a.m. panic attack, as Dr. Darcy pointed out. ‘I think people have probably underestimated the power of being able to engage in a therapeutic technique in the moment that you need to,’ she said.”

The article includes criticism of chatbots: “John Torous, director of digital psychiatry for Beth Israel Deaconess Medical Center in Boston, said therapeutic bots might be promising, but he’s worried they are being rolled out too soon, before the technology has caught up to the psychiatry.”

Dr. Torous is quoted: “If you deliver C.B.T. in these bite-size parts, how much exposure to bite-size parts equals the original?  We don’t have a good way to predict who’s going to respond to them or not – or who it’s good or bad for.”

A few thoughts:

  1. This is an interesting article.
  1. And, of course, the topic itself is very interesting. Given the incredible need for mental health care, can AI-infused apps like Woebot offer more access for our patients?
  1. The article mentions the literature but doesn’t exactly do an exhaustive review. In a recent paper, Valdyam et al. review several papers and find that users had a generally good experience. That paper was considered in a past Reading, which can be found here:

  1. It’s cool but is it therapy?
  1. Would Woebot and other conversational agents be appealing to special populations? For some, Woebot’s lack of humanity may prove attractive, perhaps including some who have problems on the autism spectrum.
  1. AI-infused psychotherapy may not be a solution to all access issues, but could it be part of the solution? Darcy makes the case: “It’s like saying if every time you’re hungry, you must go to a Michelin star restaurant, when actually a sandwich is going to be OK. Woebot is a sandwich. A very good sandwich.”

The full New York Times article can be found here:


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