From the Editor

This week, we turn closer to home. All the selections are from The Canadian Journal of Psychiatry. The Canadian connection includes the journal, of course, as well as the data and topics. That said, these topics – suicide, school cellphone restrictions, and irritability – are relevant for those in my home country and elsewhere.

In the first selection, Sara Zulyniak (of the University of Calgary) and her co-authors look at suicide trends in Canada from 2000 to 2024, drawing on Statistics Canada data. “Overall trends and many Canadian age and sex groups have seen declining rates of suicide mortality beginning in 2018, though some young female groups have continued to have increasing rates of suicide from 2000 to 2024.” We consider the paper and its implications.

In the second selection, Kimberley C. Tsujimoto (of the Hospital for Sick Children) and her co-authors analyzed data on the early implementation of school cellphone restrictions in Ontario and the association with screen use and mental health outcomes for children and youth. “We found that greater adherence to school cellphone restrictions was associated with lower social media use, and subsequently fewer depressive and anxiety symptoms.”

In the third selection, Michael Uebel (of The University of Texas at Austin) writes about irritability in depression and anxiety. “Irritability carries information that standard depression scales miss, and that tracking it offers an early, actionable read on whether to continue or modify a treatment.”

DG

Selection 1: “Trends in Canadian Suicide Mortality by Age and Sex From 2000 to 2024”

Sara Zulyniak, Gina Dimitropoulos, Eric C. Chan, and Scott B. Patten

The Canadian Journal of Psychiatry, 10 September 2026  Online First

Previous Canadian suicide analyses have observed overall decreases in age-standardized mortality rates by suicide from 1980 to 2017, though many have identified differential trends by age and sex categorizations. Primarily, suicide trends in Canada appear to be relatively stable, or declining in all age and sex categorizations except adolescent and young adult females, who have seen increases in their rates of suicide through 2018. Age and sex differences have similarly been identified by other global analyses, with an Austrian study showing declines in young male suicide from 2001 to 2014, though young female suicide trends remained stable over this time. On the contrary, suicide in adolescents of both sexes in the United States appears to be increasing from 1999 to 2020, though the degree of increase varied by ethnicity and method…

The previously detailed suicide mortality analyses are supported by evidence that self-reported suicide attempts and suicidal ideation were increasing in young Canadian females prior to the COVID-19 pandemic. Of some concern is whether this trend has continued throughout COVID-19. Broadly, research has indicated that self-harm related emergency visits increased in 2020 when compared to data from 2018 and 2019. Further, when assessing paediatric mental health-related emergency department visits temporally over COVID-19, the largest increase in visits by both sexes was seen during initial school closures, indicating that routine disruptions and feelings of isolation or loneliness associated with the beginning of the pandemic may have driven an increase in poor mental health… Many of these prior analyses focussed on adolescent or young adult samples, meaning recent trends in suicide among middle-aged/older Canadian adults during and beyond the COVID-19 pandemic are relatively unknown.

So begins a paper by Zulyniak et al.

Here’s what they did:

  • The researchers used Statistics Canada mortality data to examine deaths by suicide in Canada from 2000 to 2024.
  • They calculated suicide rates by year, sex, and five-year age groups, using population estimates to account for differences in population size.
  • They used statistical methods (joinpoint regression analysis) to identify changes in suicide rates over time, including when rates began to rise or fall.
  • They examined trends separately by sex and age.
  • They adjusted their statistical tests to account for multiple comparisons.

Here’s what they found:

  • Overall trends. Suicide rates increased from 2007 to 2018, rising by about 1.1% per year. From 2018 to 2024, rates declined by about 4.8% per year. 
  • Sex differences. Similar to the overall trend, male suicide rates declined. The decline after 2018 was particularly evident among younger males. And in the group of males aged 15–19, from 2018 to 2024, the rate declined by an estimated 8.37% per year. (!)
  • Young females. In contrast, suicide rates increased over the full study period among females aged 10–14 and 25–29 years. Rates rose by approximately 2.4% and 1.9% per year, respectively.
  • Age differences. Many age and sex groups experienced declining suicide rates beginning around 2018, while some groups of young females continued to see increases. 

A few thoughts:

1. This is a solid paper providing a fresh look at an important question.

2. The main finding in two words: good news.

3. In recent years, suicide rates have declined across most groups. The Canadian trend is similar to that observed in other high-income countries, including those of the European Union. (The United States appears to be an outlier.)

4. That said, young females weren’t part of that larger trend, including during the COVID-19 pandemic years. Ouch.

5. What explains the decline? What are we doing right? The authors comment on the complexity of these issues. “It is important to note that existing mental disorder may not always be the best predictor of suicide. In fact, one longitudinal study from the US suggested that up to 20% of people with no preceding psychiatric diagnosis had attempted suicide in their lifetime. In a Canadian context, previous evidence has demonstrated that up to two-thirds of Canadians reporting suicidality did not also have depression…” 

6. And how should we understand the concerning trend among young females? Again, the authors note complexity. “Recent trend analyses of Canadian community samples have identified the most prominent increases in poor mental health to have been amongst adolescent and young adult females, pointing to a potential hypothesis explaining why suicide rates in this group have continued to increase. However, the prevalence of mental disorders is not exclusively increasing in young Canadian females, with young males also seeing an increasing prevalence of poor mental health, along with middle-aged/older adults of both sexes, despite suicide declining in these age and sex groups.”

7. Like all studies, there are limitations. The authors note several, including that some suicide deaths may have been misclassified.

8. Suicide has been considered in past Readings. In a recent selection from a podcast interview, Dr. Mark Sinyor (of the University of Toronto) commented on suicide prevention: “There’s no intervention that’s 100%. So nothing gets you all of the way. But does the intervention make a difference and make a huge difference? The answer is yes.” That Reading can be found here: 

https://davidgratzer.com/reading-of-the-week/suicide-papers-from-bjpsych-lancet-psychiatry-and-dr-mark-sinyor-on-prevention/

The full Canadian Journal of Psychiatry paper can be found here:

https://journals.sagepub.com/doi/full/10.1177/07067437261480922

Selection 2: “School Cellphone Restrictions: Preliminary Data Examining the Policy Implications for Child and Youth Mental Health”

Kimberley C. Tsujimoto, Eric Tu, Catherine S. Birken, et al.

The Canadian Journal of Psychiatry, 10 September 2026  Online First

Screen time has been implicated as a contributing factor for worsening student outcomes, including mental health (MH) outcomes, observed in schools in recent years. In the 2024/2025 school year, province-wide school cellphone restrictions were introduced in public schools in Ontario, Canada, with the aim of addressing these concerns. Despite widespread implementation of school cellphone restrictions, however, their effectiveness in reducing screen use and subsequently improving children’s MH is not known.

So begins a research letter by Tsujimoto et al. 

Here’s what they did:

  • They drew on data collected as part of a prospective longitudinal study examining the mental health impacts of the COVID-19 pandemic. Assessments were conducted in spring 2024, immediately before Ontario introduced province-wide school cellphone restrictions, and in fall 2024, following implementation.
  • “Participants completed online questionnaires about school cellphone policies, screen use, and child and youth MH symptoms. Parents and youth were asked whether their school had cellphone policies and if so, when and how cellphones were restricted. Policy adherence was defined by level of enforcement, ranging from 1 =  ‘not at all enforced’ to 5 = ‘always/strictly enforced.’”
  • Screen use was assessed using the average daily time spent watching television, playing video games, using social media, video chatting, and engaging in e-learning. 
  • Mental health outcomes included symptoms of depression, anxiety, irritability, inattention, and hyperactivity, measured using validated instruments.
  • The researchers conducted several statistical analyses, including mediation analyses to examine whether screen use mediated the association between adherence to school cellphone restrictions and mental health outcomes.

Here’s what they found:

  • The study included 624 children and adolescents.
  • Demographics and diagnoses. Participants had a mean age of 14.4 years; 47.1% were female. About half (49.7%) had no mental health or neurodevelopmental disorder diagnosis, while 36.5% had a mental health diagnosis only, 3.8% had a neurodevelopmental diagnosis only, and 9.9% had both. Participants included students in elementary school (18.6%), middle school (38.9%), and high school (42.5%).
  • School policies. Before implementation, 71% of parents and 68% of youth reported that their school had cellphone policies. These figures increased to 86% and 83%, respectively, after implementation. (!) The most common policy restricted cellphone use during class unless permitted by a teacher.
  • Policy enforcement. Reported adherence to cellphone restrictions remained similar before and after implementation. Parents perceived slightly greater enforcement than youth did, with mean ratings of 3.5 before and 3.8 after implementation among parents, compared with 3.0 at both time points among youth, on a five-point scale.
  • Social media use. Greater adherence to school cellphone restrictions was associated with lower social media use. No comparable associations were observed for television, video games, video chatting, or e-learning.
  • Mental health outcomes. Mediation analyses found that greater policy adherence was indirectly associated with fewer depressive symptoms (β = −0.03) and anxiety symptoms (β = −0.01) through lower social media use in adjusted parent-reported models. Similar patterns emerged in youth self-reports, but these analyses were statistically underpowered.

A few thoughts:

1. This is an interesting study, presenting early data.

2. The main finding in three words: it was beneficial.

3. The authors see clinical implications. “The observed indirect effects suggest that well-enforced cellphone restrictions may provide downstream MH benefits by limiting social media use among children and youth.”

4. This is one of several studies that have been published. An NBER paper finds a drop in disciplinary problems, but the impact on test scores was “consistently close to zero.” We should remember that school cellphone restrictions are still in their early days, and all findings should be interpreted with caution.

The full Canadian Journal of Psychiatry letter can be found here:

https://journals.sagepub.com/doi/abs/10.1177/07067437261483882

Selection 3: “Irritability in Adult Depression and Anxiety: A Clinically Useful Signal Amid an Imprecise Construct”

Michael Uebel

The Canadian Journal of Psychiatry, 14 October 2026  Online First

A 34-year-old man presents to his family physician reporting poor sleep and a ‘short fuse.’ He denies sadness. His partner, present at his request, describes weeks of snapping over trivia, withdrawal, and uncharacteristic anger. He works long hours and drinks more than he used to. He does not think he is depressed. He is wrong, and his irritability is the clue.

Irritability is among the most common and least examined features of mood and anxiety disorders in adults. It is near ubiquitous in mood disorders, yet it remains poorly understood and under-researched in adults specifically. Roughly half of adults in a depressive episode report irritability for much of that episode, and its presence marks greater symptom severity, earlier onset, and a more chronic course.

So begins a paper by Uebel.

He notes that irritability correlates with depression and anxiety. “In youth, longitudinal and genetically informed studies show that irritability specifically predicts later depression and anxiety, and that its overlap with depression is largely explained by shared genetic factors.” He turns to genetic research. “Recent genome-wide work in adults points the same way: depressed adults with and without prominent irritability are genetically almost identical and share the same links to anxiety and neuroticism, suggesting irritable depression is not a separate illness but the same condition in a different guise.” There is also a genetic association with anxiety. “Irritability and anxiety appear to share neurobiological origins, plausibly representing approach and avoidance sides of a common threat-response system.”

He offers practical advice: “For the clinician, the takeaway is that irritability in a depressed or anxious adult is part of the illness, not a personality flaw or a comorbid nuisance to be managed separately.”

He sees clinical implications: “In a large, replicated analysis of treatment-seeking outpatients with major depression, early reduction in irritability over the first four weeks of antidepressant treatment predicted higher likelihood of remission and lower likelihood of no meaningful benefit, independent of change in depression severity itself. A one-standard-deviation greater reduction in irritability predicted a 1.73-fold higher likelihood of remission. Improvement in irritability appeared as early as week one and was not fully accounted for by improvement in core depressive symptoms.”

He focuses on men. “Irritability may also flag depression that would otherwise be missed. Men are diagnosed with major depression at roughly half the rate of women, and there is longstanding concern that some men express depression through externalizing features, including anger.”

He makes several management suggestions:

  • Assessment. “Assess irritability at the outset and re-measure it early, because its trajectory in the first weeks is informative.” 
  • Underlying disorder. “Treat the underlying disorder rather than the irritability in isolation; serotonergic antidepressants reduce irritability in depression and premenstrual dysphoric disorder, and the presence of irritability may itself predict responsiveness to specific agents.”
  • Contributors. “Attend to modifiable physiological contributors such as sleep loss, which lower the threshold for irritability and are correctable.”

A few thoughts:

1. This is a practical and thoughtful paper, part of The Canadian Journal of Psychiatry’s Clinician’s Corner series.

2. He returns to the case and notes the importance of recognizing the irritability. “The man in the vignette, who denies sadness but presents irritable, withdrawn, and drinking more, fits this pattern. Treating his irritability as an entry point rather than a distraction may be what gets him diagnosed and treated.”

3. Is irritability overlooked?

4. Other papers in the Clinician’s Corner series are worth reading, including a recent one on chatbots for psychotherapy. (Of course, I may be biased.) That paper can be found here:

https://journals.sagepub.com/doi/10.1177/07067437261461955

The full Canadian Journal of Psychiatry paper can be found here:

https://journals.sagepub.com/doi/10.1177/07067437261490170


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