From the Editor

In the first weeks of the pandemic, mental health services underwent rapid transformation. The webcam became an indispensable component of psychiatric practice.

What’s happened since the lockdowns? In a new paper for JAMA Psychiatry, Dr. Mark Olfson (of Columbia University) and his colleagues look at outpatient services in the United States. They drew on US survey data, analyzing the use of telemental health, hydrid, and in-person care. “The findings of this cross-sectional study indicate that telehealth has become a common means of receiving outpatient mental health care in the US, especially for resourced patients with less serious psychological distress who receive psychotherapy from mental health specialists.” We consider the paper and its implications.

Can semaglutide help those with schizophrenia? In the second selection, from JAMA Psychiatry, Marie R. Sass (of the Capitol Region of Denmark) and her co-authors report on an RCT where 104 participants received a glucagon-like peptide 1 receptor agonists or placebo, focusing on individuals with early-stage glycemic dysregulation. “Results of this randomized clinical trial show that adjunctive semaglutide significantly improved glycemic control and weight outcomes in individuals with schizophrenia spectrum disorders.” 

Finally, Drs. David E. Freedman and Anthony Feinstein (both of the University of Toronto) write about multiple sclerosis and depression for The Canadian Journal of Psychiatry. In a practical paper, they discuss therapy, medications, and more. “Depression is a manageable contributor to increased morbidity and mortality in people with MS.”

DG

Selection 1: “Telemental Health, Hybrid, and In-Person Outpatient Mental Health Care in the US”

Mark Olfson, Chandler McClellan, Samuel H. Zuvekas, et al.

JAMA Psychiatry, 26 November 2025  Online First

In response to social distancing measures during the COVID-19 pandemic, telemental health care rapidly expanded in US. There was an increase in outpatient mental health treatment facilities providing telehealth and in telemental health visits. While telemental health care can save time, overcome transportation barriers, and provide greater confidentiality than in-person care, concern developed that telehealth may not been equally accessible to all patients. Variation within and between public and private third-party coverage for telemental health, a lack of broadband access in some low income rural communities, and deficits in digital literacy skills can contribute to inequities in telemental health care. According to a review, telemental health care is disproportionately accessed by urban, young adult, and White patients compared to their rural, older adult, and Black counterparts. Some clinicians also report their patients with serious mental illnesses have difficulties accessing telemental health.

Several health care entities have provided data comparing patients receiving telemental health and in-person care. However, little is known about the national sociodemographic and clinical distribution of adult mental health outpatients who receive only telemental health care, a hybrid combination of telemental health and in-person care, or only in-person mental health care.

So begins a paper by Olfson et al.

Here’s what they did:

  • They conducted a “cross-sectional analysis of all telehealth, hybrid, and all in-person mental health care by adults (aged ≥18 years) in the 2021-2022 Medical Expenditure Panel Survey.” The MEPS, which include interviews, are “nationally representative surveys of the US civilian noninstitutionalized population, conducted by the Agency for Healthcare Research and Quality.”
  • They focused on outpatient care, including visits with psychiatrists or allied health professionals, as well as psychotherapy. 
  • Care could be delivered in person, by telephone, or by video.
  • Data were analyzed from January to August 2025.
  • Primary outcome: “Average annual percentages of adult mental health outpatients who used all telemental health care, hybrid, and all in-person mental health care were calculated overall and stratified by sociodemographic and clinical characteristics.”

Here’s what they found:

  • There were 4 720 participants.
  • Demographics. Most were female (63.7%) and younger (47.4% were aged 18-44 years). 
  • Care. 50.6% received exclusively in-person care; 27.8% received exclusively telemental health care; 21.5% received hybrid care. 
  • Age and all telemental healthcare. The percentage was higher for those who were younger (aged 18-44 years; 31.7%) than middle age (aged 45-64 years; 24.2%) or older (aged ≥65 years; 19.4%).
  • Education and all telemental healthcare. The percentage was higher for those who completed high school (23.1%) and college (34.5%) than those without a high school diploma (19.9%). 
  • Income and all telemental healthcare. The percentage was higher for patients with incomes >400% federal poverty level (33.8%) than those with lower incomes (range, 20.6% to 23.7%). 
  • Geography and all telemental healthcare. The percentage was higher from those from urban (29.2%) rather than rural (14.0%) residence.
  • Distress. Those with less than moderate distress (29.2%) were also more likely than those with serious distress (21.2%) to use all telemental health.

A few thoughts:

1. This is a good paper, with a solid dataset, published in a major journal.

2. The main findings in a sentence: those receiving telemental health services tended to be younger, more educated, more affluent, more urban, and less distressed.

3. The paper clarifies what is already apparent: mental health services have changed profoundly.

4. Of course, the paper didn’t answer some basic questions. Was the care appropriate? Effective? Have inequities increased – or were more in-person services focused on those who needed them?

5. Like all studies, there are limitations. The authors note several, including with the survey itself. “MEPS uses household respondent recall and diaries that could underestimate mental health care use.”

The full JAMA Psychiatry paper can be found here:

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2841438

Selection 2: “Semaglutide and Early-Stage Metabolic Abnormalities in Individuals With Schizophrenia Spectrum Disorders: A Randomized Clinical Trial”

Marie R. Sass, Mette Kruse Klausen, Christine R. Schwarz, et al.

JAMA Psychiatry, 3 December 2025  Online First

Individuals with schizophrenia have approximately 2- to 3-fold higher mortality and 15-year shorter life expectancy, largely due to cardiovascular disease. Obesity, dysglycemia, and type 2 diabetes are common, driven by lifestyle factors and genetic alterations affecting insulin, glucose, and inflammatory pathways. Although antipsychotic medications play a central role in managing schizophrenia, they are associated with substantial weight gain, metabolic dysregulation, and increased risk of diabetes, further contributing to elevated cardiovascular risk. The second-generation antipsychotics (SGAs) clozapine and olanzapine confer the greatest metabolic risk, even after relatively short durations of treatment. Switching antipsychotic medications or lifestyle modifications often show limited success… The most commonly used add-on treatments to manage weight gain from SGAs have been topiramate and metformin. However, their impact is modest, typically resulting in a weight loss of only 3 to 4 kg over 12 to 24 weeks… These findings emphasize the urgent need for more effective strategies to complement antipsychotic therapy – approaches that can prevent, reduce, or reverse weight gain while achieving meaningful glycemic improvements… Beyond their metabolic effects, GLP-1RAs demonstrate cardioprotective properties and emerging neurobiological benefits, including neuroprotection, modulation of reward pathways, and potential cognitive improvements… Data on the early use of long-acting GLP-1RAs for preventing metabolic deterioration in individuals who recently began treatment with clozapine or olanzapine remains largely unexplored.

Here’s what they did:

  • They conducted a “multicenter, double-blind, placebo-controlled, randomized clinical trial.” 
  • Participants were enrolled from three sites in Denmark. 
  • Inclusion criteria: individuals were aged 18 to 65 years; they had schizophrenia spectrum disorders; clozapine or olanzapine treatment initiated within the past five years; they had early-stage glycemic dysregulation (hemoglobin A1c, 5.4%-7.4%) and were not receiving antidiabetic therapy.
  • Participants received a weekly subcutaneous semaglutide (1 mg) or a matching placebo, administered adjunctively to SGA therapy for 26 weeks.
  • Primary outcome: change in HbA1c level from baseline to week 26. 

Here’s what they found:

  • Of 104 individuals screened, 73 were randomized and 78% completed the trial. 
  • Demographics. The mean age was 35 years; most were female (65%); the mean body mass index was 36.1. 
  • Reduction of HbA1c. “At week 26, semaglutide significantly it compared with placebo (mean difference, −0.25%); 43% of participants (12 of 28) treated with semaglutide achieved low-risk HbA1c levels (<5.4%) vs 3% with placebo.”
  • Secondary outcomes. “Greater reductions in body weight (−9.2 kg…), waist circumference (−7.0 cm…), and fat mass (−6.1 kg…) were observed with semaglutide. No differences in lipid levels, liver function, blood pressure, or psychiatric symptoms were observed.”
  • Safety. “Gastrointestinal adverse effects were the most reported, with similar frequency across treatment groups.”

A few thoughts:

1. This is a good study providing new data on an important issue and published in a major journal.

2. The main finding in a sentence: “In this placebo-controlled randomized clinical trial, 26 weeks of treatment with once-weekly semaglutide (target, 1 mg) significantly improved glycemic control and weight-associated outcomes in individuals with schizophrenia spectrum disorders and early-stage glycemic dysregulation who recently initiated treatment with clozapine or olanzapine.” 

3. Wow. 43% with semaglutide vs. 3% in the placebo group – a big result.

4. Though early, this study adds to a small, growing literature suggesting that GLP-1 RAs are helpful to patients with schizophrenia.

5. Of course, for many of our patients, such medications remain out of reach because of the hesitation of public and private insurers.

6. Like all studies, there are limitations. The authors discuss several, including the small sample size. The pharmaceutical connection of the first author is worth noting.

The full JAMA Psychiatry paper can be found here:

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2842202

Selection 3: “Depression in Multiple Sclerosis: A Clinical Primer for Psychiatrists”

David E. Freedman and Anthony Feinstein

The Canadian Journal of Psychiatry, 18 November 2025  Online First

Multiple sclerosis (MS) is an immune-mediated demyelinating neurological disease that affects approximately 1 in 350 Canadians. Depression is common in people with MS (pwMS) but is often under-recognized and under-treated. It is thus essential for mental health clinicians to be confident in diagnosing and managing depression in the context of MS. Tailored for the practicing psychiatrist, this article provides a clinical primer about depression in MS, focused on its prevalence and impact, assessment, biopsychosocial correlates and management.

So begins a paper by Drs. Freedman and Feinstein.

Prevalence of Depression in Multiple Sclerosis

“Depression is 3 times more common in pwMS than in the general population. The prevalence of depression does not appear to differ according to age or sex. This latter point merits emphasis, considering its contrast with well-described sex differences in depression in the general population. Reasons for this are unclear.”

Correlates of Depression in Multiple Sclerosis

“MS depression is associated with increased lesion volume within a ‘depression network,’ consisting of the prefrontal, retrosplenial, and medial temporal cortices and the ventral tegmental area. Other biological correlates include gray matter atrophy and immunological abnormalities such as elevated pro-inflammatory cytokines. These findings indicate that depressive symptoms are intertwined with neuro-inflammatory and neurodegenerative factors in MS.”

Link Between Depression and Cognitive Dysfunction in Multiple Sclerosis

“Cognitive impairment affects 30% to 90% of pwMS and contributes to reduced quality of life, difficulties with completing activities of daily living, and unemployment. Commonly affected domains include processing speed, memory, learning, and executive function. A recent study demonstrated a link between depression, particularly with comorbid anxiety, and cognitive dysfunction in MS.”

Assessment of Depression in Multiple Sclerosis

“Depressive symptomatology in MS is characterized by increased irritability and a chronic course of symptoms. As part of the clinical assessment, one must consider comorbid symptoms (such as anxiety), the timeline of depressive symptoms in relation to the MS clinical course, and a cognitive assessment. Although cognitive screening is recommended for all pwMS, a comprehensive cognitive evaluation is recommended if there is a positive screen or evidence of cognitive decline. The Montral Cognitive Assessment is not validated in pwMS. The Symbol Digit Modalities Test (SDMT) and the Minimal Assessment of Cognitive Function in MS battery are recommended cognitive screening (for pwMS over age 8) and comprehensive assessments, respectively. For practicing psychiatrists, the SDMT takes 5 minutes to administer and a positive screen indicates the need to refer for comprehensive cognitive evaluation.”

Management of Depression in Multiple Sclerosis

“Cognitive-behavioural therapy (CBT) and mindfulness-based interventions are effective in reducing depressive symptoms in pwMS. CBT may also reduce pain, improve sleep, and foster social connections. A systematic review of 28 qualitative studies of CBT involving clinicians and pwMS suggests potential facilitators of therapy effectiveness. These factors include tailoring therapy to participant needs, financial and online accessibility, involving care partners, and incorporating opportunities for social connections between therapy participants… Few studies have evaluated whether antidepressant medications are effective in pwMS, and mixed findings in small samples limit the clinical application of these data. Nonetheless, antidepressants are widely prescribed to pwMS… Examples of commonly prescribed antidepressants include bupropion (e.g., in pwMS with sexual dysfunction and fatigue), duloxetine (e.g., in those with chronic pain), and sertraline (e.g., in pwMS who need small dose increments due to difficulties with tolerability).”

A few thoughts:

1. This is a clear, concise, and practical paper. 

2. All psychiatrists and learners would benefit from reading it.

3. The examples of different antidepressants are particularly helpful.

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

https://journals.sagepub.com/doi/10.1177/07067437251396765

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