From the Editor

Welcome 2024.

It’s our tradition that we begin the New Year by reviewing the best of the past one.

So, this week, we consider the best papers of 2023.

Of course, the list is hardly definitive. The 10 papers selected are interesting and relevant to your clinical work. But another 10 – or 20 or 30 – could have been picked. 

These papers cover everything from AI to virtual care. The one common thread: they are all clinically relevant. 

And I name a person of the year, a remarkable advocate.


“The lived experience of depression: a bottom-up review co-written by experts by experience and academics”

Paolo Fusar-Poli, Andrés Estradé, Giovanni Stanghellini, et al.

World Psychiatry, October 2023

We often describe depression with a list of symptoms (drawn from the DSM-5, for instance), but how do people with MDD experience their illness?

Fusar-Poli et al. tap experts and those with lived experience, drawing from multiple studies and other sources, and involving several steps. The resulting World Psychiatry paper is impressive and unique, finding various themes. Those with depression spoke of many things, including a lack of energy. Commented one: “My vital energy is depleted.”

If you read one paper on depression this year, make it the Fusar-Poli et al. effort.

“Written Exposure Therapy vs Prolonged Exposure Therapy in the Treatment of Posttraumatic Stress Disorder: A Randomized Clinical Trial”

Denise M. Sloan, Brian P. Marx, Ron Acierno, et al.

JAMA Psychiatry, 23 August 2023

Psychotherapies for PTSD like Prolonged Exposure Therapy (or PE) are resource intense and demanding of patients – and have, thus, high drop-out rates. 

In this RCT, Sloan et al. compare PE to Written Exposure Therapy (or WET), “an emerging alternative” that requires less therapist and patient time. They find: WET was non-inferior to Prolonged Exposure Therapy and had significantly less attrition.

This JAMA Psychiatry study suggests that less is sometimes more.

“Comparing Physician and Artificial Intelligence Chatbot Responses to Patient Questions Posted to a Public Social Media Forum”

John W. Ayers, Adam Poliak, Mark Dredze, et al.​

JAMA Internal Medicine, June 2023

To borrow a joke from Dr. Derek Tracy in The British Journal of Psychiatry, AI will be the end of us or the beginning of a new era of prosperity. But let’s set aside the big (and contradictory) predictions and consider the implications for clinical work.

In this short paper, Ayers et al. compare physician and AI-generated answers to some common medical questions, with a blinded panel of docs judging the responses in terms of quality and empathy. Evaluators preferred the AI-generated responses over physician ones by a ratio of 4 to 1. 

Whoa – but don’t weigh re-training just yet. Instead think of the possibilities: AI may be a way to help with paperwork and the demands of EMRs.

“Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression”

Amit Anand, Sanjay J. Mathew, Gerard Sanacora, et al.

The New England Journal of Medicine, 24 May 2023

In the past few years, ketamine has created a buzz as a new treatment for those with depression. But how does it compare to ECT, arguably the gold standard intervention? 

In this New England Journal of Medicine paper, Anand and co-authors describe a noninferiority study directly comparing the two treatments. “This randomized trial evaluating the comparative effectiveness of ketamine and ECT in patients with treatment-resistant depression without psychosis showed noninferiority of ketamine to ECT…” It’s a big result for ketamine – though I note that the ECT was a bit underutilized in the study. 

Here’s a prediction for 2024: expect the ketamine buzz to continue.

“Comparison of mental health symptoms before and during the covid-19 pandemic: evidence from a systematic review and meta-analysis of 134 cohorts”

Ying Sun, Yin Wu, Suiqiong Fan, et al.

The BMJ, 8 March 2023

Early in the pandemic, the predictions were dire, with some experts saying that there would be a mental health tsunami. 

Sun et al. offer a systematic review and meta-analysis, pulling together 124 cohorts in a paper for The BMJ. They don’t find much evidence of a change in mental health for the general population. “Most symptom change estimates for general mental health, anxiety symptoms, and depression symptoms were close to zero and not statistically significant, and significant changes were of minimal to small magnitudes…” Sun et al. note that certain sub-populations were more effected.

Telepsychiatry versus face-to-face treatment: systematic review and meta-analysis of randomised controlled trials

Katsuhiko Hagi, Shunya Kurokawa, Akihiro Takamiya, et al.

The British Journal of Psychiatry, September 2023 

With the pandemic, so much mental health care switched to virtual. As we move past COVID-19, when is telepsychiatry appropriate and when isn’t it?

In this impressive study, Hagi et al. analyzed 32 papers, involving 3 600 patients, across 11 mental illnesses. For the most part, telepsychiatry matched face-to-face treatment, though the authors find: “Telepsychiatry was significantly more effective than face-to-face treatment for improving depressive symptoms (k = 6, n = 561…). On the other hand, for eating disorders, face-to-face treatment was significantly more effective than telepsychiatry for improving symptoms, based on one study (n = 128…).” 

So – no need then to retire the webcam just yet.

“Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients”

Pim Cuijpers, Clara Miguel, Mathias Harrer, et al.

World Psychiatry, February 2023

Cognitive behavioural therapy is decades old, but controversies continue. Controversy 1: Does it really work better than control? Controversy 2: Is CBT superior to other psychotherapies? Controversy 3: Does it beat medication management? Controversy 4: Are combinations of meds and CBT best? 

Pim Cuijpers (of the Vrije Universiteit Amsterdam) and his co-authors offer a new meta-analysis including more than 400 randomized trials with almost 53 000 patients (yes, you read that correctly). In this World Psychiatry paper, they find interesting results. Controversy 1: CBT has a moderate to large effect size compared to control. Controversy 2: CBT may or may not be superior to other psychotherapies. Controversy 3: CBT bests medications. Controversy 4: CBT in combination with meds may or maybe not get better outcomes than CBT on its own.

“Clinical Outcomes of Magnetic Seizure Therapy vs Electroconvulsive Therapy for Major Depressive Episode: A Randomized Clinical Trial”

Zhi-De Deng, Bruce Luber, Shawn M. McClintock, et al.

JAMA Psychiatry, 6 December 2023  Online First

ECT is highly effective – it’s also connected with problems, including memory impairment.

Could magnetic seizure therapy (or MST) provide an alternative? In a study where 73 patients with depression were given ECT or MST, Deng at al. find similar results.“This randomized clinical trial found that the efficacy of MST was indistinguishable from that of ultrabrief pulse [right unilateral] ECT, the safest form of ECT currently available.” But cognitive issues were much less common with MST. 

Could MST be the new ECT?

“Medical Assistance in Dying for Mental Illness as a Sole Underlying Medical Condition and Its Relationship to Suicide: A Qualitative Lived Experience-Engaged Study”

Lisa D. Hawke, Hamer Bastidas-Bilbao, Vivien Cappe, et al.

The Canadian Journal of Psychiatry, 26 October 2023  Online First

In March, medical assistance in dying will be expanded in Canada to include those with mental illness. Many in psychiatry have strong opinions on this topic.

But what do patients and family members think? How does it relate to their views of suicide in general? In a paper for The Canadian Journal of Psychiatry, Hawke et al. describe a qualitative analysis, interviewing 30 people with mental illness and 25 family members. “Participants acknowledge the intersections between MAiD [medical assistance in dying when the sole underlying medical condition is mental illness] and suicidality and the benefits of [it] as a more dignified way of ending suffering, but also the inherent complexity of considering [such] requests in the context of suicidality.”

This paper offers an important contribution to the debate.

“Eight ‘truths’ about suicide”

Rachel Gibbons

BJPsych Bulletin, 14 September 2023

Over our careers, most of us lose patients to suicide. In this personal and thoughtful review, Dr. Rachel Gibbons writes about losses that she has experienced as a psychiatrist, and then mulls eight “truths” about suicide. The resulting paper is thus personal and yet offers a good review of relevant literature.

“In research we conducted, around two-thirds of psychiatrists and other clinicians felt it was their job to predict suicide. Our fantasy that we can do this, and our fear that we can’t, becomes a constant preoccupation in our work, distracts us from providing therapeutic care and closes our hearts to those in distress.”

Rachel Gibbons

The paper is a must read.

The Person of the Year

We shouldn’t even know his name. He should be busy with his life, and not busy with his advocacy. But his brother’s illness and tragic death changed all that.

In selecting a Person of the Year, I consider people who have made contributions to scholarship or clinical work or academic life. Past selections have included a former Minister of Finance, the CEO of a major hospital, and the former chair of a university department of psychiatry.

This year, I choose Yusuf Faqiri, whose brother died in jail, clearly suffering from a psychiatric emergency. 

Faqiri has proven to be a tireless advocate for his brother who should have been in a Toronto hospital and not in a Lindsay correctional institution. There are real villains in this story, which includes lies, deception, a cover-up, and total incompetence. But there is a hero. Because of his efforts, there was an inquest and an important list of recommendations.

Yusuf Faqiri

In The Globe and Mail, Faqiri writes: 

“My brother is dead. But this inquest has enabled me to fulfill my promise to my brother: to find the truth. It took Canadians into the darkness of a prison in their own country where a citizen was abandoned, ill, bound and beaten by guards. The recommendations of an inquest are not binding, but some good may still come from Soli’s life if they are adopted.”

We do know his name – and thank goodness for Faqiri’s efforts.

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