From the Editor

By international standards, we are doing well. As a percentage of the population, more Canadians are doubly vaccinated than people in many other nations.

But let’s not be too pleased. Some Canadians haven’t received both shots – or even one. As is often the case with public health efforts (think smoking cessation and flu shots), those with mental disorders are harder to reach than the general population.

This week, there are two selections. In the first, Noel T. Brewer (of the University of North Carolina at Chapel Hill) and Neetu Abad (of the US Centers for Disease Control and Prevention) discuss ways that we can boost the rate of vaccination of those with mental health problems in a new JAMA Psychiatry paper. They recognize the unique challenges of reaching this population – and the clear opportunities for mental health professionals. “Although mental health is not the first thing that comes to mind when thinking about vaccination, strategic use of mental health professionals’ expertise could provide new opportunities to encourage COVID-19 vaccination.” We consider the paper and its clinical implications.


In the second selection, also on the theme of nudging our patients to get better outcomes, Gabriela K. Khazanov (of Veterans Affairs) and her co-authors consider using behavioural economics. In this Psychiatric Services paper, they note that Veterans Affairs (VA) “has successfully implemented a financial incentive program aimed at improving psychiatric treatment engagement…”



Selection 1: “Ways That Mental Health Professionals Can Encourage COVID-19 Vaccination”

Noel T. Brewer and Neetu Abad

JAMA Psychiatry, 23 September 2021  Online First


The potential of mental health professionals and agencies to address barriers to COVID-19 vaccination has received inadequate attention. Mental health professionals and teams are trained to use empathy, reflective listening, and cooperative goal setting to help patients address challenges. These professionals actively support patients’ well-being, including their adoption of health behaviors such as receiving COVID-19 vaccination. Around 18% of US adults see a mental health professional in a 12-month period, providing an important opportunity. Such care may be particularly important in the context of greater mental health problems during the pandemic. We briefly review what little is known about mental health and vaccination behavior and then address 3 areas for intervention by mental health professionals, based on the Increasing Vaccination Model (IVM). The model identifies 3 main influences on vaccination behavior: what people think and feel, their social experiences, and opportunities for direct behavior change.

So begins a paper by Brewer and Abad.

They note the challenges of this population: “Mild psychological symptoms and more severe mental illness can interfere with planning and execution of preventive behaviors, likely including vaccination. It is plausible that anxiety could lead people to fixate on possible harms of vaccination; depression may disrupt seeing benefit from and goal setting for vaccination; and attentional limitations could undermine sifting through misinformation about vaccines.”

Drawing on the Increasing Vaccination Model (IVM), they focus on three areas:

Thinking and Feeling 

This area “contains disease risk appraisals, vaccine confidence, and motivation. Disease risk appraisals include perceived susceptibility, worry, fear, and anticipated regret. Meta-analyses show risk appraisals are reliably associated with being vaccinated. However, interventions to boost risk appraisals have been ineffective in increasing vaccine uptake, as shown in a recent meta-analyses of 16 randomized trials.”

They write: “Therapists are skilled at identifying and addressing internal conflicts, skills that may extend to allaying concerns about COVID-19 vaccination effectiveness and safety, the speed of vaccine development, and distrust of government. While it is not yet clear whether unravelling such beliefs would increase COVID-19 vaccine uptake, an approach tested for other health behaviors is motivational interviewing.”

Social Processes 

They write that social processes include “contains social networks, social norms, and social preferences.”

They continue: “A clinician recommendation builds on interpersonal trust that is often generated over many visits and imparts a potent signal (or social norm) about behavior that is desirable. It is unsurprising that clinician recommendations are one of the strongest motivators of uptake for all vaccines and will likely do the same for COVID-19 vaccination.” They also see benefit in the suggestions of primary care providers and other health care providers.

Direct Behavior Change 

This includes “approaches that change behavior directly without attempting to change what people think or feel or their social world.”

They write: “In a mental health context, the success of direct behavior change approaches suggests a focus on the mechanics of identifying points of access and reducing barriers. The focus on action planning could be as direct as sitting with clients as they book an appointment and helping them to think through and plan for potential barriers they may face. Reminding clients of the opportunity to vaccinate and upcoming appointments may also be effective in increasing vaccine uptake.”

A few thoughts:

  1. This is an important and timely “viewpoint” paper.
  1. Written by Americans for an American audience, this essay is very relevant here, too. Though we have done well compared to our neighbours to the south, many Canadians remain unvaccinated and we speak of efforts to reach them – the so called “last mile” – which must include initiatives aimed at those with mental disorders.
  1. The recommendations are practical. I particularly like the idea of incorporating motivational interviewing techniques into patient conversations.
  1. So… are you talking to your patients about vaccinations?
  1. And what can we do to make it easier for those with mental disorders to receive their jabs? Some hospitals and clinics are very creative. A recent Toronto Star article focused on the work of the staff at the Center for Addiction and Mental Health who offer a needle phobia clinic. “I knew I had to get it, but I honestly didn’t think I’d be able to,” comments Samantha Yammine. The article discusses the neuroscientist’s struggle to get the vaccination that she wanted because of her needle anxiety. Spoiler alert: a happy ending – she did get the jab. The link:

The full JAMA Psychiatry paper can be found here:


Selection 2: “Increasing the Impact of Interventions Incentivizing Psychiatric Treatment Engagement: Challenges and Opportunities”

Gabriela K. Khazanov, Sarah E. Forster, Dominick DePhilippis

Psychiatric Services, 9 September 2021  Online First


Poor treatment engagement is a substantial barrier to improving mental health outcomes. Individuals pursuing psychiatric treatment often do not attend their initial appointments or discontinue treatment early, resulting in little improvement in symptoms. Only one-third of individuals with psychiatric disorders receive minimally adequate treatment, and engagement is lower for psychiatric services than for other medical services.

So begins a paper by Khazanov et al.

“Financial incentives have been shown to increase several components of psychiatric treatment engagement, including the target behavior itself (e.g., abstinence from substance use, adherence to psychiatric medications) and engagement with mechanisms that lead to behavior change (e.g., treatment attendance and completion of treatment goals).”

They comment on the literature:

  • “Most research on incentive-based programs has focused on the effectiveness of providing financial incentives for abstinence among individuals with substance use disorders, an intervention called contingency management.”
  • “Many studies have also incentivized health behaviors, such as exercising, losing weight, and controlling chronic conditions (e.g., HIV). Overall, these interventions result in medium effect sizes and are cost effective in the long term.”
  • “Additionally, certain intervention characteristics increase the effectiveness of these programs (e.g., providing greater incentives and delivering them immediately after the behavior is completed).”
  • “Recently, studies have found that incentives can increase psychiatric treatment engagement more broadly, including outcomes such as treatment attendance, medication adherence, and completion of homework or other treatment goals.”

They describe the implementation of incentivized psychiatric care at VA. The core idea: “program costs are reduced through the use of a probability-based prize system that distributes coupons provided by the Veterans Canteen Service, a business within the VA.” They also note organizational incentives, and monthly emails promoting success stories.

The paper talks about opportunities. We focus on two here:

Extending interventions to target a range of psychiatric disorders

“Although studies have consistently found that incentives increase occurrence of the targeted behavior (e.g., attendance), additional research is needed to determine the extent to which incentivizing treatment participation (e.g., attendance or completion of treatment goals) versus treatment outcomes (e.g., abstinence or medication adherence) leads to improved outcomes. Research is also needed to establish operational definitions of new target behaviors (e.g., level of homework completion in cognitive-behavioral therapy for depression) and acceptable and feasible methods of monitoring these behaviors.”

Partnerships with corporations

“The VA’s incentive program has expanded across the country in large part because of the support of the Veterans Canteen Service, although VA clinical funds are also used for training and incentives. Because incentive programs are limited by health care systems’ financial constraints and by poor reimbursement for behavioral health interventions, wider implementation of these programs would benefit from partnerships with corporations that can fund incentives directly (with items or gift cards) or indirectly (by providing financial support).”

A few thoughts:

  1. This is an interesting paper.
  1. The topic is good, and the results seem impressive: “By 2018, 126 VA medical centers had implemented contingency management for veterans with substance use disorders, with clinical outcomes comparable to those from studies conducted in community clinics.”
  1. The paper, though, is short on data. (To borrow a line from Deming: “In God we trust, all others must bring data.”) How did patients respond to incentives? Which ones worked? What sub-populations seemed to do best?
  1. There is something very compelling about nudging our patients to get better results.
  2. A quick note on the ambition of the project which uses incentives for those with substance (supported by a rich literature) and those with psychiatric disorders (supported by a small if growing literature).
  3. Are there any challenges? The authors briefly note some, including concerns about coercion: “providers and administrators may hesitate to buy in to incentive-based interventions because of concern that they are coercive or will change the patient-provider relationship. These concerns can be addressed by adapting intervention features (e.g., not having the patient’s main provider deliver incentives), training providers and allowing them to observe the intervention’s effectiveness, and motivating providers to implement these interventions through social or organizational incentives, as described above.” These are reasonable points – but do they fully address the coercion issue? To play the devil’s advocate: given the vulnerability of those with severe mental illness, is a nudge really a push?
  4. Past Readings have considered behavioural economics, including in smoking cessation. For example, see:

The full Psychiatric Services paper can be found here:


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