From the Editor
This month, Reading of the Week celebrates its 12th anniversary. Over these past years, the program has grown, establishing partnerships in seven countries and promotional arrangements in three more.
A quick word of thanks for your ongoing interest.
In March 2020, mental health services were transformed by the reality of the pandemic and the webcam became indispensable. Today, many clinical programs offer a mix of video, in-person, and phone visits. But what are the outcomes?
In a new JAMA Network Open paper, Samantha L. Connolly (of Harvard University) and her co-authors attempt to answer that question. Using Veterans Affairs’ data involving 813 699 participants, they compared different modalities of care and looked at outcomes over a year, including inpatient admissions. “In this comparative effectiveness study, receiving mental healthcare via video was associated with improved clinical outcomes compared with receiving care via phone or in-person.” We consider the paper and its implications.
In the second selection, Rakhi Dandona (of the Public Health Foundation of India) and Dr. Rajesh Sagar (of the All India Institute of Medical Sciences) write about suicide prevention in JAMA Psychiatry. They offer lessons from India, where one in five suicides occur. “If most suicides occur in LMICs, then the future of suicide prevention should increasingly be shaped by evidence generated within them.”
And in the third selection from The Globe and Mail, Pat Barford writes about being a “fake patient,” to use her term. She describes her work as a standardized patient for medical students. “I get to watch the highest level of learning happen in real-time.”
DG
Selection 1: “Comparative Outcomes of Video, Phone, and In-Person Mental Health Care”
Samantha L. Connolly, Rebecca A. Raciborski, Hassen Abdulkerim, et al.
JAMA Network Open, 16 September 2026 Online First
The use of tele–mental health (MH) care via synchronous video visits and audio-only phone is widespread. Approximately half of outpatient MH care within the US Department of Veterans Affairs (VA) occurs remotely, with similar rates in community settings. While tele-MH care utilization skyrocketed during COVID-19 to help prevent infection, its popularity has persisted in the postpandemic period, with patients and clinicians endorsing high satisfaction rates…
A strong body of literature comparing the quality of video and in-person MH care within and outside of the VA existed well before the pandemic. Rigorous randomized clinical trials (RCTs) and noninferiority trials have demonstrated video’s equivalence to in-person care in reducing symptoms of depression and posttraumatic stress disorder. Studies conducted during the pandemic have also demonstrated increased appointment completion for video visits compared with in-person visits. The convenience of video visits is thought to have contributed to this effect, given that video care removes many barriers to attendance, including transportation, distance, traffic, parking, weather, and needing to arrange for childcare, eldercare, or time away from work or school… There is relatively little literature comparing the quality of video and phone care. However, studies have noted that the loss of nonverbal information during phone visits may have significant impacts on quality of care by limiting clinicians’ ability to assess patient functioning as well as by potentially weakening rapport and therapeutic alliance.
So begins a paper by Connolly et al.
Here’s what they did:
- They conducted a retrospective comparative-effectiveness study using administrative and electronic medical record data from the US Department of Veterans Affairs (VA). The study examined outcomes over a one-year follow-up period, from 2022 to 2023.
- They included VA patients who completed at least three outpatient mental health appointments between July 2021 and October 2022, aiming to capture people receiving ongoing mental health care.
- Participants were classified according to the modality used for more than 50% of their mental healthcare: video, telephone, or in-person.
- The primary outcome: at least one mental health hospitalization during follow-up.
- Different statistical analyses were used. Because patients were not randomly assigned to a treatment modality, the authors used an inverse probability–weighted regression adjustment (IPWRA) to estimate average treatment effects.
Here’s what they found:
- There were 813 699 veterans in the final analysis.
- Care. 343 543 participants (42.2%) received most of their mental healthcare by video; 305 189 (37.5%), in person; and 164 967 (20.3%), by telephone.
- Demographics. Many (43.6%) were aged 60 years or older; most were men (82.7%). The video group tended to be “younger, had higher income, and lived in more urban areas, with a greater percentage of women and lower clinical severity…”
- Hospitalizations (absolute numbers). Hospitalizations occurred in 0.9% in the video group, 2.1% of the in-person group, and 1.6% of the phone group.
- Hospitalizations (probability). After adjustment for differences between the groups, the expected probability of a mental health hospitalization was 0.5 percentage points lower with video than with either in-person or telephone care – equivalent to about five fewer hospitalizations per 1 000 patients. There was no significant difference between telephone and in-person care.
- Emergency department visits. Video care was also associated with fewer mental health ED visits: the expected probability was 0.5 percentage points lower than with in-person care and 0.6 percentage points lower than with telephone care. Again, there was no significant difference between telephone and in-person care.
- Suicidal behaviour. The expected probability of suicidal behaviour was 0.1 percentage points lower with video than with in-person care and 0.3 percentage points lower than with telephone care.
- Appointment completion. The expected percentage of appointments completed was 4.1 percentage points higher in the video group than in the phone group and 3.6 percentage points higher in the video group than in the in-person group.
A few thoughts:
1. This is an important study, drawing on a good dataset and addressing a very relevant clinical question, published in a leading journal.
2. The main findings in a sentence: participants in the video group did better than those receiving in-person or telephone care in terms of hospitalizations, ED visits, suicidal behaviours, and completed appointments.
3. But the differences were small, and the study could not completely eliminate confounding. Two cheers, then, for the webcam.
4. Putting this in a larger perspective, perhaps what is most important is what the study doesn’t show: that the video group did worse than those who were receiving in-person care. The pandemic shifted appointments from the office to the virtual office and, years later, our patients don’t appear to have suffered for the change.
5. Like all studies, there are limitations. The authors note several, including the crudeness of the approach: “The reasons for completing a given session by video, phone, or in-person are likely complex and multifaceted and may vary from session to session for each patient based on factors such as access, clinical severity, and both patient and clinician preference. Our decision to limit inclusion to patients with 1 dominant modality prevents examination of this nuance.”
The full JAMA Network Open paper can be found here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2853801
Selection 2: “Rebalancing Global Suicide Prevention”
Rakhi Dandona and Rajesh Sagar
JAMA Psychiatry, 9 September 2026 Online First
Suicide is among the leading causes of mortality globally, accounting for more than 700 000 deaths each year. Suicide prevention presents an unusual paradox in global health. Nearly three-quarters of suicides occur in low- and middle-income countries (LMICs), yet much of the evidence, theory, and policy discourse architecture guiding prevention has been developed in high-income countries (HICs). As a result, prevailing frameworks may overemphasize pathways and interventions characteristic of settings where the minority of suicides occur as it may not fully capture the social, health system, and demographic realities of settings where most suicides occur… Accounting for more than 1 in 5 suicide deaths globally, India is central to understanding the global burden of suicide.
So begins a Viewpoint by Dandona and Dr. Sagar.
They focus on three lessons.
Lesson 1—LMICs and the Importance of Social and Structural Determinants
“One of the central assumptions of modern suicide prevention is that suicide is primarily a problem for mental health services to address. Much of the evidence base underpinning suicide prevention has emerged from HICs where specialist mental health services are comparatively accessible and where suicide research has historically been closely linked to psychiatry. The experience of India suggests that many pathways to suicide originate outside the health sector. National suicide data consistently identify family problems, financial difficulties, unemployment, alcohol use, chronic illness, and social pressures among the factors associated with suicide deaths…”
They add: “The largest reductions in suicide observed globally have often resulted from regulatory and social policies—restrictions on highly hazardous pesticides and social protection programs—by modifying the environments in which suicide risk emerges rather than expansion of specialist psychiatric care… Suicide prevention should be understood not only as a clinical endeavor, but also as a social, economic, and regulatory one.”
Lesson 2—LMICs and Male-Centered Narratives of Suicide
“Global suicide prevention discourse has been shaped by a striking epidemiological pattern; in most HICs, men die by suicide at substantially higher rates than women… Although men account for the majority of suicide deaths in India, women experience a disproportionately high burden of suicide mortality and account for a substantial share of female suicide deaths globally. Their suicide death rate is approximately twice the global average for women. More broadly, suicide has overtaken maternal disorders as a leading cause of death among young women globally, yet it remains comparatively neglected within global health discussions. The contrast is striking; although maternal mortality has rightly attracted sustained attention, investment, and advocacy, far less attention has been directed toward understanding why so many young women die by suicide. Studies from LMIC settings have highlighted elevated suicide risks among women exposed to gender-based violence, economic dependence, social exclusion, and restricted autonomy.”
Lesson 3—LMICs and Understanding of Who Records and Prevents Suicide
“Suicide surveillance is often viewed as a technical process of classifying and counting deaths. Yet the institutions responsible for producing suicide data vary considerably across countries, and these differences shape not only what is counted but also how suicide is understood and prevented… In India, police are the primary gatekeepers of suicide data. Through the National Crime Records Bureau, information collected by police stations forms the basis of the country’s most widely used suicide statistics. Although concerns about underreporting and data quality are well recognized, police-generated data often provide the most comprehensive information on suicide mortality available…”
A few thoughts:
1. This is an excellent commentary.
2. They write about India – but the second lesson seems very relevant across the West.
3. Suicide prevention has been considered in past Readings. In June, we highlighted a podcast interview with Dr. Mark Sinyor (of the University of Toronto). “You don’t actually need billions of dollars to prevent suicide. You just need really good coordination.” That Reading can be found here:
The full JAMA Psychiatry Viewpoint can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2853913
Selection 3: “My job as a fake patient is an exercise in improvisation and empathy”
Pat Barford
The Globe and Mail, 24 June 2026
I recently spent an afternoon having my breasts fondled by strangers. Sixteen young, med students in fact. I was helping them prepare for their second-year final exams.
I’ve had a checkered career with a wide range of interesting jobs, but this may well be the strangest. I’m a fake patient, or in medical education circles, what’s known as a Standardized Patient or SP. Med students spend huge amounts of time learning facts and science with hard core book learning. In the case of my breasts, these students had yet to practice their knowledge of lymph node examinations on a real person. So, for $27.50 an hour, I find my motivation and go to work.
So begins an essay by Barford.
“I sit in a gown on an examining table in a windowless beige room. A facilitator/physician gives a brief lecture and quizzes four students. The instructor demonstrates the procedure, and each student takes a turn. Armpits first. All good. Next, a little lower and each student follows the steps demonstrated by the instructor. Brief discussion, review, questions.
“The bell rings, the first group exits and another four students enter. And so goes the afternoon.”
She speaks of her work. “I am one of many Standardized Patients providing a body, an improvised response or a detailed script of ailments, for students to practice situational learning, or pass a test. The work varies and it absolutely makes for the best stories when I tell people about being a fake patient. Some of these gigs are practice scenarios; others are exams with high stakes.” The roles vary. “I’ve played patients with sore knees, sore shoulders, dry eyes, a homeless, drug-addicted sex worker and a politician hoping to hide a Parkinson’s diagnosis.”
She notes the importance of consistency. “That’s why the ‘standard’ part of being a Standardized Patient is crucial. Just like a written test, every question or scenario must be identical, so all candidates get the same chance. I have a script. I cannot deviate. The time frame is tight – eight to 10 minutes for a diagnosis, before a bell ends the session. Fake patients have questions or lines that we absolutely must deliver within that window.”
She speaks of the toughest assignments, including scenarios where students need to break bad news. “I played an unassuming patient looking for test results that might indicate a grim cancer diagnosis. It’s an improvisational role performed before a group with the student sitting close to deliver the news. Most got it right by saying more tests were needed and we shouldn’t jump to conclusions. But one answered my questions a little too breezily, with an ‘about that…’ tone I recognized from my teenage daughter.” She notes her disappointment, as well as that of the medical student, who ends up in tears.
She describes the occasional levity. “One student is given my ‘symptoms’ by the doctor/facilitator, including the line, ‘She has no pain.’ The student nodded her head, repeating the facts, going down a mental checklist as each bit of information was delivered. The facilitator had an accent so the last detail was heard as: ‘She has no brain.’ The student nodded, check, and repeats, ‘She has no brain,’ then looks at me, startled, as what she said sunk in. The three of us laughed hysterically.”
She closes by noting the joy of her work. “I see the wheels turn as these incredibly hard-working young people think, process and make sense of what they know. It’s quite something. Awe inspiring, actually.”
A few thoughts:
1. This is a fun essay written by an actor who has a great stage: a medical school.
2. The line about learning is particularly good and worth repeating: “I get to watch the highest level of learning happen in real-time.”
3. Years ago, for an afternoon, I joined several actors who work as standardized patients at the University of Toronto. Our project wasn’t so memorable, but I was dazzled by their professionalism and seriousness.
The full Globe and Mail article can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
Recent Comments