Reading of the Week: Is Psychoanalysis Relevant? Paris vs. Ravitz

From the Editor

“Today, psychoanalysis has been marginalized and is struggling to survive in a hostile academic and clinical environment. This raises the question as to whether the paradigm is still relevant in psychiatric science and practice.”

This week, we consider the relevance of psychoanalysis.

Drawing from the May issue of The Canadian Journal of Psychiatry, we look at two papers.

Freud and analysis: debating his relevance

In a Perspectives piece, Dr. Joel Paris argues that psychoanalysis is part our legacy – but not much more. In an Editorial, Dr. Paula Ravitz responds. She opens by writing: “My concern is that by unnecessarily pitting psychiatry against psychoanalysis, we may throw out the baby with the bathwater.”

It’s a great and important debate.



Paris on Therapy

“Is Psychoanalysis Still Relevant to Psychiatry?”

Joel Paris

The Canadian Journal of Psychiatry, May 2017



“Psychoanalysis is a theory of psychopathology and a treatment for mental disorders. Fifty years ago, this paradigm had great influence on the teaching and practice of psychiatry. Today, psychoanalysis has been marginalized and is struggling to survive in a hostile academic and clinical environment. This raises the question as to whether the paradigm is still relevant in psychiatric science and practice.


“In a difficult climate for the theory and practice of psychoanalysis, several responses have emerged, either by attempting to bridge the gap with science or by redefining the field as lying outside of science. Thus, some analysts have supported revised paradigms, such as attachment theory, that are better supported by evidence. Others have taken the view that Freud’s ideas concerning the unconscious mind are compatible with modern neuroscience. Still others have moved in the opposite direction, arguing that it is sufficient to offer a coherent interpretation of psychological phenomena. This review will briefly examine all these attempts to revive psychoanalysis.”

Joel Paris

So opens McGill’s Joel Paris in his paper. He predicts a “continued and lingering decline” for psychoanalysis. In a sweeping essay that draws heavily from the literature, he makes several points.


  • Psychoanalysis has been undermined by a lack of scientific study. “The absence of solid and persuasive evidence for the theory may be the consequences of self-imposed isolation from the empirical sciences.” (He notes that attachment theory is the “notable exception.”)
  • Even psychoanalysts, he writes, concede there is limited evidence. “Peter Fonagy, a psychoanalyst who is also a respected researcher, has acknowledged that ‘the evidence base for psychoanalytic therapy remains thin.’”
  • Though there is evidence for time-limited dynamic psychotherapies, Dr. Paris argues that this isn’t generalizable to psychoanalysis. With psychoanalysis, “a few reports have attempted to examine” outcomes, but there have been serious limitations.
  • Attempts to tap brain imaging to confirm analytic theories – such as using REM activity – have been “incompatible with empirical data.” Some, like Norman Doidge, have argued that the “brain can change itself” – but Doidge’s books are bestsellers, but “have had little impact in medicine.”


“Whatever its limitations, psychoanalysis left an important legacy to psychiatry. It taught a generation of psychiatrists how to understand life histories and to listen attentively to what patients say. In an era dominated by neuroscience, diagnostic checklists, and psychopharmacology, we need to find a way to retain psychotherapy, whose basic concepts can be traced back to the work of Freud, as part of psychiatry.”



Ravitz Responds

“Contemporary Psychiatry, Psychoanalysis, and Psychotherapy”

Paula Ravitz

The Canadian Journal of Psychiatry, May 2017

“In his Perspective, ‘Is Psychoanalysis Still Relevant to Psychiatry?’ Paris presents a critical perspective on psychoanalysis in the context of evidence-based care. Scientific discourse demands critical dialogue, and so in this editorial, I provide alternative perspectives on some of Paris’s arguments and further thoughts on psychoanalytic training, research, and treatment. My concern is that by unnecessarily pitting psychiatry against psychoanalysis, we may throw out the baby with the bathwater.”

Paula Ravitz

So responds the University of Toronto’s Dr. Paula Ravitz to the Paris paper. She forwards several arguments.


  • She notes that psychoanalytic thought is traced to various theories – and that a typical scientific consideration isn’t necessarily appropriate. “[C]urrent psychoanalytic thought is informed by theory of mind, feminist theory, queer theory, sociology, cognitive psychology, nonlinear dynamics, evolutionary biology, political science, anthropology, Buddhism, evolutionary psychology, and ethology. Many aspects of this rich interdisciplinary landscape of influences lie outside the domain of science and its standards of evidence, but not all.”
  • That said, she observes “the strength of evidence” for different psychotherapies. “Canadian position papers and working group papers on psychotherapy published over the past 4 decades highlight that psychotherapy treatments are integral, core components of psychiatric practice.”
  • And she taps the literature, “Although there are fewer controlled studies of psychoanalytic treatment, there is in fact evidence for the efficacy of both short- and long-term psychodynamic psychotherapy (LTPP). Leichsenring and Rabung’s systematic review of 23 studies conducted between 1984 and 2008 identified 11 prospective RCTs and 12 observational studies of >1000 patients receiving LTPP in which there was a large within group effect size of 0.96… for pre- to posttreatment overall outcomes, and for the 8 studies that included a comparison group, the overall between-group effect size was even larger at 1.8…”


“Psychotherapy treatments can effectively address suffering and enhance outcomes and the quality of care of mental illnesses across a spectrum of health care settings. As evidence-based practitioners and psychiatrists, we must use what is best for our patients and be trained in a broad range of effective treatments, including psychotherapies and psychoanalytic principles. Based on 40 years of outcome and process research, it is clear that psychotherapy treatments are helpful for patients with psychiatric disorders and therefore a critical component to be preserved in the training and practice of psychiatrists of the 21st century.”


A few thoughts:

  1. What a terrific exchange.
  1. Congratulations to the authors – and to The Canadian Journal of Psychiatry for publishing this debate. (And I would encourage readers to look at the papers themselves, since this summary is just that – a summary.)
  1. Though these two psychiatrists take different positions, there is clearly common ground. Note, for instance, that they both acknowledge the contribution of psychoanalysis to current care, including attachment theory. And both acknowledge the incredible importance of psychotherapy in terms of evidence-based care.


  1. A past Reading considered this topic, drawing on a clever Guardian essay, and then discussing an American Journal of Psychiatry paper that showed that CBT helped patients with bulimia achieve symptom relief faster than those treated with analysis – though the study did show that neither psychotherapy was particularly effective.


You can find the Reading here:

ROTW: Freud is Dead are his Ideas Dead Too?


  1. In a publicly-funded system, there are larger questions. Does analysis justify its cost given the system’s limited resources? Is it problematic to think in these terms, with government officials then trying to pick winners and losers in treatment, potentially micro-managing patient care?


  1. These two selections, then, touch on a broader discussion – the relevance of psychoanalysis has implications for education, clinical practice, and health care financing. I’ll close the way I started: by noting that it’s a great and important debate.



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


-Dr. David Gratzer


Happy Nurses Week

Happy Nurses week to all our amazing nurses here at SRH!

You are the backbone of the healthcare system!

Here at Mental Notes we would like to recognize the toughest of nurses in the healthcare system, the Psych Nurse.  From in-patient, to out-patient,  and to community nurses, we recognize the hard work you put in.  Mental Health nursing is one the most challenging areas in the field.  We salute you and thank you for the hard work you put in day after day.

So instead of the cliched basket of random snacks or small piece of cake or even breakfast/lunch supplied by our favorite doctors.  Mental notes would like to give all you nurses the gift of laughter.

Enjoy a carefully curated run of Nurses meme’s.

Happy Nurses Week!!

nw16nw17nw18nw7nw5nw4nw10nw1nw2nw 11nw13nw19nw6nw20nw15nw8nw9nw12nw14nw3

-Mental Notes

3 in the Key (March/April)

Sorry for the delay.

A lot of changes happening at TS(R)H.  We all hope that these changes will maintain the exceptional care we provide to our community as well as push forward with the innovative visions we have put into place.

That being said, here is a semi-late post of 3 in the Key (March/April)


So what do these 3 stars have in common?


Introducing 3 Key staff members of the MH team at the Scarborough Sites……

(**Click on any of the underlined links for more information**)


Nancy R. (Secretary at MH Adult Out-Patient Clinics, 1225 Kennedy Rd.)



What is your best childhood memory?

Summers in Portugal

Who would play you in the movie adaptation of your life?

Angelina Joile

What do you feel most proud of?

My three wonderful children

If you could travel anywhere, where would you go and why?

Bora Bora, love the peace of nature and the water

What are your top three favorite books and why?

Receipe books – love to cook and bake,  try new things

If you were prime minister, what is the first thing you would do?

Created programs to support people in need (poverty, disability, single parents, mental health)

What is your favorite part of your job?

My fellow co-workers and patients make me love to work here. I love making people smile.

How long have you worked at TSH?

16 ½ years

How would your friends describe you?

Easy going, friendly, caring, helpful and dependable

What does a perfect day look like to you?

at the cottage, waking up and having my coffee looking out at the lake. Going kayaking on the lake, followed by a BBQ with family and bon fire with a few glasses of wine. lol

What is a skill you’d like to learn and why?

Crisis training, CPR, De-escalating conflict and  info sessions on specific illnesses to increase my understanding and ability to serve my patients.

Fill in the blank: If you really knew me, you’d know_____.

I like to cook

What’s your favorite type of cuisine?

I love a variety, love to try different culture cuisine. I love Indian, Italian, Chinese, Portuguese, greek etc.

Who did you first see live in concert?

Bon Jovi

What’s the 1 thing you’ve waited in line the longest for?


If you could choose 1 amenity to add to the workplace, what would it be?

Renovate office, a nicer waiting area for patients and no carpet.

What other languages do you know?

Portuguese, understand Italian, Spanish. My patients teach me how to greet them in their language, Polish, Greek and Cantonese.

Do you have any hobbies?

Cooking, and I love the out doors

Which of your 5 senses is the strongest? How about weakest?

Strongest:  Taste

Weakest: sight (I wear glasses lol)

What was the most incredible exotic place you’ve ever traveled to?

Being a single mother, I can’t afford to travel but would love too. I went to Aruba


Steve T. (Case Manager, Community Programs Assertive Community Treatment Team, 2425 Eglinton)


What is your best childhood memory?

My Grandmother cooking in the kitchen.  I was just in awe of how many dishes she was able to make.

Who would play you in the movie adaptation of your life?

Paul Sun-Hyung Lee (of Kim’s Convenience) – he seems to channel how I look only he carries it better!

What do you feel most proud of?

At home: My family.

At SRH: Having the privilege of working at the community programs site with some of the best people I have ever met.  Their sense of caring and compassion for clients and colleagues are what I feel most proud of.

If you could travel anywhere, where would you go and why?

I would love to take a cross-country trip across Canada as there is so much to love about our wonderful nation that I haven’t yet had the opportunity to experience seeing it from coast to coast.

What are your top three favorite books and why?

A Wrinkle in Time: This was the first book that made an impression on me in grade 3 and got me interested in the Sci-Fi genre.

The Art of Racing in the Rain: An unexpected book where the author tells the story from an auto-racing loving golden retriever’s perspective and how we develop our inextricable connections with our beloved canines.

Ordinary Moments – The Disabled Experience: A wonderful book of compiled individuals’ accounts of their struggles with various disabilities in their daily lives.

If you were prime minister, what is the first thing you would do?

I would ensure there are more supportive housing resources for people who are at-risk.

What is your favorite part of your job?

Seeing over time how individuals we work with tap into their own strength and resilience to forge ahead and reach their recovery goals.

How long have you worked at TSH?

18 years

How would your friends describe you?

Thoughtful, helpful, with an ok sense of humour.

What does a perfect day look like to you?

Waking up to a warm, sunny spring day and going for a drive with no particular destination in mind and no place I have to be at.

What is a skill you’d like to learn and why?

I would really like to learn to play the guitar as it seems so versatile to be able to take it wherever you want and to play a tune either for yourself or to entertain others.

Fill in the blank: If you really knew me, you’d know_____.

I really like to watch improvisational comedy.

What’s your favorite type of cuisine?

Yes! Cuisine is my favorite…. any.  As long as it’s cooked with care and love.

Who did you first see live in concert?

I think the first concert I saw live was when I was in school and went on a field trip to see the Toronto Symphony Orchestra.  The amazing richness of the live sounds subtle and loud made quite an impression on me.  As for the first live concert I paid money to see, I believe it was Genesis (the band).

What’s the 1 thing you’ve waited in line the longest for?

I seem to remember it was for Krispy Kreme doughnuts when they first opened in Mississauga.  I waited with some friends for two hours to try those “super-delicious” warm classic glazed wonders.  Ahhhh memories……  (see #13)

If you could choose 1 amenity to add to the workplace, what would it be?

Individual hvac controls for each office

What other languages do you know?


Do you have any hobbies?

Aside from food…..?  Does barbecuing count?!  I do like to work on/geek out on cars, music and woodworking.

Which of your 5 senses is the strongest? How about weakest?

I think my strongest sense is of hearing, my weakest – smells.

What was the most incredible exotic place you’ve ever traveled to?

China was amazing as I’ve never been to mainland China until we went there to adopt our eldest son Justin.  The sheer numbers of people in the cities were incredible as was the Great Wall.


Ashley M.  (RPN/Case Manager, Community Crisis, Birchmount Campus)


What is your best childhood memory?

Skiing with my grandfather

Who would play you in the movie adaptation of your life?

Cameron Diaz

What do you feel most proud of?

My nursing career

If you could travel anywhere, where would you go and why?

If I could go anywhere, I would travel to Africa. I would really enjoy helping the communities and going on an adventurous safari!

What are your top three favorite books and why?

I don’t have much time to read, however when I do get a chance I enjoy reading Jodi Picoult novels. One of my favourite is “House Rules” which is about a child with Asperger’s syndrome that finds himself involved in a murder. Very intense, had me reading for hours.

If you were prime minister, what is the first thing you would do?

Put more money in to mental health programs in the community

What is your favorite part of your job?

Being a positive influence in my patients lives.

How long have you worked at TSH?

Since 2005, I started on 3C medicine at the general campus

How would your friends describe you?

Well, I asked my friends this question and got many interesting answers…I will go with “Hardworking, genuine, passionate and empathetic”

What does a perfect day look like to you?

Hiking with my dog, cooking a new meal and killing it at the gym!

What is a skill you’d like to learn and why?

How to have better control of a motorcycle so I could get my full M license this year!

Fill in the blank: If you really knew me, you’d know________.

I love ice cream!

What’s your favorite type of cuisine?

I enjoy food in general… but would have to say italian.

Who did you first see live in concert?

The Backstreet Boys

What’s the 1 thing you’ve waited in line the longest for?

Tim Hortons… otherwise I don’t do lines!

If you could choose 1 amenity to add to the workplace, what would it be?

Be able to open the windows in the crisis office on 3B so we could get fresh air

What other languages do you know?

Sadly, none

Do you have any hobbies?

Cooking, hiking with my dog, the gym and travelling

Which of your 5 senses is the strongest? How about weakest?

Strongest- Smell Weakest- Hearing…however maybe I have selective hearing!

What was the most incredible exotic place you’ve ever traveled to?

Been to many places but I would say Santorini, Greece



Mental Notes would like to thank Nancy, Steve & Ashley for this months contribution.  You are all Key players in our department.


Patient Experience Week at Scarborough & Rouge Hospital



This April 24 – 27th, 2017, Scarborough & Rouge Hospital will be having Patient Experience Week, an annual event that celebrates health care staff impacting the patient experience everyday. Patient Experience Week provides a focused time for our hospital to celebrate accomplishments, re-energize efforts, and honour those who make a difference in the patient experience. From nurses and physicians, to support staff and executive professionals, to patients, families, and communities served, we hope to bring everyone together.


Why Participate in Patient Experience Week?
By supporting Patient Experience Week, Scarborough and Rouge Hospital shows our employees that we appreciate their hard work and encourage their continued efforts on behalf of patients. This week is a great way to enhance patient and staff relations, increase hospital morale, and improve communication.


How will our hospital be celebrating?

Our three-site team is collaborating on a series of hospital-wide events that invite participation from all staff, volunteers, patients, and families. Our schedule of events for this year is as follows:


Patient Experience Week Kick-Off Ceremony | Monday April 24, 2017| 12:00-1:00p.m all sites

Every SRH site will host an opening ceremony to kick-off the start of Patient Experience Week. This ceremony will include celebratory remarks from a member of our senior management team, opportunities for all staff to sign a hospital-wide pledge towards providing a quality patient experience, and light refreshments. Members of the community and local media are invited to participate and celebrate in its hospital’s commitment towards continued efforts to improve health care on behalf of patients and families. The hospital-wide pledge to patient experience will be proudly displayed in our main entrance areas for all members to reflect, acknowledge, and celebrate.


“Honouring Our Patients” Day | Tuesday April 25, 2017 | 9:00-12:00 all sites

Our patients and families are a central part of our hospital community and help us continually improve our standard and quality of care. “Honouring Our Patients” Day is a way for our hospital to thank our patients and families for giving us the opportunity to deliver the best care possible. Staff and senior leadership will welcome and greet patients and families at main entrances of all three sites, personally thanking them with a token of appreciation, and expressing their commitment to a quality patient experience.


Celebrating Quality Care Rounds | Wednesday April 26, 2017

Over the years, every hospital unit and program has worked towards providing high quality care for patients and families. Celebrating Quality Care Rounds is a unique opportunity for program and unit level teams to showcase the great work they have been doing to senior leadership, celebrate their achievements, and re-energize efforts. Program areas and unit level teams choose what they would like to highlight, which may include, but are not limited to: increased compliance with infection control, excellent patient satisfaction survey results, implementation of new practices/policies to improve quality of care, and/or improved communication methods with patients and families.


Patient Family Advisor “Roadshow” | Thursday April 27, 2017

At SRH, Patient Family Advisors (PFAs) demonstrate our hospital commitment towards the highest level of Patient & Family Centred Care. PFAs are volunteers who are past SRH patients and/or family members of SRH patients. Collaborating closely with hospital staff on committees and projects, PFAs harness the power of their patient story and perspective to improve the way healthcare is delivered. On this day, PFAs join hospital staff in sharing the impact of their work on the quality of healthcare at SRH, thank staff for their efforts in patient and family centred care, and provide resources that enable program areas to recruit their own PFAs. This event celebrate both the positive impact that health care providers and PFAs have made and continue to make at this hospital.


Patient & Family Centred Care (PFCC) Huddles | Monday April 24 – Thursday April 27, 2017

Program and unit level huddles are a key way for staff to stay informed, review work, make plans, and move ahead quickly in a fast-past health care environment. During Patient Experience Week, the Office of Patient and Family Centred Care (PFCC) will provide teams with activity materials that can be used to facilitate thinking, collaboration, and discussion around providing a quality patient experience. Activity topics for huddles may include inviting teams to reflect on program area practices that align with key PFCC principles, review a patient story and its impact on quality of care, or brainstorm how to effectively partner with patients and families in discussing plan of care. The hope is that these PFCC huddles during Patient Experience Week will help build and reinforce a culture of thinking and practice focused on supporting a quality care experiences.


If you would like more information or are interested in participating in any of the events please contact us prior to Monday April 17, 2017.



Kristy M, MSW RSW

Manager, Patient and Family Centred Care (PFCC)


Ettsa P, MSW, RSW

PFCC Steering Committee Co-Lead

Reading of the Week: Schizophrenia & Diabetes: The Gap in Care; Also, Swedish Health Care

From the Editor 

“The pain in my feet. It’s killing me.”

That’s what John told me when I asked him what he needed help with. It’s not quite the answer I thought he’d give – John has schizophrenia and he has significant side effects from his medications. But, like many people with mental illness, he also struggles with physical illness (diabetes and the accompanying neuropathy).

Many of our patients have both physical and mental illnesses. When faced with these twin challenges, how do they fair?

In this week’s first selection, we look at a new paper that considers people with schizophrenia and diabetes. The study authors find a significant gap between the care received by those with and without mental illness.

An old drug, an old illness, and a big problem for those with mental illness


In our second selection, drawing from a lively blog written by medical student Ali Damji, we look at Swedish health care.


 Diabetes and Care

“Diabetes quality of care and outcomes: Comparison of individuals with and without schizophrenia”

Paul Kurdyak, Simone Vigod, Raquel Duchen, Binu Jacob, Thérèse Stukel, Tara Kiran

General Hospital Psychiatry, May-June 2017 (Published Online First)


“Diabetes is common among individuals with schizophrenia, with a median prevalence rate of 13%, and documented prevalence rates as high as 50%. Diabetes is more common among individuals with schizophrenia than among those with other mental illnesses, and much more common than in the general population. Individuals with schizophrenia have more diabetes risk factors such as obesity, poor diet, and reduced physical activity relative to individuals without schizophrenia. Additionally, second-generation antipsychotics, a mainstay of treatment for schizophrenia, contribute to the high prevalence of diabetes through weight gain and insulin resistance. The substantial mortality gap between individuals with and without schizophrenia is largely explained by an increase in cardiovascular deaths, for which diabetes is a significant risk factor.

“Careful monitoring of blood pressure, cholesterol and glycemic control reduce morbidity and mortality for individuals with diabetes, and diabetes care guidelines have been developed in multiple jurisdictions to encourage optimal care. When diabetes is comorbid with schizophrenia, there are patient, provider, and system-level factors that make it challenging to follow evidence-based guidelines. Patients with schizophrenia have a significant level of cognitive disorganization and social instability that makes engaging in care difficult. Providers may be overwhelmed by the complexity and may not have the time or resources needed to provide optimal care. Finally, mental health care and primary care can be fragmented and there is relatively little evidence on how to design care that involves multiple health care providers when one of the comorbidities is a serious mental illness.”

Dr. Paul Kurdyak


So begins a paper by Kurdyak et al. that uses a retrospective cohort study to compare the diabetic care of those with schizophrenia and diabetes, and those with only diabetes.

Here’s what they did.

  • The authors drew data from several databases covering different aspects of health service delivery including the Ontario Health Insurance Plan (outpatient physician billing, as well as diagnostic codes and procedures) and CIHI Discharge Abstract Database (acute hospitalizations).
  • The participants were adults eligible for the Ontario Health Insurance Plan, with the study covering a period of two years, from April 1, 2011.
  • Diabetic care was based on participants getting the care recommended by the Canadian Diabetes Association 2013 Clinical Practice Guidelines – at least 4 Hb1AC tests, one cholesterol test, and one retinal exam.
  • They looked at demographic information, and other co-variables: residential instability, maternal deprivation, etc.
  • Statistical analysis was done, including an ANOVA analysis.


Here’s what they found:

  • On April 1, 2011, there were 1,131,415 individuals with diabetes age 19 to 105; of these, 26,259 (or 2.3%) had schizophrenia.
  • Demographically: those with schizophrenia were significantly more likely to be female and younger. They were significantly more likely to live in an urban setting, and in lower income neighbourhoods.
  • In terms of health care use: individuals with schizophrenia were more likely to use health care: they were more likely to have at least one ED visit for a diabetes complication (8.1% vs. 5.9%), and at least one ED visit for any reason excluding trauma (55.5% vs. 40.2%), and to be hospitalized for a diabetes complication (6.0% vs. 4.7%).
  • In terms of diabetic care: “Individuals with schizophrenia were less likely to receive guideline-level screening for diabetes.” They received the recommended number of cholesterol tests less than those without schizophrenia (72.4% vs. 80.3%) and the recommended number of eye exams (56.8% vs. 67.4%). “There was a smaller, but significant difference in the proportion of individuals who received the recommended number of HbA1c tests between the two groups (35.8% vs. 37.7%…).”
  • In terms of an adjusted odds ratio: “Individuals with schizophrenia were less likely to be guideline-concordant with one of the 3 recommended tests (aOR = 0.84 95% CI 0.81–88), two tests (aOR = 0.71 95% CI 0.68–0.74) and three tests (aOR = 0.60 95% CI 0.57–0.62) in comparison to individuals without schizophrenia.” See the following graph:

Relative risk


They note:

They also have approximately 30% more visits with their primary care physician. Despite this frequent primary care contact, individuals with schizophrenia are less likely to have cholesterol testing and eye exams, and are one third less likely to receive all three guideline-based tests (HbA1c, cholesterol testing and eye exams). Finally, individuals with schizophrenia are about one third more likely to have diabetes-related hospitalizations and ED visits.”

The authors go on to consider ways that diabetic care could be improved for those with major mental illness. They note evidence in the literature for co-location of specialists, as well as the use of diabetic nurses in primary care.


A few thoughts: 

  1. This is a good study. It speaks to the gap in care – but, at the same time, the strikingly high costs of that gap (greater utilization of primary care, more visits to the ED, and more hospitalizations).


  1. We often speak about access issues when talking about mental health problems. But it’s important to recognize the full needs of those with major mental illness – yes, there are issues in terms of access to mental health services, but physical health needs must be considered and addressed too.


  1. The paper asks a good question and finds the answer that we suspect it would. But the contribution here is the actual data. Drawing on databases that cover millions of Ontarians, the authors are able to demonstrate the difference between the diabetic care of those with and without schizophrenia.


  1. Once again, Dr. Paul Kurdyak pushes us.


Lessons from Sweden

“Guest Post: Ali Damji (Canada) – Snapshots of Patient Co-Produced Care”

Ali Damji

Co-learning with Qulturum, 5 March 2017


“Time really flies when you’re having fun!

“This is my second reflection, from when I participated in a Study Visit with a team from Singapore Institute for Mental Health (all of us pictured above). It was co-learning at its finest, where I not learned about quality improvement and healthcare in Jonkoping, but also a great deal about Singapore too!

“One of the main reasons that I traveled to Jonkoping was to learn about patients as partners, and patient-led care. This blog post will focus on a few encounters where patients co-produced better care that I witnessed firsthand.”

Ali Damji


In this essay, University of Toronto medical student Ali Damji describes his experience learning about health care in Sweden.

He notes several aspects of the Swedish health care system that are different from the Canadian system.

  • Patients are invited to attend and participate in ward rounds.
  • Self-management includes self-dialysis.
  • Hospital staff wear a similar uniform as it’s been shown to reduce infection rates. (Ali is wearing this uniform in the picture above).

He discusses at some length the inclusion of “Esther” in discussions.

“In Jonkoping, one of the key ingredients to their successes is a flipped perspective when thinking about quality improvement and change. Rather than thinking about, ‘What’s best for the system? Or what’s best for me, the provider?’, the question always is, ‘What is best for Esther?’ Esther is a hypothetical patient that many of us in healthcare are familiar with. She is a person with a life beyond the walls of the institution, not purely a patient. She is elderly and frail. She has complex health needs. She lives alone. If she lacks effective primary care or transitions from the hospital back to home without support, she does not do well. She’s called a ‘frequent flyer’. But what about the other elements of her life? What drives her? What motivates her? And most importantly, what matters to her? And how is her problem, our problem (not long term care’s problem or the hospital’s problem – our collective problem!)? How can connections be developed and the system be built so it can respond to the things that matter most to her, beyond simply her medical needs?”

Ali notes that Esther is considered at various levels of decision-making, even with program funding

A few thoughts:

  1. This is a fun and lively blog. It doesn’t directly tie into psychiatric care, but does tie into patient care.


  1. There are a couple of other blogs in the series and the observations on Swedish health care are worth reading. So often we look at other health care systems through the narrow prism of funding; this blog is broader in perspective.


  1. Ali has just been accepted into the University of Toronto’s Family Medicine program. Congratulations. We look forward to reading more health-care insights from him in the coming years.


  1. You can find his other Swedish blogs here:


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

-Dr. David Gratzer

Reading of the Week: Are Cats Making Us Sick? The Solmi et al.

From the Editor 

A few years ago, Czech scientist Jaroslav Flegr made a splash by arguing that our feline friends were causing psychosis in people – The Atlantic provocatively titled their article on him: “How Your Cat is Making You Sick.” Flegr’s argument was based in part on several papers (including by prominent researcher E. Fuller Torrey) noting that cat ownership confers an increased risk of psychotic disorders like schizophrenia.

So, are cats safe for household use?

In our first selection, we look at a new Psychological Medicine paper that, with a cohort study, finds no connection between cat ownership and psychotic symptoms.


Good news, tabby: you can stay

How to help the homeless? In our second selection, drawing from The Guardian, we look at a Hawaiian effort to prescribe the housing to the homeless – literally.

Please note that there will be no Readings for the next two weeks. Enjoy the March break.

-David Gratzer


 Pets and Problems

“Curiosity killed the cat: no evidence of an association between cat ownership and psychotic symptoms at ages 13 and 18 years in a UK general population cohort”

  1. Solmi, J. F. Hayes, G. Lewis, J. B. Kirkbride

Psychological Medicine, 22 February 2017 Online


“House cats are the primary hosts of Toxoplasma gondii, a protozoan parasite that can infect various warm-blooded animals, including humans. Infection can occur in utero or postnatally, via ingestion of either the parasite’s oocysts–which might be present in soil, water, or food–or tissue cysts from infected animals (e.g. in raw or undercooked meat). In intermediate hosts (e.g. humans or animals other than cats), the parasite exploits lymphocytes to encroach in muscle tissues and, importantly, the brain, where it can form tissue cysts in neurons, microglia, and astrocytes.

“Although the evidence is not unequivocal, data from several epidemiological, experimental, and animal studies suggests that T. gondii infection may be implicated in the aetiology of psychosis. For example, dopaminergic dysfunction and cognitive impairments – similar to those observed in people with schizophrenia–have been observed in infected rodents and humans; these people may also experience hallucinations during acute infection with the parasite. A recent meta-analysis of 38 studies found that compared with controls, people with schizophrenia were nearly three times more likely to be seropositive for T. gondii antibodies [odds ratio (OR) 2.71, 95% confidence interval (CI) 1.93– 3.80]. Higher seroprevalence and serointensity of T. gondii IgG (but not IgM, an indicator of recent infection) in people with schizophrenia and their mothers suggest that either early life exposure to the parasite, congenital infection, or transmission of maternal antibodies could alter neuro-development of subsequent offspring.

“Assuming a causal relationship between T. gondii infection and later psychosis, some researchers have hypothesized that cat ownership should confer an increased risk of psychotic disorders…”

Francesca Solmi

So begins a paper by Solmi et al. that seeks to test this hypothesis by looking at cat ownership in pregnancy and childhood, and whether ownership is associated with psychotic experiences (PEs) in early and late adolescence.

Here’s what they did.

  • The authors drew data from the Avon Longitudinal Study of Parents and Children (ALSPCA) study, which had “invited 16734 pregnant women expected to deliver between 1 April 1991 and 31 April 1992 resident in the former county of Avon (England) to participate.”
  • Information on pet ownership was reported “by mothers via postal questionnaires during pregnancy, and subsequently when their child was aged 8, 21, 31 and 47 months.”
  • “At approximately ages 13 and 18 years, children attended clinic visits where they were administered the psychotic-like symptoms interview (PLIKSi), a semi-structured interviewer-rated screening assessment for PEs [psychotic experiences].”
  • Statistical analysis was done. The authors used logical regression to consider if cat ownership had an association with psychotic experiences, and adjusted for socioeconomic factors (like overcrowding).


Here’s what they found:

  • The sample: 6,705 at age 13 and 4,676 at age 18 had complete data on psychotic symptoms. Of those, 776 (11.57%) and 370 (7.91%) had psychotic symptoms that were suspected or definite at 13 and 18 years, respectively.
  • Demographically: The youth included in the study included slightly more female than male (51.03% at age 13), were overwhelmingly white (96.05%), and had a mother who has married (81.24%).
  • “Cat ownership in pregnancy was not associated with psychotic symptoms at age 13 or 18 years in either univariable (age 13: OR 1.15; age 18; OR 1.08) or in multivariable (age 13: adjusted OR 1.15; age 18; OR 1.08) models…”
  • “Owning a cat at age 4 years was associated with higher odds of having PEs at age 13 years in univariable models (OR 1.23), but this effect was no longer significant after multivariable adjustment (OR 1.18).
  • “There was no evidence that cat ownership at age 4 years was associated with PEs at age 18 years (univariable OR 1.11; adjusted OR 0.97).”


In sum:

We found no evidence that cat ownership in pregnancy or childhood was associated with PEs in early and late adolescence using prospectively collected data from a large population-based cohort, following control for several confounders and methods that investigate the likely impact of missing data.”


A few thoughts:

  1.  This is a good study.
  2.  The research question is topical and catchy. This paper was picked up widely, including CNN.
  3.  On the results, lead author Francesca Solmi commented: “The message for cat owners is clear: there is no evidence that cats pose a risk to children’s mental health…” But why do these results differ so greatly from the earlier literature? This paper had a significantly different methodology – among other things: they did a cohort study with data stretching for years; in the statistical analysis, the authors also sought to rule out other factors.
  4. The authors did weigh this, and argue for the strength of their approach. They also question earlier studies: “Previous reports of positive associations between cat ownership and schizophrenia may therefore have been attributable to Type I error, particularly given the small sample sizes and lack of control for confounders inherent to some studies.” But by attempting to statistically eliminate confounders, did they end up compromising the data? In a CNN interview, researcher E. Fuller Torrey – who was the lead author on several papers on schizophrenia and cat ownership – suggested as much (specifically about overcrowding). The CNN article can be read here:


Cat ownership not linked to mental health problems, study says – CNN


Housing and Homelessness

 “Doctors could prescribe houses to the homeless under radical Hawaii bill”

-Liz Barney

guardian, 28 February 2017 Online


“One day last month, Stephen Williams asked a passerby for help and then collapsed on the sidewalk. When the ambulance arrived in downtown Honolulu, his temperature was well over 104F.

“A life-threatening staph infection had entered his bloodstream. Williams, who lives on the dusty streets of Chinatown, spent seven days hooked to an IV, treatment that can cost $40,000, according to the hospital that admitted him. But Williams didn’t pay: the bill was covered by government dollars in the form of Medicaid. Over the past four years, he has been to the hospital for infections 21 times, he said, a consequence of psoriasis flare-ups in a humid climate and unsanitary conditions.

“Cases such as these have prompted a groundbreaking new proposal in Hawaii. Instead of prescribing medication to homeless patients like Williams, what if doctors could prescribe something else that might ameliorate their health problems more effectively? The prescription would be housing.”

Liz bamey
Liz Barney

So begins a Guardian article by Liz Barney. The article describes the effort of State Senator Josh Green, who is a physician, to classify homelessness as a medical condition. People then could be “prescribed” housing.

The article notes the connection between homelessness and health costs.

  • In a recent study by a Hawaiian insurer, a small percentage of Medicaid users account for over half of the $2 billion of annual spending; high needs users were often dealing with homelessness.
  • Housing reduces health care costs for the homeless by 43%.
  • Green notes that health spending on some homeless is $120,000 but housing would be just $18,000.

 The article continues by noting supporters and critics of the approach. Kimo Carvalho of the Institute for Human Services notes the need for targeted funding, particularly in light of people “walking out” of housing.


A few thoughts:

  1.  The debate in Hawaii, like much of North America, has changed dramatically in recent years. A few years ago, Hawaii had strict laws on homelessness; today, Housing First is discussed. The Economist wrote about Hawaii and homelessness here:   Homelessness in Hawaii: Paradise Lost – The Economist
  2. Housing First is an active area of research. I’ll note the incredible work done in the area – and the Canadian connection. And, of course, we have looked at this in past Readings. See, for example:  Reading of the Week:  Housing First and At Home/Chez Soi – David Gratzer
  3. What a great public-policy debate to watch unfold. #Progress


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


Dr.  David Gratzer

1st Break 2nd Break

One trait of a successful blog is content.  This new segment will be broken up in two parts.  1st Break, which focusing on articles & news related to mental health.  2nd break, focusing on current events affecting our community.

1st Break

Can You Really Solve Mental Health Problems With an App? – (Beth Skwarecki-Vitals via Lifehacker)

If you’re struggling with a problem like anxiety or depression, making an appointment with a professional may be the last thing you feel up to doing. Apps and online services promise that help is just a few taps away, and in some cases they may be the right choice for you.  continue to article…


Why DIY solutions for mental health are on the rise in Toronto – (Michelle Da Silva-Now Toronto)

Eighteen years ago, Shelley Marshall attempted suicide. The writer, performer and mental-health advocate survived, but when it came time to get help, she felt like resources were limited. She wasn’t welcome into a suicide survivors group because her illness wasn’t deemed severe enough. She tried another group for children of survivors (Marshall’s father died by suicide), but also had trouble getting in. After an eight-month wait, she was finally admitted into a program at CAMH.  continue to article…

Video:  No Fixed Address: Rental market for Torontonians on disability ‘absolutely horrible’ – (CBC News)


CAMH’s Queen Street Expansion Breaking Ground This Fall – (Greg Lipinski-Urban Toronto)

A proponent team has been awarded a contract for the development of Toronto’s CAMH Phase 1C on Toronto’s West Queen West. Infrastructure Ontario and the Centre for Addiction and Mental Health (CAMH) have selected a consortium named ‘Plenary Health CAMH’ to carry out the development of two new buildings within CAMH’s 27-acre Queen Street campus, which is bounded by Shaw Avenue on the east and White Squirrel Way on the south and west ends. continue to article… 


2nd Break

2 new cases of Mumps confirmed in Toronto, total up to 28 cases – (680 News)

Toronto’s total number of confirmed mumps cases grew to 28 Tuesday, with two more cases from the Toronto District School Board testing positive for the virus.  The outbreak began last month and an investigation was launched after 14 people tested positive for the virus. continue to article…

Mayor John Tory’s executive committee approves plan for $3.35 billion one-stop Scarborough subway – (Jennifer Pagliaro –the Star)

With no certainty on funding from other levels of government or certainty on costs, Mayor John Tory’s executive committee supported moving ahead with a one-stop subway extension in Scarborough Wednesday.  While critics called the plan estimated to cost at least $3.35 billion an “albatross” that is destined to be a “colossal mistake,” Tory and supporters said they were “diligently” moving ahead with the plan as promised while contradicting evidence from city staff on the benefits of a subway. continue to article…

Are Toronto’s new green bins working?  Dead raccoons may hold the answer – (Jeff Gray –The Globe and Mail)

Suzanne MacDonald, an associate professor of psychology and biology at York University, does research on all sorts of exotic creatures, including apes, lions and even the pandas at the Toronto Zoo. But her work on that infuriatingly ingenious masked urban pest, the raccoon, inevitably gets all the attention. For her current project, every few months she takes a baby scale and a measuring tape and writes down the weight and length of up to 20 frozen, dead raccoons, collected by city staff after run-ins with cars. continue to article…


Feel free to comment on any of the linked articles!

-Mental Notes