Canadian Journal of Psychiatry-Revue Canadienne De Psychiatrie最新文献

BackgroundTrials of deep brain stimulation (DBS) to the subcallosal cingulate gyrus (SCG) for treatment-resistant depression (TRD) have yielded mixed results. While open-label studies suggest effectiveness, randomized controlled trials (RCTs) have not consistently supported these findings. The study compared the efficacy of active versus sham SCG stimulation for TRD.MethodsParticipants (n = 35) in a major depressive episode and treatment resistance completed a 6-month double blind, crossover RCT, with an 18-month open-label phase. A Balaam design was applied with participants randomized to 1 of 4 stimulation groups over two 3-month phases. The primary outcome was a change in Hamilton Depression Rating Scale (HDRS) score at 6 months, with response defined as ≥50% reduction in HDRS-17 scores.ResultsWhile all groups showed improvement at 3 and 6 months, no significant differences were found among them. The OFF-OFF group had a numerically lower HDRS-17 score compared to the ON-ON group at the end of the RCT. No unexpected adverse events occurred. During the open-label phase, participants showed sustained reduction in HDRS-17 scores at 12, 18, and 24 months post-implantation, with successive observed-case response rates of 65.7%, 69%, and 73.1%, respectively. Improvements in life functioning were also noted.ConclusionsThis trial represents the largest single-centre, sham-controlled study of SCG DBS for TRD in the literature. Although the RCT showed no significant group differences, most participants achieved response during the open-label phase. Safety outcomes aligned with previous trials. Future RCTs should integrate insights from the past decade of DBS for TRD research to optimize outcomes. Key considerations include selecting DBS contact locations that ensure engagement of critical white matter tracts, employing novel and sufficiently long clinical trial designs to account for the non-specific effects of the DBS procedure, as well as incorporating biomarkers to guide DBS programming.

Objective: In the age of social media, public perception of borderline personality disorder (BPD) is shaped as much by clinical settings as by online comments. This study aimed to explore how internet users react to TikTok videos about BPD. The primary objective was to identify emerging themes in the comments and to better understand social perceptions of BPD in the digital space.

Method: A qualitative study was conducted, based on the systematic collection of 25,197 comments from 141 public TikTok videos about BPD. A representative sample of comments was extracted and subjected to thematic analysis using a categorical iteration method. Themes and sub-themes were identified inductively, based on rigorous coding and cross-validation among evaluators.

Results: The results reveal a strong concern among internet users regarding diagnostic confusion between BPD and other psychiatric disorders, particularly autism spectrum disorder and ADHD. The issue of self-diagnosis and self-treatment is frequently addressed, reflecting a need for identity appropriation and mistrust of professional diagnoses. The impact of BPD on interpersonal relationships is widely discussed, ranging from relationship tensions to coping strategies. The ambivalent role of social media is highlighted, both as a source of support and a vehicle for misinformation. Finally, internet users report experiences of social isolation, stigmatisation and fear of being labelled, emphasising the importance of emotional support in the recovery process.

Conclusions: TikTok is becoming a space for building mental health identities for people living with BPD. Our findings call for the development of digital education initiatives and targeted interventions to counter stigma and support care pathways in the digital environment.

ObjectivePatients with intellectual and developmental disabilities (IDDs) and psychiatric disorders are at higher risk for prolonged hospitalisations. The aim of this study was to examine the prevalence of IDD among long-stay inpatients in Ontario psychiatric beds, and compare the demographic and clinical profiles of long-stay inpatients with and without IDD.MethodsThis Ontario population-based cross-sectional study used linked health administrative databases. All patients over 18 years of age occupying a non-forensic psychiatric inpatient bed in Ontario on September 30th, 2023 were included in the analysis. We examined prevalence of IDD among patients with a length of stay (LOS) ≥ 365 days ('long-stay patients'). Standardised differences were used to compare demographic, clinical, functional, and health care utilisation characteristics between patients with and without IDD.ResultsOf the 1,466 long-stay patients in an Ontario non-forensic psychiatric inpatient bed, 22.0% had IDD. They were younger (mean age 44.3 vs. 47.6) and a higher proportion were male (64.3% vs. 50.1%). In the 2 years prior to admission, a higher proportion of long-stay patients with IDD had a psychotic disorder (73.3% vs. 54.0%), and they had a higher median number of ED visits (5 vs. 3). Long-stay inpatients with IDD were more likely to have difficulty with activities of daily living (39.8% vs. 15.0%), moderate/severe cognitive impairment (63.0% vs. 29.9%) and fewer social contacts in place to support discharge (59.3% vs. 48.6%). While in hospital, a greater proportion of long-stay patients with IDD were subject to restraints (12.4% vs. 8.0%) and seclusion (20.2% vs. 11.2%).ConclusionsAdults with IDD account for more than one in five long-stay psychiatric inpatients and have unique needs including greater cognitive impairment and difficulty caring for themselves. Successful transitions out of hospital require specialised resources and cross-sectoral collaboration.

BackgroundDeep brain stimulation targeting the subcallosal cingulate (SCC-DBS) is a promising therapy for treatment-resistant depression. However, the lack of a consistent, rapid behavioural response to SCC-DBS complicates the selection of optimal stimulation settings following implantation, requiring a prolonged and burdensome trial-and-error process. Immediate biomarkers of effective stimulation could overcome this problem.MethodsIn this proof-of-concept study, three patients with SCC-DBS implants were scanned at 3 T using a block-design paradigm in which stimulation alternated between "ON" and "OFF" states in 30-s cycles during a single 6.5-min acquisition. Scans were performed using participants' clinically optimized parameters. Blood-oxygen-level-dependent (BOLD) response maps were generated by contrasting DBS-ON and DBS-OFF conditions, and exploratory correlations with clinical outcome-indexed by percentage reduction in Hamilton Depression Rating Scale scores at 12 months-were also assessed.ResultsContrasting stimulation settings enabled the identification of regional BOLD signal changes associated with DBS, revealing consistent hemodynamic changes in several brain regions during active stimulation. Specifically, the precuneus, posterior cingulate cortex, middle frontal gyrus, and frontal pole exhibited decreased BOLD responses during active DBS, while the occipital cortex, middle temporal gyrus, inferior parietal lobule, and superior frontal gyrus showed increased BOLD responses. Exploratory analysis further suggested a potential correlation between precuneus BOLD signal change and clinical improvement (R = -0.98, p_permute = 0.09).ConclusionThese findings speak to the utility of block-design fMRI with cycling DBS stimulation as a tool to identify objective, brain-based biomarkers of effective SCC-DBS, potentially expediting stimulation parameter selection and therapeutic optimization.

ObjectiveAccess to cognitive behavioural therapy (CBT) in Canada is limited by long wait times. Our objective was to determine the optimal dose of CBT sessions for patients to maximize recovery and minimize treatment time.MethodOutpatient data from electronic medical records at a specialized mental health centre between 1 January 2017 and 31 May 2024 was used. The primary outcome was having experienced a reliable and clinically significant improvement (RCSI) in symptoms since start of treatment. Kaplan-Meier estimators were used to determine the percentile who had achieved RCSI after a given number of CBT sessions. Adjusted Cox regression determined predictors of treatment response.ResultsAmong patients (n = 1,853) receiving treatment, 50% showed response in Patient Health Questionnaire-9 (PHQ-9) scores at 7 sessions of low-intensity CBT (LiCBT) and 95% showed response at 23 sessions. For high-intensity CBT (HiCBT), treatment response occurred between 14 and 36 sessions for 50-95% of patients. In Generalized Anxiety Disorder Assessment-7 (GAD-7) scores, treatment response occurred between 8 and 30 sessions in LiCBT and 15 and 37 sessions in HiCBT for 50-95% of patients. Cox regression results found that neighbourhood dependency [PHQ-9: hazard ratio (HR) (95% confidence interval (CI)) = 1.32 (1.08 to 1.63), GAD-7: HR (95% CI) = 1.36 (1.12 to 1.65)] and sex (male) [PHQ-9: HR (95% CI) = 0.83 (0.70 to 0.99), GAD-7: HR (95% CI) = 0.80 (0.66 to 0.96)] were significant predictors of non-response in HiCBT. Older age at admission was a significant predictor of non-response to LiCBT [PHQ-9: HR (95% CI = 0.99 (0.98 to 1.00), GAD-7: HR (95% CI) = 0.99 (0.98 to 1.00)].ConclusionsThere are differences in the dose and the predictors of patients' responses to LiCBT and HiCBT. These results provide insight into potential check-in points for clinicians to assess CBT treatment plans. These results may inform treatment planning, reducing longer than necessary length of stays, allowing for more patients to access mental healthcare services.

Patients with mania are often acutely unwell yet do not meet criteria for involuntary hospitalization. This creates a clinical and ethical dilemma the authors refer to as the liminal zone. These patients refuse treatment despite clear foreseeable harms, but the legal threshold for certification is not met. This situation produces moral discomfort for clinicians, disrupts team consensus, and is often equally distressing for families and friends who recognize impending consequences but lack formal authority to intervene. This article outlines practical approaches for managing liminal-zone patients. First, values-based containment reframes hospitalization using the patient's own motivations. This involves focusing on the protection of their business, relationships, reputation, or other priorities, rather than emphasizing illness. Clinicians may also need to share factual information about regulatory obligations that could apply if safety concerns emerge. Early engagement of family or key supports helps maintain alignment and extends containment beyond the inpatient unit. Second, when discharge appears unavoidable, the focus shifts to preparing a soft landing. This includes arranging next-day outpatient follow-up, offering rapid readmission pathways, communicating clearly with community providers, and documenting the decision-making process. Documentation should outline why legal criteria were not met, the foreseeable risks, and the mitigation strategies that were attempted. Third, the liminal zone affects clinical teams. Manic symptoms fluctuate across short periods of time, which results in different team members observing different presentations. This variability can be mistaken for manipulation. Naming this pattern and acknowledging systemic constraints can help reduce tension and prevent burnout. Liminal-zone patients sit at the boundary between autonomy and safety. Effective management relies on clarity, consistency, and collaboration, with an emphasis on maintaining engagement and creating future opportunities for care.