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

ObjectiveThe current supply and distribution of child psychiatrists in Ontario is not well understood, making it difficult to effectively plan mental healthcare services for children and adolescents. Therefore, we developed a data-driven definition of psychiatrists who focus on treating child and adolescents, and described their demographic characteristics, geographic distribution, and practice patterns across Ontario in 2023.MethodA cross-sectional study was employed using administrative data from ICES. All practicing Ontario-based psychiatrists, defined as those submitting at least one billing claim to the Ontario Health Insurance Plan were included. Psychiatrists from the years 2013-2023 were included to create the definition of child-focused psychiatrists. Child-focused psychiatrists were defined as those with ≥50% or more of their patients ≤18 years of age. Then, this definition was applied to psychiatrists in 2023 to compare and descriptively summarize data (e.g., age, sex, rurality of practice location, and practice patterns) between child- and adult-focused psychiatrists.ResultsIn 2023, there was a total of 259 child-focused psychiatrists and 2,099 adult-focused psychiatrists in Ontario. Child-focused psychiatrists were younger (mean age ± SD: 55.8 ± 9.3 vs. 60.1 ± 11.5, p < 0.001), more likely to be female (59.1% vs. 46.2%, p < 0.001), and less likely to work in rural regions than adult-focused psychiatrists. Both, on average, saw a similar number of patients overall (276.7 ± 265.9 vs. 329.3 ± 403.1, p = 0.115), but child-focused psychiatrists saw patients less frequently than adult-focused psychiatrists (3.0 ± 1.8 vs 6.5 ± 9.1, p<0.001). Child-focused psychiatrists were less likely to have small patient panels as well (p < 0.001).ConclusionsChild-focused psychiatrists represent a small proportion of the psychiatric workforce in Ontario, with particularly limited availability in rural regions. Compared to adult-focused psychiatrists, they are less likely to maintain smaller practices and they see their patients less frequently.

Plain Language Summary TitleCitalopram vs. Escitalopram for major depression: No Real Difference in Efficacy or Safety, Just Higher Cost.Plain Language SummaryBackground:Citalopram is an antidepressant. Escitalopram is a closely related drug-basically a slightly modified version of citalopram-that drug companies promote as being safer, more effective, and faster acting. In Canada, escitalopram costs about twice as much as citalopram. We wanted to know how these two drugs are actually used in British Columbia and whether escitalopram really works better or is any safer.What We Did:We looked at prescription records for the nine most common antidepressants in BC between 2005 and 2024. We also reviewed all the studies that directly compared citalopram with escitalopram. We focused on whether any differences were large enough to matter to patients, whether study results were reliable, and whether studies had problems such as bias or conflicts of interest.What We Found:By 2013, escitalopram had become the most prescribed antidepressant in BC, while citalopram use dropped. We found 16 studies that compared the two drugs. Many had problems such as missing data, selective reporting, or funding from the drug manufacturer. None of the studies showed meaningful differences in effectiveness. Claims that escitalopram works faster were weak and inconsistent. Side effects were essentially the same, including risks for heart rhythm changes (QT prolongation).

ObjectivesCurrent pharmacological antidepressant treatments suffer from low remission rates and slow initiation of therapeutic effects. In addition, the development of new antidepressant treatments is confounded by the lack of consensus on efficient and valid neurophysiological targets. Temporal complexity is an alternative measure of dynamic brain activity that estimates brain signal variability at several timescales. It can be easily extracted from non-invasive brain recordings and provides new insights into pathophysiological mechanisms. We aim to assess the potential of brain temporal complexity as a novel neuromarker to predict the effectiveness of antidepressant treatments.MethodWe measured longitudinal changes in temporal complexity of electroencephalography signals in patients undergoing 8 weeks of escitalopram treatment through a Canadian Biomarker Integration Network in Depression (CAN-BIND) trial.ResultsAs early as 2 weeks after the start of treatment, reduction of complexity in fine timescales was associated with improvement in depressive symptoms. After 8 weeks of treatment, the treatment-related effect shifted towards an increase in coarse timescale complexity, linked to symptom improvement.ConclusionsThese results suggest a relative shift away from local, segregated information processing, measured by complexity at fine timescales, in the short term, potentially in favour of a higher long-range communication across networks, as indicated by higher complexity measures at coarse timescales in the long term. Further research into the modulation of multiscale temporal complexity by antidepressant treatments could open new possibilities for faster-acting and more efficient treatments.

BackgroundGuidelines for treatment-resistant schizophrenia (TRS) advocate for a trial of clozapine monotherapy before the consideration of antipsychotic augmentation. Commonly cited justifications for augmentation include inadequate response to clozapine monotherapy and the potential to lower the necessary clozapine dose or serum concentration, thereby reducing dose-dependent adverse effects. Nonetheless, the degree to which these outcomes are realized in routine clinical practice, particularly among individuals with concurrent disorders, remains uncertain. This study aimed to explore the extent to which clozapine monotherapy is utilized before the initiation of antipsychotic augmentation strategies, and to assess the effects of antipsychotic augmentation on clozapine serum concentrations and the incidence of related adverse effects.MethodsWe retrospectively analyzed clinical and drug monitoring data from 80 adults with TRS and substance use disorder (SUD) comorbidity at a provincial inpatient centre for concurrent disorders. Antipsychotic augmentation was quantified using Defined Daily Dose (DDD). Generalized and linear mixed models compared the impact of monotherapy vs. augmentation on clozapine serum levels and adverse effects, adjusting for covariates.ResultsMost patients receiving antipsychotic augmentation (78%) did not have an adequate trial of clozapine monotherapy. Analysis revealed that clozapine with antipsychotic augmentation was modestly and negatively associated (B = -0.039; 95% CI = -0.078 - -0.001) with clozapine serum concentrations, particularly at higher DDD (≥2). Clozapine with antipsychotic augmentation was not associated with reduced incidence of dose-dependent adverse events (tachycardia, constipation, or overall anticholinergic medication use).ConclusionFindings from this study indicate that commonly cited rationales for combining clozapine with antipsychotic augmentation - namely, enhancing tolerability through clozapine dose reduction or mitigating inadequate response to monotherapy - are not consistently supported by real-world outcomes. These results underscore the necessity for clinical guidelines to incorporate context-sensitive recommendations that address the complexities inherent in managing individuals with TRS and comorbid SUDs, while integrating real-world considerations and the perspectives of those with lived experience.

BackgroundDespite well-known benefits of family involvement and interventions, gaps remain in their implementation in early intervention for psychosis. Guidelines have been developed for early psychosis services to bridge evidence-implementation gaps. Little attention has been paid to their nature, quality and recommendations regarding family involvement and interventions. We aimed to identify, describe, and appraise family-focused recommendations in Canadian early psychosis guidelines.MethodsWe conducted a systematic review (PROSPERO#CR042020208974), including Canadian guidelines/standards for first-episode psychosis/early intervention in psychosis, or for psychosis/schizophrenia with a section on first-episode psychosis/early intervention for psychosis. The search was conducted in Google and Google Advanced of 58 websites (April 2024). From each document, bibliographic information and family-focused recommendations were extracted. All family-focused recommendations were subject to content analysis and mapped against a patient and family engagement framework. All guidelines were appraised using Appraisal of Guidelines Research & Evaluation-Recommendation EXcellence (AGREE-REX), assessing rigor and implementability. Family-focused recommendations were rated on three AGREE-REX items. Findings were narratively synthesized.ResultsSeven documents were included, with five provincial early psychosis guidelines and two Canada-wide schizophrenia-spectrum guidelines. 96 family-focused recommendations were extracted covering 21 themes (19 appeared in ≤4 guidelines; two (family psychoeducation; involving families in treatment-planning) in five guidelines). No guidelines had recommendations regarding families in inpatient care; only two guidelines had recommendations for navigating consent vis-à-vis family involvement. 77.4% of recommendations were about direct care; 22.5% about involving families in organizational design/governance; and none about policymaking involvement. AGREE-REX ratings for relevant outcomes and local applicability were lower for family-focused recommendations than overall guidelines. Most guidelines fared poorly in eliciting families' values/preferences.ConclusionFew family-focused recommendations featured consistently across early psychosis guidelines. There was little guidance on navigating barriers to family involvement. Our analysis revealed critical gaps, including in viewing families as partners in treatment decision-making and services/policy design. Future guidelines must integrate stakeholders' values/preferences and guidance on real-world implementation.

Objective: To identify sociodemographic, lifestyle, and psychological correlates of flourishing mental health (i.e., feeling good and functioning well) in a population-based sample of young adults.

Method: Data for this cross-sectional study were drawn from the ongoing Nicotine Dependance in Teens study, Québec, Canada. Of 799 participants in cycle 23, 792 (mean (SD) age = 30.6 (1.0) years) provided data on positive mental health using the Mental Health Continuum - Short Form (MHC-SF) and were retained for analysis. Each potential correlate was studied in an unadjusted model, a model adjusted for age and sex, and a model adjusted for age, sex and other covariates related to the specific correlate of interest.

Results: Of 792 participants retained for analysis, 39.4% (39.9% of females; 38.8% of males) reported flourishing mental health. Variables associated with higher odds of flourishing included attended university (OR: 1.44 [1.05, 1.99]), being in a relationship (OR: 1.64 [1.22, 2.21], being employed (OR: 1.97 [1.27, 3.11]), high sleep quality (OR: 3.45 [2.53, 4.73]), meeting leisure screen time guidelines (OR: 2.12 [1.59, 2.85]), and relatively high levels of coping ability (OR: 3.11 [2.58, 3.80]). Variables associated with lower odds of flourishing included living alone (OR: 0.58 [0.38, 0.86]), relatively low household income (OR: 0.37 [0.20, 0.64]), and high depressive (OR: 0.05 [0.01, 0.15]) and anxiety (0.17 [0.09, 0.29]) symptoms.

Conclusions: Sociodemographic (education, relationship status, employment status, and income), lifestyle (sleep, screen time), and psychological (coping ability, depressive and anxiety symptoms) factors are correlates of flourishing mental health in this population-based sample of young adults. Results provide a foundation for future research to inform the development of effective programs targeting specific subgroups to promote positive mental health in young adults.

ObjectivesEarly psychosis intervention (EPI) programs play a crucial role in detecting and treating psychosis early, yet disparities in access persist. This study aimed to assess the spatial accessibility of EPI programs in Toronto, Canada, and to explore the association between access and indicators of neighbourhood-level marginalization.MethodsWe conducted a geospatial analysis using floating catchment area and two-step floating catchment area methods, examining EPI program locations, census population estimates for the 158 Toronto neighbourhoods, and area-level marginalization data. Spatial regression models were used to estimate the association between marginalization factors and spatial accessibility.ResultsOn average, the closest EPI program is 4 km away from the centre of any given neighbourhood (range 0.8-11 km), with variability across the city. Clustering is observed in some neighbourhoods, indicating better spatial accessibility, whereas other neighbourhoods face lower access. A full spatial regression model showed increasing levels of housing and dwelling marginalization, as well as material resource marginalization, to be associated with better access.ConclusionWe identified neighbourhoods that have poorer spatial accessibility to EPI services. Some neighbourhood-level marginalization indicators previously found to be associated with psychosis risk are also associated with better spatial accessibility. It is notable that EPI services in Toronto may be located where they are most needed the most. The study underscores the importance of geospatial analyses to identify and address geographic distance as a potential source of disparity in access.

Background: Suicide is a leading cause of mortality among youth globally. Evidence suggests that individuals with physical illness, mental illness, or neurodevelopmental disorders are at increased risk of suicide. However, few studies have estimated the prevalence of suicidal ideation and suicide attempts among youth with compounding health burdens. The purpose of this study is to estimate the prevalence of suicidal ideation and suicide attempts and their associations across morbidity status among youth in Canada.

Methods: Data come from 6,915 youth aged 15-17 years (49% female) enrolled in the 2019 Canadian Health Survey on Children and Youth. The person most knowledgeable or the youth themselves provided responses regarding sociodemographic characteristics, morbidity status, and indicators of suicide. The prevalence of suicidal ideation (past year) and suicide attempts (lifetime) were compared across morbidities (none, physical illness only, mental illness only, neurodevelopmental disorder only, and multimorbidity). Logistic regression models estimated adjusted associations between morbidity status and suicidal behaviour.

Results: Suicidal ideation and suicide attempts were most commonly reported by youth with mental illness only (32%, 18%) and multimorbidity (28%, 19%). While all morbidities were associated with indicators of suicide, the strongest association was found between multimorbidity and suicide attempts odds ratio = 5.2 (3.4, 8.0).

Conclusions: These contemporary estimates of youth in Canada suggest that suicidal ideation and suicide attempts are common and reinforce the need for integrated physical and mental health services for youth with multimorbidity to reduce the incidence. Research investigating causal mechanisms of the intersections between physical illness, mental illness, neurodevelopmental disorders, and suicide is needed.Plain Language Summary Title:Morbidity, suicidal ideation and suicide attempts among youth in Canada.

ObjectivesDelayed sleep-wake phase disorder (DSWPD) most commonly affects young individuals (adolescents and young adults), but it is often undetected in clinical practice. Despite several reports suggesting a link between DSWPD and depression, no systematic review has investigated this association. The aim of this systematic review was to determine whether DSWPD is associated with depression among young individuals.MethodsMEDLINE, EMBASE, PsycINFO, and CINAHL Plus were searched up to 29 July 2024. Primary studies investigating DSWPD and depression among young individuals were eligible. Methodological quality and risk of bias was assessed with the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Common-effect models were conducted to examine the relationship between DSWPD status (categorical variable: yes or no) and depression severity (continuous variable). PROSPERO ID: CRD42023458889.ResultsSixteen studies were included with 766 participants being evaluated against the diagnostic criteria for DSWPD from the International Classification of Sleep Disorders. Thirteen out of 15 studies demonstrated that young individuals with DSWPD had a significantly greater severity of depressive symptoms than young individuals without DSWPD. NIH quality assessment scores ranged between 5 and 9 (out of a total of 11). DSWPD status had a significantly large effect on depression severity in the common-effect model (N: 16 estimates, 693 participants, Cohen's d = 0.92, 95% confidence interval (95% CI) [0.76-1.08]). The subgroup analysis also demonstrated significant findings with the common-effect model that only utilized data from studies that controlled for psychiatric disorders (N: 12 estimates, 535 participants, Cohen's d = 0.88, 95% CI [0.70-1.06]).ConclusionsDSWPD is associated with a greater severity of depressive symptoms among young individuals. Although more research is required to understand this association, it may be useful to consider the presence of DSWPD when managing young individuals who present with persistent sleep disturbances (e.g., sleep-onset insomnia) and depressive symptoms.