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

ObjectivesThis study provides an overview of the key medico-legal issues associated with attempted or completed suicide in Canada. Specifically, we identify factors that were criticized and found to contribute to medico-legal risk in these cases.MethodsA national repository was retrospectively searched for cases involving patients who attempted or completed suicide while under the care of a physician. The study included cases closed at the Canadian Medical Protective Association between 2013 and 2023. The study involved in- and outpatients who attempted or completed suicide. The frequencies and proportions of patient safety events and medico-legal risks for physicians were calculated by exploring factors that contributed to each incident.ResultsA total of 378 cases were identified, involving 460 physicians. The majority of patients in these cases experienced a healthcare-related harm (224/378, 59%). Psychiatrists were involved in 61% (231/378) of cases. The most common reasons for patient/family complaints were deficient assessments, diagnostic errors, and communication breakdowns with the patient or their family. The most common contributing factors identified by peer experts were deficient assessments of a suicidal patient and inadequate documentation.ConclusionsThis study addressed the gap in the published literature of healthcare-related contributing risk factors associated with a patient safety incident from Canadian medico-legal cases. The most common omissions identified by peer experts were comprehensive assessment and clear documentation. Physicians treating suicidal patients may reduce their medico-legal risk by completing and documenting thorough and timely suicide risk assessments.Plain Language Summary TitleInvestigation of factors leading to physicians' legal risks when their patients attempted suicide.

ObjectiveIn this study, we evaluated the concordance between urine drug screening (UDS) and self-reported use in a pragmatic randomized clinical trial.MethodsOur data was drawn from OPTIMA, a 24-week pragmatic multicentric open-label randomized-controlled trial comparing flexible take-home dosing of buprenorphine/naloxone to the methadone standard model of care for treating prescription-type opioid use disorder. A total of 272 participants were randomized (1:1 ratio) to methadone or buprenorphine/naloxone. Following treatment initiation, participants were followed-up every 2 weeks for 24 weeks. During each visit, participants provided urine samples for UDS and self-reported their substance use over the past 2 weeks. Self-reported use was dichotomized to align with UDS detection windows. Tetrachoric correlations and 2 × 2 contingency tables were used to estimate the sensitivity, specificity, positive predictive value and negative predictive value of self-reported use. A generalized linear mixed model assessed how substance type, time in the study, treatment assignment, study site, unstable housing, and sex impacted self-report accuracy.ResultsSignificant differences were found between substance types (p < 0.001) and study sites (p < 0.001). Fentanyl, cannabis, and amphetamines consistently showed the greatest concordance between measurement methods. Hydromorphone, oxycodone, heroin, and benzodiazepines had low sensitivity and low positive predictive value. Participants from Québec showed higher concordance between UDS and self-reported use compared to those from British Columbia, Alberta, and Ontario. There was no moderating effect of treatment assignment (p = 0.174), time in the study (p = 0.221), unstable housing (p = 0.733), or sex (p = 0.321) on the concordance between UDS and self-reported use.ConclusionsOur results indicate that concordance between UDS and self-reported use is impacted by several factors. Combining UDS and self-reported use could help provide a more accurate assessment of substance use.Clinical trial registrationThis study was registered in ClinicalTrials.gov (NCT03033732).

BackgroundSchizophrenia brings about diverse challenges to patients, their families and society. It is up to the healthcare system to effectively resolve these concerns and benefit all involved parties. With the emerging development and adaptation of virtual reality (VR), this may offer a new direction and potential for treating people with schizophrenia. Our goal was to employ meta-analysis to evaluate the influence of VR on the clinical outcomes and quality of life in people with schizophrenia.MethodsWe performed an extensive screening of randomized controlled trials (RCTs) examining the effect of VR on the clinical outcomes in people with schizophrenia. Our search included the scientific databases PubMed, Embase, Web of Science and the Cochrane Library, and included RCTs from the date of database establishment till 1 June 2023 and we followed a strict study of inclusion and exclusion criteria. The meta-analysis was conducted in RevMan 5.4.ResultsWe selected 963 patients from 10 RCTs. Relative to other forms of interventions, VR therapy considerably alleviated overall clinical (SMD = -4.33, 95% CI = [-6.92, -1.74], P = 0.001) and negative symptomology (SMD = -1.38, 95% CI = [-2.46, -0.30], P = 0.01) among in people with schizophrenia. In contrast, no significant improvements were observed in positive symptoms or quality of life among these patients. Further subgroup analyses of the results indicated that there were differences in the improvement of negative symptoms among patients across the different interventions (P = 0.01).ConclusionsBased on our meta-analysis, VR-based treatment regimen significantly improves overall and negative symptoms in people with schizophrenia. Further exploration is warranted to elucidate the influence of VR on patient positive symptoms and quality of life.

ObjectivesThis study aimed to implement an artificial intelligence-assisted psychiatric triage program, assessing its impact on efficiency and resource optimization.MethodsThis project recruited patients on the waitlist for psychiatric evaluation at an outpatient hospital. Participants (n = 101) completed a digital triage module that used natural language processing and machine learning to recommend a care intensity level and a disorder-specific digital psychotherapy program. A psychiatrist also assessed the same information, and the decisions for care intensity and psychotherapy programs were compared with the artificial intelligence recommendations.ResultsThe overall wait time to receive care decreased by 71.43% due to this initiative. Additionally, participants received psychological care within three weeks after completing the triage module. In 71.29% of the cases, the artificial intelligence-assisted triage program and the psychiatrist suggested the same treatment intensity and psychotherapy program. Additionally, 63.29% of participants allocated to lower-intensity treatment plans by the AI-assisted triage program did not require psychiatric consultation later.ConclusionsUsing artificial intelligence to expedite psychiatric triaging is a promising solution to address long wait times for mental health care. With future accuracy refinements, this could be a valuable tool to implement in hospital settings to assist care teams and improve mental health care. This could result in increased care capacity and improved workflow and decision-making.Plain Language Summary TitleEvaluation of AI and Online Psychotherapy Initiative to Improve Psychiatric Care Access and Efficiency.

ObjectiveElectroconvulsive therapy (ECT) is an important but underused treatment for severe psychiatric illnesses. We sought to examine the variability of ECT utilization at a population level and between several subgroups. We also sought to quantify the impact of the COVID-19 pandemic on ECT utilization.MethodsWe used population level data from Ontario to examine all ECT procedures administered from 1 January 2007 to 31 December 2023. Our primary measure of variability was the rate of ECT procedures per 1,000 population. We included three subgroups at time of ECT procedure: age (18-39, 40-64, and 65+), biologic sex (male/female), and Ontario Health (OH) region of residence (West, Central, Toronto, East, North West, North East). To quantify the impact of the COVID-19 pandemic we calculated the change in ECT rate from 2019 to 2020 (acute effect) and 2019 to 2023 (persistent effect).ResultsThere were 450,381 ECT procedures delivered during the observation period. The yearly rate of ECT increased from 1.69 per 1,000 in 2007 to a peak of 3.08 per 1,000 in 2019. In 2023 the greatest per capita rates of ECT use were in the 65+ age group, female sex, and North East geographic region. In 2023, the rates of ECT use in different geographic regions ranged from 1.28 (North West) to 4.19 per 1,000 (North East). The COVID-19 pandemic resulted in an immediate 26.73%, followed by a 17.47% persistent drop in the rate of ECT with notable regional heterogeneity.ConclusionsWhile ECT use increased over time, there were differences in this increase between age groups, biological sex, and geographic regions. The COVID-19 pandemic had significant immediate and persistent impacts on the rates of ECT use highlighting the need for ongoing population level monitoring of this important treatment.Plain Language Summary TitleElectroconvulsive therapy volume in Ontario from 2007 to 2023.

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.