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

BackgroundEmerging evidence suggests overlap in brain areas implicated in the pathophysiology of bipolar I disorder (BD-I) and vestibular activity in the brainstem, potentially underlying the postural instability observed in BD-I. Computerized Dynamic Posturography (CDP), a validated tool that quantifies the functional contributions of somatosensory, visual, and vestibular inputs, as well as the central mechanisms responsible for integrating these inputs, was employed to examine the sensory processing and postural control in BD-I.Aims and ObjectivesTo investigate the integrity of dynamic postural control and the contributions of somatosensory, visual, and vestibular sensory systems to postural stability in individuals with BD-I in remissionMethodThirty participants aged 18-50 years with BD-I in remission (ICD-11; female = 12), not on known vestibular suppressants, and 30 matched controls (female = 13) underwent CDP, which included the Sensory Organization Test (SOT), adaptation test, Motor Control Test (MCT), fall risk test, and Optokinetic test (OKN). The differences between the groups were assessed using an independent samples t-test.ResultsBD-I participants showed significantly poorer scores on SOT, fall risk test, and OKN test (all p < 0.005). We did not find significant differences in the adaptation test and MCT.Discussion and ConclusionsBD-I subjects exhibited greater postural alterations compared to healthy controls, indicating impaired sensory integration, especially when visual input was altered. Fall risk and OKN tests suggest central deficits in processing vestibular and proprioceptive input. These findings support postural control assessment as a potential biomarker for BD-I, though medication effects remain an important consideration.

Background: Subjective cognitive complaints, or neurocognitive insight, reflect to patients' awareness of cognitive functioning. In schizophrenia, these complaints show inconsistent links with objective cognition, psychiatric symptoms, and illness insight. The Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS), a validated self-report tool developed in Canada and used internationally, enables a homogeneous synthesis. Objective: This meta-analysis examined whether subjective complaints measured with the SSTICS are associated with objective cognition, psychiatric symptoms, and illness insight, and reviewed its factorial structure. Method: We conducted a meta-analysis following PRISMA guidelines. Systematic searches of PubMed, Web of Science, and Google Scholar identified studies using the SSTICS in psychiatric populations. Eligible studies compared patients to healthy controls and/or examined correlations with cognition, symptoms, or illness insight or conducted factor analyses of the SSTICS domains. Results: Twenty-five studies (N = 3,205) met criteria. Schizophrenia patients reported more cognitive complaints than controls (d = 0.746). No significant correlation emerged with global objective cognition (r = 0.105). Complaints were unrelated to positive, negative, or general symptoms but showed a moderate association with depressive symptoms (r = 0.300) and a small one with illness insight (r = 0.155). Factor analyses consistently identified 3 domains: memory, attention, and daily living. Conclusions: SSTICS-based complaints are substantial in schizophrenia but largely dissociated from objective cognition, reflecting impaired neurocognitive insight. Instead, they are more strongly linked to depressive symptoms, suggesting complaints reflect emotional distress rather than actual deficits. Findings support refining SSTICS subscales and extending investigations to other psychiatric populations.

BackgroundIndividuals with psychotic disorders face an elevated risk of suicide, yet current assessment tools often lack adaptations for this population's unique clinical realities. No standardized guidelines exist specifically for assessing suicide risk in psychosis, contributing to variability in clinical practice.MethodsA two-round Delphi survey was conducted with 42 professionals specializing in suicide prevention or psychotic disorders. Participants rated the relevance of 100 items related to suicide risk assessment and potential systemic facilitators. The top 35 items from the first round were retained for further prioritization in the second round. Descriptive statistics were used to analyze consensus levels.ResultsOnly eight out of 29 systemic factors received strong support, mostly related to the availability of practical tools and structural supports. Of the 71 risk assessment items, 35 surpassed the 4.25/5 relevance threshold. Highest consensus was found for items related to suicidal ideation and planning, such as intent, method, and access to means. Protective factors were also endorsed, while psychological/internal states (e.g., burdensomeness) were rated less relevant.DiscussionFindings underscore clinicians' emphasis on immediate risk and practical tools over abstract internal states. Results advocate for developing standardized, population-specific assessment protocols that balance risk and protective factors in individuals with a psychotic disorder.

ObjectiveCognitive impairment is a core feature of schizophrenia spectrum disorders. Our previous study on a first-episode psychosis cohort showed that symptoms related to impoverished/disorganized communication and motor impoverishment predicted verbal and working memory scores, respectively. This study aimed to explore those predictors in people across the range of illness chronicity.MethodsWe employed iterative Constrained Principal Component Analysis (iCPCA) to investigate the relationship between 15 cognitive measures from the MATRICS battery, including processing speed, attention, working, verbal and nonverbal memory, reasoning, and problem-solving, and 27 Positive and Negative Syndrome Scale (PANSS) items in 198 outpatients from two sites in Australia and one in Canada. The iCPCA method was used to determine symptoms that reliably predict specific combinations of cognitive measures while controlling Type I errors.ResultsWe found that a verbal memory and learning component was predicted by the PANSS item Lack of Spontaneity and Flow of Conversation, and a visual attention/working memory component was linked to the PANSS item Motor Retardation.ConclusionsThese accord with our previous findings in an early psychosis sample, that is, negative symptoms of diminished expression are key predictors of cognitive abilities in schizophrenia. Namely, communication and motor impoverishments predicted lower scores on tests of verbal memory, learning, visual attention, and working memory. These findings may inform personalized treatment approaches targeting cognitive deficits and negative symptoms in schizophrenia.

BackgroundIn 2023/2024, there were 15 psychiatrists/100,000 Canadians with inequitable distribution across Canada and unprecedented demand for mental health and addiction services. Psychiatry human resource planning in Canada has not occurred for more than a decade. The objectives of this study were to understand the current state and future directions related to Psychiatry Human Resources in the Canadian mental health care system.MethodsUsing Delphi methods, we surveyed the 17 chairs of the academic departments of psychiatry in Canada and held focus groups. The Royal College and subspecialty programs were also engaged. Themes were extracted, summarized and refined. The refined themes were distributed via an online survey to all 17 chairs for final review and input, ensuring alignment and consensus across institutions.ResultsCommon themes focused on: the role of psychiatrists working in teams to provide care for complex mental disorders and addictions; need for innovative models of care including use of physician extenders, technology to reach the larger population of patients with mild to moderate disorders, working closely with primary care in collaborative care models. Due to the large proportion of Canadian psychiatrists being 35 years or more in practice (26%) and close to retirement, the chairs supported the need to expand the number of residency positions for psychiatry and continue strong recruitment efforts for international medical graduates. Although the majority of chairs supported shortening the general psychiatry residency program from 5 to 4 years, the Association of Chairs of Psychiatry of Canada (ACPC) could not reach a consensus on this issue. Pan-Canadian licensing for psychiatrists should be considered due to inequitable distribution of psychiatrists in Canada and advances in virtual care post-COVID-19 pandemic.ConclusionsThis study will contribute to the dialogue on psychiatry human resources planning in Canada.

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.

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.