Assessing research competency development in Canadian psychiatry residency programs: A systematic review and future directions.

Objective: We aimed to conduct a systematic review to identify curricular and educational interventions to build research competency among Canadian psychiatry residents and fellows transitioning to the competency-by-design framework. Methods: The PRISMA guidelines were followed, searching five databases from their inception to February 2023 for relevant evaluation-type studies exploring research competency among psychiatry residents and fellows. We appraised thestudy's quality using the Joanna Briggs Institute's risk of bias tool for observational designs. Results: Overall, 36 original articles met our inclusion criteria. Surveys (n = 10) showed that participation in scholarly research, quality improvement, or educational projects relevant to psychiatry is needed in most residency programs. However, these vary significantly across programs; few need direct research experience for residency completion. The interventions spanned four categories: externally funded comprehensive research training programs (n = 5); resident research tracks (n = 11); workshops and seminars (n = 7); and specific modules (n = 3). Reported outcomes included overall program ratings, research output, and career trajectory. The quality of most studies was low because of the lack of controls or validated metrics for evaluating outcomes. Conclusions: While many studies have explored best practices in research curricula, the current literature does not inform competency-based models for Canadian psychiatry residency programs incorporating research training requirements. Further description is needed from Canadian psychiatric training bodies regarding appropriate curricula, milestones, and metrics for evaluating research competencies.

Postictal Trismus Complicating Electroconvulsive Therapy: A Case Report.

We report a case of a 72-year-old woman who experienced postictal episodes of trismus lasting several minutes on 6 occasions during a series of 18 episodes of electroconvulsive therapy (ECT). There was no clear relationship between the development of trismus and any medications used during the treatments. The patient had no adverse outcomes or discomfort, but the development of trismus can put patients at significant risk.

Making a case for the inclusion of refractory and severe mental illness as a sole criterion for Canadians requesting medical assistance in dying (MAiD): a review.

BACKGROUND: Following several landmark rulings and increasing public support for physician-assisted death, in 2016, Canada became one of a handful of countries legalising medical assistance in dying (MAiD) with Bill C-14. However, the revised Bill C-7 proposes the specific exclusion of MAiD where a mental disorder is the sole underlying medical condition (MAiD MD-SUMC). AIM: This review explores how some persons with serious and persistent mental illness (SPMI) could meet sensible and just criteria for MAiD under the Canadian legislative framework. METHODS: We review the proposed Bill C-7 criteria (capacity, voluntariness, irremediability and suffering) as well as the nuances involved in separating a well-reasoned request for assisted suicide from what might be solely a manifestation of a SPMI. FINDINGS: In this paper, we argue against the absolute exclusion of patients with SPMIs from accessing MAiD. Instead, we propose that in some circumstances, MAiD MD-SUMC may be justifiable while remaining the last resort. Conducting MAiD eligibility assessments removes the need to introduce diagnosis-specific language into MAiD legislation. Competent psychiatric patients who request MAiD should not be treated any differently from other eligible candidates. Many individuals with psychiatric disorders will be incapable of consenting to MAiD. The only ethical option is to assess eligibility for MAiD on an individual basis and include as legitimate candidates those who suffer solely from psychiatric illness who have the decisional capacity to consent to MAiD.

Treatment-resistant major depressive disorder: Canadian expert consensus on definition and assessment.

BACKGROUND: Treatment-resistant depression (TRD) is a debilitating chronic mental illness that confers increased morbidity and mortality, decreases the quality of life, impairs occupational, social, and offspring development, and translates into increased costs on the healthcare system. The goal of this study is to reach an agreement on the concept, definition, staging model, and assessment of TRD. METHODS: This study involved a review of the literature and a modified Delphi process for consensus agreement. The Appraisal of Guidelines for Research & Evaluation II guidelines were followed for the literature appraisal. Literature was assessed for quality and strength of evidence using the grading, assessment, development, and evaluations system. Canadian national experts in depression were invited for the modified Delphi process based on their prior clinical and research expertize. Survey items were considered to have reached a consensus if 80% or more of the experts supported the statement. RESULTS: Fourteen Canadian experts were recruited for three rounds of surveys to reach a consensus on a total of 27 items. Experts agreed that a dimensional definition for treatment resistance was a useful concept to describe the heterogeneity of this illness. The use of staging models and clinical scales was recommended in evaluating depression. Risk factors and comorbidities were identified as potential predictors for treatment resistance. CONCLUSIONS: TRD is a meaningful concept both for clinical practice and research. An operational definition for TRD will allow for opportunities to improve the validity of predictors and therapeutic options for these patients.

A new suicide risk assessment tool in Nova Scotia, Canada.

Suicide is a major public health concern. In Canada, suicide is the ninth leading cause of death in all ages, with a rate of 10.3 deaths per 100,000 people. In Nova Scotia, Canada, 137 suicides were reported in 2016 [1]. Suicide risk assessment (SRA) and management are clinical competencies required for patient care. Strategies used for SRA include the use of formal self-report measures [2], personalized clinical interview however vital information about suicide risk may be missed during that unstructured assessment [3] and structured tool to supplement the clinical interview.

Delivery of electroconvulsive therapy in Canada: a first national survey report on usage, treatment practice, and facilities.

OBJECTIVES: The aims of this study were to document electroconvulsive therapy use in Canada with respect to treatment facilities and caseloads based on a survey of practice (Canadian Electroconvulsive Therapy Survey/Enquete Canadienne Sur Les Electrochocs-CANECTS/ECANEC) and to consider these findings in the context of guideline recommendations. METHOD: All 1273 registered hospitals in Canada were contacted, and 175 sites were identified as providing electroconvulsive therapy; these sites were invited to complete a comprehensive questionnaire. The survey period was calendar year 2006 or fiscal year 2006/2007. National usage rates were estimated from the responses. RESULTS: Sixty-one percent of the sites completed the questionnaire; a further 10% provided caseload data. Seventy were identified as general; 31, as university teaching; and 21, as provincial psychiatric/other single specialty (psychiatric) hospitals. Caseload volumes ranged from a mean of fewer than 2 to greater than 30 treatments per week. Estimated national usage during the 1-year survey period was 7340 to 8083 patients (2.32-2.56 per 10,000 population) and 66,791 to 67,424 treatments (2.11-2.13 per 1000 population). The diagnostic indications, admission status, and protocols for course end points are described. CONCLUSIONS: The usage rates are in keeping with earlier Canadian data and with those from other jurisdictions. The difficulty obtaining caseload data from individual hospitals is indicative of the need for standardized data collection to support both clinical research and quality assurance. The wide variation in protocols for number of treatments per course indicates a need for better informed clinical guidelines. The broad range of caseload volumes suggests the need to review the economies of scale in the field.

Delivery of electroconvulsive therapy in Canada: a first national survey report on devices and technique.

OBJECTIVE: Electroconvulsive therapy (ECT) is an effective treatment for mood and other psychiatric disorders. Despite widespread use, the specifics of ECT practice in Canada are largely unknown. A nationwide survey designed to document current delivery was therefore conducted. METHOD: One hundred seventy-five Canadian ECT delivery sites were identified. A detailed questionnaire (13 pages, 76 questions grouped in 11 subheadings) was developed, translated into French, piloted, and then forwarded to all ECT centers. RESULTS: Return rate for the full questionnaire was 61%. Wide-ranging information pertaining to ECT was gathered. This article, which addresses the data specifically pertaining to ECT devices, electrical stimulus parameters and electrode placements, showed that many core aspects of ECT practice in Canada are in keeping with current recommendations. The use of old sine wave devices is virtually nonexistent. Electroencephalographic (EEG) monitoring of seizures is widespread. CONCLUSIONS: Specific concerns were identified, including the need for access to back-up devices at all centers, the lack of ECT credentialing requirements by Canadian hospitals, and a striking variation in dosing practices. An audit of Canadian practice and the development of a National Standards Document would be an essential next undertaking.

Increased drinking following social isolation rearing: implications for polydipsia associated with schizophrenia.

Primary polydipsia, excessive drinking without known medical cause, is especially associated with a diagnosis of schizophrenia. We used animal models of schizophrenia-like symptoms to examine the effects on schedule-induced polydipsia: post-weaning social isolation rearing, subchronic MK-801 treatment (an NMDA-receptor antagonist) or the two combined. Male, Sprague-Dawley rats reared in groups or in isolation beginning at postnatal day 21 were further divided to receive subchronic MK-801 (0.5 mg/kg twice daily) or saline for 7 days beginning on postnatal day 62. Following a 4-day withdrawal period, all groups were trained on a schedule-induced polydipsia paradigm. Under food-restriction, animals reared in isolation and receiving food pellets at 1-min intervals developed significantly more drinking behavior than those reared with others. The addition of subchronic MK-801 treatment did not significantly augment the amount of water consumed. These findings suggest a predisposition to polydipsia is a schizophrenia-like behavioral effect of post-weaning social isolation.

Electroconvulsive therapy teaching in Canada: cause for concern.

AIM: The objective of this study was to present survey data on the teaching of electroconvulsive therapy (ECT) in health care centers across Canada. METHODS: Of 1273 centers identified, 175 were found to practice ECT. These centers were asked to complete a questionnaire, and 107 (61%) of them answered 5 questions dealing specifically with ECT teaching. These questions were as follows: (1) Does your facility have an ECT teaching program for residents in psychiatry? (2) How is ECT taught to residents in psychiatry? (3) If direct supervision of the administration of ECT is a requirement of the psychiatry training program, is there a minimum number of supervised treatments or minimum duration of training period? (4) Do residents provide unsupervised ECT at your center? (5) Which other groups of learners, if any, are provided with orientation, teaching, or training in ECT? RESULTS: Sixty percent of respondents had no ECT teaching program for psychiatry residents. Pedagogical methods varied, ranging from direct observation of ECT treatments to directed readings. Few centers required a minimum number of supervised treatments. No resident-administered ECT is performed without direct supervision. Interestingly, various groups of health care professionals were often invited to participate in ECT training. CONCLUSIONS: The situation regarding ECT teaching continues to be a cause for concern given the noted absence of organized, structured, and mandatory programs. No resident administering ECT, however, goes unsupervised, which is in keeping with good practice. Electroconvulsive therapy is taught in many different ways, and teaching is accessible to different groups of health care professionals. However, much remains to be done to standardize ECT teaching to render this therapy available to all those who need it and to overcome the stigma and bias associated with it.

The Canadian Survey of Standards of Electroconvulsive Therapy Practice: a call for accreditation.

OBJECTIVE: To report the results of the policies and procedures subsection of a nationwide electroconvulsive therapy (ECT) survey: Canadian Electroconvulsive Therapy Survey/Enquête canadienne sur les electrochocs. METHOD: We contacted 1273 registered health care institutions in Canada and invited the 175 centres identified as providing ECT to complete a comprehensive postal questionnaire. Nonresponding sites were repeatedly reminded and then eventually contacted by telephone. RESULTS: Sixty-one per cent (107/175) of the institutions returned survey questionnaires. Most (84%) of the responding sites have a written general policy for the delivery of ECT. Only 27% of respondents indicated having some written policy for managing concurrent medications during ECT, and practice was quite variable regarding individual psychotropics. Informed consent was usually obtained by the attending physician (88%), and most sites indicated conveying information before ECT by using interdisciplinary and multimodal means. Almost all of the sites (93%) discharged outpatients with accompaniment home by a responsible adult. CONCLUSIONS: It is reassuring to note that general ECT policies and procedures do exist in most Canadian ECT centres. Wider variations in practice were observed in several areas, such as the elements of consent provided to patients and families, the use of concurrent medications, and the degree of supervision on discharge home after outpatient ECT. However, adherence to these policies was not captured by the results of the survey. Based on experiences in other countries, establishing a Canadian ECT accreditation service could further improve standards of practice.

Canadian survey of perianesthetic care for patients receiving electroconvulsive therapy.

OBJECTIVES: We report on the anesthesia subsection of a comprehensive nationwide survey (Canadian Electroconvulsive Therapy Survey/Enquête canadienne sur les electrochocs) on the practice of electroconvulsive therapy (ECT) in Canada. METHODS: This comprehensive survey was sent to the 175 Canadian institutions identified as providers of ECT in 2007. Among other topics, 9 anesthesia-related questions were administered regarding anesthesiology consultation; high-risk patients; credentials of the anesthesia provider; monitoring, airway, and resuscitation equipment; anesthetic induction, muscle relaxant, vasoactive, and other perianesthetic drugs and practices; and postanesthetic discharge. RESULTS: Sixty-one percent (107/175) of the institutions returned completed survey questionnaires. More than 70% of the sites reported pre-ECT anesthesiology consultation for all (61%) or most (11%) patients. In more than 90%, a Canadian Royal College-certified anesthesiologist, or equivalent, provided anesthetic care. Routine use of oximetry, electrocardiography, and blood pressure monitoring were reported by all but 2 sites; use of bite block was reported by all but 4 sites; and preoxygenation was reported by all but 7 sites. Dantrolene and capnography were not reported as readily available by 35% and 40%, respectively, with comparatively less frequent availability at non-operating room and lower-volume sites. CONCLUSIONS: These results suggest safe practices of anesthesia for ECT in Canada. Further attention needs to be paid to ready availability of dantrolene and capnography, particularly at non-operating room ECT sites. Improvements in anesthetic care of patients undergoing ECT may be realized through continued knowledge translation efforts and by expanding access to currently unavailable anesthetic induction agents and, in some settings, limited clinical anesthesiology resources.

Electroconvulsive therapy in patients with skull defects or metallic implants: a review of the literature and case report.

CONTEXT: Head injury is often associated with psychiatric morbidity. While it is well understood that the loss of critical areas of the brain may play a role in cognitive dysfunction and change in personality, head injury can also have profound effects on mood and cognition. The role of medications in the treatment of mood disorders associated with brain injury is well documented, and there is also evidence favoring the use of electroconvulsive therapy (ECT) in this context. However, data are limited on the use of ECT in patients with skull defects or metallic head implants. EVIDENCE ACQUISITION: First, a review of the literature on use of ECT in patients with metallic head implants is provided. Electronic databases and online sites, including PubMed, Cochrane Library of Systematic Reviews, and UpToDate, were used to search for relevant articles and case reports on the use of ECT in patients with and without metallic implants in the head (1964 to 2009). The search terms electroconvulsive, electroconvulsive therapy, ECT, electroshock therapy, EST, head injury, brain injury, metallic plates, metallic implants, skull prosthesis, and depression were used interchangeably. The search produced 7 articles discussing exclusively the use of ECT in patients with a metallic skull plate. Second, the case of the successful and safe use of ECT in an individual with a previous history of brain trauma and metallic plate implantation is described. RESULTS: Most cases of head injury are managed by neurologists and rehabilitation consultants; the more severe cases of depression and other mood disorders tend to be referred for specialist psychiatric care. With greater degrees of deficit following head injury, management becomes more complicated. Our patient showed positive results with ECT, including improvement in depressive features and resolution of suicidal ideas/plans. CONCLUSION: ECT is an effective and safe alternative in patients with a history of brain trauma and metallic plate implantation who subsequently develop treatment-resistant depression and associated suicidal ideas or plans refractory to management with medications.

Probabilistic classification and gambling in patients with schizophrenia receiving medication: comparison of risperidone, olanzapine, clozapine and typical antipsychotics.

RATIONALE: We have previously shown that patients with schizophrenia treated with typical antipsychotics were impaired on the weather prediction probabilistic classification learning (PCL) task that relies on striatal function, and that similar patients treated with atypical antipsychotics were impaired on the Iowa gambling task (IGT) that depends on medial prefrontocortical function. OBJECTIVES: We tested the hypothesis that test performance of patients treated with risperidone will be more similar to those treated with typical rather than atypical antipsychotics. RESULTS: Groups of schizophrenia patients treated with risperidone, olanzapine, clozapine or typical antipsychotics did not differ on the Positive and Negative Syndrome Scale or the Mini Mental State Exam (MMSE) but scored lower than controls on the MMSE. For the PCL task, patients treated with clozapine improved over trials while those treated with typical antipsychotics, olanzapine, or risperidone did not. For the IGT, patients treated with typical antipsychotics or risperidone improved over trials while those treated with clozapine or olanzapine did not. CONCLUSIONS: Results generally supported the hypothesis that patients treated with risperidone perform more like those treated with typical antipsychotics than those treated with other atypical antipsychotics.

Access to electroconvulsive therapy services in Canada.

OBJECTIVES: We sought to determine factors governing access to electroconvulsive therapy (ECT) in Canada. METHODS: We contacted all 1273 registered health care institutions in Canada and invited the 175 centers identified as providing ECT to complete a comprehensive questionnaire. To determine geographic access to ECT, we used a geographic information system, population density data, and road network data. Responses to 5 questions from the questionnaire were used to identify local barriers to access. RESULTS: Approximately 84% of the population in the 10 Canadian provinces live within a 1-hour drive of an ECT center, but 5% live more than 5 hours' drive away. There was significant province-to-province variation, with all of the citizens of Prince Edward Island living within 2 hours of an ECT center but 12.5% of those in Newfoundland and Labrador living more than 5 hours' distance away. There are no ECT services at all in the 3 territories, which contain 3% of the Canadian population. Nongeographic barriers to access included inadequate human resources, particularly, a lack of anesthesiologists, in 59% of the centers; logistical impedances (52%); space limitations (45%); strictures on the hiring of adequate staff (29%); imposed limits to number of treatments or to operating or postanesthetic room time (28%); and a lack of funds to purchase up-to-date ECT or related anesthesiology equipment (14%). CONCLUSIONS: Electroconvulsive therapy is geographically accessible for most Canadians. Even when geography is not a factor, however, there are significant barriers to access resulting from inadequate availability of qualified professional staff, treatment areas, and funding.

Increased schedule-induced polydipsia in the rat following subchronic treatment with MK-801.

Primary polydipsia, defined as excessive fluid intake not explained by medical causes, has been reported to occur in over 20% of chronically ill psychiatric inpatients and is especially common in schizophrenic populations. We tested the hypothesis that in an animal model of schizophrenia-like symptoms (subchronic injections of MK-801, 0.5 mg/kg twice daily for 7 days) an increase in the acquisition of schedule-induced polydipsia (SIP) will occur. Young adult, male rats acquired SIP when food-restricted and placed on a non-contingent fixed-time 1-min food schedule. In comparison with saline-treated control animals, subchronic MK-801 treatment significantly increased SIP. These findings suggest an animal model of polydipsia associated with schizophrenia in humans.

Specific effects of escitalopram on neuroendocrine response.

PURPOSE: Citalopram, a selective serotonin reuptake inhibitor, is used as a neuroendocrine probe in human subjects to assess serotonin function as reflected in prolactin and plasma cortisol release. Citalopram is a racemic mixture of equal proportions of the S(+) and R(-) enantiomers. Inhibition of serotonin reuptake and, consequently, antidepressant activity is associated, almost exclusively, with the S(+) enantiomer ("escitalopram"). Studies in animal models indicate that the presence of the R(-) isomer may interfere with the serotonin reuptake activity of escitalopram. The current study compared the neuroendocrine effects of citalopram and escitalopram in healthy human volunteers. METHODS: Plasma cortisol and prolactin levels following a single oral dose of citalopram (40 mg) or escitalopram (20 mg) were compared in samples taken every 15-30 min over a period of 240 min. Plasma citalopram concentration was determined at the same intervals. RESULTS: Escitalopram and citalopram caused equivalent increases in plasma cortisol and prolactin. The administration of dexamethasone prior to the escitalopram challenge blocked the evoked increase in cortisol. CONCLUSION: This is the first study to prove that a single dose of escitalopram acts centrally and not peripherally, providing further support of the use of oral escitalopram as a probe for brain serotonergic function.