Cost of privatisation versus government alcohol retailing systems: Canadian example.

INTRODUCTION AND AIMS: Alcohol retail monopolies have been established in many countries to restrict alcohol availability and thus, minimise alcohol-related harm.The aim of this study was to estimate the impact of the privatisation of alcohol sales on the burden and direct health-care, law enforcement costs and indirect costs (lost productivity due to disability or premature mortality) in Canada. DESIGN AND METHODS: Simulation modelling. International Guidelines for the Estimation of the Avoidable Costs of Substance Abuse were used. All burden and costs were compared with the baseline taken from the aggregate Cost Study on Substance Abuse in Canada 2002. RESULTS: If all Canadian provinces and territories were to privatise alcohol sales we assume that consumption would increase from 10% to 20% based on available Canadian literature. Under the 10% scenario the costs would increase from 6% ($828 million) and under the 20% scenario costs would increase 12% ($1.6 billion).This increase is substantially greater than the tax and mark-up revenue gained from increased sales,and represents a net loss. DISCUSSION AND CONCLUSIONS: Alcohol-attributable burden and associated costs will increase markedly if all Canadian provinces and territories gave up the government alcohol retailing systems.For public health and economic reasons, governments should continue to have a strong role in alcohol retailing.

Systematic review of intervention practices for depression in the workplace.

DESIGN: Systematic Review. OBJECTIVE: To determine which intervention approaches to manage depression in the workplace have been successful and yielded value for employers in developed economies. DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL, Central, PsycINFO, and Business Source Premier up to June 2010 using search terms in four broad areas: work setting, depression, intervention, and work outcomes. STUDY SELECTION: Two independent reviewers selected potential articles that met the following criteria: working age individuals with mild or moderate depression; interventions or programs that were workplace-based or could be implemented and/or facilitated by the employer; inclusion of a comparator group in the analysis; outcomes of prevention, management, and recurrences of work disability or sickness absence, and work functioning. METHODS: Two reviewers independently reviewed each article for quality and extracted data using standardised forms. Following guidelines from the GRADE Working Group, the quality of evidence addressing each outcome was graded as high, moderate, low, or very low on the basis of six criteria: study design, risk of bias, consistency, generalisability, data precision, and economic benefit. Using this information and following Cochrane Collaboration guidelines, the findings for each intervention were summarised and key messages were developed. RESULTS: We identified ten randomised trials and two non-randomised studies from various countries and jurisdictions that evaluated a wide range of intervention practices. The evidence was graded as "very low" for all outcomes identified. Therefore, no intervention could be recommended. CONCLUSIONS: To date, there is insufficient quality of evidence to determine which interventions are effective and yield value to manage depression in the workplace.

Depressive symptoms as a determinant of breast and cervical cancer screening in women: a population-based study in Ontario, Canada.

The objective of this study was to investigate the relationship between depression and screening for breast and cervical cancer. The study sample included Ontario female respondents to the Canadian Community Health Survey Cycle 1.2, Mental Health and Well Being component (2002). Women with Major Depressive Disorder (MDD) were identified based on the World Mental Health Composite International Diagnostic Interview and women with clinically significant depressive symptoms were identified using the Kessler 6-item Distress Scale (K6 ≥ 8). Respondents eligible for screening (N = 4,042 for cervical cancer and N = 1,403 for breast cancer) were linked to Ontario administrative data to prospectively ascertain screening outcomes. Both women with MDD and K6 ≥ 8 were less likely to receive breast cancer screening than their non-depressed counterparts (46.1% vs. 61.5% for MDD, Χ(2) = 5.47, p = 0.02; 49.9% vs. 61.9% for K6, Χ(2) = 6.61, p = 0.01). Adjusted analyses revealed persistence of the association between K6 ≥ 8 and breast cancer screening (adjusted odds ratio (AOR) 0.63, 95% CI 0.40-0.97). Neither MDD nor K6 ≥ 8 were found to be associated with cervical cancer screening in the full sample. A sub-group analysis by age revealed that women over age 40 years with K6 ≥ 8 were less likely to receive cervical cancer screening than their non-depressed counterparts (49.9% vs. 64.5%, X(2) = 6.47, p = 0.01). This association approached statistical significance in adjusted analysis (AOR = 0.65, 95% CI 0.41-1.04). This study's findings suggest that attention to the uptake of preventive services in women with depressive symptoms is warranted.

Depression and self-reported functional status: impact on mortality following acute myocardial infarction.

OBJECTIVE: The cause of increased post-AMI (acute myocardial infarction) mortality associated with depression remains poorly elucidated. The objective of this study was to examine the extent to which self-reported cardiac functional status accounted for depression-mortality associations following AMI. METHODS: Using a prospective cohort design (n = 1941), the authors obtained self-reported measures of depression and developed profiles of the patients' pre-hospitalization cardiac risks, co-morbid conditions and drugs and revascularization procedures during or following index AMI hospitalization. To create these profiles, the patients' self-reports were retrospectively linked to no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, income, cardiovascular risk, co-morbid conditions, selected process-of-care factors and self-reported cardiac functional status. RESULTS: Depression was strongly correlated with 2-year mortality rate [crude hazard ratio (HR) of severe vs. minimal depression category, 2.48 (95% CI 1.20-5.15); P = 0.01]. However, after sequential adjustment for age, sex, income and self-reported cardiac functional status, the effect of depression was greatly attenuated [adjusted HR for severe vs. minimal depression category, 1.35 (95% CI 0.63-2.87); P = 0.44]. Cardiac risk factors and non-cardiac co-morbidities had negligible explanatory effect. DISCUSSION: The main factor determining the increased mortality rate in depressed patients is self-reported cardiac functional status. Efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status.

Avoidable cost of alcohol abuse in Canada.

AIMS: To estimate avoidable burden and avoidable costs of alcohol abuse in Canada for the year 2002. METHODS: A policy effectiveness approach was used. The impact of six effective and cost-effective alcohol policy interventions aimed to reduce alcohol consumption was modeled. In addition, the effect of privatized alcohol sales that would increase alcohol consumption and alcohol-attributable costs was also modeled. The effects of these interventions were compared with the baseline (aggregate) costs obtained from the second Canadian Study of Social Costs Attributable to Substance Abuse. RESULTS: It was estimated that by implementing six cost-effective policies from about 900 million to two billion Canadian dollars per year could be saved in Canada. The greatest savings due to the implementation of these interventions would be achieved in the lowering of productivity losses, followed by health care, and criminality. Substantial increases in burden and cost would occur if Canadian provinces were to privatize alcohol sales. CONCLUSION: The implementation of proven effective population-based interventions would reduce alcohol-attributable burden and its costs in Canada to a considerable degree.

Suicide mortality by occupation in Canada, 1991-2001.

OBJECTIVE: To describe the association between occupation and risk of suicide among working-age men and women in Canada. METHOD: This study of suicide mortality over an 11-year period is based on a broadly representative 15% sample of the noninstitutionalized population of Canada aged 30 to 69 years at cohort inception. Age-standardized mortality rates (ASMRs) and rate ratios were calculated for men and women in 5 categories of skill level and 80 specific occupational groups, as well as for people not occupationally active. RESULTS: The suicide mortality rate was 20.1/100 000 person years for occupationally active men (during 9 600 000 person years of follow-up) and 5.3/100 000 person years for occupationally active women (during 8 100 000 person years of follow-up). Among occupationally active men, elevated rates of suicide mortality were observed for 9 occupational groups and protective effects were observed for 6 occupational groups. Among women, elevated rates of suicide were observed in 4 occupational groups and no protective effects were observed. For men and women, ASMRs for suicide were inversely related to skill level. CONCLUSIONS: The limited number of associations between occupational groups and suicide risk observed in this study suggests that, with few exceptions, the characteristics of specific occupations do not substantially influence the risk for suicide. There was a moderate gradient in suicide mortality risk relative to occupational skill level. Suicide prevention strategies in occupational settings should continue to emphasize efforts to restrict and limit access to lethal means, one of the few suicide prevention policies with proven effectiveness.

A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder.

OBJECTIVE: The authors sought to evaluate the clinical efficacy of dialectical behavior therapy compared with general psychiatric management, including a combination of psychodynamically informed therapy and symptom-targeted medication management derived from specific recommendations in APA guidelines for borderline personality disorder. METHOD: This was a single-blind trial in which 180 patients diagnosed with borderline personality disorder who had at least two suicidal or nonsuicidal self-injurious episodes in the past 5 years were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. The primary outcome measures, assessed at baseline and every 4 months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes. RESULTS: Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in borderline personality disorder symptoms, symptom distress, depression, anger, and interpersonal functioning. No significant differences across any outcomes were found between groups. CONCLUSIONS: These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.

The relationship between depressive symptoms, health service consumption, and prognosis after acute myocardial infarction: a prospective cohort study.

BACKGROUND: The use of cardiovascular health services is greater among patients with depressive symptoms than among patients without. However, the extent to which such associations between depressive symptoms and health service utilization are attributable to variations in comorbidity and prognostic disease severity is unknown. This paper explores the relationship between depressive symptoms, health service cardiovascular consumption, and prognosis following acute myocardial infarction (AMI). METHODS: The study design was a prospective cohort study with follow-up telephone interviews of 1,941 patients 30 days following AMI discharged from 53 hospitals across Ontario, Canada between December 1999 and February, 2003. Outcome measures were post discharge use of cardiac and non-cardiac health care services. The service utilization outcomes were adjusted for age, sex, income, comorbidity, two validated measures of prognosis (cardiac functional capacity and risk adjustment severity index), cardiac procedures (CABG or PTCA) and drugs prescribed at discharge. RESULTS: Depressive symptoms were associated with a 24% (Adjusted RR:1.24; 95% CI:1.19-1.30, P < 0.001), 9% (Adjusted RR:1.09; 95% CI:1.02-1.16, P = 0.007) and 43% (Adjusted RR: 1.43; 95% CI:1.34-1.52, P < 0.001) increase in total, cardiac, and non-cardiac hospitalization days post-AMI respectively, after adjusting for baseline patient and hospital characteristics. Depressive-associated increases in cardiac health service consumption were significantly more pronounced among patients of lower than higher cardiac risk severity. Depressive symptoms were not associated with increased mortality after adjusting for baseline patient characteristics. CONCLUSION: Depressive symptoms are associated with significantly higher cardiac and non-cardiac health service consumption following AMI despite adjustments for comorbidity and prognostic severity. The disproportionately higher cardiac health service consumption among lower-risk AMI depressive patients may suggest that health seeking behaviors are mediated by psychosocial factors more so than by objective measures of cardiovascular risk or necessity.

Small signal, big noise: performance of the CIDI depression module.

OBJECTIVES: With the release of data from the Canadian Community Health Survey: Mental Health and Well-Being (Cycle 1.2), researchers have, for the first time, information on several psychiatric disorders from a nationally representative sample of Canadians residing in households. This survey used the Composite International Diagnostic Interview (CIDI) to identify persons with one or more psychiatric disorders. In this paper, our primary purpose was to evaluate the evidence supporting the validity of the CIDI--that is, the extent to which the depression diagnoses generated by the CIDI reflect true cases of depression. METHOD: We conducted a critical review of the CIDI, focusing on the depression module. RESULTS: Reliability studies indicate that the CIDI performs reliably, as measured by interrater reliability. However, the use of different versions of the CIDI and the occasional exclusion of the Depression module from studies suggest that the reliability of the CIDI Depression module remains unconfirmed. The most critical issue in regard to the CIDI's performance is that clinical samples are used to test validity. A clinical sample has a higher prevalence of depression than a community sample. CONCLUSION: The results generated by the CIDI in a community setting likely will have a high false-positive rate, resulting in a falsely elevated prevalence rate. Given the widespread application of the CIDI internationally, addressing the outstanding concerns about validity with proper validation studies should become an international priority.

Medication management of depression: the impact of comorbid chronic medical conditions.

OBJECTIVE: This paper addresses the following question: Does quality of care for depression differ between depressed persons with and without chronic medical conditions (CMCs)? METHODS: We used a population-based mental health survey to identify respondents aged 18 to 64 with the diagnosis of major depression in the past year (N = 278). In our model, the dependent variable was guideline-level medication management of depression. Determinants for guideline-level care were modeled using multivariate logistic regression. RESULTS: Depressed persons with CMCs were significantly more likely to receive guideline-level care for depression than were the depressed persons without CMCs (OR = 1.46; 95% C.I. = 1.12-1.90). This increased likelihood did not persist when the sample excluded persons seeing physicians at more than eight visits per year (OR = 0.81; 95% CI = 0.35-1.90). Previous psychiatric hospitalization was the only other significant determinant of guideline-level care. CONCLUSION: Depressed persons with comorbid CMCs are more likely to receive guideline-level care for depression than are depressed persons without comorbid CMCs. However, the association did not persist once we excluded respondents who were high utilizers. This finding implies that further understanding of the interaction between depression care and comorbid CMCs will require a longitudinal focus on repeated physician-patient interactions.

Research priorities are critical.

Building on the review by Goldner et al., I argue that the first research tasks for disability management in Canada should be to articulate conceptual models; define promising disability management interventions and characterize the current longitudinal health and labour market trajectories of Canadians disabled by mental conditions. Research should next emphasize pilot studies of novel interventions and observational studies that examine the relationship between treatment, workplace interventions, work environments and disability outcomes. Selective randomized trials of disability management interventions should be considered downstream. Mental health treatment optimization should be assigned a lower funding priority than research on workplace interventions.

Antidepressants and the risk of breast cancer.

BACKGROUND: A recent national newspaper article highlighted 2 published research papers that suggest an association between antidepressants and an increased risk of breast cancer. The authors of the 2 papers recommend switching or avoiding the antidepressants implicated in their studies. METHOD: We critically review these papers and, based on our review, consider what clinical practices, if any, should be modified as a result of their findings. RESULTS: Both articles are based upon case-control studies. In the first paper, the authors examine the relation between tricyclic antidepressants (TCAs) and an increased risk of breast cancer. The study upon which the paper is based has several design strengths, and the paper presents findings that have biological plausibility. However, the conclusions are weakened by the lack of accounting for potential confounding factors and multiple statistical comparisons. In the second paper, the authors combined survey and administrative data to examine the association between antidepressant use and breast cancer risk. The press article notwithstanding, the second paper does not find a significant association between specific antidepressants and an increased risk of breast cancer, after adjusting for potential confounders. There are significant methodological limitations to the research upon which the paper is based. CONCLUSIONS: The finding of an association between TCA use and increased risk of breast cancer merits further testing using stronger research designs. However, because of the methodological concerns described, the 2 papers we review provide insufficient evidence to guide practitioners to change clinical practice.