Clinical utility of combinatorial pharmacogenomic testing in depression: A Canadian patient- and rater-blinded, randomized, controlled trial.

The pharmacological treatment of depression consists of stages of trial and error, with less than 40% of patients achieving remission during first medication trial. However, in a large, randomized-controlled trial (RCT) in the U.S. ("GUIDED"), significant improvements in response and remission rates were observed in patients who received treatment guided by combinatorial pharmacogenomic testing, compared to treatment-as-usual (TAU). Here we present results from the Canadian "GAPP-MDD" RCT. This 52-week, 3-arm, multi-center, participant- and rater-blinded RCT evaluated clinical outcomes among patients with depression whose treatment was guided by combinatorial pharmacogenomic testing compared to TAU. The primary outcome was symptom improvement (change in 17-item Hamilton Depression Rating Scale, HAM-D17) at week 8. Secondary outcomes included response (≥50% decrease in HAM-D17) and remission (HAM-D17 ≤ 7) at week 8. Numerically, patients in the guided-care arm had greater symptom improvement (27.6% versus 22.7%), response (30.3% versus 22.7%), and remission rates (15.7% versus 8.3%) compared to TAU, although these differences were not statistically significant. Given that the GAPP-MDD trial was ultimately underpowered to detect statistically significant differences in patient outcomes, it was assessed in parallel with the larger GUIDED RCT. We observed that relative improvements in response and remission rates were consistent between the GAPP-MDD (33.0% response, 89.0% remission) and GUIDED (31.0% response, 51.0% remission) trials. Together with GUIDED, the results from the GAPP-MDD trial indicate that combinatorial pharmacogenomic testing can be an effective tool to help guide depression treatment in the context of the Canadian healthcare setting (ClinicalTrials.gov NCT02466477).

Access to psychiatrists by French-speaking patients in Ontario hospitals: 2005 to 2013.

There has been a limited amount of research suggesting that cultural and linguistic variables may affect access to health services, but no study has examined the access of French-speaking Canadians to psychiatrists. The present study used data from the Ontario Mental Health Reporting System to examine patterns of daily contact with psychiatrists in the first 3 days of admission to mental health facilities in Ontario. The results showed that after controlling for a broad range of covariates, French-speaking Ontarians were about one-third as likely to have daily contact with psychiatrists in that time period compared to English-speaking patients. These results were not explained by regional differences. Instead, they point to the possibility that language poses an important barrier to specific and highly specialized mental health services in this province.

Independent association of chronic smoking and abstinence with suicide.

OBJECTIVE: The study examined whether chronic exposure to nicotine is independently associated with suicide. METHODS: Data from the 1993 National Mortality Followback Survey in the United States were analyzed by using a case-control design. Data for 989 suicide decedents were compared with data for 3,125 accident and homicide decedents. Inclusion criteria were ever smoking 100 cigarettes and white or black race. The exclusion criterion was death from natural or undetermined causes. Three smoking parameters were compared: lifetime smoking duration, ever quitting, and abstinence duration. Covariates were the manner of death, which was derived from coroners' death certificates, and data pertaining to the last year of life, which was reported by next of kin, on depressive symptoms, alcohol and drug use, veteran status, having a firearm in the home, and living alone. RESULTS: In multivariate, fully adjusted analyses, longer lifetime smoking (≥ 41 versus ≤ 10 years) was associated with higher odds of suicide (odds ratio [OR]=2.26, 95% confidence interval [CI]=1.30-3.93). Quitting smoking was associated with lower odds of suicide (OR=.37, CI=.25-.55), as was longer abstinence duration (≥ 11 versus <5 years) (OR=.33, CI=.21-.52). These associations were observed only among males. CONCLUSIONS: Findings indicated a probable independent association between suicide and current smoking and longer lifetime smoking duration. The findings are additional grounds to investigate smoking as a possible independent cause of suicide.

Long-term trend in pediatric antidepressant use, 1983-2007: a population-based study.

OBJECTIVE: Research is needed to clarify and improve our understanding of appropriateness and safety issues concerning antidepressant (AD) treatment. We explored the long-term trend in the dispensing of pediatric ADs using provincial, population-based data from Canada. METHODS: Data covering 22 ADs were drawn from the Saskatchewan Ministry of Health administrative data files in outpatient settings. The data were for 9 triennial years from 1983 to 2007, a 24-year period, for those aged 0 to 19 in the general population. Descriptive analyses were used. RESULTS: In 1983, 5.9 per 1000 population aged 0 to 19 were dispensed at least 1 AD; this decreased to 5.1 per 1000 population in 1989, and then increased to 15.4 per 1000 population in 2007, with a slower increase after 2004. Both sexes were dispensed more ADs from 1989 onwards, with females being the heavier users. The rate of AD use increased significantly with age, and this trend became more pronounced after 1998. Family physicians were the major prescribers and their prescriptions significantly increased from 1989 to 2004 and decreased in 2007. The use of selective serotonin reuptake inhibitors (SSRIs) was the major reason for the increase. The number of AD scripts per patient also increased. CONCLUSIONS: The growth in the prevalence of AD use among children and youth was largely caused by the use of SSRIs. The possibility of safety issues induced by AD use among children and adolescents, and different patterns of medication practice, suggest continuing education is warranted.

Official language minority communities in Canada: is linguistic minority status a determinant of mental health?

OBJECTIVES: Language has been identified as a determinant of mental health. Within Canada, individuals may speak an official language and still belong within the linguistic minority (Francophones outside Quebec and Anglophones within Quebec). The objectives of this study were to compare mental health problems between minority and majority official language communities, and examine the association between official language minority and mental health problems. METHODS: Data from the Canadian Community Health Survey, Cycle 1.2 were used to make two comparisons: Francophones to Anglophones within Quebec, and Francophones to Anglophones outside Quebec. Twelve-month and lifetime prevalences of mental disorders (major depressive episode, anxiety disorders, and alcohol/substance abuse/dependence) and mental health indices were compared. Logistic regression analysis examined whether official language minority status was a determinant of mental health. RESULTS: Mental health between minority and majority language groups was similar. Official language minority status was not a significant determinant of mental health. Self-rated mental health indices varied between groups. In some cases, minority language groups reported lower levels of life satisfaction (minority Anglophones versus majority Francophones), while in other cases more majority Anglophones reported poor life satisfaction and mental health (majority Anglophones versus minority Francophones). CONCLUSIONS: Overall, few differences were found between language groups, though variations in self-rated mental health indices were observed. In order to better understand the role of context in determining health outcomes, future research should examine mental health problems among official language minority groups provincially to help stakeholders in directing resources and programs to populations in most need.

Trends in psychotropic use in Saskatchewan from 1983 to 2007.

OBJECTIVE: There has been little research reported on trends in the use of a full spectrum of psychotropics in a general population. We provide an overview of trends in psychotropic use over a 24-year period for Saskatchewan. METHODS: Data were drawn from the Saskatchewan Ministry of Health administrative data files. It covers antidepressants (ADs), antipsychotics, mood stabilizers, anxiolytics, stimulants, and cholinesterase inhibitors in outpatient settings. We analyzed data from 9 triennial years from 1983 to 2007. Descriptive statistics were used. RESULTS: Among the Saskatchewan population in our study, 8.38% were prescribed at least 1 psychotropic in 1983. The prevalence decreased to 7.44% in 1989, then gradually increased to 12.90% in 2007. We found a continuous increase in the number of psychotropic prescriptions for both males and females. The trend became more marked during the 1990s. Females used more psychotropics. Family physicians were the major prescribers, and their prescriptions dramatically increased over the period. There was an increase in the prescribing of all psychotropics except for anxiolytics. AD prescriptions dramatically increased, especially from 1995 onward. The proportion of patients with 8 to 11 and 12 or more prescriptions per year also gradually increased, whereas the proportion of patients with less than 3 prescriptions per year decreased. CONCLUSIONS: AD prescriptions are the major reason for the increasing trend of psychotropic use. Given the major role of family physicians in the use of psychotropics, the need for appropriate training and continuing education is reinforced.

Objectif :Peu de recherche a été publié sur les tendances de l'utilisation du spectre entier des psychotropes dans une population générale. Nous offrons un aperçu des tendances de l'utilisation de psychotropes sur une période de 24 ans pour la Saskatchewan. Méthodes : Les données sont tirées des fichiers de données administratives du ministère de la Santé de la Saskatchewan. Elles couvrent les antidépresseurs (AD), les antipsychotiques, les psychorégulateurs, les anxiolytiques, les stimulants, et les inhibiteurs de cholinestérase dans des contextes ambulatoires. Nous avons analysé les données de 9 cycles triennaux, de 1983 à 2007. Des statistiques descriptives ont été utilisées. Résultats : Parmi la population de la Saskatchewan de notre étude, 8,38 % se sont fait prescrire au moins 1 psychotrope en 1983. La prévalence a baissé à 7,44 % en 1989, puis a graduellement augmenté à 12,90 % en 2007. Nous avons observé un accroissement continu du nombre de prescriptions de psychotropes tant pour les hommes que les femmes. La tendance devient plus marquée durant les années 1990. Les femmes utilisaient plus de psychotropes. Les médecins de famille étaient les principaux prescripteurs, et leurs prescriptions ont radicalement augmenté durant cette période. Il y a eu une augmentation des prescriptions de tous les psychotropes sauf les anxiolytiques. Les prescriptions d'AD ont connu une hausse radicale, spécialement depuis 1995. La proportion de patients ayant de 8 à 11 et 12 ou plus prescriptions par année a augmenté graduellement, tandis que la proportion de patients ayant moins de 3 prescriptions par année a diminué. Conclusions : Les prescriptions d'AD sont la principale raison de la tendance à la hausse de l'utilisation de psychotropes. Étant donné le rôle majeur des médecins de famille dans l'utilisation de psychotropes, le besoin de formation appropriée et continue est renforcé.

Perceived emotional support in remission: results from an 18-month follow-up of patients with early episode psychosis.

PURPOSE: Serious mental illness is known for the damage that it inflicts on the social network and social support of patients. Although many studies have used relapse and rehospitalisation as outcomes, recent research has emphasized the importance of a fuller definition of recovery that includes social function. In this study, our goal is to investigate the association of social support with sustained remission in patients with early episode psychosis. METHODS: A secondary analysis of remission and social support was performed with 123 of 144 patients enrolled in the Lambeth Early Onset randomized clinical trial who ever achieved symptom-free status in 18 months of follow-up. Social support was measured by hours of family contact, perceived support, and network size at 6 months into an early intervention treatment program. Consensus judgments made by clinicians on symptom status at each of 18 months of follow-up were analyzed for consecutive months spent in remission. Direct and mediated effects of social support on remission were calculated using Poisson regression and path analysis, respectively. RESULTS: 114 of 123 patients achieved remission after about 7 months on average [mean 6.81 (SD 4.17)]. In univariate models, perceived emotional support predicted longer time spent in remission, while moderate family contact predicted shorter remission duration. Perceived practical support was not associated with remission. Perceived emotional support mediated the association between family contact and remission and between network size and remission. These results are not totally attributable to a specialized early intervention treatment. CONCLUSION: Structural measures of support probably contribute to the maintenance of remission through the patient's perception of emotional support.

The impact of stigma of mental illness in a Canadian community: a survey of patients experiences.

We examined stigma experiences and its impact among patients (n = 41) hospitalized for mental illness. We studied their characteristics contributing to the expectation, intensity, and frequency of stigma they could experience. Opinions were compared on the Experiences with the Stigma of Mental Illness scale measuring stigma experiences and impact. There were differences on perceived stigma in: being 19 years or younger at first symptom or treatment, having had one previous psychiatric hospitalizations and having attended one or more outpatient sessions. Those having attended outpatient sessions, being previously hospitalized or younger suffered more impact.

Does assertive community outreach improve social support? Results from the Lambeth Study of early-episode psychosis.

OBJECTIVES: Specialized early intervention by a team providing assertive community treatment (ACT) is beneficial to the recovery, housing, and employment of individuals with schizophrenia, but few studies have examined its effect on social support. This study assessed whether the ACT model of care was related to clinical and social outcomes among patients who had experienced a first episode of psychosis. METHODS: The sample was drawn from the Lambeth Early Onset Trial, a study of 144 patients in the United Kingdom who sought treatment for a first episode of psychosis between January 2000 and October 2001 and who were randomly assigned to a specialized early intervention modeled on ACT or standard care. The Positive and Negative Syndrome Scale, the Global Assessment of Functioning, and the Significant Others Scale were administered at six-month and 18-month follow-ups. RESULTS: Data on social support were available at both follow-ups for 57 patients assigned to specialized care and 50 patients assigned to standard care. The two groups were similar in personal characteristics, relationship status, and living arrangements at baseline and at six-month follow-up, but by 18 months, patients in specialized care reported having a higher mean±SD number of significant others in their social networks than did standard care patients (2.40±1.20 and 1.71±1.06, respectively; p=.01). They also achieved superior clinical outcomes at 18 months, and these outcomes were associated with network size. CONCLUSION: Early intervention by using an ACT model of care may improve clinical results by reestablishing or maintaining bonds between patients and family, friends, and acquaintances.

Survival of patients with incident dementia who had a pre-existing psychiatric disorder: a population-based 7-year follow-up study.

OBJECTIVES: Although it is widely accepted that psychiatric disorders and dementia coexist and survival data for dementia patients have been published, there is a paucity of information regarding the survival of patients with a psychiatric disorder who develop dementia. This study fills this information gap providing survival data on patients with such comorbidity and identifies mortality risk factors. METHODS: All residents of Saskatchewan, a Canadian province, diagnosed with psychiatric problems and/or dispensed a psychiatric drug in 2000 and without dementia were followed through to 31 December 2006; the development of incident dementia was noted. Median survival time (in months) and selected predictors of mortality were measured. Analyses used Cox's proportional hazard model. Incidence density of dementia for the year 2000 was also computed. RESULTS: By December 2006, 5,583 subjects with psychiatric disorders in 2000 had been diagnosed with incident dementia, and 60.65% of them died. Dementia-incidence density in this population for 2000 was 0.01 per 1000 person years at risk among those aged 18-64 years and rapidly increased to 3.13 per 1000 person years at risk among those aged 75 to 84 years. The median survival time from dementia onset to death was 32.66 months (interquartile range 31.21-34.14). Being male, later age of onset of dementia, having a lower income, and a high chronic disease score predicted shorter survival. CONCLUSIONS: The comorbidity of psychiatric disorders and dementia resulted in shorter survival compared with that reported for patients with dementia only. These findings can be used for prognosis for patients, caregivers, and service providers.

Comparing the rates of mental disorders among different linguistic groups in a representative Canadian population.

PURPOSE: We aimed to determine whether linguistic group influences reported prevalence rates for a number of common mental disorders. METHODS: Secondary data analyses of the Canadian Community Health Survey cycle 1.2 (CCHS 1.2) were carried out on representative bilingual French and English, monolingual French and English and other language groups in Canada. Past year prevalence of major depression, anxiety disorders (agoraphobia, social phobia, panic disorder) and alcohol abuse/dependence were ascertained using versions of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI) questionnaire. Multivariate data analyses were used to model past year presence of a mental disorder as a function of linguistic group, defined as languages can converse in, and adjusting for socioeconomic, demographic and cultural factors. RESULTS: Overall, past year rates for the presence of a common mental disorder were 10.7% (9.7-11.7%) for the bilingual English; 9.0% (8.1-9.9%) for the bilingual French; 10.2% (9.8-10.6) for the monolingual English; 8.5% (7.7-9.3%) for the monolingual French; and 8.3% (6.1-10.4%) for the other language group. After adjusting for a number of socio-demographic, economic and cultural factors, the multivariate analyses showed that the linguistic groups were equally likely to report the presence of a past year common mental disorder. This was also true for comparisons between the bilingual participants responding in French and English. CONCLUSIONS: The differences observed in the reported crude rates for the presence of mental disorders across the different linguistic groups in Canada were explained by socio-demographic, economic, and factors such as immigration, spoke a third language and province of residence, and not explained by language of interview.

Prevalence and risk indicators of depressed mood in on-reserve first nations youth.

OBJECTIVES: The first objective was to determine the prevalence of depressive mood in First Nations youth in school grades 5 through 8 in seven on-reserve communities. The second objective was to determine the unadjusted and adjusted risk indicators associated with depressed mood in these youth. METHODS: Students in grades 5 through 8 in the seven reserve communities of the Saskatoon Tribal Council were asked to complete a paper and pencil, comprehensive youth health survey in May 2010. An eight-stage consent protocol was followed prior to participation. RESULTS: Out of 271 students eligible to participate, 204 youth completed the survey for a response rate of 75.3%. Using the Center for Epidemiological Studies of Depression scale, 25% of the youth had moderate depressive symptoms. After cross-tabulation, 1 socioeconomic variable, 10 social variables, 3 social support variables, 1 self-esteem variable, 5 parental relationship variables and 3 bullying variables were associated with depressed mood. Logistic regression was used to determine four independent risk indicators associated with having depressed mood in First Nations youth, including: 1) not having worked through things that happened during childhood, 2) not having someone who shows love and affection, 3) having a lot of arguments with parents and 4) being physically bullied at least once per week. CONCLUSIONS: Our study found high rates of depressed mood in on-reserve First Nations youth. These youth are now at increased risk for problems later in life unless successful interventions can be implemented.

From benzos to berries: treatment offered at an Aboriginal youth solvent abuse treatment centre relays the importance of culture.

First Nations and Inuit youth who abuse solvents are one of the most highly stigmatized substance-abusing groups in Canada. Drawing on a residential treatment response that is grounded in a culture-based model of resiliency, this article discusses the cultural implications for psychiatry's individualized approach to treating mental disorders. A systematic review of articles published in The Canadian Journal of Psychiatry during the past decade, augmented with a review of Canadian and international literature, revealed a gap in understanding and practice between Western psychiatric disorder-based and Aboriginal culture-based approaches to treatment and healing from substance abuse and mental disorders. Differing conceptualizations of mental health and substance abuse are discussed from Western psychiatric and Aboriginal worldviews, with a focus on connection to self, community, and political context. Applying an Aboriginal method of knowledge translation-storytelling-experiences from front-line workers in a youth solvent abuse treatment centre relay the difficulties with applying Western responses to Aboriginal healing. This lends to a discussion of how psychiatry can capitalize on the growing debate regarding the role of culture in the treatment of Aboriginal youth who abuse solvents. There is significant need for culturally competent psychiatric research specific to diagnosing and treating First Nations and Inuit youth who abuse substances, including solvents. Such understanding for front-line psychiatrists is necessary to improve practice. A health promotion perspective may be a valuable beginning point for attaining this understanding, as it situates psychiatry's approach to treating mental disorders within the etiology for Aboriginal Peoples.

Reporting on the prevalence of drug and alternative health product use for mental health reasons: results from a national population survey.

BACKGROUND: Concomitant use of alternative health products with commonly prescribed medications has been associated with elevated risks of adverse effects. OBJECTIVE: The aim of this study was to determine the prevalence and determinants of the use of alternative health products and psychotropic drugs in the same year for mental health reasons and to examine this for specific psychiatric and physical conditions. METHODS: This study used data from the Canadian Community Health Survey: Mental Health and Well-Being cycle 1.2 carried out by Statistics Canada in 2002 on 36,984 Canadians. Multivariate analyses were carried out to identify determinants of health product use. RESULTS: Overall, 13% of Canadians reported the use of alternative health products. Among respondents with a psychiatric diagnosis, heart disease, high blood pressure and diabetes the rate was 20.0%, 12.0%, 12.6% and 9.4% respectively. Use of alternative health products and psychotropic drugs within the same year was reported by 21.3%. Determinants of alternative health product use included older age, female sex, higher education, and mental disorder, the use of cardiovascular drugs, consulting a health care provider for mental health reasons and reporting an unmet mental health need. People with diabetes were less likely to be users. CONCLUSIONS: Concomitant use of alternative health products and psychotropic drugs for mental health reasons are prevalent. This increases the risk for potential drug-herb interactions. Health professionals need to be aware of patient alternative health product use, especially in the presence of co-morbid mental and physical conditions. Public health campaigns aimed towards increasing awareness and education may incite discussions between health professionals and patients on the risks and benefits of these products.

Prevalence and risk indicators of smoking among on-reserve First Nations youth.

OBJECTIVE: To determine the current prevalence of smoking among First Nations youth living on reserve within the Saskatoon Tribal Council, and to determine the independent risk indicators associated with smoking among First Nations youth. METHODS: Students in grades 5 to 8 attending school within the Saskatoon Tribal Council were asked to complete a youth health survey. RESULTS: Of 271 eligible students, 204 completed the consent protocol and the school survey, yielding a response rate of 75.3%; 26.5% of youth were defined as current smokers. Regression analysis indicated that older age, not having a happy home life, suicide ideation and having three or more friends who smoke cigarettes were independent risk indicators of smoking in First Nations youth. DISCUSSION: Smoking prevalence among on-reserve First Nations youth is quite high. The identification of four main risk indicators should assist with the design of youth smoking prevention and cessation programs.

Comparing mental health of francophone populations in Canada, france, and belgium: 12-month prevalence rates of common mental disorders (part 1).

OBJECTIVE: To compare the 12-month prevalence of common mental disorders among francophones in Canada, France, and Belgium. This is the first article in a 2-part series comparing mental disorders and service use prevalence of French-speaking populations. METHODS: This is a secondary analysis of data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) in 2002 and the European Study of Epidemiology of Mental Disorders-Mental Health Disability (ESEMeD) from 2001 to 2003, where comparable questionnaires were administered to representative samples of adults in Canada, France, and Belgium. In Canada, francophone respondents living in Quebec (n = 7571) and outside Quebec (n = 500) completed the French version of the CCHS 1.2 questionnaire. Francophone respondents in Belgium (n = 389) and in France (n = 1436) completed the French version of the ESEMeD population survey questionnaire. Major depressive episodes (MDEs), specific anxiety disorders (ADs), and alcohol abuse and (or) dependence disorders' rates were assessed. RESULTS: The overall prevalence rate for the presence of any MDE, AD, or alcohol abuse and (or) dependence was similar in all francophone populations studied in Canada and Europe and averaged 8.5%. CONCLUSIONS: Mental disorders were equally distributed in all francophone populations studied. Cross-national comparisons continue to be instrumental in providing information useful for the creation of appropriate policies and programs for specific subsets of populations.

Comparing mental health of francophones in Canada, france, and belgium: 12-month and lifetime rates of mental health service use (part 2).

OBJECTIVES: To compare 12-month and lifetime service use for common mental disorders in 4 francophone subsamples using data from national mental health surveys in Canada, Quebec, France, and Belgium. This is the second article in a 2-part series comparing mental disorders and service use prevalence of French-speaking populations. METHODS: Comparable World Mental Health-Composite International Diagnostic Interviews (WMH-CIDI) were administered to representative samples of adults (aged 18 years and older) in Canada during 2002 and in France and Belgium from 2001 to 2003. Two groups of francophone adults in Canada, in Quebec (n = 7571) and outside Quebec (n = 500), and respondents in Belgium (n = 389) and France (n = 1436) completed the French version of the population survey. Prevalence rates of common mental health service use were examined for major depressive episodes and specific anxiety disorders (that is, agoraphobia, social phobia, and panic disorder). RESULTS: Overall, most francophones with mental disorders do not seek treatment. Canadians consulted more mental health professionals than their European counterparts, with the exception of psychiatrists. CONCLUSIONS: Patterns of service use are similar among francophone populations. Variations that exist may be accounted for by differences in health care resources, health care systems, and health insurance coverage.