The Mood Disorders Association of British Columbia Psychiatric Urgent Care Program: A Preliminary Evaluation of a Suggested Alternative Model of Outpatient Psychiatric Care

Objective:

To describe an alternative model of psychiatric outpatient care for patients with mood and anxiety disorders (the Mood Disorders Association of British Columbia Psychiatric Urgent Care Program or the MDA Program) using group medical visits (GMV) and (or) email communications in lieu of individual follow-up appointments.

Method:

Annual costs of the MDA Program were compared with average costs of private psychiatrists offering outpatient care and patients being treated in a mental health centre. In addition, questionnaires as to patient satisfaction with the MDA Program intake, GMV experience, and family physician satisfaction with the MDA Program were administered.

Results:

The MDA Program model of care is significantly more cost effective than individual psychiatric outpatient care or health authority mental health centre care for patients with moderate or severe illness. Patients and family physicians were very satisfied with the model of care and GMVs offered.

Conclusions:

The MDA Program model of care appears to be efficient and cost-effective, and patients and referring physicians appear satisfied with the care offered in this program.     

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 4: Criminal Recidivism

Objective:

To examine criminal recidivism rates of a large sample of people found not criminally responsible on account of mental disorder (NCRMD) in Canada’s 3 most populous provinces, British Columbia, Ontario, and Quebec. Public concern about the dangerousness of people found NCRMD has been fed by media attention on high-profile cases. However, little research is available on the rate of reoffending among people found NCRMD across Canadian provinces.

Method:

Using data from the National Trajectory Project, this study examined 1800 men and women in British Columbia (n = 222), Ontario (n = 484), and Quebec (n = 1094) who were found NCRMD between May 2000 and April 2005 and followed until December 2008.

Results:

Recidivism was relatively low after 3 years (17%). There were interprovincial differences after controlling for number of prior criminal offences, diagnosis, seriousness of the index offence, and supervision by the review boards. British Columbia (10%) and Ontario (9%) were similar, whereas Quebec had almost twice the recidivism (22%). People who had committed severe violent index offences were less likely to reoffend than those who had committed less severe offences. People from the sample were less likely to reoffend when under the purview of review boards, across all 3 provinces.

Conclusion:

The results of this study, along with other research on processing differences, suggest systemic differences in the trajectories and outcomes of persons found NCRMD need to be better understood to guide national policies and practices.     

Intensive Psychotherapy Training in Korean Psychiatric Residency Programs

Objective

The authors investigated the current practice of intensive psychotherapy by residents in the department of psychiatry.

Methods

We mailed a questionnaire to 126 fourth-year psychiatry residents in order to obtain data on their clients'' sociodemographic characteristics, the settings in which psychotherapy is being conducted, the effects of psychotherapy, the difficulties associated with psychotherapy, the state of supervision and the level of clients'' satisfaction.

Results

Approximately 51.5% of the residents completed the questionnaires. The average number of clients was 4.9±3.8, the average number of psychotherapy sessions was 26.2±20.1, and 69.4% of the residents had performed insight-oriented psychotherapy. Approximately 69.8% of the fourth-year residents had received some form of supervision, and 58.7% agreed to increase the frequency of supervision. Approximately 74.2% of the cases were supervised. The average number of supervisions per case was 9.2±10.5.

Conclusion

The setting in which psychotherapy is conducted, number of clients, and type of supervision varied greatly among the training institutes surveyed. Based on these findings, we expect to create better psychotherapy training programs for psychiatric residents.     

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 3: Trajectories and Outcomes Through the Forensic System

Objective:

To examine the processing and Review Board (RB) disposition outcomes of people found not criminally responsible on account of mental disorder (NCRMD) across the 3 most populous provinces in Canada. Although the Criminal Code is federally legislated, criminal justice is administered by provinces and territories. It follows that a person with mental illness who comes into conflict with the law and subsequently comes under the management of a legally mandated RB may experience different trajectories across jurisdictions.

Method:

The National Trajectory Project examined 1800 men and women found NCRMD in British Columbia (n = 222), Quebec (n = 1094), and Ontario (n = 484) between May 2000 and April 2005, followed until December 2008.

Results:

We found significant interprovincial differences in the trajectories of people found NCRMD, including time detained in hospital and time under the supervision of an RB. The odds of being conditionally or absolutely discharged by the RB varied across provinces, even after number of past offences, diagnosis at verdict, and most severe index offence (all covariates decreased likelihood of discharge) were considered.

Conclusions:

Considerable discrepancies in the application of NCRMD legislation and the processing of NCRMD cases through the forensic system across the provinces suggests that fair and equitable treatment under the law could be enhanced by increased national integration and collaboration.     

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label

Objective:

To examine the psychosocio-criminological characteristics of not criminally responsible on account of mental disorder (NCRMD)–accused people and compare them across the 3 most populous provinces. In Canada, the number of people found NCRMD has risen during the past 20 years. The Criminal Code is federally legislated but provincially administered, and mental health services are provincially governed. Our study offers a rare opportunity to observe the characteristics and trajectories of NCRMD–accused people.

Method:

The National Trajectory Project examined 1800 men and women found NCRMD in British Columbia (n = 222), Quebec (n = 1094), and Ontario (n = 484) between May 2000 to April 2005, followed until December 2008.

Results:

The most common primary diagnosis was a psychotic spectrum disorder. One-third of NCRMD–accused people had a severe mental illness and a concomitant substance use disorder, with British Columbia having the highest rate of dually diagnosed NCRMD–accused people. Most accused people (72.4%) had at least 1 prior psychiatric hospitalization. Two-thirds of index NCRMD offences were against the person, with a wide range of severity. Family members, followed by professionals, such as police and mental health care workers, were the most frequent victims. Quebec had the highest proportion of people with a mood disorder and the lowest median offence severity. There were both interprovincial differences and similarities in the characteristics of NCRMD–accused people.

Conclusions:

Contrary to public perception, severe violent offenses such as murder, attempted murder or sexual offences represent a small proportion of all NCRMD verdict offences. The results reveal a heterogeneous population regarding mental health and criminological characteristics in need of hierarchically organized forensic mental health services and levels of security. NCRMD–accused people were well known to civil psychiatric services prior to being found NCRMD. Risk assessment training and interventions to reduce violence and criminality should be a priority in civil mental health services.     

Depression and Employment Status in Primary and Tertiary Care Settings

Objective:

Major depressive disorder (MDD) is a leading cause of disability. Impairment in work function considerably adds to symptom burden and increases the economic impact of this disorder. Our study aimed to investigate the factors associated with work status in MDD within primary and tertiary care.

Method:

We used data from 2 large databases for our analysis—Study 1: the InSight database, a chart review of MDD patients treated by primary care physicians across Canada (n = 986); and Study 2: the International Mood Disorders Collaborative Project, a cross-sectional study of mood disorder patients (Canadian data only: n = 274).

Results:

Both studies demonstrated high rates of unemployment and disability (30.3% to 42.1%). Quebec showed the highest rate of unemployment (21%) and British Columbia had the greatest percentage of patients on disability (15%). Employed and unemployed groups were similar based on clinical characteristics; however, unemployed people may have higher age, prevalence of medical comorbidity, and greater likelihood of receiving a benzodiazepine. Increased disability rates were associated with history of childhood abuse, duration of current major depressive episode, comorbidity, benzodiazepine use, as well as greater depression and anxiety severity. The unemployed–disability groups had greater somatic symptoms and anhedonia. In keeping with this, anhedonia was the strongest predictor of disability. Absenteeism was also high across both studies.

Conclusions:

Unemployment and disability rates in MDD are high. The presence of anhedonia and medical comorbidity significantly influenced work status, emphasizing the need for treatment strategies to alleviate the additional symptom burden in this subpopulation.     

Facteurs de satisfaction et d’épuisement des psychiatres aux urgences

Background and aim

Psychiatric emergency services (PES) have recently occupied a new and growing place in the landscape of mental health services. However, few data are available on the way psychiatrists practice in the PES. Our aim was to survey psychiatrists working in PES, focusing on their job satisfaction and the theoretical models they use in their everyday practice.

The Mistreatment of Major Depressive Disorder

Objective:

To examine the effects of classification on treatment in major depressive disorder (MDD).

Method:

This is a narrative review.

Results:

MDD is a highly heterogeneous category, leading to problems in classification and in specificity of treatment. Current models classify all depressions within a single category. However, the construct of MDD obscures important differences between severe disorders that require pharmacotherapy, and mild-to-moderate disorders that can respond to psychotherapy or remit spontaneously. Patients with mild-to-moderate MDD are being treated with routine or overly aggressive pharmacotherapy.

Conclusions:

The current classification fails to address the heterogeneity of depression, leading to mistreatment.     

Current use of depression rating scales in mental health setting

Objective

This study was to investigate the current use of depression rating scales by psychiatrists and clinical psychologists in Korea.

Methods

The questionnaires from many psychiatrists and clinical psychologists were included in the analysis. The questionnaire was composed of items about examining the percentage of patients clinically using depression rating scales, reasons for not use of them, the degree of satisfaction, the perceived agreement rate between the result of depression rating scales and doctor''s clinical interview in the evaluation of patients with depressive symptoms. Data were analyzed by χ² and independent t-test.

Results

The clinical use of depression rating scales was more frequent in the psychologists than in the psychiatrists. The purposes for using depression rating scales were assessed into six areas, there was no significant difference in between two groups, and both groups pointed out their purpose as rating of severity and screening. The reasons for not using scales were that their interview may be sufficient for diagnosis and assessment of depressive patients and they are not familiar with the use of depression rating scales. The psychiatrists usually prefer the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale and Symptom Checklist 90-Revision (SCL-90-R) in order of frequency, and the clinical psychologists are more likely to use the BDI, Minnesota Multiphasic Personality Inventory and SCL-90-R. Overall rate of satisfaction in the use of the scales was 67.29±14.45% and overall perceived agreement rate was 70.89±16.45%.

Conclusion

Currently used depression rating scales at the clinical practice were not various. Therefore, to heighten clinicians'' utility of these depression rating scales measures, either educational efforts or advertisements, or both, will be necessary to spread them wildly.     

Multistrategic memory training with the metamemory concept in healthy older adults

Objective

According to the increase of older people, the need for effective methods to maintain or improve cognitive functions in the elderly has increased. These cognitive enhancing methods may contribute to the prevention of elderly cognitive decline by aging and dementing illness as well. This study aimed to examine the effectiveness of multistrategic memory training with the metamemory concept on cognitive functions in the normal health elderly in Korea.

Methods

The program used in this study was developed by psychiatrists and psychologists in accordance with Korean situations. We applied the training program to the community-dwelling elderly with subjective memory complaints. Twenty participants were randomly received the intervention with 20 non-treatment controls. This program consisted of 10 sessions and was administered once a week. We examined the effects of this memory training for verbal memory, visuospatial memory, working memory, and verbal fluency ability by repeated ANOVA.

Results

There were significant improvements in Word List Short-term Delayed Free and Cued Recall, Word list Long-term Delayed Free and Cued Recall and visuospatial recognition memory. Performance improvements in visuospatial span forwards and the Categorical Fluency Test were also significant. These improvements were still significant after adjusting for depression improvement exact categorical fluency.

Conclusion

This study shows that multistrategic memory training with the metamemory concept may improve memory ability and other cognitive functions which are not trained and that these improvements may be achieved by pure cognitive training effects.     

Kynurenine 3-monooxygenase polymorphisms: relevance for kynurenic acid synthesis in patients with schizophrenia and healthy controls

Background

Patients with schizophrenia show increased brain and cerebrospinal fluid (CSF) concentrations of the endogenous N-methyl-d-aspartate receptor antagonist kynurenic acid (KYNA). This compound is an end-metabolite of the kynurenine pathway, and its formation indirectly depends on the activity of kynurenine 3-monooxygenase (KMO), the enzyme converting kynurenine to 3-hydroxykynurenine.

Methods

We analyzed the association between KMO gene polymorphisms and CSF concentrations of KYNA in patients with schizophrenia and healthy controls. Fifteen single nucleotide polymorphisms (SNPs) were selected covering KMO and were analyzed in UNPHASED.

Results

We included 17 patients with schizophrenia and 33 controls in our study. We found an association between a KMO SNP (rs1053230), encoding an amino acid change of potential importance for substrate interaction, and CSF concentrations of KYNA.

Limitations

Given the limited sample size, the results are tentative until replication.

Conclusion

Our results suggest that the nonsynonymous KMO SNP rs1053230 influences CSF concentrations of KYNA.     

The glucocorticoid receptor N363S polymorphism and steroid response in Duchenne dystrophy

Background

Steroid administration is beneficial in Duchenne muscular dystrophy (DMD), but the response, incidence, and the severity of side effects are variable.

Aims

To investigate whether glucocorticoid receptor (GRL) gene polymorphisms may be responsible for glucocorticoid sensitivity in DMD.

Methods

Forty eight DMD patients treated either with prednisone or deflazacort were subjected to genetic analyses of the GRL gene.

Results

Mutation studies revealed an heterozygous A to G mutation at GRL cDNA position 1220 in three DMD patients resulting in an asparagine to serine amino acid change at amino acid position 363 (N363S). The N363S carrier DMD patients showed a trend towards a later age at loss of ambulation in comparison with non‐carrier patients.

Conclusions

These data suggest that the N363S GRL polymorphism may be implicated in the long term response to glucocorticoids.     

Residence Conditions on Community Treatment Orders

Objective:

To identify the clinical reasons and legal authority for including a residential placement condition in a community treatment order (CTO).

Method:

We describe the clinical reasons for imposing a residence condition and discuss how this is authorized by the laws of the Canadian provinces (using Ontario as the main example).

Results:

A residence condition can facilitate numerous benefits, including: regular access to a person by a clinical team; continuing therapeutic relations; supervision of medication; provision of general medical care; and reduction in substance use, risks of victimization, and other unintended harm. A resident condition can be lawfully imposed when it clearly fits the purposes of the CTO legislation and stops short of authorizing detention in a community facility.

Conclusions:

In certain circumstances, a residence condition is clinically justified and a lawful aspect of a CTO.     

Emotional learning during dissociative states in borderline personality disorder

Background

Neurobiological findings and clinical data suggest that dissociative experience inhibits conditioning processes, but experimental studies are lacking. The aim of our study was to determine whether high states of dissociative experience would specifically alter emotional learning, but not declarative knowledge.

Methods

We used an aversive differential delay conditioning procedure in 33 unmedicated patients with borderline personality disorder (BPD) and 35 healthy controls.

Results

Patients with BPD who had high state dissociative experiences (BPD D+) showed diminished acquisition of differential aversive delay conditioning with respect to emotional learning compared with those who did not experience dissociative symptoms (BPD D−) and healthy controls (skin conductance response; interaction dissociation × quadratic time × type, p = 0.009). Specifically, the control group and the BPD D− subgroup showed an increase in valence and arousal to the conditioned stimulus (CS+) during the conditioning procedure (all p < 0.012) and demonstrated differential skin conductance responses in the acquisition and extinction phases. In contrast, the BPD D+ subgroup showed no increase in valence and arousal to CS+ or differential response regarding skin conductance. We examined general psychopathology, trauma history, perceptual differences and posttraumatic stress disorder as confounding factors, but we found no evidence of bias.

Limitations

Subdividing the BPD group reduced power. In addition, because our sample included only women, the generalizability of our results is constrained. Furthermore, we performed no separate analysis of the influence of different aspects of dissociation on the learning process.

Conclusion

Emotional, amygdala-based learning processes seem to be inhibited during state dissociative experience. State dissociative experience may alter acquisition and extinction processes and should be closely monitored in exposure-based psychotherapy.     

Predictors of nonresponse to cognitive behavioural therapy or venlafaxine using glucose metabolism in major depressive disorder

Background

Longitudinal neuroimaging investigations of antidepressant treatment offer the opportunity to identify potential baseline biomarkers associated with poor outcome.

Methods

To explore the neural correlates of nonresponse to cognitive behavioural therapy (CBT) or venlafaxine (VEN), we compared pretreatment (18)F-fluoro-2-deoxy-d-glucose positron emission tomography scans of participants with major depressive disorder responding to either 16 weeks of CBT (n = 7) or VEN treatment (n = 9) with treatment nonresponders (n = 8).

Results

Nonresponders to CBT or VEN, in contrast to responders, exhibited pretreatment hypermetabolism at the interface of the pregenual and subgenual cingulate cortices.

Limitations

Limitations of our study include the small sample sizes and the absence of both arterial sampling to determine absolute glucose metabolism and high-resolution structural magnetic resonance imaging coregistration for region-of-interest analyses.

Conclusion

Our current findings are consistent with those reported in previous studies of relative hyperactivity in the ventral anterior cingulate cortex in treatment-resistant populations.     

Using Avoidable Admissions to Measure Quality of Care for Cardiometabolic and Other Physical Comorbidities of Psychiatric Disorders: A Population-Based,Record-Linkage Analysis

Objective:

Quality of care for comorbid physical disorders in psychiatric patients can be assessed by the number of avoidable admissions for ambulatory care sensitive (ACS) conditions. These are admissions for physical conditions that, with appropriate primary care, should not require inpatient treatment. Avoidable admissions for ACS conditions feature prominently in Australia’s National Health Performance Framework and have been used to assess health care provision for marginalized groups, such as Indigenous patients or those of lower socioeconomic status. They have not been applied to people with mental illness.

Methods:

A population-based, record-linkage analysis was used to measure ACS admissions for physical disorder in psychiatric patients of state-based facilities in Queensland, Australia, during 5 years.

Results:

There were 77 435 males (48.0%) and 83 783 females (52%) (total n = 161 218). Among these, 13 219 psychiatric patients (8.2%) had at least 1 ACS admission, the most common being for diabetes (n = 6086) and angina (n = 2620). Age-standardized rates were double those of the general population. Within the psychiatric group, and after adjusting for confounders, those who had ever been psychiatric inpatients experienced the highest rates of ACS admissions, especially for diabetes.

Conclusions:

In common with other marginalized groups, psychiatric patients have increased ACS admissions. Therefore, this measure could be used as an indicator of difficulties in access to appropriate primary care in Canada, given the availability of similar administrative data.     

Folate, Vitamin B12, and Homocysteine as Risk Factors for Cognitive Decline in the Elderly

Objective

Cross-sectional studies have shown that the dysregulation of one-carbon metabolism is associated with cognitive impairment. However, the findings of longitudinal studies investigating this association have been inconsistent. This study investigated the prospective associations between cognitive decline and the levels of folate, vitamin B₁₂ and homocysteine both at baseline and over course of the study period.

Methods

A total of 607 (83%) elderly individuals were selected from a group of 732 elderly individuals without dementia at baseline and followed over a 2.4-year study period. The Mini-Mental State Examination (MMSE) was administered to the subjects, and the serum levels of folate, vitamin B₁₂ and homocysteine were assayed both at baseline and at follow-up examinations. Covariates included demographic data, disability, depression, alcohol consumption, physical activity, vascular risk factors, serum creatinine level, vitamin intake, and apolipoprotein E genotype.

Results

Cognitive decline was associated with decreasing quintiles of folate at baseline, a relative decline in folate and an increase in homocysteine across the two examinations after adjustment for relevant covariates.

Conclusion

These results suggest that folate and homocysteine are involved in the etiology of cognitive decline in the elderly.     

Comparative Efficacy of the Generalized Anxiety Disorder 7-Item Scale and the Edinburgh Postnatal Depression Scale as Screening Tools for Generalized Anxiety Disorder in Pregnancy and the Postpartum Period

Objective:

About 24.1% of pregnant women suffer from at least 1 anxiety disorder, 8.5% of whom suffer specifically from generalized anxiety disorder (GAD). GAD is often associated with major depressive disorder (MDD). During the perinatal period, the presence of physical and somatic symptoms often makes differentiation between depression and anxiety more challenging. To date, no screening tools have been developed to detect GAD in the perinatal population. We investigated the psychometric properties of the GAD 7-item Scale (GAD-7) as a screening tool for GAD in pregnant and postpartum women.

Methods:

Two hundred and forty perinatal women (n = 155 pregnant and n = 85 postpartum) referred for psychiatric consultation were enrolled. On the day of initial assessment, all women completed the GAD-7 and the Edinburgh Postnatal Depression Scale (EPDS). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–based diagnoses were made by experienced psychiatrists. Scores from the GAD-7 and EPDS were compared with the clinical diagnoses to evaluate the psychometric properties of the GAD-7 and EPDS when used as a screening tool for GAD.

Results:

The GAD-7 yielded a sensitivity of 61.3% and specificity of 72.7% at an optimal cut-off score of 13. Compared with the EPDS and the EPDS-3A subscale, the GAD-7 displayed greater accuracy and specificity over a greater range of cut-off scores and more accurately identified GAD in patients with comorbid MDD.

Conclusion:

Our findings suggest that the GAD-7 represents a clinically useful scale for the detection of GAD in perinatal women.     

Osteoprotegerin levels in patients with severe mental disorders

Background

Severe mental disorders are associated with elevated levels of inflammatory markers. In the present study, we investigated whether osteoprotegerin (OPG), a member of the tumour necrosis factor receptor family involved in calcification and inflammation, is elevated in patients with severe mental disorders.

Methods

We measured the plasma levels of OPG in patients with severe mental disorders (n = 312; 125 with bipolar disorder and 187 with schizophrenia) and healthy volunteers (n = 239).

Results

The mean plasma levels of OPG were significantly higher in patients than in controls (t₅₃₁ = 2.6, p = 0.01), with the same pattern in bipolar disorder and schizophrenia. The increase was significant after adjustment for possible confounding variables, including age, sex, ethnic background, alcohol consumption, liver and kidney function, diabetes, cardiovascular disease, autoimmune diseases and levels of cholesterol, glucose and C-reactive protein.

Limitations

Owing to the cross-sectional design, it is difficult to determine causality.

Conclusion

Our results indicate that elevated OPG levels are associated with severe mental disorders and suggest that mechanisms related to calcification and inflammation may play a role in disease development.     

Similar Age-Related Decline in Cortical Activity Over Frontotemporal Regions in Schizophrenia: A Multichannel Near-Infrared Spectroscopy Study

Objectives:

Although recent studies have demonstrated that patients with schizophrenia and healthy controls did not differ in the speed of age-related decline in cortical thickness and performances on cognitive tests, hemodynamic changes assessed by functional neuroimaging remain unclear. This study investigated age effects on regional brain cortical activity to determine whether there is similar age-related decline in cortical activity as those observed in cortical thickness and cognitive test performance.

Method:

A total of 109 patients with schizophrenia (age range: 16–59 y) and 106 healthy controls (age range: 16–59 y) underwent near-infrared spectroscopy (NIRS) while performing a verbal fluency test (VFT). Group comparison of cortical activity was examined using 2-tailed t tests, adopting the false discovery rate method. The relationship between age and cortical activity was investigated using correlational and multiple regression analyses, adjusting for potential confounding variables. A 2-way ANOVA was conducted to investigate differences in the age effects between diagnostic groups.

Results:

The patient group exhibited significantly decreased cortical activity in several regions of the frontotemporal cortices. However, slopes of age-dependent decreases in cortical activity were similar between patients and healthy individuals at the bilateral frontotemporal regions.

Conclusions:

Our study showed no significant between-group differences in the age-related decline in cortical activity, as measured by NIRS, over the frontotemporal regions during a VFT. The results of our study may indicate a decrease in cortical activity in a relatively limited period around illness onset rather than continuously progressing over the course of the illness.Key words: schizophrenia, near infrared spectroscopy, age effect, NIRS