Antidepressant utilization in Canada

Objective Antidepressant utilization can be used as an indicator of appropriate treatment for major depression. The objective of this study was to characterize antidepressant utilization in Canada, including the relationships of antidepressant use with sociodemographic variables, past-year and lifetime depression, number of past depressive episodes, and other possible indications for antidepressants. Method We examined data from the Canadian Community Health Survey (CCHS) Cycle 1.2. The CCHS was a nationally representative mental health survey (N=36,984) conducted in 2002 that included a diagnostic instrument for past-year and lifetime major depressive episodes and other psychiatric disorders and a record of past-year antidepressant use. Results Overall, 5.8% of Canadians were taking antidepressants, higher than the annual prevalence of major depressive episode (4.8%) in the survey. Among persons with a past-year major depressive episode, the frequency of antidepressant use was 40.4%. After application of adjustments for probable successful outcomes of treatment, the estimated frequency of antidepressant use for major depression was more than 50%. Frequency of antidepressant treatment among those with a history of depression but without a past-year episode increased with the number of previous episodes. Among those taking antidepressants over the past year, only 33.1% had had a past-year episode of major depression. Migraine, fibromyalgia, anxiety disorder, or past depression was present in more than 60% of those taking antidepressants without a past-year episode of depression. Conclusions The CCHS results suggest that antidepressant use has increased substantially since the early 1990s, and also that these medications are employed extensively for indications other than depression. Disclaimer: this research and analysis were based on data from Statistics Canada. The opinions expressed in this paper do not represent the views of Statistics Canada. This research was presented at the Canadian Academy for Psychiatric Epidemiology 2004 Annual Scientific Symposium on October 14, 2004 in Montreal, Canada.     

Sequential action of phase I and II enzymes cytochrome p450 1B1 and glutathione S-transferase P1 in mammary estrogen metabolism

The Phase I enzyme cytochrome p450 1B1 (CYP1B1) has been postulated to play a key role in estrogen-induced mammary carcinogenesis by catalyzing the oxidative metabolism of 17beta-estradiol (E(2)) to catechol estrogens (2-OHE(2) and 4-OHE(2)) and highly reactive estrogen quinones (E(2)-2,3-Q and E(2)-3,4-Q). The potential of the quinones to induce mutagenic DNA lesions is expected to be decreased by their conjugation with glutathione (GSH) either nonenzymatically or catalyzed by glutathione S-transferase P1 (GSTP1), a Phase II enzyme. Because the interaction of the Phase I and Phase II enzymes is not well defined in this setting, we prepared recombinant purified CYP1B1 and GSTP1 to examine their individual and combined roles in the oxidative pathway and used gas and liquid chromatography/mass spectrometry to measure the parent hormone E(2), the catechol estrogens, and the GSH conjugates. 2-OHE(2) and 4-OHE(2) did not form conjugates with GSH alone or in the presence of GSTP1. However, incubation of GSH and CYP1B1 with 2-OHE(2) resulted in nearly linear conjugation through C-4 and C-1 (i.e., 2-OHE(2)-4-SG and 2-OHE(2)-1-SG), whereas the reaction of 4-OHE(2) yielded only 4-OHE(2)-2-SG. When CYP1B1 and GSTP1 were added together, the rate of conjugation was accelerated with a hyperbolic pattern of product formation in the order 4-OHE(2)-2-SG > 2-OHE(2)-4-SG > 2-OHE(2)-1-SG. Incubation of E(2) with CYP1B1 and GSTP1 resulted in the formation of 4-OHE(2), 2-OHE(2), 4-OHE(2)-2-SG, 2-OHE(2)-4-SG, and 2-OHE(2)-1-SG. The production of GSH-estrogen conjugates was dependent on the concentrations of E(2) and GSTP1 but overall yielded only one-tenth of the catechol estrogen production. The concentration gap between catechol estrogens and GSH-estrogen conjugates may result from nonenzymatic reaction of the labile quinones with other nucleophiles besides GSH or may reflect the lower efficiency of GSTP1 compared with CYP1B1. In summary, both reactions are coordinated qualitatively in terms of product formation and substrate utilization, but the quantitative gap would leave room for the accumulation of estrogen quinones and their potential for DNA damage as part of estrogen-induced mammary carcinogenesis.     

Comparison of craving between pathological gamblers and alcoholics

BACKGROUND: Craving is a central phenomenon in addiction. Temperament factors are also important for pathologic gambling and other addictions. The aim of this study was to compare craving between pathologic gamblers (PG) and alcohol-dependent subjects (ADS), correlating craving with personality. METHODS: Forty-nine PG and 101 ADS willing to start treatment were recruited. A trained psychiatrist diagnosed them according to DSM-IV criteria. To be included in this study, subjects had to be abstinent for at least five days and no longer than 21 days. Alcoholics should have no significant physical withdrawal symptoms by the time of craving assessment. Subjects with current comorbidity with other addictions were excluded, except nicotine. ADS rated craving for alcohol and PG rated craving for gambling on the same questions, respectively. Both answered a semistructured interview, the Temperament and Character Inventory and the Beck Scales for anxiety and depression. RESULTS: Pathologic gamblers scored higher than ADS on craving measures (p<0.001) and novelty seeking (p=0.01). ADS scored higher in harm avoidance (p=0.01). Alcohol craving correlated positively with anxiety and novelty seeking and negatively with length of abstinence and persistence. Gambling craving correlated positively with depression and negatively with length of abstinence and reward dependence CONCLUSIONS: Pathologic gamblers experienced stronger cravings than did ADS. This may be a disturbing experience for PG and a potential cause for relapse. The higher scores on novelty seeking concur with previous studies that associate PG and impulsivity. ADS higher scores on harm avoidance suggest anxiety vulnerability. The positive relation between alcohol craving, anxiety, and harm avoidance suggests that ADS rely on alcohol to deal with a proclivity to negative emotions. The positive relation of gambling craving to depression and negative relation to reward dependence suggests that individuals who have a lesser susceptibility to experience positive emotions are the ones who most miss gambling when abstaining.     

Strike action at the major teaching psychiatric facility

This article reviews the literature on strikes at psychiatric facilities and describes one such experience. The need in labor contracts to define a crisis in patient care and to protect the non-striking staff from extra-professional liability is highlighted.N. el-Guebaly, M.D. is Associate Professor and Head of the Department of Psychiatry, St. Boniface General Hospital, 409 Tache Ave., Winnipeg, Manitoba, Canada. R2H 2A6. J. Toews, M.D. is Associate Professor and Assistant Clinical Head of the Department of Psychiatry, Health Sciences Centre. Requests for reprints should be addressed to Dr. el-Guebaly at the above address.     

Examining the predictive validity of low-risk gambling limits with longitudinal data

Aims To assess the impact of gambling above the low‐risk gambling limits developed by Currie et al. (2006) on future harm. To identify demographic, behavioural, clinical and environmental factors that predict the shift from low‐ to high‐risk gambling habits over time. Design Longitudinal cohort study of gambling habits in community‐dwelling adults. Setting Alberta, Canada. Participants A total of 809 adult gamblers who completed the time 1 and time 2 assessments separated by a 14‐month interval. Measurements Low‐risk gambling limits were defined as gambling no more than three times per month, spending no more than CAN$1000 per year on gambling and spending less than 1% of gross income on gambling. Gambling habits, harm from gambling and gambler characteristics were assessed by the Canadian Problem Gambling Index. Ancillary measures of substance abuse, gambling environment, major depression, impulsivity and personality traits assessed the influence of other risk factors on the escalation of gambling intensity. Findings Gamblers classified as low risk at time 1 and shifted into high‐risk gambling by time 2 were two to three times more likely to experience harm compared to gamblers who remained low risk at both assessments. Factors associated with the shift from low‐ to high‐risk gambling behaviour from time 1 to time 2 included male gender, tobacco use, older age, having less education, having friends who gamble and playing electronic gaming machines. Conclusions An increase in the intensity of gambling behaviour is associated with greater likelihood of future gambling related harm in adults.     

A call for primary prevention: reality or utopia

The efficacy of primary prevention of mental disorders has been debated over the years. The debate is complicated by ideology, semantic confusion, methodological difficulties and a paucity of good evaluative studies. This paper reviews newer concepts of primary prevention and mental health promotion, methodological issues, model programs, and inherent ethical concerns. Further evaluative studies and an increased contribution of psychiatrists to the primary prevention debate are recommended as necessary steps in further evolution of the field.     

Change with time in patients' reactions to committal

The influence of time on patients' reactions to involuntary committal is a variable seldom considered in reports. The reactions to committal of thirty-four subjects interviewed one week/one month/three months/six months post committal are reported. Generally committal was viewed neutrally. The major changes in attitudes related to knowledge of the fact of committal and of rights of appeal. The importance of these findings for the management of committed patients is stressed.     

Alcohol, Alcoholism, and Biological Rhythms

Chronobiological rhythms contribute to our understanding of the effect of alcohol and of several features of alcoholism. The observation of infradian periodicities suggests preventive seasonal strategies aimed at reducing the consumption of alcohol and its consequences. Circadian variations in blood alcohol levels and behavioral impairment indicate a complex temporal rhythmicity with both physiological and psychosocial determinants. Circadian differences are noted among possible mediators of susceptibility towards alcoholism. Ultradian patterns may be of prognostic value in assessing risks such as that of relapse during withdrawal from alcohol. Recommendations for future animal and human investigations are suggested.