February 22, 2012

The Canadian Journal of Psychiatry January 2012, Volume 57, Number 1 ________________________________________ In Review Beyond Pharmacotherapy: Understanding the Links Between Obesity and Chronic Mental Illness Valerie H Taylor, MD, PhD, FRCPC; Roger S McIntyre, MD, FRCPC;Gary Remington, MD, PhD, FRCPC; Robert D Levitan, MD, FRCPC;Brian Stonehocker, MD, FRCPC; Arya M Sharma, MD, PhD, FRCPC Correspondence: Dr Valerie H Taylor, Psychiatrist-in-Chief, Women’s College Hospital, Toronto, Ontario; Associate Professor, University of Toronto, 76 Grenville Street, Toronto, ON M5S 1B2; valerie.taylor@wchospital.ca. While differences in weight-gain potential exist, both between and within classes of psychiatry medications, most commonly used atypical antipsychotics, mood stabilizers, and antidepressants result in some degree of weight gain. This is not new information and it requires an understanding of the tolerability profiles of different treatments and their goodness of fit with specific patient phenotypes. However, this iatrogenic association represents only a piece of this obesity–mental illness dyad. The complex interplay between psychiatric illness and weight involves neurobiology, psychology, and sociological factors. Parsing the salient variables in people with mental illness is an urgent need insofar as mortality from physical health causes is the most common cause of premature mortality in people with chronic mental illness. Our review examines issues associated with common chronic mental illnesses that may underlie this association and warrant further study if we hope to clinically intervene to control this life-threatening comorbidity. Key Words: obesity, major depressive disorder, bipolar disorder, schizophrenia, attention-deficit hyperactivity disorder, trauma, inflammation, cytokines Received, revised, and accepted September 2011. Can J Psychiatry. 2012;57(1):5–12 ________________________________________ In Review An Overview of Treatments for Obesity in a Population With Mental Illness Valerie H Taylor, MD, PhD, FRCPC; Brian Stonehocker, MD, FRCPC;Margot Steele, MA, RPsych; Arya M Sharma, MD, PhD, FRCPC Correspondence: Dr Valerie H Taylor, Psychiatrist-in-Chief, Women’s College Hospital, Toronto, Ontario; Associate Professor, University of Toronto, 76 Grenville Street, Toronto, ON M5S 1B2; valerie.taylor@wchospital.ca. Obesity is associated with early mortality and has overtaken smoking as the health problem with the greatest impact on quality of life, mortality, and morbidity. Despite public health initiatives and numerous commercial enterprises focusing on weight loss, obesity rates continue to rise. In part, this is because obesity is a multifaceted, complex illness, impacted by numerous social, psychological, and behavioural factors that are unrecognized in most current initiatives. One significant factor associated with obesity is mental illness. While having a psychiatric illness does not make weight gain inevitable, it does often require that additional tools be added to lifestyle recommendations around diet and exercise. The following article reviews the common approaches to obesity management and addresses how these strategies can be implemented in psychiatric care. It is important that health professionals involved in the care of people with a mental illness become familiar with the interventions available to control and treat the obesity epidemic, as this will improve treatment compliance and ultimately lead to improved physical and psychological outcomes. Key Words: obesity, cognitive-behavioural therapy, bariatric surgery Received, revised, and accepted September 2011. Can J Psychiatry. 2012;57(1):13–20 ________________________________________ Original Research Emergency Department Assessment of Self-Harm Risk Using Psychometric Questionnaires Jason R Randall, MSc; Brian H Rowe, MD, MSc; Ian Colman, PhD Correspondence: Mr Jason R Randall, Assistant Professor, Department of Epidemiology and Community Medicine, University of Ottawa, 451 Smyth Road, Room 3230C, Ottawa, ON K1H 8M5; icolman@uottawa.ca. Objective: To examine several potential predictive screening tools for emergency department assessment of risk of self-harm. Methods: Adult patients presenting with self-harm or suicidal ideation were enrolled at 2 emergency departments at large teaching hospitals in Edmonton, Alberta. Patients completed a brief interview assessing demographics and psychiatric history and several questionnaires (the Beck Hopelessness Scale, the Barrett Impulsiveness Scale [BIS], and the Brief Symptom Inventory [BSI]) and drug and alcohol abuse screens (Drug Abuse Screening Test [DAST-10] and the Cut down, Annoyed, Guilt, Eye-opener [commonly referred to as CAGE] Questionnaire). At 3 months, patients were followed up via telephone and electronic health records to ascertain self-harm outcome. Questionnaires and their subscales were assessed using logistic regression. Receiver operating characteristic (ROC) analysis was performed on the results. Results: Among the 157 patients enrolled, 49% were women and 36% (of the total) were aged 18 to 29 years. Several of the subscales of the BSI and BIS as well as the DAST-10 were significant predictors of self-harm (P < 0.05). ROC analysis showed that none of the scales in isolation were very strong predictors. Hierarchical regression analysis that combined the significant scales with clinical risk factors that were significantly related to self-harm (that is, age, education level, history of self-harm, and whether they presented with self-harm or only suicidal ideation) indicated that the BIS and DAST-10 questionnaires each added significantly to the predictive ability of a model with these risk factors. Conclusions: While many of the questionnaires and their related constructs are related to future self-harm, none of them are particularly strong and their diagnostic usefulness is limited. Key Words: self-injurious behaviours, risk assessment, emergency medicine, psychiatry Received April 2011, revised, and accepted July 2011. Can J Psychiatry. 2012;57(1):21–28 ________________________________________ Original Research Wait Time Impact of Co-Located Primary Care Mental Health Services: The Effect of Adding Collaborative Care in Northern Ontario John M Haggarty, MD; Janelle A Jarva, MA; Zack Cernovsky, PhD; Kim Karioja, MBA (Doctoral Candidate); Lynn Martin, PhD Correspondence: Dr John M Haggarty, Professor, Northern Ontario School of Medicine, Thunder Bay, Ontario; Medical Director, Mental Health Outpatient Programs, St Joseph’s Care Group, 710 Victoria Avenue East, Thunder Bay, ON P7C 5P7; haggartyj@tbh.net. Objectives: In the shared care model, psychiatrists and physicians work in the same office areas, write their notes in the same casebooks, and can more rapidly exchange information about referrals and health conditions of their patients. We evaluated the impact of the introduction of a shared mental health care service, co-located with a primary care site, on wait times for mental health services in a northern Ontario city. Method: Chart reviews were conducted to examine a total of 3589 referrals for 5 mental health outpatient services (1 shared care and 4 existing services) from January 2001 to the end of June 2004. The shared mental health care service site was started in July 2001. Wait time was measured 6 months prior to and up to 3 years after the introduction of the shared care service. Results: The shared care site offered services more than 40 days sooner and also helped to reduce wait time on the nonshared care sites. After shared care began, the pre-existing, nonshared care services had wait times of about 13 days shorter during the 3 subsequent years. Conclusions: The shared care service maintained the lowest overall wait times, compared with the existing nonshared care services. The existing services experienced a decrease in the number of days waiting when the baseline wait time was compared with that of the following year. Key Words: wait time, collaborative care, primary mental health, health access, health services, epidemiology Received February 2011, revised, and accepted July 2011. Can J Psychiatry. 2012;57(1):29–33 ________________________________________ Original Research Waist Circumference Is a Sensitive Screening Tool for Assessment of Metabolic Syndrome Risk in Children Treated With Second-Generation Antipsychotics Constadina Panagiotopoulos, MD, FRCPC; Rebecca Ronsley, BSc; Boris Kuzeljevic, MA; Jana Davidson, MD, FRCPC Correspondence: Dr Constadina Panagiotopoulos, Assistant Professor, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia; Endocrinologist, Endocrinology and Diabetes Unit, British Columbia Children’s Hospital Department of Pediatrics, University of British Columbia, 4480 Oak Street, ACB K4–213 Vancouver, BC V6H 3V4; dpanagiotopoulos@cw.bc.ca. Objective: To compare the prevalence of metabolic syndrome (MetS) and its components in second-generation antipsychotic (SGA)-treated and SGA-naive children; and to explore the utility of clinical markers, such as waist circumference (WC) and body mass index (BMI), as screening tools for MetS. Methods: Subjects were prospectively recruited from the Psychiatry Emergency Unit at British Columbia Children’s Hospital. As part of a quality-assurance project, a metabolic monitoring protocol was implemented, including collection of anthropomorphic and laboratory data. Results: From January 2008 to February 2010, there were 117 SGA-treated and 217 SGA-naive children recruited. The overall prevalence of MetS was 19.0% (16/84; median treatment duration = 14 months) in SGA-treated and 0.8% (1/127) in SGA-naive children (OR 29.7; 95% CI 3.85 to 228.40, P < 0.001), with an increased prevalence of all components except high-density lipoprotein cholesterol (HDL-C), respectively: elevated WC (40.7% and 10.1%; P < 0.001); hypertriglyceridemia (33.7% and 18.8%; P = 0.01); impaired fasting glucose (12.5% and 0.7%; P = 0.005); and elevated blood pressure (41.2% and 16.5%; P < 0.001). SGA treatment was the strongest predictor of MetS (OR 19.2; 95% CI 2.30 to 160.44, P = 0.006) followed by male sex (OR 5.7; 95% CI 1.08 to 30.62, P = 0.04). Presence of abdominal obesity was more sensitive (92.9%) than BMI (68.8%), while fasting glucose of 5.6 mmol/L or more and HDL-C of 1.03mmol/L or less were most specific (94.1%) in correctly identifying MetS. Conclusions: SGA treatment confers a significantly increased risk for MetS over the long term. WC measurement is a simple and sensitive screening tool for determining MetS risk in SGA-treated children. These data highlight the dangers of SGA treatment and the importance of standardized metabolic monitoring using sex- and age-adjusted tables in this population. Key Words: metabolic syndrome, second-generation antipsychotics, waist circumference, screening, children, adolescents Received March 2011, revised, and accepted July 2011. Can J Psychiatry. 2012;57(1):34–44 ________________________________________ Original Research Parental Sexual Abuse and Suicidal Behaviour Among Women With Major Depressive Disorder Banu Cankaya, PhD; Nancy L Talbot, PhD; Erin A Ward, MSW; Paul R Duberstein, PhD Correspondence: Dr Nancy L Talbot, Associate Professor, University of Rochester Medical Center, University of Rochester School of Medicine and Dentistry, Department of Psychiatry, 300 Crittenden Boulevard, Rochester, NY 14642–8409, USA; Nancy_Talbot@urmc.rochester.edu. Objective: Women with major depressive disorder (MDD) and childhood sexual abuse histories have an increased risk for suicidal behaviours, but it is unclear whether specific abuse characteristics contribute to risk. We aimed to examine the contributions of abuse characteristics to lifetime history of suicide attempts and multiple suicide attempts, independent of posttraumatic stress disorder and borderline personality disorder. Method: Women with MDD and sexual abuse histories (n = 106) were assessed regarding sexual abuse characteristics, psychiatric diagnoses, and suicide attempts. Results: In multivariate logistic regressions, the odds of having multiple suicide attempts increased 12.27-fold when childhood sexual abuse was perpetrated by a parent figure or a parent, compared with a nonparent. Conclusions: Parental perpetration of sexual abuse increases the likelihood of multiple suicide attempts among women outpatients. The relationship of the perpetrator to the abused woman is important in suicide risk evaluation and treatment planning. Clinical Trial Registration Number: NCT00843700 Key Words: depression, sexual abuse, suicide Received February 2011, revised, and accepted July 2011. Can J Psychiatry. 2012;57(1):45–51 ________________________________________ Original Research Ten Years of Antipsychotic Prescribing to Children: A Canadian Population-Based Study Silvia Alessi-Severini, PhD; Robert G Biscontri, PhD, FCPA (Aust), CGA; David M Collins, PhD; Jitender Sareen, MD, FRCPC; Murray W Enns, MD, FRCPC Correspondence: Dr Silvia Alessi-Severini, Assistant Professor, Faculty of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Avenue, Winnipeg, MB R3E 0T5; alessise@cc.manitoba.ca. Objective: To report the prescribing of antipsychotics to the youth population of the Canadian province of Manitoba during the course of a decade. Methods: Use of antipsychotics in children and adolescents (aged 18 years or younger) was described using data collected from the administrative health databases of Manitoba Health and the Statistics Canada census between the fiscal years of 1999 and 2008. Results: The prevalence of antipsychotic use in this segment of the population increased with the introduction of the second-generation antipsychotics (SGAs) from 1.9 per 1000 in 1999 to 7.4 per 1000 in 2008. The male-to-female antipsychotic usage ratio increased from 1.9 to 2.7 as the male youth population represented the fastest-growing subgroup of antipsychotic users in the entire population of Manitoba. The total number of prescriptions also increased significantly despite the lack of approved indications in this population. Proportion of use remained equally split between high- and low-income users. More than 70% of antipsychotic prescriptions to children and adolescents were written by general practitioners. The most common diagnoses linked to antipsychotic use were attention-deficit hyperactivity disorder and conduct disorders. Use of antipsychotics in combination with methylphenidate increased from 13% to 43%. Conclusion: Extensive off-label use of SGAs has been observed in the youth population of Manitoba for treatment of aggressive behaviours across a range of diagnoses. It is important to monitor antipsychotic prescribing to children as more reports of significant adverse events associated with antipsychotics become available. Key Words: antipsychotics, prescribing, children, adolescents Received May 2011, revised, and accepted June 2011. Can J Psychiatry. 2012;57(1):52–58 ________________________________________ Next Issue Current Issue Past Issues Subject and Author indices Editorial Board Advertising Information Subscription Information Instructions for Authors

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