The Canadian Journal of Psychiatry
August 2012, Volume 57, Number 8
From Sin to Science: Fighting the Stigmatization of Mental Illnesses
Julio Arboleda-Flórez, MD, PhD (Epidemiology), FRCPC, FRCM; Heather Stuart, MA (Sociology), PhD (Epidemiology)
Correspondence: Dr Julio Arboleda-Flórez, 3rd Floor, Abramsky Hall, Queen’s University, Kingston, ON K7L 3N6; Professor Emeritus, Queen’s University, Kingston, Ontario.
Our paper provides an overview of current stigma discourse, the origins and nature of the stigma associated with mental illnesses, stigmatization by health providers, and approaches to stigma reduction. This is a narrative review focusing on seminal works from the social and psychological literature, with selected qualitative and quantitative studies and international policy documents to highlight key points. Stigma discourse has increasingly moved toward a human rights model that views stigma as a form of social oppression resulting from a complex sociopolitical process that exploits and entrenches the power imbalance between people who stigmatize and those who are stigmatized. People who have a mental illness have identified mental health and health providers as key contributors to the stigmatization process and worthy targets of antistigma interventions. Six approaches to stigma reduction are described: education, protest, contact-based education, legislative reform, advocacy, and stigma self-management. Stigma denigrates the value of people who have a mental illness and the social and professional support systems designed to support them. It creates inequities in funding and service delivery that undermine recovery and full social participation. Mental health professionals have often been identified as part of the problem, but they can redress this situation by becoming important partners in antistigma work.
Key Words: stigma, discrimination, stigmatization, stigma reduction
Received, revised, and accepted January 2012.
Can J Psychiatry. 2012;57(8):457–463
On the Self-Stigma of Mental Illness: Stages, Disclosure, and Strategies for Change
Patrick W Corrigan, PsyD; Deepa Rao, PhD, MA
Correspondence: Dr Patrick W Corrigan, Illinois Institute of Technology, 3424 South State Street, Chicago, IL 60616; Distinguished Professor and Associate Dean for Research, College of Psychology, Illinois Institute of Technology, Chicago, Illinois.
People with mental illness have long experienced prejudice and discrimination. Researchers have been able to study this phenomenon as stigma and have begun to examine ways of reducing this stigma. Public stigma is the most prominent form observed and studied, as it represents the prejudice and discrimination directed at a group by the larger population. Self-stigma occurs when people internalize these public attitudes and suffer numerous negative consequences as a result. In our article, we more fully define the concept of self-stigma and describe the negative consequences of self-stigma for people with mental illness. We also examine the advantages and disadvantages of disclosure in reducing the impact of stigma. In addition, we argue that a key to challenging self-stigma is to promote personal empowerment. Lastly, we discuss individual- and societal-level methods for reducing self-stigma, programs led by peers as well as those led by social service providers.
Key Words: self-stigma, stigma reduction, mental illness, empowerment
Manuscript received and accepted January 2012.
Can J Psychiatry. 2012;57(8):464–469
Evidence-Based Review of Clinical Outcomes of Guideline-Recommended Pharmacotherapies for Generalized Anxiety Disorder
Basil G Bereza, MSc; Márcio Machado, PhD; Arun V Ravindran, MD, PhD, MRCPsych, FRCPC; Thomas R Einarson, PhD
Correspondence: Dr Basil G Bereza, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON M5S 3M2; Student, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario.
Objective: To quantify the rates of clinical outcomes of Canadian Psychiatric Association (CPA) guideline-recommended pharmacotherapies for generalized anxiety disorder (GAD) by drug classification within each treatment line.
Methods: Evidence from original research cited by the CPA was included. Pooled analyses, duplicates, and studies with nonextractable data were excluded. Response, remission, and baseline–endpoint or mean reductions scores of the Hamilton Anxiety Rating Scale (HARS) were extracted. The Cochrane Collaboration’s computer program, Review Manager, version 5, with a random effects model, was used to pool results.
Results: A total of 50 articles were cited as evidence for managing GAD by the CPA. There was sufficient evidence of remission with first- or third-line agents to pool reported rates, and with agents from all 3 treatment lines to pool response rates and reduction in HARS scores. The mean range of effect size varied considerably from study to study within each treatment line. Comparison of pooled remission rates between first- and second-line agents was not possible. While the range of values by drug and drug class overlapped, the summary results for the probability of response and reduction in HARS scores was greater for first-line, compared with second-line, treatments. Drug components for third-line treatments were heterogeneous and produced mixed results.
Conclusion: Despite the abundance of evidence in its totality presented in the CPA guidelines, there is inadequate evidence to formulate recommendations based on the pooled results from this study alone. However, such analysis provides an additional resource for clinicians to make more effective treatment decisions for individual patients with GAD.
Key Words: anxiety, meta-analysis, pharmacotherapy
Received October 2011, revised, and accepted January 2012.
Can J Psychiatry. 2012;57(8):470–478
Common and Unique Risk Factors and Comorbidity for 12-Month Mood and Anxiety Disorders Among Canadians
Xiangfei Meng, PhD; Carl D’Arcy, PhDi]
Correspondence: Dr Xiangfei Meng, Department of Psychiatry, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK S7N 0W8; Postdoctoral Fellow, Department of Psychiatry and Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan.
Objective: To explore the common and unique risk factors for mood and anxiety disorders. What sociodemographic, psychological, and physical risk factors are associated with mood and anxiety disorders and their comorbidities? What is the impact of multiple risk factors?
Method: Data from the Canadian Community Health Survey: Mental Health and Well-Being were analyzed. Appropriate sampling weights and bootstrap variance estimation were employed. Multiple logistic regression was used to estimate odds ratios and confidence intervals.
Results: The annual prevalence of any mood disorder was 5.2%, and of any anxiety disorder 4.7%. Major depressive episode was the most prevalent mood and anxiety disorder (4.8%), followed by social phobia, panic disorder, mania, and agoraphobia. Among people with mood and anxiety disorders, 22.4% had 2 or more disorders. Risk factors common to mood and anxiety disorders were being young, having lower household income, being unmarried, experiencing greater stress, having poorer mental health, and having a medical condition. Unique risk factors were found: major depressive episode and social phobia were associated with being born in Canada; panic disorder was associated with being Caucasian; lower education was associated with panic and agoraphobia; and poor physical health was associated with mania and agoraphobia. People who were young, unmarried, not fully employed, and had a medical condition, greater stress, poorer self-rated mental health, and dissatisfaction with life, were more likely to have a comorbid mood and (or) anxiety disorder. As the number of common risk factors increases, the probability of having mood and anxiety disorders also increases.
Conclusions: Common and unique risk factors exist for mood and anxiety disorders. Risk factors are additive in increasing the likelihood of disease.
Key Words: mood and anxiety disorders, comorbidity, risk, common risks
Received October 2011, revised, and accepted January 2012.
Can J Psychiatry. 2012;57(8):479–487
The Essential and Potentially Inappropriate Use of Antipsychotics Across Income Groups: An Analysis of Linked Administrative Data
Joseph H Puyat, MA (Psych), MSc (PhD Candidate); Michael R Law, MSc, PhD;
Sabrina T Wong, PhD, RN; Jason M Sutherland, MSc, PhD; Steven G Morgan, MA, PhD
Correspondence: Dr Joseph H Puyat, School of Population and Public Health, University of British Columbia, 201–2206 East Mall, Vancouver, BC V6T 1Z3; Student, Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia.
Objective: To examine the essential and potentially inappropriate use of antipsychotics across income groups.
Method: Linked health, pharmaceutical use, and income data from British Columbia were analyzed to examine antipsychotic use in 2 study cohorts. In the first cohort, the essential use of antipsychotics was assessed among adults who had a recorded diagnosis of schizophrenia in a 2-year period, 2004–2005. In the second cohort, potentially inappropriate use of antipsychotics was examined in people with no recorded diagnosis of schizophrenia or bipolar disorders in 2004–2005. The second cohort was also composed exclusively of seniors with a dementia-related diagnosis who are either in long-term care or living in the community. Income-related differences in antipsychotic use in these 2 cohorts were assessed using logistic regression, controlling for health and sociodemographic characteristics known to influence medicine use.
Results: Among adults, the prevalence of essential antipsychotic use was high (85%), with higher odds of use evident among those in the middle-income group. Among seniors, the prevalence of potentially inappropriate antipsychotic treatment is 23%, with prevalence higher in long-term care (56%) than in the community (13%). No income-related differences were found in long-term care; however, in the community, higher odds of use were found in low-income seniors.
Conclusion: People from low-income households have slightly lower levels of essential antipsychotic use and are more likely to receive potentially inappropriate antipsychotic treatment.
Key Words: antipsychotic, schizophrenia, dementia, income, disparity, essential use, potentially inappropriate use, adult, seniors
Received October 2011, revised, and accepted February 2012.
Can J Psychiatry. 2012;57(8):488–495
Examining the Association Between Psychiatric Illness and Suicidal Ideation in a Sample of Treatment-Seeking Canadian Peacekeeping and Combat Veterans With Posttraumatic Stress Disorder PTSD
J Don Richardson, MD, FRCPC; Kate CM St Cyr, MSc, PPH;
Alexandra M McIntyre-Smith, PhD; David Haslam, MD, FRCPC; Jon D Elhai, PhD;
Jitender Sareen, MD, FRCPC
Correspondence: Dr J Don Richardson, Operational Stress Injury Clinic, Parkwood Hospital, 3rd Floor, Hobbins Building, Room H3012, 801 Commissioners Road East, London, ON N6C 5J1; Consultant Psychiatrist, Operational Stress Injury Clinic, Parkwood Hospital, St Joseph’s Health Care London, London, Ontario; Adjunct Professor, Department of Psychiatry, The University of Western Ontario, London, Ontario; Assistant Professor, Department of Psychiatry and Behavioural Neuroscience, McMaster University, Hamilton, Ontario.
Objective: Our study examines the association between suicidal ideation and and self-reported symptoms of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and alcohol use disorder (AUD) in a sample of treatment-seeking Canadian combat and peacekeeping veterans; and identifies potential predictors of suicidal ideation.
Methods: Actively serving Canadian Forces and Royal Canadian Mounted Police members and veterans seeking treatment at the Parkwood Hospital Operational Stress Injury Clinic (n = 250) completed measures including the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, the Alcohol Use Disorder Identification Test, and the PTSD Checklist—Military Version (PCL-M) between January 2002 and December 2010. Regression analyses were used to determine the respective impact of PTSD, and self-reported symptoms of MDD, GAD, AUD, and anxiety on suicidal ideation.
Results: Most people met PCL-M screening criteria for PTSD (73.6%, n = 184), while 70.8% (n = 177) screened positively for a probable major depressive episode. PTSD symptom was significantly associated with suicidal ideation (β = 0.412, P < 0.001). After controlling for self-reported depressive symptom severity, AUD severity, and generalized anxiety, PTSD severity was no longer significantly associated with suicidal ideation (β = 0.043, P = 0.58).
Conclusions: Although PTSD alone is associated with suicidal ideation, after controlling for common comorbid psychiatric illnesses, self-reported depressive symptom severity emerged as the most significant predictor of suicidal ideation. These findings support the importance of screening for comorbidities, particularly an MDD, as potentially modifiable conditions that are strongly related to suicidal ideation in military personnel’s endorsing criteria for PTSD.
Key Words: military, posttraumatic stress disorder, psychiatric comorbidities, suicidal ideation
Received December 2011, revised, and accepted February 2012.
Can J Psychiatry. 2012;57(8):496–504
Forty-Five-Year Mortality Rate as a Function of the Number and Type of Psychiatric Diagnoses Found in a Large Danish Birth Cohort
Wendy Madarasz, MPE; Ann Manzardo, PhD; Erik Lykke Mortensen, CandPsych;
Elizabeth Penick, PhD; Joachim Knop MD, DrMed; Holger Sorensen, MD, PhD;
Ulrik Becker, MD; Elizabeth Nickel, MS; William Gabrielli Jr, MD, PhD
Correspondence: Dr Ann Manzardo, 3901 Rainbow Boulevard, Mail Stop 4015, Kansas City, Kansas 66160; Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Kansas Medical Center, Kansas City, Kansas.
Objective: Psychiatric comorbidities are common among psychiatric patients and typically associated with poorer clinical prognoses. Subjects of a large Danish birth cohort were used to study the relation between mortality and co-occurring psychiatric diagnoses.
Method: We searched the Danish Central Psychiatric Research Registry for 8109 birth cohort members aged 45 years. Lifetime psychiatric diagnoses (International Classification of Diseases, Revision 10, group F codes, Mental and Behavioural Disorders, and one Z code) for identified subjects were organized into 14 mutually exclusive diagnostic categories. Mortality rates were examined as a function of number and type of co-occurring diagnoses.
Results: Psychiatric outcomes for 1247 subjects were associated with 157 deaths. Early mortality risk in psychiatric patients correlated with the number of diagnostic categories
(Wald χ2 = 25.0, df = 1, P < 0.001). This global relation was true for anxiety and personality disorders, but not for schizophrenia and substance abuse, which had intrinsically high mortality rates with no comorbidities.
Conclusions: Risk of early mortality among psychiatric patients appears to be a function of both the number and the type of psychiatric diagnoses.
Key Words: mortality, mental illness, psychiatric illness, comorbidity
Received October 2011, revised, and accepted January 2012.
Can J Psychiatry. 2012;57(8):505–511
Neuroleptic Malignant Syndrome—An 11-Year Longitudinal Case–Control Study
René Ernst Nielsen, MD; Signe Olrik Wallenstein Jensen, MSc; Jimmi Nielsen, MD, PhD
Correspondence: Dr René Ernst Nielsen, Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Mølleparkvej 10, 9000 Aalborg, Denmark; Researcher, Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Aalborg, Denmark; Clinician, Regional Psychiatric Services West, Central Denmark Region, Herning, Denmark.
Objective: To describe patients with neuroleptic malignant syndrome (NMS), to establish occurrence of NMS, to investigate risk factors of NMS, and to investigate mortality associated with NMS.
Method: We conducted a longitudinal register linkage case–control study of NMS.
Result: In health care registers covering the period from 1996 to 2007, we identified, among 224 372 patients with organic, psychotic, affective, or neurotic diagnosis, 83 patients with NMS, equivalent to an occurrence of 0.04%. Treatment with second-generation antipsychotics (SGAs) in the 3 months preceding admission increased the NMS risk (OR 4.66; 95% CI 1.96 to 11.10) and also first-generation antipsychotics (FGAs) of high potency (OR 23.41; 95% CI 5.29 to 103.61) and mid potency (OR 4.81; 95% CI 1.96 to 11.79), and depot antipsychotics (OR 4.53; 95% CI 1.60 to 12.80). Benzodiazepines (BDZs) also increased the risk of NMS (OR 3.43; 95% CI 1.68 to 12.80). NMS was associated with an increased mortality (HR 1.88; 95% CI 1.19 to 2.98) in patients, compared with sex-, age-, and diagnosis-matched control subjects, but no significant difference in mortality between patients and control subjects was observed after the initial 30 days (P = 0.27).
Conclusions: The occurrence of NMS is low, and the prediction of NMS is difficult. Previous treatment with FGAs, SGAs, and BDZs was identified as a risk factor for developing NMS. NMS increased mortality within 30 days after NMS.
Key Words: psychosis, psychopharmacology, neuropsychiatry, mortality, risk factor
Received November 2011, revised, and accepted January 2012.
Can J Psychiatry. 2012;57(8):512–518
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