April 16, 2014

   
The Canadian Journal of Psychiatry
November 2012, Volume 57, Number 11
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In Review

Mental Illness and Mental Health: Is the Glass Half Empty or Half Full?

Joseph M Pierre, MD

Correspondence: Dr Joseph M Pierre, 11301 Wilshire Boulevard, Building 210, Room 15, Los Angeles, CA 90073; Associate Director of Residency Education, UCLA Semel Institute for Neuroscience and West Los Angeles VA Medical Center, Los Angeles, California;
Co-Chief, Schizophrenia Treatment Unit, West Los Angeles VA Medical Center, Los Angeles, California; Health Sciences Clinical Professor, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California. joseph.pierre2@va.gov.


During the past century, the scope of mental health intervention in North America has gradually expanded from an initial focus on hospitalized patients with psychoses to outpatients with neurotic disorders, including the so-called worried well. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, is further embracing the concept of a mental illness spectrum, such that increasing attention to the softer end of the continuum can be expected in the future. This anticipated shift rekindles important questions about how mental illness is defined, how to distinguish between mental disorders and normal reactions, whether psychiatry is guilty of prevalence inflation, and when somatic therapies should be used to treat problems of living. Such debates are aptly illustrated by the example of complicated bereavement, which is best characterized as a form of adjustment disorder. Achieving an overarching definition of mental illness is challenging, owing to the many different contexts in which DSM diagnoses are used. Careful analyses of such contextual utility must inform future decisions about what ends up in DSM, as well as how mental illness is defined by public health policy and society at large. A viable vision for the future of psychiatry should include a spectrum model of mental health (as opposed to exclusively mental illness) that incorporates graded, evidence-based interventions delivered by a range of providers at each point along its continuum.

Key Words: diagnostic expansion, prevalence inflation, bereavement, adjustment disorder, contextual utility, neuroenhancement, mental illness, mental health

Received and accepted March 2012.

CanJPsychiatry 2012;57(11):651–658
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In Review

Bipolar Disorder: The Shift to Overdiagnosis

Philip B Mitchell, AM, MB BS, MD, FRANZCP, FRCPsych

Correspondence: Dr Philip B Mitchell, School of Psychiatry, Prince of Wales Hospital, Randwick, NSW 2031, Australia; Scientia Professor and Head, School of Psychiatry, University of New South Wales and Black Dog Institute, Sydney, Australia.
phil.mitchell@unsw.edu.au.

Sometimes dramatically changing vogues in diagnostic practice in psychiatry resemble the volatility of international share markets. One such quickly shifting diagnostic area has been that of bipolar disorder (BD). Historically regarded as a relatively uncommon condition until recent decades, the construct of BD underwent a major expansion in the 1990s and 2000s with promulgation of the concept of the soft bipolar spectrum disorder, from which the recent research focus on subthreshold BD presentations was derived. Related to this has been renewed interest in treatments for BD from the pharmaceutical industry. The increasing rates of diagnosis have largely related to BD II, for which there has been a dramatic broadening of diagnostic criteria. This article critically reviews research data, both for broadening the diagnostic criteria for BD and, conversely, for the growing evidence of overdiagnosis in clinical practice. Why does this debate matter? I would suggest that there are many valid reasons to be concerned about overdiagnosis: first, the potential for overtreatment or inappropriate treatment of such patients with mood stabilizing treatments, including antipsychotics; second, the potential for diagnostic oversimplification, with consequent diagnostic deskilling and loss of credibility for the psychiatric profession; and third, the potential major impact on etiologic research for this condition. Psychiatry should not uncritically accept the shift to overdiagnosis, which has developed a rapid momentum in recent decades, in both clinical and academic circles. We must ensure, as a profession, that any change in diagnostic practice is underpinned by rigorous and critical research inquiry.

Key Words: bipolar disorder, bipolar spectrum, subthreshold, overdiagnosis, underdiagnosis

Received and accepted March 2012.

CanJPsychiatry 2012;57(11):659–665
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Original Research

Predictors of Psychiatric Aftercare Among Formerly Hospitalized Adolescents

Corine E Carlisle, MD, MSc; Muhammad Mamdani, PharmD, MA, MPH;
Russell Schachar, MD; Teresa To, PhD


Correspondence: Dr Corine E Carlisle, CAMH, Youth Addiction and Concurrent Disorders Service, 80 Workman Way, Room 5332, Toronto, ON M6J 1H4; Clinician Scientist, Centre for Addiction and Mental Health, Toronto, Ontario; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. corine.carlisle@camh.ca.


Objective: Timely aftercare can be viewed as a patient safety imperative. In the context of decreasing inpatient length of stay (LOS) and known child psychiatry human resource challenges, we investigated time to aftercare for adolescents following psychiatric hospitalization.
Method: We conducted a population-based cohort study of adolescents aged 15 to 19 years with psychiatric discharge between April 1, 2002, and March 1, 2004, in Ontario, using encrypted identifiers across health administrative databases to determine time to first psychiatric aftercare with a primary care physician (PCP) or a psychiatrist within 395 days of discharge.
Results: Among the 7111 adolescents discharged in the study period, 24% had aftercare with a PCP or a psychiatrist within 7 days and 49% within 30 days. High socioeconomic status (adjusted hazard ratio [AHR] 1.31; 95% CI 1.21 to 1.43, P < 0.001) and psychotic disorders (AHR 1.24; 95% CI 1.12 to 1.36, P < 0.001) were associated with greater likelihood of aftercare. Youth in the northern part of the province (AHR 0.48; 95% CI 0.32 to 0.71, P < 0.001), rural areas (AHR 0.82; 95% CI 0.76 to 0.89, P < 0.001), and with self-harm or suicide attempts (AHR 0.58; 95% CI 0.53 to 0.64, P < 0.001) and substance use disorders (AHR 0.50; 95% CI 0.44 to 0.56, P < 0.001) were less likely to receive aftercare.
Conclusions: Hospitalization is our most intensive, intrusive, and expensive psychiatric treatment setting, yet in our cohort of formerly hospitalized adolescents fewer than 50% received psychiatry-related aftercare in the month postdischarge. Innovations are necessary to address geographic inequities and improve timely access to mental health aftercare for all youth.


Key Words: rural, urban, mental health services, aftercare, continuity of care, health care disparity, health policy, health care reform

Received December 2011, revised, and accepted May 2012.

CanJPsychiatry 2012;57(11):666–676
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Original Research

Childhood Maltreatment and Substance Use Disorders Among Men and Women in a Nationally Representative Sample

Tracie O Afifi, PhD; Christine A Henriksen, MA (PhD Candidate); Gordon J G Asmundson, PhD; Jitender Sareen, MD

Correspondence: Dr Tracie O Afifi, S113 Medical Services Building, 750 Bannatyne Avenue, Winnipeg, MB R3E 0W3; Assistant Professor, Departments of Community Health Sciences, Psychiatry, and Family Social Sciences, University of Manitoba, Winnipeg, Manitoba.
T_Afifi@umanitoba.ca.

Objective: To examine the association between a history of 5 types of childhood maltreatment (that is, physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect) and several substance use disorders (SUDs), including alcohol, sedatives, tranquilizers, opioids, amphetamines, cannabis, cocaine, hallucinogens, heroin, and nicotine, in a nationally representative US adult sex-stratified sample.
Method: Data were drawn from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative US sample of adults aged 20 years and older (n = 34 653). Logistic regression models were conducted to understand the relations between 5 types of childhood maltreatment and SUDs separately among men and women after adjusting for sociodemographic variables and Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I and II mental disorders.
Results: All 5 types of childhood maltreatment were associated with increased odds of all individual SUDs among men and women after adjusting for sociodemographic variables, with the exception of physical neglect and heroin abuse or dependence, emotional neglect, and amphetamines and cocaine abuse or dependence among men (adjusted odds ratio range 1.3 to 4.7). After further adjustment for other DSM Axis I and II mental disorders, the relations between childhood maltreatment and SUDs were attenuated, but many remained statistically significant. Differences in the patterns of findings were noted for men and women for sexual abuse and emotional neglect.
Conclusions: This research provides evidence of the robust nature of the relations between many types of childhood maltreatment and many individual SUDs. The prevention of childhood maltreatment may help to reduce SUDs in the general population.

Key Words: child abuse, neglect, alcohol, drugs, nicotine, cannabis, cocaine, heroin, sedatives, opioids

Received December 2011, revised, and accepted May 2012.

CanJPsychiatry 2012;57(11):677–686
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Original Research

Real-World Evaluation of the Resident Assessment Instrument–Mental Health Assessment System

Karen A Urbanoski, PhD; Benoit H Mulsant, MD, MS; Peggie Willett, MA;
Sahar Ehtesham, HBSc; Brian Rush, PhD


Correspondence: Dr Karen A Urbanoski, Centre for Addiction and Mental Health, 33 Russell Street, T309, Toronto, ON M5S 2S1; Independent Scientist, Health Systems and Health Equity Research Group, Centre for Addiction and Mental Health, Toronto, Ontario; Assistant Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario.
karen_urbanoski@camh.net.

Objective: We evaluated the Resident Assessment Instrument—Mental Health (RAI-MH) assessment platform at a large psychiatric hospital in Ontario during the 3 years following its provincially mandated implementation in 2005. Our objectives were to document and consider changes over time in front-line coding practices and in indicators of data quality.
Methods: Structured interviews with program staff were used for preliminary information-gathering on front-line coding practices. A retrospective data review of assessments conducted from 2005 to 2007 examined 5 quantitative indicators of data quality.
Results: There is evidence of improved data quality over time; however, low scores on the outcome scales highlight potential shortcomings in the assessment system’s ability to support outcome monitoring. There was variability in implementation and performance across clinical programs.
Conclusions: This evaluation suggests that the RAI-MH–based assessment platform may be better suited to longer-term services for severely impaired clients than to short-term, highly specialized services. In particular, the suitability of the RAI-MH for hospital-based addictions care should be re-examined. Issues of staff compliance and motivation and problems with assessment system performance would be highly entwined, making it inappropriate to attempt to allocate responsibility for areas of less than optimal performance to one or the other. The ability of the RAI-MH to perform well on clinical front lines is, in any case, essential for it to meet its objectives. Continued evaluation of this assessment platform should be a priority for future research.

Key Words: clinical assessment, outcome monitoring, care planning, inpatient care, standardized assessment, Resident Assessment Instrument—Mental Health (RAI-MH)

Received January 2012, revised, and accepted May 2012.

CanJPsychiatry 2012;57(11):687–695
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Original Research

Predicting Hospital Length of Stay for Geriatric Patients With Mood Disorders

Zahinoor Ismail, MD, FRCPC; Tamara Arenovich, MSc; Charlotte Grieve, MSc; Peggie Willett, MA; Gautam Sajeev, MSc; David C Mamo, MSc, MD, FRCPC; Glenda M MacQueen, MD, PhD, FRCPC; Benoit H Mulsant, MS, MD, FRCPC

Correspondence: Dr Zahinoor Ismail, 1403–29 Street NW, Calgary, AB T2N 2T9; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Clinical Associate Professor, Department of Psychiatry, University of Calgary, Calgary, Alberta; Member, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta. zahinoor@gmail.com.

Objective: To determine predictors of hospital length of stay (LOS) for adult and geriatric patients with mood disorders admitted to inpatient psychiatric beds.
Methods: Admission and discharge data from a large urban mental health centre, from 2005 to 2010 inclusive, were retrospectively analyzed. Using the Resident Assessment Instrument—Mental Health, an assessment that is used to collect demographic and clinical information within 72 hours of hospital admission, 199 geriatric mood disorder admissions were compared with 570 adult mood disorder admissions. Predictors of hospital LOS were determined using a series of general linear models.
Results: Living alone, number of recent psychiatric admissions, involuntary admission, and close or constant observation level predict longer hospital LOS in geriatric, but not in adult mood disorder, patients. Conversely, pain on admission predicts shorter hospital LOS in geriatric, but not among adult, mood disorder patients. Predictors of longer hospital LOS, irrespective of admission group (adult, compared with geriatric), include incapacity, negative symptoms, and increased dependence for instrumental activities of daily living.
Conclusions: Addressing these predictive factors early on during admission and in the community may result in shorter hospital LOS and more optimal use of resources.

Key Words: geriatric psychiatry, length of stay, inpatient, predictors, mood disorders, bipolar, depression, service delivery, capacity, pain

Received January 2012, revised, and accepted April 2012.

CanJPsychiatry 2012;57(11):696–703
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Review Paper

Emerging Risk Factors for Postpartum Depression: Serotonin Transporter Genotype and Omega-3 Fatty Acid Status

Gabriel D Shapiro, MPH (PhD Candidate); William D Fraser, MD, MSc, FRCSC; Jean R Séguin, PhD

Correspondence: Dr Jean R Séguin, Department of Psychiatry, Université de Montreal and Centre de recherche de l’Hôpital Ste-Justine, 3175 Côte Ste-Catherine, Bloc 5, Local 1573, Montreal, QC H3T 1C5; Professor and Research Director, Department of Psychiatry, Université de Montreal, Montreal, Quebec; Assistant Head to the Brain Diseases Research Axis, Centre de recherche du CHU Sainte-Justine, Montreal, Quebec. Jean.Seguin@UMontreal.ca.

Objective: Depression is a leading cause of disability and hospitalization. Women are at the highest risk of depression during their childbearing years, and the birth of a child may precipitate a depressive episode in vulnerable women. Postpartum depression (PPD) is associated with diminished maternal somatic health as well as health and developmental problems in their offspring. This review focuses on 2 PPD risk factors of emerging interest: serotonin transporter (5-HTT) genotype and omega-3 polyunsaturated fatty acid (n-3 PUFA) status.
Methods: The MEDLINE, PubMed, and Web of Science databases were searched using the key words postpartum depression, nutrition, omega-3 fatty acids, and serotonin transporter gene. Studies were also located by reviewing the reference lists of selected articles.
Results: Seventy-five articles were identified as relevant to this review. Three carefully conducted studies reported associations between the 5-HTT genotype and PPD. As well, there is accumulating evidence that n-3 PUFA intake is associated with risk of PPD. Preliminary evidence suggests that there could be an interaction between these 2 emerging risk factors. However, further studies are required to confirm such an interaction and to elucidate the underlying mechanisms.
Conclusions: Evidence to date supports a research agenda clarifying the associations between n-3 PUFAs, the 5-HTT genotype, and PPD. This is of particular interest owing to the high prevalence of poor n-3 PUFA intake among women of childbearing age and the consequent potential for alternative preventive measures and treatments for PPD.

Key Words: serotonin transporter gene, omega-3 fatty acids, postpartum depression, nutrition

Received November 2011, revised, and accepted June 2012.

CanJPsychiatry 2012;57(11):704–712
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