April 20, 2014

   
The Canadian Journal of Psychiatry
June 2013, Volume 58, Number 6
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In Review

Current Trends in the Empirical Study of Cognitive Remediation for Schizophrenia

Alice M Saperstein, PhD; Matthew M Kurtz, PhD

Correspondence: Dr Alice M Saperstein, Columbia University Medical Center, 1051 Riverside Drive, Mailbox 100, New York, NY 10032; Assistant Professor, Department of Psychiatry, Columbia University Medical Center, New York, New York.
saperst@nyspi.columbia.edu.

Cognitive remediation (CR) for schizophrenia is a learning-based behavioural skills training intervention designed to enhance neuro and (or) social cognitive skills, with the ultimate goal of generalization to improve psychosocial outcomes. This review summarizes conceptual approaches to CR for schizophrenia and the evidence for efficacy in clinical research settings. Four issues are at the forefront of ongoing research: the identification of techniques that produce the largest cognitive change, delineation of techniques that enhance transfer of cognitive skills to functional skills, the identification of CR methods that can be personalized to meet the specific cognitive and functional needs of each individual, and, all the while, ensuring that when CR methods are developed in a research setting, they remain scalable for delivery in the larger clinical community. In response to these issues, 3 prominent research trends have emerged: the rise of a new generation of computerized restorative cognitive training, the integration of CR with skills training to promote generalization, and the application of techniques to enhance motivation and learning during CR. As data on the neural basis of learning in people with schizophrenia become available, new technologies that harness the ability of the brain to make sustainable, functional changes may be integrated within a therapeutic context that promotes a personalized approach to learning. The development of transportable and scalable methods of CR that maximize the ability of people with schizophrenia to improve cognition will help them achieve personal goals for recovery.

Key Words: cognitive remediation, schizophrenia, neuroplasticity, psychiatric rehabilitation, neurocognition

Received May 2012, revised, and accepted August 2012.

CanJPsychiatry 2013;58(6):311–318
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In Review

Cognitive Remediation Therapy for Mood Disorders: Rationale, Early Evidence, and Future Directions

Christopher R Bowie, PhD; Maya Gupta, MSc (PhD Candidate); Katherine Holshausen, MSc (PhD Candidate)

Correspondence: Dr Christopher R Bowie, 356 Humphrey Hall, Psychology Department, Queen’s University, Kingston, ON K7L 3N6; Associate Professor, Department of Psychology and Department of Psychiatry, Queen’s University, Kingston, Ontario.
bowiec@queensu.ca.

People with mood disorders experience cognitive impairments that are predictive of functional disability. Cognitive remediation (CR) is an empirically validated intervention that is designed to remediate neurocognitive deficits and improve functioning. Although much of the focus of this treatment during the last decade has centred on attention deficit disorders, brain injury, and schizophrenia spectrum disorders, emerging evidence suggests that CR is an effective intervention for mood disorders and that these treatment effects translate into improvements in cognitive performance and possibly functioning. Our review aims to examine the profile and magnitude of cognitive impairments in mood disorders, review the evidence in support of CR for this population, and discuss future research directions in CR.

Key Words: cognitive remediation, mood disorders, depression, bipolar disorder, cognition, functional outcome, psychosocial treatment, cognitive-behavioural therapy

Received May 2012, revised, and accepted August 2012.

CanJPsychiatry 2013;58(6):319–325
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Original Research

Implementing Panic-Focused Psychodynamic Psychotherapy Into Clinical Practice

Manfred E Beutel, MD; Vera Scheurich, Dipl Psych; Achim Knebel, Dipl Psych; Matthias Michal, MD; Jörg Wiltink, MD; Mechthild Graf-Morgenstern, MD; Regine Tschan, PhD; Barbara Milrod, MD; Stefan Wellek, PhD; Claudia Subic-Wrana, PhD

Correspondence: Dr Manfred E Beutel, Department of Psychosomatic Medicine and Psychotherapy, University Medicine Mainz, Untere Zahlbacher Str 8, D-55131 Mainz, Germany; Professor and Director, Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Mainz, Germany.
manfred.beutel@unimedizin-mainz.de.

Objective: To determine the effectiveness of manualized panic-focused psychodynamic psychotherapy (PFPP) in routine care in Germany.
Method: German psychoanalysts were trained according to the PFPP manual. Fifty-four consecutive outpatients with panic disorder (with or without agoraphobia) were randomly assigned in a 2:1 ratio to PFPP or cognitive-behavioural therapy (CBT) plus exposure therapy. Subjects (female 57.4%; mean age 36.2 years) had high rates of psychiatric (68.5%) and somatic (64.8%) comorbidity, and previous psychiatric treatments (57.4%). Assessments were performed pre- and posttreatment and at 6-month follow-up. The primary outcome measure was the Panic Disorder Severity Scale.
Results: Both treatments were highly effective. In patients randomized to PFPP, remission was achieved in 44.4% at termination and by 50% at follow-up (CBT 61.1% and 55.6%, respectively). No significant differences were found. Emotional awareness, a posited moderator of good outcome in psychotherapies, was significantly higher in the CBT group at baseline. It was found to be a strong moderator of treatment effectiveness in both treatments. After adjusting for initial Levels of Emotional Awareness Scale (LEAS) scores, effect sizes (ESs) for the primary outcome were Cohen d = 1.28, from pre- to posttreatment, and d = 1.03, from pretreatment to follow-up, for PFPP, and d = 1.81 and 1.28 for CBT, respectively.
Conclusions: PFPP was implemented effectively into clinical practice by psychoanalysts in the community in a sample with severe mental illness with large ESs. Assessment of LEAS may facilitate the identification of patients suitable for short-term psychotherapy.
(Clinical Trial Registration Number: German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111–1112–4245)

Key Words: panic-focused psychodynamic psychotherapy, cognitive-behavioural therapy, panic disorder, agoraphobia, effectiveness, follow-up

Received October 2012, revised, and accepted November 2012.

CanJPsychiatry 2013;58(6):326–334
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Original Research

Continuing Education To Go: Capacity Building in Psychotherapies for Front-Line Mental Health Workers in Underserviced Communities

Paula Ravitz, MD, FRCPC; Robert G Cooke, MD, FRCPC; Scott Mitchell, BA; Scott Reeves, PhD; John Teshima, MD, FRCPC; Bhadra Lokuge, BSc; Andrea Lawson, PhD; Nancy McNaughton, PhD; Wayne Skinner, MSW, RSW; Carolynne Cooper, MSW, RSW; Mark Fefergrad, MD, FRCPC; Ari Zaretsky, MD, FRCPC

Correspondence: Dr Paula Ravitz, Mt Sinai Hospital, Department of Psychiatry, Joseph & Wolf Lebovic Health Complex, 600 University Avenue, Toronto, ON M5G 1X5; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Morgan Firestone Psychotherapy Chair, Mount Sinai Hospital, Department of Psychiatry, Joseph and Wolf Lebovic Health Complex, Toronto, Ontario.
pravitz@mtsinai.on.ca.

Objective: To address the gaps between need and access, and between treatment guidelines and their implementation for mental illness, through capacity building of front-line health workers.
Methods: Following a learning needs assessment, work-based continuing education courses in evidence-supported psychotherapies were developed for front-line workers in underserviced community settings. The 5-hour courses on the fundamentals of cognitive-behavioural therapy, interpersonal psychotherapy, motivational interviewing, and dialectical behaviour therapy each included videotaped captioned simulations, interactive lesson plans, and clinical practice behaviour reminders. Two courses, sequentially offered in 7 underserviced settings, were subjected to a mixed methods evaluation. Ninety-three nonmedical front-line workers enrolled in the program. Repeated measures analysis of variance was used to assess pre- and postintervention changes in knowledge and self-efficacy. Qualitative data from 5 semistructured focus groups with 25 participants were also analyzed.
Results: Significant pre- and postintervention changes in knowledge (P < 0.001) were found in course completers. Counselling self-efficacy improved in participants who took the first course offered (P = 0.001). Dropouts were much less frequent in peer-led, small-group learning than in a self-directed format. Qualitative analysis revealed improved confidence, morale, self-reported practice behaviour changes, and increased comfort in working with difficult clients.
Conclusions: This work-based, multimodal, interactive, interprofessional curriculum for knowledge translation of psychotherapeutic techniques is feasible and helpful. A peer-led group format is preferred over self-directed learning. Its application can build capacity of front-line health workers in helping patients who suffer from common mental disorders.

Key Words: continuing education, capacity building, community mental health services, psychotherapy, health education, knowledge translation

Received September 2012, revised, and accepted November 2012.

CanJPsychiatry 2013;58(6):335–343
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Original Research

Profiles and Mental Health Correlates of Alcohol and Illicit Drug Use in the Canadian Population: An Exploration of the J-Curve Hypothesis

Alexandre Dumais, MD, PhD, FRCPC; Luigi De Benedictis, MD, MSc, FRCPC; Christian Joyal, PhD; Jean-François Allaire, MSc; Alain Lesage, MD, MPhil, FRCPC; Gilles Côté, PhD

Correspondence: Dr Alexandre Dumais, Philippe-Pinel Institute of Montreal, Fernand-Seguin Research Centre, Department of Psychiatry, University of Montreal, 10905 Henri-Bourassa Boulevard East, Montreal, QC H1C 1H1; Psychiatrist and Researcher, Philippe-Pinel Institute of Montreal, Fernand-Seguin Research Centre, Department of Psychiatry, University of Montreal, Montreal, Quebec.
alexandre.dumais@umontreal.ca.

Objective Alcohol and (or) illicit drug use (AIDU) problems are associated with mental health difficulties, but low-to-moderate alcohol consumption may have mental health benefits, compared with abstinence. Our study aimed to explore the hypothesis of a nonlinear, or J-curve, relation between AIDU profiles and psychological distress, psychiatric disorders, and mental health service use in the general Canadian population..
Method: Data were collected from a representative sample of the Canadian population (n = 36 984). Multiple correspondence analyses and cluster analyses were used to extract AIDU profiles. Sociodemographics, psychological distress, psychiatric disorders, and mental health service use were assessed and compared between profiles.
Results: Seven AIDU profiles emerged, including 3 involving risky or problematic AIDU that correlate with major affective disorders, anxiety disorders, suicidal behaviours, and higher levels of psychological distress. No J-curve relation was found for psychiatric disorders and mental health service use. The lifetime-abstainer profile correlates with the lowest rates of psychiatric disorders and mental health service use. Lifetime abstainers are also more often female, immigrant, and unemployed. Compared with other profiles, spirituality is more important in their life.
Conclusions: The hypothesis of a nonlinear relation between psychiatric disorders and AIDU was not supported. Lifetime AIDU abstainers have specific sociodemographic and cultural background characteristics in Canada.

Key Words: lifetime abstainers, alcohol, illicit drugs, mental disorders, suicide, multiple correspondence analysis, psychological distress

Received June 2012, revised, and accepted November 2012.

CanJPsychiatry 2012;58(6):344–352
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Original Research

High Positive Psychiatric Screening Rates in an Urban Homeless Population

Aravind Ganesh, MD; David J T Campbell, MD, MSc (PhD Candidate); Janette Hurley, MD, CCFP; Scott Patten, MD, PhD, FRCPC

Correspondence: Dr Aravind Ganesh, 221 Valley Ridge Green NW, Calgary, AB T3B 5L6; Resident, Clinical Neurosciences, University of Calgary, Calgary, Alberta.
aravindganeshy@yahoo.ca.

Objectives: To carry out a preliminary assessment of the use of a psychiatric screening tool in an urban homeless population, and to estimate the potential prevalence of undiagnosed and (or) unmanaged mental illness in this population.
Methods: Participants (n = 166) were recruited from the Calgary Drop-in and Rehab Centre to complete a questionnaire containing 6 modules screening for common psychiatric disorders. Summary statistics were used in the analysis.
Results: Only 12 respondents (7%) screened negative on each of the 6 modules. The screening process determined that 60.2% of the sample (n = 100) had probable mental illness but reported no history of psychiatric diagnosis or treatment.
Conclusion: A straightforward application of screening (in which screen-positive subjects are referred for assessment) would be difficult in this population as most will screen positive. The results highlight the tremendous burden of psychiatric symptoms in this population.

Key Words: homelessness, mental illness, psychiatric screening

Received August 2012, revised, and accepted November 2012.

CanJPsychiatry 2013;58(6):353–360
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Original Research

A Population-Based Study of Antipsychotic Prescription Trends in Children and Adolescents in British Columbia, From 1996 to 2011

Rebecca Ronsley, BSc; David Scott, MA; William P Warburton, PhD; Ramsay D Hamdi, MBA; Dianna Clare Louie, MD; Jana Davidson, MD, FRCPC; Constadina Panagiotopoulos, MD, FRCPC

Correspondence: Dr Constadina Panagiotopoulos, 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; Associate Professor, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia; Endocrinologist, British Columbia Children’s Hospital, Vancouver, British Columbia.
dpanagiotopoulos@cw.bc.ca.

Objectives: To establish prevalence rates of antipsychotic (AP) prescriptions for children 18 years of age or younger in British Columbia (BC) from 1996 to 2011 by age, sex, AP type, and primary diagnosis; and to identify the predominant AP prescribers for children by specialty training.
Methods: BC Ministry of Health administrative data were used to describe AP prescriptions for youth aged 18 years or younger. Comparisons were made using population prevalence based on sex; age group; AP; International Classification of Diseases, Ninth Revision, diagnosis; and prescriber specialty.
Results: From 1996 to 2011, overall AP (both first and second generation) prescription prevalence rate increased 3.8-fold (1.66 to 6.37 per 1000 population); second-generation AP (SGA) prescriptions increased 18.1-fold (0.33 to 5.98 per 1000 population). The highest increase in all AP prescriptions occurred in males aged 13 to 18 years (3.3 to 14.4 per 1000 population; 4.4-fold), followed by similar increases in males aged 6 to 12 years (2.3 to 8.6 per 1000 population; 3.7-fold) and in females aged 13 to 18 years (2.8 to 10.7 per 1000 population; 3.8-fold). Overall, the 3 most common diagnoses associated with all AP prescriptions were depressive disorders (12.8%), hyperkinetic syndrome of childhood (11.7%), and neurotic disorders (11.1%); however, variation was observed by prescriber specialty training. Among all new AP prescriptions in 2010/11, 38.6%, 34.3%, and 15.6% were provided by psychiatrists, family physicians, and pediatricians, respectively.
Conclusion: There has been an exponential rise in SGA prescriptions in BC secondary to extensive off-label use, not only by psychiatrists but also by family physicians and pediatricians. Knowledge translation initiatives promoting evidence-based prescribing and monitoring practices related to SGA treatment need to target all 3 prescriber groups and be tailored for age subgroups.

Key Words: antipsychotics, prescribing, children, adolescents

Received September 2012, revised, and accepted November 2012.

CanJPsychiatry 2013;58(6):361–369
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