The Canadian Journal of Psychiatry最新文献

{"title":"A Combined Analysis of Genetically Correlated Traits Identifies Genes and Brain Regions for Insomnia: Une analyse combinée de traits génétiquement corrélés identifie les gènes et les régions du cerveau pour l’insomnie","authors":"Kezhi Liu, Lingyi Zhu, Minglan Yu, X. Liang, Jin Zhang, Youguo Tan, Chao-hua Huang, Wenying He, W. Lei, J. Chen, Xiaochu Gu, Bo Xiang","doi":"10.25384/SAGE.C.5057221.V1","DOIUrl":"https://doi.org/10.25384/SAGE.C.5057221.V1","url":null,"abstract":"Aims:Previous studies have inferred that there is a strong genetic component in insomnia. However, the etiology of insomnia is still unclear. This study systematically analyzed multiple genome-wide...","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"67 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-07-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121798669","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"mGluR5 Facilitates Long-Term Synaptic Depression in a Stress-Induced Depressive Mouse Model","authors":"Xiangzhi Jiang, Wei Lin, Yuanyuan Cheng, Dongming Wang","doi":"10.1177/0706743719874162","DOIUrl":"https://doi.org/10.1177/0706743719874162","url":null,"abstract":"Background Glutamatergic system has been known to play a role in the pathogenesis of major depression disorder by inducing N-methyl-d-aspartate receptor-dependent long-term depression (LTD) or metabotropic glutamate receptors (mGluR)-dependent LTD. Here, we characterized the LTD in a chronic social defeat stress (CSDS)-induced depressive mouse model. Methods CSDS was used to induce the depressive-like behaviors in C57BL/6 male mice, which were assessed using sucrose preference test and social interaction test. The synaptic strength including LTD and long-term potentiation (LTP) induced by paired-pulse low frequency stimulation (PP-LFS) was measured using whole-cell recording technique. Results CSDS induced depressive-like behaviors and facilitated PP-LFS-induced LTD in hippocampal CA3-CA1 pathway in the susceptible mice. Interestingly, mGluR5 but not N-methyl-d-aspartate receptor mediated the PP-LFS-induced LTD. In addition, mGluR5 agonist dihydroxyphenylglycine promoted PP-LFS-induced LTD specifically in susceptible mice, which was diminished by activating the BDNF/TrkB signaling pathway. Conclusions Our results suggest that mGluR5-dependent LTD might be responsible for the development of depressive-like behaviors in CSDS-induced depression mice model.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"66 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126645711","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Look Before You Leap: Representativeness of Those Completing Self-Reports in Early Psychosis Research","authors":"S. Iyer, S. Mustafa, S. Abadi, R. Joober, A. Malla","doi":"10.1177/0706743719879356","DOIUrl":"https://doi.org/10.1177/0706743719879356","url":null,"abstract":"A randomized controlled trial (RCT) was conducted to compare the efficacy of early intervention (EI) for psychosis extended for 5 years with 2 years of EI followed by 3 years of regular care (details in prior publications). As secondary hypotheses, we postulated that the extended EI group (n 1⁄4 110) would have higher levels of alliance with their treatment providers than the control group (n 1⁄4 110) and that differences in medication adherence and retention in treatment between the two groups would be predicted by working alliance. Alliance was to be measured every 6 months after randomization (i.e., Months 30, 36, 42, 48, 54, and 60) with the Working Alliance Inventory (WAI), a self-report instrument. The average working alliance in the extended EI and regular care groups was 63.53 (SD 1⁄4 12.24, range: 24 to 84, N 1⁄4 85) and 59.35 (SD 1⁄4 12.30, range: 30 to 82, N 1⁄4 46), respectively, t(129) 1⁄4 1.862, P 1⁄4 0.065. The minimum score on the WAI is 12 and the maximum 84, indicating that in both arms, individuals reported moderate to high levels of alliance. Our results should not be interpreted as indicative of a true lack of difference in therapeutic alliance between persons receiving extended EI and regular care, given that individuals in the EI group were significantly likelier to have filled out the WAI at least once during follow-up than those receiving regular care (83% vs.44%, respectively; w 1⁄4 36.129, P < 0.001). We therefore chose not to conduct any additional analyses of the impact of alliance on group differences in medication adherence and retention. Willingness to fill out self-reports may in itself serve as an indicator of alliance/engagement with mental health systems/teams. Earlier, we reported that individuals receiving extended EI were likelier to remain engaged in their followup and have more contacts with their doctors and other treatment providers. That they were also likelier to complete the WAI may be an additional indicator of better “engagement” in the EI group. Assessments were conducted in both arms by the same research assistant. Nonetheless, some factors may have facilitated completion of measures in the EI group. Selfreports and structured interviews to assess symptoms were completed during in-person appointments with the research assistant who was in the same institution as the EI program, albeit in a separate pavilion. When individuals could not come in person, the research assistant completed the structured symptom interviews on the telephone. Self-reports, however, could not be done telephonically. This may have contributed to a higher rate of completion of symptom assessments (our primary outcome). If individuals consented, self-report measures were mailed to them, but very few mailed measures were returned. In the context of an RCT, it was important for the research assistant to be blind to treatment condition. This impeded us from adopting methods that prior research including in psychosis suggests may ","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"104 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117344062","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Psychotherapies for Adolescents with Subclinical and Borderline Personality Disorder: A Systematic Review and Meta-Analysis","authors":"J. Wong, A. Bahji, S. Khalid-Khan","doi":"10.1177/0706743719878975","DOIUrl":"https://doi.org/10.1177/0706743719878975","url":null,"abstract":"Background: Evidence regarding the efficacy of psychotherapy in adolescents with borderline personality disorder (BPD) symptomatology has not been previously synthesized. Objective: To conduct a systematic review and meta-analysis of the randomized controlled trials (RCTs) in order to assess the efficacy of psychotherapies in adolescents with BPD symptomatology. Methods: Seven electronic databases were systematically searched using the search terms BPD, adolescent, and psychotherapy from database inception to July 2019. Titles/abstracts and full-texts were screened by one reviewer; discrepancies were resolved via consensus. We extracted data on BPD symptomatology, including BPD symptoms, suicide attempts, nonsuicidal self-injury, general psychopathology, functional recovery, and treatment retention. Data were pooled using random-effects models. Results: Of 536 papers, seven trials (643 participants) were eligible. Psychotherapy led to significant short-term improvements in BPD symptomatology posttreatment (g = −0.89 [−1.75, −0.02]) but not in follow-up (g = 0.06 [−0.26, 0.39]). There was no significant difference in treatment retention between the experimental and control groups overall (odds ratio [OR] 1.02, 95% confidence interval [CI], 0.92 to 1.12, I 2 = 52%). Psychotherapy reduced the frequency of nonsuicidal self-injury (OR = 0.34, 95% CI, 0.16 to 0.74) but not suicide attempts (OR = 1.03, 95% CI, 0.46 to 2.30). Conclusions: There is a growing variety of psychotherapeutic interventions for adolescents with BPD symptomatology that appears feasible and effective in the short term, but efficacy is not retained in follow-up—particularly for frequency of suicide attempts.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"159 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127406537","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Systematic Review and Meta-Analyses of Psychotherapies for Adolescents With Subclinical and Borderline Personality Disorder: Methodological Issues","authors":"M. S. Jørgensen, O. J. Storebø, E. Simonsen","doi":"10.1177/0706743719893893","DOIUrl":"https://doi.org/10.1177/0706743719893893","url":null,"abstract":"Dear Lakshmi N. Yatham, We thank Jennifer Wong, Anees Bahji, and Sarosh Khalid-Khan for a much needed systematic review of psychotherapies for adolescents with subclinical and borderline personality disorder (BPD). Previous reviews have largely excluded subclinical BPD presentations and therefore excluded the majority of the trials for this age-group. The authors found that psychotherapies for adolescents with subclinical and BPD are effective but that the efficacy was not statistically significant at follow-up. There are, however, some limitations to this review. First, we have not been able to retrieve any published protocol, which makes it difficult to determine whether the review could be prone to selective reporting bias. Second, the authors conclude that “the studies were rated as being of very high quality” (p. 5), but it is unclear on what ground this quality assessment was made. The use of tools like the Grading of Recommendations Assessment, Development and Evaluation could have increased the confidence of quality ratings. The authors conclude that the risk of bias was low on all domains except two instances with unclear risk of bias. However, the ratings on several domains may be too optimistic. For instance, it is left unaddressed that the developer of the experimental intervention was involved in four of the studies, which raises high risk of allegiance bias. Furthermore, all studies either did not publish a protocol or there were discrepancies between the protocols and the outcomes reported in the paper, thus warranting an unclear or high risk of selective outcome reporting bias. Concern about how missing data was handled, i.e. incomplete outcome data bias, in instances where no intention-to-treat analysis or multiple imputation were applied, only completers were included or there were extensive loss to follow-up are also not addressed. Instances of missing or unclear adherence ratings or skewed intensity between the experimental and control interventions are also not addressed even though these pose concerns for adherence or attention bias. Additionally, the review is prone to some methodological issues concerning clinical heterogeneity. The authors pooled experimental therapies and control therapies into metaanalyses not taking into consideration the heterogeneity of the experimental interventions, control treatments, type of outcome assessors, and time points. Lastly, the authors only searched seven electronic databases for relevant articles and used an English language restriction. This may have caused for some randomized controlled trials to be left out, for example, Santisteban et al., Salzer et al., and a pilot study by Gleeson et al. Valuable information have thus not been included. Publishing a systematic review with risk of bias assessments of psychological therapies for adolescents with BPD or subclinical BPD is an important first step to outline the evidence base. Early intervention and stage-linked care in potentially s","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122905357","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Who Benefits from Physician Wellness?","authors":"N. Lawson","doi":"10.1177/0706743719890729","DOIUrl":"https://doi.org/10.1177/0706743719890729","url":null,"abstract":"In their recent Position Paper for the CPA’s Professional Standards and Practice Committee, Myers and Freeland state that there is a “clear relationship between physician wellness and competence to practice medicine.” This grounding assumption, and other questionable claims about the dangers posed by physicians with burnout and the effectiveness of physician health programs, is not helpful to physicianemployees with or without mental health disorders. Physician wellness policies and initiatives in general seem more likely to help hospital management. Myers and Freeland’s statement about physician wellness and competence is similar to statements in the new Accreditation Council for Graduate Medical Education program requirements on resident well-being. The requirements claim that programs “have the same responsibility to address well-being as other aspects of resident competence.” The American Psychiatric Association Publishing Textbook of Psychiatry also states that “Psychiatrists will play an increasingly important role as leaders in medicine in the future and can help to emphasize the links among physician well-being, clinical competence, and the importance of well-being as an ethical imperative. . . . ” “[P]hysician wellness [is a term] used interchangeably with physician well-being” that loosely refers to health. The effect of defining physicians’ competence in terms of well-being is to refocus appraisals of physicians’ abilities not on their performance, but on their health. Another problem with physician wellness is that studies suggest physician wellness initiatives are not effective. Even if they were, it is doubtful that even effective treatments could overcome the harm done to physicians with mental health disorders by such stigmatizing links between wellness and competence. In addition, what might be framed a “voluntary” physician-initiated participation in a wellness program may often be more accurately characterized as an employerinitiated requirement for assessment of potential impairment. Imagine a physician who checks a box on his initial employment paperwork asking, “Would you like to sign up for our free mindfulness and relaxation classes?” or “Would you like to work with wellness counselors and hospital management to evaluate and improve your mental health and work performance?” Follow-up contact from the wellness program and subsequent participation may be appropriately characterized as voluntary. But what if a resident is called into a meeting with program leadership, who to her surprise, express concerns about her performance and say they want to provide their residents with every available resource they need to succeed: “Do you feel that psychological testing— which we can offer right here at the hospital wellness program—might be helpful?” I would argue that the resident’s subsequent participation and any “voluntary” waiver of confidentiality in this setting would not actually be voluntary. Furthermore, the authors’ medica","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"52 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125674145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Burden of Mental, Neurological, Substance Use Disorders and Self-Harm: Counting the Cards, or Shuffling the Deck?","authors":"S. Patten","doi":"10.1177/0706743719892706","DOIUrl":"https://doi.org/10.1177/0706743719892706","url":null,"abstract":"In this issue’s paper entitled: “Burden of Mental, Neurological, Substance Use Disorders and Self-Harm in North America: A Comparative Epidemiology of Canada, Mexico, and the United States,” Vigo et al. provide an alternative perspective on disease-burden estimates from the Global Burden of Disease (GBD) Project. The authors criticize the GBD for what they consider to be an arbitrary reclassification of “mental health-related burden” into other categories and express concern that the GBD approach dilutes the apparent burden attributable to mental health issues. The authors base their reclassification on the creation of a new aggregate category that they call “mental, neurological, substance use disorders and self-harm” (MNSS). MNSS includes suicide mortality, some selected neurological conditions (neurocognitive disorders, epilepsy, and headaches), physical conditions attributable to alcohol, and a proportion of chronic pain issues (to capture the burden of somatic symptom disorders). Analysis of the reclassified data indicates that MNSS is the largest source of disease burden between the ages of 10 and 60. The GBD covers 359 diseases and injuries for 195 countries, with the most recently published estimates covering from 1990 to 2017. The GBD aggregates disease-specific estimates using four hierarchical levels. The fourth level includes burden related to specific disorders (e.g., major depression, dysthymia) although some conditions remain grouped (e.g., anxiety disorders are a Level 4 grouping as of 2017). The third level includes additional aggregation (e.g., depressive disorders), the second level includes a category called “mental disorders,” and at the top of the hierarchy, the first level includes only three overarching categories: noncommunicable diseases; injuries; and communicable, maternal, neonatal, and nutritional diseases. It is these aggregate groupings, and their labeling, that Vigo et al. consider problematic. They point out that the “mental disorders” category does not capture suicide deaths, some relevant neurological morbidity, alcohol-related morbidity, and somatic symptom disorders. Their concern is that the GBD’s approach may reduce “the visibility of the burden related to mental health.” For example, in the 2017 Canadian ranking of disease burden, “mental disorders” rank fifth (although they rank first in the 15 to 24 age range). The purpose of the GBD is to describe mortality and morbidity from health conditions (causes) and risk factors at global, national, and (in some countries, but not in Canada) subnational or regional levels. They make comparisons across populations that enable a better understanding of changing health across the world. While it is not the intention of the GBD to provide an arena in which healthcare sectors compete for resources and prestige, it is possible that naive decision makers, especially those who are unaware of the GBD methodology, could misinterpret GBD estimates in ways that undervalue me","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"64 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125867781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Barriers to Brain Stimulation Therapies for Treatment-Resistant Depression: Beyond Cost Effectiveness","authors":"D. Goldbloom, D. Gratzer","doi":"10.1177/0706743719893584","DOIUrl":"https://doi.org/10.1177/0706743719893584","url":null,"abstract":"In this issue of the journal, Fitzgibbon and colleagues create an elaborate simulation model based on a broad consideration of costs and treatment efficacies to determine the comparative cost-effectiveness of rapid transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT) in management of treatment-resistant depression (TRD). In so doing, they take the oldest continuing biological intervention in psychiatry, ECT—arguably our field’s most effective and most stigmatized treatment—and stack it up against one of our newer forms of brain stimulation. Even though rTMS has been subject to more than two decades of multiple randomized controlled trials in depression as well as network meta-analyses, it remains unknown or unfamiliar to many health professionals, patients, and families. While many generations of clinicians easily recall patients they knew who received and benefited from ECT, very few have a personal data bank of patients treated with rTMS. If ECT has secured a firm— if controversial—place in our therapeutic armamentarium and cultural history, rTMS is still virtually unavailable in most clinical settings and not yet a therapeutic skill that is a core part of psychiatry training. Depression is the leading cause of disability globally. In Ontario, depression alone represented a greater burden of disease (as reflected by years lived with disability and years lost due to premature death) than lung, prostate, colon, and breast cancer combined. Although we have reasonably effective psychological and pharmacological treatments for depression, too many people are left in a state of TRD after countless drug trials and drug combinations or extensive courses of psychotherapy. In the context of therapeutic frustration, it can even result in familiar patient-blaming verbal lapses such as, “the patient failed a trial of . . . ” We need to own the reality that our treatments fail some patients, not the other way around. There is both a clinical and economic imperative to develop new options as well as to use existing evidence-based options. ECT was developed over 80 years ago, spread rapidly around the globe, and remains for a number of psychiatrists the treatment they would want for themselves if they became severely depressed—a good yardstick to use when recommending treatments for other people. Jeff Daskalakis, co-director of the Temerty Centre for Therapeutic Brain Intervention at the Centre for Addiction and Mental Health (arguably the busiest center in the country for both ECT and rTMS), often states that the numbers needed to treat for ECT in TRD is 2 to 3 (based on a 65% remission rate for ECT in TRD vs. a 15% remission rate for placebo)—an astonishingly low number that very few treatments throughout medicine could match. However, it remains an intrusive and intensive treatment with significant cognitive sequelae, and the need for alternatives persists. In considering alternative forms of brain stimulation to ECT, the concept of ","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"27 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126280275","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Protocol for Clozapine Rechallenge in a Case of Clozapine-Induced Myocarditis","authors":"G. Shivakumar, N. Thomas, Miranda Sollychin, A. Takács, S. Kolamunna, P. Melgar, Fiona Connally, C. Neil, C. Bousman, M. Jayaram, C. Pantelis","doi":"10.1177/0706743719892709","DOIUrl":"https://doi.org/10.1177/0706743719892709","url":null,"abstract":"Objective: Protocol for clozapine rechallenge in patients with a history of clozapine-induced myocarditis. Method: Clozapine-related cardiovascular adverse effects including myocarditis and cardiomyopathy have limited its widespread use in treatment-resistant schizophrenia. Here, we present a case of clozapine-induced myocarditis and successful cautious rechallenge. Ms. AA, a young female patient with severe psychosis developed myocarditis during her initial clozapine titration phase, which was thus discontinued. Subsequent response to other medications was poor, and she remained significantly disabled. We reviewed blood-based biomarkers identified during the emergence of her index episode of myocarditis and developed a successful clozapine rechallenge protocol, based on careful monitoring of changes in these indices and a very slow clozapine re-titration. Results and Conclusions: This protocol may have utility in the management of patients with a history of clozapine-induced myocarditis.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134317131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Primary Care Practitioner Training in Child and Adolescent Psychiatry (PTCAP): A Cluster-Randomized Trial","authors":"S. Espinet, Sandra Gotovac, Sommer Knight, L. Wissow, M. Zwarenstein, L. Lingard, M. Steele","doi":"10.1177/0706743719890161","DOIUrl":"https://doi.org/10.1177/0706743719890161","url":null,"abstract":"Objectives Rural primary care practitioners (PCPs) have a pivotal role to play in frontline pediatric mental health care, given limited options for referral and consultation. Yet they report a lack of adequate training and confidence to provide this care. The aim of this study was to test the effectiveness of the Practitioner Training in Child and Adolescent Psychiatry (PTCAP) program, which was designed to enhance PCPs’ pediatric mental health care confidence. The program includes brief therapeutic skills and practice guidelines PCPs can use to address both subthreshold concerns and diagnosable conditions, themselves. Methods The study design was a pilot, cluster-randomized, multicenter trial. Practices were randomly assigned to intervention (n practices = 7; n PCPs = 42) or to wait-list control (n practices = 6; n PCPs = 34). The intervention involved 8 hr of training in practice guidelines and brief therapeutic skills for depression, anxiety, attention deficit hyperactivity disorder, and behavioral disorders with case discussion and video examples, while the control practiced as usual. A linear random-effects model controlling for clustering and baseline was carried out on the individual-level data to examine between-group differences in the primary (i.e., confidence) and secondary (i.e., attitude and knowledge) outcomes at 1-week follow-up. Results Findings were a statistically significant difference in the primary outcomes. Compared to the control group, the intervention group indicated significantly greater confidence in managing diagnosable conditions (d = 1.81) and general concerns (d = 1.73), as well as in making necessary referrals (d = 1.27) and obtaining consults (d = 0.74). While the intervention did not significantly impact secondary outcomes (attitudes and knowledge), regression analysis indicated that the intervention may have increased confidence, in part, by ameliorating the adverse impact of negative mental health care attitudes. Conclusion PTCAP enhances PCPs’ child/youth mental health care confidence in managing both general and diagnosable concerns. However, an 8-hr session focused on applying brief therapeutic skills was insufficient to significantly change attitudes and knowledge. Formal testing of PTCAP may be warranted, perhaps using more intensive training and including outcome assessments capable of determining whether increased PCP confidence translates to more effective management and better patient outcomes.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116779780","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}