The Canadian Journal of Psychiatry最新文献

{"title":"Community Treatment Order Outcomes in Quebec: A Unique Jurisdiction","authors":"Daniel Frank, Daniel Frank, E. Fan, A. Georghiou, V. Verter","doi":"10.1177/0706743719892718","DOIUrl":"https://doi.org/10.1177/0706743719892718","url":null,"abstract":"Objective: We study compulsory community treatment orders (CTOs) for patients with severe and persistent mental illness (SPMI). Focusing on a unique jurisdiction in Canada that allows for long duration CTOs with strict enforcement procedures, our objectives are to determine whether extended duration CTOs are effective and to determine whether associated hospitalization costs are reduced. Method: A mirror image, naturalistic design was employed using patients as their own controls to enhance external validity. No inclusive or exclusive criteria were employed for the 367 SPMI clinic patients who were studied over a 5-year period. Detailed documentation of the dates of all CTOs, long-acting antipsychotic injections (LAIs), emergency visits, hospitalizations, duration of hospitalizations, crimes and/or police involvement were collected. To study the relation between CTO and injection adherence, we use a mixed-effect linear regression model. To study the effect of injection adherence and hospitalization, we use survival analysis via Kaplan–Meier and Cox survival models. Results: CTO and non-CTO patients did not differ with respect to demographics, but CTO patients were significantly more severely ill. Following a CTO, adherence to LAIs increased over time (P < 0.001). The average time the patients spent in the community, that is, outside the hospital, was significantly longer under a CTO, and the duration of hospitalizations was decreased. Conclusions: LAI adherence and outpatient office visits were enhanced by extended duration CTOs, as was time out of the hospital. The shorter duration of hospital stays implies cost savings. These must be weighed against their undesirable coercive nature.","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":"114241573","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":"The Global Burden of Disease Methodology Has Been Good for Mental Disorders: But Not Good Enough","authors":"N. Weye, M. Christensen, N. Momen, K. Iburg, O. Plana-Ripoll, J. Mcgrath","doi":"10.1177/0706743719893591","DOIUrl":"https://doi.org/10.1177/0706743719893591","url":null,"abstract":"The global burden of disease (GBD) studies have revolutionized how we quantitate the burden of disease. Bold in vision, virtuosic in methodology, encyclopedic in scope— the findings have been highly influential. GBD has allowed the health community to combine a measure of premature mortality (years of life lost [YLLs]) with a measure of disability (years lived with disability [YLDs]) in order to derive an overall measure of disease burden (disability adjusted life-years; DALYs). These innovative health metrics have highlighted the increasing contribution of chronic disability to the total burden of disease in the epidemiological transition seen in all countries and territories of the world. Total YLDs are influenced by the years of life lived with a disorder and a disability weight allocated to that disorder. Prevalent disorders with small disability weights may contribute more YLDs to the total compared to rare disorders with large disability weights. Within the common disorders with mild to moderate disability, those with an early onset, and a persistent or recurrent trajectory, will figure prominently in total YLDs. Mental disorders, among others, often have an early onset and thus meet these criteria. If cardiovascular and respiratory disorders are the chronic disorders of the elderly, mental disorders are the chronic disorders of people of all ages—children, adolescents, middle-aged, and old. The contribution of mental disorders to disease burden has been put into sharp focus by the GBD methodology. In the “league table of disorders,” mental disorders make a major contribution to the YLDs associated with noncommunicable disorders and was the Top 2 YLD burden of all diseases in the world in 2017. So, three cheers for the GBD—these methods have been good for mental disorders. Vigo and colleagues have drawn attention to instances where the GBD may underestimate the true contribution of mental disorders to the total disease burden. In the target article, they revisit this topic, with data extracted from the 2017 estimates for Canada, the United States, and Mexico. They provide a convincing case that mental disorders should include the YLDs from intentional self-harm and the YLLs from suicide along with the officially sanctioned mental disorder-associated causes of death (alcohol use disorders, drug use disorders, eating disorders). Furthermore, they argue that mental disorders should harvest YLLs and YLD from selected neurological disorders, which are currently reported separately from mental disorders in GBD. With the redistribution of disorders into the “mental, neurological, substance use disorders and self-harm,” Vigo and colleagues estimated that the burden associated with this revised definition is the largest of all disorder groupings, especially in the United States. Where the boundary should be drawn between neurological and psychiatric disorders is debatable (and influenced more by history and discipline loyalties than by empirical dat","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":"130059262","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":"Cost–Utility Analysis of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Ontario","authors":"Kyle P. Fitzgibbon, Donna Plett, B. Chan, R. Hancock-Howard, P. Coyte, D. Blumberger","doi":"10.1177/0706743719890167","DOIUrl":"https://doi.org/10.1177/0706743719890167","url":null,"abstract":"Objectives: To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), and combining both treatments in a stepped care pathway for patients with treatment-resistant depression (TRD) in Ontario. Methods: A cost–utility analysis evaluated the lifetime costs and benefits to society of rTMS and ECT as first-line treatments for TRD using a Markov model, which simulates the costs and health benefits of patients over their lifetime. Health states included acute treatment, maintenance treatment, remission, and severe depression. Treatment efficacy and health utility data were extracted and synthesized from randomized controlled trials and meta-analyses evaluating these techniques. Direct costing data were obtained from national and provincial costing databases. Indirect costs were derived from government records. Scenario, threshold, and probabilistic sensitivity analyses were performed to test robustness of the results. Results: rTMS dominated ECT, as it was less costly and produced better health outcomes, measured in quality-adjusted life years (QALYs), in the base case scenario. rTMS patients gained an average of 0.96 additional QALYs (equivalent to approximately 1 year in perfect health) over their lifetime with costs that were $46,094 less than ECT. rTMS remained dominant in the majority of scenario and threshold analyses. However, results from scenarios in which the model’s maximum lifetime allowance of rTMS treatment courses was substantially limited, the dominance of rTMS over ECT was attenuated. The scenario that showed the highest QALY gain (1.19) and the greatest cost-savings ($46,614) was when rTMS nonresponders switched to ECT. Conclusion: From a societal perspective utilizing a lifetime horizon, rTMS is a cost-effective first-line treatment option for TRD relative to ECT, as it is less expensive and produces better health outcomes. The reduced side effect profile and greater patient acceptability of rTMS that allow it to be administered more times than ECT in a patient’s lifetime may contribute to its cost-effectiveness.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"83 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116468971","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":"Brain-Wide Functional Dysconnectivity in Schizophrenia: Parsing Diathesis, Resilience, and the Effects of Clinical Expression","authors":"Shuixia Guo, Ningning He, Zhening Liu, Z. Linli, H. Tao, L. Palaniyappan","doi":"10.1177/0706743719890174","DOIUrl":"https://doi.org/10.1177/0706743719890174","url":null,"abstract":"Background: The functional dysconnectivity observed from functional magnetic resonance imaging (fMRI) studies in schizophrenia is also seen in unaffected siblings indicating its association with the genetic diathesis. We intended to apportion resting-state dysconnectivity into components that represent genetic diathesis, clinical expression or treatment effect, and resilience. Methods: fMRI data were acquired from 28 schizophrenia patients, 28 unaffected siblings, and 60 healthy controls. Based on Dosenbach’s atlas, we extracted time series of 160 regions of interest. After constructing functional network, we investigated between-group differences in strength and diversity of functional connectivity and topological properties of undirected graphs. Results: Using analysis of variance, we found 88 dysconnectivities. Post hoc t tests revealed that 62.5% were associated with genetic diathesis and 21.6% were associated with clinical expression. Topologically, we observed increased degree, clustering coefficient, and global efficiency in the sibling group compared to both patients and controls. Conclusion: A large portion of the resting-state functional dysconnectivity seen in patients represents a genetic diathesis effect. The most prominent network-level disruption is the dysconnectivity among nodes of the default mode and salience networks. Despite their predisposition, unaffected siblings show a pattern of resilience in the emergent connectomic topology. Our findings could potentially help refine imaging genetics approaches currently used in the pursuit of the pathophysiology of schizophrenia.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127376803","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":"Lithium, an Infrequently Used Medication","authors":"S. Patten, J. Williams","doi":"10.1177/0706743719890714","DOIUrl":"https://doi.org/10.1177/0706743719890714","url":null,"abstract":"Lithium is recommended as a first-line treatment for bipolar disorder by contemporary clinical practice guidelines. With a prevalence of bipolar disorder believed to be in the range of 1% to 2% in Canada, expectation holds that lithium should be frequently used. However, its use is complicated by the need for safety monitoring and the possibility of adverse events. The prevalence of lithium use in the Canadian population is unknown. Prescription data are, in principle, available from provincial databases in several provinces, but these do not provide national estimates. In the current study, we sought to estimate the frequency of lithium use in the household population using national survey data. Several national surveys, based on representative samples of the Canadian household population, have collected data on psychotropic (and other) medication use. In this analysis, we used data from two national Mental Health Surveys: the 2002 Canadian Community Health Survey (CCHS) 1.2 and the 2012 CCHS-MH. We also used estimates from the Canadian Health Measures Survey, pooling two sets of estimates, 2009 to 2011 and 2013 to 2017. The surveys collected medication data by including questions about medication use, including asking respondents to collect and look at the bottles, tubes, or boxes containing their medications. Data are recorded using product identification numbers and recorded using Anatomic Therapeutic Codes (in the case of lithium, N05AN). Methods employed in CCHS and Canadian Health Measures Survey (CHMS) are extensively documented on the Statistics Canada website. Notably, the CCHS collected data on medication use in the 2 days preceding the interview, whereas the CHMS assesses past month use. We were interested not only in the most recent data but also in historical data in view of the possibility of secular trends. The final estimates derived from a recommended procedure using replicate bootstrap weights to account for survey design effects (such as clustering, unequal selection probabilities) and adjusting for nonresponse. The estimates and their associated 95% confidence intervals are presented in the form of a forest plot in Figure 1. There is no obvious impression of increasing or decreasing prevalence over time. Consistent with this, heterogeneity was moderate (I value1⁄4 55.1%, t 0.0) and not statistically significant (heterogeneity w 1⁄4 6.7, df 1⁄4 3, P 1⁄4 0.083). We combined the estimates using random effects meta-analysis in Stata, Release 15. First, using the “metaprop” command, we employed a Freeman-Tukey double arcsine transformation for variance stabilization of the raw proportions. This procedure accounts for the dependence of the standard error of a proportion on its value, a potential source of bias with inverse variance weighting in meta-analysis. However, the transformation cannot be used with weighted proportions. In a second analysis, using “metan,” we pooled the untransformed weighted proportions. The results were n","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123516880","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":"Decoding Microbiome Research for Clinical Psychiatry","authors":"J. Foster","doi":"10.1177/0706743719890725","DOIUrl":"https://doi.org/10.1177/0706743719890725","url":null,"abstract":"It is remarkable to see how fast and furious microbiome research over the past decade has advanced to the forefront of neuroscience and psychiatry. From an insider’s perspective, there are several reasons to consider the microbiome in clinical psychiatry: (1) to identify biomarkers related to biological differences that allow us to identify subgroups of clinical populations and improve the ability to match individuals to the best treatment, (2) to identify individuals at risk for early intervention, (3) to provide novel targets for drug development, and (4) to facilitate the expansion and new development of microbiome-targeted therapies including, but not limited to, diet, prebiotics, and probiotics. An individual’s microbiome is their own, and the colonization of all surfaces of our body that begins at birth continues through early life. The diversity, composition, and function of an individual’s microbiome are influenced early in life by mode of delivery, breast milk versus formula, exposure to antibiotics and nonantibiotic drugs, sex, diet, stress, housing conditions, and geography. Our own genetics influences our microbiome, and gene–environment interactions over life influence the microbe–host interactions that impact host physiological processes. Advances in our understanding of the microbiome in health and disease are promising. Media, public, academics, and health-care providers are challenged to understand this dynamic area of research and to implement best practices to improve treatment approaches in mental health. In a recent issue of The Canadian Journal of Psychiatry, Butler et al. provide an excellent overview of recent microbiome research and advice on best practices in clinical psychiatry related to the microbiome. For neuroscience and psychiatry, a few key studies using germ-free mice provided the spark for neuroscientists to consider how microbes may influence brain function. As additional neuroscientists considered the microbiome, new results demonstrated that the microbe–host interactions and signaling of the microbiota–gut–brain axis influence neurodevelopment, neuroplasticity, neurotransmitter systems, neurogenesis, many behavioral phenotypes, and more. Based on this preclinical work, interest in understanding a role for the microbiome in clinical psychiatry has recently emerged. As reviewed in the study of Butler et al., alterations in microbiota composition have been reported in major depressive disorder, bipolar affective disorder, anxiety disorders, schizophrenia and psychotic disorders, neurodegenerative disorders, and autism spectrum disorder. While differences between diagnostic groups and healthy volunteers have been observed, identifying key taxa and the functional microbial pathways that influence host physiology is an essential step to advance the translation of microbiome research to clinical applications. To date, many studies have relied on 16S rRNA gene sequencing and analytical tools that limit the specificit","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"57 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129712786","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":"The Burden Is Even Greater, The Solution Needs Rethinking","authors":"V. Patel","doi":"10.1177/0706743719890712","DOIUrl":"https://doi.org/10.1177/0706743719890712","url":null,"abstract":"Vigo et al.’s paper in this issue of the Journal builds on their earlier work to calculate the burden of mental disorders, addressing limitations of the original Global Burden of Disease estimates, by reclassifying the burden associated with suicide, certain neurological disorders with significant behavioral implications (notably dementia), drug and alcohol use disorders and their somatic consequences, and syndromes associated with prominent pain which often have a psychogenic origin (such as headaches) to arrive at a composite estimate of “mental, neurological, substance use disorders and self-harm” (MNSS) disorders. This reclassification is justified to take into consideration a “clinically and epidemiologically rational framework for attributing disease burden to disorder groupings, rather than arbitrary methodological considerations” adopted by the Global Burden of Disease estimates; this is an argument I completely endorse and which we adopted in the Disease Control Priorities project. They show how this reclassification leads to a dramatic 3-fold increase in the proportionate burden of disease, estimated in Disability Adjusted Life Years, in the three countries of North America in 2017: in Canada, from 7.4% to 23.8%; in the United States, from 7.1% to 24.7%; and in Mexico, from 5.6% to 16.9%. Notably, while the relative burden is lowest in Mexico, partly due to the higher burden attributed to other health conditions (such as injuries and other noncommunicable diseases), it is also evident that Mexico has the lowest per capita burden of DALYs due to MNSS disorders. The highest burden is in the United States, which is 50% higher for men and 63% higher for women in Mexico, with Canada occupying a roughly midway position between these two countries. A substantial proportion of the excess burden in the United States can be attributed to opiate use disorders and self-harm. These observations are consistent with a recent study that reported the rising rates of suicide in the United States and the mounting evidence testifying to the devastating epidemic of opioid use disorders sweeping the country. The overriding implication of these findings is the need for greater investments to reduce the burden of suffering consequent to MNSS disorders. The allocation of resources, whether for research or service delivery, was already disproportionately lower than the original estimates of the burden of mental disorders in all three countries; if we used the recalculated burden estimates, this inequity reaches alarming proportions. But spending more money on mental health care alone cannot be the entire solution to the high burden for, if that were the case, surely we should have seen a higher burden per capita in Mexico which not only has the least resources allocated to mental health care but whose population also face a much higher prevalence of a range of social determinants of poor mental health, such as poverty and violence. Indeed, Mexico is a middle-inc","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"28 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114928471","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":"Physical Activity as a Predictor of Clinical Trial Outcomes in Bipolar Depression: A Subanalysis of a Mitochondrial-Enhancing Nutraceutical Randomized Controlled Trial","authors":"M. Ashton, M. Mohebbi, A. Turner, W. Marx, M. Berk, G. Malhi, C. Ng, S. Cotton, S. Dodd, J. Sarris, M. Hopwood, B. Stubbs, O. Dean","doi":"10.1177/0706743719889547","DOIUrl":"https://doi.org/10.1177/0706743719889547","url":null,"abstract":"Objectives Individuals with bipolar disorder (BD) generally engage in low levels of physical activity (PA), and yet few studies have investigated the relationship between PA and change in BD symptom severity. The aim of this subanalysis of an adjunctive nutraceutical randomized controlled trial for the treatment of bipolar depression was to explore the relationship between PA, the active adjunctive treatments (a nutraceutical “mitochondrial cocktail”), and clinical outcomes. Methods Participants with bipolar depression were randomized to receive N-acetylcysteine alone, N-acetylcysteine with a combination of nutraceuticals (chosen for the potential to increase mitochondrial activity), or placebo for 16 weeks. Participants (n = 145) who completed the International Physical Activity Questionnaire–Short Form (IPAQ-SF; measured at Week 4) were included in this exploratory subanalysis. Assessments of BD symptoms, functioning, and quality of life were completed at monthly visits up until Week 20. Generalised Estimating Equations were used to explore whether IPAQ-SF scores were a moderator of treatment received on outcomes of the study. Results Week-4 PA was not related to changes in Montgomery Åsberg Depression Rating Scale scores across the study until Week 20. However, participants who engaged in more PA and who received the combination treatment were more likely to have a reduction in scores on the Bipolar Depression Rating Scale (P = 0.03). However, this was not consistent in all domains explored using the IPAQ-SF. Participants who engaged in higher levels of PA also experienced greater improvement in social and occupational functioning and less impairment in functioning due to their psychopathology and improvement in quality of life at Week 20, irrespective of treatment. Conclusions This study provides novel evidence of the association between PA and reduction in BD symptoms in a nutraceutical clinical trial. However, further research assessing the potential synergistic effects of PA in BD is required.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"41 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132010927","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 in North America: A Comparative Epidemiology of Canada, Mexico, and the United States","authors":"D. Vigo, L. Jones, G. Thornicroft, R. Atun","doi":"10.1177/0706743719890169","DOIUrl":"https://doi.org/10.1177/0706743719890169","url":null,"abstract":"Objective: To estimate the burden of mental, neurological, substance use disorders and self-harm (MNSS) in Canada, Mexico, and the United States. Method: We extracted 2017 data from the Global Burden of Disease online database. Based on a previously developed framework to classify and aggregate the burden of specific disorders and symptoms, we reestimated the MNSS burden to include suicide, alcohol use, drug use, specific neurological, and painful somatic symptom disorders. We analyzed age–sex-specific patterns within and between countries. Results: The MNSS burden is the largest of all disorder groupings. It is lowest in Mexico, intermediate in Canada, and highest in the United States. Exceptions are alcohol use, bipolar, conduct disorders, and epilepsy, which are highest in Mexico; and painful somatic syndromes and headaches, which are highest in Canada. The burden of drug use disorders in the United States is twice the burden in Canada, and 7 times the burden in Mexico. MNSS become the most burdensome of all disorder groups by age 10, staying at the top until age 60, and show a distinct pattern across the lifetime. The top three MNSS disorders for men are a combination of substance use disorders and self-harm (United States), with the addition of painful somatic syndromes (Canada), and headaches (Mexico). For women, the top three are headaches and depression (all countries), drug use (United States), neurocognitive disorders (Mexico), and painful somatic syndromes (Canada). Conclusion: MNSS are the most burdensome disease grouping and should be prioritized for funding in Canada, Mexico, and the United States.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132882114","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":"Psychiatry and the Opioid Crisis in Canada","authors":"G. Neilson, A. Freeland, Christian G Schütz","doi":"10.1177/0706743719861118","DOIUrl":"https://doi.org/10.1177/0706743719861118","url":null,"abstract":"A position statement developed by the Canadian Psychiatric Association’s Professional Standards and Practice Committee and approved by the CPA’s Board of Directors on April 18, 2019.","PeriodicalId":309115,"journal":{"name":"The Canadian Journal of Psychiatry","volume":"196 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123236259","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}