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Vigod SN, Levitt AJ. Seasonal severity of depressive symptoms as a predictor of health service use in a community-based sample. J Psychiatr Res 2011; 45:612-8. [PMID: 20980021 DOI: 10.1016/j.jpsychires.2010.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 09/24/2010] [Accepted: 10/05/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine whether severity of seasonal depressive symptoms is an independent predictor of depression-specific health service use. METHODS Cross-sectional telephone survey evaluating mood-related symptom changes across seasons using a structured interview based on the World Mental Health Composite International Diagnostic Interview, in a community sample representative of the province of Ontario, Canada (N = 1605). This study focuses on the 625 individuals (out of a total of 1605 interviewed) who screened positive for lifetime depressive symptoms. Severity of seasonal symptoms of depression (or "seasonality") was measured using the Seasonal Depression Severity (SDS) score (range 0-36). The primary outcome was lifetime depression-specific use of health services from a physician (family physician or psychiatrist). Lifetime psychotropic medication use, use of health services from a non-physician therapist, and psychiatric hospitalization were secondary outcomes. Other important variables that are known to predict depression-specific health service use were considered in multivariable analysis. RESULTS In our sample of individuals with depressive symptoms, those who had used physician health services had higher SDS scores than non-users (11.5 (SD 7.2) vs. 9.7 (SD 6.4), t(616) = 3.182, P = 0.001). In multivariable analysis, SDS score was independently associated with depression-specific health service use by a physician (OR = 1.04, 95% CI 1.01-1.07, p = 0.004). The relationship between seasonality and use of psychotropic medication use was similar (OR = 1.04, 95% CI 1.01-1.07, p = 0.007). CONCLUSIONS Seasonality was independently associated with depression-specific health service use for individuals with depressive symptoms. The results imply that greater seasonality may independently reflect increased severity and need for treatment of depression.
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Kozloff N, Cheung AH, Schaffer A, Cairney J, Dewa CS, Veldhuizen S, Kurdyak P, Levitt AJ. Bipolar disorder among adolescents and young adults: results from an epidemiological sample. J Affect Disord 2010; 125:350-4. [PMID: 20226535 DOI: 10.1016/j.jad.2010.02.120] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 12/08/2009] [Accepted: 02/18/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over the past decade, the clinical recognition and treatment of bipolar disorder (BD) in youth have increased significantly; however, little is known about prevalence of and service use for this disorder at a population level. The objective of this study was to measure the lifetime prevalence of BD, and to describe the socio-demographics, comorbidities, and use of mental health services among 15-24-year-olds with BD. METHODS Data were extracted from the Canadian Community Health Survey: Mental Health and Well-being (CCHS 1.2), a representative population-based survey of 36,984 people age 15 and older. Among subjects age 15-18 and 19-24 (N=5673), we calculated lifetime prevalence rates of BD and report the demographic and clinical characteristics and rates of service use of this sample. RESULTS The weighted lifetime prevalence of BD was 3.0% among 15-24-year-olds (N=191): 2.1% among 15-18-year-olds, and 3.8% among 19-24-year-olds. Rates of psychiatric comorbidity were high, with anxiety disorders, problematic substance use, and suicidality present among nearly half of the sample. Mental health services were accessed in the previous 12 months by 56.1% of youth with BD. LIMITATIONS The questionnaire used in CCHS 1.2 relied on self-report, limiting its applicability to this younger sample. CONCLUSIONS BD is particularly common among young adults and there are specific factors associated with BD in youth. Nearly half of all youth with BD have never used mental health services, suggesting that clinicians should be more vigilant about the signs and symptoms of BD in young people.
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Abstract
OBJECTIVE To determine whether rates of suicide changed in Toronto after a barrier was erected at Bloor Street Viaduct, the bridge with the world's second highest annual rate of suicide by jumping after Golden Gate Bridge in San Francisco. DESIGN Natural experiment. SETTING City of Toronto and province of Ontario, Canada; records at the chief coroner's office of Ontario 1993-2001 (nine years before the barrier) and July 2003-June 2007 (four years after the barrier). PARTICIPANTS 14 789 people who completed suicide in the city of Toronto and in Ontario. MAIN OUTCOME MEASURE Changes in yearly rates of suicide by jumping at Bloor Street Viaduct, other bridges, and buildings, and by other means. RESULTS Yearly rates of suicide by jumping in Toronto remained unchanged between the periods before and after the construction of a barrier at Bloor Street Viaduct (56.4 v 56.6, P=0.95). A mean of 9.3 suicides occurred annually at Bloor Street Viaduct before the barrier and none after the barrier (P<0.01). Yearly rates of suicide by jumping from other bridges and buildings were higher in the period after the barrier although only significant for other bridges (other bridges: 8.7 v 14.2, P=0.01; buildings: 38.5 v 42.7, P=0.32). CONCLUSIONS Although the barrier prevented suicides at Bloor Street Viaduct, the rate of suicide by jumping in Toronto remained unchanged. This lack of change might have been due to a reciprocal increase in suicides from other bridges and buildings. This finding suggests that Bloor Street Viaduct may not have been a uniquely attractive location for suicide and that barriers on bridges may not alter absolute rates of suicide by jumping when comparable bridges are nearby.
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Sinyor M, Levitt AJ, Cheung AH, Schaffer A, Kiss A, Dowlati Y, Lanctôt KL. Does inclusion of a placebo arm influence response to active antidepressant treatment in randomized controlled trials? Results from pooled and meta-analyses. J Clin Psychiatry 2010; 71:270-9. [PMID: 20122371 DOI: 10.4088/jcp.08r04516blu] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 01/02/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine if the inclusion of a placebo arm and/or the number of active comparators in antidepressant trials influences the response rates of the active medication and/or placebo. DATA SOURCES Searches of MEDLINE, PsycINFO, and pharmaceutical Web sites for published trials or trials conducted but unpublished between January 1996 and October 2007. STUDY SELECTION 2,275 citations were reviewed, 285 studies were retrieved, and 90 were included in the analysis. Trials reporting response and/or remission rates in adult subjects treated with an antidepressant monotherapy for unipolar major depression were included. DATA EXTRACTION The primary investigator recorded the number of responders and/or remitters in the intent-to-treat population of each study arm or computed these numbers using the quoted rates. DATA SYNTHESIS Poisson regression analyses demonstrated that mean response rate for the active medication was higher in studies comparing 2 or more active medications without a placebo arm than in studies comparing 2 or more active medications with a placebo arm (65.4% vs 57.7%, P < .0001) or in studies comparing only 1 active medication with placebo (65.4% vs 51.7%, P = .0005). Mean response rate for placebo was significantly lower in studies comparing 1 rather than 2 or more active medications (34.3% vs 44.6%, P = .003). Mean remission rates followed a similar pattern. Meta-analysis confirmed results from the pooled analysis. CONCLUSIONS These data suggest that antidepressant response rates in randomized control trials may be influenced by the presence of a placebo arm and by the number of treatment arms and that placebo response rates may be influenced by the number of active treatment arms in a study.
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Joffe RT, Levitt AJ. Basal thyrotropin and major depression: relation to clinical variables and treatment outcome. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2008; 53:833-8. [PMID: 19087481 DOI: 10.1177/070674370805301209] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE There is a current argument in thyroidology about whether the normal range for basal thyrotropin (TSH) is too broad. Some groups suggest that a TSH of less than 2.5 mIU/L is a better cut-off for euthyroidism. Because major depression is associated with changes in thyroid hormone status and thyroid hormones may be an effective treatment for major depression, we examined whether TSH levels above or below 2.5 mIU/L were related to clinical variables or treatment outcome in euthyroid patients with major depression. METHODS Outpatients with major depression (n =166) were assigned to high-normal and low-normal TSH groups based on their basal TSH levels. The 2 groups were compared along clinical variables and treatment outcome. RESULTS The low-normal TSH group was significantly more depressed, as measured by Hamilton Depression Rating Scale scores, and had more anxiety symptoms and suicidal tendencies than the high-normal group. There was no difference in treatment response between the groups. CONCLUSIONS A comparison of low-normal and high-normal basal TSH groups with major depression revealed significant differences in severity and symptoms of depression but no difference in treatment outcome. These data are preliminary and require replication in a larger sample.
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Goldstein BI, Levitt AJ. The specific burden of comorbid anxiety disorders and of substance use disorders in bipolar I disorder. Bipolar Disord 2008; 10:67-78. [PMID: 18199243 DOI: 10.1111/j.1399-5618.2008.00461.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Uncertainty exists regarding whether comorbid substance use disorders (SUDs) in bipolar I disorder are more prevalent among persons with versus without comorbid anxiety disorders. Moreover, the independent contribution of these comorbidities to the burden of bipolar disorder (BD) is unclear. METHODS The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions was used to identify respondents with lifetime BD (n = 1,411). Illness severity was compared across four groups based on the presence of lifetime anxiety disorders, lifetime SUDs, neither, or both. Variables included lifetime prevalence of mixed mania, prolonged mood episodes, BD-related health service utilization, and forensic history, 12-month prevalence of mania and depression, and current general mental health functioning. Diagnoses were generated using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV Version. Analyses were computed separately for males and females. RESULTS For females only, the lifetime prevalence of SUDs was significantly greater among those with lifetime anxiety disorders [odds ratio (OR) = 1.41, 95% confidence interval (CI) = 1.08-1.86]; this was not found among males (OR = 1.15, 95% CI = 0.79-1.68). In multiple logistic regression analyses among both males and females, anxiety disorders were significantly associated with mixed episodes, prolonged depressive episodes, 12-month prevalence of depression, BD-related health service utilization, and poorer current mental health functioning. SUDs were significantly associated with mixed episodes among females, 12-month prevalence of depression among males, and with forensic history among both males and females. CONCLUSIONS Whereas comorbid anxiety disorders appear to confer increased liability towards poor mental health functioning and greater BD-related health service utilization, comorbid SUDs are associated with positive forensic history. Early identification and treatment of these comorbid conditions are of paramount importance. Further representative prospective studies are needed.
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Goldstein BI, Levitt AJ. Prevalence and correlates of bipolar I disorder among adults with primary youth-onset anxiety disorders. J Affect Disord 2007; 103:187-95. [PMID: 17328960 PMCID: PMC2206538 DOI: 10.1016/j.jad.2007.01.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Revised: 01/24/2007] [Accepted: 01/24/2007] [Indexed: 02/08/2023]
Abstract
OBJECTIVES It is of potentially great public health importance to determine whether youth-onset anxiety disorders are associated with the increased prevalence of subsequent bipolar I disorder (BD) among adults, and to identify risk factors for BD in this population. METHODS The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions was used to identify respondents with social phobia, panic disorder, or generalized anxiety disorder that onset in youth (<19 years) and was not preceded by a major depressive, manic, or mixed episode (N=1571; 572 males, 999 females). The prevalence of BD among subjects with, versus without, these youth-onset anxiety disorders was examined. Variables that could be associated with the increased risk of BD among subjects with youth-onset anxiety disorders were examined, including conduct disorder, youth-onset substance use disorders (SUD), and family history of depression and/or alcoholism. Analyses were computed separately for males and females. RESULTS The prevalence of BD was significantly greater among adults with, versus without, primary youth-onset anxiety disorders for both males (15.9% vs 2.7%; chi2=318.4, df=1, p<0.001) and females (13.8% vs 2.9%; chi2=346.2, df=1, p<0.001). Youth-onset anxiety disorders remained significantly associated with BD after controlling for interceding major depression, and this was true for each of the specific anxiety disorders examined. Among males with youth-onset primary anxiety disorders, conduct disorder and loaded family history of depression were associated with significantly increased risk of BD. Among females, conduct disorder and loaded family history of alcoholism were associated with significantly increased risk of BD. CONCLUSIONS The prevalence of BD was elevated among subjects with youth-onset primary anxiety disorders, particularly if comorbid conduct disorder was present. Future studies are needed to confirm these findings prospectively, and to develop preventive strategies for populations at risk.
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Joffe RT, Brimacombe M, Levitt AJ, Stagnaro-Green A. Treatment of Clinical Hypothyroidism With Thyroxine and Triiodothyronine: A Literature Review and Metaanalysis. PSYCHOSOMATICS 2007; 48:379-84. [PMID: 17878495 DOI: 10.1176/appi.psy.48.5.379] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Thyroxine is the standard replacement therapy for patients with clinical hypothyroidism. However, there has been recent interest in examining the potential advantages of combined thyroxine and triiodothyronine treatment for the treatment of hypothyroidism. The authors review the nine studies to-date and conclude that the variability and limitations in study design make definitive and clinically useful recommendations difficult. They therefore conducted a metaanalysis of the nine controlled studies examining the impact of combined thyroxine-plus-triiodothyronine versus thyroxine alone, with measures of psychiatric symptoms as the primary outcome. Their analysis reveals no significant difference in treatment effect on psychiatric symptoms in the nine controlled studies to date.
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Korczak DJ, Goldstein BI, Levitt AJ. Panic disorder, cardiac diagnosis and emergency department utilization in an epidemiologic community sample. Gen Hosp Psychiatry 2007; 29:335-9. [PMID: 17591510 DOI: 10.1016/j.genhosppsych.2007.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 03/20/2007] [Accepted: 03/22/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We examined the association between panic disorder (PD), physician-diagnosed cardiac disease (CD), and the interaction of these variables in relation to health care utilization, as measured by emergency department (ED) visitations, in an epidemiologic sample. METHODS Subjects were identified from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of 43,093 adult respondents from the United States who completed face-to-face computer-assisted structured clinical interviews. RESULTS Among patients with CD, the 12-month prevalence of PD (6.0%; 613/10,239) was significantly higher than that among non-CD subjects (3.4%; 1106/32,854; adjusted odds ratio=2.4; 95% confidence interval=2.2-2.7). CD patients with PD had a significantly greater prevalence of angina, tachycardia and alcohol use disorders as compared with PD-negative patients. PD-positive patients reported significantly greater mean 12-month ED visits (1.2) as compared with the PD-negative patients (0.6; P<.001). PD and tachycardia were found to have a significant interaction effect on ED visits for males (F=25.1; df=1,7; P<.001) but not for females (F=1.2; df=1,7; P=.28), with age, income, race and alcohol use included as covariates. CONCLUSIONS Epidemiological data support a relationship between PD and CD that impacts ED utilization. These findings have potential implications for medical, psychiatric and ED-based screening and interventions.
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Michalak EE, Murray G, Levitt AJ, Levitan RD, Enns MW, Morehouse R, Tam EM, Cheung A, Lam RW. Quality of life as an outcome indicator in patients with seasonal affective disorder: results from the Can-SAD study. Psychol Med 2007; 37:727-736. [PMID: 17112403 DOI: 10.1017/s0033291706009378] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although a host of studies have now examined the relationship between quality of life (QoL) and non-seasonal depression, few have measured QoL in seasonal affective disorder (SAD). We report here on results from the Can-SAD trial, which assessed the impact of treatment with either antidepressant medication or light therapy upon QoL in patients diagnosed with SAD. METHOD This Canadian double-blind, multicentre, randomized controlled trial included 96 patients who met strict diagnostic criteria for SAD. Eligible patients were randomized to 8 weeks of treatment with either: (1) 10000 lux light treatment and a placebo capsule or (2) 100 lux light treatment (placebo light) and 20 mg fluoxetine. QoL was measured with the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Medical Outcomes Study (MOS) Short-Form General Health Survey (SF-20) at baseline and 8 weeks. RESULTS Both intervention groups showed significant improvement in QoL over time with no significant differences being detected by treatment condition. Q-LES-Q scores increased significantly in seven of eight domains, with the average scores rising from 48 x 0 (S.D.=10 x 7) at baseline to 69 x 1 (S.D.=15 x 6) at week 8. Treatment-related improvement in QoL was strongly associated with improvement in depression symptoms. DISCUSSION Patients with SAD report markedly impaired QoL during the winter months. Treatment with light therapy or antidepressant medication is associated with equivalent marked improvement in perceived QoL. Studies of treatment interventions for SAD should routinely include broader indices of patient outcome, such as the assessment of psychosocial functioning or life quality.
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Joffe RT, Sokolov STH, Levitt AJ. Lithium and triiodothyronine augmentation of antidepressants. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2006; 51:791-3. [PMID: 17168254 DOI: 10.1177/070674370605101209] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the relative benefits of the combination of lithium and triiodothyronine (T3) in augmentation of antidepressants, compared with either lithium or T3 alone. METHODS We performed a 2-week, randomized, double-blind, placebo-controlled pilot study of the addition of lithium compared with T3 compared with the combination of both in subjects with major depressive disorder who had not responded to an antidepressant. RESULTS All groups improved significantly over the 2 weeks of treatment, but there were no significant between-group differences. CONCLUSION There may be no advantage to a combination of these augmenting agents, although we failed to show separation between active treatments and placebo.
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Goldstein BI, Levitt AJ. Is current alcohol consumption associated with increased lifetime prevalence of major depression and suicidality? Results from a pilot community survey. Compr Psychiatry 2006; 47:330-3. [PMID: 16905393 DOI: 10.1016/j.comppsych.2006.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2005] [Revised: 12/30/2005] [Accepted: 01/27/2006] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE Alcohol use disorders are associated with increased illness severity and suicidality in major depressive disorder (MDD). However, little is known about how alcohol use across the continuum relates to MDD. METHOD Subjects were 496 adults (201 men, 295 women) who completed a community-based telephone survey that incorporated a validated structured diagnostic interview for depression and a validated alcohol questionnaire. Subjects were divided into 3 alcohol consumption groups based on Canadian low-risk drinking guidelines: minimal (MIN), moderate (MOD), and heavy (HVY) alcohol consumption. RESULTS Among subjects with MDD, drinking group was not associated with measures of disability, health service use, or life satisfaction. Among all women, the prevalence of depression increased significantly across drinking groups (MIN, 24.6%; MOD, 30.3%; HVY, 44.0% [linear-by-linear association chi(2) = 4.1, df = 1, P < .05]), as did the prevalence of suicidality among women with MDD (MIN, 16.3%; MOD, 29.6%; HVY, 45.5% [chi(2) = 4.5, df = 1, P < .05]). CONCLUSION A range of alcohol consumption, not just heavy drinking, may be associated with major depression and suicidality.
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Goldstein BI, Levitt AJ. Further evidence for a developmental subtype of bipolar disorder defined by age at onset: results from the national epidemiologic survey on alcohol and related conditions. Am J Psychiatry 2006; 163:1633-6. [PMID: 16946191 DOI: 10.1176/ajp.2006.163.9.1633] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study examines the relationship between age at onset of bipolar I disorder and illness characteristics among adults in a community sample. METHOD The National Epidemiologic Survey on Alcohol and Related Conditions identified 1,411 adults with bipolar disorder. For analyses, bipolar disorder subjects were divided into three age at onset groups: childhood (less than 13 years old, N=113), adolescence (13-18 years old, N=339), and adulthood (19 years or older, N=959). RESULTS Nonremitting bipolar disorder was most prevalent among childhood-onset subjects, and childhood-onset subjects were most likely to experience prolonged episodes. Antisocial personality disorder was most prevalent among childhood-onset subjects. Drug use disorders were more prevalent among childhood-onset and adolescent-onset, as compared with adult-onset, subjects. Prevalence of mixed episodes or irritability did not differ significantly between groups. CONCLUSIONS Findings corroborate clinical studies: illness characteristics among adults with childhood-onset bipolar disorder are similar to those described in children with bipolar disorder.
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Enns MW, Cox BJ, Levitt AJ, Levitan RD, Morehouse R, Michalak EE, Lam RW. Personality and seasonal affective disorder: results from the CAN-SAD study. J Affect Disord 2006; 93:35-42. [PMID: 16647139 DOI: 10.1016/j.jad.2006.01.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Accepted: 01/05/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Personality factors have been implicated in seasonal affective disorder (SAD). The present study investigated the relationship between the five-factor model of personality (neuroticism, extraversion, openness, agreeableness, conscientiousness) and SAD. METHODS Ninety-five patients with SAD completed personality measures before and after treatment in a clinical trial and during the summer months. The personality scores of the SAD patients were compared with a matched group of non-seasonal depressed patients and published normative data. Stability and change in personality scores with changes in mood state were assessed. Personality dimensions were evaluated as possible predictors of treatment outcome. RESULTS SAD patients showed elevated openness scores relative to both non-seasonal depressed patients and norms. Their neuroticism scores were lower than non-seasonal depressed patients, but higher than norms. All personality dimensions showed large and highly significant test-retest correlations but several personality dimensions, particularly neuroticism and extraversion, also showed considerable change with changing mood state. None of the personality dimensions were significantly associated with treatment outcome. LIMITATIONS Personality assessment relied on self-report. CONCLUSIONS The personality profile of SAD patients differs from both non-seasonal depressed patients and norms. Elevated openness scores appear to be a unique feature of patients with SAD. Since mood state has a significant impact on personality scores, assessment of personality in SAD patients should ideally be conducted when they are in remission. Further investigation of the relationship between personality and SAD, especially the potential significance of elevated openness scores, is warranted.
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Goldstein BI, Levitt AJ. A gender-focused perspective on health service utilization in comorbid bipolar I disorder and alcohol use disorders: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2006; 67:925-32. [PMID: 16848652 DOI: 10.4088/jcp.v67n0609] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study compares health service utilization by individuals with comorbid lifetime bipolar I disorder and lifetime alcohol use disorders (AUD) to that of individuals with either diagnosis alone, using nationally representative data. METHOD The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions was used to identify respondents with bipolar I disorder only (BD-only; N = 636), AUD only (N = 11,068), and comorbid bipolar I disorder and AUD (BD-AUD; N = 775). Diagnoses were generated using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. The 3 groups were compared with respect to self-reported health service utilization. RESULTS For both men and women, respondents in the BD-AUD group were significantly more likely than AUD-only respondents to report any alcohol-related service utilization (p < .001). BD-AUD respondents were significantly more likely to report bipolar disorder-related hospital admissions as compared with BD-only respondents among males only (p = .009). Within the BD-AUD group, males reported significantly greater utilization of AUD treatment only (p < .001), and females reported significantly greater utilization of bipolar disorder treatment only (p < .001) and significantly greater likelihood of utilizing mental health services overall (p < .001). There was no gender difference in the proportion of respondents who utilized both AUD and bipolar disorder services. CONCLUSIONS As expected, individuals with comorbid bipolar I disorder and AUD utilize significantly more mental health services than individuals with either disorder alone. The primary original finding is that among those with comorbid bipolar I disorder and AUD, bipolar I disorder is more likely to go untreated among males and AUD is more likely to go untreated among females. Gender may be an important factor to consider in future health service planning for comorbid bipolar I disorder and AUD.
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Lam RW, Levitt AJ, Levitan RD, Enns MW, Morehouse R, Michalak EE, Tam EM. The Can-SAD study: a randomized controlled trial of the effectiveness of light therapy and fluoxetine in patients with winter seasonal affective disorder. Am J Psychiatry 2006; 163:805-12. [PMID: 16648320 DOI: 10.1176/ajp.2006.163.5.805] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Light therapy and antidepressants have shown comparable efficacy in separate studies of seasonal affective disorder treatment, but few studies have directly compared the two treatments. This study compared the effectiveness of light therapy and an antidepressant within a single trial. METHOD This double-blind, randomized, controlled trial was conducted in four Canadian centers over three winter seasons. Patients met DSM-IV criteria for major depressive disorder with a seasonal (winter) pattern and had scores > or = 23 on the 24-item Hamilton Depression Rating Scale. After a baseline observation week, eligible patients were randomly assigned to 8 weeks of double-blind treatment with either 1) 10,000-lux light treatment and a placebo capsule, or 2) 100-lux light treatment (placebo light) and fluoxetine, 20 mg/day. Light treatment was applied for 30 minutes/day in the morning with a fluorescent white-light box; placebo light boxes used neutral density filters. RESULTS A total of 96 patients were randomly assigned to a treatment condition. Intent-to-treat analysis showed overall improvement with time, with no differences between treatments. There were also no differences between the light and fluoxetine treatment groups in clinical response rates (67% for each group) or remission rates (50% and 54%, respectively). Post hoc testing found that light-treated patients had greater improvement at 1 week but not at other time points. Fluoxetine was associated with greater treatment-emergent adverse events (agitation, sleep disturbance, palpitations), but both treatments were generally well-tolerated with no differences in overall number of adverse effects. CONCLUSIONS Light treatment showed earlier response onset and lower rate of some adverse events relative to fluoxetine, but there were no other significant differences in outcome between light therapy and antidepressant medication. Although limited by lack of a double-placebo condition, this study supports the effectiveness and tolerability of both treatments for seasonal affective disorder and suggests that other clinical factors, including patient preference, should guide selection of first-line treatment.
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Goldstein BI, Levitt AJ. Factors associated with temporal priority in comorbid bipolar I disorder and alcohol use disorders: Results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2006; 67:643-9. [PMID: 16669730 DOI: 10.4088/jcp.v67n0416] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare illness characteristics, comorbidities, treatment utilization, and family history among individuals with comorbid bipolar I disorder and alcohol use disorders (AUD) based on temporal priority of onset. METHOD The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions identified respondents with lifetime comorbid bipolar I disorder and AUD for whom AUD were antecedent (Alcohol First; N = 311), the onset of the 2 conditions occurred in the same year (Same Year; N = 113), or bipolar I disorder was antecedent (Bipolar First; N = 233). Diagnoses were generated using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. This study examined between-group differences in bipolar I- and AUD-related variables. RESULTS Bipolar First respondents were most likely to experience prolonged manic episodes. There were no differences in the 12-month prevalence of bipolar I disorder among respondents with prior history of bipolar I disorder. The 12-month prevalence of AUD among respondents with prior history of AUD was lower among Alcohol First respondents compared to Same Year or Bipolar First respondents. Same Year respondents were most likely to seek AUD treatment and reported comparatively short latency between onset and treatment of both bipolar I disorder and AUD. The prevalence of family history of comorbid depression and AUD was greatest among Same Year respondents. Same Year respondents also showed the lowest prevalence of anxiety disorders. Overall psychosocial functioning was similar across groups. CONCLUSION Temporal priority in comorbid bipolar I disorder and AUD is associated with several significant between-group differences in features of bipolar I disorder and AUD severity, treatment utilization, other comorbidities, and family history. Same-year onset of bipolar I disorder and AUD may be a marker of a specific subtype of bipolar I-AUD comorbidity. Potential implications of these findings are discussed.
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Schaffer A, Cairney J, Cheung AH, Veldhuizen S, Levitt AJ. Use of treatment services and pharmacotherapy for bipolar disorder in a general population-based mental health survey. J Clin Psychiatry 2006; 67:386-93. [PMID: 16649824 DOI: 10.4088/jcp.v67n0308] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study examined characteristics of treatment utilization in a large general population-based sample of bipolar subjects. METHOD Data source was the Canadian Community Health Survey-Mental Health and Well-Being, a nationally representative, community mental health survey of over 36,000 individuals conducted from May to December 2002. Subjects who met study criteria for a current or past manic episode were classified as having bipolar disorder. Sociodemographic and illness-related factors influencing likelihood of accessing treatment, delay to contact with treatment services, and use of pharmacotherapy among bipolar subjects were determined. RESULTS Among the 852 bipolar subjects, 45.2% had never accessed treatment services. Male gender (p = .001), lower level of education (p = .003), and immigrant status (p < .001) were each significantly negatively correlated with use of treatment services. Mean delay from illness onset to contact with any treatment services was 3.1 years. Sixty-six percent of bipolar subjects had not taken a mood stabilizer or antidepressant medication in the past year, and 22% used antidepressants without a mood stabilizer. Female bipolar subjects were significantly more likely than male subjects to be prescribed an antidepressant medication (OR = 1.99, p = .01), even in the absence of higher frequency of recent depressions. CONCLUSION Many individuals with bipolar disorder never receive any form of mental health treatment, and, among those that do, use of pharmacotherapy is not consistent with guideline-based recommendations. These findings reinforce the importance of continued efforts to better identify bipolar individuals early in their course of illness, and the need for further educational focus on bipolar disorder for all mental health treatment providers.
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Murray G, Michalak EE, Levitt AJ, Levitan RD, Enns MW, Morehouse R, Lam RW. O sweet spot where art thou? Light treatment of Seasonal Affective Disorder and the circadian time of sleep. J Affect Disord 2006; 90:227-31. [PMID: 16337687 DOI: 10.1016/j.jad.2005.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2005] [Revised: 10/17/2005] [Accepted: 10/17/2005] [Indexed: 10/25/2022]
Abstract
This study investigated Lewy's Phase Shift Hypothesis (PSH) for winter Seasonal Affective Disorder, which asserts that the phase angle difference (PAD) between circadian and sleep rhythms is critical in the mechanism of light's therapeutic action. Specifically, we sought to test whether a euthymic "sweet spot" could be identified at a PAD (between temperature minimum and wake time) of circa 3 h. After a baseline week, symptomatic SAD patients (N = 43) received 8 weeks of morning light treatment. Analyses were based on SIGH-SAD ratings made at baseline and posttreatment. Also estimated pre- and posttreatment were T(min) (calculated from an algorithm based on Morningness-Eveningness self-report scores), and the phase of the sleep-wake rhythm (as assessed by daily sleep logs). It was predicted that a quadratic relationship would exist between PAD and depression ratings at baseline and posttreatment, with lowest levels around PAD = 3 h. It was further predicted that shift towards PAD = 3 h with treatment would be associated with decreases in depression with treatment. Although trends were in the expected direction, none of the three predictions were supported. Findings are discussed in terms of the study's limitations and the experimental challenge of parsing independent and interacting contributions of sleep and circadian phase.
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Murray G, Michalak EE, Levitt AJ, Levitan RD, Enns MW, Morehouse R, Lam RW. Therapeutic mechanism in seasonal affective disorder: do fluoxetine and light operate through advancing circadian phase? Chronobiol Int 2006; 22:937-43. [PMID: 16298778 DOI: 10.1080/07420520500263292] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In the context of Lewy's phase delay hypothesis, the present study tested whether effective treatment of winter Seasonal Affective Disorder (SAD) is mediated by advancing of circadian phase. Following a baseline week, 78 outpatients with SAD were randomized into 8 weeks of treatment with either fluoxetine and placebo light treatment or light treatment and placebo pill. Depression levels were measured on the Ham17+7 and the BDI-II, and circadian phase was estimated on the basis of daily sleep logs and self-reported morningness-eveningness. Among the 61 outpatients with complete data, both treatments were associated with significant antidepressant effect and phase advance. However, pre- and post-treatment comparisons found that the degree of symptom change did not correlate with the degree of phase change associated with treatment. The study therefore provides no evidence that circadian phase advance mediates the therapeutic mechanism in patients with SAD. Findings are discussed in terms of the limitations of the circadian measures employed.
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Cheung AH, Dewa CS, Levitt AJ. Clinical review of mania, hostility and suicide-related events in children and adolescents treated with antidepressants. Paediatr Child Health 2005; 10:457-63. [PMID: 19668657 PMCID: PMC2722596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Recent controversy surrounding the use of non-tricyclic antidepressants and the emergence of suicide-related events, hostility/behavioural activation and mania in youth with depression warrants an exploration of the results from randomized controlled trials (RCTs) and published case reports for the emergence of these adverse events. OBJECTIVE To provide a clinical review of the available evidence from RCTs and case reports regarding the safety of nontricyclic anti-depressants in youth with depression. METHODS Seven RCTs of antidepressant use in youth with depression, four case reports of suicide-related adverse events, three case reports of hostility/behavioural activation, and 12 case reports of precipitation of mania were reviewed. RESULTS The majority of patients with suicide-related adverse events from both RCTs and published case reports were suicidal before the start of antidepressant treatment. Hostility/behavioural activation generally developed within days to weeks after the start of antidepressant treatment; in the majority of cases, symptoms resolved within four weeks of dosage lowering or discontinuation of the medication alone. Rates for precipitation of mania from RCTs ranged from 0% to 6%. In approximately 60% of published case reports, manic symptoms resolved with the discontinuation or lowering of the dosage of medication alone. CONCLUSIONS Several trends were observed in the association between adverse events and the use of nontricyclic antidepressants in youth. When prescribing antidepressants to youth, clinicians should closely monitor patients and fully inform them and their families of the risks and benefits of treatment with antidepressants.
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Schaffer A, Levitt AJ. Double-blind, placebo-controlled pilot study of mexiletine for acute mania or hypomania. J Clin Psychopharmacol 2005; 25:507-8. [PMID: 16160638 DOI: 10.1097/01.jcp.0000177852.08287.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shin K, Schaffer A, Levitt AJ, Boyle MH. Seasonality in a community sample of bipolar, unipolar and control subjects. J Affect Disord 2005; 86:19-25. [PMID: 15820267 DOI: 10.1016/j.jad.2004.11.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2004] [Accepted: 11/30/2004] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study examined seasonality in a community sample of five diagnostic groups: normal subjects, those with non-seasonal depression (NSD), seasonal depression (SD), non-seasonal bipolar disorder (NSBD) and seasonal bipolar disorder (SBD). METHODS Telephone interviews were conducted across the Province of Ontario. Seasonal changes in mood and behaviour were determined using the Seasonal Pattern Assessment Questionnaire (SPAQ). Five additional seasonality items consisting of depressive symptoms were included in the interview. The mean global severity of seasonality (GSS) scores were obtained and the entire inventory of 11 seasonality items were compared across the identified groups. RESULTS The mean GSS score for the controls was 5.2 (S.D. = 4.0), 8.0 (S.D. = 4.9) for NSD, 10.5 (S.D. = 3.9) for SD, 10.5 (S.D. = 5.4) for NSBD and 13.4 (S.D. = 5.4) for SBD. These scores differed significantly (F = 61.68, df = 4, p < 0.001). For the majority of the individual items, the SBD group rated the highest degree of seasonal fluctuation, while the NSBD and SD groups had nearly identical item scores. LIMITATIONS Limitations in this study include the relatively small number of subjects in the NSBD and SBD groups, and the inherent limitations in a telephone interview. CONCLUSIONS Individuals with bipolar disorder experience greater seasonality than those with depression or healthy controls. Even the non-seasonal bipolar group had as much seasonal fluctuation as the seasonal depression group, which has important implications for the management of bipolar illness.
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Michalak EE, Tam EM, Manjunath CV, Levitt AJ, Levitan RD, Lam RW. Quality of life in patients with seasonal affective disorder: summer vs winter scores. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2005; 50:292-5. [PMID: 15968846 DOI: 10.1177/070674370505000510] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare perceived quality of life (QoL) in patients diagnosed with seasonal affective disorder (SAD) during the winter and summer months. METHODS Twenty-six patients who were enrolled in an ongoing multicentre study in Canada completed 2 measures of QoL (the 20-item Medical Outcomes Study Short-Form General Health Survey [SF-20] and the Quality of Life Enjoyment and Satisfaction Questionnaire, [Q-LES-Q]) during the winter, when suffering from depression, and again during the summer months. RESULTS Both general and health-related QoL scores were significantly improved in patients with SAD during the summer months, with scores for the most part falling within normal range. CONCLUSIONS Perceived QoL in patients with SAD is markedly impaired during the winter months but shows a substantial rebound during the summer months. The findings of this study provide further evidence that SAD is a distinct diagnostic entity.
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