Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study

OBJECTIVE

To describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service.

DESIGN

A pragmatic mixed-methods approach using routinely collected administrative data between 1 April 2020 and 31 March 2022 and semi-structured interviews with clients, caregivers, clinicians and staff. Interview data were coded according to the Consolidated Framework for Implementation Research (CFIR) and examined for patterns of similarity or divergence across data sources, respondents or other relevant characteristics.

SETTING

Child and adolescent outpatient mental health service, Nova Scotia, Canada.

PARTICIPANTS

IWK Health clinicians and staff who had participated in virtual mental healthcare following its implementation in March 2020 and clients (aged 12-18 years) and caregivers of clients (aged 3-18 years) who had received treatment from an IWK outpatient clinic between 1 April 2020 and 31 March 2022 (n=1300). Participants (n=48) in semi-structured interviews included nine clients aged 13-18 years (mean 15.7 years), 10 caregivers of clients aged 5-17 years (mean 12.7 years), eight Community Mental Health and Addictions booking and registration or administrative staff and 21 clinicians.

RESULTS

During peak pandemic activity, upwards of 90% of visits (first or return) were conducted virtually. Between waves, return appointments were more likely to be virtual than first appointments. Interview participants (n=48) reported facilitators and barriers to virtual care within the CFIR domains of 'outer setting' (eg, external policies, client needs and resources), 'inner setting' (eg, communications within the service), 'individual characteristics' (eg, personal attributes, knowledge and beliefs about virtual care) and 'intervention characteristics' (eg, relative advantage of virtual or in-person care).

CONCLUSIONS

Shared decision-making regarding treatment modality (virtual vs in-person) requires consideration of client, caregiver, clinician, appointment, health system and public health factors across episodes of care to ensure accessible, safe and high-quality mental healthcare.

Associations of active and passive smartphone use with measures of youth mental health during the COVID-19 pandemic

Smartphone use provides a significant amount of screen-time for youth, and there have been growing concerns regarding its impact on their mental health. While time spent in a passive manner on the device is frequently considered deleterious, more active engagement with the phone might be protective for mental health. Recent developments in mobile sensing technology provide a unique opportunity to examine behaviour in a naturalistic manner. The present study sought to investigate, in a sample of 451 individuals (mean age 20.97 years old, 83% female), whether the amount of time spent on the device, an indicator of passive smartphone use, would be associated with worse mental health in youth and whether an active form of smartphone use, namely frequent checking of the device, would be associated with better outcomes. The findings highlight that overall time spent on the smartphone was associated with more pronounced internalizing and externalizing symptoms in youth, while the number of unlocks was associated with fewer internalizing symptoms. For externalizing symptoms, there was also a significant interaction between the two types of smartphone use observed. Using objective measures, our results suggest interventions targeting passive smartphone use may contribute to improving the mental health of youth.

Implementation of a Knowledge Management System in Mental Health and Addictions: Mixed Methods Case Study

BACKGROUND

Mental health and addictions (MHA) care is complex and individualized and requires coordination across providers and areas of care. Knowledge management is an essential facilitator and common challenge in MHA services.

OBJECTIVE

This paper aimed to describe the development of a knowledge management system (KMS) and the associated processes in 1 MHA program. We also aimed to examine the uptake and use, satisfaction, and feedback on implementation among a group of pilot testers.

METHODS

This project was conducted as a continuous quality-improvement initiative. Integrated stakeholder engagement was used to scope the content and design the information architecture to be implemented using a commercially available knowledge management platform. A group of 30 clinical and administrative staff were trained and tested with the KMS over a period of 10 weeks. Feedback was collected via surveys and focus groups. System analytics were used to characterize engagement. The content, design, and full-scale implementation planning of the KMS were refined based on the results.

RESULTS

Satisfaction with accessing the content increased from baseline to after the pilot. Most testers indicated that they would recommend the KMS to a colleague, and satisfaction with KMS functionalities was high. A median of 7 testers was active each week, and testers were active for a median of 4 days over the course of the pilot. Focus group themes included the following: the KMS was a solution to problems for staff members, functionality of the KMS was important, quality content matters, training was helpful and could be improved, and KMS access was required to be easy and barrier free.

CONCLUSIONS

Knowledge management is an ongoing need in MHA services, and KMSs hold promise in addressing this need. Testers in 1 MHA program found a KMS that is easy to use and would recommend it to colleagues. Opportunities to improve implementation and increase uptake were identified. Future research is needed to understand the impact of KMSs on quality of care and organizational efficiency.

Choice and Partnership Approach to community mental health and addiction services: a realist-informed scoping review

OBJECTIVES

The Choice and Partnership Approach (CAPA) was developed to create an accessible, child-centred and family-centred model of child and adolescent mental health service delivery that is adaptable to different settings. We sought to describe the state of evidence regarding the extent, outcomes and contextual considerations of CAPA implementation in community mental health services.

DESIGN

Scoping review.

DATA SOURCES

Published and grey literature were searched using MEDLINE, Embase, CINAHL, PsycINFO, Scopus and Google to 13 and 20 July 2022, respectively.

ELIGIBILITY CRITERIA

We included reports focused on the implementation, outcomes (clinical, programme or system) or a discussion of contextual factors that may impact CAPA implementation in either child and adolescent or adult mental health services.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a codebook that reflected the five domains of the Consolidated Framework for Implementation Research (CFIR) and reviewed for agreement and accuracy. Data were synthesised according to the five CFIR domains.

RESULTS

Forty-eight reports describing 36 unique evaluations were included. Evaluations were observational in nature; 10 employed pre-post designs. CAPA implementation, regardless of setting, was largely motivated by long wait times. Characteristics of individuals (eg, staff buy-in or skills) were not reported. Processes of implementation included facilitative leadership, data-informed planning and monitoring and CAPA training. Fidelity to CAPA was infrequently measured (n=9/36) despite available tools. Health system outcomes were most frequently reported (n=28/36); few evaluations (n=7/36) reported clinical outcomes, with only three reporting pre/post CAPA changes.

CONCLUSIONS

Gaps in evidence preclude a systematic review and meta-analysis of CAPA implementation. Measurement of clinical outcomes represents an area for significant improvement in evaluation. Consistent measurement of model fidelity is essential for ensuring the accuracy of outcomes attributed to its implementation. An understanding of the change processes necessary to support implementation would be strengthened by more comprehensive consideration of contextual factors.

Interventions to change clinicians' behavior related to suicide-prevention care in the emergency department: a scoping review

OBJECTIVE

The objective of this scoping review was to explore, characterize, and map the literature on interventions and intervention components implemented to change emergency department clinicians' behavior related to suicide prevention using the Behaviour Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet patients are often discharged without proper suicide risk assessments and/or referrals. In response, we must support emergency department clinicians' behavior change to follow evidence-based suicide prevention strategies. However, reviews to date have yet to systematically and theoretically examine interventions' functional characteristics and how they can influence emergency department clinicians' behaviors related to suicide-prevention care.

INCLUSION CRITERIA

This review considered interventions that targeted emergency department clinicians' behavior change related to suicide prevention. Behavior change referred to observable practice changes as well as proxy measures of behavior change, including changes in knowledge and attitude.

METHODS

This review followed JBI methodology for scoping reviews. Searches included PubMed, PsycINFO, CINAHL, Embase, and gray literature, including targeted Google searches for relevant organizations/websites, ProQuest Dissertations and Theses Global, and Scopus conference papers (using a specific filter). This review did not apply any date limits, but our search was limited to the English language. Data extraction was undertaken using a charting table developed specifically for the review objective. Narrative descriptions of interventions were coded using the Behavior Change Wheel's intervention functions. Reported outcome measures were categorized. Findings are tabulated and synthesized narratively.

RESULTS

Forty-one studies were included from the database searches, representing a mixture of experimental (n = 2), quasi-experimental (n = 24), non-experimental (n = 12), qualitative (n = 1), and mixed methods (n = 2) approaches. An additional 29 citations were included from gray literature searches. One was a pilot mixed methods study, and the rest were interventions. In summary, this review included a total of 70 citations, describing 66 different interventions. Identified interventions comprised a wide range of Behaviour Change Wheel intervention functions to change clinicians' behavior: education (n = 48), training (n = 40), enablement (n = 36), persuasion (n = 21), environmental restructuring (n = 18), modeling (n = 7), and incentivisation (n = 2). Based on the Behaviour Change Wheel analysis, many interventions targeted more than one determinant of behavior change, often employing education and training to improve clinicians' knowledge and skills simultaneously. Among the 42 studies that reported outcome measures, effectiveness was measured at clinician (n = 38), patient (n = 4), and/or organization levels (n = 6). Few studies reported implementation outcomes, such as measures of reach (n = 4), adoption (n = 5), or fidelity (n = 1). There were no evaluation data reported on the interventions identified through Google searches.

CONCLUSIONS

Interventions included in this review were diverse and leveraged a range of mechanisms to change emergency department clinicians' behavior. However, most interventions relied solely on education and/or training to improve clinicians' knowledge and/or skills. Future research should consider diverse intervention functions to target both individual- and/or organization-level barriers for a given context. Secondly, the ultimate goal for changing emergency department clinicians' behavior is to improve patient health outcomes related to suicide-related thoughts and behaviors, but current research has most commonly evaluated clinicians' behavior in isolation of patient outcomes. Future studies should consider reporting patient-level outcomes alongside clinician-level outcomes.

Interventions to change clinicians' behavior in relation to suicide prevention care in the emergency department: a scoping review protocol

OBJECTIVE

This review aims to explore, characterize, and map the literature on interventions implemented to change emergency department clinicians' behavior related to suicide prevention using the Behavior Change Wheel as a guiding theoretical framework.

INTRODUCTION

An emergency department is a critical place for suicide prevention, yet many patients who present with suicide-related thoughts and behaviors are discharged without proper assessment or appropriate treatment. Supporting clinicians (who provide direct clinical care, including nurses, physicians, and allied health professionals) to make the desired behavior change following evidence-based suicide prevention care is an essential step toward improving patient outcomes. However, reviews to date have yet to take a theoretical approach to investigate interventions implemented to change clinicians' behavior.

INCLUSION CRITERIA

This review will consider literature that includes interventions that target emergency department clinicians' behavior related to suicide prevention. Behavior change refers to observable practice changes as well as proxy measures of behavior change, including knowledge and attitudes. There are many ways in which an intervention can change clinicians' behavior (eg, education, altering service delivery). This review will include a wide range of interventions that target behavior change regardless of the type, but will exclude interventions that exclusively target patients.

METHODS

Multiple databases will be searched: PubMed, PsycINFO, CINAHL, and Embase. We will also include gray literature, including Google search, ProQuest Dissertations and Theses Global, and Scopus conference papers. Full texts of included studies will be reviewed, critically appraised, and extracted. Extracted data will be coded to identify intervention functions using the Behavior Change Wheel. Findings will be summarized in tables accompanied by narrative reports.

Text Message Interventions in Adolescent Mental Health and Addiction Services: Scoping Review

BACKGROUND

The vast majority of adolescent mental health and substance use disorders go undiagnosed and undertreated. SMS text messaging is increasingly used as a method to deliver adolescent health services that promote psychological well-being and aim to protect adolescents from adverse experiences and risk factors critical for their current and future mental health. To date, there has been no comprehensive synthesis of the existing literature on the extent, range, and implementation contexts of these SMS text message interventions.

OBJECTIVE

The objective of this scoping review was to map and categorize gaps in the current body of peer-reviewed research around the use of SMS text messaging-based interventions for mental health and addiction services among adolescents.

METHODS

A scoping review was conducted according to Levac's adaptation of Arksey and O'Malley's methodological framework for scoping reviews in six iterative stages. A search strategy was cocreated and adapted for five unique databases. Studies were screened using Covidence software. The PICO (patient, intervention, comparator, outcome) framework and input from multiple stakeholder groups were used to structure and pilot a data extraction codebook. Data were extracted on study methodology and measures, intervention design, and implementation characteristics, as well as policy, practice, and research implications.

RESULTS

We screened 1142 abstracts. Of these, 31 articles published between 2013 and 2020 were eligible for inclusion. Intervention engagement was the most common type of outcome measured (18/31), followed by changes in cognitions (16/31; eg, disease knowledge, self-awareness) and acceptability (16/31). Interventions were typically delivered in less than 12 weeks, and adolescents received 1-3 messages per week. Bidirectional messaging was involved in 65% (20/31) of the studies. Limited descriptions of implementation features (eg, cost, policy implications, technology performance) were reported.

CONCLUSIONS

The use of SMS text messaging interventions is a rapidly expanding area of research. However, lack of large-scale controlled trials and theoretically driven intervention designs limits generalizability. Significant gaps in the literature were observed in relation to implementation considerations, cost, clinical workflow, bidirectionality of texting, and level of personalization and tailoring of the interventions. Given the growth of mobile phone-based interventions for this population, a rigorous program of large-scale, well-designed trials is urgently required.

Meal regularity is associated with self-esteem among grade 5 children

BACKGROUND

Meal regularity is associated with many aspects of mental health. However, few studies have examined whether a relationship exists between meal regularity and self-esteem in children.

OBJECTIVES

The objective of this study was to determine whether an association exists between meal regularity and self-esteem in grade 5 children.

METHODS

Among 4009 grade 5 students (mean age = 11.0 years ± SEM = 0.006) from the 2011 Children's Lifestyle and School Performance Study (CLASS-II; Nova Scotia, Canada), cross-sectional meal regularity survey data (family supper, supper in front of the television, supper alone, skipping breakfast, and skipping lunch) were collected using the Harvard Youth/Adolescent Food Frequency Questionnaire and examined in relation to self-esteem. Multilevel mixed-effects logistic regression was used to determine the ORs and 95% CIs associated with low self-esteem. Analyses were stratified by sex and adjusted for sociodemographic and lifestyle covariates.

RESULTS

Compared to children who ate supper in front of the television or alone either never or less than once/week, children had greater odds of low self-esteem if 5 or more times/week they ate supper in front of the television (OR = 1.85; 95% CI, 1.40-2.43) or alone (OR = 4.23; 95% CI, 2.58-6.95). Compared to children who ate family supper 5 or more times/week, children who ate family supper never or less than once/week had greater odds of low self-esteem (OR: 1.97; 95% CI, 1.51-2.56). Skipping breakfast and skipping lunch were associated with greater odds of low self-esteem [OR = 2.92 (95% CI, 1.87-4.57) and OR = 4.82 (95% CI, 2.14-10.87) respectively].

CONCLUSIONS

In our study of grade 5 children, all 5 indicators of meal regularity tested are significantly and consistently associated with self-esteem.

Opening the door: inviting youth and parent perspectives on youth mental health emergency department use

BACKGROUND

Canadian Emergency Departments (EDs) have seen increasing use by children and youth for mental health concerns in recent years. This trend is likely a result of several complex factors, and researcher-posed potential explanations include gaps or access problems in primary care or mental health services, increasing prevalence or awareness of mental disorders and fear of potentially harmful outcomes, or expectations of need for urgent specialist care. Youth, parent, or caregiver perceptions and reasons for increasing mental health ED use may differ, and to date have been underrepresented in informing research directions. We sought to engage with youth and parents or caregivers served by a Canadian tertiary paediatric health centre to: 1) inform research directions for an emerging program of research in child and youth ED use for mental health care; and 2) develop strategies to support ongoing patient engagement in our research.

METHODS

Youth and parents were consulted to inform the development of a research engagement strategy. Partnerships with local community agencies facilitated supported engagement with both youth and parents. Group and individual in-person engagement opportunities were offered, as well as opportunities for written submissions and information sharing.

RESULTS

Youth and parents identified specific mechanisms to support engagement and for sharing ongoing opportunities and progress, including providing multiple platforms for engagement, offering separate opportunities for youth and parents or caregivers, and minimizing the potential for distress by ensuring appropriate supports and providing alternative opportunities for feedback, including written submissions. They identified lack of timely access to mental health care in primary care and community mental health settings, and accessibility, dependability, and familiarity of the ED as areas for further research.

CONCLUSIONS

Strategies to mitigate potential concerns regarding distress, readiness for participation, literacy, and protection of privacy were highlighted as important considerations. Youth and parents were interested in ongoing research engagement through consultation and information sharing. Youth and parents identified areas of interest for research and refined the research team's proposed research directions by adding contextualizing information.

TRIAL REGISTRATION

Not applicable.

The Choice and Partnership Approach to community mental health and addictions services: a realist-informed scoping review protocol

INTRODUCTION

Early identification and appropriate treatment of child and adolescent mental health disorders can often be hampered by patchwork services with poorly planned or unclear pathways. The Choice and Partnership Approach (CAPA) is an evidence-based transformational model of community (community-based or outpatient) mental health and addictions services for children and adolescents that aims to better match services to needs and to improve timely access to care. CAPA has been variably implemented across jurisdictions but has not been comprehensively evaluated for its impact on system and client outcomes. Our research question is, 'To what degree does CAPA work, for whom and under what circumstances?'. The purpose of this review is twofold: (1) to gain an understanding of the extent and outcomes of the implementation of CAPA in community mental health and addictions services; and (2) to identify the role of context as it influences the implementation of CAPA and resulting client and system outcomes.

METHODS AND ANALYSIS

We will conduct a realist-informed scoping review of the literature related to CAPA in either child and adolescent or adult community mental health and addictions services. Relevant studies, reports and documentation will be identified by searching the following online databases: MEDLINE, Embase, CINAHL, PsycINFO, Academic Search Premier, ERIC, Web of Science, Cochrane, Dissertations Abstracts, NCBI Bookshelf, PubMed Central and the Canadian Health Research Collection. The search strategy was developed by a health sciences library scientist and informed by a multidisciplinary team comprising methodological and content knowledge experts. The search will gather evidence from multiple online databases of peer-reviewed literature and grey literature repositories. All articles will be independently assessed for inclusion by pairs of reviewers. The key themes derived from a thematic analysis of extracted data will be presented in a narrative overview.

ETHICS AND DISSEMINATION

Research ethics review is not required for this scoping review. The results will be disseminated through meetings with stakeholders (including clients and families, clinicians and decision-makers), conference presentations and peer-reviewed publication. The results of this review will inform an overarching programme of research, policy and quality indicator development to ultimately improve mental health and addictions care and subsequent mental health outcomes for children and adolescents.

Maternal pre-pregnancy weight status and health care use for mental health conditions in the offspring

The objective of this study was to examine the relationship between pre-pregnancy maternal weight status and offspring physician visits for mental health conditions in childhood and adolescence. We conducted a population-based retrospective cohort study of singleton infants born between the years of 1989 and 1993 using a linkage of the Nova Scotia Atlee Perinatal Database with administrative health data. Offspring were followed from birth to age 18 years. Maternal weight status was categorized according to WHO body mass index cutoffs. The number of physician visits for any mental health condition, mood, anxiety, and adjustment disorders, conduct disorder, and attention-deficit hyperactivity disorder (ADHD) from age 0-18 years was determined from ICD codes in physician billings and hospital discharge abstract data. Negative binomial regression adjusting for sociodemographics, maternal psychiatric disorders and smoking was used to model the association. In total, 38,211 mother-offspring pairs were included in the cohort. Within the first 18 years of life, offspring of mothers with obesity had significantly more physician visits for any mental health condition [adjusted incidence rate ratio (IRR) 1.26, 95% CI 1.19-1.34], mood, anxiety, and adjustment disorders (IRR 1.16, 95% CI 1.07-1.25), conduct disorder (IRR 1.25, 95% CI 1.08-1.45), and ADHD (IRR 1.45, 95% CI 1.24-1.69) compared to mothers of normal weight. Associations for mood, anxiety, and adjustment disorders and conduct disorder were strongest at 13-18 years. Offspring of mothers with obesity appear to use health care for mental health conditions more frequently than offspring of normal weight mothers.

Functionalized silver nanoparticles depress aerobic metabolism in the absence of overt toxicity in brackish water killifish, Fundulus heteroclitus

Engineered nanomaterials (ENMs) tend to precipitate in saline waters so the majority of aquatic toxicity studies have focused on freshwaters, where bioavailability is presumed to be higher. Recent studies have illustrated that some ENM formulations are bioavailable and bioactive in salt water and that their effects are more pronounced at the physiological than biochemical level. These findings raise concerns regarding the effects of ENMs on marine organisms. Therefore, our goal was to characterize the effects of polyvinylpyrolidone-functionalized silver ENMs (nAg) on aerobic performance in the killifish (Fundulus heteroclitus), a common euryhaline teleost. Fish were exposed to 80 μg L^-1 of 5 nm nAg for 48 h in brackish water (12 ppt) and routine (ṀO_2min) and maximum (ṀO_2max) rates of oxygen consumption were quantified. Silver dissolution was minimal and nAg remained well dispersed in brackish water, with a hydrodynamic diameter of 21.0 nm, compared to 19.3 in freshwater. Both ṀO_2min and ṀO_2max were significantly lower (by 53 and 30%, respectively) in killifish exposed to nAg and a reduction in ṀO₂ variability suggested spontaneous activity was suppressed. Neither gill Na⁺/K⁺-ATPase activity, nor various other biochemical markers were affected by nAg exposure. The results illustrate that a common ENM formulation is bioactive in salt water and, as in previous studies on functionalized copper ENMs, that effects are more pronounced at the whole animal than the biochemical level.

Routine measurement of mental health service outcomes: Health of the Nation Outcome Scales in Nova Scotia

Aims and Method

Although the Health of the Nation Outcome Scales (HoNOS) were designed for routine clinical use, completion rates in clinical settings rarely exceed 60%. We evaluated two initiatives to increase completion rates: timely feedback to clinicians, useful at individual, team and service levels, and improved supporting materials (tabulated glossaries for all versions covering the life-span).

Results

Clinicians in South Shore Health district provided ratings on all outpatient referrals over 12 months as part of routine care. Data were captured using the Nova Scotia routine administrative data system. Completion rates rose from 61% to 86% (n=1190). Clinicians' ratings of the instrument's ease of use were significantly improved.

Clinical Implications

Use of a tabulated glossary and enhanced feedback of clinically useful information improved clinician support for the routine measurement of health outcomes with HoNOS.

The next vaccine-autism question: Are school-aged youth with autism spectrum disorder undervaccinated and, if so, why?

Over the past two decades, the words 'autism' and 'vaccination' have often been linked and mired in controversy. In this commentary, we raise a different question about autism spectrum disorder (ASD) and vaccines: Are school-aged youth with ASD undervaccinated and, if so, why? There are several reasons why youth with ASD might be undervaccinated, including: belief in a vaccine-ASD link, challenges faced by youth with ASD when seeking health care and vaccine hesitancy factors that affect the general population. Possible undervaccination in this group is concerning given the prevalence of ASD and the key role of vaccinations in preventing infectious diseases. More research is needed to establish definitively whether youth with ASD are undervaccinated and to understand facilitators and barriers to vaccination for this population. This would help public health officials to develop and implement targeted policy and practice changes to increase vaccination uptake in youth with ASD, thereby increasing immunization equity.

Field Trial Performance of Herculex XTRA (Cry34Ab1/Cry35Ab1) and SmartStax (Cry34Ab1/Cry35Ab1 + Cry3Bb1) Hybrids and Soil Insecticides Against Western and Northern Corn Rootworms (Coleoptera: Chrysomelidae)

Western corn rootworm, Diabrotica virgifera virgifera LeConte (Coleoptera: Chrysomelidae), and northern corn rootworm, Diabrotica barberi Smith and Lawrence (Coleoptera: Chrysomelidae), are important insect pests in corn, Zea mays L. For more than a decade, growers have been using transgenic plants expressing proteins from the bacterium Bacillus thuringiensis (Bt) to protect corn roots from feeding. In 2011, western corn rootworm populations were reported to have developed resistance to Bt hybrids expressing Cry3Bb1 and later found to be cross-resistant to hybrids expressing mCry3A and eCry3.1Ab. The identification of resistance to Cry3 (Cry3Bb1, mCry3A, and eCry3.1Ab) hybrids led to concerns about durability and efficacy of products with single traits and of products containing a pyramid of a Cry3 protein and the binary Bt proteins Cry34Ab1 and Cry35Ab1. From 2012 to 2014, 43 field trials were conducted across the central United States to estimate root protection provided by plants expressing Cry34Ab1/Cry35Ab1 alone (Herculex RW) or pyramided with Cry3Bb1 (SmartStax). These technologies were evaluated with and without soil-applied insecticides to determine if additional management measures provided benefit where Cry3 performance was reduced. Trials were categorized for analysis based on rootworm damage levels on Cry3-expressing hybrids and rootworm feeding pressure within each trial. Across scenarios, Cry34Ab1/Cry35Ab1 hybrids provided excellent root protection. Pyramided traits provided greater root and yield protection than non-Bt plus a soil-applied insecticide, and only in trials where larval feeding pressure exceeded two nodes of damage did Cry34Ab1/Cry35Ab1 single-trait hybrids and pyramided hybrids show greater root protection from the addition of soil-applied insecticides.

Effects of Bt Corn and Egg Density on Western Corn Rootworm (Coleoptera: Chrysomelidae) Adult Emergence and Estimation of Effective Bt Dose

Since 2003, rootworm-protected transgenic corn has been commercially deployed in the United States as a principal method of control of western corn rootworm, Diabrotica virgifera virgifera LeConte. Durability of this technology depends partly on larval mortality ("dose") exerted by the traits, but density-dependent mortality can confound calculations of dose. Research reported here examined the effects of density-dependent mortality on adult emergence and estimates of trait dose. At sites in Illinois and Indiana, western corn rootworm eggs were infested at four densities on non-Bt corn and at a single density on corn hybrids with transgenic events MON 88017 (VT Triple PRO), DAS-59122-7 (Herculex Insect Protection), and MON 88017 × DAS-59122-7 (SmartStax corn). Beetles were collected weekly in large emergence cages. Density-dependent mortality and the effect of Bt traits were examined using percent survival from egg to adult, sex ratio, and beetle mass. Beetle emergence from Bt treatments was very low, and percent survival from non-Bt treatments was greatest at the lowest egg density (410 eggs per row-meter). Therefore, emergence from the lowest infestation density on non-Bt corn was used to estimate the effective dose of the Bt treatments. Sex ratio and beetle mass were unaffected by density-dependent effects and were not consistently affected by Bt traits. Dose was estimated at 97.4-99.3% for MON 88017, 98.8-99.9% for DAS-59122-7, and 99.7-100.0% for MON 88017 × DAS-59122-7. This study confirms the need to account for density-dependent mortality when estimating dose of corn rootworm protection events even at relatively low egg infestation densities.

Understanding the Effects of Competition for Constrained Colonoscopy Services with the Introduction of Population-level Colorectal Cancer Screening

BACKGROUND

Median wait times for gastroenterology services in Canada exceed consensus-recommended targets and have worsened substantially over the past decade. Meanwhile, efforts to control colorectal cancer have shifted their focus to screening asymptomatic, average-risk individuals. Along with increasing prevalence of colorectal cancer due to an aging population, screening programs are expected to add substantially to the existing burden on colonoscopy services, and create competition for limited services among individuals of varying risk. Failure to understand the effects of operational programmatic screening decisions may cause unintended harm to both screening participants and higher-risk patients, make inefficient use of limited health care resources, and ultimately hinder a program's success.

METHODS

We present a new simulation model (Simulation of Cancer Outcomes for Planning Exercises, or SCOPE) for colorectal cancer screening which, unlike many other colorectal cancer screening models, reflects the effects of competition for limited colonoscopy services between patient groups and can be used to guide planning to ensure adequate resource allocation. We include verification and validation results for the SCOPE model.

RESULTS

A discrete event simulation model was developed based on an epidemiological representation of colorectal cancer in a sample population. Colonoscopy service and screening modules were added to allow observation of screening scenarios and resource considerations. The model reproduces population-based data on prevalence of colorectal cancer by stage, and mortality by cause of death, age, and sex, and attendant demand and wait times for colonoscopy services.

CONCLUSIONS

The study model differs from existing screening models in that it explicitly considers the colonoscopy resource implications of screening activities and the impact of constrained resources on screening effectiveness.

Evaluation of an extended-release formulation of ceftiofur crystalline-free acid in koi (Cyprinus carpio)

The use of an extended release ceftiofur crystalline-free acid formulation (CCFA, Excede For Swine(®) , Pfizer Animal Health) in koi was evaluated after administration of single intramuscular (i.m.) or intracoelomic (i.c.) doses. Twenty koi were divided randomly into a control group and four treatment groups (20 mg/kg i.m., 60 mg/kg i.m., 30 mg/kg i.c., and 60 mg/kg i.c.). Serum ceftiofur-free acid equivalents (CFAE) concentrations were quantified. The pharmacokinetic data were analyzed using a nonlinear mixed-effects approach. Following a CCFA injection of 60 mg/kg i.m., time durations that serum CFAE concentrations were above the target concentration of 4 μg/mL ranged from 0.4 to 2.5 weeks in 3 of 4 fish, while serum CFAE concentrations remained below 4 μg/mL for lower doses evaluated. Substantial inter-individual variations and intra-individual fluctuations of CFAE concentrations were observed for all treatment groups. Histological findings following euthanasia included aseptic granulomatous reactions, but no systemic adverse effects were detected. Given the unpredictable time vs. CFAE concentration profiles for treated koi, the authors would not recommend this product for therapeutic use in koi at this time. Further research would be necessary to correlate serum and tissue concentrations and to better establish MIC data for Aeromonas spp. isolated from naturally infected koi.

The contribution of estuary-resident life histories to the return of adult Oncorhynchus kisutch

This study evaluated estuarine habitat use, life-history composition, growth and survival of four successive broods of coho salmon Oncoryhnchus kisutch in Salmon River, Oregon, U.S.A. Subyearling and yearling O. kisutch used restored and natural estuarine wetlands, particularly in the spring and winter. Stream-reared yearling smolts spent an average of 2 weeks in the estuary growing rapidly before entering the ocean. Emergent fry also entered the estuary in the spring, and some resided in a tidal marsh throughout the summer, even as salinities increased to >20. A significant portion of the summer stream-resident population of juvenile O. kisutch migrated out of the catchment in the autumn and winter and used estuary wetlands and adjacent streams as alternative winter-rearing habitats until the spring when they entered the ocean as yearling smolts. Passive integrated transponder (PIT) tag returns and juvenile life-history reconstructions from otoliths of returning adults revealed that four juvenile life-history types contributed to the adult population. Estuarine-associated life-history strategies accounted for 20-35% of the adults returning to spawn in the four brood years, indicating that a sizable proportion of the total O. kisutch production is ignored by conventional estimates based on stream habitat capacity. Juvenile O. kisutch responses to the reconnection of previously unavailable estuarine habitats have led to greater life-history diversity in the population and reflect greater phenotypic plasticity of the species in the U.S. Pacific Northwest than previously recognized.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To update the previously published systematic review.

SEARCH METHODS

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed-effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random-effects mean difference = -2.26 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects mean difference -0.81 95% CI -2.35, 0.74). There was no effect on severity (random-effects mean difference = -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

The effect of study design on the reporting of mortality due to colorectal cancer in adults with mental illness in Nova Scotia

OBJECTIVE

Some studies suggest a higher case fatality from colorectal cancer (CRC) in psychiatric patients even though the incidence is no greater than in the general population. However, this finding is not universal and may be confounded by study design (for example, inception, compared with historical, cohort), mean cohort age, or delays in presentation with more advanced staging at diagnosis. We assessed how study design and cancer stage at presentation affected outcomes in psychiatric patients.

METHODS

A retrospective historical cohort of CRC presentations was used comparing psychiatric patients with control subjects. Psychiatric status was defined by either health service use or psychotropic prescription, and outcomes by logistic or Cox proportional hazards regression.

RESULTS

There were 3501 new presentations of CRC from 2001 to 2005. Psychiatric cases, as defined by in- or outpatient contacts, made up 15.9% (n = 558) of patients with CRC. There was no association between psychiatric status and stage at presentation, surgical intervention, or mortality after adjusting for confounders. There was a reduced likelihood of resection, an indicator of curative treatment, when on a selective serotonin reuptake inhibitor or serotonin noradrenergic reuptake inhibitor (n = 194; AOR 0.54; 95% CI 0.30 to 0.97) or antipsychotics (n = 28; AOR 0.27; 95% CI 0.08 to 0.92).

CONCLUSIONS

The association between psychiatric status and CRC may vary by study design and how psychiatric status is defined. These factors should be considered when interpreting any association between mental illness and cancer. As in studies of all-cause and cardiac mortality, historical cohorts of prevalent psychiatric cases may be less sensitive than inception cohorts of new patients, possibly because the excess of deaths is greatest within 7 years of initial presentation for a psychiatric disorder.

Pathogens and atherosclerosis: update on the potential contribution of multiple infectious organisms to the pathogenesis of atherosclerosis

It is currently unclear what causes the chronic inflammation within atherosclerotic plaques. One emerging paradigm suggests that infection with bacteria and/or viruses can contribute to the pathogenesis of atherosclerosis either via direct infection of vascular cells or via the indirect effects of cytokines or acute phase proteins induced by infection at non-vascular sites. This paradigm has been supported by multiple epidemiological studies that have established positive associations between the risk of cardiovascular disease morbidity and mortality and markers of infection. It has also been supported by experimental studies showing an acceleration of the development of atherosclerosis following infection of hyperlipidaemic animal models. There are now a large number of different infectious agents that have been linked with an increased risk of cardiovascular disease. These include: Chlamydia pneumoniae, Porphyromonas gingivalis, Helicobacter pylori , influenza A virus, hepatitis C virus, cytomegalovirus, and human immunodeficiency virus. However, there are significant differences in the strength of the data supporting their association with cardiovascular disease pathogenesis. In some cases, the infectious agents are found within the plaques and viable organisms can be isolated suggesting a direct effect. In other cases, the association is entirely based on biomarkers. In the following review, we evaluate the strength of the data for individual or groups of pathogens with regard to atherosclerosis pathogenesis and their potential contribution by direct or indirect mechanisms and discuss whether the established associations are supportive of the infectious disease paradigm. We also discuss the failure of antibiotic trials and the question of persistent infection.

Can we use medical examiners’ records for suicide surveillance and prevention research in Nova Scotia?

Introduction

Medical examiners’ records can contribute to our understanding of the extent of suicide in a population, as well as associated sociodemographic and other factors.

Methods

Using a mixed methods approach, the key objective of this pilot study was to determine the sources and types of information found in the Nova Scotia Medical Examiner Service (NSMES) records that might inform suicide surveillance and targeted prevention efforts. A secondary objective was to describe the one-year cohort of 108 individuals who died by suicide in 2006 in terms of available sociodemographic information and health care use in the year prior to death.

Results

Data extraction revealed inconsistencies both across and within files in terms of the types and amounts of sociodemographic and other data collected, preventing correlational analyses. However, linkage of the records to administrative databases revealed frequent health care use in the month prior to death.

Conclusion

The introduction of systematic data collection to NSMES investigations may yield a comprehensive dataset useful for policy development and population level research.

Can we use medical examiners' records for suicide surveillance and prevention research in Nova Scotia?

INTRODUCTION

Medical examiners' records can contribute to our understanding of the extent of suicide in a population, as well as associated sociodemographic and other factors.

METHODS

Using a mixed methods approach, the key objective of this pilot study was to determine the sources and types of information found in the Nova Scotia Medical Examiner Service (NSMES) records that might inform suicide surveillance and targeted prevention efforts. A secondary objective was to describe the one-year cohort of 108 individuals who died by suicide in 2006 in terms of available sociodemographic information and health care use in the year prior to death.

RESULTS

Data extraction revealed inconsistencies both across and within files in terms of the types and amounts of sociodemographic and other data collected, preventing correlational analyses. However, linkage of the records to administrative databases revealed frequent health care use in the month prior to death.

CONCLUSION

The introduction of systematic data collection to NSMES investigations may yield a comprehensive dataset useful for policy development and population level research.

Factors associated with not seeking professional help or disclosing intent prior to suicide: a study of medical examiners' records in Nova Scotia

OBJECTIVE

Individual-level data from clinical settings lack information on people who did not seek professional help prior to suicide. We used records of the Nova Scotia Medical Examiner Service (NSMES) to compare people who had contact with a health professional prior to suicide with those who did not.

METHOD

We linked data from the NSMES to routine administrative data of the province.

RESULTS

The NSMES recorded 108 suicides in Nova Scotia from January 1, 2006, to December 31, 2006; there were 90 male and 18 female suicide deaths. Mean and median age at death were 44.73 (SD 13.33) and 44 years, respectively. Patients aged 40 to 49 years made up one-third of the cases (n = 35) and this was the decade of life with the highest number of suicides. This was also the group least likely to have suicidal intent recorded in the NSMES files (χ(2) = 3.86, df = 1, P = 0.05). Otherwise, there were no significant differences between people who sought help, or disclosed intent, prior to suicide and people who did not. The samples in all cases were predominately male and single.

CONCLUSIONS

People aged 40 to 49 years were the age group with the highest absolute number of suicides, but were the least likely to have suicidal intent recorded in the NSMES files. This finding merits further investigation. Medical examiner or coroner data may provide additional information not obtained elsewhere for the surveillance of suicide.

The development of community health indicators: a district-wide approach

INTRODUCTION

In response to high rates of chronic disease, the Capital District Health Authority in Nova Scotia recognized a need to move from a focus on acute care in decision making to one that also values a population health approach guided by community health indicators.

METHODS

Stakeholders were surveyed on the choice, knowledge and utility of selected indicators.

RESULTS

Respondents reported high scores for changes in their knowledge and attitude regarding community health indicators, and identified priority indicators for action.Decision makers' use of community health indicators was increased by stakeholder involvement, supporting evidence in plain language, and wide dissemination.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

BACKGROUND

There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation.

OBJECTIVES

To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness.

SEARCH STRATEGY

We undertook searches of the Cochrane Schizophrenia Group Register 2003, 2008, and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study.

SELECTION CRITERIA

All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness.

DATA COLLECTION AND ANALYSIS

We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H).

MAIN RESULTS

We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8). In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review.

AUTHORS' CONCLUSIONS

Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.

A controlled before-and-after evaluation of a mobile crisis partnership between mental health and police services in Nova Scotia

OBJECTIVES

Police are often the front-line response to people experiencing mental health crises. This study examined the impact of an integrated mobile crisis team formed in partnership between mental health services, municipal police, and emergency health services. The service offered short-term crisis management, with mobile interventions being attended by a plainclothes police officer and a mental health professional.

METHODS

We used a mixed-methods design encompassing: a controlled before-and-after quantitative comparison of the intervention area with a control area without access to such a service, for 1 year before and 2 years after program implementation; and qualitative assessments of the views of service recipients, families, police officers, and health staff at baseline and 2 years afterward.

RESULTS

The integrated service resulted in increased use by people in crisis, families, and service partners (for example, from 464 to 1666 service recipients per year). Despite increased service use, time spent on-scene and call-to-door time were reduced. At year 2, the time spent on-scene by police (136 minutes) was significantly lower than in the control area (165 minutes) (Student t test = 3.4, df = 1649, P < 0.001). After adjusting for confounders, people seen by the integrated team (n = 295) showed greater engagement than control subjects as measured by outpatient contacts (b = 1.3, chi square = 92.7, df = 1, P < 0.001). The service data findings were supported by the qualitative results of focus groups and interviews.

CONCLUSIONS

Partnerships between the police department and mental health system can improve collaboration, efficiency, and the treatment of people with mental illness.

Do the Health of the Nation Outcome Scales measure outcome?

OBJECTIVE

Among mental health outcome measures that have been developed for routine use, most of the information concerns the Health of the Nation Outcome Scales (HoNOS). This instrument is widely used in Europe, Australia, and New Zealand, but not in Canada. We tested its sensitivity and predictive validity under conditions that would resemble, as closely as possible, routine use.

METHOD

Treating clinicians were asked to assess patients of all ages referred to outpatient mental health facilities of 2 district health authorities in Nova Scotia using either the HoNOS for adults or the HoNOS for Children and Adolescents (HoNOSCA). Data were entered using the existing routine administrative data system.

RESULTS

We obtained at least 1 rating on 4620 patients, giving a completion rate of 82%. On follow-up, ratings for the global score and most of the individual items were sensitive to change (n = 808). After adjusting for confounders, a baseline HoNOS score was significantly associated with subsequent in and outpatient service use including admissions, bed days, and psychiatric contacts (n = 1359).

CONCLUSIONS

HoNOS has satisfactory sensitivity and predictive validity for routine use. We could introduce the adult version and HoNOSCA simultaneously and collect data using routine databases. Given the widespread routine use of HoNOS internationally, using the same outcome measure in Canada would enable comparisons of illness severity and outcomes between jurisdictions.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2008, Issue 4), MEDLINE (1966 to December 2008), CINAHL (1982 to December 2008) EMBASE (1980 to December 2008), PsycINFO (1887 to December 2008), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to December 2008). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Ten RCTs (484 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (mean difference = -1.73 (95% CI -2.21 to -1.26)) and severity (mean difference = -6.86 (95% CI -10.74 to -2.97)). However, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Treatment of ischaemic heart disease and stroke in individuals with psychosis under universal healthcare

BACKGROUND

Most data on the quality of vascular care for individuals with psychiatric conditions come from countries without universal healthcare.

AIMS

To investigate the treatment of people with psychosis admitted for ischaemic heart disease or stroke under universal healthcare.

METHOD

A population-based study of administrative data comparing Canadians with and without a history of schizophrenia or related psychosis (n = 65,039).

RESULTS

Of 49 248 admissions for ischaemic heart disease, 1285 had a history of psychosis. Despite a higher 1-year mortality, they were less likely to receive guideline-consistent treatment: e.g. coronary artery bypass grafting (adjusted odds ratio (OR) = 0.35, 95% CI 0.25-0.48), beta-blockers (adjusted OR = 0.82, 95% CI 0.71-0.95) and statins (adjusted OR = 0.51, 95% CI 0.41-0.63). Of 15 791 admissions for stroke, 594 had a history of psychosis. Despite higher 1-year mortality rates, they were less likely to receive cerebrovascular arteriography or warfarin.

CONCLUSIONS

People with a history of psychosis do not receive equitable levels of vascular care under universal healthcare.

Use of administrative data for the surveillance of mental disorders in 5 provinces

OBJECTIVE

To evaluate the usefulness of administrative data for the surveillance of mental illness in Canada using databases in the following 5 provinces: British Columbia, Ontario, Quebec, Nova Scotia, and Alberta.

METHOD

We used a population-based record-linkage analysis with data from physician billings, hospital discharge abstracts, and community-based clinics. The following diagnostic codes from the International Classification of Diseases, Ninth Edition, were used to define cases: 290 to 319, inclusive.

RESULTS

The prevalence of treated psychiatric disorder was similar in Nova Scotia, British Columbia, Alberta, and Ontario at about 15%. The prevalence for Quebec was slightly lower at 12%. Findings from the provinces showed remarkable consistency across age and sex, despite variations in data coding. Women tended to show a higher prevalence overall of treated mental disorders than men. Prevalence increased steadily to middle age, declining in the 50s and 60s, and then increasing again after age 70 years.

CONCLUSIONS

Provincial and territorial administrative data can provide a useful, reliable, and economical source of information for the surveillance of treated mental disorders. Such a surveillance system can provide longitudinal data at little cost to support health service provision and planning.

An epidemiologic study of psychotropic medication and obesity-related chronic illnesses in older psychiatric patients

OBJECTIVE

Adverse effects from medication vary with age. Weight gain with several psychotropics is well known in adults but less information is available related to extent and complications of psychotropic-induced weight gain in older psychiatric patients. We determined the relative incidence of 2 obesity-related conditions (diabetes and hypertension) in older psychiatric patients receiving antipsychotics, antidepressants, and mood stabilizers.

METHOD

A population-based case-control study of all psychiatric patients aged 67 years or older in contact with either specialist services or primary care using administrative data from Nova Scotia.

RESULTS

We identified incident cases of diabetes (n = 608) and of hypertension (n = 1056), as well as an equal number of control subjects for each condition. Amitryptiline, selective serotonin reuptake inhibitors (SSRIs), and olanzapine were associated with an increased risk of presenting with hypertension 6 months after initial prescription. By contrast, conventional antipsychotics were associated with a reduced incidence of hypertension. Olanzapine was also significantly associated with diabetes after 6 months (OR adj = 2.58, 95% CI 1.12 to 5.92). The findings for SSRIs and olanzapine remained significant after adjusting for potential confounders such as sociodemographic characteristics, schizophrenia, beta blockers, thiazide diuretics, and corticosteroids.

CONCLUSIONS

Our results suggest that the association of psychotropics and 2 obesity-related conditions, hypertension and diabetes, applies to older psychiatric patients as well as younger populations. Within drug classes, there are drugs that have a greater association than others, and this may be a factor when choosing a specific agent.

Advance treatment directives for people with severe mental illness

BACKGROUND

An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been used in end-of-life settings to direct care but should be well suited to the mental health setting.

OBJECTIVES

To examine the effects of advance treatment directives for people with severe mental illness.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (February 2008), the Cochrane Library (Issue 1 2008), BIOSIS (1985 to February 2008), CINAHL (1982 to February 2008), EMBASE (1980 to February 2008), MEDLINE (1966 to February 2008), PsycINFO (1872 to February 2008), as well as SCISEARCH and Google - Internet search engine (February 2008). We inspected relevant references and contacted first authors of included studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs), involving adults with severe mental illness, comparing any form of advance directive with standard care for health service and clinical outcomes.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For homogenous dichotomous data we calculated fixed-effect relative risk (RR) and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD) and their 95% confidence interval again using a fixed-effect model.

MAIN RESULTS

We were able to include two trials involving 321 people with severe mental illnesses. There was no significant difference in hospital admission (n=160, 1 RCT, RR 0.69 0.5 to 1.0), or number of psychiatric outpatient attendances between participants given advanced treatment directives or usual care. Similarly, no significant differences were found for compliance with treatment, self harm or number of arrests. Participants given advanced treatment directives needed less use of social workers time (n=160, 1 RCT, WMD -106.00 CI -156.2 to -55.8) than the usual care group, and violent acts were also lower in the advanced directives group (n=160, 1 RCT, RR 0.27 CI 0.1 to 0.9, NNT 8 CI 6 to 92). The number of people leaving the study early were not different between groups (n=321, 2 RCTs, RR 0.92 CI 0.6 to 1.6).

AUTHORS' CONCLUSIONS

There are too few data available to make definitive recommendations. More intensive forms of advance directive appear to show promise, but currently practice must be guided by evidence other than that derived from randomised trials. More trials are indicated to determine whether higher intensity interventions, such as joint crisis planning, have an effect on outcomes of clinical relevance.

Excess cancer mortality in psychiatric patients

OBJECTIVES

There are conflicting data on cancer incidence and mortality in psychiatric patients, although most studies suggest that while cancer mortality is higher, incidence is no different from that in the general population. Different methodologies and outcomes may account for some of the conflicting results. We investigated the association between mental illness and cancer incidence, first admission rates, and mortality in Nova Scotia using a standard methodology.

METHOD

A population-based record-linkage study of 247,344 patients in contact with primary care or specialist mental health services during 1995 to 2001 was used. Records were linked with cancer registrations and death records.

RESULTS

Cancer mortality was 72% higher in males (95%CI, 63% to 82%) and 59% higher in females (95%CI, 49% to 69%) among patients in contact with mental health services. This was reflected in similarly elevated first admission rates. However, there was weaker and less consistent evidence for increased incidence. For several cancer sites, incidence rate ratios were lower than might be expected given the mortality and first admission rate ratios, and no higher than that of the general population. These were melanoma, prostate, bladder, and colorectal cancers in males.

CONCLUSION

People with mental illness in Nova Scotia have increased mortality from cancer, which cannot always be explained by increased incidence. Possible explanations for further study include delays in detection or initial presentation leading to more advanced staging at diagnosis, and difficulties in communication or access to health care.

Use of smoking cessation therapies in individuals with psychiatric illness : an update for prescribers

Individuals with mental illness are particularly disadvantaged by their use of tobacco, spending as much as 40% of their income on cigarettes. They also have increased mortality from cardiovascular and respiratory disorders. The most effective interventions to help psychiatric patients stop smoking are similar to those that are effective in the general population. These include psychological treatments, nicotine replacement therapy (NRT), bupropion and nortriptyline, at least in the short term. Most studies agree that these gains can be achieved in the absence of significant adverse effects in terms of psychological morbidity. Effects diminish over time, but these findings also apply to the general population. The best long-term results have come from extended prescription and psychological interventions, and apply equally to patients with and without a history of psychiatric disorder, such as major depression. In spite of this, clinicians are not fully exploiting opportunities to help psychiatric patients stop smoking. It is not possible to plan a programme to help individuals stop smoking in mental health settings unless factors such as demographics, diagnosis and concurrent medication are taken into account.

Taking consultation-liaison psychiatry into primary care

Up to 50% of patients seen in primary care have mental health problems, the severity and duration of their problems often being similar to those of individuals seen in the specialized sector. This article describes the reasons, advantages, and challenges of collaborative or shared care between primary and mental health teams, which are similar to those of consultation-liaison psychiatry. In both settings, clinicians deal with the complex interrelationships between medical and psychiatric disorders. Although initial models emphasized collaboration between family physicians, psychiatrists, and nurses, collaborative care has expanded to involve patients, psychologists, social workers, occupational therapists, pharmacists, and other providers. Several factors are associated with favorable patient outcomes. These include delivery of interventions in primary care settings by providers who have met face-to-face and/or have pre-existing clinical relationships. In the case of depression, good outcomes are particularly associated with approaches that combined collaborative care with treatment guidelines and systematic follow-up, especially for those with more severe illness. Family physicians with access to collaborative care also report greater knowledge, skills, and comfort in managing psychiatric disorders, even after controlling for possible confounders such as demographics and interest in psychiatry. Perceived medico-legal barriers to collaborative care can be addressed by adequate personal professional liability protection on the part of each practitioner, and ensuring that other health care professionals with whom they work collaboratively are similarly covered.

Does compulsory or supervised community treatment reduce 'revolving door' care? Legislation is inconsistent with recent evidence

Supervised community treatment to address 'revolving door' care is part of the new Mental Health Act in England and Wales. Two recent epidemiological studies in Australia (n>118 000), as well as a systematic review of all previous literature using appropriately matched or randomised controls (n=1108), suggest that it is unlikely to help.

Are the Health of the Nation Outcome Scales a valid and practical instrument to measure outcomes in North America? A three-site evaluation across Nova Scotia

We tested the usability, sensitivity and validity of the Health of the Nation Outcome Scales (HoNOS) in routine clinical practice in North America. Three pilot sites provided ratings on all inpatient and outpatient referrals over 4 months using versions covering children and adolescents (HoNOSCA), working-age adults and the over-65s. Data were entered using the routine administrative data system. Sixty-one percent of eligible patients had at least one HoNOS rating (n = 485). Following the initial rating, subsequent completion rates reached 80%. Ratings were sensitive to time and setting, with significantly higher scores in inpatients than outpatients. Individual diagnoses had different patterns of scores, further supporting validity.

Inequitable access for mentally ill patients to some medically necessary procedures

BACKGROUND

Although universal health care aims for equity in service delivery, socioeconomic status still affects death rates from ischemic heart disease and stroke as well as access to revascularization procedures. We investigated whether psychiatric status is associated with a similar pattern of increased mortality but reduced access to procedures. We measured the associations between mental illness, death, hospital admissions and specialized or revascularization procedures for circulatory disease (including ischemic heart disease and stroke) for all patients in contact with psychiatric services and primary care across Nova Scotia.

METHODS

We carried out a population-based record-linkage analysis of related data from 1995 through 2001 using an inception cohort to calculate rate ratios compared with the general public for each outcome (n = 215,889). Data came from Nova Scotia's Mental Health Outpatient Information System, physician billings, hospital discharge abstracts and vital statistics. We estimated patients' income levels from the median incomes of their residential neighbourhoods, as determined in Canada's 1996 census.

RESULTS

The rate ratio for death of psychiatric patients was significantly increased (1.34), even after adjusting for potential confounders, including income and comorbidity (95% confidence interval [CI] 1.29-1.40), which was reflected in the adjusted rate ratio for first admissions (1.70, 95% CI 1.67-1.72). Their chances of receiving a procedure, however, did not match this increased risk. In some cases, psychiatric patients were significantly less likely to undergo specialized or revascularization procedures, especially those who had ever been psychiatric inpatients. In the latter case, adjusted rate ratios for cardiac catheterization, percutaneous transluminal coronary angioplasty and coronary artery bypass grafts were 0.41, 0.22 and 0.34, respectively, in spite of psychiatric inpatients' increased risk of death.

CONCLUSIONS

Psychiatric status affects survival with and access to some procedures for circulatory disease, even in a universal health care system that is free at the point of delivery. Understanding how these disparities come about and how to reduce them should be a priority for future research.

Randomized and non-randomized evidence for the effect of compulsory community and involuntary out-patient treatment on health service use: systematic review and meta-analysis

BACKGROUND

There is limited randomized controlled trial (RCT) evidence for compulsory community treatment. Other study methods may clarify their effectiveness. We reviewed RCT and non-RCT evidence for the effect of compulsory community treatment on hospital admissions, bed-days, compliance and out-patient contacts.

METHOD

A systematic review of RCTs, controlled before-and-after (CBA) studies, and interrupted time series (ITS) analyses. Meta-analysis of RCTs.

RESULTS

Eight papers covering five studies (two RCTs and three CBAs) met inclusion criteria (total n=1108). There was no statistical difference in 12-month admission rates between subjects on involuntary out-patient treatment and controls. Survival analyses of time to admission were equivocal. All five studies reported decreases in the number of bed-days following involuntary out-patient treatment but this only reached statistical significance in one situation; patients receiving the intervention were less likely to have admissions of over 100 days. There was no difference in treatment adherence between the intervention and control groups in either RCT or two of the CBA studies. However, the third CBA study reported a statistically significant increase of nearly five visits in the mean number of overall contacts in the involuntary out-patient treatment group.

CONCLUSIONS

The evidence for involuntary out-patient treatment in reducing either admissions or bed-days is very limited. It therefore cannot be seen as a less restrictive alternative to admission. Other effects are uncertain. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.

Can epidemiological studies assist in the evaluation of community treatment orders? - The experience of Western Australia and Nova Scotia

Epidemiological studies using administrative databases have several advantages over other methodologies in studying the effectiveness of compulsory community treatment such as community treatment orders (CTOs). We compared patients placed on CTOs in Western Australia with controls drawn from both within the jurisdiction and from another without this measure (Nova Scotia). Although in different countries, the mental health services in both jurisdictions share common characteristics. Notably, we were able to control for forensic history in our comparison within Western Australia. We analysed predictors of admission and number of bed-days using multiple, logistic or Cox regression as appropriate. Of the 274 subjects placed on a CTO, we were able to find controls for up to 96% (n=265). CTO placement was not associated with reduced admissions or mean bed-days, although there was a threshold effect with a reduced risk of inpatient stays exceeding 100 days. Outpatient contacts were significantly greater for the CTO group. However, we do not know whether the intensity of treatment, or its compulsory nature, effected outcome.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

BACKGROUND

There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation.

OBJECTIVES

To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness.

SEARCH STRATEGY

We undertook searches of the Cochrane Schizophrenia Group Register to 2003 and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study.

SELECTION CRITERIA

All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness.

DATA COLLECTION AND ANALYSIS

We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H).

MAIN RESULTS

We identified two randomised clinical trials (total n=416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence to indicate that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n=416, RR readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2), social functioning (2 RCTs, n=416, RR outcome 'arrested at least once by 11-12 months' 0.97 CI 0.62 to 1.52), mental state, quality of life (2 RCTs, n=416, RR homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n=416, RR perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n=264, RR 0.5 CI 0.31 to 0.8, NNT 6 CI 6 to 6.5). In terms of numbers needed to treat, it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest.

AUTHORS' CONCLUSIONS

Based on current evidence, community treatment orders may not be an effective alternative to standard care. It appears that compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. There is currently no evidence of cost effectiveness. People receiving compulsory community treatment were, however, less likely to be victim of violent or non-violent crime. It is, nevertheless, difficult to conceive of another group in society that would be subject to measures that curtail the freedom of 85 people to avoid one admission to hospital or of 238 to avoid one arrest. We urgently require further, good quality randomised controlled studies to consolidate findings and establish whether it is the intensity of treatment in compulsory community treatment or its compulsory nature that affects outcome. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.

A 6 week course of azithromycin treatment has no beneficial effect on atherosclerotic lesion development in apolipoprotein E-deficient mice chronically infected with Chlamydia pneumoniae

OBJECTIVES

To evaluate whether antimicrobial chemotherapy prevents acceleration of atherosclerotic lesion development induced by infection with Chlamydia pneumoniae.

METHODS

ApoE-deficient mice which develop hyperlipidaemia and atherosclerosis spontaneously were inoculated intranasally with C. pneumoniae. Animals were treated with azithromycin for 6 weeks after the third inoculation and the atherosclerotic lesion areas in the aortic sinus were measured by computer-assisted morphometry.

RESULTS

At 12 weeks post-infection, infected untreated animals developed significantly larger lesion areas compared with sham-inoculated controls (8.7 x 10(4)+/-2.3 x 10(4) microm(2) versus 5.6 x 10(4)+/-2.4 x 10(4) microm(2)). However, there were no differences in lesion size of infected mice treated with azithromycin in comparison with untreated infected controls (11.0 x 10(4)+/-3.0 x 10(4) microm(2) versus 8.7 x 10(4)+/-2.3 x 10(4) microm(2)).

CONCLUSIONS

Antibiotic treatment against C. pneumoniae has no beneficial effects on hyperlipidaemia-induced atherosclerosis accelerated by C. pneumoniae in a mouse model.