Associations Between Canada's Cannabis Legalization and Emergency Department Presentations for Transient Cannabis-Induced Psychosis and Schizophrenia Conditions: Ontario and Alberta, 2015–2019

Objective Cannabis legalization in many jurisdictions worldwide has raised concerns that such legislation might increase the burden of transient and persistent psychotic illnesses in society. Our study aimed to address this issue. Methods Drawing upon emergency department (ED) presentations aggregated across Alberta and Ontario, Canada records (April 1, 2015–December 31, 2019), we employed Seasonal Autoregressive Integrated Moving Average (SARIMA) models to assess associations between Canada's cannabis legalization (via the Cannabis Act implemented on October 17, 2018) and weekly ED presentation counts of the following ICD-10-CA-defined target series of cannabis-induced psychosis (F12.5; n = 5832) and schizophrenia and related conditions (“schizophrenia”; F20-F29; n = 211,661), as well as two comparison series of amphetamine-induced psychosis (F15.5; n = 10,829) and alcohol-induced psychosis (F10.5; n = 1,884). Results ED presentations for cannabis-induced psychosis doubled between April 2015 and December 2019. However, across all four SARIMA models, there was no evidence of significant step-function effects associated with cannabis legalization on post-legalization weekly ED counts of: (1) cannabis-induced psychosis [0.34 (95% CI −4.1; 4.8; P = 0.88)]; (2) schizophrenia [24.34 (95% CI −18.3; 67.0; P = 0.26)]; (3) alcohol-induced psychosis [0.61 (95% CI −0.6; 1.8; P = 0.31); or (4) amphetamine-induced psychosis [1.93 (95% CI −2.8; 6.7; P = 0.43)]. Conclusion Implementation of Canada's cannabis legalization framework was not associated with evidence of significant changes in cannabis-induced psychosis or schizophrenia ED presentations. Given the potentially idiosyncratic rollout of Canada's cannabis legalization, further research will be required to establish whether study results generalize to other settings.

The Impact of Policy Changes, Dedicated Funding and Implementation Support on Early Intervention Programs for Psychosis

Introduction Early intervention services for psychosis (EIS) are associated with improved clinical and economic outcomes. In Quebec, clinicians led the development of EIS from the late 1980s until 2017 when the provincial government announced EIS-specific funding, implementation support and provincial standards. This provides an interesting context to understand the impacts of policy commitments on EIS. Our primary objective was to describe the implementation of EIS three years after this increased political involvement. Methods This cross-sectional descriptive study was conducted in 2020 through a 161-question online survey, modeled after our team's earlier surveys, on the following themes: program characteristics, accessibility, program operations, clinical services, training/supervision, and quality assurance. Descriptive statistics were performed. When relevant, we compared data on programs founded before and after 2017. Results Twenty-eight of 33 existing EIS completed the survey. Between 2016 and 2020, the proportion of Quebec's population having access to EIS rose from 46% to 88%; >1,300 yearly admissions were reported by surveyed EIS, surpassing governments’ epidemiological estimates. Most programs set accessibility targets; adopted inclusive intake criteria and an open referral policy; engaged in education of referral sources. A wide range of biopsychosocial interventions and assertive outreach were offered by interdisciplinary teams. Administrative/organisational components were less widely implemented, such as clinical/administrative data collection, respecting recommended patient-to-case manager ratios and quality assurance. Conclusion Increased governmental implementation support including dedicated funding led to widespread implementation of good-quality, accessible EIS. Though some differences were found between programs founded before and after 2017, there was no overall discernible impact of year of implementation. Persisting challenges to collecting data may impede monitoring, data-informed decision-making, and quality improvement. Maintaining fidelity and meeting provincial standards may prove challenging as programs mature and adapt to their catchment area's specificities and as caseloads increase. Governmental incidence estimates may need recalculation considering recent epidemiological data.

“One Degree of Separation”: A Mixed-Methods Evaluation of Canadian Mental Health Care User and Provider Experiences With Remote Care During COVID-19

Objectives The COVID-19 pandemic has contributed to a shift from in-person to remote mental health care. While remote care methods have long existed, their widespread use is unprecedented. There is little research about mental health care user and provider experiences with this transition, and no published studies to date have compared satisfaction between these groups. Methods Canadian mental health care users ( n = 332) and providers ( n = 107) completed an online self-report survey from October 2020 to February 2021 hosted by the Canadian Biomarker Integration Network in Depression. Using a mixed-methods approach, participants were asked about their use of remote care, including satisfaction, barriers to use, helpful and unhelpful factors, and suggestions for improvement. Results Overall, 59% to 63% of health care users and 59% of health care providers were satisfied with remote care. Users reported the greatest satisfaction with the convenience of remote care, while providers were most satisfied with the speed of provision of care; all groups were least satisfied with therapeutic rapport. Health care providers were less satisfied with the user-friendliness of remote care ( P < 0.001) than users, while health care users were less satisfied than providers with continuity of care ( P < 0.001). The use of a video-based platform was associated with remote care satisfaction among health care users ( P < 0.02), and qualitative responses support the importance of visual cues in maintaining therapeutic rapport remotely. The majority of users (55%) and providers (87%) reported a likelihood of using remote care after the pandemic. Conclusions Remote mental health care is generally accepted by both users and providers, and the majority would consider using remote care following the pandemic. Suggestions for improvement include greater use of video, increased attention to body language and eye contact, consistency with in-person care, as well as increased provider training and administrative support.

Naturalistic Study on the Effects of Electroconvulsive Therapy (ECT) on Depressive Symptoms

Objective The effectiveness of ECT under naturalistic conditions has not been well-studied. The current study aimed to 1) characterize a naturalistic sample of ECT patients; and 2) examine the long-term outcomes of ECT on depressive symptoms (Beck Depression Inventory-II; BDI-II) and functional disability symptoms (WHO Disability Assessment Schedule 2.0) in this sample. Methods Participants were adults who received ECT for a major depressive episode at an ambulatory ECT clinic between September 2010 and November 2020. Clinical and cognitive assessments were completed at baseline ( n = 100), mid-ECT ( n = 94), 2–4 weeks post-ECT ( n = 64), 6-months post-ECT ( n = 34), and 12-months post-ECT ( n = 19). Results At baseline, participants had severe levels of depressive symptoms (BDI-II: M = 41.0, SD = 9.4), and 62.9% screened positive for multiple psychiatric diagnoses on the MINI International Neuropsychiatric Interview. Depressive symptoms ( F(4,49.1) = 49.92, P < 0.001) and disability symptoms ( F(3,40.72) = 12.30, P < 0.001) improved significantly following ECT, and this was maintained at 12-months follow-up. Improvement in depressive symptoms trended towards significantly predicting reduction in disability symptoms from baseline to post-ECT, ( F(1,56) = 3.67, P = 0.061). Although our clinical remission rate of 27% (BDI-II score [Formula: see text] 13 and [Formula: see text] 50% improvement) and overall response rate of 41.3% ([Formula: see text]50% improvement in BDI-II score) were lower than the rates reported in the extant RCT and community ECT literature, 36% of those treated with ECT were lost to follow-up and did not complete post-ECT rating scales. At baseline, remitters had significantly fewer psychiatric comorbidities, lower BDI-II scores, and lower disability symptoms than non-responders ( P < 0.05). Conclusions Participants were severely symptomatic and clinically complex. ECT was effective at reducing depressive symptoms and functional disability in this heterogeneous sample. Although a large amount of missing data may have distorted our calculated response/remission rates, it is also likely that clinical heterogeneity and severity contribute to lower-than-expected remission and response rates to ECT.

Facteurs D’adversité Chez des Adolescents Issus de Milieu Aisé Hospitalisés en Psychiatrie

Malgré l’enjeu majeur de santé publique qu’elles représentent, les maltraitances infantiles, et particulièrement les négligences, restent sous-estimées en psychiatrie, tant dans leur prévalence que leur impact sur la santé. De plus, le phénomène de maltraitance reste habituellement associé à un fort déterminisme socio-culturel et est très peu évalué dans les catégories sociales aisées. Cette étude mesure la prévalence et l’impact sur l’état médical des facteurs d’adversité précoce - maltraitances (abus et négligences) et événements de vie (divorce, séparations précoces, antécédents familiaux de maladie psychiatrique) - dans une population d’adolescents hospitalisés en psychiatrie et issus de milieux aisés, afin d’en évaluer l’ampleur et l’impact. Les résultats montrent l’ampleur et le cumul des facteurs d’adversité, incluant des fréquences élevées de maltraitances (64.8%), d’événements de vie difficile (dont 29.7% de séparations précoces et 36.4% de troubles psychiatriques familiaux). Ils soutiennent ainsi l’idée d’une sous-estimation importante de ces phénomènes en population générale et en psychiatrie, et ce, notamment dans les catégories sociales aisées. Les maltraitances sont associées à la gravité médicale (niveau de fonctionnement global, nombre et durée d’hospitalisation). Les abus sont particulièrement corrélés au nombre d’hospitalisations, alors que les négligences semblent également impacter leur durée et le niveau de gravité médicale de l’adolescent. Cette étude invite à une évaluation systématique des phénomènes d’adversité en pédopsychiatrie, quel que soit le contexte environnemental du patient, et à renforcer les prises en charge familiales ainsi que la prévention des abus et négligences.

Youth Perspectives on Integrated Youth Services: A Discrete Choice Conjoint Experiment

Objective Integrated youth services (IYS) are an emerging model of care offering a broad range of mental health and social services for youth in one location. This study aimed to determine the IYS service characteristics most important to youth, as well as to determine whether different classes of youth have different service preferences, and if so, what defines these classes. Methods Ontario youth aged 14–29 years with mental health challenges were recruited to participate in a discrete choice experiment (DCE) survey. The DCE contained 12 attributes, each represented by 4 levels representing core characteristics of IYS models. To supplement the DCE questions, demographic information was collected and a mental health screener was administered. Preferences were examined, latent class analyses were conducted, and latent classes were compared. Results As a whole, participants endorsed the IYS model of service delivery. Among 274 youth, there were three latent classes: 1) the Focused Service (37.6%) latent class prioritized efficient delivery of mental health services. 2) The Holistic Services (30.3%) latent class prioritized a diverse array of mental health and social services delivered in a timely fashion. 3) The Responsive Services (32.1%) latent class prioritized services that matched the individual needs of the youth being served. Differences between classes were observed based on sociodemographic and clinical variables. Conclusions IYS is an acceptable model of care, in that it prioritizes components that reflect youth preferences. The differences in preference profiles of different groups of youth point to the need for flexible models of service delivery. Service design initiatives should take these preferences into account, designing services that meet the needs and preferences of a broad range of youth. Working locally to co-design services with the youth in the target population who wish to be engaged will help meet the needs of youth.

Near-Fatal Self-Harm Among Canadian Adolescents

Objective To evaluate the clinical features of Canadian adolescents admitted to the intensive care unit (ICU) for medically serious self-harm. Methods 2700 Canadian paediatricians were surveyed monthly over two years (January 2017 to December 2018) through the Canadian Paediatric Surveillance Program to ascertain data from eligible cases. Results Ninety-three cases (73 female; age 15.2 ± 1.5) met the case definition. Four provinces reported the majority of cases: Quebec (n = 27), Ontario (n = 26), Alberta (n = 21), and British Columbia (n = 8). There were 10 deaths, 9 by hanging. Overdose and hanging were the most frequently reported methods of self-harm (74.2% and 19.4%, respectively). Overdose was more common in females (80.8% females vs. 50% males; χ2 = 7.8 (1), p = .005), whereas hanging was more common in males (35% males vs. 15.1% females, χ2 = 3.9 (1), p = .04). More females than males had a past psychiatric diagnosis (79% vs. 58%; χ2 = 4.1 (1), p = .06), a previous suicide attempt (55.9% vs. 29.4%, χ2 = 3.8 (1), p = .05), and prior use of mental health service (69.7% vs. 27.8%, χ2 = 10.4 (1), p = .001). Family conflict was the most commonly identified precipitating factor (43%) of self-harm. Conclusions Among Canadian adolescents admitted to the ICU with medically serious self-harm, females demonstrate a higher rate of suicide attempts and prior mental health care engagement, whereas males are more likely to die by suicide. These findings are consistent with data from other adolescent samples, as well as data from working-age and older adults. Therefore, a sex-specific approach to suicide prevention is warranted as part of a national suicide prevention strategy; family conflict may be a specific target for suicide prevention interventions among adolescents.