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Background: Multiple survey studies have demonstrated a mental health (MH) burden of COVID-19 globally. However, few studies have examined relevant risk factors for pandemic-related MH issues., Methods: A link to an online survey was posted from April 8th - June 11th, 2020 which included questions regarding COVID-19 experience, perceived impact of the pandemic on life domains (e.g., social communication, finances), behavioural alterations (e.g., online activities, substance use), and MH treatment history. Current psychiatric symptom severity and impairment were evaluated using the Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and the Perceived Stress Scale., Results: Overall, 632 individuals (82% female, mean age:42.04 ± 16.56) in Canada and the United States completed the survey. While few reported contracting COVID-19 (0.5%), the impact of the pandemic was evident, with a vast majority reporting anxiety around COVID-19 infecting loved ones (88%). Almost half (43%) reported previous MH treatment and 31% met criteria for GAD, 29% for MDD and 63% reported significantly high levels of stress. Female sex, younger age and past MH treatment emerged as significant predictors of these issues(p < .01). Age-related differences in the impact of COVID-19 on life domains, substance use, and online activity were also noted., Conclusion: The findings from the current sample add to the growing literature suggesting negative effects of COVID-19 on MH, while highlighting specific risk factors. Age may be an important factor in predicting MH during this pandemic., (Copyright © 2021. Published by Elsevier Ltd.)

Competing Interests: M. Van Ameringen has received personal fees for serving on the advisory boards of Allergan, Almatica, Brainsway, Lundbeck, Myriad Neuroscience, Otsuka and Purdue Pharma (Canada); speaker fees from Allergan, Lundbeck, Purdue Pharma (Canada) and Pfizer; a Hamilton Academic Health Sciences Organization Innovation Grant; a research grant from Purdue Pharma (Canada); and clinical trial funding from Janssen-Ortho Inc. A. Pipe and B. Patterson declare no competing interests.

Purpose of Review: Cannabis use for medical purposes has become increasingly common, including as treatment for mental health disorders such as anxiety. Unfortunately, the evidence examining its use in mental health has been slow to evolve, but is emerging. Given the widespread use of cannabis, it is important for both clinicians and those who suffer with anxiety to understand the effects of cannabis on symptoms of anxiety. In this review, we present recent, available evidence from animal models, clinical trials, and survey studies and evaluate the contribution of these studies to the current understanding of the role of cannabis in treating anxiety., Recent Findings: In reviewing recent evidence, we observed significant inconsistencies across findings from preclinical studies. Large-scale surveys suggest that cannabis may be effective in reducing anxiety, however, these results stand in contrast to equivocal findings from clinical trials., Summary: The literature evaluating the efficacy of cannabis in anxiety disorders is in its infancy. The survey data is generally positive. Although, while some animal studies posit cannabis constituents to have anxiolytic effects, others suggest the opposite or null results. Few new clinical trials have been conducted recently, and the extant trials have significant flaws in methodology. Although anecdotal evidence from survey studies, and a small signal found in animal studies and single-dose clinical trials provide early support that cannabis may be effective for alleviating anxiety, ultimately, the current evidence is equivocal. More high-quality clinical trials must be published before sound conclusions regarding the efficacy of cannabis for treating anxiety can be drawn.

Cannabis is commonly used recreationally for its euphoric and relaxing effects, while its medical use is permitted in several jurisdictions. With only low-quality evidence suggesting anxiolytic effects of cannabis and strong public sentiment surrounding such purported effects, the purpose of this study was to examine the prevalence of cannabis for medicinal purposes (CMP) use for anxiety symptoms. An online survey was disseminated to CMP users registered with a Canadian licensed producer. Respondents completed demographic and validated self-report questionnaires (GAD-7, PHQ-9, MINI-SPIN, and panic disorder/agoraphobia DSM-5 criteria). Cannabis use behaviors were also discussed. Overall, 2032 completed responses with a verified user number were collected. Of the total sample, 888 (43.7%) reported CMP authorization to treat anxiety symptoms and completed all psychometric screening instruments. Rates of probable disorders were high (Generalized Anxiety Disorder: 45.6%, Social Anxiety Disorder: 42.4%, Major Depressive Disorder: 25.7%, Panic Disorder/Agoraphobia: 25.7%); 63.4% met screening criteria for ≥1 disorder. Most (92%) reported that cannabis improved their symptoms, despite continuing to endorse moderate-level severity. Nearly half (49%) reported replacing a non-psychiatric (53.7%) or psychiatric medication (46.3%) prescribed to them by their physician with CMP. Respondents endorsed daily CMP use and severity of anxiety (GAD-7, p < 0.001) and depressive (PHQ-9, p < 0.001) symptoms were positively associated with the amount of cannabis used/day. The vast majority perceived symptom improvement with CMP use and did not believe CMP use was associated with impairment or an inability to control use. Nevertheless, the possibility of cannabis use disorder cannot be ruled out as well as the possibility that improvements in non-psychiatric conditions were attributed to improvements in anxiety. These results highlight the need to systematically evaluate CMP use for mental illness., (Copyright © 2019. Published by Elsevier Ltd.)

Anxiety and related disorders are the most common mental conditions affecting the North American population. Despite their established efficacy, first-line antidepressant treatments are associated with significant side effects, leading many afflicted individuals to seek alternative treatments. Cannabis is commonly viewed as a natural alternative for a variety of medical and mental health conditions. Currently, anxiety ranks among the top five medical symptoms for which North Americans report using medical marijuana. However, upon careful review of the extant treatment literature, the anxiolytic effects of cannabis in clinical populations are surprisingly not well-documented. The effects of cannabis on anxiety and mood symptoms have been examined in healthy populations and in several small studies of synthetic cannabinoid agents but there are currently no studies which have examined the effects of the cannabis plant on anxiety and related disorders. In light of the rapidly shifting landscape regarding the legalization of cannabis for medical and recreational purposes, it is important to highlight the significant disconnect between the scientific literature, public opinion, and related policies. The aim of this article is to provide a comprehensive review of the current cannabis treatment literature, and to identify the potential for cannabis to be used as a therapeutic intervention for anxiety, mood, and related disorders. Searches of five electronic databases were conducted (PubMed, MEDLINE, Web of Science, PsychINFO, and Google Scholar), with the most recent in February 2017. The effects of cannabis on healthy populations and clinical psychiatric samples will be discussed, focusing primarily on anxiety and mood disorders., (© 2017 Wiley Periodicals, Inc.)

Mental health apps are viewed as a promising modality to extend the reach of mental health care beyond the clinic. They do so by providing a means of assessment, tracking, and treatment through a smartphone. Given that nearly 2/3 of the American population owns a smartphone, mental health apps offer the possibility of overcoming treatment barriers such as geographic location or financial barriers. Unfortunately, the excitement surrounding mental health apps may be premature as the current supporting literature regarding their efficacy is limited. The app marketplace is littered with apps claiming to treat or assess symptoms, but even those created by reputable organizations or those incorporating components of evidence-based treatments have not yet been validated in terms of their efficacy. This review aims to provide a comprehensive review of the current state of the mental health app literature by examining published reports of apps designed for DSM-5 anxiety and mood disorders, OCD, and PTSD. The breadth of apps reviewed includes those oriented around assessment, symptom tracking, and treatment as well as "multipurpose" apps, which incorporate several of these components. This review will also present some of the most popular mental health apps which may have clinical utility and could be prescribed to clients. While we discuss many potential benefits of mental health apps, we focus on a number of issues that the current state of the app literature presents. Overall there is a significant disconnect between app developers, the scientific community and health care, leaving the utility of existing apps questionable., (© 2017 Wiley Periodicals, Inc.)

Current evidence suggests that the strength of the psychological control condition greatly impacts treatment outcomes. Psychological controls can be grouped into three general classes: no-treatment or waitlist (delayed treatment), attention placebo or the best available treatment comparison. Of these three, the use of the waitlist condition is the most common and is used in up to 73% of published psychological treatment studies. Many psychological interventions are in use today based on the efficacy demonstrated in waitlist controlled trials. In the field of anxiety disorders, cognitive behavioural therapy (CBT) is considered a first-line treatment. Meta-analyses in anxiety disorders have revealed that effect sizes for CBT compared to waitlist controls are much higher than those found using psychological placebos as comparators. Furthermore, waitlists have been associated with deleterious effects and have been described as "no-cebos" in related conditions such as major depressive disorder. Despite these findings, the use of waitlist controls continues to be a mainstay in the psychological anxiety disorders literature. The purpose of this paper is to examine the use of waitlists with a focus on the anxiety disorders. Methodological and ethical issues associated with waitlist controls will be explored, as well the use of alternative psychological placebos., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: A systematic review and meta-analysis was conducted to explore the efficacy of medication augmentation strategies compared to control treatments in patients who have had a partial or no response to initial treatment for generalized anxiety disorder, social anxiety disorder, and panic disorder., Methods: Double-blind controlled trials of medication augmentation in adult treatment-resistant anxiety disorders conducted between January 1990 and January 2015 were systematically reviewed and evaluated by two independent raters. The search identified 625 articles; 610 were excluded following abstract review and 15 had full-text screening. Studies had to include a definition of treatment resistance, exclude concomitant medications, and have a parallel or crossover design. Data extraction forms were completed in duplicate., Results: Six studies were included in the meta-analysis. Effect estimates were calculated using random effects modeling; heterogeneity was assessed and subgroup and sensitivity analyses were completed. Primary outcome was response, defined by Clinical Global Impression-Improvement score of ≤2. Augmentation was not associated with an increased risk of response, as compared with placebo (RR = 1.08, 95% CI = 0.94-1.24). A small significant effect was found in reduction in symptom severity: standard mean difference = -0.32, 95% CI = -0.56 to -0.08. No significant differences between augmentation with medication versus placebo were found in ratings of functional impairment and dropouts due to adverse events., Conclusions: Augmentation does not appear to be beneficial in treatment-resistant anxiety disorders. These results may be limited by small study samples, and a small number of overall studies in the analysis., (© 2016 Wiley Periodicals, Inc.)

Although many people use the internet to diagnose mental health problems, little is known about the relationship between internet self-diagnosis and treatment-seeking. The MACSCREEN (a validated, self-report screening tool for anxiety and depression) was posted on our clinic homepage and respondents were invited to take an anxiety test. Three months after completing the MACSREEN and a variety of symptom severity scales, respondents were emailed a follow up questionnaire asking about treatment-seeking behaviours. Of the 770 MACSCREEN respondents, 103 completed the follow-up questionnaire. Of these, 100% met criteria for at least one anxiety or mood disorder diagnosis and 51% sought treatment after completing the MACSCREEN. In the 49% who did not seek treatment, fear of medication (57%), discomfort talking to their doctor about anxiety (28%) and the belief that symptoms were not severe enough (28%) were cited as barriers. Compared to non-seekers, treatment-seekers were significantly more likely to meet screening criteria for Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Posttraumatic Stress Disorder and Depression. Higher Sheehan Disability Scale scores and being married (versus single) significantly increased the odds of treatment-seeking, suggesting that functional impairment and disease burden on the family may be stronger predictors of treatment seeking than overall severity of symptoms., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: The process of migration and resettlement has been associated with increased risk for psychiatric illness. Our study sought to examine the association between age at immigration and risk for mood, anxiety, and substance use disorders (SUDs) among adult immigrants in Canada., Method: Data from the Canadian Community Health Survey: Mental Health and Well-Being, a cross-sectional study of psychiatric disorder conducted in 2002, was used to identify a representative sample of adult immigrants in Canada (n = 4946). Logistic regression was used to examine the association between age at immigration (0 to 5 years, 6 to 17 years, and 18 years and older) and 12-month prevalence of mood and anxiety disorders, and SUDs., Results: Immigrants who arrived prior to age 6 years reported the highest risk for mood (OR 3.41; 95% CI 1.7 to 7.0) and anxiety disorders (OR 6.89; 95% CI 3.5 to 13.5), compared with those who immigrated at the age of 18 years or older, after adjusting for covariates, including duration of residence., Conclusions: Younger age at immigration was associated with increased risk of having a current mood disorder, anxiety disorder, or SUD. These findings speak to the importance of developing and evaluating targeted prevention programs for young immigrant children and adolescents.

Panic attacks have been reported by patients with generalized anxiety disorder (GAD) in response to catastrophic worry. This has not been characterized in the literature. We examined the prevalence of GAD panic attacks in an anxiety disorders clinic sample. Charts of 254 patients with DSM-IV GAD were retrospectively evaluated. The presence and type of panic attacks were examined as well as correlates including comorbidity, baseline symptom severity, demographic variables, and family history. Twenty-one percent had GAD panic attacks, 21.7% had situationally predisposed attacks, 15.6% had situationally bound attacks, and 39.4% had unexpected panic attacks. The individuals who had GAD panic attacks had higher scores on the Anxiety Sensitivity Index compared with those who also had other types of panic attacks. One in five patients with GAD reported GAD panic attacks; however, these individuals did not differ significantly on the correlates that were evaluated. These findings require replication and further evaluation.

Adult Attention Deficit Hyperactivity Disorder (ADHD) is a life-long, chronic disorder, which has its onset in childhood and is associated with significant functional impairment. ADHD appears to be highly comorbid with other psychiatric disorders, however, literature is lacking concerning ADHD/anxiety comorbidity. To that end, we examined the prevalence of ADHD in an anxiety disorder sample. Consecutive patients referred to an anxiety disorders clinic completed a variety of anxiety disorder self-report measures as well as the Adult ADHD self-report scale and were clinically assessed using the Structured Clinical Interview for DSM-IV, and the ADHD module of the Mini International Neuropsychiatric Interview. Of the 129 patients assessed, the rate of adult ADHD was 27.9%. The mean age of the sample was 33.1 ± 12.5 years, and the mean baseline CGI-S was 4.6 ± 1.1 (moderate to marked severity). The majority of the sample was female (63.6%) and single (49.5%). The most common comorbid disorders associated with ADHD were major depressive disorder (53.8%), social phobia (38.5%), generalized anxiety disorder (23.1%), and impulse control disorders (30.8%). Individuals with ADHD had higher symptom severity scores for obsessive-compulsive disorder, (P≤ 0.05) and for GAD (P≤ 0.05) and reported a significantly earlier age of onset for depression as compared to those without (P≤ 0.05). The prevalence of adult ADHD was higher in our anxiety disorders clinic sample than found in the general population. Clinical implications of these findings are discussed., (© 2010 Blackwell Publishing Ltd.)

It is well established that individuals with anxiety disorders experience significant impairments in social and occupational functioning. However, the impact of anxiety disorders on family members has not been adequately studied. The objective of the present study was to examine the burden experienced by relatives of anxiety disorder patients. In all, 74 outpatients and 74 family members participated in the study. Family members completed measures that assessed the impact of having an anxiety disordered relative. Results indicate that family members experience significant burden. The burden encompasses several domains including negative effects on physical health, psychological well-being, and family functioning. Burden was positively correlated with the severity of the patient's condition. The presence of a comorbid mood disorder in patients was associated with increased burden. Health-care professionals should assess the impact of anxiety disorders on the patient's family and provide interventions to reduce burden and improve the quality of life of family members.

Background: The Internet is a widely used resource for obtaining health information. Internet users are able to obtain anonymous information on diagnoses and treatment, seek confirmatory information, and are able to self-diagnose. We posted a self-report diagnostic screening questionnaire for DSM-IV anxiety and mood disorders (MACSCREEN) on our clinic website., Method: Three hundred and two individuals completed the MACSREEN. For those who qualified for a DSM-IV disorder, self-report symptom severity measures were completed for the specified disorder: Quick Inventory of Depressive Symptomatology, self-report, Social Phobia Inventory, GAD-7, Davidson Trauma Scale, Panic and Agoraphobia Scale, and Yale/Brown Obsessive Compulsive Scale, self-report. Cutoff scores for each self-report measure were used to evaluate clinically significant symptom severity. Respondents were also asked to complete a series of questions regarding their use of the Internet for health information., Results: The mean age of the MACSCREEN sample was 35.2 years (±13.9), where the majority (67.2%) were female. The most frequently diagnosed conditions were social phobia (51.0%), major depressive disorder (32.4%), and generalized anxiety disorder (25.5%). Sixty-five percent of the sample met criteria for at least one disorder. Most respondents reported completing the MACSCREEN, as they were concerned they had an anxiety problem (62.3%). The majority of respondents reported seeking health information concerning specific symptoms they were experiencing (54.6%) and were planning to use the information to seek further assessment (60.3%)., Conclusion: Individuals with clinically significant disorder appear to be using the Internet to self-diagnose and seek additional information., (© 2010 Wiley-Liss, Inc.)

The association between migraine and psychiatric disorders has been reported in both clinical and epidemiological studies. The prevalence of psychiatric disorders has been found to be increased among individuals with migraine. Studies assessing migraine in psychiatric patients are limited and the majority of these studies have focused solely on examining patients with major depression. In the present study, we examined the prevalence and characteristics of migraine headache in an anxiety disorders clinic sample in order to better understand the relationship between these commonly associated conditions. We evaluated 206 consecutive outpatients to an Anxiety Disorders Clinic for the prevalence of migraine. The presence of migraine was established using International Headache Society Criteria. Subjects completed a modified self-report version of the Headache Diagnostic Questionnaire. In order to assess the relationship between migraine and anxiety disorder symptom severity, subjects completed standardized measures of symptom severity. The prevalence of migraine in our anxiety disorder clinic sample was 67%. Anxiety disorder patients with migraine presented with a significantly greater number of comorbid psychiatric disorders than patients without migraine (P= 0.012). The prevalence of migraine was significantly higher in patients with a diagnosis of either panic disorder with agoraphobia (P= 0.048) or major depressive disorder/dysthymia (P= 0.008) compared to other psychiatric disorders. The severity of anxiety disorder symptoms was significantly higher in patients with migraine compared to patients without migraine. This study suggests that there is an increased prevalence of migraine headaches among anxiety disorder patients as compared to the general population. Migraine comorbidity may have important clinical implications, such that the treatment of one condition could potentially ameliorate the development or progression of the other. Further research is required to better understand the nature and implications of the association between migraine and psychiatric disorders.

Generic agents do not require large clinical trials of safety and efficacy to enter the market, although they must demonstrate both pharmacological and bioequivalence to the brand name drug. Bioequivalence is attained when the extent of absorption of the generic falls within an FDA predefined range relative to the brand name drug. This potential variation in bioequivalence is not thought to be clinically meaningful, however, there are reports of a lack of therapeutic equivalence between some generic medications and the brand name. This study examines the potential risks posed by a switch from Celexa to generic citalopram. Twenty patients at an Anxiety Disorders Clinic who were unknowingly switched to generic citalopram, from Celexa (Lundbeck, Montreal, Quebec, Canada) and experienced a re-emergence of their anxiety symptoms or development of new adverse events are described in this case series report. The mean time for re-emergence of symptoms or development of adverse events was 3.4 +/- 1.6 weeks (range 0.5-8 weeks). All patients reestablished previous treatment response with a change back to Celexa in a mean time of 3.8 +/- 2.6 weeks (range 0.7-12 weeks). Given these results, it is important for clinicians to be aware of the potential for loss of treatment effect or symptom re-emergence posed by a switch to a generic agent. Randomized, double blind, controlled investigations would likely provide useful information as current bioequivalence and pharmacological equivalence do not necessarily translate into clinical equivalence.