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BackgroundWinnipeg, Canada operates a 16-bed subacute unit, the Crisis Stabilization Unit (CSU), for voluntary patients in crisis not requiring hospital admission. The virtual CSU (vCSU) launched in March 2020 as an adjunct to the in-person CSU during the COVID-19 pandemic, providing the same resources virtually, allowing patients to remain at home.MethodsProgram data were collected for vCSU admissions between April 1, 2020 and April 7, 2021 (n = 266) to examine patient characteristics and discharge outcomes. Data were retrieved from the electronic patient record (EPR) for both in-person and vCSU admissions during the same period for comparison (n = 712). vCSU admissions (n = 191) were summarized by patient demographics, clinical factors/outcomes, and compared on the same measures to in-person CSU admissions (n = 521) using binary logistic regression.Results30.1% of patients admitted to the vCSU received initial mental health assessment virtually (phone/videoconference), therefore receiving all care at home. Clinical symptoms at assessment included depression/anxiety (39.0%), psychosis/mania (2.7%), suicidal behaviour/self-harm (27.4%), psychosocial event/stressor (19.8%). Average stay was 4.9 days. Compared to the in-person CSU, vCSU referrals were associated with the absence of psychosis [odds ratio (OR).40, 95% confidence interval (CI).18–0.89] and no prior 1-year contact with referral site (OR.43, 95% CI.28–0.64). Those living farther away from the referral site were more likely to receive a vCSU referral.ConclusionThe vCSU model is feasible for a diverse group of patients experiencing mental health crises. Future work is needed to better determine who the model is right for and examine longer term outcomes.

To determine if self-reported baseline psychological distress moderates the association between lifetime psychiatric diagnosis and weight loss 1 year after bariatric surgery. An exploratory analysis assessed change in psychological distress from baseline on weight loss at 1 year. A retrospective cohort study using data from the Ontario Bariatric Registry for all individuals undergoing surgery between January 1, 2012, and December 31, 2018, with a complete baseline psychological assessment and 1-year post-operative weight recorded (N = 11,159). Multiple linear regressions assessed the relationship between psychiatric diagnosis and percentage of excess body mass index loss (%EBMIL) at 1-year post-surgery, controlling for baseline body mass index, socio-demographics, medical co-morbidities, and surgical complications. Baseline psychological distress, measured with the EQ-5D-5L anxiety/depression rating, was examined as a moderator of this relationship. %EBMIL was separately regressed on change in psychological distress from baseline to 1 year, controlling for psychiatric diagnosis. In the adjusted model, psychiatric diagnosis was associated with lower %EBMIL at 1 year (B = − 1.00, P = .008). Baseline psychological distress was not a moderator, but had a significant main effect on %EBMIL (B = − .84, P = .001). Those who experienced a decrease in psychological distress at 1 year, or remained low throughout, fared better than those who increased or had persistently high symptoms. These findings support use of a self-report assessment for psychological distress prior to bariatric surgery. Addressing active psychological distress prior to and/or following surgery may increase the likelihood of successful outcomes.

The covid-19 pandemic created major challenges for mental health crisis care. Our crisis centre in Winnipeg, Manitoba rapidly virtualized the full spectrum of services offered with remarkable uptake, resulting in avoided hospitalizations and reduced transmission risk for covid-19. We must determine how to best adopt these approaches into post-pandemic crisis care.

Physician assistants (PAs) are a growing group of healthcare providers who could facilitate the adoption of electronic healthcare (e-Health) into practice. In 2018, we conducted a Canada-wide web-based survey study of practicing PAs and student PAs regarding their current exposure to e-Health, as well as their perceived value for its use and interest in future adoption. For this study, e-Health was defined as technology that allows direct communication between patients and healthcare providers or facilitates patient self-management for the purpose of assessment and management. We focused on telehealth, direct messaging (e.g. text, email), patient-directed web-based applications (apps) and patient-provider shared web-based apps. Survey responses were analysed descriptively and compared between practicing and student PAs with Chi-square tests of independence. We also examined correlations between age, exposure, perceived value and interest in future adoption for practicing PAs and student PAs separately. About 186 respondents completed the survey; 145 practicing PAs and 39 student PAs. Fewer than half of respondents had exposure to the studied e-Health modalities. Compared to practicing PAs, student PAs more often perceived value in e-Health and expressed interest in its expanded adoption. In both groups, perceived value frequently correlated significantly with interest in adoption. Student PAs report little formal education during their training, and both practicing PAs and student PAs note a need for infrastructure support, and general knowledge about what is available and safe in order to enable them to expand their use of e-Health in practice. The most interest is present for patient-directed apps and patient-provider shared apps. With workload and remuneration barriers to physician adoption of e-Health, salary-based PAs could have a role in facilitating the integration of e-Health solutions into practice. Additional awareness, exposure and support for PAs to do so are required.

Background The COVID-19 pandemic was accompanied by the accelerated uptake of virtual care, leading to a proliferation of virtual ward models as alternatives to facility-based care. Early in the pandemic, our program implemented a virtual mental health crisis ward (vWard) to provide options for individuals requiring intense psychiatric and/or crisis support but who preferred to remain in the community and were deemed safe to do so. Objective The aim of this study was to identify early learnings from the vWard, which was implemented rapidly in a resource-constrained environment, to inform the future state should it be sustained beyond the pandemic. Methods Mixed methods of data collection were used to evaluate provider perspectives on the vWard, develop archetypes for individuals who are a good fit for the vWard model, and create a driver diagram. Data sources included an anonymous survey of clinical and managerial staff involved in the vWard, a service planning workshop, and program discharge forms for all individuals admitted between March 2020 and April 2021. Survey responses were coded for themes under categories of “benefits” and “challenges.” Discharge forms where the team indicated that the vWard was a good fit for an individual were examined for characteristics common to these admissions. These findings were reviewed in the service planning workshop and refined with input from the participants into patient archetypes. A driver diagram was created for the future state. Results Survey respondents (N=60) represented diverse roles in crisis services and the vWard team. Ten providers took part in the service planning workshop. A total of 467 discharge forms were reviewed. The vWard was felt to be a model that worked by 39 survey respondents, one respondent felt it did not work, and the remaining participants had no response. Several benefits for the individual and the system were identified alongside challenges, including certain processes and materials related to the nature of rapid implementation during the pandemic, and others due to lack of fit for certain individuals. The model was felt to be a good fit for 67.5% of admissions. Four patient archetypes representing a good fit with the model were developed. The driver diagram connected the program aim with primary drivers of (1) reduce barriers to care; (2) improve outcomes; and (3) provide collaborative, patient- and family-centered care to secondary drivers and interventions that leveraged virtual technology among other crisis care interventions. Conclusions Despite some challenges, the vWard demonstrated high levels of provider acceptance and a range of mechanisms by which the model works for a variety of patient archetypes. These early learnings provide a foundation for growth, sustainability, and spread of this model going forward beyond the pandemic.

Background The Coronavirus Disease 2019 (COVID–19) pandemic has exacerbated mental health challenges among physicians and non–physicians. However, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. We evaluated the difference in mental health and addictions health service use between physicians and non–physicians, before and during the COVID–19 pandemic. Methods and findings We conducted a population–based cohort study in Ontario, Canada between March 11, 2017 and August 11, 2021 using data collected from Ontario’s universal health system. Physicians were identified using registrations with the College of Physicians and Surgeons of Ontario between 1990 and 2020. Participants included 41,814 physicians and 12,054,070 non–physicians. We compared the first 18 months of the COVID–19 pandemic (March 11, 2020 to August 11, 2021) to the period before COVID–19 pandemic (March 11, 2017 to February 11, 2020). The primary outcome was mental health and addiction outpatient visits overall and subdivided into virtual versus in–person, psychiatrists versus family medicine and general practice clinicians. We used generalized estimating equations for the analyses. Pre–pandemic, after adjustment for age and sex, physicians had higher rates of psychiatry visits (aIRR 3.91 95% CI 3.55 to 4.30) and lower rates of family medicine visits (aIRR 0.62 95% CI 0.58 to 0.66) compared to non–physicians. During the first 18 months of the COVID–19 pandemic, the rate of outpatient mental health and addiction (MHA) visits increased by 23.2% in physicians (888.4 pre versus 1,094.7 during per 1,000 person–years, aIRR 1.39 95% CI 1.28 to 1.51) and 9.8% in non–physicians (615.5 pre versus 675.9 during per 1,000 person–years, aIRR 1.12 95% CI 1.09 to 1.14). Outpatient MHA and virtual care visits increased more among physicians than non–physicians during the first 18 months of the pandemic. Limitations include residual confounding between physician and non–physicians and challenges differentiating whether observed increases in MHA visits during the pandemic are due to stressors or changes in health care access. Conclusions The first 18 months of the COVID–19 pandemic was associated with a larger increase in outpatient MHA visits in physicians than non–physicians. These findings suggest physicians may have had larger negative mental health during COVID–19 than the general population and highlight the need for increased access to mental health services and system level changes to promote physician wellness.

ObjectivesThe aim of this study was to investigate physician benzodiazepine (BZD) self-use pre-COVID-19 pandemic and to examine changes in BZD self-use during the first year of the pandemic.DesignPopulation-based retrospective cohort study using linked routinely collected administrative health data comparing the first year of the pandemic to the period before the pandemic.SettingProvince of Ontario, Canada between March 2016 and March 2021.ParticipantsInterventionOnset of the COVID-19 pandemic in March 2020.Outcomes measuresThe primary outcome measure was the receipt of one or more prescriptions for BZD, which was captured via the Narcotics Monitoring System.ResultsIn a cohort of 30 798 physicians (mean age 42, 47.8% women), we found that during the year before the pandemic, 4.4% of physicians had 1 or more BZD prescriptions. Older physicians (6.8% aged 50+ years), female physicians (5.1%) and physicians with a prior mental health (MH) diagnosis (12.4%) were more likely than younger (3.7% aged female=0.90, 95% CI: 0.83 to 0.98) compared with male physicians (aORmale=0.79, 95% CI: 0.72 to 0.87, pinteraction=0.046 during the pandemic. Physicians presenting with an incident MH visit had higher odds of filling a BZD prescription during COVID-19 compared with the prior year.ConclusionsPhysicians’ BZD prescriptions decreased during the first year of the COVID-19 pandemic in Ontario, Canada. These findings suggest that previously reported increases in mental distress and MH visits among physicians during the pandemic did not lead to greater self-use of BZDs.

Objective The life course of children and adolescents with mental disorders is an important area of investigation, yet it remains understudied. This study provides a first-ever comprehensive examination of the relationship between child and adolescent mental disorders and subsequent suicidal and adverse social outcomes in early adulthood using population-based data. Methods De-identified administrative databases were used to create a birth cohort of 60,838 residents of Manitoba born between April 1980 to March 1985 who were followed until March 2015. Unadjusted and adjusted hazard ratios (aHRs) and odds ratios (aORs) were calculated to determine associations between physician-diagnosed mental disorders in childhood or adolescence and a range of adverse early adulthood (ages 18 to 35) outcomes. Results Diagnoses of mood/anxiety disorders, attention-deficit hyperactivity disorder, substance use disorder, conduct disorder, psychotic disorder, personality disorders in childhood or adolescence were associated with having the same diagnoses in adulthood. These mental disorder diagnoses in childhood/adolescence were strongly associated with an increased risk of suicidal behaviors and adverse adult social outcomes in adulthood. Similarly, suicide attempts in adolescence conferred an increased risk in adulthood of suicide death (aHR: 3.6; 95% confidence interval [CI]: 1.9-6.9), suicide attempts (aHR: 6.2; CI: 5.0–7.6), social housing use (aHR: 1.7; CI 1.4–2.1), income assistance (aHR: 1.8; CI 1.6–2.1), criminal accusation (aHR: 2.2; CI 2.0–2.5), criminal victimization (aHR:2.5; CI 2.2–2.7), and not completing high school (aOR: 3.1; CI: 2.5–3.9). Conclusion Mental disorders diagnosed in childhood and adolescence are important risk factors not only for mental disorders in adulthood but also for a range of early adult adversity. These findings provide an evidence-based prognosis of children's long-term well-being and a rationale for ensuring timely access to mental health services. Better population-level mental health promotion and early intervention for children and adolescents with mental disorders are promising for improving future adult outcomes.

This study aimed to examine the needs of clients accessing a community mental health crisis stabilization unit (CSU) in Winnipeg, Canada. Sociodemographics, service connections, and need were assessed among CSU clients. The Camberwell Assessment of Need Short Appraisal Schedule - Patient (CANSAS-P) was administered to differentiate need domains that were met and unmet. An ordinal regression examined sociodemographics and level of total unmet need; client characteristics were correlated with unmet need. In total, 271 questionnaires were analyzed. On average, respondents had 6.2 areas of unmet need, with "psychosocial distress" (n = 186, 68.6%), "safety to self" (n = 140, 51.7%), "company" (n = 139, 51.3%), and "physical health" (n = 124, 45.8%) being reported most often. Higher level of unmet need was predicted by disability income and absence of income. Overall, CSU clients had high rates of unmet need reflecting important determinants of health. This information can inform community mental health crisis service delivery to positively impact mental health recovery.

Objectives: To report on the perceived barriers surrounding the use of telepsychiatry for emergency assessments and our approach to overcoming those barriers to achieve successful implementation of a program to increase access to emergency psychiatric assessment in a Canadian urban setting. Methods: We conducted a survey of emergency care staff to inform the implementation of an emergency telepsychiatry program in the urban setting of Winnipeg, Manitoba, where hospitals have variable on-site emergency psychiatric coverage. We analyzed survey responses for perceived barriers we would need to address in implementation. We employed implementation strategies for each barrier and scaled the program to three sites over the first year. Data from the first year were collected including number of telepsychiatry assessments, reasons for referral, wait time, and percentage of patient transfers avoided. Results: Survey respondents ( N = 111) had little prior exposure to telepsychiatry, but the majority were open to its use for emergency psychiatric assessments in the region. We identified three categories of perceived barriers: clinical, logistical/technical, and readiness barriers. Implementation planning addressed each barrier, and a hub-and-spoke program was launched. After the first year, the program had one hub serving three spokes, and 243 emergency telepsychiatry assessments had been completed. After 12 months, we were avoiding 65% of patient transfers. Conclusions: By conducting a user survey to identify perceived barriers, and addressing these during implementation, we successfully scaled our emergency telepsychiatry program across our region. Our report of this experience may benefit others attempting to implement a similar program.

A significant minority of unspecified psychosis presentations progress to schizophrenia. Clinical risk factors can inform targeted referral to specialized treatment programs, but few population studies have examined this. In this study, we used health administrative data for a population-based cohort from Manitoba, Canada to characterize the risk and identify vulnerable subgroups for a future diagnosis of schizophrenia after a diagnosis of unspecified psychotic disorder. Individuals aged 13–60 years with an inpatient or outpatient diagnosis of unspecified psychotic disorder between April 1, 2007 and March 31, 2012, and without any prior diagnosis of schizophrenia or related disorder, were identified (N = 3, 289). The primary outcome was a diagnosis of schizophrenia recorded after the index diagnosis of unspecified psychotic disorder and before March 31, 2015. Adjusted hazard ratios were computed controlling for age, sex, urbanicity, income, prior diagnosis of unspecified psychotic disorder, provider making the diagnosis, prior 12-month psychiatric hospitalization, and prior 12-month diagnoses of mood, anxiety, substance use, or personality disorders, and substance-induced psychosis. A classification tree identified vulnerable subgroups. The cumulative risk of a future diagnosis of schizophrenia was 26% during the follow-up period (mean 4.5 years), with a mean time to diagnosis of 2.0 years. The most vulnerable subgroup was diagnosed by a psychiatrist, younger than 27 years, without a mood or anxiety disorder, male, and residing in a low-income neighborhood; the rate of a subsequent schizophrenia diagnosis was 61.2%. These results support that identification of specific sociodemographic and clinical factors can help clinicians counsel and intervene with those at highest risk.

Background Persons with mental illness are more at risk for sedentary behaviour and associated consequences. We assessed the feasibility of outdoor walking during psychotherapy sessions in an outpatient trauma therapy program to challenge sedentary behaviour. Methods In this pilot trial in Toronto, Canada, female therapists and patients >18 years, were encouraged to walk during 12 consecutive trauma therapy sessions. Both groups were provided wearable pedometers. We assessed protocol feasibility and desirability, and 12-week changes in patient post-traumatic stress [PTSD check-list for DSM-5 (PCL-5)], and depression, anxiety, and stress symptoms [Depression, Anxiety and Stress Scale (DASS)]. Results 91% (20/22) of patients approached for the study consented to participate and 17 (85%) completed follow-up questionnaires. There was walking in 132/197 (67%) of total therapy sessions (mean 7.3 out of 10.9 sessions per participant). Inclement weather was the predominant reason for in-office sessions. At 12-week follow-up, PCL-5 mean scores decreased from 38.4 [standard deviation, ((SD) 11.8) to 30.7 (SD 14.7)], [mean difference (MD) 7.7, 95% CI: 1.5 to 13.8]; 41% (7/17) participants had a clinically significant PCL-5 score reduction of >10 points. DASS-stress mean scores decreased from 19.0 to 16.0 (MD 3.0, 95% CI: 0.3 to 5.6). No changes were observed for DASS depression (MD -0.9, 95% CI: −5.1 to 3.3) nor DASS anxiety (MD -0.2, 95% CI: −3.1 to 2.7). Daily step reporting was inconsistent and not analyzed. There was high acceptability amongst patients and therapists to walk, but not to record daily steps. There were no adverse outcomes. Conclusions It was feasible and acceptable to incorporate outdoor walking during trauma therapy sessions for patients and therapists. Weather was the greatest barrier to implementation. Further randomized-control study to compare seated and walking psychotherapy can clarify if there are psychotherapeutic and physical benefits with walking.

Background With the growing need for accessible, high-quality mental health services, especially during the COVID-19 pandemic, there has been increasing development and uptake of web-based interventions in the form of self-directed mental health platforms. The Big White Wall (BWW) is a web-based platform for people experiencing mental illness and addiction that offers a range of evidence-based self-directed treatment strategies. Drawing on existing data from a large-scale evaluation of the implementation of BWW in Ontario, Canada (which involved a pragmatic randomized controlled trail with an embedded qualitative process evaluation), we sought to investigate the influences on the extent to which people engage with BWW. Methods In this paper we drew on BWW trial participants’ usage data (number of logins) and the qualitative data from the process evaluation that explored participants’ experiences, engagement with and reactions to BWW. Results Our results showed that there were highly complex relationships between the influences that contributed to the level of engagement with BWW intervention. We found that a) how people expected to benefit from using a platform like BWW was an important indicator of their future usage, b) moderate perceived symptoms were linked with higher engagement; whereas fewer actual depressive symptoms predicted use and anxiety had a positive linear relationship with usage, and that c) usage depended on positive early experiences with the platform. Conclusions Our findings suggest that the nature of engagement with platforms such as BWW is not easily predicted. We propose a theoretical framework for explaining the level of user engagement with BWW that might also be generalizable to other similar platforms.

Purpose Virtual care has almost become the norm since COVID-19 mandated social distancing Prior, the use of personal videoconferencing was being explored as an appealing option to overcome barriers to care, but little was studied about how we should do it and for whom This study aimed to answer these questions for women receiving psychotherapy in the postpartum period when there are significant barriers to attending office-based care Methods Twelve postpartum women who had the option to attend their psychotherapy sessions for the treatment of mood and/or anxiety symptoms via videoconferencing over a 3-month time period were interviewed about their experience The three therapists providing care were also interviewed early in adoption of the virtual treatment and at the end of the study Thematic analysis was conducted to identify themes for the initial and ongoing engagement with videoconferencing, which were triangulated with therapist input Findings Major themes which emerged related to (a) initial willingness to engage with videoconferencing, (b) technological compatibility, and (c) a good patient fit, with positive and negative influencers for each Therapeutic considerations were identified, including (a) an initial in-person meeting when possible, (b) matching the therapy format to the clinical situation, (c) attention to the home environment, and (d) a clear therapy frame Conclusions Therapists should consider that videoconferencing might not be appropriate for every patient;but in the right context and with appropriate therapeutic considerations, offering this treatment format may actually facilitate an individual's recovery These findings can help to inform the future delivery of videoconferencing psychotherapy (PsycInfo Database Record (c) 2020 APA, all rights reserved)

Objective: The role of mental illness and addiction in acute care use for chronic medical conditions that are sensitive to ambulatory care management requires focussed attention. This study examines how mental illness or addiction affects risk for repeat hospitalization and/or emergency department use for ambulatory care–sensitive conditions (ACSCs) among high-cost users of medical care. Method: A retrospective, population-based cohort study using data from Ontario, Canada. Among the top 10% of medical care users ranked by cost, we determined rates of any and repeat care use (hospitalizations and emergency department [ED] visits) between April 1, 2011, and March 31, 2012, for 14 consensus established ACSCs and compared them between those with and without diagnosed mental illness or addiction during the 2 years prior. Risk ratios were adjusted (aRR) for age, sex, residence, and income quintile. Results: Among 314,936 high-cost users, 35.9% had a mental illness or addiction. Compared to those without, individuals with mental illness or addiction were more likely to have an ED visit or hospitalization for any ACSC (22.8% vs. 19.6%; aRR, 1.21; 95% confidence interval [CI], 1.20-1.23). They were also more likely to have repeat ED visits or hospitalizations for the same ACSC (6.2% vs. 4.4% of those without; aRR, 1.48; 95% CI, 1.44-1.53). These associations were stronger in stratifications by mental illness diagnostic subgroup, particularly for those with a major mental illness. Conclusions: The presence of mental illness and addiction among high-cost users of medical services may represent an unmet need for quality ambulatory and primary care.

Background Multimorbidity is significant for obesity and mental health issues. As a consequence, mental illness is overrepresented in patients seeking bariatric surgery. This review addresses that overlap, with a focus on Canadian data. Conclusion The healthcare system in Canada is unique, but issues related to prevalence of mental health in patients seeking bariatric surgery are similar to those in studies conducted in other countries. Although data on suicide are lacking, Canadian data have shown similar rates of self-harm behaviours and linkages between psychopathology and weight regain after surgery. Geographic issues that make it difficult for individuals to attend regular follow-up appointments have encouraged the use of e-health tools to engage patients and ensure access to follow-up care, which may provide unique opportunities going forward. Additional work is needed to inform best practices in the Canadian system, but in keeping with other data, the consistent message from Canada is that appropriate evaluation and aftercare are essential components of a well-informed bariatric program.

Chronic Kidney Disease (CKD) is a pressing global health concern that is placing increased strain on health care resources. CKD patients regularly receive peritoneal dialysis as a common CKD treatment. An emerging technological solution is telehomecare as way to support patients receiving PD in their homes. This study protocol outlines a mixed methods evaluation exploring a telehomecare developed to enhance CKD patients’ outcomes and experiences. The study aims to assess the usability, acceptability and scalability of this virtual care application. A realist evaluation using an embedded case study design will be used to understand the usability, acceptability and scalability of a telehomecare application for patients with CKD undergoing PD. The realist evaluation that is further described in this paper is part of a larger evaluation of the eQ Connect™ intervention that includes a randomized, parallel-arm control trial aimed at determining if utilizing eQ Connect improves selected clinical outcomes for PD patients (CONNECT Trial). Potential implications of this study include elucidating which components of the intervention are most effective and under what conditions with a focus on the contextual influences. Collectively, our multi-method design will yield knowledge around how best to implement, sustain and spread the telehomecare application that will be useful to guide the development, implementation and evaluation of future virtual care applications aimed at improving the quality of care outcomes and experiences of patients. NCT02670512 . Registered: January 18, 2016.

ObjectivesTo characterize the health-care utilization and economic burden associated with depression in Manitoba, Canada.MethodsPatient-level data were retrieved from the Manitoba Centre for Health Policy administrative, clinical, and laboratory databases for the study period of January 1, 1996, through December 31, 2016. Patients were assigned to the depression cohort based on diagnoses recorded in hospitalizations and outpatient physician claims, as well as antidepressant prescription drug claims. A comparison cohort of nondepressed subjects, matched with replacement for age, gender, place of residence (urban vs. rural), and index date, was created. Demographics, comorbidities, intentional self-harm, mortality, health-care utilization, prescription drug utilization, and costs of health-care utilization and social services were compared between depressed patients and matched nondepressed patients, and incidence rate ratios and hazard ratios were reported.ResultsThere were 190,065 patients in the depression cohort and 378,177 patients in the nondepression cohort. Comorbidities were 43% more prevalent among depressed patients. Intentional self-harm, all-cause mortality, and suicide mortality were higher among patients with depression than the nondepression cohort. Health-care utilization—including hospitalizations, physician visits, physician-provided psychotherapy, and prescription drugs—was higher in the depression than the nondepression cohort. Mean health-care utilization costs were 3.5 times higher among depressed patients than nondepressed patients ($10,064 and $2,832, respectively). Similarly, mean social services costs were 3 times higher ($1,522 and $510, respectively). Overall, depression adds a total average cost of $8,244 ( SD = $40,542) per person per year.ConclusionsDepression contributes significantly to health burden and per patient costs in Manitoba, Canada. Extrapolation of the results to the entire Canadian health-care system projects an excess of $12 billion annually in health system spending.

Purpose of Review This review summarizes digital health solutions being used for Indigenous mental well-being, with emphasis on available evidence and examples reported in the literature. We also describe our own local experience with a rural telemental health service for Indigenous youth and discuss the unique opportunities and challenges. Recent Findings Digital health solutions can be grouped into three main categories: (1) remote access to specialists, (2) building and supporting local capacity, and (3) patient-directed interventions. Limited evidence exists for the majority of digital solutions specifically in Indigenous contexts, although examples and pilot projects have been described. Telemental health has the strongest evidence, along with a growing evidence for web-based applications, largely led by Australia. Other digital approaches remain areas of promise requiring additional study. Co-design and service integration and respect for Indigenous history and ideologies are essential for success. Summary While the use of digital health solutions for Indigenous mental well-being holds promise, there is a limited evidence base for most of them. Future efforts to expand the use of digital solutions in this population should adhere to best practices for the delivery of Indigenous health services.

Background Depression and anxiety during the postpartum period are common, with psychotherapy often being the preferred method of treatment. However, psychological, physical, and social barriers prevent women from receiving appropriate and timely psychotherapy. The option of receiving psychotherapy through videoconferencing (VC) during the postpartum period presents an opportunity for more accessible and flexible care. Objective The aim of this study was to assess the feasibility, acceptability, and preliminary effectiveness of optional VC added to usual office-based psychotherapy, with a psychotherapist during the postpartum period. Methods We conducted a pilot randomized controlled trial with 1:1 randomization to office-based care (treatment as usual; TAU) or office-based care with the option of VC (treatment as usual plus videoconferencing; TAU-VC) for psychotherapy during the postpartum period. We assessed the ability to recruit and retain postpartum women into the study from an urban perinatal mental health program offering postpartum psychotherapy, and we evaluated the uptake, acceptability, and satisfaction with VC as an addition to in-person psychotherapy. We also compared therapy attendance using therapist logs and symptoms between treatment groups. Symptoms were assessed at baseline and 3 months postrandomization with the Edinburgh Postnatal Depression Scale, Generalized Anxiety Disorder 7-item, and Parental Stress Scale. Furthermore, 3-month scores were compared between groups with intention-to-treat linear mixed-effects models controlling for baseline score. Results We enrolled 38 participants into the study, with 19 participants in each treatment group. Attendance data were available for all participants, with follow-up symptom measures available for 25 out of 38 participants (66%). Among the 19 TAU-VC participants, 14 participants (74%) utilized VC at least once. Most participants were highly satisfied with the VC option, and they reported average savings of Can $26 and 2.5 hours in travel and childcare expenses and time per appointment. There were no significant differences between the 2 groups for psychotherapy attendance or symptoms. Conclusions The option of VC appears to be an acceptable method of receiving psychotherapy for postpartum women, with benefits described in costs and time savings. On the basis of this small pilot sample, there were no significant differences in outcomes between office-based care with or without the option of VC. This study has demonstrated the feasibility of such a program in an urban center, which suggests that a larger study would be beneficial to provide evidence that is more conclusive.

Background Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. Objective In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients' outcomes and experiences. Methods This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders-6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers-participated in this study. Results The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case. Conclusions Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.

Objectives Barriers to in-person mental health care are common in pregnant and postpartum women with depression. We assessed the feasibility of a trial protocol for evaluating the use of secure, in-home synchronous virtual psychiatric care. Methods In this pilot randomized controlled trial in Toronto, Canada, women aged ≥18 years, pregnant or 0-12 months postpartum, with Edinburgh Postnatal Depression Scale (EPDS) scores >12, were randomized 1:1 to in-person visits only, or to an intervention condition where they were offered the option of video-visits for some or all of their follow-up care. We assessed trial protocol feasibility, and secondarily EPDS score at 12 weeks post-randomization. Results 63 women were randomized (33 intervention, 30 control) of which 87.9% (n = 29) in the intervention group and 66.7% (n = 20) in control group completed the 12-week follow-up questionnaire. About 48.5% (n = 16) of intervention group participants used video-visits at least once, with high acceptability for participants and providers across a number of domains, and no adverse events. EPDS mean scores decreased from 16.6(SD 5.06) to 11.6(SD 4.77) and 16.9(SD 3.15) to 12.4(SD 3.96) for intervention and control groups, respectively (adjusted mean difference -0.64, 95%CI -2.95 to 1.67). Conclusion It was feasible to recruit for a protocol evaluating psychiatrist video-visits for perinatal depression. Video-visits were acceptable to users and the psychiatrists providing their healthcare. A future non-inferiority efficacy trial can assess treatment outcome moderators to explore variability in effectiveness by illness severity and other factors, and cost-effectiveness of various types of video-visit strategies for psychiatric care in this population.

Background Studies worldwide have reported an increased prevalence of abuse histories among bariatric surgery candidates. The impact of abuse history on weight loss after surgery has not been examined in Canada. Objectives Determine the prevalence of abuse and its impact on postoperative outcomes in Ontario, Canada. Setting Data from the Ontario Bariatric Registry. Methods A retrospective cohort study of laparoscopic gastric bypass and sleeve gastrectomy surgeries from 2010 to 2014, for which any follow-up data were available (N = 6016). Weight loss outcomes at 3 months (n = 5147), 6 months (n = 4749), and 1 year (n = 4024) were compared between those with and without a self-reported history of any of emotional, physical or sexual abuse and those with and without a history of sexual abuse specifically. Mixed repeated measures models were adjusted for age, sex, type of surgery, and baseline body mass index. One-year postoperative occurrence of revisions or repairs, hospitalization, and death were also examined. Results The prevalence of documented abuse was 21.5%. Emotional abuse was most common (13.1%), followed by sexual abuse (10.6%), then physical abuse (8.9%). There was no significant association between presence of abuse history and weight loss at any time point in repeated measures analyses. Conclusion Abuse histories are common in bariatric surgery candidates in Ontario, but at a lower prevalence than what has been reported elsewhere. History of abuse does not appear to affect weight loss out to 1 year postoperatively and may alert providers to offer additional support perioperatively and postoperatively, particularly in the setting of psychiatric co-morbidity.

BACKGROUND Depression and anxiety during the postpartum period are common, with psychotherapy often being the preferred method of treatment. However, psychological, physical, and social barriers prevent women from receiving appropriate and timely psychotherapy. The option of receiving psychotherapy through videoconferencing (VC) during the postpartum period presents an opportunity for more accessible and flexible care. OBJECTIVE The aim of this study was to assess the feasibility, acceptability, and preliminary effectiveness of optional VC added to usual office-based psychotherapy, with a psychotherapist during the postpartum period. METHODS We conducted a pilot randomized controlled trial with 1:1 randomization to office-based care (treatment as usual; TAU) or office-based care with the option of VC (treatment as usual plus videoconferencing; TAU-VC) for psychotherapy during the postpartum period. We assessed the ability to recruit and retain postpartum women into the study from an urban perinatal mental health program offering postpartum psychotherapy, and we evaluated the uptake, acceptability, and satisfaction with VC as an addition to in-person psychotherapy. We also compared therapy attendance using therapist logs and symptoms between treatment groups. Symptoms were assessed at baseline and 3 months postrandomization with the Edinburgh Postnatal Depression Scale, Generalized Anxiety Disorder 7-item, and Parental Stress Scale. Furthermore, 3-month scores were compared between groups with intention-to-treat linear mixed-effects models controlling for baseline score. RESULTS We enrolled 38 participants into the study, with 19 participants in each treatment group. Attendance data were available for all participants, with follow-up symptom measures available for 25 out of 38 participants (66%). Among the 19 TAU-VC participants, 14 participants (74%) utilized VC at least once. Most participants were highly satisfied with the VC option, and they reported average savings of Can $26 and 2.5 hours in travel and childcare expenses and time per appointment. There were no significant differences between the 2 groups for psychotherapy attendance or symptoms. CONCLUSIONS The option of VC appears to be an acceptable method of receiving psychotherapy for postpartum women, with benefits described in costs and time savings. On the basis of this small pilot sample, there were no significant differences in outcomes between office-based care with or without the option of VC. This study has demonstrated the feasibility of such a program in an urban center, which suggests that a larger study would be beneficial to provide evidence that is more conclusive.

IntroductionThe relationship between childhood/adolescent mental disorders and adult outcomes has been studied using surveys and clinical samples. These studies are prone to selection, recall and self-reporting biases. No previous studies have used population-based administrative databases linking individual-level data that could address these biases and further elucidate this relationship. Objectives and ApproachUsing de-identified administrative databases housed at the Manitoba Centre for Health Policy, we aimed to determine whether people diagnosed with mental disorders in childhood/adolescence, compared to those without, were at higher risk of early adverse adult outcomes. We created a birth cohort of 60,838 residents of Manitoba, Canada, born from fiscal years 1980/81 to 1984/85 and followed them to the end of study period in 2014/15. Through a scrambled health identifier, health, education, social services and justice system data were linked at an individual level. Survival analysis was used to test for differences controlling for key childhood covariates. ResultsWe found that 16.5% of the cohort had a diagnosed mental disorder at some point in their childhood/adolescence. Having a diagnosed mental disorder in childhood/adolescence increased the risk of being diagnosed with the same disorder in early adulthood (at age 30 to 34 years old). It also increased the risk of suicidal death (hazard ratio (HR): 2.41), suicide attempts (HR: 3.05), public housing use (HR: 1.44), income assistance use (HR: 2.07), criminal accusation (HR:1.53), and criminal victimization (HR:1.54) in adulthood. Similarly, but to a greater extent, suicide attempts in adolescence increased the risk of suicidal death (HR: 3.65), suicide attempts (HR: 5.68), public housing use (HR: 1.64), income assistance use (HR: 1.68), criminal accusation (HR: 2.18), or criminal victimization (HR: 2.43) in adulthood. Conclusion/ImplicationsYoung people’s mental health has significant influence on their health and well-being trajectories into adulthood. This knowledge could directly inform policy and practice to provide better population-based mental health promotion, prevention and early interventions for children/adolescents with mental disorders and subsequently prevent adverse adult outcomes in the future.

Background Direct support providers (DSPs) in community residential services are often central figures in the lives of service recipients. There is little research to date focusing on what motivates these employees to remain in the field despite stressful work conditions.Methods An exploratory descriptive analysis of qualitative data obtained from semistructured interviews with 19 community residential DSPs in Ontario, Canada, was conducted. Data were analysed for modes of entry into the field and reasons for remaining.Results DSPs are motivated to remain in the sector because of the people supported, the nature of the work and the work environment, practical reasons like job security, and personal ambitions and reward. Most staff are motivated in multiple domains.Conclusion Future research can use these findings to further explore DSP work motivations and relationships to job performance and turnover. For researchers and human resource practitioners, adapting existing models and measures of organ...

Revisions to the posttraumatic stress disorder (PTSD) diagnostic criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) clarify that secondary exposure can lead to the development of impairing symptoms requiring treatment. Historically known as secondary traumatic stress (STS), this reaction occurs through repeatedly hearing the details of traumatic events experienced by others. Professionals who work therapeutically with trauma victims may be at particular risk for this exposure. This meta-analysis of 38 published studies examines 17 risk factors for STS among professionals indirectly exposed to trauma through their therapeutic work with trauma victims. Small significant effect sizes were found for trauma caseload volume (r = .16), caseload frequency (r = .12), caseload ratio (r = .19), and having a personal trauma history (r = .19). Small negative effect sizes were found for work support (r = -.17) and social support (r = -.26). Demographic variables appear to be less implicated although more work is needed that examines the role of gender in the context of particular personal traumas. Caseload frequency and personal trauma effect sizes were moderated by year of publication. Future work should examine the measurement of STS and associated impairment, understudied risk factors, and effective interventions.

BACKGROUND As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A1c (HbA1c) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear. OBJECTIVE The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA1c levels compared with controls. METHODS The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app. RESULTS The results of an analysis of covariance controlling for baseline HbA1c levels did not show evidence of intervention impact on HbA1c levels at 3 months (mean difference [ITG−WLC] −0.42, 95% CI −1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants’ 3-month HbA1c levels (95% CI −0.03 to −0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51). CONCLUSIONS The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed. CLINICALTRIAL Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)

BackgroundAs the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A1c (HbA1c) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear. ObjectiveThe primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA1c levels compared with controls. MethodsThe study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app. ResultsThe results of an analysis of covariance controlling for baseline HbA1c levels did not show evidence of intervention impact on HbA1c levels at 3 months (mean difference [ITG−WLC] −0.42, 95% CI −1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants’ 3-month HbA1c levels (95% CI −0.03 to −0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51). ConclusionsThe results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed. Trial RegistrationClinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)

PURPOSE Depression comorbid with cardiovascular disease is associated with higher rates of morbidity and mortality, with studies suggesting that this is especially true among women. This study examined depressive symptoms and their relationship to cardiac risk factors among women referred to a women's cardiac rehabilitation and primary prevention program. METHODS A secondary analysis of data collected between 2004 and 2014 for 1075 women who completed a baseline assessment at the Women's Cardiovascular Health Initiative, a women-only cardiac rehabilitation and prevention program in Toronto, Canada. Descriptive statistics for sociodemographic variables, quality of life (SF-36), and cardiac risk factors were stratified by depression symptom severity using cutoff scores from the Beck Depression Inventory-2nd version (BDI-II) and compared with analysis of variance and χ statistics. Prevalence of antidepressant use among those with moderate to high depressive symptoms was assessed as an indicator of under- or untreated depression. RESULTS Overall, 38.6% of women scored above the BDI-II cutoff for depression; 23.6% in the moderate or severe range. Socioeconomic status and quality of life decreased with increasing depression severity. Body mass index increased with depressive severity (P < .001), as did the percentage of individuals with below target age predicted fitness (P < .001). Only 39.0% of women in the moderate and severe BDI-II groups were taking antidepressants. CONCLUSION In this sample, we found a significant prevalence of untreated and undertreated depressive symptoms among women with, or at high risk of developing, cardiovascular disease. Additional strategies are needed to identify these patients early and link them to appropriate treatment.

Many direct support providers (DSPs) are exposed to aggressive behaviour in their work supporting adults with developmental disabilities service recipients. This is a work environment factor that has been linked to job burnout. The objective of this study was to examine the impact of positive work factors on emotional exhaustion (EE) among DSPs who are exposed to aggressive behaviour. Survey responses from 671 DSPs who were working in community service settings for adults with developmental disabilities, and were exposed to aggressive behaviour at least monthly were examined. Hierarchical linear regression examined the direct contribution and moderating role of positive work factors (self-efficacy for dealing with aggression and work contributions) on EE measured with the Maslach Burnout Inventory-Human Services Survey, after controlling for demographics, occupational variables, exposure to aggression and negative emotional reactions to aggression. Results showed that younger age, more experience, more depression/anger emotions in response to aggression, lower self-efficacy and low positive work contributions were significantly associated with EE. Positive work motivation was a moderator of exposure to aggression and EE. When work motivations were low, DSPs were more negatively affected by higher exposure to aggression. These findings suggest that in addition to addressing the negative emotional reactions to the aggressive behaviour encountered at work, it is also important to foster positive work factors which may be protective against EE.

BACKGROUND Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. OBJECTIVE In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences. METHODS This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders—6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers—participated in this study. RESULTS The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case. CONCLUSIONS Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.

Objective To understand whether high-cost users of medical care with and without comorbid mental illness or addiction differ in terms of their sociodemographic and health characteristics. Unique characteristics would warrant different considerations for interventions and service design aimed at reducing unnecessary health care utilization and associated costs. Methods From the top 10% of Ontarians ranked by total medical care costs during fiscal year 2011/2012 (N = 314,936), prior 2-year mental illness or addiction diagnoses were determined from administrative data. Sociodemographics, medical illness characteristics, medical costs, and utilization were compared between those high-cost users of medical care with and without comorbid mental illness or addiction. Odds of being a frequent user of inpatient (≥3 admissions) and emergency (≥5 visits) services were compared between groups, adjusting for age, sex, socioeconomic status and medical illness characteristics. Results High-cost users of medical care with comorbid mental illness or addiction were younger, had a lower socioeconomic status, had greater historical medical morbidity, and had higher total medical care costs (mean excess of $2,031/user) than those without. They were more likely to be frequent users of inpatient (12.8% vs 10.2%; adjusted OR, 1.14; 95% CI: 1.12–1.17) and emergency (8.4% vs 4.8%; adjusted OR, 1.55; 95% CI: 1.50–1.59) services. Effect sizes were larger in major mood, psychotic, and substance use disorder subgroups. Conclusions High-cost medical care users with mental illness or addiction have unique characteristics with respect to sociodemographics and service utilization patterns to consider in interventions and policies for this patient group.

Background: The increasing use of Web-based solutions for health prevention and promotion presents opportunities to improve self-management and adherence to guideline-based therapy for individuals with type 2 diabetes (T2DM). Despite promising preliminary evidence, many users stop using Web-based solutions due to the burden of data entry, hidden costs, loss of interest, and a lack of comprehensive features. Evaluations tend to focus on effectiveness or impact and fail to evaluate the nuanced variables that may interact to contribute to outcome success (or failure). Objective: This study aimed to evaluate a Web-based solution for improving self-management in T2DM to identify key combinations of contextual variables and mechanisms of action that explain for whom the solution worked best and in what circumstances. Methods: A qualitative realist evaluation was conducted with one-on-one, semistructured telephonic interviews completed at baseline, and again toward the end of the intervention period (3 months). Topics included participants’ experiences of using the Web-based solution, barriers and facilitators of self-management, and barriers and facilitators to effective use. Transcripts were analyzed using thematic analysis strategies, after which the key themes were used to develop statements of the relationships between the key contextual factors, mechanisms of action, and impact on the primary outcome (glycated hemoglobin, HbA1c). Results: Twenty-six interviews (14 baseline, 12 follow-up) were completed with 16 participants with T2DM, and the following 3 key groups emerged: the easiest fit, the best fit, and those who failed to activate. Self-efficacy and willingness to engage with the solution facilitated improvement in HbA1c, whereas competing priorities and psychosocial issues created barriers to engagement. Individuals with high baseline self-efficacy who were motivated, took ownership for their actions, and prioritized diabetes management were early and eager adopters of the app and recorded improvements in HbA1c over the intervention period. Individuals with moderate baseline self-efficacy and no competing priorities, who identified gaps in understanding of how their actions influence their health, were slow to adopt use but recorded the greatest improvements in HbA1c. The final group had low baseline self-efficacy and identified a range of psychosocial issues and competing priorities. These participants were uncertain of the benefits of using a Web-based solution to support self-management, ultimately resulting in minimal engagement and no improvement in HbA1c. Conclusions: Self-efficacy, competing priorities, previous behavior change, and beliefs about Web-based solutions interact to determine engagement and impact on the clinical outcomes. Considering the balance of these patient characteristics is likely to help health care providers identify individuals who are apt to benefit from a Web-based solution to support self-management of T2DM. Web-based solutions could be modified to incorporate the existing screening measures to identify individuals who are at risk of suboptimal adherence to inform the provision of additional support(s) as needed. [J Med Internet Res 2018;20(3):e81]

Aim The aim of this study was to fill a gap in the literature by examining agreement on need as rated by clients and their key workers from first-episode psychosis early intervention programmes. Compared with adult populations and more chronic courses of illness, these clients may have unique needs given the onset of their illness in adolescence or early adulthood. Methods Needs agreement between clients and key workers was assessed using the Camberwell Assessment of Need in a sample of 188 client–key worker pairs recruited from six early intervention programmes in Ontario, Canada. Ratings were assessed with percentage agreement and prevalence-adjusted Cohen's kappa. Results At the aggregate level, both clients and key workers rated a mean of 2.6 unmet needs. Compared with other diagnoses, key workers rated significantly more unmet need in clients with primary psychotic disorders. Agreement between individual client and key worker ratings was highest (adjusted κ > 0.85) in the domains of telephone, risk to others, child care and accommodation. Lowest agreement (adjusted κ

Research on staff supporting individuals with intellectual and developmental disabilities (IDD) tends to focus on negative aspects of the work. This study expanded on previous research on the positive consequences that work in the IDD field has on staff using a brief version of the Staff Positive Contributions Questionnaire with 926 staff. Factor analysis suggested two factors: General positive contributions and Positive work motivation. Positive work motivation was associated with high levels of personal accomplishment, but shared limited variance with the other two burnout dimensions (emotional exhaustion, depersonalization). Findings lend support to the idea that we need to consider both positive and negative aspects of work life. This brief scale may be a useful index of how staff benefit from their work.

Background Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support. Objective The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care. Methods A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers. Results Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (−1.83 points, 95% CI −2.85 to −0.82) and GAD-7 score (−1.55 points, 95% CI −2.42 to −0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group. Conclusions The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions. Trial Registration ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO)

Integrating care for physical health and behavioural health (mental health and addictions) has been a longstanding challenge, although research supports the clinical and cost effectiveness of integrated care for many clients. In one such model, primary care (PC) physicians work with specialist physicians and non-physician providers (NPPs) to provide mental health and addictions care in PC settings. This Ontario, Canada-focused policy analysis draws on research evidence to examine potential barriers and enablers to this model of integrated care, focusing on mental health. Funding challenges pertain to incentivizing PC physicians to select patients with mental illness, include NPPs on the treatment team, and collaborate with specialist providers. Legal/regulatory challenges pertain to NPP scopes of practice for prescribing and counselling. Integrated care also requires revising the role of the physician and distribution of functions among the team. Policy support to integrate addictions treatment in PC may face similar challenges but requires further exploration.

Experiencing aggressive behaviour has been associated with increased stress and turnover among staff who support adults with intellectual disabilities. Incident perception is a strong predictor of psychological outcomes after trauma but has not been studied in this staff group. This study clustered exposure to aggression and endorsement of emotional difficulties among 386 community residential group home staff and evaluated the contribution of four behavioural topographies to staff-rated perceived severity. Staff exposure varied considerably. Perceived severity correlated with subjective emotional difficulties. High perceived severity was associated with daily exposure, aggression towards others causing injury, and property aggression causing injury or damage. Therefore, the role the staff plays, whether a witness or target, may impact their experience.

Objective: To quantify the burden of mental illness and addiction among high-costing users of medical services (HCUs) using population-level data from Ontario, and compare to a referent group of nonusers. Method: We conducted a population-level cohort study using health administrative data from fiscal year 2011-2012 for all Ontarians with valid health insurance as of April 1, 2011 ( N = 10,909,351). Individuals were grouped based on medical costs for hospital, emergency, home, complex continuing, and rehabilitation care in 2011-2012: top 1%, top 2% to 5%, top 6% to 50%, bottom 50%, and a zero-cost nonuser group. The rate of diagnosed psychotic, major mood, and substance use disorders in each group was compared to the zero-cost referent group with adjusted odds ratios (AORs) for age, sex, and socioeconomic status. A sensitivity analysis included anxiety and other disorders. Results: Mental illness and addiction rates increased across cost groups affecting 17.0% of the top 1% of users versus 5.7% of the zero-cost group (AOR, 3.70; 95% confidence interval [CI], 3.59 to 3.81). This finding was most pronounced for psychotic disorders (3.7% vs. 0.7%; AOR, 5.07; 95% CI, 4.77 to 5.38) and persisted for mood disorders (10.0% vs. 3.3%; AOR, 3.52; 95% CI, 3.39 to 3.66) and substance use disorders (7.0% vs. 2.3%; AOR, 3.82; 95% CI, 3.66 to 3.99). When anxiety and other disorders were included, the rate of mental illness was 39.3% in the top 1% compared to 21.3% (AOR, 2.39; 95% CI, 2.34 to 2.45). Conclusions: A high burden of mental illness and addiction among HCUs warrants its consideration in the design and delivery of services targeting HCUs.

Studies have shown that there is an association between exposure to people with intellectual disability who are aggressive and burnout in the staff who support them. Little is known, however, about the experience of summer camp staff who work with this population. This study examined the relationship between aggression and burnout in 169 staff members working at summer camps in Ontario, Canada. The questionnaire used included demographic information, exposure to aggression (frequency and severity), and the Maslach Burnout Inventory—Human Services Survey. Results showed that summer camp staff was exposed to frequent and relatively severe aggression. Severe exposure was associated with higher levels of emotional exhaustion and personal accomplishment. Given that summer camp staff is likely to be exposed to at least some aggression in their summer job, and that this aggression is associated with burnout, greater attention should be paid to training and supporting staff for when aggression occurs.