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Patients with treatment-resistant unipolar depression (TRD) are treated with antidepressant combinations (ADs) or with second-generation antipsychotics plus AD (SGA+AD) augmentation; however, the clinical characteristics, the factors associated independently with response to SGA+AD, and the outcome trajectories have not yet been characterized. We performed a naturalistic study on the latest stable trial (medication unchanged for about 3 months) in 86 TRD patients with resistance to at least two ADs trials, who received ADs (n=36) or SGA+AD (n=50) treatments. Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton-Depression Rating Scale (HAM-D17), and other scales were administered before (T0) and after the latest 3-month stable trial (T3). Compared to ADs, the SGA+AD group showed increased percentage of depression with psychotic features, comorbidity for personality disorders and substance use disorders (SUD), higher number of failed ADs pharmacotherapies and depressive symptoms at T0 on all scales (P

This study examined whether the number of emergency department visits for "mental and psychosocial problems" varies with temperature or humidity.The number of visits in three geographic areas of Québec were examined as a function of temperature and humidity by using routinely collected May-September data for 1995-2007 (N=347,552 visits). Data for two age groups (under age 65 and age 65 and older) were examined. Incidence rate ratios for mean temperature and humidity were estimated by using Poisson regression and generalized additive models.The number of visits tended to increase with increasing mean temperature. At 22.5 °C (72.5 °F) and 25 °C (77.0 °F), the number was usually significantly higher than average. Visits increased with humidity in the younger age group.Results suggest increased use of emergency departments for mental and psychosocial problems with higher mean temperature and humidity, especially in metropolitan areas and in southern Québec. Climate change may make this effect increasingly important.

Cet article vise à sensibiliser les professionnels de la santé aux effets de la chaleur accablante sur les personnes avec des troubles mentaux ou prenant certains médicaments, ces dernières étant particulièrement vulnérables aux maladies qui y sont liées. Aussi, compte tenu des changements climatiques, la menace de températures caniculaires ira en grandissant. L’auteur passe en revue les caractéristiques épidémiologiques, physiologiques et cliniques des maladies liées à la chaleur. Pour des soins aigus, il renvoie le lecteur aux lignes directrices existantes. L’auteur examine les facteurs de risque et de protection et présente les stratégies de prévention pour réduire l’impact des maladies liées à la chaleur auprès de cette population., This review is intended to alert health professionals to the particular vulnerability of persons with mental health problems or taking certain medications to heat-related illness, a threat that is increasing due to climate change. It reviews epidemiology, physiology and clinical features of heat-related illness. For acute medical management, it refers readers to existing guidelines and recommendations. It reviews risk and protective factors. Finally, it presents preventive strategies that may help reduce the impact of heat-related illness in this population., Este artículo busca sensibilizar a los profesionales de la salud en relación con la vulnerabilidad, particularmente de las personas que sufren de trastornos mentales o que toman ciertos medicamentos para las enfermedades ligadas al calor agobiante, amenaza que aumenta con los cambios climáticos. El autor repasa las características epidemiológicas, fisiológicas y clínicas de las enfermedades relacionadas con el calor. Remite al lector a las líneas directrices y las recomendaciones en curso para los cuidados agudos. Examina los factores de riesgo y protección. Por último, el autor presenta las estrategias de prevención para reducir el impacto de las enfermedades relacionadas con el calor en este tipo de población., Este artigo visa sensibilizar os profissionais da saúde à vulnerabilidade particular das pessoas que sofrem de transtornos mentais ou que fazem uso de alguns medicamentos para tratar de doenças ligadas às ondas de calor, uma ameaça cada vez maior com as mudanças climáticas. O autor passa em revista as características epidemiológicas, fisiológicas e clínicas das doenças ligadas ao calor. Para cuidados em casos de doenças agudas, ele remete o leitor às linhas diretrizes e às recomendações atuais. O autor examina os fatores de risco e de proteção. Finalmente, ele apresenta as estratégias de prevenção para reduzir o impacto das doenças ligadas ao calor junto a esta população.

Background: Respirable crystalline silica is a highly prevalent occupational exposure and a recognized lung carcinogen. Most previous studies have focused on selected high-exposure occupational groups. This study examines the relationship between occupational exposure to silica and lung cancer in an occupationally diverse male population. Methods: Two large population-based case-control studies of lung cancer were conducted in Montreal, one in 1979-1986 (857 cases, 533 population controls, 1,349 cancer controls) and the second in 1996-2001 (738 cases and 899 controls). Interviews provided descriptive lifetime job histories, smoking histories, and other information. Industrial hygienists translated job histories into histories of exposure to a host of occupational substances, including silica. Relative risk was estimated, adjusting for several potential confounders, including smoking. Results: The odds ratio for substantial exposure to silica was 1.67 (95% confidence interval, 1.21-2.31) and for any exposure was 1.31 (95% confidence interval, 1.08-1.59). Joint effects between silica and smoking were between additive and multiplicative, perhaps closer to the latter. In this population, it is estimated that approximately 3% of lung cancers were attributable to substantial silica exposure. Conclusions: The carcinogenicity of inhaled crystalline silica was observed in a population with a wide variety of exposure circumstances. Impact: The finding of carcinogenicity across a wide range of occupations complements prior studies of specific high-exposure occupations. This suggests that the burden of cancer induced by silica may be much greater than previously thought. Cancer Epidemiol Biomarkers Prev; 19(6); 1602–11. ©2010 AACR.

Background: It is unclear whether there is a relationship between lithium administration and vitamin B12 metabolism. Methods: We compared serum B12, serum folate, and red blood cell folate concentrations in patients receiving and not receiving lithium at two Mood Disorders Clinics. As the two centers differed in vitamin assay methods, data were first analyzed separately and then combined. To rule out an in vitro effect of lithium on the assays, we also added varying amounts of lithium to lithium-free blood samples and measured vitamin concentrations. Results: Mean serum B12 concentrations were approximately 20% lower in the lithium than in the nonlithium group at each center. This difference was statistically significant for each center and on combination (two-tailed p = .017, .021, and .0009). The parametric effect size for each center and the combined weighted mean effect size were moderate in magnitude (.605, .523, and .565). There was a nonsignificant trend toward an increased prevalence of assay-defined B12 deficiency in the lithium group at one center only, with no cases in either group at the other center and a nonsignificant combined relative risk. Conclusions: Our data may represent a lithium-associated decrease in serum B12 concentration. The clinical significance of these findings is not yet clear.

This review is intended to alert health professionals to the particular vulnerability of persons with mental health problems or taking certain medications to heat-related illness, a threat that is increasing due to climate change. It reviews epidemiology, physiology and clinical features of heat-related illness. For acute medical management, it refers readers to existing guidelines and recommendations. It reviews risk and protective factors. Finally, it presents preventive strategies that may help reduce the impact of heat-related illness in this population.

Abuse and neglect of the elderly represent an important social problem in Canada. Forms of elder abuse and neglect include physical, psychological and material abuse; neglect, both intentional and unintentional; and violation of legal rights. The definitions, signs, and symptoms of elder abuse and neglect are discussed, as are estimates of incidence and prevalence, and descriptions of possible risk factors. The evolution of legislation regarding the reporting of elder abuse and neglect is reviewed, as are relevant areas of common law, the Civil Code, and the Criminal Code. This is followed by an overview of practical considerations in clinical management, and finally by recommendations for further research.

This study compares the performance of the Cornell Scale for Depression in Dementia (CSDD) and the Hamilton Depression Scale (HDS) in detecting Research Diagnostic Criteria (RDC) major depression in subjects with mild-to-moderate Alzheimer's disease (AD). Thirty-four subjects with this diagnosis and their caregivers were interviewed. The senior author conducted a diagnostic interview to determine RDC diagnosis. An investigator, blind to diagnosis, obtained demographic information and administered the Mini Mental State Examination, Global Deterioration Scale, CSDD and HDS. For each depression scale, the correlation with the RDC diagnosis of major depression was calculated, as were the sensitivity and specificity at various cutoff scores. Nonparametric receiver operating characteristic analysis was used to compare the performance of the two scales. The area under the receiver operating characteristic curve was .91 for the CSDD and .87 for the HDS. This differed from chance to a highly significant degree for both the CSDD and the HDS but the difference between the two scales was not statistically significant. Although the precision of the present study is limited by the small sample size, a cutpoint of 7 provided reasonable performance for both the CSDD and the HDS, yielding a sensitivity of .90 for both scales and a specificity of .75 for the CSDD and 0.63 for the HDS. Although the CSDD and the HDS are rating scales rather than diagnostic instruments, receiver operating characteristic analysis indicates that both demonstrate statistically significant discriminating ability for RDC major depression in mild to moderate, probable AD. Our data suggest that for most clinical purposes, a cutpoint of 7 may be suitable for the detection of RDC major depression in mild-to-moderate probable AD.

Background: While antipsychotic (AP) medications are frequently used in long-term care, current evidence suggests that the risks may offset the benefits, necessitating periodic reassessment of their use. The aims of this present study were: (1) to assess rates of AP use five years after our first intervention to determine the long-term impact; and (2) to implement an updated AP reduction educational intervention program at the same center five years later in order to determine whether AP use could be further reduced.Methods: Participants were residents with dementia receiving AP medication. The educational program component included separate lectures on pharmacologic and non-pharmacologic treatment of behavioral and psychological symptoms of dementia (BPSD). Completion of the Nursing Home Behavior Problems Scale (NHBPS), physician interviews concerning AP treatment plans for subjects with dementia, and AP administration and dose assessment occurred both at baseline and again between four to five months after the educational program.Results: Of 308 long-term residents with dementia, 53 (17.2%) were receiving regular APs, primarily for agitation, aggressivity, other behavioral problems and psychosis. Of these, six died and one was transferred, leaving 46 participants. At five months, ten (21.7%) residents were no longer receiving APs and seven (15.2%) were on a lower dose; thus, 17 (37.0%) were either discontinued or on a lower dose. There was no worsening of NHBPS scores.Conclusion: Despite the low prevalence (17.2%) of AP users at the beginning of the current study compared to that observed five years prior (30.5%), it is still possible to further decrease the proportion of users.

Sensitivity and specificity are key measures of the performance of a given test in detecting a given disorder. For tests yielding numerical scores, sensitivity and specificity usually vary inversely over the range of theoretically possible cutoff scores, complicating the task of quantifying and comparing the diagnostic accuracy of tests. Receiver Operating Characteristic analysis (ROC) approaches this problem by plotting the curve of sensitivity versus 1-specificity for all possible cutoff scores of the test. The area under the ROC curve (AUC) can be used to describe the diagnostic accuracy of the test. Parametric and non-parametric methods exist that allow the calculation of the AUC and the comparison of tests. A disadvantage of parametric formulations is the assumption of a normal or Gaussian distribution of test scores. The present article presents a computer program that utilizes non-parametric formulations that do not require the normal distribution of test scores. The program calculates the sensitivity and specificity of a test at all possible cutoff scores, plots the ROC curve, calculates the AUC, its standard error and 95% confidence limits, and allows the comparison of tests on independent and correlated samples.

The behaviour profiles of 176 mentally retarded individuals from two reception centres and nine group homes were assessed. The correlations between behaviour and age, sex, degree of mental retardation, etiology of mental retardation and medical diagnosis were assessed using the Revised Child Behaviour Profile. The severity of behaviour disturbance did not vary with age or medical diagnosis. The moderately retarded subjects presented with more severe behaviour problems, such as aggression, than the severely mentally retarded subjects. The variable most predictive of behavioural problems was etiology of the disorder. Individuals with Down's syndrome had significantly fewer behaviour disturbances and those with autism and pervasive developmental disorder had significantly more behaviour disturbances than other subjects. A psychiatric disorder was found in 10.2% of the sample. The implications of these findings are discussed with respect to public policy.

The use of confidence intervals to estimate population parameters is briefly reviewed. Exact binomial confidence intervals can be calculated through the use of tables or statistical software packages. As an alternative, a microcomputer program to calculate sensitivity and specificity, point estimates and binomial confidence intervals for false-negative and -positive rate, positive and negative predictive power, prevalence of cases and non-cases, correct classification rate, and misclassification rate has also been developed. Characteristics of the computer program, 'AccuCon', which is available from the authors, are described.

Objectives: To examine delirium, chronic medical problems and sociodemographic factors as predictors of activities of daily living (ADL), basic ADL (BADL) and instrumental ADL (IADL).Methods: A prospective cohort study of four groups of elderly patients examined in the emergency department (ED): those with delirium, dementia, neither, and both. All were aged 66 years or older and living at home. Delirium was assessed with the Confusion Assessment Method and dementia with the Informant Questionnaire on Cognitive Decline in the Elderly. Demographic variables and chronic medical problems were ascertained with questionnaires. Outcome was ADL at 6, 12 and 18 months, measured with the ADL subscale of the Older Americans Resources and Services instrument.Results: Univariate analyses suggested significantly poorer ADL, particularly IADL, at 18 months in the delirium versus the non-delirium group, in the absence of dementia only. Statistically significant independent predictors of poorer ADL at 18 months in the non-dementia groups were poorer initial ADL, stroke, Parkinson's disease, hypertension and female sex. Independent predictors of poorer BADL at 18 months in the non-dementia groups were poorer initial BADL, Parkinson's disease, stroke, cancer, colds/sinusitis/laryngitis, female sex and hypertension. Independent predictors of poorer IADL at 18 months in the non-dementia groups were poorer initial IADL, stroke, never-married status, colds/sinusitis/laryngitis, arthritis and hypertension, with Parkinson's disease showing a non-significant but numerically large regression coefficient.Conclusion: Rather than finding delirium to be a predictor of poorer functional outcome among survivors, we found an interaction between delirium and dementia and several plausible confounders, primarily chronic medical problems, although we cannot rule out the effect of misclassification or survivor bias.

Objective: To determine the prevalence and correlates of 4 types of elder abuse and neglect in a geriatric psychiatry service. Method: We conducted a cross-sectional retrospective chart review of new in- and outpatients seen by the Montreal General Hospital Division of Geriatric Psychiatry in one calendar year. Results: Abuse or neglect was suspected or confirmed in 20 (16%) of 126 patients, comprising financial abuse in 16 (13%), neglect in 7 (6%), emotional abuse in 5 (4%), physical abuse in 3 (2%), and multiple abuse in 7 (6%). On bivariate analysis, patients living with nonspouse family, friends, or other persons were significantly more likely to have suffered abuse than were those living with their spouse or in a supervised setting (OR 10.5; 95%CI, 2.3 to 47.8); widowed, divorced, or separated patients were significantly more likely to have suffered abuse than were married patients (OR 4.7; 95%CI, 1.02 to 22.0). Nonsignificant trends included female sex (OR 4.1; 95%CI, 0.89 to 18.6); alcohol abuse (OR 2.1; 95%CI, 0.71 to 6.2); behaviour problems (OR 1.9; 95%CI, 0.71 to 5.2); and chronic cognitive impairment (OR 1.4; 95%CI, 0.55 to 3.8). Although living situation with nonspouse family, friends, or others and marital status of widowed, divorced, or separated were significantly associated with abuse when examined in separate logistic regression models, both were nonsignificant when examined together, suggesting collinearity. Both were retained in the model because they probably represent different aspects of vulnerability. The final model included living situation with nonspouse family, friends, or others (OR 6.1; 95%CI, 0.75 to 49.5) and widowed, divorced, or separated marital status (OR 2.4; 95%CI, 0.21 to 26.8). Nonsignificant trends included female sex (OR 2.6; 95%CI, 0.45 to 14.4); alcohol abuse (OR 2.2; 95%CI, 0.59 to 7.9); and lowest quartile on the Global Assessment of Functioning (GAF) scale (GAF < 35; OR 2.0; 95%CI, 0.64 to 6.0). Conclusions: The practical implications of our study are that elder abuse and neglect are common among patients referred to geriatric psychiatry services, that such services should have access to multidisciplinary expertise and resources to deal with abuse, and that certain situations may signal higher risk. In our setting, the situation of living with nonspouse family, friends, or other persons in a nonsupervised setting and a history of family disruption by widowhood, divorce, or separation were significant correlates of abuse. Suggestive but nonsignificant trends of potential importance (OR > 2.0) included female sex, alcohol abuse, and lowest quartile of functional status. Study limitations include a cross-sectional retrospective chart review design, a clinically derived sample, a small sample size, and a lack of structured instruments for several variables.

This article reviews the reliability and validity of eight scales for behavior and mood problems that were identified in a comparative analysis ofAlzheimer's disease (AD) drug trials. The scales are the Brief Psychiatric Rating Scale, the Alzheimer's Disease Assessment Scale-noncognitive, the Relative's Assessment of Global Symptomatology, the Consortium to Establish a Registry for Alzheimer's Disease-Behavior Rating Scale for Dementia, the Dementia Behavior Disturbance scale, the Neuropsychiatric Inventory, and two scales for depressive symptoms, the Cornell Scale for Depression in Dementia and the Dementia Mood Assessment Scale. This article also examines methodological limitations in the way the published literature has assessed the psychometric properties of these scales. The aim is to help clinicians and potential trial investigators select appropriate measurement instruments with which to assess behavior and mood problems in AD and to assist AD researchers in the evaluation of the psychometric properties of such scales. (J Geriatr Psychiatry Neurol 2000; 13:181-196).

Due to the scarcity of clinical trials (CTs) directly comparing newer antidepressants, clinicians and reviewers often compare drugs on the basis of active drug and placebo-subtracted adverse event rates (AERs) published in references such as the Physician's Desk Reference in the United States, the Compendium of Pharmaceutical Specialities in Canada, and product monographs. This study examined the suitability of the above data and methods for comparing AERs of nine newer antidepressants: bupropion, citalopram, fluoxetine, fluvoxamine, moclobemide, nefazodone, paroxetine, sertraline, and venlafaxine. First, the authors examined data precision and comparability across drugs by analyzing placebo-arm AERs and their 95% confidence limits for each drug and by testing the homogeneity of placebo-arm AERs across drugs. The rationale was that placebo AER heterogeneity is likely a reflection of heterogeneity of nonpharmacologic factors among CTs. For all 16 adverse events examined, placebo AERs were found to be significantly heterogenous, suggesting significant nonpharmacologic heterogeneity across drugs. Second, using placebo AER heterogeneity as a measure of nonpharmacologic heterogeneity, the authors estimated the degree to which active drug and placebo-subtracted AERs were related to nonpharmacologic heterogeneity by estimating the degree of association between active drug and placebo AERs and between placebo-subtracted and placebo AERs. Also, 95% confidence limits for placebo-subtracted AERs were calculated. It was found that most active drug AERs and some placebo-subtracted AERs were significantly correlated with placebo AERs, suggesting a relationship with nonpharmacologic heterogeneity. Placebo-subtracted AERs were less strongly related than were active drug AERs. Finally, the authors discuss factors that may be associated with the observed heterogeneity and offer suggestions that may improve the methodology and reporting of CTs.

This study was undertaken to estimate the point-prevalence of Research Diagnostic Criteria (RDC) depressive syndromes in Alzheimer's disease (AD) and to evaluate the validity of existing and potential alternative diagnostic criteria for major depression in the presence of probable AD. Twenty-six subjects with probable AD of mild to moderate severity and their caregivers were interviewed to estimate the prevalence of RDC depressive syndromes. For the evaluation of the validity of RDC for major depression, an additional 8 probable-AD subjects with suspected depression were added to the sample. Sensitivity, specificity, and correlation with diagnosis of RDC major depression were calculated for each diagnostic criterion, and existing major depressive criteria were compared to potential alternative criteria currently used for RDC minor depression. Of the subjects in our prevalence sample, 15.4% were found to have major depression; 23.1%, minor depression; and 11.5%, intermittent depression. In our validation sample, two criteria for major depression, self-reproach/guilt and thinking/concentration difficulty, were weakly associated with the final diagnosis of major depression because of poor sensitivity or specificity. In contrast, three possible alternative criteria were significantly associated with the diagnosis of major depression and showed high sensitivity and specificity. These included nonverbal manifestations of depression, irritability/complaining, and demandingness/dependency. We conclude that RDC depressive syndromes are common in probable AD of mild to moderate severity. In the presence of AD, the validity of some existing major depressive criteria may be limited in comparison to several potential alternative criteria because of relatively poor sensitivity and/or specificity.

Several lines of evidence have implicated acetylcholine (ACh) as one of the neurotransmitters found to be decreased in Alzheimer's disease (AD). Various methods of cholinergic augmentation have been attempted, with mixed results. Tetrahydroaminoacridine (THA), an acetylcholinesterase inhibitor, is currently being investigated at the McGill Centre for Studies in Aging. Preliminary uncontrolled data from a 10-week clinical trial of THA and lecithin, reported elsewhere, suggest a clinically modest but statistically significant beneficial effect on cognition, although problems exist with side effects, particularly gastrointestinal. Since the suggestion by Janowsky in 1972 that cholinergic neurotransmission may exert an inhibitory or depressant effect on mood, the evidence accumulated in the literature has been inconclusive. We undertook to assess several potential pretreatment correlates of depressive symptoms in AD and to monitor the course of these symptoms during the 10 week treatment period, using the Geriatric Depression Scale (GDS) of Brink and Yesavage. Pretreatment GDS scores were found to correlate with degree of overall disability and dementia as measured by the Rapid Disability Rating Scale (RDRS) and the Mini Mental State Examination (MMS), respectively. GDS scores over the treatment period did not change to a statistically significant degree. The meaning of these results is discussed, particularly with reference to the difficulty of diagnosis and measurement of depression in the setting of dementia.

The literature on the phenomenology of childhood bereavement is reviewed. Several authors, particularly in the psychoanalytic literature, have suggested or supported the concept of “absence of grief” in children, based on the postulate that children are unable to tolerate the intense affects of mourning. More recently, systematic studies of nonclinical samples of bereaved children have found “absence of grief” to be uncommon, with most children in fact showing features such as sadness, crying, irritability, and a wide variety of other affective and behavioural symptoms. There does not appear to be a coherent syndrome of childhood bereavement, although tentative associations have been found between some phenomenological features and various child-related, family-related, societal, and circumstantial factors. The level of overall psychological adjustment after parental loss is both variable and controversial. Several tentative predictors of adverse reactions have been described. The possible place of childhood bereavement in current nosology is discussed. Preliminary evidence suggests that the phenomenology of childhood bereavement differs considerably from the DSM-III-R description of “uncomplicated bereavement.” Recent evidence suggests that the DSM-III-R concept of uncomplicated bereavement needs to be expanded to include many of the affective and behavioural features of childhood bereavement, although confirmatory controlled research is required. Suggestions for improvement of research designs are made.

Background There is conflicting evidence regarding the associations between cigarette smoking and glioma or meningioma. Our purpose is to provide further evidence on these possible associations. Methods We conducted a set of case–control studies in three Canadian cities, Montreal, Ottawa and Vancouver. The study included 166 subjects with glioma, 93 subjects with meningioma, and 648 population-based controls. A lifetime history of cigarette smoking was collected and various smoking indices were computed. Multivariable logistic regression was used to estimate odds ratios (ORs) between smoking and each of the two types of brain tumours. Results Adjusted ORs between smoking and each type of brain tumour were not significantly elevated for all smokers combined or for smokers with over 15 pack-years ((packs / day) x years) accumulated. We tested for interactions between smoking and several sociodemographic variables; the interaction between smoking and education on glioma risk was significant, with smoking showing an elevated OR among subjects with lower education and an OR below unity among subjects with higher education. Conclusion Except for an unexplained and possibly artefactual excess risk in one population subgroup, we found little or no evidence of an association between smoking and either glioma or meningioma.