Connecting again with elders in our community: A project to stay together during COVID-19 restrictions and beyond

COVID-19 government regulations resulted in increased social isolation, risk of stress, depression, anxiety, cognitive decline, and re-hospitalization. Telehealth has been highlighted as a potential bridge for healthcare needs, especially in the COVID-19 context. In response to this need our group developed a multicultural, intergenerational, community-based psychosocial intervention. We trained more than 300 volunteers who were able to provide friendly phone support in more than 17 languages to more than 600 older adults across the Greater Montreal Area who could benefit from social connection and support to access community resources. The experience has been heartwarming and facilitating enriching life experiences for seniors, volunteers, and clinicians alike. Furthermore, some preliminary observations suggest that this intervention might have positive effects on the seniors’ mental health

Assessing cardiometabolic parameter monitoring in inpatients taking a second-generation antipsychotic : the CAMI-SGA study – a crosssectional study

Objectives This study aims to determine the proportion of initial cardiometabolic assessment and its predicting factors in adults with schizophrenia, bipolar disorder or other related diagnoses for whom a second-generation antipsychotic was prescribed in the hospital setting. Design Cross-sectional study. Setting The psychiatry unit of a Canadian tertiary care teaching hospital in Montreal, Canada. Participants 402 patients with aforementioned disorders who initiated, restarted or switched to one of the following antipsychotics: clozapine, olanzapine, risperidone, paliperidone or quetiapine, between 2013 and 2016. Primary outcome measures We assessed the proportion of cardiometabolic parameters monitored. Secondary outcome measures We identified predictors that influence the monitoring of cardiometabolic parameters and we assessed the proportion of adequate interventions following the screening of uncontrolled blood pressure and fasting glucose or glycated haemoglobin (HbA1c) results. Results Only 37.3% of patients received monitoring for at least three cardiometabolic parameters. Blood pressure was assessed in 99.8% of patients; lipid profile in 24.4%; fasting glucose or HbA1c in 33.3% and weight or body mass index in 97.8% of patients while waist circumference was assessed in 4.5% of patients. For patients with abnormal blood pressure and glycaemic values, 42.3% and 41.2% subsequent interventions were done, respectively. The study highlighted the psychiatric diagnosis (substance induced disorder OR 0.06 95% CI 0.00 to 0.44), the presence of a court-ordered treatment (OR 0.79 95% CI 0.35 to 1.79) and the treating psychiatrist (up to OR 34.0 95% CI 16.2 to 140.7) as predictors of cardiometabolic monitoring. Conclusions This study reports suboptimal baseline cardiometabolic monitoring of patients taking an antipsychotic in a Canadian hospital. Optimising collaboration within a multidisciplinary team may increase cardiometabolic monitoring

The Montreal model: an integrative biomedical-psychedelic approach to ketamine for severe treatment-resistant depression

BackgroundSubanesthetic ketamine has accumulated meta-analytic evidence for rapid antidepressant effects in treatment-resistant depression (TRD), resulting in both excitement and debate. Many unanswered questions surround ketamine’s mechanisms of action and its integration into real-world psychiatric care, resulting in diverse utilizations that variously resemble electroconvulsive therapy, conventional antidepressants, or serotonergic psychedelics. There is thus an unmet need for clinical approaches to ketamine that are tailored to its unique therapeutic properties.MethodsThis article presents the Montreal model, a comprehensive biopsychosocial approach to ketamine for severe TRD refined over 6 years in public healthcare settings. To contextualize its development, we review the evidence for ketamine as a biomedical and as a psychedelic treatment of depression, emphasizing each perspectives’ strengths, weaknesses, and distinct methods of utilization. We then describe the key clinical experiences and research findings that shaped the model’s various components, which are presented in detail.ResultsThe Montreal model, as implemented in a recent randomized clinical trial, aims to synergistically pair ketamine infusions with conventional and psychedelic biopsychosocial care. Ketamine is broadly conceptualized as a brief intervention that can produce windows of opportunity for enhanced psychiatric care, as well as powerful occasions for psychological growth. The model combines structured psychiatric care and concomitant psychotherapy with six ketamine infusions, administered with psychedelic-inspired nonpharmacological adjuncts including rolling preparative and integrative psychological support.DiscussionOur integrative model aims to bridge the biomedical-psychedelic divide to offer a feasible, flexible, and standardized approach to ketamine for TRD. Our learnings from developing and implementing this psychedelic-inspired model for severe, real-world patients in two academic hospitals may offer valuable insights for the ongoing roll-out of a range of psychedelic therapies. Further research is needed to assess the Montreal model’s effectiveness and hypothesized psychological mechanisms

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe

Evaluating the Clinical Feasibility of an Artificial Intelligence-Powered, Web-Based Clinical Decision Support System for the Treatment of Depression in Adults: Longitudinal Feasibility Study.

BACKGROUND: Approximately two-thirds of patients with major depressive disorder do not achieve remission during their first treatment. There has been increasing interest in the use of digital, artificial intelligence-powered clinical decision support systems (CDSSs) to assist physicians in their treatment selection and management, improving the personalization and use of best practices such as measurement-based care. Previous literature shows that for digital mental health tools to be successful, the tool must be easy for patients and physicians to use and feasible within existing clinical workflows. OBJECTIVE: This study aims to examine the feasibility of an artificial intelligence-powered CDSS, which combines the operationalized 2016 Canadian Network for Mood and Anxiety Treatments guidelines with a neural network-based individualized treatment remission prediction. METHODS: Owing to the COVID-19 pandemic, the study was adapted to be completed entirely remotely. A total of 7 physicians recruited outpatients diagnosed with major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Patients completed a minimum of one visit without the CDSS (baseline) and 2 subsequent visits where the CDSS was used by the physician (visits 1 and 2). The primary outcome of interest was change in appointment length after the introduction of the CDSS as a proxy for feasibility. Feasibility and acceptability data were collected through self-report questionnaires and semistructured interviews. RESULTS: Data were collected between January and November 2020. A total of 17 patients were enrolled in the study; of the 17 patients, 14 (82%) completed the study. There was no significant difference in appointment length between visits (introduction of the tool did not increase appointment length; F2,24=0.805; mean squared error 58.08; P=.46). In total, 92% (12/13) of patients and 71% (5/7) of physicians felt that the tool was easy to use; 62% (8/13) of patients and 71% (5/7) of physicians rated that they trusted the CDSS. Of the 13 patients, 6 (46%) felt that the patient-clinician relationship significantly or somewhat improved, whereas 7 (54%) felt that it did not change. CONCLUSIONS: Our findings confirm that the integration of the tool does not significantly increase appointment length and suggest that the CDSS is easy to use and may have positive effects on the patient-physician relationship for some patients. The CDSS is feasible and ready for effectiveness studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT04061642; http://clinicaltrials.gov/ct2/show/NCT04061642

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142934/1/bdi12609.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142934/2/bdi12609_am.pd

Nephrogenic diabetes insipidus, chronic kidney injury, and other medical disorders in older lithium users

Background: Although it is an important treatment for bipolar disorder and depression, lithium has been associated with several medical illnesses, including nephrogenic diabetes insipidus (NDI) and chronic kidney disease (CKD). These and other medical effects remains poorly understood in older lithium users, who may be most vulnerable. As a large proportion of lithium-using patients approaches late life, there remain a number of unanswered questions, including: Is lithium-associated medical comorbidity different in geriatric compared to adult lithium users? What are the independent clinical correlates of NDI and CKD in lithium-exposed patients? Answers to these questions may contribute to the eventual development of care approaches that lower medical comorbidity in older lithium users.Methods: This was a cross-sectional study of 45 geriatric (age≥65) and 55 adult (age 18-64) lithium-exposed outpatients. Patients underwent medical laboratory tests, including urine osmolality (UOsm) and estimated glomerular filtration rate (eGFR). We compared rates of medical comorbidity (NDI (UOsm <300mOsm/Kg), CKD (eGFR <60mL/min/1.73m2), hypothyroidism, hypercalcemia, hypercholesterolemia, diabetes mellitus, and hypertension) between geriatric and adult patients. We also performed multivariate analyses to examine potential correlates of NDI and CKD.Results: Geriatric and adult lithium users had similar rates of decreased UOsm (12.5% vs. 17.9%, p=0.74), but geriatric patients reported less symptoms (p<0.05). Hypertension, diabetes mellitus and hypercholesterolemia, hypothyroidism and CKD were common amongst all lithium users (>19%), but was more prevalent in late life. Age, lithium duration, and serum lithium level were independently associated with decreased UOsm. Age, hypertension, and UOsm, but not lithium duration were independently correlated with both CKD and decreased eGFR.Conclusions: Medical comorbidities are common in lithium users, especially among elderly users. We recommend clinical monitoring for NDI, CKD, hypothyroidism, dyslipidemia, diabetes mellitus, and hypertension in older lithium users. Lithium users with advanced age, longer duration of lithium exposure, and higher lithium levels are more prone to decreased UOsm and NDI. Likewise, lithium users who are older, hypertensive, and have lower UOsm have a higher probability of having CKD. Prospective longitudinal studies will be needed to better understand the risk factors for and molecular mechanisms underlying medical comorbidities in lithium users.Introduction: Même si c'est une traitement importante pour les troubles bipolaire et dépressifs, lithium est associé avec plusieurs conditions physiques, incluant le diabète insipide néphrogénique (DIN) et l'insuffisance rénale chronique (IRC). Les effets médicaux reste mal compris dans les utilisateurs de lithium gériatrique, qui sont vulnérables. Comme une grande proportion des utilisateurs de lithium vieillissent, il reste un certain nombre de questions sans réponse: Est-ce que la comorbidité médicale associée avec lithium est différent dans les patients gériatriques et adultes? Quels sont les corrélats cliniques indépendantes de DIN et IRC chez les patients prenant de lithium? Les réponses à ces questions peuvent contribuer à l'élaboration éventuelle d'approches de soins qui pourraient diminuer la comorbidité médicale dans les utilisateurs de lithium gériatrique.Méthodes: Ceci est une étude transversale de 45 patients gériatrique (âge ≥ 65) et 55 patients adultes (18-64 ans) exposée au lithium. Les patients ont subi des tests de laboratoire médical, y compris: l'osmolalité urinaire (UOsm) et le taux de filtration glomérulaire estimé (eGFR). Nous avons comparé les taux de comorbidité médicale (DIN (UOsm < 300mOsm/Kg )), IRC (eGFR < 60mL/min/1.73m2), l'hypothyroïdie, hypercalcémie, l'hypercholestérolémie, le diabète et l'hypertension) entre les patients gériatriques et adultes. Nous avons également effectué des analyses multivariée pour examiner les corrélats potentiels de NDI et IRC.Résultats: Les utilisateurs de lithium gériatriques et adultes ont eu des taux similaires de UOsm diminué (12,5% vs 17,9% , p = 0,74), mais les patients gériatriques ont rapporté moins de symptômes (p <0,05). L’hypertension, la diabète, l'hypercholestérolémie, l'hypothyroïdie et CKD étaient communs parmi tous les utilisateurs de lithium (>19%), mais étaient plus fréquente en fin de vie. L'âge, la durée de lithium, le niveau de lithium sérique ont été associés de façon indépendante avec l’UOsm diminué. L'âge, l'hypertension, et l’UOsm diminué, mais pas la durée de lithium ont été corrélées de façon indépendante avec IRC et le eGFR diminué.Conclusions : Les comorbidités médicales sont fréquentes chez les usagers de lithium, en particulier chez les utilisateurs âgés. Nous recommandons une surveillance clinique de DIN, IRC, l'hypothyroïdie, la dyslipidémie, le diabète, et l'hypertension dans les utilisateurs de lithium geriatrique. Personnes avec l'âge avancé, durée d'exposition au lithium, et les niveaux de lithium plus élevés sont plus enclins à l’Uosm diminué et DIN. Les utilisateurs de lithium qui sont plus âgés, hypertendus, et avec l’UOsm diminué ont une probabilité plus élevée d'avoir IRC. Des études longitudinales prospectives seront nécessaires pour mieux comprendre les facteurs de risque et les mécanismes moléculaires sous-jacents comorbidités médicales chez les utilisateurs de lithiu

Update on the Epidemiology, Diagnosis, and Treatment of Mania in Older-Age Bipolar Disorder

Purpose of Review: The population over age 60 is growing more rapidly than the general population. Given the projected increase and need for data that can inform treatment, this review provides a brief description of newer publications focused on mania in older-age bipolar disorder (OABD), including epidemiology, diagnosis, and treatments. Recent Findings: Age cutoffs to define OABD range from 50 to 65 years. OABD clinical presentation and course of illness is highly variable, often characterized by mood episode recurrence, medical comorbidity, cognitive deficits, and impaired functioning. There is little pharmacotherapy data on mania in OABD. Lithium and valproate have been tested in a single randomized controlled trial and there is data of more limited quality with other compounds. Summary: Treating OABD is challenging due to medical complexity, comorbidity, diminished tolerance to treatment, and a limited evidence base. More data is needed to keep pace with clinical demand