Pan-Canadian study of psychiatric care (PCPC): protocol for a mixed-methods study.

INTRODUCTION: The Canadian population has poor and inequitable access to psychiatric care despite a steady per-capita supply of psychiatrists in most provinces. There is some quantitative evidence that practice style and characteristics vary substantially among psychiatrists. However, how this compares across jurisdictions and implications for workforce planning require further study. A qualitative exploration of psychiatrists' preferences for practice style and the practice choices that result is also lacking. The goal of this study is to inform psychiatrist workforce planning to improve access to psychiatric care by: (1) developing and evaluating comparable indicators of supply of psychiatric care across provinces, (2) analysing variations and changes in the characteristics of the psychiatrist workforce, including demographics and practice style and (3) studying psychiatrist practice choices and intentions, and the factors that lead to these choices. METHODS AND ANALYSIS: A cross-provincial mixed-methods study will be conducted in the Canadian provinces of British Columbia, Manitoba, Ontario and Nova Scotia. We will analyse linked-health administrative data within three of the four provinces to develop comparable indicators of supply and characterise psychiatric services at the regional level within provinces. We will use latent profile analysis to estimate the probability that a psychiatrist is in a particular practice style and map the geographical distribution of psychiatrist practices overlayed with measures of need for psychiatric care. We will also conduct in-depth, semistructured qualitative interviews with psychiatrists in each province to explore their preferences and practice choices and to inform workforce planning. ETHICS AND DISSEMINATION: This study was approved by Ontario Tech University Research Ethics Board (16637 and 16795) and institutions affiliated with the study team. We built a team comprising experienced researchers, psychiatrists, medical educators and policymakers in mental health services and workforce planning to disseminate knowledge that will support effective human resource policies to improve access to psychiatric care in Canada.

The Health and Psychosocial Profiles of Adults Who Sought Mental Health and Addiction Specialty Services Through a Centralized Intake Process in Nova Scotia in 2020 and 2021.

OBJECTIVES: (1) To calculate the proportions of people who sought mental health and addiction (MHA) specialty services in Nova Scotia, overall and by sex and age. (2) To describe the health and psychosocial profiles of the MHA Intake clients. (3) To identify factors associated with acceptance for MHA services. METHODS: The data of the Nova Scotia MHA Intake clients aged 19 to 64 years old in 2020 (N = 10,178) and in 2021 (N = 12,322) were used. The proportions of unique clients in the general population were calculated based on 2021 census data. The percentages of primary presenting concerns, the presence and frequency of psychiatric symptoms in the past month, suicide risk levels, current or past provisional psychiatric diagnosis, medical problems, and psychosocial stressors were calculated. Logistic regression was conducted to identify factors associated with the acceptance of MHA services after the assessment. RESULTS: It was found that 1.48% and 2.33% of Nova Scotians aged 19 to 64 contacted the MHA Intake in 2020 and 2021. Over 66% were self-referrals, followed by physician referrals (28.34%). Mood (28.3%), anxiety (25.17%), and substance use (19.81%) were the top three presenting concerns for the contact. Many clients had a current or past provisional psychiatric diagnosis (58.7% in 2020, 61.8% in 2021). Among the clients, 74.67% and 68.29% reported at least 1 psychosocial stressor in 2020 and 2021, respectively. The clients with a current or past psychiatric diagnosis, suicide risk, and 2 or more psychosocial stressors, those who lived outside of Central Zone, and who had employee assistance program benefits/private insurance, were more likely to be qualified and accepted for MHA services than others. CONCLUSIONS: The Intake clients have complex health and psychosocial profiles. Future studies are needed to monitor the trajectories of the clients to reduce inequities in receiving MHA services and improve client outcomes.

Addressing Stigma and Promoting Help-Seeking Among African Nova Scotian Youth Experiencing Psychosis and Other Mental Health Problems.

OBJECTIVES: The purpose of this study was to gain an in-depth understanding of perceptions of mental illnesses (especially psychosis), help-seeking, barriers to help-seeking, and opportunities to facilitate help-seeking in the African Nova Scotian Community. METHODS: A qualitative interpretive narrative approach, using the focus group method, was employed to engage African Nova Scotians in discussions on their perceptions and beliefs about mental illnesses and help-seeking in their communities. Youth in Early Intervention services, their caregivers, youth in the community, their caregivers, community leaders, and health service providers, were recruited from four locations in the Halifax Regional Municipality. A total of 75 individuals (37 female, 38 male) participated in the study. Narrative emplotment was used to analyse data from focus groups. RESULTS: Findings from focus groups were categorized based on four areas of discussion: (a) perceptions about psychosis and other mental illnesses among youth, caregivers, service providers and community leaders (b) beliefs about help-seeking among youth, caregivers, services providers and community leaders; (c) barriers and facilitators to seeking help for mental illnesses; and (d) the content and format of educational resources to educate and support youth, families and communities. CONCLUSIONS: Stigma surrounding mental illnesses in the community, lack of knowledge of illness and available services, concerns regarding negative involvement with police, or dismissal of difficulties by health care providers represent significant barriers to help-seeking in this community. Additionally, barriers include a lack of trust in health care services and a dearth of African Nova Scotian service providers. Bolstering capacity of community organizations to support and educate individuals around illness as well as fostering collaboration between health services and community organizations could reduce barriers to care. Future research should focus on examining ways to engage African Nova Scotians in collaboration with existing community organizations.

Real-life effectiveness of transitioning from paliperidone palmitate 1-monthly to paliperidone palmitate 3-monthly long-acting injectable formulation.

Background: Non-adherence to antipsychotics in schizophrenia is associated with an increased risk of psychotic relapse and hospitalization, a risk that is reduced with the use of long-acting injectable (LAI) antipsychotics. Randomized clinical trials (RCTs) have demonstrated the efficacy of paliperidone palmitate 3-monthly (PP3M) for psychotic relapse prevention in schizophrenia, but it remains poorly documented among individuals treated in real-life settings who can benefit the most out of LAIs. Objectives: The objective of this study was to evaluate the effectiveness of PP3M in relapse prevention among patients with schizophrenia. Methods: This is a multicentre retrospective study conducted in four outpatients' clinics across Canada. All consecutive patients with a main diagnosis of schizophrenia who initiated PP3M between June 2016 and March 2020 were included. The primary outcome was psychotic relapse, defined using broad and clinically relevant criteria. Results: Among 178 consecutive patients who were switched to PP3M, the 12-month relapse rate was 18.5% and the relapse-free survival probability was 0.788 (95% confidence interval [CI] = 0.725-0.856). Comorbid diagnoses of personality disorders and substance use disorders were associated with hazard rates (HRs) of 3.6 (95% CI = 1.8-7.3, p < 0.001) and 3.1 (95% CI = 1.6-6.2), respectively. Increased psychopathology severity was associated with an increased likelihood of relapse, while having a job or being in school was protective. Conclusion: These findings reinforce the necessity of conducting research in patients with comorbid psychiatric disorders who are typically underrepresented in RCTs, yet overrepresented in real-life settings, in order to better inform and guide clinical practice.

A Chart Audit Study of Clozapine Utilization in Early Psychosis.

PURPOSE: This study aimed to document the treatment trajectories and clozapine use in first-episode psychosis patients and to document the underlying reasons for using or not using clozapine in patients not achieving psychosis remission. METHODS: We conducted a retrospective chart audit of patients aged 18 to 30 years having DSM-5 diagnoses of schizophrenia spectrum psychotic disorders treated in 3 Canadian early intervention programs for psychosis. The severity of the patient's illness (using the Clinical Global Impression Severity [CGI-S] scale) and remission of psychosis were rated before and after each antipsychotic trial. RESULTS: One hundred and forty-seven patients were included in the study. There were 19.7% patients exposed to clozapine after an average of 2.4 antipsychotic trials and a mean delay of 470.8 days. There were 75.9% patients who improved their CGI-S score (mean improvement, 2.5) after the clozapine trial and 62.1% achieved a CGI-S score ≤3. Full remission of psychosis on clozapine was achieved in 69.0% of the patients. Clozapine was successfully used for some patients with a nonadherent profile in our sample (eg, personality disorder, substance use disorder). Although the mean duration of clozapine trials during the observation period was 688.6 days, no patient discontinued clozapine because of adherence issues. CONCLUSIONS: Clozapine use in these early intervention programs were at a rate consistent to what is expected from the literature and allowed a majority of patients to achieve remission of psychosis and to experience a robust improvement of severity of illness.

Où en sommes-nous? An Overview of Successes and Challenges after 30 Years of Early Intervention Services for Psychosis in Quebec: Où en sommes-nous? Un aperçu des réussites et des problèmes après 30 ans de services d'intervention précoce pour la psychose au Québec.

INTRODUCTION: Over the last 30 years, early intervention services (EIS) for first-episode psychosis (FEP) were gradually implemented in the province of Quebec. Such implementation occurred without provincial standards/guidelines and policy commitment to EIS until 2017. Although the literature highlights essential elements for EIS, studies conducted elsewhere reveal that important EIS components are often missing. No thorough review of Quebec EIS practices has ever been conducted, a gap we sought to address. METHODS: Adopting a cross-sectional descriptive study design, an online survey was distributed to 18 EIS that existed in Quebec in 2016 to collect data on clinical, administrative, training, and research variables. Survey responses were compared with existing EIS service delivery recommendations. RESULTS: Half of Quebec's population had access to EIS, with some regions having no programs. Most programs adhered to essential components of EIS. However, divergence from expert recommendations occurred with respect to variables such as open referral processes and patient-clinician ratio. Nonurban EIS encountered additional challenges related to their geography and lower population densities, which impacted their team size/composition and intensity of follow-up. CONCLUSIONS: Most Quebec EIS offer adequate services but lack resources and organizational support to adhere to some core components. Recently, the provincial government has created EIS guidelines, invested in the development of new programs and offered implementation support from the National Centre of Excellence in Mental Health. These changes, along with continued mentoring and networking of clinicians and researchers, can help all Quebec EIS to attain and maintain recommended quality standards.

"Worried about relapse": Family members' experiences and perspectives of relapse in first-episode psychosis.

BACKGROUND: The purpose of this study was to gain an in-depth understanding on the subject of relapse from the perspectives of family members of young people receiving services for a first-episode psychosis (FEP). METHODS: A qualitative descriptive approach, using focus group methods, was used to elicit experiences, understandings, and knowledge of relapse in FEP. Family members were recruited from 4 specialized early intervention programmes for psychosis in Canada. A total of 24 (6 male, 18 female) family members participated in the study. Thematic analysis was used to examine the data. RESULTS: The core underlying theme in all focus groups was worrying about relapse, which was often accompanied by significant levels of fear and anxiety, and was influenced by: (1) impact of an episode of psychosis; (2) limited confidence in recognizing and coping with relapse; (3) unmet needs for coping skills and emotional support and (4) unmet needs regarding frequency and continuity of communication with clinicians. CONCLUSIONS: Family members' unmet needs for relapse-focused education, support and communication with service providers and peers, can have a negative impact on relapse prevention. Addressing family members' education and support needs in a tailored manner (including preferences for types of peer support) can contribute positively to their confidence and ability to recognize and respond to relapse. This can help reduce fear and anxieties about relapse, and positively influence the ability to function as caregivers. Future research should focus on best approaches for providing education, sustained contact with the clinical team and family peer support.

What Is the Place of Clozapine in the Treatment of Early Psychosis in Canada?

Research and development of early intervention (EI) services for first-episode psychosis have brought much-needed transformation of service delivery for this serious mental disorder to many jurisdictions. The effectiveness of the EI model of service delivery is contingent on timely access to all evidence-informed treatment interventions, including a rational approach to pharmacotherapy. In this perspective paper, we present a brief review of the well-established effectiveness of clozapine in patients who clearly show lack of response to regular antipsychotic therapy. We concentrate, in particular, on the need to identify eligibility for clozapine therapy very early on following failure of treatment on 2 antipsychotic medications. We suggest that attention to the low use of clozapine in the very early phase of treatment of psychosis may be of particular value, as the response to clozapine at this stage is likely to produce larger benefits in other domains of outcomes because of the greater retention of patients' personal and social agency.

Early Intervention for Psychosis in Canada: What Is the State of Affairs?

OBJECTIVE: Early intervention services (EIS) for psychosis have been developed in several countries, including Canada. There is some agreement about the program elements considered essential for improving the long-term outcomes for patients in the early phase of psychotic disorders. In the absence of national standards, the current state of EIS for psychosis in Canada needs to be examined in relation to expert recommendations currently available. METHOD: A detailed online benchmark survey was developed and administered to 11 Canadian academic EIS programs covering administrative, clinical, education, and research domains. In addition, an electronic database and Internet search was conducted to find existing guidelines for EIS. Survey results were then compared with the existing expert recommendations. RESULTS: Most of the surveyed programs offer similar services, in line with published expert recommendations (i.e., easy and rapid access, intensive follow-up through case management with emphasis on patient engagement and continuity of care, and a range of integrated evidence-based psychosocial interventions). However, differences are observed among programs in admission and discharge criteria, services for patients at ultra high risk (UHR) for psychosis, patient to clinician ratios, accessibility of services, and existence of specific inpatient units. These seem to diverge from expert recommendations. CONCLUSIONS: Although Canadian programs are following most expert recommendations on clinical components of care, some programs lack administrative and organizational elements considered essential. Continued mentoring and networking of clinicians through organizations such as the Canadian Consortium for Early Intervention in Psychosis (CCEIP), as well as the development of a fidelity scale through further research, could possibly help programs attain and maintain the best standards of early intervention. However, simply making clinical guidelines available to care providers is not sufficient for changing practices; this will need to be accompanied by adequate funding and support from organizations and policy makers.

A qualitative study of experiences with and perceptions regarding long-acting injectable antipsychotics: Part I-patient perspectives.

OBJECTIVE: Despite the well-acknowledged problem of poor adherence to antipsychotic (AP) medication, long-acting injectables (LAIs) that could improve adherence are underused in Canada. Attitudes concerning LAIs among patients and psychiatrists may contribute to this underuse. Our objective was to investigate perceptions of and attitudes toward LAIs among patients in Canada. METHOD: Focus groups were conducted with 34 patients with a diagnosis of schizophrenia spectrum psychoses in 4 Canadian provinces. The focus groups inquired about experiences with and attitudes toward LAI APs. The sessions were audiotaped and transcribed verbatim, and transcripts were coded using a combination of deductive and inductive methods. RESULTS: Four themes emerged: awareness of and knowledge about LAIs; perceptions about LAIs; cost and convenience considerations; and issues arising from the coercive context under which LAIs were often prescribed. Nine patients had never heard about LAIs, and some others reported not having understood what was discussed with them regarding LAIs. Patients had typically heard about LAIs in either a context of coercion or of medication nonadherence. Patients had positive and negative perceptions concerning LAIs. The positive perceptions centred on relapse prevention and reduced effort in ensuring adherence, and the negative perceptions centred on financial costs and the inconvenience of appointments to receive injections. CONCLUSION: To enhance LAI usage, some of the issues that need to be addressed are the inadequacy of information given to patients, the element of coercion involved in LAI introduction, the pragmatic barriers to LAI uptake by patients, and negative subjective perceptions about LAIs.

Objectif : Malgré le problème largement reconnu de la mauvaise observance des antipsychotiques (AP), les injectables à action prolongée (IAP) qui pourraient améliorer l'observance sont sous-utilisés au Canada. Les attitudes à l'égard des IAP chez les patients et les psychiatres peuvent contribuer à cette sous-utilisation. Notre objectif était d'enquêter sur les perceptions et les attitudes des patients à l'égard des IAP au Canada. Méthode : Des groupes de discussion ont été formés de 34 patients ayant reçu un diagnostic de psychose du spectre de la schizophrénie dans 4 provinces canadiennes. Les groupes de discussion portaient sur les expériences avec les AP IAP et les attitudes à leur égard. Les séances ont fait l'objet d'un enregistrement sonore et ont été transcrites textuellement, et ces transcriptions ont été codées à l'aide d'une combinaison de méthodes déductives et inductives. Résultats : Quatre thèmes se sont dégagés : conscience et connaissance des IAP; perceptions des IAP; considérations concernant le coût et la commodité; et les questions liées au contexte coercitif dans lequel les IAP sont souvent prescrits. Neuf patients n'avaient jamais entendu parler des IAP, et d'autres ont déclaré ne pas avoir compris lorsqu'on a discuté avec eux des IAP. Les patients avaient habituellement entendu parler des IAP dans un contexte soit de coercition, soit de non-observance des médicaments. Les patients avaient des perceptions positives et négatives à l'égard des IAP. Les perceptions positives étaient axées sur la prévention de la rechute et l'effort réduit pour maintenir l'observance, et les perceptions négatives portaient sur les coûts financiers et la complication des rendez-vous pour recevoir les injections. Conclusion : Afin d'accroître l'utilisation des IAP, il faut aborder certaines questions, notamment l'insuffisance de l'information donnée aux patients, l'élément de coercition présent dans l'instruction aux IAP, les obstacles pratiques à la prise d'IAP par les patients, et les perceptions subjectives négatives à l'égard des IAP.

A qualitative study of experiences with and perceptions regarding long-acting injectable antipsychotics: part II-physician perspectives.

OBJECTIVE: In many countries, including Canada, a small proportion of people with psychotic disorders receive long-acting injectable (LAI) antipsychotics (APs), despite their demonstrated effectiveness and possible advantages for improving adherence rates. Attitudes regarding LAIs among physicians may influence their prescribing practices and thereby contribute to the underuse of LAIs. Here, we report on a qualitative study of perceptions and attitudes toward LAIs among psychiatrists in Canada. METHOD: Focus groups were conducted with 24 psychiatrists in 4 Canadian provinces. The focus groups inquired about experiences with and attitudes toward LAI APs. The sessions were audiotaped and transcribed verbatim, and transcripts were coded using a hybrid process of deductive and inductive methods. A brief pre-focus group questionnaire was administered. RESULTS: The pre-focus group questionnaires indicated that psychiatrists in our study prescribed the oral formulation of APs most of the time and had limited experience with LAIs. The focus groups yielded 4 main themes: limited knowledge about and experience with LAIs; attitudes toward LAIs (beliefs about negative perceptions of patients regarding LAIs, personal bias against needles, and consensus about some advantages of LAIs); prescribing practices around LAIs (generally seen as a last-resort option for patients with a history of nonadherence); and pragmatic barriers to using LAIs (for example, cost, storage, and staffing). CONCLUSION: Several factors may be contributing to the underuse of LAIs and the continuing stigmatized and coercive image of LAIs. Psychiatrists may benefit from better education about LAIs, and from self-examination of their attitudes to LAIs and their prescribing practices.

Objectif : Dans de nombreux pays, dont le Canada, seule une petite proportion de personnes souffrant de troubles psychotiques reçoit des antipsychotiques (AP) injectables à action prolongée (IAP), malgré leur efficacité démontrée et leurs avantages possibles d'améliorer les taux d'observance. Les attitudes des médecins à l'égard des IAP peuvent influencer leurs pratiques de prescription et subséquemment contribuer à la sous-utilisation des IAP. Ici, nous faisons le compte rendu d'une étude qualitative des perceptions et des attitudes à l'égard des IAP chez les médecins du Canada. Méthode : Des groupes de discussion ont été formés de 24 psychiatres dans 4 provinces canadiennes. Les groupes de discussion portaient sur les expériences avec les AP IAP et les attitudes à leur égard. Les séances ont fait l'objet d'un enregistrement sonore et ont été transcrites textuellement, et ces transcriptions ont été codées à l'aide d'une procédure hybride de méthodes déductives et inductives. Un questionnaire abrégé a été administré avant le groupe de discussion. Résultats : Les questionnaires précédant le groupe de discussion ont indiqué que les psychiatres de notre étude prescrivaient la formule orale des AP la plupart du temps, et qu'ils avaient une expérience limitée des IAP. Les groupes de discussion ont dégagé 4 principaux thèmes : une expérience et des connaissances limitées des IAP; les attitudes à l'égard des IAP (croyances que les patients ont des perceptions négatives à l'égard des IAP, préjugés personnels contre les aiguilles, et consensus à propos de certains avantages des IAP); les pratiques de prescription des IAP (généralement vus comme une option de derniers recours pour les patients ayant des antécédents de non-observance); et les obstacles pratiques (par exemple, coût, entreposage, et dotation en personnel) à l'utilisation des IAP. Conclusion : Plusieurs facteurs peuvent contribuer à la sous-utilisation des IAP et à l'image coercitive et stigmatisée des IAP qui se poursuit. Les psychiatres pourraient bénéficier d'une meilleure formation sur les IAP, et d'un auto-examen de leurs attitudes à l'égard des IAP et de leurs pratiques de prescription.

Long-acting injectable antipsychotics: recommendations for clinicians.

A major source of limitation to the real effectiveness of antipsychotics is the high rate of patient nonadherence or, more frequently, partial adherence. Using long-acting injectable (LAI) formulations is likely to reduce the impact of such adherence problems. Conversely, the use of LAIs in Canada remains low relative to many other jurisdictions. Based on effectiveness data from randomized control trials and other, less rigorous, studies, as well as our 2 qualitative studies exploring numerous issues around the use of LAIs, including their low use, we put forward 10 different recommendations for consideration by clinicians. These are also based on the experience of many clinicians and clinician scientists. These recommendations address mostly clinical challenges associated with the use of LAIs. Their application in clinical settings is illustrated in our report through several case examples highlighting the large variation across patients and different phases of illness. It is recommended that LAIs should be considered as a treatment option for psychotic disorders across all phases, including the first 2 to 5 critical years.

Une source importante de limitation de l'efficacité réelle des antipsychotiques est le taux élevé de non-observance ou plus souvent, d'observance partielle des patients. Recourir à des formules injectables à action prolongée (IAP) est susceptible de réduire l'effet de ces problèmes d'observance. À l'inverse, l'utilisation des IAP au Canada demeure faible relativement à de nombreux autres pays. Selon les données d'efficacité tirées d'essais randomisés contrôlés et d'autres études moins rigoureuses, ainsi que de nos 2 études qualitatives explorant de nombreuses questions liées à l'utilisation des IAP, y compris leur faible utilisation, nous présentons 10 différentes recommandations aux fins d'examen par les cliniciens. Celles-ci sont également basées sur l'expérience de nombreux cliniciens et scientifiques cliniciens, et abordent surtout les problèmes cliniques associés à l'utilisation des IAP. Leur application en milieu clinique est illustrée dans notre rapport par plusieurs exemples de cas mettant en évidence la vaste variation entre les patients et les différentes phases de la maladie. Il est recommandé de considérer les IAP comme option de traitement pour toutes les phases des troubles psychotiques, y compris les 2 à 5 premières années cruciales.

Long-acting injectable antipsychotics: evidence of effectiveness and use.

OBJECTIVE: To review the evidence for the role of long-acting injectable (LAI) antipsychotics (APs), especially the second-generation AP (SGA) LAIs, in the treatment of schizophrenia and to discuss the use rates of LAIs in Canada. METHOD: A search of online medical databases was conducted of the published literature (1995-2012) of the effects of LAIs on the domains of remission, adherence, relapse, and hospitalization. Results obtained from randomized controlled trials (RCTs), systematic reviews, meta-analyses, and large-scale observational studies were included. Expert consensus data were also solicited on LAI use within a Canadian context. RESULTS: While the efficacy of LAIs, compared with placebo, is well established, the evidence from RCTs is equivocal for any specific advantage for SGA LAIs, compared with oral medications, probably owing to challenges in conducting such RCTs. Evidence from methodologically less rigorous studies and from clinical practice suggests some advantages in achieving and maintaining remission, risk of relapse, and hospitalization. The rate of LAI (first-generation AP and SGA) use from published outpatient studies is low at 6.3% in Canada, compared with 15% to 80% worldwide. However, there is a relatively high rate of use in specific early psychosis programs and in conjunction with community treatment orders in Canada. CONCLUSIONS: LAIs are at least as effective as oral APs in the treatment of psychotic disorders. The former may have specific advantages for patients who demonstrate covert nonadherence. The underuse of LAIs in Canada needs to be better understood and addressed.

Objectif : Examiner les données probantes sur le rôle des antipsychotiques (AP) injectables à action prolongée (IAP), spécialement ceux de la deuxième génération (APDG) IAP, dans le traitement de la schizophrénie et discuter des taux d'utilisation des IAP au Canada. Méthode : Une recherche des bases de données médicales a été menée dans la littérature publiée (1995­2012) sur les effets des IAP sur les domaines de la rémission, l'observance, la rechute, et l'hospitalisation. Les résultats obtenus des essais randomisés contrôlés (ERC), des revues systématiques, des méta-analyses, et des études d'observation à grande échelle ont été inclus. Les données de consensus des experts ont aussi été sollicitées en ce qui concerne l'utilisation des IAP dans un contexte canadien. Résultats : Bien que l'efficacité des IAP, comparativement aux placebos, soit bien établie, les données probantes des ERC sont équivoques quant à un avantage spécifique des APDG IAP, comparativement aux médicaments oraux, ce qui est probablement attribuable aux difficultés de mener de tels ERC. Les données probantes d'études moins rigoureuses sur le plan méthodologique et de la pratique clinique suggèrent certains avantages pour atteindre et maintenir la rémission, le risque de rechute, et l'hospitalisation. Le taux d'utilisation des IAP (AP de première génération et APDG), tiré des études publiées sur les patients externes, est faible à 6,3 % au Canada, comparativement à 15 % à 80 % dans le monde. Cependant, le taux d'utilisation est relativement élevé dans des programmes spécifiques de psychose précoce et conjointement avec les ordonnances de traitement en milieu communautaire au Canada. Conclusions : Les IAP sont au moins aussi efficaces que les AP par voie orale dans le traitement des troubles psychotiques. Les IAP peuvent présenter des avantages spécifiques pour les patients qui démontrent une non-observance secrète. La sous-utilisation des IAP au Canada doit être mieux comprise et traitée.

Procedural learning in first episode schizophrenia investigated with functional magnetic resonance imaging.

OBJECTIVE: The present investigation assessed the severity, course, and cerebral implications of serial reaction time (SRT) procedural learning deficits in schizophrenia. METHOD: Hemodynamic changes on fMRI were assessed during an SRT task in 17 unmedicated first episode psychosis (FEP) patients and matched healthy controls. RESULTS: The groups demonstrated comparable procedural learning and associated activation of anterior cingulate cortex, subcortical structures, and many left frontal structures. The groups also demonstrated comparable increased activation of right parietal structures on trials with demands for spatial localization without procedural memory. Relative to healthy controls, the schizophrenia sample showed less activation of one region of the left middle frontal cortex and more activation of left superior temporal cortex on procedural trials, but more activation of right medial frontal cortex on localization trials. CONCLUSIONS: Intact SRT procedural learning and normal or enhanced hemodynamic response in subcortical and right cortical structures diverges from prior results with medicated samples, suggesting a more focal cerebral dysfunction in the left middle frontal cortex before the onset of treatment.

Abnormal prefrontal cortical activity and connectivity during response selection in first episode psychosis, chronic schizophrenia, and unaffected siblings of individuals with schizophrenia.

The search for genes conferring liability for schizophrenia may be aided by the identification of endophenotypes. Response selection is a heritable cognitive function that is impaired in patients with schizophrenia and their unaffected siblings. The abnormalities in cerebral function that presumably underlie the deficit in patients and unaffected siblings remain to be elucidated. Cerebral neurophysiology during performance of a 4-choice reaction time (CRT) task in 25 patients with schizophrenia (15 medication free first episode (FEP) and 10 chronic patients), 32 controls, and 12 unaffected siblings of individuals with schizophrenia was investigated using fMRI. CRT was impaired in both medication free FEP and chronic patients with schizophrenia, and unaffected siblings. FEP patients, chronic patients, and unaffected siblings demonstrated greater BOLD response in the right dorsolateral prefrontal cortex (dlPFC) during CRT task blocks. The nature of the altered activation in the dlPFC was further examined using functional connectivity analysis. This revealed marked reductions in connectivity between the right dlPFC and multiple brain regions in both patient groups and, to a lesser degree, unaffected siblings. The magnitude of connectivity between right dlPFC and inferior parietal lobule correlated with task performance in the combined patient/unaffected siblings group, but not controls suggesting that the network of brain regions recruited to perform the task differed as a function of genetic liability for schizophrenia. The findings suggest that altered activity and connectivity of the right dlPFC appears to be related to genetic vulnerability for schizophrenia and may represent a potential endophenotype of the disorder.

An fMRI investigation of procedural learning in unaffected siblings of individuals with schizophrenia.

Vulnerability for schizophrenia is related, in part, to genetic predisposition. The identification of pathophysiological abnormalities associated with the disorder that are also present in unaffected family members of individuals with schizophrenia may assist in delineating the genetic contributions to vulnerability for schizophrenia. Previous functional Magnetic Resonance Imaging (fMRI) investigations of procedural learning in patients with schizophrenia identified reduced activity in the frontal cortex, basal ganglia, and parietal cortex during performance of the serial reaction time (SRT) task suggesting that abnormal function of these regions may relate to genetic vulnerability for schizophrenia. In order to examine this hypothesis, 12 unaffected siblings of patients and 15 controls underwent fMRI during performance of the SRT task. Unaffected siblings demonstrated normal performance on the SRT task. However, compared to controls unaffected siblings demonstrated less activity in regions of the frontal and parietal lobes and, to a lesser extent, basal ganglia, during procedural learning. Interestingly, unaffected siblings demonstrated greater activity in regions of the frontal cortex during the control condition compared to the procedural learning condition of the SRT task, an idiosyncratic pattern that was also observed in patient groups but not control subjects of two prior imaging studies. The findings support previous investigations suggesting that altered cerebral neurophysiology during performance of cognitive tasks may be related to genetic vulnerability for schizophrenia. Identification of genes related to the function of cerebral regions such as the prefrontal cortex, parietal lobe, and basal ganglia may assist in delineating the genetic contributions to schizophrenia.