Postdischarge Mortality in a Cohort Hospitalized With Anorexia Nervosa.

OBJECTIVE: To characterize mortality after hospital discharge in cohorts with and without anorexia nervosa (AN). METHODS: We obtained data for all hospitalizations for psychiatric reasons in Canada (except Quebec) between April 1, 2006, and March 31, 2021 (n = 1.3 million admissions). Cases of AN were identified using ICD-10 (F50.0 and F50.1) codes. First admissions during this interval for AN and other psychiatric conditions were linked to vital statistics data. Mortality was characterized through cross-tabulation, Cox proportional hazards models, and competing cause regression. RESULTS: After adjustment for age and sex, there was no significant difference in mortality between AN and those with other psychiatric conditions (HR = 1.04; p = 0.644). Among AN admissions, 25% (95% CI 18.6-31.4) of deaths were attributed to psychiatric conditions (ICD-F codes), with 88% of these (comprising 22% of all deaths in the AN group) having AN itself identified as the underlying cause of death. In contrast, only 8% of deaths among non-AN admissions were attributed to a mental disorder. DISCUSSION: Prevention of premature mortality in the general psychiatric population emphasizes modification of metabolic (e.g., hyperlipidemia) and lifestyle-related (e.g., sedentary behavior) risk factors. However, as AN itself makes a major contribution to mortality, specialized preventive strategies may be required.

Neighborhood material versus social deprivation in Canada: different patterns of associations with child and adolescent mental health problems.

PURPOSE: In a nationwide study, we aimed to study the association of neighborhood deprivation with child and adolescent mental health problems. METHODS: We used data from the Canadian Health Survey on Children and Youth (N = 47,871; age range: 1-17 years) and linked these to Neighborhood Material and Social Deprivation data calculated using Canada's Census of Population. Using a series of logistic regressions, we studied the association between living in deprived areas and mental health problems among children and youth. We used bootstrap replicate weights for all analyses and adjusted them for individual sociodemographic characteristics. RESULTS: In the adjusted model, the parent-reported developmental disorder was associated with more socially deprived neighborhoods (OR 1.29; 95% CI 1.07, 1.57 for most vs. least deprived quintiles). However, mental health service need or use was associated with living in less materially deprived areas (OR 0.78; 95% CI 0.63, 0.96 for most vs. least deprived quintiles). Among mental health problems reported by the youth (12-17 years old), poor/fair general mental health, alcohol drinking, and cannabis use were associated with neighborhood social deprivation in the adjusted models. In contrast, poor/fair general mental health, suicide ideas, alcohol drinking, and cannabis use were all negatively associated with higher materially deprived quintiles. CONCLUSION: Our study provides further support for the existing evidence on the association between neighborhood deprivation, particularly social deprivation, and the mental health of children and adolescents. The findings can help public health policymakers and service providers better understand and address children's mental health needs in their neighborhoods.

Association Between Excess Sleep Duration and Risk of Stroke: A Population-Based Study.

BACKGROUND: Excess sleep is associated with higher risk of stroke, but whether the risk is modified by age and if it remains elevated after accounting for the competing risk of death is not well understood. METHODS: We used nine years of the Canadian Community Health Survey between 2000 to 2016 to obtain self-reported sleep duration and created a cohort of individuals without prior stroke, heart disease, or cancer. We linked to hospital records to determine subsequent admissions or emergency department visits for acute stroke until December 31, 2017. We used Cox proportional hazard models to determine the association between sleep duration and risk of stroke, assessing for modification by age and sex and adjusting for demographic, vascular, and social factors. We obtained cumulative incidence of stroke accounting for the competing risk of death. RESULTS: There were 82,795 individuals in our cohort who met inclusion criteria and had self-reported sleep duration, with 1705 stroke events in follow-up. There was an association between excess sleep (≥10 h/night) and risk of stroke in those <70 years (fully adjusted hazard ratio 2.29, 95% CI 1.04-5.06), but not ≥70 years of age, with a similar association after accounting for the competing risk of death. CONCLUSION: Sleep duration ≥10 h/night is associated with increased risk of stroke in those <70 years of age. The findings support current guidelines for 7-9 h of sleep per night. Further research is needed to elucidate the relationship between sleep and cerebrovascular disease.

Impairment in Health-Related Quality of Life among Community-Dwelling Stroke Survivors.

INTRODUCTION: Health utility instruments are increasingly being used to measure impairment in health-related quality of life (HRQoL) after stroke. Population-based studies of HRQoL after stroke and assessment of differences by age and functional domain are needed. METHODS: We used the Canadian Community Health Survey linked with administrative databases to determine HRQoL using the Health Utilities Index Mark 3 (HUI3) among those with prior hospitalization or emergency department visit for stroke and compared to controls without stroke. We used multivariable linear regression to determine the difference in HUI3 between those with stroke and controls for the global index and individual attributes, with assessment for modification by age (<60, 60-74, and 75+ years) and sex, and we combined estimates across survey years using random effects meta-analysis. RESULTS: Our cohort contained 1240 stroke survivors and 123,765 controls and was weighted to be representative of the Canadian household population. Mean health utility was 0.63 (95% confidence interval [CI] 0.58, 0.68) for those with stroke and 0.83 (95% CI 0.82, 0.84) for controls. There was significant modification by age, but not sex, with the greatest adjusted reduction in HUI3 among stroke respondents aged 60-74 years. Individual HUI3 attributes with the largest reductions in utility among stroke survivors compared to controls were mobility, cognition, emotion, and pain. CONCLUSIONS: In this population-based study, the reduction in HUI3 among stroke survivors compared to controls was greatest among respondents aged 60-74, and in attributes of mobility, cognition, emotion, and pain. These results highlight the persistent impairment of HRQoL in the chronic phase of stroke and potential targets for community support.

Association Between Excess Leisure Sedentary Time and Risk of Stroke in Young Individuals.

Background and Purpose: The association between physical activity (PA) and lower risk of stroke is well established, but the relationship between leisure sedentary time and stroke is less well studied. Methods: We used 9 years of the Canadian Community Health Survey between 2000 and 2012 to create a cohort of healthy individuals without prior stroke, heart disease, or cancer. We linked to hospital records to determine subsequent hospitalization or emergency department visit for stroke until December 31, 2017. We quantified the association between self-reported leisure sedentary time (categorized as <4, 4 to <6, 6 to <8, and 8+ hours/day) and risk of stroke using Cox regression models and competing risk regression, assessing for modification by PA, age, and sex and adjusting for demographic, vascular, and social factors. Results: There were 143 180 people in our cohort and 2965 stroke events in follow-up. Median time from survey response to stroke was 5.6 years. There was a 3-way interaction between leisure sedentary time, PA, and age. The risk of stroke with 8+ hours of sedentary time was significantly elevated only among individuals <60 years of age who were in the lowest PA quartile (fully adjusted hazard ratio, 4.50 [95% CI, 1.64­12.3]). The association was significant across multiple sensitivity analyses, including adjustment for mood disorders and when accounting for the competing risk of death. Conclusions: Excess leisure sedentary time of 8+ hours/day is associated with increased risk of long-term stroke among individuals <60 years of age with low PA. These findings support efforts to enhance PA and reduce sedentary time in younger individuals.

Mental Health among Canadian Postsecondary Students: A Mental Health Crisis?

OBJECTIVE: Recent reports express concerns about a mental health crisis among postsecondary students. These assertions, however, often arise from surveys conducted in postsecondary settings that lack the broader context of a referent group. The objectives of this study were (1) to assess the mental health status of postsecondary students 18 to 25 years old from 2011 to 2017 and (2) to compare the mental health status of postsecondary students to nonstudents. METHODS: Prevalence was estimated for a set of mental health outcomes using seven annual iterations of the Canadian Community Health Survey (2011 to 2017). Logistic regression was used to derive odds ratio estimates comparing mental health status among postsecondary students and nonstudents, adjusting for age and sex. Random effects metaregression and meta-analyses techniques were used to evaluate trends in prevalence and odds ratio estimates over time. RESULTS: Over the study period, the prevalence of perceived low mental health, diagnosed mood and anxiety disorders, and past-year mental health consultations increased among female students, whereas binge drinking decreased among male students. With the exception of perceived stress, the odds of experiencing each mental health outcome were lower among postsecondary students compared to nonstudents. CONCLUSIONS: These findings do not support the idea that postsecondary students have worse mental health than nonstudents of similar age. The perception of a crisis may arise from greater help-seeking behavior, diminishing stigma, or increasing mental health literacy. Regardless, the observance of these trends provide an opportunity to address a previously latent issue.

Living with Migraine in Canada - A National Community-Based Study.

OBJECTIVE: To develop a detailed profile of individuals living with migraine in Canada. Such a profile is important for planning and administration of services. METHODS: The 2011-2012 Survey of Living with Neurological Conditions in Canada (SLNCC), a cross-sectional community-based survey, was used to examine a representative sample of migraineurs (N = 949) aged 15 years and older. Several health-related variables were examined (e.g., general health, health utility index (HUI) [a measure of health status and health-related quality of life, where dead = 0.00 and perfect health = 1.00], stigma, depression, and social support). Respondents were further stratified by sex, age, and age of migraine onset. Weighted overall and stratified prevalence estimates and odds ratios, both with 95% CIs, were used to estimate associations. RESULTS: Overall, males had poorer health status compared with females (e.g., mean HUI was 0.67 in males vs. 0.82 in females; men had over two times the odds of their migraine limiting educational and job opportunities compared with females). Poorer health-related variables were seen in the older age groups (35-64 years/≥65 years) compared with the 15-34-year age group. There were no differences between those whose migraine symptoms began before versus after the age of 20 years. CONCLUSIONS: In this Canadian sample, migraine was associated with worse health-related variables in men compared with women. However, both men and women were significantly affected by migraine across various health-related variables. Thus, it is important to improve clinical and public health interventions addressing the impact of migraine across individuals of all ages, sexes, and sociodemographic backgrounds.

Stability and resilience of the intestinal microbiota in children in daycare - a 12 month cohort study.

BACKGROUND: We performed a 12-month cohort study of the stability and resilience of the intestinal microbiota of healthy children in daycare in Denmark in relation to diarrheal events and exposure to known risk factors for gastrointestinal health such as travelling and antibiotic use. In addition, we analyzed how gut microbiota recover from such exposures. RESULTS: We monitored 32 children in daycare aged 1-6 years. Fecal samples were submitted every second month during a one-year observational period. Information regarding exposures and diarrheal episodes was obtained through questionnaires. Bacterial communities were identified using 16S rRNA gene sequencing. The core microbiota (mean abundance > 95%) dominated the intestinal microbiota, and none of the tested exposures (diarrheal events, travel, antibiotic use) were associated with decreases in the relative abundance of the core microbiota. Samples exhibited lower intra-individual variation than inter-individual variation. Half of all the variation between samples was explained by which child a sample originated from. Age explained 7.6-9.6% of the variation, while traveling, diarrheal events, and antibiotic use explained minor parts of the beta diversity. We found an age-dependent increase of alpha diversity in children aged 1-3 years, and while diarrheal events caused a decrease in alpha diversity, a recovery time of 40-45 days was observed. Among children having had a diarrheal event, we observed a 10x higher relative abundance of Prevotella. After travelling, a higher abundance of two Bacteroides species and 40% less Lachnospiraceae were seen. Antibiotic use did not correlate with changes in the abundance of any bacteria. CONCLUSION: We present data showing that Danish children in daycare have stable intestinal microbiota, resilient to the exposures investigated. An early age-dependent increase in the diversity was demonstrated. Diarrheal episodes decreased alpha diversity with an estimated recovery time of 40-45 days.

The impact of seizures on epilepsy outcomes: A national, community-based survey.

OBJECTIVE: The aim of this study was to examine the impact of seizures on persons living with epilepsy in a national, community-based setting. METHODS: The data source was the Survey of Living with Neurological Conditions in Canada (SLNCC), a cohort derived from a national population-based survey of noninstitutionalized persons aged 15 or more years. Participants had to be on a seizure drug or to have had a seizure in the past 5 years to meet the definition of active epilepsy. The respondents were further stratified by seizure status: the seizure group experienced ≥1 seizure in the past 5 years versus the no seizure group who were seizure-free in the past ≥5 years regardless of medication status. Weighted overall and stratified prevalence estimates and odds ratios were used to estimate associations. RESULTS: The SLNCC included 713 persons with epilepsy with a mean age of 45.4 (standard deviation 18.0) years. Fewer people in the seizure group (42.7%) reported being much better than a year ago versus those in the no seizure group (70.1%). Of those with seizures, 32.1% (95% confidence interval [95% CI] 18.8-45.3) had symptoms suggestive of major depression (as per the Patient Health Questionnaire-9) compared to 7.7% (95% CI 3.4-11.9) of those without seizures. Driving, educational, and work opportunities were also significantly limited, whereas stigma was significantly greater in those with seizures. SIGNIFICANCE: This community-based study emphasizes the need for seizure freedom to improve clinical and psychosocial outcomes in persons with epilepsy. Seizure freedom has an important influence on overall health, as those with at least one seizure over the prior 5 years had an increased risk of mood disorders, worse quality of life, and faced significantly more stigma.

A comparison of recommendations and received treatment for mood and anxiety disorders in a representative national sample.

BACKGROUND: The exact nature of treatment and management recommendations made, and received, for mood and anxiety disorders in a community population is unclear. In addition, there is limited evidence on the impact of recommendations on actual receipt of treatment or implementation of management strategies. We aim to describe the frequency with which specific recommendations were made and implemented; and thus assess the size of any gap between the recommendation and implementation of treatments and management strategies. METHODS: We used the Survey 'Living with a Chronic Condition in Canada - Mood and Anxiety Disorders (SLCDC-MA), a unique crossectional survey of a large (N = 3358) and representative sample of Canadians with a diagnosed mood or anxiety disorder, which was conducted by Statistics Canada. The survey collected information on recommendations for medication, counselling, exercise, reduction of alcohol consumption, smoking cessation and reduction of street drug use. We also estimate the frequency that recommendations are made and followed, as well the impact of the prior on the latter. We consulted people with lived experience of the disorders to help interpret our results. RESULTS: The results generally showed that most people would receive recommendations, almost all for antidepressant medications (94.6%), with lower proportions for the other treatment and management strategies (e.g. 62.1 and 66% for counselling and exercise). Most recommendations were implemented and had an impact on behaviour. The exception to this was smoking reduction/cessation, which was often not recommended or followed through. Other than with medication, at least 20% of the population, for each recommendation, would not have their recommendation implemented. A substantive group also exists who access treatments, and employ various management strategies, without a recommendation. CONCLUSIONS: The results indicate that there is a gap between recommendations made and the implementation of treatments. However, its size varies substantially across treatments.

Descriptive Epidemiology of Generalized Anxiety Disorder in Canada.

OBJECTIVE: The first national survey to assess the prevalence of generalized anxiety disorder (GAD) in Canada was the 2012 Canadian Community Health Survey: Mental Health and Well-Being (CCHS-MH). The World Mental Health Composite International Diagnostic Interview (WMH-CIDI), used within the representative sample of the CCHS-MH, provides the best available description of the epidemiology of this condition in Canada. This study uses the CCHS-MH data to describe the epidemiology of GAD. METHOD: The analysis estimated proportions and odds ratios and used logistic regression modelling. All results entailed appropriate sampling weights and bootstrap variance estimation procedures. RESULTS: The lifetime prevalence of GAD is 8.7% (95% CI, 8.2% to 9.3%), and the 12-month prevalence is 2.6% (95% CI, 2.3% to 2.8%). GAD is significantly associated with being female (OR 1.6; 95% CI, 1.3 to 2.1); being middle-aged (age 35-54 years) (OR 1.6; 95% CI, 1.0 to 2.7); being single, widowed, or divorced (OR 1.9; 95% CI, 1.4 to 2.6); being unemployed (OR 1.9; 95% CI, 1.5 to 2.5); having a low household income (<$30 000) (OR 3.2; 95% CI, 2.3 to 4.5); and being born in Canada (OR 2.0; 95% CI, 1.4 to 2.8). CONCLUSIONS: The prevalence of GAD was slightly higher than international estimates, with similar associated demographic variables. As expected, GAD was highly comorbid with other psychiatric conditions but also with indicators of pain, stress, stigma, and health care utilization. Independent of comorbid conditions, GAD showed a significant degree of impact on both the individual and society. Our results show that GAD is a common mental disorder within Canada, and it deserves significant attention in health care planning and programs.

Major Depression Prevalence Increases with Latitude in Canada.

OBJECTIVE: To determine whether there is an association between latitude and annual major depressive episode (MDE) prevalence in Canada. METHODS: Data from 2 national survey programs (the National Population Health Survey and the Canadian Community Health Survey) were used, providing 10 data sets collected between 1996 and 2013, together including 922,260 respondents, of whom 495,739 were assessed for MDE using 1 of 2 versions of the Composite International Diagnostic Interview, a short-form version (8 studies), and a Canadian adaptation of the World Mental Health version (2 studies). Approximate latitude was determined by linkage to postal code data. Data were analyzed using logistic regression and pooled across surveys using individual-level meta-analytic methods. RESULTS: In models including latitude as a continuous variable, a statistically significant association was observed, with prevalence increasing with increasing latitude. This association persisted after adjustment for a set of known risk factors. The latitude gradient was modest in magnitude, a 1% to 2% increase in the prevalence odds of MDE per degree of latitude was observed. Due to sparse data, this gradient cannot be confidently generalized beyond major population centres, which tend to occur at less than 55° latitude in Canada. CONCLUSION: A latitude gradient has not previously been reported. If replicated, the gradient may have implications for the planning of services and generation of aetiological hypotheses. However, this cross-sectional analysis cannot confirm aetiology and could not evaluate the potential contributions of variables such as light exposure, weather patterns, or social determinants.

The Prevalence of Major Depressive Episodes Is Higher in Urban Regions of Canada.

OBJECTIVE: Major depressive disorder is an important contributor to disease burden. Anticipation of service needs is important, yet basic information is lacking. For example, there is no consensus as to whether major depressive episodes (MDE) are more or less prevalent in urban or rural areas. The objective of this study was to determine whether a difference exists in Canada. METHOD: A series of 11 Canadian national cross-sectional studies were examined from 2000 to 2014, providing much greater precision than prior analyses. Survey-specific MDE prevalence estimates were synthesized into a pooled odds ratio comparing urban to rural areas using meta-analytic methods. RESULTS: Differences in the survey-specific estimates were not in excess of what would be expected due to sampling variability. This suggests that inconsistency in the prior literature is due to inadequate power and precision, an issue addressed by the meta-analytic pooling. The pooled odds ratio for Canada is 1.18 (95% confidence interval, 1.12 to 1.25), indicating that urban regions have higher MDE prevalence than rural regions. However, the difference is very small and of uncertain significance for policy and planning. CONCLUSIONS: Prevalence of MDE is approximately 18% higher in urban compared to rural regions of Canada. The difference is insufficient to impute differing need for services, but the result resolves an inconsistency in the existing literature and may play a role in future needs assessment.

Characterization of Disability in Canadians with Mental Disorders Using an Abbreviated Version of a DSM-5 Emerging Measure: The 12-Item WHO Disability Assessment Schedule (WHODAS) 2.0.

OBJECTIVE: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a disability scale included in Section 3 of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a possible replacement for the Global Assessment of Functioning Scale (GAF). To assist Canadian psychiatrists with interpretation of the scale, we have conducted a descriptive analysis using data from the 2012 Canadian Community Health Survey-Mental Health component (CCHS-MH). METHODS: The 2012 CCHS-MH was a cross-sectional survey of the Canadian community (n = 23,757). The survey included an abbreviated 12-item version of the WHODAS 2.0. Mental disorder diagnoses were assessed for schizophrenia, other psychosis, major depressive episode (MDE), generalized anxiety disorder (GAD), bipolar I disorder, substance abuse/dependence, and alcohol abuse/dependence. RESULTS: Mean scores ranged from 14.2 (95% CI, 14.1 to 14.3) for the overall community population to 23.1 (95% CI, 19.5 to 26.7) for those with schizophrenia, with higher scores indicating greater disability. Furthermore, the difference in scores between those with lifetime and past-month episodes suggests that the scale is sensitive to changes occurring during the course of these disorders; for example, scores varied from 23.6 (95% CI, 22.2 to 25.1) for past-month MDE to 14.4 (95% CI, 14.2 to 14.7) in the lifetime MDE group without a past-year episode. CONCLUSION: This analysis suggests that the WHODAS 2.0 may be a suitable replacement for the GAF. As a disability measure, even though it is not a mental health-specific instrument, the 12-item WHODAS 2.0 appears to be sensitive to the impact of mental disorders and to changes over the time course of a mental disorder. However, the clinical utility of this measure requires additional assessment.

Perceived Stigma among Recipients of Mental Health Care in the General Canadian Population.

OBJECTIVES: The Mental Health Experiences Scale is a measure of perceived stigma, the perception of negative attitudes and behaviours by people with mental disorders. A recent Canadian survey (Canadian Community Health Survey-Mental Health) included this scale, providing an opportunity to describe perceived stigma in relation to diagnosis for the first time in the Canadian general population. METHODS: The survey interview began with an assessment of whether respondents had utilised services for an "emotional or mental health problem" in the preceding 12 months. The subset reporting service utilisation were asked whether others "held negative opinions" about them or "treated them unfairly" for reasons related to their mental health. The analysis reported here used frequencies, means, cross-tabulation, and logistic regression, all incorporating recommended replicate sampling weights and bootstrap variance estimation procedures. RESULTS: Stigma was perceived by 24.4% of respondents accessing mental health services. The frequency was higher among younger respondents (<55 years), those who were not working, those reporting only fair or poor mental health, and the subset who reported having received a diagnosis of a mental disorder. Sex and education level were not associated with perceived stigma. People with schizophrenia reported stigmatization only slightly more frequently than those with mood and anxiety disorders. CONCLUSIONS: Stigmatization is a common, but not universal, experience among Canadians using services for mental health reasons. Stigmatization was a problem for a sizeable minority of respondents with mood, anxiety, and substance use disorders as well as bipolar and psychotic disorders.

Major Depression in Canada: What Has Changed over the Past 10 Years?

OBJECTIVE: Major depressive episodes (MDE) make an important contribution to disease burden in Canada. The epidemiology of MDE in the national population has been examined in 2 mental health surveys, one conducted in 2002 and the other in 2012. Our objective was to compare selected variables from the 2 surveys to determine whether changes have occurred in the prevalence, treatment, and impact of MDE. METHOD: The World Health Organization World Mental Health Composite International Diagnostic Interview was used in both surveys and the MDE module (which was not modified) was scored using the same algorithm. Some variables assessing impact and management of MDE were also identical in the 2 surveys. The analysis was based on frequency estimates and associated 95% confidence intervals. RESULTS: The annual prevalence of MDE was 4.7% (95% CI 4.3% to 5.1%) in 2012, nearly identical to 4.8% (95% CI 4.5% to 5.1%) in 2002. Receipt of potentially adequate treatment (defined as taking an antidepressant or 6 or more visits to a health professional for mental health reasons) increased from 41.3% in 2002 to 52.2% in 2012, mostly due to an increase in respondents reporting 6 or more visits. Use of second generation antipsychotics also increased. There was no evidence of diminishing prevalence or impact (as assessed by symptoms of distress). CONCLUSIONS: There appears to have been an increase in receipt of treatment for people with MDE and a changing pattern of management. However, it was not possible to confirm that the impact of MDE is diminishing as a result.