Community pharmacists' experiences and people at risk of suicide in Canada and Australia: a thematic analysis.

PURPOSE: To explore Canadian and Australian community pharmacists' practice experiences in caring for people at risk of suicide. METHODS: We conducted a thematic analysis of 176 responses to an open-ended extension question in an online survey. RESULTS: Four themes were identified and include referrals and triage, accessibility for confiding, emotional toll, and stigma. Subthemes included gatekeeping the medication supply, sole disclosure, planning for end of life, concerns of support people, assessing the validity of suicidality, gaps in the system, not directly asking, ill-equipped, resources in the pharmacy, relying on others to continue care, and attention seeking. CONCLUSIONS: Community pharmacists are caring for patients at risk of suicide frequently, and often with patients seeking the help of pharmacists directly. Pharmacists engage in activities and actions that would be considered outside of the traditional dispensing roles and provide support and intervention to people at risk of suicide through collaboration and other mechanisms. Further research to determine appropriate education and training and postvention supports is required.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews.

OBJECTIVE: We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts. METHODS: Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings. RESULTS: No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%. CONCLUSIONS: Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Survey of Australian and Canadian Community Pharmacists' Experiences With Patients at Risk of Suicide.

OBJECTIVE: The study's objective was to examine Canadian and Australian community pharmacists' experiences with people at risk of suicide. METHODS: A survey was developed and administered online. Countries were compared by Fisher's exact and t tests. Multivariable logistic-regression analysis was used to identify variables associated with preparedness to help someone in a suicidal crisis. RESULTS: The survey was completed by 235 Canadian and 161 Australian pharmacists. Most (85%) interacted with someone at risk of suicide at least once, and 66% experienced voluntary patient disclosure of suicidal thoughts. More Australians than Canadians had mental health crisis training (p<0.001). Preparedness to help in a suicidal crisis was negatively associated with being Canadian, having a patient who died by suicide, lacking training and confidence, and permissive attitudes toward suicide. CONCLUSIONS: Several perceived barriers impede pharmacists' abilities to help patients who voluntarily disclose suicidal thoughts. Gatekeeper and related suicide prevention strategy training for community pharmacists is warranted.

Problems with access to adolescent mental health care can lead to dealings with the criminal justice system.

Mental disorders collectively constitute the largest burden of disease in young people. They have substantial negative short- and long-term outcomes across many domains, yet early identification and effective intervention can improve outcomes and can often lead to recovery. Unfortunately, many young people do not receive the mental health care they require and may consequently enter the justice system. Studies of incarcerated youths show that up to 70% of them have mental disorders. Many of these youth receive primarily custodial care. A variety of social, legal and medical interventions can and should be implemented to ensure that young people suffering from mental disorders do not inappropriately enter the justice system due to lack of access to health care and other services.

Creating Evidence-Based Youth Mental Health Policy in Sub-Saharan Africa: A Description of the Integrated Approach to Addressing the Issue of Youth Depression in Malawi and Tanzania.

Addressing depression in young people is a health-care policy need in sub-Saharan Africa. There exists poor mental health literacy, high levels of stigma, and weak capacity at the community level to address this health-care need. These challenges are significant barriers to accessing mental health care for depression, soon to be the largest single contributor to the global burden of disease. We here describe an innovative approach that addresses these issues simultaneously while concurrently strengthening key mental health components in existing education and health-care systems as successfully applied in Malawi and replicated in Tanzania. Improving the pathway to care for young people with depression requires the following: improving mental health literacy (MHL) of communities, youth, and teachers; enhancing case identification and linking schools to community health clinics; improving the capacity of community health-care providers to identify, diagnose, and effectively treat depression in youth. Funded by Grand Challenges Canada, we developed and applied a program called "An Integrated Approach to Addressing the Challenge of Depression Among the Youth in Malawi and Tanzania" (IACD). This was an example of, a horizontally integrated pathway to care model designed to be applied in low-resource settings. The model is designed to 1) improve awareness/knowledge of mental health and mental disorders (especially depression) in communities; 2) enhance mental health literacy among youth and teachers within schools; 3) enhance capacity for teachers to identify students with possible depression; 4) create linkages between schools and community health clinics for improved access to mental health care for youth identified with possible depression; and 5) enhance the capacity of community-based health-care providers to identify, diagnose, and effectively treat youth with depression. With the use of interactive, youth-informed weekly radio programs, mental health curriculum training for teachers and peer educators in secondary schools, and a clinical competency training program for community-based health workers, the innovation created a "hub and spoke" model for improving mental health care for young people. Positive results obtained in Malawi and replicated in Tanzania suggest that this approach may provide an effective and potentially sustainable framework for enhancing youth mental health care, thus providing a policy ready framework that can be considered for application in sub-Saharan Africa.

Validation of the Kutcher Adolescent Depression Scale in a Caribbean student sample.

BACKGROUND: Research on depression among Caribbean children has been limited by a lack of valid and reliable measures. We addressed this problem by exploring the internal consistency reliability and the concurrent and discriminant validity of the Kutcher Adolescent Depression Rating Scale (KADS) among a wide cross-section of the student population attending elementary schools in Jamaica and Barbados. METHODS: Students enrolled in grade 6 in a cross-section of schools in Jamaica and Barbados were invited to participate in the study. Schools included a balance of government-funded public schools and privately funded preparatory schools. All schools that were invited to participate accepted, and all grade 6 classrooms in each school were sampled. The following instruments were administered to the students during the fall semester of 2015: KADS, Adolescent Depression Rating Scale (ADRS), major depression disorder subscale of the Revised Children's Anxiety and Depression Scale (RCADS), and state and trait anxiety visual analogue scales. RESULTS: In total, 759 children (376 girls [49.5%] and 363 boys [47.8%]; in 20 cases [2.6%], sex was missing) with a mean age of 10.7 (standard deviation 0.66) years (median 11.0 yr) took part in the study. Overall, the KADS had an acceptable degree of reliability (α = 0.76). The instrument had reasonably good concurrent validity, as evidenced by strong correlations with scores on the ADRS (r = 0.62) and the major depression disorder subscale of the RCADS (r = -0.61). It had acceptable discriminant validity, as shown through low correlations with the state and trait anxiety visual analogue scales (r = 0.21 and 0.18, respectively). This pattern of results suggests that a large part (37%) of the variance underlying the KADS assesses depression, and a smaller degree of the variance (3%-4%) measures a conceptually similar but distinct concept. INTERPRETATION: The KADS is a reliable and valid measure for assessing depressive symptoms among Jamaican and Barbadian elementary school students. The sample may not be representative of all Caribbean children.

Clinic outcomes of the Pathway to Care Model: A cross-sectional survey of adolescent depression in Malawi.

BACKGROUND: Depression is one of the leading contributors to the global burden of disease and often has an onset during adolescence. While effective treatments are available, many low-income countries, such as Malawi, lack appropriately trained health providers in community health settings, and this limits access to effective mental healthcare for young people with depression. To address this need, a Canadian-developed youth depression Pathway to Care Model, linking school-based mental health literacy interventions to training of community healthcare providers, was adapted for use in Malawi and successfully applied. METHODS: A sample of healthcare providers (N = 25) from community health clinics (N = 9) were trained in the use of comprehensive, systematic clinical interventions, addressing the identification, diagnosis, and treatment of depression in youth who had been referred from schools where mental health literacy interventions had been implemented. Referral outcomes were obtained using a standardised clinical record form. RESULTS: Over 120 clinical outcome forms were available for analysis. Seventy percent of youth referred by their teachers were diagnosed with depression. Most youth diagnosed with depression identified physical symptoms as their primary difficulty. Available standardised outcome measures applied by clinicians indicated that, overall, youth showed positive outcomes as a result of treatment. CONCLUSIONS: Community healthcare providers in Malawi were trained in the identification, diagnosis, and treatment of youth depression. When this training was applied in usual clinical care to youth referred from schools, it led to generally favourable clinical outcomes. To our knowledge, this is the first demonstration of a clinically feasible intervention that results in positive outcomes for young people with depression in Malawi, and it may provide a useful model to replicate elsewhere in sub-Saharan Africa.

System struggles and substitutes: A qualitative study of general practitioner and psychiatrist experiences of prescribing antipsychotics to children and adolescents.

There are significant controversies regarding rising antipsychotic prescription trends in children and adolescents. Many pharmacoepidemiology trend studies have been published, and interpretations of these data are helpful in explaining what is happening in prescribing practices, but not why these patterns exist. There is a lack of qualitative data in this area, and the experience of prescribing antipsychotics to children and adolescents has not been adequately researched. We conducted a qualitative study using an interpretive phenomenological analysis of physicians' experiences of antipsychotic prescribing to children and adolescents. Prescribers participated in individual interviews and a focus group. We used a staged approach for data analysis of transcriptions. In all, 11 physicians including psychiatrists and general practitioners participated in our study. We identified themes related to context, role and identity, and decision-making and filtering Struggles with health system gaps were significant leading to the use of antipsychotics as substitutes for other treatments. Physicians prescribed antipsychotics to youth for a range of indications and had significant concerns regarding adverse effects. Our results provide knowledge regarding the prescribers' experience of antipsychotics for children and adolescents. Important gaps exist within the health system that are creating opportunities for the initiation and continued use of these agents.

Impact of a Mental Health Curriculum on Knowledge and Stigma Among High School Students: A Randomized Controlled Trial.

OBJECTIVE: This study evaluated the effectiveness of a school-based mental health literacy intervention for adolescents on knowledge and stigma. METHOD: A total of 24 high schools and 534 students in the regional area of Ottawa, Ontario, Canada participated in this randomized controlled trial. Schools were randomly assigned to either the curriculum or control condition. The curriculum was integrated into the province's grade 11 and 12 "Healthy Living" courses and was delivered by teachers. Changes in mental health knowledge and stigma were measured using pre- and posttest questionnaires. Descriptive analyses were conducted to provide sample characteristics, and multilevel modeling was used to examine study outcomes. RESULTS: For the curriculum condition, there was a significant change in stigma scores over time (p = .001), with positive attitudes toward mental illness increasing from pre to post. There was also a significant change in knowledge scores over time (p < .001), with knowledge scores increasing from pre to post. No significant changes in knowledge or stigma were found for participants in the control condition. A meaningful relationship was found whereby increases in knowledge significantly predicted increases in positive attitudes toward mental health (p < .001). CONCLUSION: This is the first large randomized controlled trial to demonstrate the effectiveness in mental health literacy of an integrated, manualized mental health educational resource for high school students on knowledge and stigma. Findings also support the applicability by teachers and suggest the potential for broad-based implementation of the educational curriculum in high schools. Replication and further studies are warranted. Clinical trial registration information-Impact of a Mental Health Curriculum for High School Students on Knowledge and Stigma; http://clinicaltrials.gov/; NCT02561780.

Temporal coherence in ultradian sleep EEG rhythms in a never-depressed, high-risk cohort of female adolescents.

BACKGROUND: Previous work has indicated that low temporal coherence of ultradian sleep electroencephalographic rhythms is characteristic of depressed patients and of depressed women, in particular. It may also be evident in one quarter of those at high risk, based on a family history of depression. METHODS: The present study evaluated temporal coherence of sleep electroencephalographic rhythms in 41 adolescent girls with a maternal history of depression (high risk) and 40 healthy controls (low risk). The entire sample was followed clinically every 6 months for 2 years. RESULTS: Temporal coherence was significantly lower among the high-risk girls than in controls. Regression analyses predicted group from coherence values and correctly classified 70% of the high-risk group with a false-positive rate of 5% among controls. Moreover, 54% of the high-risk girls were identified with extreme low coherence. On clinical follow up, 14 girls showed depressive symptoms, 9 in the high-risk group (22.5%) and 5 controls (12.2%). Six met DSM-IV criteria for first-episode major depressive disorder, five high-risk and one control. Most importantly, 41% of those identified as having the most abnormal coherence values either showed symptoms of depression or met diagnostic criteria upon follow up. CONCLUSIONS: Low temporal coherence is evident in adolescent girls at high risk for depression. The more abnormal the coherence, the greater the risk of a first episode of major depressive disorder within 2 years of sleep study, approximately 10 times greater than in controls.

Mathematics deficits in adolescents with bipolar I disorder.

OBJECTIVE: This study examined mathematical ability in adolescents with bipolar I disorder, compared to adolescents with major depressive disorder and psychiatrically healthy comparison subjects. METHOD: Participants (N=119) included adolescents in remission from bipolar disorder (N=44) or major depressive disorder (N=30), as well as comparison subjects (N=45) with no psychiatric history. Participants were assessed with the following measures: the Wide-Range Achievement Test, Revised 2 (WRAT-R2), Peabody Individual Achievement Test, Bay Area Functional Performance Evaluation Task-Oriented Assessment (functional mathematics subtest), Test of Nonverbal Intellegence-2, and a self-report of mathematics performance. RESULTS: WRAT-R2 and Peabody Individual Achievement Test scores for spelling, mathematics, and reading revealed that adolescents with bipolar disorder had significantly lower achievement in mathematics, compared to subjects with major depressive disorder and comparison subjects. Results for the Test of Nonverbal Intellegence-2 were not significantly different between groups. Adolescents with bipolar disorder took significantly longer to complete the Bay Area Functional Performance Evaluation mathematics task. Significantly fewer adolescents with bipolar disorder (9%) reported above-average mathematics performance, compared with the other groups. CONCLUSIONS: Adolescents with remitted bipolar disorder have a specific profile of mathematics difficulties that differentiates them from both adolescents with unipolar depression and psychiatrically healthy comparison subjects. These mathematics deficits may not derive simply from more global deficits in nonverbal intelligence or executive functioning, but may be associated with neuroanatomical abnormalities that result in cognitive deficits, including a slowed response time. These deficits suggest the need for specialized assessment of mathematics as part of a comprehensive clinical follow-up treatment plan.

Summary of the practice parameter for the use of electroconvulsive therapy with adolescents.

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75-100%), whereas psychotic disorders have a lower response rate (50-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.

Practice parameter for use of electroconvulsive therapy with adolescents.

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75%-100%), whereas psychotic disorders have a lower response rate (50%-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.

Evaluating the Impact of an Educational Program on Practice Patterns of Canadian Family Physicians Interested in Depression Treatment.

BACKGROUND: Depression is frequently unrecognized and undertreated. Therefore, there is a need to increase the knowledge and skills of primary care physicians regarding the diagnosis and treatment of depression. The aim of this study was to provide, and evaluate the impact of, a brief educational program with a number of practice tools and resources in order to improve family physicians' knowledge, diagnosis, and treatment of depression. METHODS: Two educational programs (general and enhanced) were delivered to family physicians interested in depression treatment. The enhanced program focused on more practical clinical issues such as use of diagnostic and symptom assessment tools, recommended dosing of citalopram, how to initiate and discontinue treatment, and relapse prevention. Physicians' knowledge of depression was assessed pretraining and posttraining. Chart audits were conducted for 6 months. Primary endpoints were recognition of depression and pharmacologic management (initial dose, maximum dose, length of treatment, adverse events, and concomitant psychotropic drugs). Secondary endpoints were patient satisfaction with treatment, compliance, withdrawal from the study, treatment outcome, use of adjunctive psychotherapy, and number of office visits. RESULTS: There was a global increase in physicians' knowledge of depression in the short term. Physicians in the enhanced group were more likely to use a symptom-based diagnostic checklist, record the diagnosis of depression, and prescribe the recommended initial dose of citalopram, and they referred less frequently for adjunctive psychotherapy. No difference between educational intervention groups was found in patient satisfaction, compliance, and treatment outcome. CONCLUSIONS: A well-designed brief, simple, and low-cost educational program can increase family physicians' knowledge of depression, improve their diagnostic skills, and optimize their treatment of depression.

Short-term educational intervention improves family physicians' knowledge of depression.

INTRODUCTION: Depression is frequently unrecognized and undertreated. Therefore, there is a need to increase the knowledge and skills of primary care physicians regarding management of depression. The aim of this study was to determine if a brief educational intervention can affect family physicians' knowledge of the diagnosis and treatment of depression. METHOD: Sixty-eight community-based, nonacademic family physicians completed the program, which was delivered using a mixed lecture-seminar format. Knowledge about depression was assessed pre- and post-program. Paired-sample t test and chi-square test were used to compare test scores. RESULTS: Although study physicians demonstrated high baseline knowledge of depression, 75% of them had better scores following the program. The increase in knowledge was statistically significant (p < .0001). DISCUSSION: Our study demonstrates that a simple and brief educational program can enhance family physicians' knowledge of depression; however, an increase in knowledge alone may not necessarily translate into practice behavior change.