Physician Follow-Up of Pediatric and Young Adult Emergency Department Visits for Substance Use in Ontario, Canada.

PURPOSE: To study the proportion and predictors of outpatient physician follow-up within 60 days of substance-related emergency department (ED) visits for Ontario youth. METHODS: We examined administrative data on substance-related ED visits before and during the COVID-19 pandemic among youths aged 10-24 years in Ontario, Canada. Substance-related visits were identified using International Classification of Diseases-10-CA codes. We described demographic characteristics, receipt of mental health services in the year before the ED visit, disposition from the ED, and follow-up services within 60 days of the ED visit. RESULTS: Between April 1, 2017, and May 31, 2021, 64,236 youth had at least one ED visit for substance use. Visits for alcohol were the most common (49%), followed by cannabis (32.3%). ED visits for all substances were more prevalent during the pandemic than prepandemic, except visits for alcohol. The receipt of follow-up physician care for substance use was low (33.2% prepandemic) but increased during the pandemic (41.7%; adjusted odds ratio 1.34, 95% CI 1.28, 1.39) and varied between substances. Mental health service history in the year before the substance-related ED visit had the strongest association with receipt of follow-up physician care within 60 days (adjusted odds ratio 6.86, 95% CI 6.57, 7.17). DISCUSSION: Youth frequently do not receive physician follow-ups within two months of the substance-related ED visit, although higher follow-up proportions were seen during the pandemic after the implementation of virtual care. Further research is required to understand why follow-up is low and to examine interventions that can increase connection to care.

Secondary Stroke Prevention in People With Schizophrenia.

BACKGROUND: People with schizophrenia are less likely than those without to be treated for cardiovascular disease. We aimed to evaluate the association between schizophrenia and secondary preventive care after ischemic stroke. METHODS AND RESULTS: In this retrospective cohort study, we used linked population-based administrative data to identify adults who survived 1 year after ischemic stroke hospitalization in Ontario, Canada between 2004 and 2017. Outcomes were screening, treatment, and control of risk factors, and receipt of outpatient physician services. We used modified Poisson regression to model the relative risk of each outcome among people with and without schizophrenia, adjusting for age and other factors. Among 81 163 people with ischemic stroke, 844 (1.04%) had schizophrenia. Schizophrenia was associated with lower rates of screening for hyperlipidemia (60.5% versus 66.0%, adjusted relative risk [aRR] 0.88 [95% CI, 0.84-0.93]) and diabetes (69.4% versus 73.9%, aRR 0.93 [95% CI, 0.89-0.97]), prescription of antihypertensive medications (91.2% versus 94.7%, aRR 0.96 [95% CI, 0.93-0.99]), achievement of target lipid levels (low-density lipoprotein <2 mmol/L) (30.6% versus 34.6%, aRR 0.86 [95% CI, 0.78-0.96]), and outpatient specialist visits (55.3% versus 67.8%, aRR 0.78 [95% CI, 0.74-0.83]) or primary care physician visits (94.5% versus 98.5%; aRR 0.96 [95% CI, 0.95-0.98]) within 1 year. There were no differences in prescription of antilipemic, antiglycemic, or anticoagulant medications, or in achievement of target hemoglobin A1c ≤7%. CONCLUSIONS: People with stroke and schizophrenia are less likely than those without to receive secondary preventive care. This may inform interventions to improve poststroke care and outcomes in those with schizophrenia.

Mental Health Service Use Before First Diagnosis of a Psychotic Disorder.

Importance: Characterizing mental health service use trajectories preceding diagnosis of a psychotic disorder may help identify individuals at highest risk and in which settings they are at highest risk. Objective: To examine mental health service use and diagnostic trajectories before first diagnosis of psychotic disorder and identify utilization and diagnostic patterns. Design, Setting, and Participants: This population-based, retrospective cohort study used linked provincial health administrative data. The sample included individuals aged 15 to 29 years diagnosed with a psychotic disorder in Ontario, Canada, between April 1, 2012, and March 31, 2018. These individuals were matched to individuals with a diagnosis of a mood disorder. Data were analyzed from November 2108 to November 2019. Main Outcomes and Measures: The main outcomes were rates, timing, and setting of mental health-related service use and associated diagnoses in the 3 years before the index disorder among individuals first diagnosed with a psychotic disorder compared with those first diagnosed with a mood disorder. Results: A total of 10 501 individuals with a first diagnosis of psychotic disorder were identified (mean [SD] age, 21.55 [3.83] years; 72.1% male). A total of 72.2% of individuals had at least 1 mental health service visit during the 3 years before their first psychotic disorder diagnosis, which was significantly more than matched controls with a first mood disorder diagnosis (66.8%) (odds ratio [OR], 1.34; 95% CI, 1.26-1.42). Compared with individuals diagnosed with a mood disorder, individuals diagnosed with a psychotic disorder were significantly more likely to have had mental health-related hospital admissions (OR, 3.98; 95% CI, 3.43-4.62) and emergency department visits (OR, 2.27; 95% CI, 2.12-2.43) in the preceding 3 years. Those with psychotic disorders were more likely to have had prior diagnoses of substance use disorders (OR, 2.57; 95% CI, 2.35-2.81), other disorders (personality disorders, developmental disorders) (OR, 1.75; 95% CI, 1.61-1.90), and self-harm (OR, 1.64; 95% CI, 1.36-1.98) in the past 3 years compared with those diagnosed with mood disorders. Conclusions and Relevance: This study found that in the 3 years prior to an index diagnosis, individuals with a first diagnosis of psychotic disorder had higher rates of mental health service use, particularly emergency department visits and hospitalizations, compared with individuals with a first diagnosis of a mood disorder. Individuals with psychotic disorders also had a greater number of premorbid diagnoses. Differences in health service utilization patterns between those with a first psychotic disorder diagnosis vs a first mood disorder diagnosis suggest distinct premorbid trajectories that could be useful for next steps in prediction and prevention research.

Age-dependent association of cannabis use with risk of psychotic disorder.

BACKGROUND: Epidemiologic research suggests that youth cannabis use is associated with psychotic disorders. However, current evidence is based heavily on 20th-century data when cannabis was substantially less potent than today. METHODS: We linked population-based survey data from 2009 to 2012 with records of health services covered under universal healthcare in Ontario, Canada, up to 2018. The cohort included respondents aged 12-24 years at baseline with no prior psychotic disorder (N = 11 363). The primary outcome was days to first hospitalization, ED visit, or outpatient visit related to a psychotic disorder according to validated diagnostic codes. Due to non-proportional hazards, we estimated age-specific hazard ratios during adolescence (12-19 years) and young adulthood (20-33 years). Sensitivity analyses explored alternative model conditions including restricting the outcome to hospitalizations and ED visits to increase specificity. RESULTS: Compared to no cannabis use, cannabis use was significantly associated with psychotic disorders during adolescence (aHR = 11.2; 95% CI 4.6-27.3), but not during young adulthood (aHR = 1.3; 95% CI 0.6-2.6). When we restricted the outcome to hospitalizations and ED visits only, the strength of association increased markedly during adolescence (aHR = 26.7; 95% CI 7.7-92.8) but did not change meaningfully during young adulthood (aHR = 1.8; 95% CI 0.6-5.4). CONCLUSIONS: This study provides new evidence of a strong but age-dependent association between cannabis use and risk of psychotic disorder, consistent with the neurodevelopmental theory that adolescence is a vulnerable time to use cannabis. The strength of association during adolescence was notably greater than in previous studies, possibly reflecting the recent rise in cannabis potency.

Outcomes following hip fracture surgery in adults with schizophrenia in Ontario, Canada: A 10-year population-based retrospective cohort study.

OBJECTIVE: To understand immediate and long-term outcomes following hip fracture surgery in adults with schizophrenia. METHODS: Retrospective population-based cohort study leveraging health administrative databases from Ontario, Canada. Individuals aged 40-105 years with hip fracture surgery between April 1, 2009 and March 31, 2019 were included. Schizophrenia was ascertained using a validated algorithm. Outcomes were: 30-day mortality; 30-day readmission; 1-year survival; and subsequent hip fracture within 2 years. Analyses incorporated Generalized Estimating Equation models, Kaplan-Meier curves, and Fine-Gray competing risk models. RESULTS: In this cohort study of 98,126 surgically managed hip fracture patients, the median [IQR] age was 83[75-89] years, 69.2% were women, and 3700(3.8%) had schizophrenia. In Fine-Gray models, schizophrenia was associated with subsequent hip fracture (sdRH, 1.29; 95% CI, 1.09-1.53), with male patients with schizophrenia sustaining a refracture 50 days earlier. In age- and sex-adjusted GEE models, schizophrenia was associated with 30-day mortality (OR, 1.31; 95% CI, 1.12-1.54) and readmissions (OR, 1.40; 95% CI, 1.25-1.56). Kaplan-Meier survival curves suggested that patients with schizophrenia were less likely to be alive at 1-year. CONCLUSIONS: Study highlights the susceptibility of hip fracture patients with schizophrenia to worse outcomes, including refracture, with implications for understanding modifiable processes of care to optimize their recovery.

Characteristics of Opioid Toxicity Deaths Among Adolescents and Young Adults in Ontario Prior To and During the COVID-19 Pandemic.

PURPOSE: To characterize opioid toxicity deaths among adolescents and young adults in Ontario, Canada, prior to and during the first year of the COVID-19 pandemic. METHODS: We conducted a descriptive, cross-sectional study of opioid toxicity deaths among individuals aged 15-24 in Ontario in the year prior to (March 17, 2019, to March 16, 2020) and the first year of the pandemic (March 17, 2020, to March 16, 2021) using administrative health databases. We analyzed circumstances surrounding death, substances contributing to death, and health-care encounters prior to death. RESULTS: We identified 284 deaths among Ontarians aged 15-24, including 115 in the year preceding and 169 in the first year of the pandemic. Fentanyl contributed to 84.3% of deaths in the prepandemic year, rising to 93.5% (p = .012) the following year. Stimulants contributed to approximately half of deaths in both periods (41.7% prepandemic and 49.1% during pandemic). In both periods, roughly one in 4 decedents had a health-care encounter in the week prior to death and less than 20% of those with an opioid use disorder received opioid agonist treatment in the 30 days prior to death. DISCUSSION: Among young Ontarians, the number of opioid-related deaths increased by 47% in the first year of the COVID-19 pandemic. Fentanyl contributed to the vast majority of deaths, with non-opioid substances (primarily stimulants) also contributing to approximately half of deaths. Patterns of health-care utilization prior to death suggest opportunities to better connect this population to services that address opioid use disorder needs and promote harm reduction.

Non-fatal self-harm and suicide following postpartum psychiatric emergency department visits: A population-based retrospective cohort study.

In a population-based cohort of postpartum individuals in Ontario, Canada, this study aimed to determine the risk of non-fatal self-harm and suicide within one year of an initial postpartum psychiatric emergency department (ED) visit (2008-2020), and the key associated factors. Of 16,475 postpartum individuals with psychiatric ED visits, 714 (4.3 %) had non-fatal self-harm within one year, and 23 (0.15 %) died by suicide. Risk was substantially higher for those with self-harm at the initial presentation. Further efforts to connect individuals with postpartum psychiatric ED visits with needed inpatient care and outpatient follow-up are required to reduce non-fatal self-harm and suicide risk.

Mental disorders and discrimination: A prospective cohort study of young twin pairs in Germany.

Background: Mental disorders and perceived discrimination share common risk factors. The association between having a mental disorder and experiencing discrimination is well-known, but the extent to which familial factors, such as genetic and shared environmental factors, might confound this association, including sex differences in familial confounding, remains unexplored. Aims: We investigated potential unmeasured familial confounding in the association between mental disorders and perceived discrimination using a matched twin study design. Method: We examined data from 2044 same-sex twin pairs (n = 4088) aged 16-25 years from the German population-based study 'TwinLife'. We applied random-effects logistic regression to within-individual and within-and-between pair models of the association between mental disorder and perceived discrimination, and used likelihood ratio tests (LRTs) to compare these models. Multivariable models were adjusted for body mass index, educational attainment, and life satisfaction. Results: There were 322 (8.1%) participants with a diagnosed mental disorder, and 15% (n = 604) of the cohort reported having experienced discrimination in the previous 12 months. Mental disorder and discrimination were associated in the adjusted within-individual model (adjusted odds ratio = 2.19, 95% confidence interval: 1.42-3.39, P<0.001). However, the within-and-between pair model showed that this association was explained by the within-pair mean (aOR = 4.24, 95% CI: 2.17-8.29, P<0.001) and not the within-pair difference (aOR = 1.26, 95% CI: 0.70-2.28, P = 0.4) of mental disorder. Therefore, this association was mostly explained by familial confounding, which is also supported by the LRTs for the unadjusted and adjusted models (P<0.001 and P = 0.03, respectively). This familial confounding was more prominent for males than females. Conclusions: Our findings show that the association between mental disorder and discrimination is at least partially explained by unmeasured familial factors. Designing family-based healthcare models and incorporating family members in interventions targeted at ameliorating mental ill-health and experiences of discrimination among adolescents may improve efficacy.

A Retrospective Cohort Analysis of Mental Health-Related Emergency Department Visits Among Veterans and Non-Veterans Residing in Ontario, Canada: Une analyse de cohorte rétrospective des visites au service d'urgence liées à la santé mentale parmi les vétérans et non-vétérans résidant en Ontario, Canada.

OBJECTIVES: Emergency departments (EDs) are a vital part of healthcare systems, at times acting as a gateway to community-based mental health (MH) services. This may be particularly true for veterans of the Royal Canadian Mounted Police who were released prior to 2013 and the Canadian Armed Forces, as these individuals transition from federal to provincial healthcare coverage on release and may use EDs because of delays in obtaining a primary care provider. We aimed to estimate the hazard ratio (HR) of MH-related ED visits between veterans and non-veterans residing in Ontario, Canada: (1) overall; and by (2) sex; and (3) length of service. METHODS: This retrospective cohort study used administrative healthcare data from 18,837 veterans and 75,348 age-, sex-, geography-, and income-matched non-veterans residing in Ontario, Canada between April 1, 2002, and March 31, 2020. Anderson-Gill regression models were used to estimate the HR of recurrent MH-related ED visits during the period of follow-up. Sex and length of service were used as stratification variables in the models. RESULTS: Veterans had a higher adjusted HR (aHR) of MH-related ED visits than non-veterans (aHR, 1.97, 95% CI, 1.70 to 2.29). A stronger effect was observed among females (aHR, 3.29; 95% CI, 1.96 to 5.53) than males (aHR, 1.78; 95% CI, 1.57 to 2.01). Veterans who served for 5-9 years had a higher rate of use than non-veterans (aHR, 3.76; 95% CI, 2.34 to 6.02) while veterans who served for 30+ years had a lower rate compared to non-veterans (aHR, 0.60; 95% CI, 0.42 à 0.84). CONCLUSIONS: Rates of MH-related ED visits are higher among veterans overall compared to members of the Ontario general population, but usage is influenced by sex and length of service. These findings indicate that certain subpopulations of veterans, including females and those with fewer years of service, may have greater acute mental healthcare needs and/or reduced access to primary mental healthcare.

Outcomes in Clinical Subgroups of Patients With Alcohol-Related Hospitalizations.

Importance: Alcohol-related hospitalizations are common and associated with significant cost to the health care system. We have a limited understanding of the characteristics of individuals who experience alcohol-related hospitalizations, which limits our capacity to prioritize those at the highest risk of postdischarge harm. Objective: To identify and characterize the clinical subgroups of individuals who are hospitalized for alcohol-related harms. Design, Setting, and Participants: This cohort study used latent class analysis (LCA) to identify clinical subgroups of individuals experiencing alcohol-related hospitalizations in 2 provinces in Canada. All individuals between ages 10 and 105 years who were hospitalized for an alcohol-related harm between January 2017 and December 2018 (ie, the index hospitalization) were eligible. Data were analyzed between June 2023 and August 2023. Exposures: The exposure of interest was the clinical subgroup that an individual belonged to. These subgroups were identified using an LCA based on (1) the characteristics of the index hospitalization and (2) the history of alcohol-related health service use. Main Outcomes and Measures: In-hospital mortality, alcohol-related hospital readmission, and all-cause mortality in the year following discharge from the index hospitalization. The association between subgroup membership and the risk of in-hospital and postdischarge outcomes was evaluated using multivariable regression. Results: A total of 34 043 individuals were included in analysis, 4753 from Manitoba (median [IQR] age, 49 [40-58] years; 1786 female [37.6%]) and 29 290 from Ontario (median [IQR] age, 57 [45-67] years; 8527 female [29.1%]). Seven subgroups were identified following a gradient from low-frequency service use for acute intoxication to high-frequency service use for severe alcohol use disorder and liver disease. In Ontario, there were 4431 individuals in the liver disease subgroup representing 15.5% of the cohort who were at the highest risk of 1-year mortality (1382 [31.2%]) relative to the acute intoxication subgroup (42 [4.0%]) (adjusted hazard ratio [aHR], 3.83; 95% CI, 2.80-5.24). There was also a small subgroup (10.6%) of individuals with high-frequency alcohol-related health service use who had a much higher hazard of readmission following the index hospitalization (1-year readmission: 703 of 1526 [46.1%] vs 104 of 1058 [9.8%] in the acute intoxication subgroup; aHR, 5.09; 95% CI, 4.11-6.31). Conclusions and Relevance: In this population-based cohort study of individuals experiencing alcohol-related hospitalizations, we identified several small, clinically distinct subgroups that were at a disproportionately high risk of readmission and mortality. These groups could merit prioritization in strategies aimed at reducing the risk of adverse outcomes following alcohol-related hospitalizations.

Youth cannabis use and subsequent health service use for mood and anxiety disorders: A population-based cohort study.

Epidemiologic research suggests a modest association between youth cannabis use and mood and anxiety disorders (MADs). However, current evidence is based mostly on cohort studies using data from the 20th century when cannabis was significantly less potent than today. We linked population-based survey data from 2009 to 2012 with administrative records of health services covered under universal healthcare up to 2017. The cohort included youth aged 12 to 24 years at baseline living in Ontario, Canada with no prior MAD health service use (n = 8,252). We conducted a multivariable Cox model to estimate the association between cannabis use frequency (never,

A randomized sham-controlled trial of high-dosage accelerated intermittent theta burst rTMS in major depression: study protocol.

BACKGROUND: Intermittent theta burst stimulation (iTBS), a novel form of repetitive transcranial magnetic stimulation (rTMS), can be administered in 1/10th of the time of standard rTMS (~ 3 min vs. 37.5 min) yet achieves similar outcomes in depression. The brief nature of the iTBS protocol allows for the administration of multiple iTBS sessions per day, thus reducing the overall course length to days rather than weeks. This study aims to compare the efficacy and tolerability of active versus sham iTBS using an accelerated regimen in patients with treatment-resistant depression (TRD). As a secondary objective, we aim to assess the safety, tolerability, and treatment response to open-label low-frequency right-sided (1 Hz) stimulation using an accelerated regimen in those who do not respond to the initial week of treatment. METHODS: Over three years, approximately 230 outpatients at the Centre for Addiction and Mental Health and University of British Columbia Hospital, meeting diagnostic criteria for unipolar MDD, will be recruited and randomized to a triple blind sham-controlled trial. Patients will receive five consecutive days of active or sham iTBS, administered eight times daily at 1-hour intervals, with each session delivering 600 pulses of iTBS. Those who have not achieved response by the week four follow-up visit will be offered a second course of treatment, regardless of whether they initially received active or sham stimulation. DISCUSSION: Broader implementation of conventional iTBS is limited by the logistical demands of the current standard course consisting of 4-6 weeks of daily treatment. If our proposed accelerated iTBS protocol enables patients to achieve remission more rapidly, this would offer major benefits in terms of cost and capacity as well as the time required to achieve clinical response. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04255784.

Characterizing the clinical subgroups of individuals who present to the emergency department for alcohol-related harms in Ontario, Canada: A latent class analysis.

Alcohol-related emergency department (ED) visits are common and associated with adverse clinical outcomes, including premature mortality. This population-based retrospective cohort study identified clinically distinct subgroups of individuals who experience alcohol-related ED visits and characterized differences in the risk of adverse outcomes between them. 73,658 individuals who experienced an alcohol-related ED visit in Ontario, Canada between 2017 and 2018 were identified. Latent class analysis (LCA) revealed five clinically distinct subgroups within the overall cohort. These subgroups followed a severity gradient from low-frequency service use for acute intoxication to high-frequency service use for alcohol use disorder (AUD) and related comorbidities. Relative to those presenting for acute intoxication, those presenting for AUD and comorbidities had a much higher risk of hospital admission (adjusted odds ratio [aOR]: 8.26, 95 % confidence interval [CI]: 7.81-8.75) and post-discharge mortality (adjusted hazard ratio [aHR]: 3.07, 95 % CI: 2.81-3.37). There was a subgroup of individuals with a history of high frequency alcohol-related health service use who were at the highest risk of experiencing another alcohol-related ED visit after the index event (aHR: 4.76, 95 % CI: 4.55-4.99). Individuals who experience alcohol-related ED visits are not a homogenous population, but a constellation of subgroups with different clinical characteristics and risk of adverse outcomes.

A computer-assisted telephone collaborative care intervention provided by lay providers for the treatment of comorbid depression and at-risk drinking: Analysis of a randomized controlled trial.

INTRODUCTION: Virtual collaborative care for people with comorbid depression and at-risk drinking lacks strong evidence. Our aim was to assess the impact of 12 months of telephone collaborative care (tCC) versus enhanced usual care (eUC) on depression and drinking. METHODS: We performed a secondary analysis of the Primary care Assessment and Research of a Telephone intervention for Neuropsychiatric conditions with Education and Resources study (PARTNERs), a blinded randomized controlled trial. We examined 144 participants with comorbid depression and at-risk drinking, of which 129 were from the original sample whose data have been published, and 15 were studied since the original report had been published. PARTNERs compared eUC consisting of usual care plus assessment of symptoms at baseline, and 4, 8, and 12 months later vs. tCC consisting of eUC plus telephone-based coaching and symptom monitoring provided by a lay mental health technician to patients supervised by a psychiatrist. The study assessed depression response and remission using logistic regression; we assessed trajectory of drinking using Generalized-estimating equations (GEE). Baseline factors associated with likelihood of not exceeding number of drinks at 12 months were identified using decision trees. RESULTS: tCC produced a faster decline in the number of drinks than eUC (Wald Χ2 = 9.47, p = 0.02). However, drinking and depression outcomes did not differ significantly between the two groups at the end of treatment. Higher alcohol consumption at baseline (≥18 standard drinks per week in the tCC group and ≥11 standard drinks per week in the eUC group) was associated with a higher likelihood of having at-risk drinking after 12 months of treatment. CONCLUSIONS: Our findings suggest that, compared to eUC, tCC may accelerate drinking reductions in patients with comorbid depression and at-risk drinking. Both treatments were equally effective at the end of treatment for both depression and drinking outcomes.

Chronic Psychotic Disorders and Correctional Involvement: A Population-Based Matched Case-Control Study in Ontario, Canada.

OBJECTIVE: Individuals with chronic psychotic disorders are overrepresented in correctional facilities, but little is known about factors that increase the risk of correctional involvement. The objective of this study was to compare individuals with chronic psychotic disorders who were released from correctional facilities in Ontario to individuals with chronic psychotic disorders but no correctional involvement on sociodemographic, clinical, and prior mental health-related health service utilization characteristics. METHOD: All individuals with chronic psychotic disorders who were released from a provincial correctional facility in Ontario in 2010 were matched (1:2) by age and sex to Ontario residents with chronic psychotic disorders and no correctional involvement. Covariates included sociodemographic (rural residence, marginalization such as residential instability quintile, material deprivation quintile, dependency quintile, and ethnic concentration quintile) and clinical (duration of chronic psychotic disorder and comorbidities) characteristics, and mental health-related health service utilization characteristics (primary care physician, psychiatrist and emergency department visits, and hospitalizations) 1 and 3 years prior to correctional involvement. The association between correctional involvement and prior health service utilization was measured by estimating incidence rate ratios using Poisson and negative-binomial regressions. RESULTS: Individuals with correctional involvement (N = 3,197) lived in neighbourhoods with higher material deprivation and residential instability, and had a shorter duration of illness, and more psychosocial comorbidities (e.g., behavioural issues and depression) than individuals without correctional involvement (N = 6,393). Adjusting for sociodemographic and clinical variables, individuals with correctional involvement had a higher rate of mental health-related primary care physician visits, emergency department visits, and hospitalizations but a lower rate of psychiatrist visits prior to correctional involvement, compared to individuals without correctional involvement. CONCLUSIONS: Despite higher mental health-related comorbidities and higher rates of accessing acute mental health services among individuals with chronic psychotic disorders and correctional involvement, visits to psychiatrists prior to involvement were low.

Assessing the "healthy immigrant effect" in mental health: Intra- and inter-cohort trends in mood and/or anxiety disorders.

BACKGROUND: The healthy immigrant effect implies that, at the time of immigration, new immigrants are typically healthier than the Canadian-born population. Furthermore, this health advantage fades the longer cohorts of immigrants remain in the host country. METHODS: Most studies assessing the healthy immigrant effect rely on strong, untestable assumptions to extract unique effects for length of stay (LOS) (i.e., how long an immigrant has been in a host country), period (i.e., year of observation), and cohort (i.e., year of immigration). Rather than attempting to parse out separate effects for LOS, period, and cohort, we adopt a descriptive, cohort-centric approach to study immigrant mental health, which examines intra- and inter-cohort trends, that is, joint LOS-period and cohort-period parameters, respectively. While intra-cohort trends show how immigrants' mental health change with LOS across periods, inter-cohort trends reveal how the mental health of successive cohorts of immigrants differ across time periods. To provide a thorough assessment of the healthy immigrant effect, we use both survey and administrative data on cohorts of Canadian immigrants from 2003 to 2013. RESULTS: The survey data reveal that mental health declines steeply (i.e., there is an increase in mood and/or anxiety disorders) within and across immigrant cohorts, while the administrative data show little overall change in mental health care utilization within and across cohorts. The divergent results may reflect issues related to barriers in access to mental health services because the administrative data, which are based on health care utilization, do not the capture the increase in mental disorders seen in the survey data. CONCLUSION: This study highlights the benefit of a cohort-based approach to assess the healthy immigrant effect as it pertains to mental health as well as the importance of using different types of data, which may be measuring different aspects of immigrant mental health and health care utilization.

The Toronto Adolescent and Youth Cohort Study: Study Design and Early Data Related to Psychosis Spectrum Symptoms, Functioning, and Suicidality.

BACKGROUND: Psychosis spectrum symptoms (PSSs) occur in a sizable percentage of youth and are associated with poorer cognitive performance, poorer functioning, and suicidality (i.e., suicidal thoughts and behaviors). PSSs may occur more frequently in youths already experiencing another mental illness, but the antecedents are not well known. The Toronto Adolescent and Youth (TAY) Cohort Study aims to characterize developmental trajectories in youths with mental illness and understand associations with PSSs, functioning, and suicidality. METHODS: The TAY Cohort Study is a longitudinal cohort study that aims to assess 1500 youths (age 11-24 years) presenting to tertiary care. In this article, we describe the extensive diagnostic and clinical characterization of psychopathology, substance use, functioning, suicidality, and health service utilization in these youths, with follow-up every 6 months over 5 years, including early baseline data. RESULTS: A total of 417 participants were enrolled between May 4, 2021, and February 2, 2023. Participants met diagnostic criteria for an average of 3.5 psychiatric diagnoses, most frequently anxiety and depressive disorders. Forty-nine percent of participants met a pre-established threshold for PSSs and exhibited higher rates of functional impairment, internalizing and externalizing symptoms, and suicidality than participants without PSSs. CONCLUSIONS: Initial findings from the TAY Cohort Study demonstrate the feasibility of extensive clinical phenotyping in youths who are seeking help for mental health problems. PSS prevalence is much higher than in community-based studies. Our early data support the critical need to better understand longitudinal trajectories of clinical youth cohorts in relation to psychosis risk, functioning, and suicidality.

Risk of Repeat Psychiatric Emergency Department Visits in the Postpartum Period: A Population-Based Retrospective Cohort Study.

STUDY OBJECTIVE: Approximately 1 in 100 postpartum individuals visit an emergency department (ED) for a psychiatric reason. Repeat visits can signify problems with the quality of care received during or after the initial visit; this study aimed to understand risk for repeat postpartum psychiatric ED visits. METHODS: This population-based cohort study used Ontario, Canada health administrative data available through ICES (formerly the Institute for Clinical Evaluative Sciences) to identify all individuals discharged from postpartum psychiatric ED visits (2008 to 2021) and measured the proportion with one or more repeat psychiatric ED visit within 30 days. Using modified Poisson regression, we calculated the association between one or more repeat visits and sociodemographic, medical, obstetric, infant, continuity of care, past service use, and index ED visit characteristics both overall and stratified by psychiatric diagnosis. RESULTS: Of 14,100 individuals, 11.7% had one or more repeat psychiatric ED visits within 30 days. Repeat visit risk was highest for those with schizophrenia-spectrum disorders (28.2%, adjusted risk ratio 2.41; 95% confidence interval 1.88 to 3.08, versus 9.5% anxiety referent). Low (versus no) psychiatric care continuity, prior psychiatric ED visits and admissions, and initial visits within 90 days postpartum were also associated with increased risk, whereas intentional self-injury was associated with reduced risk. In diagnosis-stratified analyses, the factors most consistently associated with repeat ED visits were past psychiatric ED visits and admissions, and initial visits within 90 days postpartum. CONCLUSIONS: Over 1 in 10 postpartum psychiatric ED visits are followed by a repeat visit within 30 days. Targeted approaches are needed across clinical populations to reduce repeat ED visits in this population with young infants.

A Rapid Access Brief Psychotherapy Intervention to Respond to Healthcare Workers in Ontario Whose Mental Health was Negatively Impacted During the COVID-19 Pandemic.

OBJECTIVE: Although the coronavirus disease 2019 (COVID-19) pandemic has had widespread negative impacts on the mental health of healthcare workers (HCWs), there has been little research on psychological interventions during the pandemic for this population. The current study examines whether a brief coping-focused treatment intervention delivered in a virtual individual format would be associated with positive changes in Canadian HCWs' mental health during the pandemic. METHOD: Three hundred and thirty-three HCWs receiving the intervention at 3 large specialty tertiary care hospitals in Ontario, Canada, completed measures of anxiety, depression, perceived stress, work/social impairment, insomnia and fear of COVID-19. After completing treatment, HCWs rated their satisfaction with the treatment. RESULTS: The intervention was associated with large effect size improvements in anxiety, depression, perceived stress, insomnia and fear of COVID-19, and moderate effect size improvements in work/social impairment. At treatment session 1, prior mental health diagnosis and treatment were both significantly correlated with depression, anxiety, and work/social impairment scores. Secondary analyses of data from one of the sites revealed that treatment-related changes in anxiety, depression, perceived stress and work/social impairment were independent of age, gender, occupational setting, profession and the presence of a previous mental health diagnosis or treatment, with the exception that nurses improved at a slightly greater rate than other professions in terms of work/social impairment. HCWs were highly satisfied with the treatment. CONCLUSIONS: A large number of HCWs experiencing significant distress at baseline self-referred for assistance. Timely and flexible access to a brief virtual coping-focused intervention was associated with improvements in symptoms and impairment, and treatment response was largely unrelated to demographic or professional characteristics. Short-term psychological interventions for HCWs during a pandemic may have a highly positive impact given their association with improvement in various aspects of HCWs' mental health improvement.

Mortality in adolescents and young adults following a first presentation to the emergency department for alcohol.

BACKGROUND AND METHODS: We conducted a population-based, retrospective cohort study of first-time emergency department (ED) visits in adolescents and young adults (AYA) due to alcohol and compared mortality to AYA with nonalcohol ED visits between 2009 and 2015 using standardized all-cause mortality ratios (age, sex, income, and rurality). We described the cause of death for AYA and examined the association between clinical factors and mortality rates in the alcohol cohort using proportional hazard models. RESULTS: A total of 71,776 AYA had a first-time ED visit due to alcohol (56.1% male, mean age 20.7 years) between 2009 and 2015, representing 3.3% of the 2,166,838 AYA with an ED visit in this time period. At 1 year, there were 2396 deaths, 248 (10.3%) following an ED visit related to alcohol. First-time alcohol ED visits were associated with a threefold higher risk in mortality at 1 year (0.35% vs. 0.10%, adjusted hazard ratio [aHR] 3.07, 95% confidence interval [CI] 2.69-3.51). Mortality was associated with age 25-29 years (aHR 3.88, 95% CI 2.56-5.86), being male (aHR 1.98, 95% CI 1.49-2.62), having a history of mental health or substance use (aHR 3.22, 95% CI 1.64-6.32), cause of visit being withdrawal/dependence (aHR 2.81, 95% CI 1.96-4.02), and having recurrent ED visits (aHR 1.97, 95% CI 1.27-3.05). Trauma (42.7%), followed by poisonings from drugs other than opioids (38.3%), and alcohol (28.6%) were the most common contributing causes of death. CONCLUSION: Incident ED visits due to alcohol in AYA are associated with a high risk of 1-year mortality, especially in young adults, those with concurrent mental health or substance use disorders, and those with a more severe initial presentation. These findings may help inform the need and urgency for follow-up care in this population.