Clinical Assessment of Judgment in Adults and the Elderly: Development and Validation of the Three Domains of Judgment Test-Clinical Version (3DJT-CV).

(1) Background: This article discusses the first two phases of development and validation of the Three Domains of Judgment Test (3DJT). This computer-based tool, co-constructed with users and capable of being administered remotely, aims to assess the three main domains of judgment (practical, moral, and social) and learn from the psychometric weaknesses of tests currently used in clinical practice. (2) Method: First, we presented the 3DJT to experts in cognition, who evaluated the tool as a whole as well as the content validity, relevance, and acceptability of 72 scenarios. Second, an improved version was administered to 70 subjects without cognitive impairment to select scenarios with the best psychometric properties in order to build a future clinically short version of the test. (3) Results: Fifty-six scenarios were retained following expert evaluation. Results support the idea that the improved version has good internal consistency, and the concurrent validity primer shows that 3DJT is a good measure of judgment. Furthermore, the improved version was found to have a significant number of scenarios with good psychometric properties to prepare a clinical version of the test. (4) Conclusion: The 3DJT is an interesting alternative tool for assessing judgment. However, more studies are needed for its implementation in a clinical context.

Effect of electroencephalography-guided anesthesia on neurocognitive disorders in elderly patients undergoing major non-cardiac surgery: A trial protocol The POEGEA trial (POncd Elderly GEneral Anesthesia).

INTRODUCTION: The number of elderly patients undergoing major surgery is rapidly increasing. They are particularly at risk of developing postoperative neurocognitive disorders (NCD). Earlier studies suggested that processed electroencephalographic (EEG) monitors may reduce the incidence of postoperative NCD. However, none of these studies controlled for intraoperative nociception levels or personalized blood pressure targets. Their results remain unclear if the reduction in the incidence of postoperative NCD relates to avoidance of any electroencephalographic pattern suggesting excessive anesthesia depth. OBJECTIVE: The objective of this trial is to investigate-in patients ≥ 70 years old undergoing major non-cardiac surgery-the effect of EEG-guided anesthesia on postoperative NCD while controlling for intraoperative nociception, personalized blood pressure targets, and using detailed information provided by the EEG monitor (including burst suppression ratio, density spectral array, and raw EEG waveform). MATERIAL AND METHODS: This prospective, randomized, controlled trial will be conducted in a single Canadian university hospital. Patients ≥ 70 years old undergoing elective major non-cardiac surgery will be included in the trial. The administration of sevoflurane will be adjusted to maintain a BIS index value between 40 and 60, to keep a Suppression Ratio (SR) at 0%, to keep a direct EEG display without any suppression time and a spectrogram with most of the EEG wave frequency within the alpha, theta, and delta frequencies in the EEG-guided group. In the control group, sevoflurane will be administered to achieve an age-adjusted minimum alveolar concentration of [0.8-1.2]. In both groups, a nociception monitor will guide intraoperative opioid administration, individual blood pressure targets will be used, and cerebral oximetry used to tailor intraoperative hemodynamic management. The primary endpoint will be the incidence of NCD at postoperative day 1, as evaluated by the Montreal Cognitive Assessment (MoCA). Secondary endpoints will include the incidence of postoperative NCD at different time points and the evaluation of cognitive trajectories up to 90 days after surgery among EEG-guided and control groups. STUDY REGISTRATION: NCT04825847 on ClinicalTrials.gov.

Incidentaloma Discoveries in the Course of Neuroimaging Research.

ABSTRACTAmong healthy volunteers in psychiatric brain functional magnetic resonance imaging (fMRI) research studies, the prevalence of incidentalomas can be as high as 34%, of which 10% show clinical significance. An incidentaloma is a lesion found by coincidence without clinical symptoms or suspicion. Like lesions and other types of accidental findings, it is found in healthy individuals recruited to take part in psychiatric studies. The prevalence of these accidental findings among specific psychiatric populations remains unknown. However, a precise understanding of cerebral neuroanatomy, neuroradiological expertise, and an appropriate choice of fMRI exploration sequences will increase the sensitivity of identifying these accidental findings and enable researchers to address their clinical relevance and nature. We present recommendations on how to appropriately inform patients or participants of the accidental findings. Additionally, we propose specific suggestions pertaining to the clinical research setting aimed for investigators and psychiatrists. Unlike current articles pertaining to incidentaloma, the current report provides a distinct focus on psychiatric issues and specific recommendations for studies involving psychiatric patients.

[The history of geriatric psychiatry at the University of Montreal: Pioneers, milestones, and future outlook]. / L'éclosion de la gérontopsychiatrie à l'Université de Montréal, une histoire à découvrir.

OBJECTIVES: Geriatric psychiatry became an official psychiatric subspecialty in Canada in 2009. The first board examinations from the Royal College of Physicians and Surgeons of Canada (RCPSC) took place in 2013. Geriatric Psychiatry focuses on the assessment, diagnosis, and treatment of complex mental disorders in late life, a time when the interface between physical and mental health issues often adds a new level of complexity.Little has been written on the history of geriatric psychiatry in Québec and in Canada. A lesser-known aspect is that from the 1970's onwards, the department of psychiatry at the Université de Montréal (UdeM) and its network of teaching hospitals have played a pioneering role in the development of geriatric psychiatry services and training. We seek to recount the history of geriatric psychiatry at UdeM, by tracing the milestones and identifying the main actors responsible for its development, from the inception of the department of psychiatry 50 years ago. This leads us to share reflections on some of the issues geriatric psychiatry is facing in Québec. METHODS: We interviewed several key actors, past and present, of geriatric psychiatry at UdeM. We read through relevant sources such as articles and monographs on the local history of psychiatric services, information bulletins and annual reports from hospitals and from UdeM, as well as other documentation from personal archives. RESULTS: One of the very first geriatric psychiatry services in Canada was founded in 1978 at the Institut universitaire en santé mentale de Montréal, with a dedicated inpatient unit for new admissions of elderly psychiatric patients. A geriatric psychiatry outpatient clinic was inaugurated the same year at the Pavillon Albert-Prévost. Throughout the years, geriatric psychiatry services were also developed in the remaining hospital sites affiliated with the department of psychiatry at the UdeM (Hôpital Maisonneuve-Rosemont, Centre hospitalier de l'Université de Montréal, Institut universitaire de gériatrie de Montréal), driven by dedicated individuals, in accordance with their respective historical background and mission. Clinical training is provided in each of these sites for medical students, psychiatry residents and more recently, for future geriatric psychiatrists. In 2014, the geriatric psychiatry residency program at UdeM was the first to be accredited in Québec by the RCPSC, as well as the first French language geriatric psychiatry program in North America. CONCLUSION: Geriatric psychiatry in 2015 is a burgeoning field, in a challenging demographic context. Despite the clinical need, major obstacles remain, particularly in the absence of specific geriatric psychiatry positions. Furthermore, the Québec healthcare system is going through a major restructuration in 2015, adding to the uncertainty. The 50th anniversary of the department of psychiatry at UdeM is an opportunity to underline the contribution of UdeM to the development of geriatric psychiatry in Québec, and to emphasize the specific needs of the elderly in terms of mental health care and geriatric psychiatry services.

[Neurocognitive markers of suicide vulnerability in the elderly: a review]. / Marqueurs neurocognitifs de la vulnérabilité suicidaire de la personne âgée : revue de la littérature.

OBJECTIVE: a comprehensive literature review suggests that suicidal behaviour results from a complex interplay between stressful events and vulnerability factors including cognitive deficits. The aim of this systematic literature review was to identify the neurocognitive markers associated with suicide vulnerability in elderly people. METHOD: a systematic English Medline literature search of cohort studies, case-control studies and cross-sectional studies published between January 1960 and December 2012 was performed, combining the MeSH terms "Suicide", "Neuropsychology", "Neuropsychological Tests", "Executive Function", "Magnetic Resonance Imaging", "Diffusion Magnetic Resonance Imaging", "Positron-Emission Tomography", "Prefrontal Cortex", "Tomography, Emission-Computed, Single-Photon", and "Diffusion Tensor Imaging". The abstract selection was based on the Strobe checklist for observational studies. RESULTS: of the 446 original articles, 10 neuropsychological and 4 brain imaging studies were selected. The number of suicidal subjects ranged from 10 to 29 (mean age=66.8 to 79.1 years old, 0-85% women). Executive functions, in particular decision-making and cognitive inhibition, were more impaired in the depressed elderly with a history of suicide attempts compared to those without such a history. fMRI data, which need to be confirmed in further details, showed abnormalities of fronto-limbic circuits which are involved in suicide vulnerability in the elderly independently of any associated psychopathological conditions including depression. CONCLUSION: this literature review confirms the existence of neurocognitive markers of suicide vulnerability in elderly people. A neuropsychological assessment could thus help to identify the suicide vulnerability of a depressed elderly person, a first step for both pharmacological and psychotherapeutic cares.

Resumption of work or studies after first-episode psychosis: the impact of vocational case management.

BACKGROUND: Psychosis compromises the educational and professional projects of young patients. Vocational case management (VCM) offers comprehensive support for reintegration into work or studies within an early psychosis intervention programme. AIMS: To evaluate the effectiveness of VCM in resumption of work or school and to identify the predictive factors of occupational outcome. METHODS: This descriptive study focused on occupational status of an early psychosis cohort during the first 5 years of VCM. RESULTS: 56.6% of 97 study subjects had a diagnosis of schizophrenia, 32% had type I bipolar disorder with psychotic features. 68% held a productive occupation the year prior to admission, and 47.4% at admission. The occupational rate rose from 57.1% at 12 months to over 70% after 48 months. 65.6% maintained or improved their occupational status. Most subjects held competitive employment, and the employment rate was similar to that of the general population. Prior employment and affective psychosis were associated with better outcome. [Correction added on 2 April 2013, after first online publication: 'Non-affective psychosis' has been changed to 'affective psychosis' in the Results section.] CONCLUSION: The majority of individuals suffering from early psychosis resume productive activity rapidly when offered VCM within an early intervention programme during a follow-up period of up to 5 years.

Ziprasidone for psychotic disorders: a meta-analysis and systematic review of the relationship between pharmacokinetics, pharmacodynamics, and clinical profile.

BACKGROUND: Among atypical antipsychotics, ziprasidone exhibits a unique clinical profile. However, prescription rates for this medication remain among the lowest of all atypical antipsychotics. OBJECTIVE: The present meta-analysis examined premature study discontinuation (PSD) and dose-response associated with ziprasidone. Furthermore, a systematic review of the clinical pharmacokinetic and pharmacodynamic properties and tolerability of ziprasidone was conducted to explain the meta-analytic findings. METHODS: A systematic search was performed in the electronic databases PubMed and EMBASE using the key words ziprasidone, randomized, positron emission tomography, pharmacokinetic, and tolerability. This search looked for open-label or blinded studies of oral ziprasidone use in patients with psychoses (schizophrenia-spectrum disorders and/or bipolar mania) published between January 1, 1992, and February 1, 2011. Comparisons with antipsychotics for which there were <3 studies in total were excluded. PSD (all causes) was used as a measure of overall effectiveness. RESULTS: Thirty-one studies were included in the final analysis. The rates of PSD were significantly higher with ziprasidone compared with olanzapine (inefficacy and all causes, P < 0.001) and risperidone (all causes, P = 0.004). In contrast, the rates of PSD due to inefficacy and adverse events were significantly lower with ziprasidone compared with quetiapine (P = 0.03) and haloperidol (P = 0.03), respectively. On dose-response analysis, the rate of all-cause PSD was significantly lower with combined 120-160 mg/d compared with placebo (P = 0.001). Low levels of hyperprolactinemia and weight gain/metabolic adverse events, and moderate extrapyramidal symptoms and corrected QT-interval prolongation were reported with ziprasidone use. Ziprasidone exposure was increased when the medication was administered with food, irrespective of fat content. Ziprasidone 120-160 mg/d was correlated with 60% to 80% occupancy in studies of D(2) binding with the administration of multiple doses. However, the same occupancy was achieved with single-dose administration at much lower doses (20-60 mg/d). CONCLUSIONS: The findings from this meta-analysis and review suggest that ziprasidone 120-160 mg/d is a less effective treatment for psychotic disorders compared with olanzapine and risperidone, but that the low levels of hyperprolactinemia and weight gain/metabolic adverse events associated with ziprasidone may make it a useful option in patients in whom antipsychotics are poorly tolerated for these reasons.

Staff perceptions and organizational factors as predictors of seclusion and restraint on psychiatric wards.

OBJECTIVE: Several factors have been shown to be involved in decisions to use seclusion and restraint in psychiatric inpatient settings. This study examined whether staff perceptions of factors related to the care team and violence on the ward predicted use of seclusion and restraint in psychiatric wards. METHODS: A total of 309 staff members (nurses, rehabilitation instructors, and nurse's aides) providing care to patients with serious mental disorders were recruited from eight university psychiatric hospitals and general-hospital psychiatric units in the province of Quebec. Factors assessed included sociodemographic characteristics, psychological distress, staff perceptions of aggression and of interaction between members of the psychiatric team (team climate), and organizational factors. RESULTS: Bivariate analyses showed that certain aspects of the team climate, staff perceptions of aggression, and organizational factors were associated with greater use of seclusion and restraint. The final multivariate model indicated that the following factors independently predicted greater use: type of hospital ward (emergency department and intensive care unit), staff perception of a higher level of expression of anger and aggression among team members, perception of the frequency of incidents of physical aggression against the self among patients, and perception of insufficient safety measures in the workplace. CONCLUSIONS: These findings represent the first stage of a research program aimed at reducing use of seclusion and restraint in psychiatric settings. They underscore the importance of evaluating a variety of factors, including perceptions of safety and violence, when examining reasons for use of these controversial interventions.

Relationships between Brain Structure and Metabolic Changes in Schizophrenia Patients Treated with Olanzapine: A Voxel-Based Morphometric Study.

Introduction. Second-generation antipsychotics treatment is associated with weight gain and metabolic disturbances. Although much research has been done on the topic, the precise mechanisms underlying such side effects are still not well understood. Method. We followed over 16 weeks a group of 17 schizophrenia patients who were treated with olanzapine and monitored biometric, clinical, and metabolic data, including ghrelin and leptin levels. All patients had a structural cerebral magnetic resonance imaging examination during the first week of their followup and at the end of the study. Results. We found positive and negative significant correlations between grey matter volumes of several brain regions and variations of body weight as well as of ghrelin and leptin levels. The right frontal operculum, bilateral precuneus, and bilateral hippocampal regions were found to be significantly associated with those changes. Conclusion. Our results suggest associations between brain structure and metabolic variations in schizophrenia patients taking olanzapine.

Psychotic symptoms as a continuum between normality and pathology.

This paper reviews the presence of psychotic features in the nonclinical population. The results of a literature review suggest that delusional and hallucinatory experiences are more common in the general population than we may think, and that there could well be a symptomatic continuum between people who have and people who have not been diagnosed with indisputable psychotic disorders. In the nonclinical population, voices are mainly positive and nonthreatening. Conversely, in the psychiatric population, they tend to be frequent, intrusive, and distressing. We address the question of voices considered as various human experiences and describe the emergence of the nonclinical group of people who hear voices. We also review the pathophysiology of auditory hallucinations as an illustration of a neurophysiological anomaly, which is useful to understand psychosis or schizophrenia. The main obstacle in the category-specific thought is that it remains impossible to unmistakably demarcate the border around schizophrenia. It is evident that the creation of a boundary is always possible by using arbitrary criteria that improve interrater reliability but exclude a considerable number of people who share multiple common features with diagnosed people.

Increased grey matter densities in schizophrenia patients with negative symptoms after treatment with quetiapine: a voxel-based morphometry study.

Among new-generation antipsychotics, quetiapine was found to be associated with a partial 'normalization' of reduced functional activation in prefrontal and temporal areas and studies conducted by our group found a clinical improvement in negative symptoms in addition to restoration of frontal activation in schizophrenia patients with blunted affect after treatment with quetiapine. Here we investigated the parallelism between improved clinical symptoms and grey mater density (GMD) changes in the frontal region after quetiapine treatment in 15 schizophrenia patients. We hypothesize that improvement in clinical symptoms will be associated with change in GMD in prefrontal regions of interest. By using voxel-based morphometry, paired t-test random-effect analysis showed a significant increase in GMD bilaterally in the inferior frontal cortex/orbitofrontal gyrus and anterior cingulate cortex after 5.5 months of treatment with quetiapine. This GMD increase was associated with a significant improvement in negative symptoms. When GMD was correlated with psychiatric assessment scores, there was a negative correlation between GMD in the anterior cingulate cortex and the Rating Scale for Emotional Blunting score (r=-665, P=0.008) and between the orbitofrontal gyrus and the total Positive and Negative Syndrome Scale negative score (r=-764, P=0.001). Results suggest that increased GMD in some frontal regions are associated with an improvement of negative symptoms. Although not unique to quetiapine, it would be reasonable to attribute the GMD changes in the study to treatment.

Do we use too much antenatal betamethasone?

OBJECTIVE: To review and rationalize the liberal use of antenatal betamethasone in the setting of threatened preterm birth. STUDY DESIGN: A retrospective review was performed using the charts of all patients at Ste-Justine Hospital, Montreal QC, who received antenatal betamethasone between 01 April 1997 and 31 March 1998. Initial treatment consisted of 2 doses of 12 mg IM given 24 hours apart. Repeat doses of 12 mg weekly were administered at the discretion of the treating physician. Optimal antenatal betamethasone therapy was defined as delivery within 1 week of initial treatment, prior to 34 weeks. Aside from number and timing of doses, other factors analyzed included: gestational age at admission and delivery, diagnosis associated with threatened preterm birth (PTB), number of hospital admissions, and delay between re-admission and delivery. RESULTS: Of the 334 patients identified, 82 (25%) received optimal treatment. Of the remaining 252 patients, 204 (81%) received repeat doses. In the repeat dose group, 112 (55%) women delivered after 34 weeks, while 70 of the 92 remaining patients were hospitalized until delivery. The other 22 patients who received serial doses were discharged at least once prior to delivery; of these patients, 8 were re-admitted more than 24 hours pre-delivery (i.e., adequate time for re-treatment), while 14 were not, but only 6 of these were delivered urgently. Thus, a maximum of 60 patients (25% of repeat doses) could potentially have benefited from this approach. Of the 48 patients not receiving repeat doses, 37 (77%) delivered after 34 weeks. Five remained hospitalized, and 6 were discharged prior to delivery and re-admitted (2 patients > 24 hr and 4 patients < 24 hr from delivery). This represented a potential underutilization of betamethasone by 3% (11/334) of the patients, but only 1.8% (6/334) were of less than 32 weeks' gestation. CONCLUSION: This study demonstrated the difficulty in predicting which of the patients presenting with threatened preterm birth would actually go on to deliver during the window of benefit of antenatal betamethasone therapy. Our desire to permit all premature fetuses to profit from the positive effects of this therapy must be balanced by a reserve in exposing too many to too much. Use of antenatal betamethasone in our unit has significantly decreased since this review.