Impact of the Pandemic was Minor Compared to Systemic Decrease in Fidelity of Assertive Community Treatment Services- A Provincial Study in Ontario, Canada.

Assertive Community Treatment (ACT) model is the gold standard in community psychiatry serving people with severe mental illness. With its outreach-based design, the pandemic has profoundly affected the operations and functioning of ACT. The Dartmouth ACT Scale (DACTS) provides a standardized comprehensive and quantitative way to evaluate ACT quality. Results could inform nature of impact and identify areas for improvement. Current online survey used DACTS during the pandemic in April-May 2021. Clinical and administrative leadership of the 80 ACT teams in Ontario, Canada cross-sectionally rated ACT quality one-year pre-Covid (2018-2019) and one-year post the start of Covid (2020-2021). The overall pre-Covid Ontario ACT DACTS fidelity was 3.65. The pandemic led to decreases in all domains of DACTS (Human Resources: -4.92%, p < 0.001, 95% CI [0.08-0.27]; Organizational Boundary: -1.03%, p < 0.013,95%CI [0.01-0.07]; and Nature of Services: -6.18%, p < 0.001, 95%CI [0.16-0.26]). These changes were accounted by expected lower face-to-face encounters, time spent with clients, reduction in psychosocial services, less interactions with hospitals and diminished workforces. The magnitude of change was modest (-3.84%, p < 0.001, 95%CI [0.09-0.19]). However, the Ontario ACT pre-Covid DACTS was substantially lower (-13.5%) when compared to that from a similar survey 15 years ago (4.22), suggestive of insidious systemic level loss of fidelity. Quantitative fidelity evaluation helped to ascertain specific pandemic impact. Changes were significant and specific, but overall relatively modest when compared to the larger system level drop over the last decade. There is both evidence for model adaptability and resilience during Covid disruption, and concerns over larger downward drift in ACT fidelity and quality.

Examining the Prevalence and Forms of Leveraged Treatment Pressure and Its Relationship to Personal Recovery: A Canadian Cross-Sectional Study.

Across jurisdictions, the use of 'leverage' to promote adherence to mental health treatment is widespread. However, little research exists on the possible association between the application of leverage and personal recovery. We examined the prevalence of various forms of leverage in a Canadian context and compared these rates with those in other jurisdictions. Additionally, we examined the relationship between two prominent forms of leverage (financial and housing) and the experience of personal recovery. Structured interviews were conducted with people receiving community-based mental health care in Toronto, Canada. Rates of overall leverage in our sample were similar to rates reported in other jurisdictions. Personal recovery was negatively associated with financial leverage but was not associated with housing leverage. Our results highlight the importance of separately examining the relationship of specific forms of leverage and personal recovery and raise questions for future research about the possible effect of financial leverage on recovery.

Decision-making biases in suicide attempters with major depressive disorder: A computational modeling study using the balloon analog risk task (BART).

BACKGROUND: In the last decade, suicidality has been increasingly theorized as a distinct phenomenon from major depressive disorder (MDD), with unique psychological and neural mechanisms, rather than being mostly a severe symptom of MDD. Although decision-making biases have been widely reported in suicide attempters with MDD, little is known regarding what components of these biases can be distinguished from depressiveness itself. METHODS: Ninety-three patients with current MDD (40 with suicide attempts [SA group] and 53 without suicide attempts [NS group]) and 65 healthy controls (HCs) completed psychometric assessments and the balloon analog risk task (BART). To analyze and compare decision-making components among the three groups, we applied a five-parameter Bayesian computational modeling. RESULTS: Psychological assessments showed that the SA group had greater suicidal ideation and psychological pain avoidance than the NS group. Computational modeling showed that both MDD groups had higher risk preference and lower ability to learn and adapt from within-task observations than HCs, without differences between the SA and NS patient groups. The SA group also had higher loss aversion than the NS and HC groups, which had similar loss aversion. CONCLUSIONS: Our BART and computational modeling findings suggest that psychological pain avoidance and loss aversion may be important suicide risk factor that are distinguishable from depression illness itself.

Highlighting psychological pain avoidance and decision-making bias as key predictors of suicide attempt in major depressive disorder-A novel investigative approach using machine learning.

OBJECTIVE: Predicting suicide is notoriously difficult and complex, but a serious public health issue. An innovative approach utilizing machine learning (ML) that incorporates features of psychological mechanisms and decision-making characteristics related to suicidality could create an improved model for identifying suicide risk in patients with major depressive disorder (MDD). METHOD: Forty-four patients with MDD and past suicide attempts (MDD_SA, N = 44); 48 patients with MDD but without past suicide attempts (MDD_NS, N = 48-42 of whom with suicide ideation [MDD_SI, N = 42]), and healthy controls (HCs, N = 51) completed seven psychometric assessments including the Three-dimensional Psychological Pain Scale (TDPPS), and one behavioral assessment, the Balloon Analogue Risk Task (BART). Descriptive statistics, group comparisons, logistic regressions, and ML were used to explore and compare the groups and generate predictors of suicidal acts. RESULTS: MDD_SA and MDD_NS differed in TDPPS total score, pain arousal and avoidance subscale scores, suicidal ideation scores, and relevant decision-making indicators in BART. Logistic regression tests linked suicide attempts to psychological pain avoidance and a risk decision-making indicator. The resultant key ML model distinguished MDD_SA/MDD_NS with 88.2% accuracy. The model could also distinguish MDD_SA/MDD_SI with 81.25% accuracy. The ML model using hopelessness could classify MDD_SI/HC with 94.4% accuracy. CONCLUSION: ML analyses showed that motivation to avoid intolerable psychological pain, coupled with impaired decision-making bias toward under-valuing life's worth are highly predictive of suicide attempts. Analyses also demonstrated that suicidal ideation and attempts differed in potential mechanisms, as suicidal ideation was more related to hopelessness. ML algorithms show useful promises as a predictive instrument.

Adaptations and Innovations to Minimize Service Disruption for Patients with Severe Mental Illness during COVID-19: Perspectives and Reflections from an Assertive Community Psychiatry Program.

Changes to community psychiatry during COVID-19 are unprecedented and without clear guidelines. Minimizing disruption, ensuring quality care to the already vulnerable people with serious mental illness is crucial. We describe and reflect our adaptations and innovations at one community psychiatry program, based on three key principles. In (i) Defining and maintaining essential services while limiting risk of contagion, we discuss such strategies and ways to assess risks, implement infection control, and other creative solutions. In (ii) Promoting health and mitigating physical and mental health impacts, we reflect on prioritizing vulnerable patients, dealing with loss of community resources, adapting group programs, and providing psychoeducation, among others. In (iii) Promoting staff resilience and wellness, we describe building on strength of the staff early, addressing staff morale and avoiding moral injury, and valuing responsive leadership. We also identify limitations and potential further improvements, mindful that COVID-19 and similar crises are likely recurring realities.

Effectiveness of an Assertive Community Treatment program for people with severe schizophrenia in mainland China - a 12-month randomized controlled trial.

BACKGROUND: Assertive Community Treatment (ACT) is an evidence-based treatment program for people with severe mental illness developed in high-income countries. We report the first randomized controlled trial of ACT in mainland China. METHODS: Sixty outpatients with schizophrenia with severe functional impairments or frequent hospitalizations were randomly assigned to ACT (n = 30) or standard community treatment (n = 30). The severity of symptoms and level of social functioning were assessed at baseline and every 3 months during the 1-year study. The primary outcome was the duration of hospital readmission. Secondary outcomes included a pre-post change in symptom severity, the rates of symptom relapse and gainful employment, social and occupational functioning, and quality of life of family caregivers. RESULTS: Based on a modified intention-to-treat analysis, the outcomes for ACT were significantly better than those of standard community treatment. ACT patients were less likely to be readmitted [3.3% (1/30) v. 25.0% (7/28), Fisher's exact test p = 0.023], had a shorter mean readmission time [2.4 (13.3) v. 30.7 (66.9) days], were less likely to relapse [6.7% (2/30) v. 28.6% (8/28), Fisher's exact test p = 0.038], and had shorter mean time in relapse [3.5 (14.6) v. 34.4 (70.6) days]. The ACT group also had significantly longer times re-employed and greater symptomatic improvement and their caregivers experienced a greater improvement in their quality of life. CONCLUSION: Our results show that culturally adapted ACT is both feasible and effective for individuals with severe schizophrenia in urban China. Replication studies with larger samples and longer duration of follow up are warranted.

The efficacy of group cognitive-behavioural therapy plus duloxetine for generalised anxiety disorder versus duloxetine alone.

OBJECTIVE: To explore whether and how group cognitive-behavioural therapy (GCBT) plus medication differs from medication alone for the treatment of generalised anxiety disorder (GAD). METHODS: Hundred and seventy patients were randomly assigned to the GCBT plus duloxetine (n=89) or duloxetine group (n=81). The primary outcomes were Hamilton Anxiety Scale (HAMA) response and remission rates. The explorative secondary measures included score reductions from baseline in the HAMA total, psychic, and somatic anxiety subscales (HAMA-PA, HAMA-SA), the Hamilton Depression Scale, the Severity Subscale of Clinical Global Impression Scale, Global Assessment of Functioning, and the 12-item Short-Form Health Survey. Assessments were conducted at baseline, 4-week, 8-week, and 3-month follow-up. RESULTS: At 4 weeks, HAMA response (GCBT group 57.0% vs. control group 24.4%, p=0.000, Cohen's d=0.90) and remission rates (GCBT group 21.5% vs. control group 6.2%, p=0.004; d=0.51), and most secondary outcomes (all p<0.05, d=0.36-0.77) showed that the combined therapy was superior. At 8 weeks, all the primary and secondary significant differences found at 4 weeks were maintained with smaller effect sizes (p<0.05, d=0.32-0.48). At 3-month follow-up, the combined therapy was only significantly superior in the HAMA total (p<0.045, d=0.43) and HAMA-PA score reductions (p<0.001, d=0.77). Logistic regression showed superiority of the combined therapy for HAMA response rates [odds ratio (OR)=2.12, 95% confidence interval (CI) 1.02-4.42, p=0.04] and remission rates (OR=2.80, 95% CI 1.27-6.16, p=0.01). CONCLUSIONS: Compared with duloxetine alone, GCBT plus duloxetine showed significant treatment response for GAD over a shorter period of time, particularly for psychic anxiety symptoms, which may suggest that GCBT was effective in changing cognitive style.

Comparison Between a Typical Undergraduate Psychiatry Program in China and Canada--an Approach to Inform Psychiatry Education Reform in China.

OBJECTIVE: Psychiatry as a field and undergraduate psychiatry education (UPE) specifically have historically been in the periphery of medicine in China, unlike the relatively central role they occupy in the West. During the current economic reform, Chinese undergraduate medical education (UME) is undergoing significant changes and standardization under the auspices of the national accreditation body. A comparative study, using Bereday's comparative education methodology and Feldmann's evaluative criteria as theoretical frameworks, to gain understanding of the differences and similarities between China and the West in terms of UPE can contribute to the UME reform, and specifically UPE development in China, and promote cross-cultural understanding. METHOD: The authors employed multi-sourced information to perform a comparative study of UPE, using the University of Toronto as a representative of the western model and Guangxi Medical University, a typical program in China, as the Chinese counterpart. RESULTS: Key contrasts are numerous; highlights include the difference in age and level of education of the entrants to medical school, centrally vs. locally developed UPE curriculum, level of integration with the rest of medical education, visibility within the medical school, adequacy of teaching resources, amount of clinical learning experience, opportunity for supervision and mentoring, and methods of student assessment. CONCLUSIONS: Examination of the existing, multi-sourced information reveals some fundamental differences in the current UPE between the representative Chinese and western programs, reflecting historical, political, cultural, and socioeconomic circumstances of the respective settings. The current analyses show some areas worthy of further exploration to inform Chinese UPE reform. The current research is a practical beginning to the development of a deeper collaborative dialogue about psychiatry and its educational underpinnings between China and the West.

"Trust in God, but tie your donkey": Holy water priest healers' views on collaboration with biomedical mental health services in Addis Ababa, Ethiopia.

This exploratory qualitative study examines holy water priest healers' explanatory models and general treatment approaches toward mental illness, and their views and reflections on a collaborative project between them and biomedical practitioners. The study took place at two holy water treatment sites in Addis Ababa, Ethiopia. Twelve semi-structured interviews with holy water priest healers found eight notable themes: they held multiple explanatory models of illness, dominated by religious and spiritual understanding; they emphasized spiritual healing and empathic understanding in treatment, and also embraced biomedicine as part of an eclectic healing model; they perceived biomedical practitioners' humility and respect as key to their positive views on the collaboration; they valued recognition of their current role and contribution in providing mental healthcare; they recognized and appreciated the biomedical clinic's effectiveness in treating violent and aggressive patients; they endorsed the collaboration and helped to overcome patient and family reluctance to the use of biomedicine; they lamented the lack of spiritual healing in biomedical treatment; and they had a number of dissatisfactions and concerns, particularly the one-way referral from religious healers to the biomedical clinic. The study results show diversity in the religious healers' etiological understanding, treatment approaches and generally positive attitude and views on the collaboration. We present insights and explorations of factors affecting this rare, but much needed collaboration between traditional healers and biomedical services, and potential ways to improve it are discussed.

Beyond Diagnosis and Comorbidities-A Scoping Review of the Best Tools to Measure Complexity for Populations with Mental Illness.

Beyond the challenges of diagnosis, complexity measurement in clients with mental illness is an important but under-recognized area. Accurate and appropriate psychiatric diagnoses are essential, and further complexity measurements could contribute to improving patient understanding, referral, and service matching and coordination, outcome evaluation, and system-level care planning. Myriad conceptualizations, frameworks, and definitions of patient complexity exist, which are operationalized by a variety of complexity measuring tools. A limited number of these tools are developed for people with mental illness, and they differ in the extent to which they capture clinical, psychosocial, economic, and environmental domains. Guided by the PRISMA Extension for Scoping Reviews, this review evaluates the tools best suited for different mental health settings. The search found 5345 articles published until November 2023 and screened 14 qualified papers and corresponding tools. For each of these, detailed data on their use of psychiatric diagnostic categories, definition of complexity, primary aim and purpose, context of use and settings for their validation, best target populations, historical references, extent of biopsychosocial information inclusion, database and input technology required, and performance assessments were extracted, analyzed, and presented for comparisons. Two tools-the INTERMED, a clinician-scored and multiple healthcare data-sourced tool, and the VCAT, a computer-based instrument that utilizes healthcare databases to generate a comprehensive picture of complexity-are exemplary among the tools reviewed. Information on these limited but suitable tools related to their unique characteristics and utilities, and specialized recommendations for their use in mental health settings could contribute to improved patient care.

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness.

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.

"It feels terrible that people are making decisions for me": Reflections and experiences of individuals with psychiatric disability who have substitute decision makers for treatment.

OBJECTIVE: In Canada and elsewhere, making treatment decisions for a person with serious mental illness (SMI) who was found incapable for treatment decisions via a substitute decision maker (SDM) is the norm. This practice is often called into question from a rights-based perspective. The literature on the views of affected individuals is limited. We explore the experiences of adults with SMI who have had SDMs to gain more in-depth understanding. METHOD: We conducted semistructured interviews with 11 consumers of psychiatric services who have had experiences with SDM (range 1-12 years) at an urban hospital in Toronto, Canada. RESULTS: Thematic analysis showed five main themes and related subthemes, including: (1) strong dissatisfaction with and rejection of the SDM's role and purpose; (2) pervasive sense of stigma associated with having a SDM; (3) ongoing struggles to gain autonomy; (4) mixed changes in relationship with and views about SDM; and (5) views on how to improve SDM process. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Our study highlights substantial dissatisfaction with the current SDM system and approaches among adults with SMI who have had SDMs. Issues of stigma and struggles to regain autonomy are prevalent. We discuss the personal, clinical, and social-legal contexts in which they occur, particularly in light of the United Nations' Convention on the Rights of Persons with Disabilities that calls for replacing SDMs with supported decision making. Rights-based approaches to care carry substantial practice implications and call for thoughtful change management. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Leg to Stand On: Working With Marginal Decision-making Capacity in a Patient With a Severe Leg Infection and Schizophrenia.

Assessment of a patient's capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.

Impact of COVID-19 on the lives of people with severe mental illness-front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada.

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers' observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

Potential neuropsychological mechanism involved in the transition from suicide ideation to action - a resting-state fMRI study implicating the insula.

BACKGROUND: Understanding the neural mechanism underlying the transition from suicidal ideation to action is crucial but remains unclear. To explore this mechanism, we combined resting-state functional connectivity (rsFC) and computational modeling to investigate differences between those who attempted suicide(SA) and those who hold only high levels of suicidal ideation(HSI). METHODS: A total of 120 MDD patients were categorized into SA group (n=47) and HSI group (n=73). All participants completed a resting-state functional MRI scan, with three subregions of the insula and the dorsal anterior cingulate cortex (dACC) being chosen as the region of interest (ROI) in seed-to-voxel analyses. Additionally, 86 participants completed the balloon analogue risk task (BART), and a five-parameter Bayesian modeling of BART was estimated. RESULTS: In the SA group, the FC between the ventral anterior insula (vAI) and the superior/middle frontal gyrus (vAI-SFG, vAI-MFG), as well as the FC between posterior insula (pI) and MFG (pI-MFG), were lower than those in HSI group. The correlation analysis showed a negative correlation between the FC of vAI-SFG and psychological pain avoidance in SA group, whereas a positive correlation in HSI group. Furthermore, the FC of vAI-MFG displayed a negative correlation with loss aversion in SA group, while a positive correlation was found with psychological pain avoidance in HSI group. CONCLUSION: In current study, two distinct neural mechanisms were identified in the insula which involving in the progression from suicidal ideation to action. Dysfunction in vAI FCs may gradually stabilize as individuals experience heightened psychological pain, and a shift from positive to negative correlation patterns of vAI-MFC may indicate a transition from state to trait impairment. Additionally, the dysfunction in PI FC may lead to a lowered threshold for suicide by blunting the perception of physical harm.

Premise and peril of Wnt signaling activation through GSK-3ß inhibition.

Wnt signaling pathways have been extensively studied in the context of several diseases, including cancer, coronary artery disease, and age-related disorders. ß-Catenin plays a central role in the most studied Wnt pathways, the Wnt/ß-catenin signaling pathway, commonly referred to as the canonical Wnt signaling pathway. ß-catenin is a substrate of glycogen synthase kinase 3ß (GSK-3ß), and the phosphorylated ß-catenin by GSK-3ß can be degraded by the proteasome through ubiquitination. Thus, GSK-3ß inhibitors have become a widely used chemical biology tool to study the canonical Wnt signaling pathway. Among the varied GSK-3ß inhibitors, a compound known as CHIR-99021 is one of the most widely used. Although these inhibitors contribute greatly to our understanding of the canonical Wnt pathway, certain pitfalls associated with such an approach may have been overlooked. In many published studies, micromolar concentrations of CHIR-99021 are used to activate the canonical Wnt pathway. Although CHIR-99021 is a specific GSK-3ß inhibitor, it specifically inhibits the kinase at the nanomolar level. Therefore, caution is required when micromolar levels of CHIR-99021 are used for the purpose of activating the canonical Wnt signaling pathway.

Psychiatric Futility and Palliative Care for a Patient With Clozapine-resistant Schizophrenia.

Recognizing futility is a challenging aspect of clinical medicine, particularly in psychiatry. We present a case of a man who suffered from clozapine-resistant schizophrenia. His illness was characterized by prominent religious delusions and severe self-starvation. Neither the intensity of his symptoms nor his quality of life improved with available psychiatric interventions, and he experienced significant iatrogenic harms from enforced treatments. Recognizing clinical futility, in collaboration with a diverse multidisciplinary team, and making a clear shift to a patient-centered palliative approach allowed the patient's treatment team to prioritize his autonomy and subjective meaning in his final months. Such approaches are understudied in psychiatry and warrant greater attention.