Beth Patterson

Post-traumatic stress disorder in Canada.

Post‐traumatic stress disorder (PTSD) has become a global health issue, with prevalence rates ranging from 1.3% to 37.4%. As there is little current data on PTSD in Canada, an epidemiological study was conducted examining PTSD and related comorbid conditions. Modified versions of the Composite International Diagnostic Interview (CIDI) PTSD module, the depression, alcohol and substance abuse sections of the Mini International Neuropsychiatric Interview (MINI), as well as portions of the Childhood Trauma Questionnaire (CTQ) were combined, and administered via telephone interview in English or French. Random digit dialing was used to obtain a nationally representative sample of 2991, aged 18 years and above from across Canada. The prevalence rate of lifetime PTSD in Canada was estimated to be 9.2%, with a rate of current (1‐month) PTSD of 2.4%. Traumatic exposure to at least one event sufficient to cause PTSD was reported by 76.1% of respondents. The most common forms of trauma resulting in PTSD included unexpected death of a loved one, sexual assault, and seeing someone badly injured or killed. In respondents meeting criteria for PTSD, the symptoms were chronic in nature, and associated with significant impairment and high rates of comorbidity. PTSD is a common psychiatric disorder in Canada. The results are surprising, given the comparably low rates of violent crime, a small military and few natural disasters. Potential implications of these findings are discussed.

A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania.

BACKGROUNDnTrichotillomania has been considered as part of the obsessive-compulsive disorder spectrum; however, trichotillomania treatment with obsessive-compulsive disorder medications has largely been unsuccessful.nnnOBJECTIVEnTo determine whether a dopaminergic treatment as used in tics and Tourettes syndrome would be effective in trichotillomania.nnnMETHODnTwenty-five participants with DSM-IV trichotillomania participated in a 12-week, randomized, double-blind, placebo-controlled trial of flexible-dose olanzapine for trichotillomania. Recruitment occurred between August 2001 and December 2005, and follow-up was completed in February 2006. The primary outcome measure was the Clinical Global Impressions-Improvement (CGI-I) scale, and secondary measures of efficacy included the Yale-Brown Obsessive Compulsive Scale for Trichotillomania (TTM-YBOCS) and the Clinical Global Impressions-Severity of Illness (CGI-S) scale.nnnRESULTSnEleven of 13 participants (85%) in the olanzapine group and 2 of 12 (17%) in the placebo group were considered responders according to the CGI-I (P = .001). There was a significant change from baseline to end point in the TTM-YBOCS (P < .01) and the CGI-S (P < .001). The mean ± SD dose of olanzapine at end point was 10.8 ± 5.7 mg/d. Twenty-one of 25 patients (84%) reported at least 1 adverse event, but no adverse events resulted in early withdrawal from the study.nnnCONCLUSIONnOlanzapine seems to be a safe and effective treatment for primary DSM-IV trichotillomania.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00182507.

DSM-5 OBSESSIVE-COMPULSIVE AND RELATED DISORDERS: CLINICAL IMPLICATIONS OF NEW CRITERIA

For the publication of DSM‐5, obsessive‐compulsive disorder (OCD) was the subject of significant revisions to its classification and diagnostic criteria. One of these significant changes was the placement of OCD in a new category, “Obsessive‐Compulsive and Related Disorders (OCRDs),” which also includes body dysmorphic disorder (BDD), trichotillomania (hair‐pulling disorder), excoriation (skin‐picking) disorder, hoarding disorder, substance/medication‐induced OCRD, OCRD due to another medical condition, and other specified OCRDs. Changes in the diagnostic criteria and grouping of these disorders may have significant clinical implications, and will be reviewed in this article.

Symptom relapse following switch from Celexa to generic citalopram: an anxiety disorders case series:

Generic agents do not require large clinical trials of safety and efficacy to enter the market, although they must demonstrate both pharmacological and bioequivalence to the brand name drug. BioequivaLence is attained when the extent of absorption of the generic falls within an FDA predefined range relative to the brand name drug. This potential variation in bioequivalence is not thought to be clinically meaningful, however, there are reports of a lack of therapeutic equivalence between some generic medications and the brand name. This study examines the potential risks posed by a switch from Celexa to generic citalopram. Twenty patients at an Anxiety Disorders Clinic who were unknowingly switched to generic citalopram, from Celexa (Lundbeck, Montreal, Quebec, Canada) and experienced a re-emergence of their anxiety symptoms or development of new adverse events are described in this case series report. The mean time for re-emergence of symptoms or development of adverse events was 3.4 ± 1.6 weeks (range 0.5—8 weeks). All patients reestabLished previous treatment response with a change back to Celexa in a mean time of 3.8 ± 2.6 weeks (range 0.7—12 weeks). Given these results, it is important for clinicians to be aware of the potentiaL for loss of treatment effect or symptom re-emergence posed by a switch to a generic agent. Randomized, doubLe blind, controlled investigations would likely provide useful information as current bioequivalence and pharmacological equivalence do not necessarily translate into clinical equivalence.

Pharmacological treatment strategies in obsessive compulsive disorder: A cross-sectional view in nine international OCD centers

Objective: It is unknown what next-step strategies are being used in clinical practice for patients with obsessive–compulsive disorder (OCD) who do not respond to first-line treatment. As part of a cross-sectional study of OCD, treatment and symptom information was collected. Method: Consecutive OCD out-patients in nine international centers were evaluated by self-report measures and clinical/structured interviews. OCD symptom severity was evaluated by the Yale Brown Obsessive Compulsive Scale (YBOCS) and Clinical Global Impression–Severity Scale (CGI-S). Clinical response to current treatment was evaluated by the CGI-Improvement Scale (CGI-I ≤ 2). Results: In total, 361 participants reported taking medication; 77.6% were taking a selective serotonin reuptake inhibitor; 50% reported use of at least one augmentation strategy. Antipsychotics were most often prescribed as augmenters (30.3%), followed by benzodiazepines (24.9%) and antidepressants (21.9%). No differences in OCD symptom severity were found between patients taking different classes of augmentation agents. Conclusions: Results from this international cross-sectional study indicate that current OCD treatment is in line with evidence-based treatment guidelines. Although augmentation strategies are widely used, no significant differences in OCD symptom severity were found between monotherapy and augmentation or between different therapeutic agents.

Adult attention deficit hyperactivity disorder in an anxiety disorders population.

Adult Attention Deficit Hyperactivity Disorder (ADHD) is a life‐long, chronic disorder, which has its onset in childhood and is associated with significant functional impairment. ADHD appears to be highly comorbid with other psychiatric disorders, however, literature is lacking concerning ADHD/anxiety comorbidity. To that end, we examined the prevalence of ADHD in an anxiety disorder sample. Consecutive patients referred to an anxiety disorders clinic completed a variety of anxiety disorder self‐report measures as well as the Adult ADHD self‐report scale and were clinically assessed using the Structured Clinical Interview for DSM‐IV, and the ADHD module of the Mini International Neuropsychiatric Interview. Of the 129 patients assessed, the rate of adult ADHD was 27.9%. The mean age of the sample was 33.1 ± 12.5 years, and the mean baseline CGI‐S was 4.6 ± 1.1 (moderate to marked severity). The majority of the sample was female (63.6%) and single (49.5%). The most common comorbid disorders associated with ADHD were major depressive disorder (53.8%), social phobia (38.5%), generalized anxiety disorder (23.1%), and impulse control disorders (30.8%). Individuals with ADHD had higher symptom severity scores for obsessive‐compulsive disorder, (P≤ 0.05) and for GAD (P≤ 0.05) and reported a significantly earlier age of onset for depression as compared to those without (P≤ 0.05). The prevalence of adult ADHD was higher in our anxiety disorders clinic sample than found in the general population. Clinical implications of these findings are discussed.

There is an app for that! The current state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder, posttraumatic stress disorder, anxiety and mood disorders

Mental health apps are viewed as a promising modality to extend the reach of mental health care beyond the clinic. They do so by providing a means of assessment, tracking, and treatment through a smartphone. Given that nearly 2/3 of the American population owns a smartphone, mental health apps offer the possibility of overcoming treatment barriers such as geographic location or financial barriers. Unfortunately, the excitement surrounding mental health apps may be premature as the current supporting literature regarding their efficacy is limited. The app marketplace is littered with apps claiming to treat or assess symptoms, but even those created by reputable organizations or those incorporating components of evidence‐based treatments have not yet been validated in terms of their efficacy. This review aims to provide a comprehensive review of the current state of the mental health app literature by examining published reports of apps designed for DSM‐5 anxiety and mood disorders, OCD, and PTSD. The breadth of apps reviewed includes those oriented around assessment, symptom tracking, and treatment as well as “multipurpose” apps, which incorporate several of these components. This review will also present some of the most popular mental health apps which may have clinical utility and could be prescribed to clients. While we discuss many potential benefits of mental health apps, we focus on a number of issues that the current state of the app literature presents. Overall there is a significant disconnect between app developers, the scientific community and health care, leaving the utility of existing apps questionable.

The prevalence of migraine headaches in an anxiety disorders clinic sample.

The association between migraine and psychiatric disorders has been reported in both clinical and epidemiological studies. The prevalence of psychiatric disorders has been found to be increased among individuals with migraine. Studies assessing migraine in psychiatric patients are limited and the majority of these studies have focused solely on examining patients with major depression. In the present study, we examined the prevalence and characteristics of migraine headache in an anxiety disorders clinic sample in order to better understand the relationship between these commonly associated conditions. We evaluated 206 consecutive outpatients to an Anxiety Disorders Clinic for the prevalence of migraine. The presence of migraine was established using International Headache Society Criteria. Subjects completed a modified self‐report version of the Headache Diagnostic Questionnaire. In order to assess the relationship between migraine and anxiety disorder symptom severity, subjects completed standardized measures of symptom severity. The prevalence of migraine in our anxiety disorder clinic sample was 67%. Anxiety disorder patients with migraine presented with a significantly greater number of comorbid psychiatric disorders than patients without migraine (P= 0.012). The prevalence of migraine was significantly higher in patients with a diagnosis of either panic disorder with agoraphobia (P= 0.048) or major depressive disorder/dysthymia (P= 0.008) compared to other psychiatric disorders. The severity of anxiety disorder symptoms was significantly higher in patients with migraine compared to patients without migraine. This study suggests that there is an increased prevalence of migraine headaches among anxiety disorder patients as compared to the general population. Migraine comorbidity may have important clinical implications, such that the treatment of one condition could potentially ameliorate the development or progression of the other. Further research is required to better understand the nature and implications of the association between migraine and psychiatric disorders.

The burden of anxiety disorders on the family.

It is well established that individuals with anxiety disorders experience significant impairments in social and occupational functioning. However, the impact of anxiety disorders on family members has not been adequately studied. The objective of the present study was to examine the burden experienced by relatives of anxiety disorder patients. In all, 74 outpatients and 74 family members participated in the study. Family members completed measures that assessed the impact of having an anxiety disordered relative. Results indicate that family members experience significant burden. The burden encompasses several domains including negative effects on physical health, psychological well-being, and family functioning. Burden was positively correlated with the severity of the patients condition. The presence of a comorbid mood disorder in patients was associated with increased burden. Health-care professionals should assess the impact of anxiety disorders on the patients family and provide interventions to reduce burden and improve the quality of life of family members.

The Impact of Changing Diagnostic Criteria in Posttraumatic Stress Disorder in a Canadian Epidemiologic Sample

BACKGROUNDnSince its inclusion in DSM-III, posttraumatic stress disorder (PTSD) has undergone a number of changes in its diagnostic criteria, including the expansion of Criterion A (traumatic stressor), the addition of symptom duration (none specified in DSM-III), and the requirement for impairment or distress (Criterion F, DSM-IV only).nnnMETHODnThis study examined the impact of changes in PTSD diagnostic criteria using a Canadian PTSD epidemiologic sample. The rates of PTSD and its correlates were evaluated in a nationally representative random sample of 3,006 adults. DSM-III, DSM-III-R, DSM-IV, and ICD-10 criteria were employed. DSM-III, DSM-III-R, and ICD-10 rates were re-evaluated, substituting specific DSM-IV criteria (A-F).nnnRESULTSnThe prevalence rates of lifetime PTSD ranged from 13.4% (DSM-III) to 13.0% (ICD-10) to 12.2% (DSM-III-R) to 9.2% (DSM-IV); all rates differed significantly from each other (P < .001). Regardless of diagnostic criteria, most people reported more than 1-year duration of symptoms, although rates were significantly higher in those with DSM-IV PTSD (68.2%, P < .0001). Rates of comorbid major depressive disorder and alcohol and substance abuse and dependence were also significantly higher (P < .05) using the DSM-IV PTSD criteria, and those with DSM-IV PTSD reported significantly higher rates of help-seeking (P < .001). When Criterion F was added to earlier versions, lifetime PTSD rates became much closer to those obtained using DSM-IV criteria: 10.6% (DSM-III), 10.2% (DSM-III-R), and 9.9% (ICD-10); however, rates fluctuated when operational definitions of Criterion F were modified. DSM-III PTSD was also substantially affected by DSM-IV Criteria A and C.nnnCONCLUSIONSnDSM-IV PTSD may identify a more severe disorder. The addition of the clinical significance criterion (F) appeared to affect the greatest change in prevalence rates. Defining Criterion F as having both clinically significant psychological distress and functional impairment lowered the diagnostic threshold to a greater degree than did either distress or impairment alone. This information may be useful for future revisions of PTSD diagnostic criteria.