Carol E. Adair

The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities

Introduction Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city,

Do Canada and the United States differ in prevalence of depression and utilization of services

110 million demonstration project and provides the rationale for key scientific decisions. Methods A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy. Ethics and dissemination Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project. Trial registration number This study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.

Population-based active surveillance for neonatal group B streptococcal infections in Alberta, Canada: implications for vaccine formulation.

OBJECTIVE This study compared the prevalence of depression and the determinants of mental health service use in Canada and the United States. METHODS The study used data from preliminary analyses of the 2003 Joint Canada/United States Survey of Health, which measured Canadian (N=3,505) and United States (N=5,183) resident ratings of health and health care services. Cross-national comparisons were made for the 12-month prevalence of DSM-IV major depression, 12-month service use for mental health reasons according to the type of professional seen, and determinants of service use. RESULTS The rates of depression were similar in Canada (8.2%) and the United States (8.7%). However, U.S. respondents without medical insurance were twice as likely as Canadian respondents and U.S. respondents with medical insurance to meet the criteria for depression. Rates of mental health service use did not differ between Canada (10.1%) and the United States (10.6%). In the United States, medical insurance was not a determinant factor of service use. However, U.S. respondents with no medical insurance were more likely than the other two groups to report an unmet need. Also, among those with depression, U.S. respondents with no medical insurance were less likely to use any type of mental health service (36.5%) than U.S. respondents with medical insurance (55.7%) and Canadians (55.7%). Further, a positive correlation between a mental health need and service use was observed in Canada but not for those without medical insurance in the United States. CONCLUSIONS There was no difference in the prevalence of depression and mental health service use between Canada and the United States. Among those with depression, however, disparities in treatment seeking were found to be associated with medical insurance in the United States. Both Canada and the United States need to improve access to health services for those with mental disorders, and special attention is needed for those without medical insurance in the United States.

E-Mental Health: A Rapid Review of the Literature

Background. Knowledge of circulating serotypes of group B Streptococcus (GBS) is important for formulation of vaccines. There are no Canadian data on the serotype distribution of neonatal GBS isolates. Methods. Using a retrospective laboratory and health record survey between 1993 and 1994 (before introduction of Canadian prevention guidelines) and prospective active laboratory-based surveillance from 1995 to 1999 of all laboratories in Alberta, we identified 168 cases of invasive neonatal GBS infections including stillbirths among 262 398 total births; 118 of 123 (96%) isolates from 1995 to 1999 were serotyped, and the corresponding neonatal health records were reviewed. Results. The average annual incidence was 0.64 of 1000 total births/year. Of these 95 (57%) had early onset disease (EOD), 15 (9%) were still births and 58 (34%) had late onset disease (LOD). Eighty-one percent of EOD cases were caused by serotypes Ia, Ia/c, Ia/c/R, III, III/R and V, V/R, whereas 81% of LOD cases were caused by serotypes III and III/R. GBS serotypes containing the C protein along with serotypes III and V as a group constituted 91% (107 of 118) of all GBS cases in our population. The most common clinical presentation was bacteremia without focus (74%) followed by meningitis (14%) and pneumonia (12%). During 1995 to 1999, in addition to 13 stillbirths, there were 6 of 64 (9%) neonatal deaths among EOD cases and 1 of 46 (2%) neonatal death among LOD cases. Conclusions. In this population-based study stillbirths account for a proportion of cases that are not routinely counted and represent a group for which intrapartum antibiotics would likely not be effective, but potentially preventable by vaccination. Inclusion of serotypes Ia, III and V in a conjugate vaccine or serotypes III and V conjugated with the C protein in a GBS vaccine could theoretically provide protection against the majority of GBS invasive disease in Alberta neonates.

Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access

OBJECTIVE The authors conducted a review of the literature on e-mental health, including its applications, strengths, limitations, and evidence base. METHODS The rapid review approach, an emerging type of knowledge synthesis, was used in response to a request for information from policy makers. MEDLINE was searched from 2005 to 2010 by using relevant terms. The search was supplemented with a general Internet search and a search focused on key authors. RESULTS A total of 115 documents were reviewed: 94% were peer-reviewed articles, and 51% described primary research. Most of the research (76%) originated in the United States, Australia, or the Netherlands. The review identified e-mental health applications addressing four areas of mental health service delivery: information provision; screening, assessment, and monitoring; intervention; and social support. Currently, applications are most frequently aimed at adults with depression or anxiety disorders. Some interventions have demonstrated effectiveness in early trials. Many believe that e-mental health has enormous potential to address the gap between the identified need for services and the limited capacity and resources to provide conventional treatment. Strengths of e-mental health initiatives noted in the literature include improved accessibility, reduced costs (although start-up and research and development costs are necessary), flexibility in terms of standardization and personalization, interactivity, and consumer engagement. CONCLUSIONS E-mental health applications are proliferating and hold promise to expand access to care. Further discussion and research are needed on how to effectively incorporate e-mental health into service systems and to apply it to diverse populations.

Diagnostic transitions from childhood to adolescence to early adulthood

Objectives: In 2002, Canada undertook its first national survey on mental health and well-being, including detailed questioning on service use. Mental disorders may affect more than 1 person in 5, according to past regional and less comprehensive mental health surveys in Canada, and most do not seek help. Individual determinants play a role in health resource use for mental health (MH) reasons. This study aimed to provide prevalence rates of health care service use for MH reasons by province and according to service type and to examine determinants of MH service use in Canada and across provinces. Methods: We assessed the prevalence rate (95% confidence interval [CI]) of past-year health service use for MH reasons, and we assessed potential determinants cross-sectionally, using data collected from the Statistics Canada Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). We estimated models of resource use with logistic regression (using odds ratios and 95%CIs). Results: The prevalence of health service use for MH reasons in Canada was 9.5% (95%CI, 9.1% to 10.0%). The highest rates, on average, were observed in Nova Scotia (11.3%; 95%CI, 9.6% to 13.0%) and British Columbia (11.3%; 95%CI, 10.1% to 12.6%). The lowest rates were observed in Newfoundland and Labrador (6.7%; 95%CI, 5.3% to 8.0%) and Prince Edward Island (7.5%; 95%CI, 5.8% to 9.3%). In Canada, the general medical system was the most used for MH reasons (5.4%; 95%CI, 5.1% to 5.8%) and the voluntary network sector was the least used (1.9%; 95%CI, 1.7% to 2.1%). No difference was observed in the rate of service use between specialty MH (3.5%; 95%CI, 3.2% to 3.8%) and other professional providers (4.0%; 95%CI, 3.7% to 4.3%). In multivariate analyses, after adjusting for age and sex, the presence of a mental disorder was a consistent predictor of health service use for MH across the provinces. Conclusions: There is up to a twofold difference in the type of service used for MH reasons across provinces. The primary care general medical system is the most widely used service for MH. Need remains the strongest predictor of use, especially when a mental disorder is present. Barriers to access, such as income, were not identified in all provinces. Different sociodemographic variables played a role in service seeking within each province. This suggests different attitudes toward common mental disorders and toward care seeking among the provinces.

Effect of Scattered-Site Housing Using Rent Supplements and Intensive Case Management on Housing Stability Among Homeless Adults With Mental Illness A Randomized Trial

BACKGROUND Quantifying diagnostic transitions across development is needed to estimate the long-term burden of mental illness. This study estimated patterns of diagnostic transitions from childhood to adolescence and from adolescence to early adulthood. METHODS Patterns of diagnostic transitions were estimated using data from three prospective, longitudinal studies involving close to 20,000 observations of 3,722 participants followed across multiple developmental periods covering ages 9-30. Common DSM psychiatric disorders were assessed in childhood (ages 9-12; two samples), adolescence (ages 13-18; three samples), and early adulthood (ages 19 to age 32; three samples) with structured psychiatric interviews and questionnaires. RESULTS Having a disorder at an early period was associated with at least a threefold increase in odds for having a disorder at a later period. Homotypic and heterotypic transitions were observed for every disorder category. The strongest evidence of continuity was seen for behavioral disorders (particularly ADHD) with less evidence for emotional disorders such as depression and anxiety. Limited evidence was found in adjusted models for behavioral disorders predicting later emotional disorders. Adult substance disorders were preceded by behavioral disorders, but not anxiety or depression. CONCLUSIONS Having a disorder in childhood or adolescence is a potent risk factor for a range of psychiatric problems later in development. These findings provide further support for prevention and early life intervention efforts and suggest that treatment at younger ages, while justified in its own right, may also have potential to reduce the risk for disorders later in development.

Health-related quality of life and eating disorders: A review and update

IMPORTANCE Scattered-site housing with Intensive Case Management (ICM) may be an appropriate and less-costly option for homeless adults with mental illness who do not require the treatment intensity of Assertive Community Treatment. OBJECTIVE To examine the effect of scattered-site housing with ICM services on housing stability and generic quality of life among homeless adults with mental illness and moderate support needs for mental health services. DESIGN, SETTING, AND PARTICIPANTS The At Home/Chez Soi project was an unblinded, randomized trial. From October 2009 to July 2011, participants (N = 1198) were recruited in 4 Canadian cities (Vancouver, Winnipeg, Toronto, and Montreal), randomized to the intervention group (n = 689) or usual care group (n = 509), and followed up for 24 months. INTERVENTIONS The intervention consisted of scattered-site housing (using rent supplements) and off-site ICM services. The usual care group had access to existing housing and support services in their communities. MAIN OUTCOMES AND MEASURES The primary outcome was the percentage of days stably housed during the 24-month period following randomization. The secondary outcome was generic quality of life, assessed by a EuroQoL 5 Dimensions (EQ-5D) health questionnaire. RESULTS During the 24 months after randomization, the adjusted percentage of days stably housed was higher among the intervention group than the usual care group, although adjusted mean differences varied across sites. [table: see text] The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group (60.5 [95%CI, 58.6 to 62.5] at baseline and 67.2 [95%CI, 65.2 to 69.1] at 24 months for the intervention group vs 62.1 [95% CI, 59.9 to 64.4] at baseline and 68.6 [95%CI, 66.3 to 71.0] at 24 months for the usual care group, difference in mean changes, 0.10 [95%CI, −2.92 to 3.13], P=.95). CONCLUSIONS AND RELEVANCE Among homeless adults with mental illness in 4 Canadian cities, scattered site housing with ICM services compared with usual access to existing housing and community services resulted in increased housing stability over 24 months, but did not improve generic quality of life. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN42520374.

Depression Literacy in Alberta: Findings From a General Population Sample

OBJECTIVE The aim of this article is to provide a narrative review of empirical studies related to health-related quality of life (HRQOL) and eating disorders and to report recent changes in the measurement of HRQOL in eating disorders. METHOD Twenty-five articles of central importance to the topic were identified in a systematic search of six databases. All articles were selected based on a consensus relevancy rating process. Key themes were extracted from the articles and validated by all authors. RESULTS We identify six themes in the extant empirical literature. DISCUSSION We discuss these six themes and review them in light of the fact that they are identified in studies using only generic measures of HRQOL. Four recently developed disease-specific HRQOL measures specific to patients with eating disorder are discussed.

If I Was Going to Kill Myself, I Wouldn't Be Calling You. I am Asking for Help: Challenges Influencing Immigrant and Refugee Women's Mental Health

Objective: To assess the publics knowledge about depression, attitudes toward treatments for depression, perceived causal factors for depression, and reported prognoses of depression, overall and by sex. Methods: We conducted a cross-sectional telephone survey in Alberta between February and June 2006. We used a random phone number selection procedure to identify a sample of adults in the community (n = 3047). Participants were presented with a vignette describing an individual with depression and then asked questions to assess recognition of depression, attitudes toward mental health treatments, possible causal factors for depression, and prognosis of depression. Results: The response rate was 75.2 %. Among the final participants, 75.6% could correctly recognize depression described in a case vignette. General practitioners or family doctors were considered as being the best help for depression. Of the participants, 35% were in complete agreement with health professionals about appropriate interventions for depression, 28% believed in dealing with depression alone, and 43% thought that “weakness of character” was a likely cause of depression. Men had poorer mental health literacy than women and were more likely to endorse the use of alcohol to cope. Conclusions: Mental health promotion and education efforts are needed to improve the general publics mental health literacy and to clarify misunderstanding about depression. Men need to be a particular target of these efforts.