Geneviève Arsenault-Lapierre

Psychiatric diagnoses in 3275 suicides: a meta-analysis

BackgroundIt is well known that most suicide cases meet criteria for a psychiatric disorder. However, rates of specific disorders vary considerably between studies and little information is known about gender and geographic differences. This study provides overall rates of total and specific psychiatric disorders in suicide completers and presents evidence supporting gender and geographic differences in their relative proportion.MethodsWe carried out a review of studies in which psychological autopsy studies of suicide completers were performed. Studies were identified by means of MEDLINE database searches and by scanning the reference list of relevant publications. Twenty-three variables were defined, 16 of which evaluating psychiatric disorders. Mantel-Haenszel Weighted Odds Ratios were estimated for these 16 outcome variables.ResultsTwenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death. There were major gender differences. Diagnoses of substance-related problems (OR = 3.58; 95% CI: 2.78–4.61), personality disorders (OR = 2.01; 95% CI: 1.38–2.95) and childhood disorders (OR = 4.95; 95% CI: 2.69–9.31) were more common among male suicides, whereas affective disorders (OR = 0.66; 95% CI: 0.53–0.83), including depressive disorders (OR = 0.53; 95% CI: 0.42–0.68) were less common among males. Geographical differences are also likely to be present in the relative proportion of psychiatric diagnoses among suicides.ConclusionsAlthough psychopathology clearly mediates suicide risk, gender and geographical differences seem to exist in the relative proportion of the specific psychiatric disorders found among suicide completers.

Chronic stress, cognitive functioning and mental health.

This review aims to discuss the evidence supporting the link between chronic stress, cognitive function and mental health. Over the years, the associations between these concepts have been investigated in different populations. This review summarizes the findings that have emerged from older populations as well as from populations suffering from pathological aging, namely Mild Cognitive Impairment and Alzheimers Disease. Although older adults are an interesting population to study in terms of chronic stress, other stress-related diseases can occur throughout the lifespan. The second section covers some of these stress-related diseases that have recently received a great deal of attention, namely burnout, depression, and post-traumatic stress disorder. Given that chronic stress contributes to the development of certain pathologies by accelerating and/or exacerbating pre-existing vulnerabilities that vary from one individual to the other, the final section summarizes data obtained on potential variables contributing to the association between chronic stress and cognition.

A transdisciplinary perspective of chronic stress in relation to psychopathology throughout life span development.

The allostatic load (AL) model represents an interdisciplinary approach to comprehensively conceptualize and quantify chronic stress in relation to pathologies throughout the life cycle. This article first reviews the AL model, followed by interactions among early adversity, genetics, environmental toxins, as well as distinctions among sex, gender, and sex hormones as integral antecedents of AL. We next explore perspectives on severe mental illness, dementia, and caregiving as unique human models of AL that merit future investigations in the field of developmental psychopathology. A complimenting transdisciplinary perspective is applied throughout, whereby we argue that the AL model goes beyond traditional stress-disease theories toward the advancement of person-centered research and practice that promote not only physical health but also mental health.

Effect of service dogs on salivary cortisol secretion in autistic children

Children with Autism Syndrome Disorders (ASDs) exhibit social, communicative, and behavioral deficits. We know that human interaction with dogs, which is thought to serve as a social catalyst, results in a decrease of cortisol levels in healthy adults. Introducing service dogs to children with ASD is an attractive idea that has received growing attention in recent decades. However, no study has measured the physiological impact of service dogs on these children. Therefore, the goal of our study was to assess the effects of service dogs on the basal salivary cortisol secretion of children with ASD. We measured the salivary cortisol levels of 42 children with ASD in three experimental conditions; prior to and during the introduction of a service dog to their family, and after a short period during which the dog was removed from their family. We compared average cortisol levels and Cortisol Awakening Response (CAR) before and during the introduction of the dog to the family and after its withdrawal. We found that the introduction of service dogs translated into a statistically significant diminished CAR. Before the introduction of service dogs, we measured a 58% increase in morning cortisol after awakening, which diminished to 10% when service dogs were present. The increase in morning cortisol jumped back to 48% once the dogs were removed from the families (p<0.05). However, service dogs did not have an effect on the childrens average diurnal cortisol levels. These results show that the CAR of children with ASD is sensitive to the presence of service dogs, which lends support to the potential behavioral benefits of service dogs for children with autism.

Seasonal effects on cortisol secretion in normal aging, mild cognitive impairment and Alzheimer's disease.

Previous studies found higher cortisol levels in Alzheimers disease (AD) compared to normal elderly controls (NCs). However, studies on individuals with mild cognitive impairment (MCI), who are at risk to progress to AD, are contentious. In this study, we examined whether seasonal variations in cortisol secretion in NCs, MCI individuals and AD patients might mask group differences in cortisol secretion. We found significant seasonal differences in salivary cortisol levels in all three groups. Moreover, by testing everyone in the same seasons, we found lower salivary cortisol levels in NCs compared to MCI individuals and AD patients. This suggests that controlling for the season of sampling may help elucidate subtle effects of normal and pathological aging on basal cortisol secretion.

Effects of anosognosia on perceived stress and cortisol levels in Alzheimer's disease.

Anosognosia, or unawareness of ones own cognitive deficits, may cause issues when measuring perceived stress and cortisol levels in Alzheimers disease (AD) and Mild Cognitive Impairment (MCI). The goal of this study was to examine the effects of anosognosia on perceived stress and salivary cortisol levels in normal elderly (NE) adults, MCI individuals, newly diagnosed AD patients, and long-lasting AD patients, suspected to show more anosognosia. An anosognosia index for perceived stress was computed by subtracting the score on the Perceived Stress Scale measured in the participants and their relative. Cortisol levels were measured four times a day over two nonconsecutive days. Greater anosognosia for dementia correlated with greater anosognosia for perceived stress in the group as a whole. However, no correlation between cortisol levels and either anosognosia for dementia or perceived stress was observed. Our results suggest that measuring perceived stress in AD patients may be influenced by anosognosia.

Shedding light on conditions for the successful passive dissemination of recommendations in primary care: a mixed methods study

BackgroundPassive dissemination of information in healthcare refers to the publication or mailing of newly established guidelines or recommendations. It is one of the least costly knowledge translation activities. This approach is generally considered to be ineffective or to result in only small changes in practice. Recent research, however, suggests that passive dissemination could, under certain conditions, result in modifications of practice, similar to more active dissemination approaches. The objective of our study was to uncover the conditions associated with the change in primary care practice, namely Family Medicine Groups (FMGs) in Quebec (Canada), following the passive dissemination of recommendations for the diagnosis and management of Alzheimer’s disease and related dementia (AD).MethodsWe used a three-step, innovative, convergent mixed methods design based on a multiple case study in eight FMGs. Two studies were conducted in parallel: (1) a before and after retrospective chart review and a cluster analysis of FMGs performed on two clinical performance indicators—the rate of AD diagnosis and the quality of follow-up care; (2) a qualitative descriptive study using interviews and focus groups with FMG clinicians and healthcare managers. The results were integrated using joint displays.ResultsAfter the passive dissemination of the recommendations, some FMGs started to implement the recommendations while other FMGs did not change their practice with respect to the AD diagnosis rate and quality of follow-up care. Three interrelated conditions were identified for the successful passive dissemination of clinical recommendations: (1) FMG clinicians with a moderate to high baseline expertise and confidence, which was linked to their existing collaboration with hospital-based specialists in dementia and their motivation; (2) the presence of a self-identified champion (individual champion or collective championship) in the FMGs taking the lead, motivating the clinical staff or organizing training; (3) the availability of sufficient clinical staff enabled these two conditions to have an impact on the implementation of recommendations through passive dissemination.ConclusionsPassive dissemination of clinical recommendations, a low-cost knowledge translation approach, may lead to practice change under some specific conditions. More active dissemination efforts may only be needed in sites where these conditions are absent.

PRIMARY CARE INITIATIVES FOR COMPLEX NEUROCOGNITIVE DISORDER CARE: PROTOCOL FOR AN INNOVATIVE MIXED-METHODS DESIGN

Background:Early referral to cognitive specialty clinics is recommended in most European practice guidelines. In the US, where most cognitive problems are managed in primary care, the role of cognitive specialty clinics is controversial and referrals are inconsistent and often delayed. Specialists without a dementia focus may not offer family education and support.Methods:We used electronic medical records from 2013 to compare outcomes in 8887 patients age >65 in primary care community clinics and in 290 patients in our transdisciplinary cognitive specialty clinic. We examined patient-centered outcomes a care partner panel identified as important, and health system outcomes a health care leadership panel judged sufficient to change practice. The difference in dichotomous outcomes was tested with Chi-square tests and count outcomes were comparedwith the exact rate ratio test assuming Poisson distribution. Results:Patients with cognitive impairment weremuchmore likely to achieve patient-centered outcomes when seen by the cognitive specialty team than only primary care. Family support from a social worker was documented in 77% vs 4.2%, use of drugs classified as inappropriate on the Beer’s list was 9% vs. 36%, and referral for driving evaluation was 30% vs. 0.8% (all p <0.001). Only documented advanced directives were not significantly different, 27% vs. 24% (p 1⁄4 0.43). Emergency visit rate was lower (0.13 vs. 0.20, p 1⁄4 0.03), and there was a trend toward better diabetes control (p1⁄40.06) with specialty care. Patients with both diabetes and cognitive impairment achieved even lower rates of patient-oriented outcomes in primary care: family support was 0.35% vs. 72% and completion of advanced directives was 12% vs. 23%, (both p <0.001). Conclusions: Cognitive specialty teams are more likely to achieve patient-centered and health system outcomes than primary care. Current strategies in primary care fail to identify as many patients with cognitive impairment as expected, so considerable opportunity for improvement remains. Cognitive impairment may contribute to poor control of diabetes and diabetes may interfere with outcomes in primary care setting because attention is distracted away from cognitive care. A pragmatic, prospective, randomized trial would address limitations of this retrospective, observational study.