Joseph H. Puyat

Is the Influence of Social Support on Mental Health the Same for Immigrants and Non-Immigrants?

The association between social support and mental health across immigrant groups were examined in this study. A population-based sample was extracted from a 2009/10 Canadian community health survey. Self-reported mood or anxiety disorders and a standardized social support scale were used as outcome and explanatory variables. The association between these variables was measured using logistic regression controlling for sex, age, marital status, education, self-rated health and perceived stress. Stratified analyses were performed to test if the strength of association differed by immigrant status. In comparison with individuals who had moderate levels of social support, individuals with low social support had higher odds of reporting mental disorders and this association appeared strongest among recent immigrants. Using the same comparison group, individuals with high social support had lower odds of reporting mental disorders and this association appeared stronger among long-term immigrants. Findings were discussed within the context of immigration stress and acculturation strategies.

The Essential and Potentially Inappropriate Use of Antipsychotics Across Income Groups: An Analysis of Linked Administrative Data

Objective: To examine the essential and potentially inappropriate use of antipsychotics across income groups. Method: Linked health, pharmaceutical use, and income data from British Columbia were analyzed to examine antipsychotic use in 2 study cohorts. In the first cohort, the essential use of antipsychotics was assessed among adults who had a recorded diagnosis of schizophrenia in a 2-year period, 2004–2005. In the second cohort, potentially inappropriate use of antipsychotics was examined in people with no recorded diagnosis of schizophrenia or bipolar disorders in 2004–2005. The second cohort was also composed exclusively of seniors with a dementia-related diagnosis who are either in long-term care or living in the community. Income-related differences in antipsychotic use in these 2 cohorts were assessed using logistic regression, controlling for health and sociodemographic characteristics known to influence medicine use. Results: Among adults, the prevalence of essential antipsychotic use was high (85%), with higher odds of use evident among those in the middle-income group. Among seniors, the prevalence of potentially inappropriate antipsychotic treatment is 23%, with prevalence higher in long-term care (56%) than in the community (13%). No income-related differences were found in long-term care; however, in the community, higher odds of use were found in low-income seniors. Conclusion: People from low-income households have slightly lower levels of essential antipsychotic use and are more likely to receive potentially inappropriate antipsychotic treatment.

Characterization of Myocardial Repolarization Reserve in Adolescent Females With Anorexia Nervosa

Background— Patients with anorexia nervosa exhibit abnormal myocardial repolarization and are susceptible to sudden cardiac death. Exercise testing is useful in unmasking QT prolongation in disorders associated with abnormal repolarization. We characterized QT adaptation during exercise in anorexia. Methods and Results— Sixty-one adolescent female patients with anorexia nervosa and 45 age- and sex-matched healthy volunteers performed symptom-limited cycle ergometry during 12-lead ECG monitoring. Changes in the QT interval during exercise were measured, and QT/RR-interval slopes were determined by using mixed-effects regression modeling. Patients had significantly lower body mass index than controls; however, resting heart rates and QT/QTc intervals were similar at baseline. Patients had shorter exercise times (13.7±4.5 versus 20.6±4.5 minutes; P<0.001) and lower peak heart rates (159±20 versus 184±9 beats/min; P<0.001). The mean QTc intervals were longer at peak exercise in patients (442±29 versus 422±19 ms; P<0.001). During submaximal exertion at comparable heart rates (114±6 versus 115±11 beats/min; P=0.54), the QTc interval had prolonged significantly more in patients than controls (37±28 versus 24±25 ms; P<0.016). The RR/QT slope, best described by a curvilinear relationship, was more gradual in patients than in controls (13.4; 95% confidence interval, 12.8–13.9 versus 15.8; 95% confidence interval, 15.3–16.4 ms QT change per 10% change in RR interval; P<0.001) and steepest in patients within the highest body mass index tertile versus the lowest (13.9; 95% confidence interval, 12.9–14.9 versus 12.3; 95% confidence interval, 11.3–13.3; P=0.026). Conclusions— Despite the absence of manifest QT prolongation, adolescent anorexic females have impaired repolarization reserve in comparison with healthy controls. Further study may identify impaired QT dynamics as a risk factor for arrhythmias in anorexia nervosa.

How Often Do Individuals with Major Depression Receive Minimally Adequate Treatment? A Population-Based, Data Linkage Study

Objective: Depression is usually treated with antidepressants, psychotherapy, or both. In this study, we examined the extent to which individuals with depression receive minimally adequate treatment with regard to the use of antidepressants and psychotherapy. Method: Using population-based administrative data, we identified individuals with inpatient or outpatient diagnoses of depression and tracked their use of publicly funded mental health services within a 12-month period. We used mixed-effects logistic regression to assess the influence of patient-level characteristics and physician-level variations on the receipt of minimally adequate treatment. Results: A total of 108 101 individuals, predominantly women (65%) and urban residents (89%), were diagnosed with depression in 2010–2011. Of these, 13% received minimally adequate counseling/psychotherapy with higher proportions observed among men, younger individuals, and urban residents. In contrast, there were more who received minimally adequate antidepressant therapy (48%), with women, older individuals, and rural residents having the highest proportions. Overall, about 53% received either type of treatment, and the pattern of use was similar to that of antidepressant therapy. Mixed-effects logistic regression results indicate that these factors remain independent predictors of the receipt of minimally adequate depression care. Significant practice variations also exist, which determine patients’ receipt of minimally adequate care, particularly with respect to counseling or psychotherapy. Conclusions: Only about half of those with depression receive either minimally adequate counseling/psychotherapy or minimally adequate antidepressant therapy. Disparities also persist, affecting mostly men and younger individuals. A multifactorial approach is needed to improve access to and reduce variations in receipt of minimally adequate depression care.

Variations in Self-Reported Practice of Physicians Providing Clinical Care to Individuals with Dementia: A Systematic Review

To determine to what extent actual practice as reported in the literature is consistent with clinical guidelines for dementia care.

Is parasternal intercostal EMG an accurate surrogate of respiratory neural drive and biomarker of dyspnea during cycle exercise testing

Recent evidence suggests that surface electromyography of the parasternal intercostals (EMGpara) can be a non-invasive alternative to diaphragmatic EMG (EMGdi) for estimating neural respiratory drive (NRD) during cardiopulmonary exercise testing (CPET). The purpose of this study was to determine if non-respiratory muscles influence EMGpara by having subjects place their hands on (Hon) and off (Hoff) the handlebars during cycling-based CPET. Ten healthy adults performed an incremental cycling test until volitional exhaustion. Participants were instrumented with an esophageal electrode catheter to measure EMGdi, and surface electrodes on the 2nd intercostal space to measure EMGpara. Subjects alternated between 30s of Hon and 30s Hoff during each exercise stage. There were no differences in EMGdi across all exercise intensities. However, EMGpara was significantly greater during the Hon vs. Hoff condition at all exercise intensities (p<0.05). These results suggest that EMGpara may not be an appropriate surrogate of NRD during cycle exercise testing due to co-activation of adjacent skeletal muscles.

A positron emission tomography study of norepinephrine transporter occupancy and its correlation with symptom response in depressed patients treated with quetiapine XR

Abstract Background Quetiapine is effective in treating depressive symptoms in major depressive disorder and bipolar disorder, but the mechanisms underlying its antidepressants effects are unknown. Norquetiapine, a metabolite of quetiapine, has high affinity for norepinephrine transporter, which might account for its therapeutic efficacy. Methods In this study, we used positron emission tomography with (S,S)-[11C]O-methyl reboxetine to estimate norepinephrine transporter density and assess the relationship between norepinephrine transporter occupancy by quetiapine XR and improvement in depression in patients with major depressive disorder (n=5) and bipolar disorder (n=5). After the baseline positron emission tomography scan, patients were treated with quetiapine XR with a target dose of 150 mg in major depressive disorder and 300 mg in bipolar disorder. Patients had a second positron emission tomography scan at the end of week 2 and a final scan at week 7. Results Norepinephrine transporter density was significantly lower in locus ceruleus in patients compared with healthy subjects. Further, there was a significant positive correlation between quetiapine XR dose and norepinephrine transporter occupancy in locus ceruleus at week 2. The norepinephrine transporter occupancy at week 2 in hypothalamus but not in other regions predicted improvement in depression as reflected by reduction in MADRS scores from baseline to week 7. The estimated dose of quetiapine XR associated with 50% norepinephrine transporter occupancy in hypothalamus at week 2 was 256 mg and the estimated plasma levels of norquetiapine to achieve 50% norepinephrine transporter occupancy was 36.8 µg/L. Conclusion These data provide preliminary support for the hypothesis that norepinephrine transporter occupancy by norquetiapine may be a contributor to the antidepressant effects of quetiapine.

Characterizing the inpatient care of young adults experiencing early psychosis: A medical record review

To characterize the inpatient care received by individuals experiencing early psychotic episodes in an inner city hospital.

Gains of Continuing Resuscitation in Refractory Out-of-hospital Cardiac Arrest: A Model-based Analysis to Identify Deaths Due to Intra-arrest Prognostication

Abstract Objective: Prognostication bias, in which a clinician predicts a negative outcome and terminates resuscitation (TR) thereby ensuring a poor outcome, is a rarely identified limitation of out-of-hospital cardiac arrest (OHCA) research. We sought to estimate the number of deaths due to intra-arrest prognostication in a cohort of OHCAs, and use this data to estimate the incremental benefit of continuing resuscitation. Methods: This study examined a cohort of consecutive non-traumatic EMS-treated OHCAs from a provincial ambulance service, between 2007 and 2011 inclusive. We used Cox and logistic regression modeling, adjusting for Utstein covariates, to estimate the probability of ROSC, survival, and favorable neurological outcomes as a function of resuscitation time, and applied these models to estimate the number of missed survivors in those who had TR (prior to 20, 30, or 40 minutes). We determined the time juncture at which (1) the likelihood of survival fell below 1%, and (2) the proportion of survivors who had achieved ROSC exceeded 99%. Results: Of 5674 adult EMS-treated cases, 46% achieved ROSC, and 12% survived. The median time of TR was 27.0 minutes (IQR 19.0–35.0). Continuing resuscitation until 40 minutes yielded an estimated 17 additional survivors (95% CI 13–21), 10 (95% CI 7–13) with favorable neurological outcomes. The probability of survival of those in refractory arrest decreased below 1% at 28 minutes (95% CI 24–30 minutes). At 36 minutes (95% CI 34–38 minutes) >99% of survivors had achieved ROSC. Conclusion: We identified possible deaths due to intra-arrest prognostication. Resuscitation should be continued for a minimum of 30 minutes in all patients, however for those with initial shockable rhythms 40 minutes appears to be warranted. Interventional trials and observational studies should standardize or adjust for duration of resuscitation prior to TR.

Comorbid Chronic General Health Conditions and Depression Care: A Population-Based Analysis

OBJECTIVE Untreated depression among persons with chronic general health conditions (chronic health conditions) affects mortality, functional disability, quality of life, and health care costs. Currently, studies of the association between depression care and chronic health conditions report inconsistent results, and studies of depression care among persons with specific health conditions are rare. This study investigated the association between chronic health conditions and the likelihood of receiving depression care among individuals with depression. METHODS Retrospective data from physician claims, hospital separations, vital statistics, and insurance plan registries were used to identify a cohort of individuals with depression and track 12-month use of health services among those with and without a chronic health condition. Disparities were analyzed by using generalized linear models. RESULTS Individuals with depression and a chronic health condition had higher use of psychological therapy, higher use of any depression care, greater continuity of care, and better adherence to antidepressant therapy compared with individuals with depression only. However, they were less likely, in general, to be on antidepressant therapy, and individuals with diabetes had fewer visits to general practitioners for a mental health-related reason compared with individuals without diabetes. A trend toward lower use of any depression care was observed among patients with cerebrovascular disease. CONCLUSIONS Use of depression care was generally higher among individuals with chronic health conditions, although there were differences in patterns of use by type of health condition. Some patients with specific health conditions could be at risk of being inappropriately treated for depression.