Anxiety Disorders: University of Toronto

Segal ZV, Kennedy SH, Cohen NL, Anonymous00075. · Department of Psychiatry and Psychology, University of Toronto, Toronto, Ontario. · Can J Psychiatry. · Pubmed #11441772 No free full text.

Abstract: BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, "Combining Psychotherapy and Pharmacotherapy," was 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Recommendations are given for the use of combined psychotherapy and pharmacotherapy for the treatment of depressive disorders. Three methods of combined treatment are identified: concurrent treatment (psychotherapy plus pharmacotherapy) for the acute-treatment phase, sequential treatment (adding the other treatment for nonresponders or partial responders to monotherapy in the acute-treatment phase), and crossover treatment (switching to psychotherapy for the maintenance-treatment phase after response to pharmacotherapy in the acute phase). CONCLUSIONS: Combined treatment with psychotherapy and pharmacotherapy is widely used in clinical practice. The recommendations for use of combined treatment are, however, based on only a limited evidence base.

Kennedy SH, Lam RW, Cohen NL, Ravindran AV, Anonymous00074. · Department of Psychiatry, University of Toronto, Toronto, Ontario. · Can J Psychiatry. · Pubmed #11441771 No free full text.

Abstract: BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, "Medications and Other Biological Treatments," is 1 of 7 articles that were drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Evidence-based recommendations are presented for 1) choosing an antidepressant, based on efficacy, tolerability, and safety; 2) the optimal use of antidepressants, including augmentation, combination, and switching strategies; 3) maintenance treatment; and 4) electroconvulsive therapy (ECT), light therapy, and additional somatic treatments. Evidence from metaanalyses is presented first, followed by conclusions from randomized controlled trials (RCTs) and, if appropriate, open-label data. CONCLUSIONS: There is significant evidence to support the role of selective serotonin reuptake inhibitors (SSRIs), novel agents, and classic agents in the treatment of major depressive disorder (MDD). There is also evidence to support the use of somatic treatments, including ECT and light therapy, for some patients with MDD. There is limited evidence for the use of specific medications to treat subtypes of MDD. There is emerging evidence to support augmentation and combination strategies for patients previously nonresponsive to medication.

Segal ZV, Whitney DK, Lam RW, Anonymous00073. · Department of Psychiatry and Psychology, University of Toronto, Toronto, Ontario. · Can J Psychiatry. · Pubmed #11441770 No free full text.

Abstract: BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section on "Psychotherapy" is 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Recommendations are given for the use of psychotherapy in the treatment of depressive disorders. Considerable evidence shows that specific, short-term psychotherapies including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) are effective acute-phase treatments. There is also evidence that group and marital/couples formats of psychotherapy are effective. There is only limited evidence that psychotherapy is effective for maintenance treatment of depressive disorders. CONCLUSIONS: Psychotherapy is effective in the treatment of depressive disorders. Despite the evidence for effectiveness of specific psychotherapies, there is still limited access to these treatments in the community.

Parikh SV, Lam RW, Anonymous00071. · Department of Psychiatry, University of Toronto, Toronto, Ontario. · Can J Psychiatry. · Pubmed #11441768 No free full text.

Abstract: BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section on "Definitions, Prevalence, and Health Burden" was 1 of 7 articles drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: The 1-year prevalence rate of major depressive disorder (MDD) in Canada is 3.2% to 4.6%, similar to the rates in other countries. MDD frequently runs a chronic or recurrent course and carries high risks for mortality and morbidity. The significant economic costs and disability associated with depressive illness are reduced by effective treatment. CONCLUSIONS: MDD is a prevalent medical condition that results in a significant health burden in the world. Vigorous efforts to improve diagnosis, treatment, and prevention are indicated to reduce the societal and personal costs of depressive disorders.

Ravindran AV, da Silva TL, Ravindran LN, Richter MA, Rector NA. · University of Toronto, Ontario, Canada. · Can J Psychiatry. · Pubmed #19497165 No free full text.

Abstract: OBJECTIVE: To provide a review of the evidence-based treatments for obsessive-compulsive spectrum disorders (OCSD), a group of conditions related to obsessive-compulsive disorder (OCD) by phenomenological and etiological similarities, the morbidity of which is increasingly recognized. METHOD: Literature relating to the following disorders: body dysmorphic disorder, hypochondriasis, trichotillomania, onychophagia, psychogenic excoriation, compulsive buying, kleptomania, and pathological gambling, and published between January 1965 and October 2007, was found using PubMed. Included in this review were 107 treatment reports. RESULTS: Serotonin reuptake inhibitors (SRIs) have shown benefits as first-line, short-term treatments for body dysmorphic disorder, hypochondriasis, onychophagia, and psychogenic excoriation, with some benefits in trichotillomania, pathological gambling, and compulsive buying. There are also suggested benefits for several atypical antipsychotics in disorders with a high degree of impulsivity, including trichotillomania and pathological gambling, and to a lesser extent, kleptomania and psychogenic excoriation. Cognitive-behavioural interventions have generally shown evidence for use as first-line treatment across the spectrum, with some variability in degree of benefit. CONCLUSIONS: As in OCD, several conditions in the proposed OCSD benefit from SRIs and (or) cognitive-behavioural interventions. However, the treatment literature is generally limited, and more randomized controlled trials (RCTs) are needed to evaluate individual and combination treatments, for short-term use and as maintenance.

Lamb J, Pepler DJ, Craig W. · University of Toronto, Department of Family and Community Medicine, Women's College Hospital, Burton Hall, 60 Grosvenor St, Toronto, Ontario. · Can Fam Physician. · Pubmed #19366941 links to  free full text

Abstract: OBJECTIVE: To review the epidemiology, identification, and management of bullying and victimization among children in the primary care setting. SOURCES OF INFORMATION: Information was obtained from PsycINFO and MEDLINE databases, as well as the authors' own clinical and research experience. Information is based on levels II and III evidence. MAIN MESSAGE: Involvement in bullying is a destructive relationship problem, with important health implications. Physicians need to be aware of the physical and psychosocial symptoms commonly associated with involvement in bullying so that they can screen and identify those children involved. This article presents a review of bullying and associated symptoms, a tool for assessing bullying involvement, and an overview of intervention and management. CONCLUSION: Bullying is a substantial problem affecting Canadian children. With an increased awareness and understanding of bullying as a health problem, physicians can play an instrumental role in identifying children involved in bullying and providing them with the support needed to develop healthy relationships.

Shukla R, Sasseville D. · Department of Dermatology, University of Toronto, ON. · J Cutan Med Surg. · Pubmed #19317947 No free full text.

Abstract: BACKGROUND: The management of psychodermatologic disease often involves the use of psychotropics by dermatologists. A general approach to the psychopharmacologic management of psychodermatological disease may be of assistance to the dermatologist. OBJECTIVE: We review and provide a current psychopharmacologically based approach to management of common psychopathologies associated with psychodermatologic disorders, common side effects, and potential drug interactions that may occur with selected psychotropics. METHODS: Using relevant MeSH terms, we performed a review of the literature from 1980 to 2006. RESULTS AND CONCLUSIONS: Effective psychopharmacologic management of psychodermatologic disease involves identifying and basing treatment on the associated psychopathology; familiarity with a variety of psychotropic agents, including antidepressants, anxiolytics, and antipsychotics; and the involvement of a psychiatrist when possible.

Einarson A. · The Motherisk Program, The Hospital for Sick Children, Toronto, Ontario. · Can J Clin Pharmacol. · Pubmed #19164847 links to  free full text

Abstract: Psychiatric disorders are relatively common among women of childbearing age, who may be prescribed psychotropic drugs. There remains a high level of anxiety regarding their safety among patients and healthcare providers alike, most likely because of the conflicting studies that have been published in the literature and warnings from government organizations. Consequently, treating a psychiatric disorder during pregnancy with pharmacotherapy, is a complex decision making process, which has to be made between the pregnant woman and her healthcare provider. The objective of this brief review is to discuss the current models for studying the use of drugs in pregnancy and to provide current information on the safety/risk of psychotropic drugs used in pregnancy. The body of evidence in the literature to date suggests that psychotropic drugs as a group are relatively safe to take during pregnancy and women and their health care providers should not be unduly concerned if a woman requires treatment. Optimal control of the psychiatric disorder should be maintained during pregnancy, the post partum period and thereafter.All pregnancies where a mother has a serious psychiatric disorder should be considered high risk and the mother and fetus must be carefully monitored.

Dennis CL, Allen K. · Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, Ontario, Canada, M5T 1P8. · Cochrane Database Syst Rev. · Pubmed #18843730 No free full text.

Abstract: BACKGROUND: Although pregnancy was once thought of as a time of emotional well-being for many women, conferring 'protection' against psychiatric disorders, a recent meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, non-pharmacological treatment options are needed. OBJECTIVES: To assess the effects, on mothers and their families, of non-pharmacological/psychosocial/psychological interventions compared with usual antepartum care in the treatment of antenatal depression. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Collaboration Depression Anxiety and Neurosis Group's Trials Registers (CCDANCTR-Studies and CCDANCTR-References) (January 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) and CINAHL (1982 to January 2007). We scanned secondary references and contacted experts in the field to identify other published or unpublished trials. SELECTION CRITERIA: All published, unpublished and ongoing randomised controlled trials of non-pharmacological/psychosocial/psychological interventions to treat antenatal depression. DATA COLLECTION AND ANALYSIS: All review authors independently participated in the evaluation of methodological quality and data extraction. . MAIN RESULTS: We included one US three-armed randomised controlled trial in this review, incorporating 61 outpatient antenatal women who met Diagnostic and Statistical Manual for Mental Disorders-IV criteria for major depression. Maternal massage, compared to non-specific acupuncture (control group), did not significantly decrease the number of women diagnosed with clinical depression immediately post-treatment (one trial, n = 38; risk ratio (RR) 0.80, 95% confidence interval (CI) 0.25 to 2.53) or at final assessment at 10 weeks' postpartum (one trial, n = 32; RR 1.93, 95% CI 0.37 to 10.01). Acupuncture specifically treating symptoms of depression, compared to non-specific acupuncture, did not significantly decrease the number of women diagnosed with clinical depression immediately post-treatment (one trial, n = 35; RR 0.48, 95% CI 0.11 to 2.13) or at final assessment at 10 weeks' postpartum (one trial, n = 32; RR 0.64, 95% CI 0.06 to 6.39). AUTHORS' CONCLUSIONS: The evidence is inconclusive to allow us to make any recommendations for massage therapy or depression-specific acupuncture for the treatment of antenatal depression. The included trial was too small with a non-generalisable sample, to make any recommendations.

Steeves TD, Fox SH. · Division of Neurology, University of Toronto, Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, Ontario, Canada. · Prog Brain Res. · Pubmed #18772048 No free full text.

Abstract: Tourette syndrome (TS) is a heritable neuropsychiatric disorder that presents in childhood with a constellation of motor and non-motor symptoms. The defining feature of the disorder is the presence of brief, stereotyped, motor or vocal behaviours called tics. Although tics are themselves voluntary, they are typically performed secondary to involuntary sensory symptoms or irresistible urges. TS is therefore said to be a disorder of human volition that likely represents a general failure of inhibition. It shares many features with obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD) and impulse control disorder with which it is also commonly associated. Much of the anatomic substrate for TS probably lies in the circuits that connect multiple areas of cortex with the basal ganglia and thalamus to subserve motivation, inhibition of behaviour, planning of motor acts and detection of threats. To date, pathological studies of TS have been very few and the number of subjects evaluated too small to reliably elucidate the nature and significance of several reported abnormalities. However, evidence derived from both pharmacological trials and selected functional imaging studies suggests that disturbances of the dopaminergic and serotonergic neurotransmitter systems play a key role in the pathogenesis of TS. At the same time, multiple studies have demonstrated reciprocal interactions between the serotonin and dopamine systems of the brain. This information, when placed in the context of the observed functional imaging abnormalities, may generate further insights into the pathophysiology of TS.

Wu LJ, Kim SS, Zhuo M. · Department of Physiology, University of Toronto, 1 King's College Circle, Toronto, ON, Canada. · Neurochem Res. · Pubmed #18386176 No free full text.

Abstract: Anxiety is a common human emotional experience that causes decreased quality of life and increased social burden worldwide. However, the treatment options currently available for anxiety are limited as the molecular mechanisms of these complicated emotional disorders are poorly understood. With the development of integrative methods including genetic manipulations, a variety of molecular targets involved in anxiety have been revealed, from membrane receptors, such as 5-HT receptor, GABA(A) receptor and GluR5 kainate receptor, and intracellular signaling proteins, such as CaMKIV and AC8, to transcription factors, such as CREB and Egr-1. We propose that all these molecules act together to form a balance between excitatory and inhibitory transmission that is critical for physiological anxiety, and that prolonged disturbance of any of them can promote pathological anxiety-like behavior. Studies on the interactions between these molecules will help elucidate the cellular mechanisms of anxiety, and will provide molecular targets for treating the disorders.

Sockalingam S, Li M, Krishnadev U, Hanson K, Balaban K, Pacione LR, Bhalerao S. · Medical Psychiatry Service, St. Michael's Hospital, Toronto, Ontario, Canada. · Issues Ment Health Nurs. · Pubmed #18214780 No free full text.

Abstract: Multidisciplinary mental health rehabilitation settings often encounter patients with complex comorbid medical and psychiatric issues that require integrative, multifaceted treatment strategies. Although medication and psychotherapy are typical treatment mainstays, a broader variety of therapeutic options are available, including animal-assisted therapy. Here we describe a patient who received animal-assisted therapy as a psychiatric rehabilitation tool to ameliorate his atypical depression following an assault and subsequent head injury. A review of the relevant literature highlights the therapeutic potential of animal-assisted therapy to restore and maintain patient independence and level of functioning, both of which are key treatment goals.

Mamo DC. · Centre for Addiction and Mental Health, Assisstant Professor of Psychiatry, University of Toronto, Ontario. · Can J Psychiatry. · Pubmed #17824353 No free full text.

Abstract: OBJECTIVE: The primary objective of this review article is to provide a coherent, systematic synthesis of the literature on the management of suicidality in schizophrenia that is relevant to the front-line clinician. METHOD: Literature searches were conducted on MEDLINE (1996 to 2007) and PubMed (1993 to 2007), using the key words "schizophrenia" and "suicide," as well as references from the resulting articles. I used my own clinical experience to create fictional case examples to illustrate the applicability of the literature discussed in this paper. RESULTS: Suicidality in schizophrenia is high, and early detection relies on the appreciation and evaluation of the clinical manifestations of depression, despair, and hopelessness, as well as on the nature and severity of the psychotic experience itself, particularly in recent-onset patients with higher cognitive function and educational background. Clinical management includes ensuring immediate safety, the use of psychosocial techniques to address depression and psychosocial stressors, targeted pharmacotherapy for depression and psychosis, and adequate discharge planning. Clozapine is the only antipsychotic with good evidence for efficacy in decreasing suicidal behaviour in schizophrenia. CONCLUSIONS: The optimal management of suicidality in schizophrenia involves the incorporation of traditional bedside clinical skills, selection of psychosocial modalities based on individual needs, and selective pharmacotherapy directed primarily at psychotic and depressive symptoms.

Sloman L. · Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, 250 College St, Toronto, On Canada M5T 1R8. · J Affect Disord. · Pubmed #17765322 No free full text.

Abstract: Difference amplification was the process whereby the difference in fitness between two competing individuals in early man was magnified by the results of the competition. It arises from adaptive and maladaptive cycles (characterized by depression and anxiety) that are initiated by winning and losing agonistic encounters. Those who were most successful were likely to find mates that were also successful and vice versa. This would have contributed to well-endowed progeny and accelerated phylogenetic evolution. The adaptive and maladaptive cycles of the difference amplification model are also a feature of the social rank and attachment models. Ineffective operation of social rank and attachment systems is associated with anxiety and depression. This paper introduces the notion that the efficient operation of these two systems in hierarchical encounters accelerates the phylogenetic adaptation of the individual's genetic line. This suggests an adaptive function of attachment and social rank mechanisms that has not been previously described. Social rank, attachment and difference amplification should be viewed as different aspects of a comprehensive evolutionary model of depression and anxiety. This new model has psychotherapeutic implications.

Ravindran AV, Bradbury C, McKay M, da Silva TL. · University of Toronto, Mood and Anxiety Disorders Program, Centre for Addiction and Mental Health, Toronto, ON, Canada. · Expert Opin Pharmacother. · Pubmed #17685886 No free full text.

Abstract: Risperidone has been shown to be a safe and effective atypical antipsychotic agent. It was initially approved for the treatment of schizophrenia, and now, in many countries, is used to treat other conditions, including bipolar disorder, dementia and behavior problems in a range of age groups. Yet, frequent off-label use by clinicians to treat other mood and anxiety disorders and behavioral disorders is common and requires an examination of the risks and benefits in such populations. A review of the literature provides varying levels of evidence supporting its use in a range of depressive and anxiety disorders, and in special populations, including children and the elderly. Most reports are based on short-term studies and include its use both as monotherapy and as an augmenting agent to other psychotropics, and in a range of doses. Further randomized controlled trials are needed to confirm the efficacy and tolerability of risperidone, both short- and long-term, in many of these conditions. The published evidence is summarized, with recommendations and suggestions for its use.

Manassis K. · University of Toronto, Department of Psychiatry, Hospital for Sick Children, Toronto, Ontario, Canada. · Expert Rev Neurother. · Pubmed #17678493 No free full text.

Abstract: Anxiety disorders (ANX) and attention-deficit/hyperactivity disorder (ADHD) commonly co-occur; this comorbidity is associated with a high degree of impairment and a poor long-term prognosis. In this review, the nature of this comorbidity and its treatment will be described, and an approach to treating children with ANX + ADHD will be presented. The etiology of ANX + ADHD is controversial, with biological, developmental, environmental and cognitive factors examined in various studies. There is increasing evidence that ANX + ADHD may be distinct from each separate disorder, and may represent a neuropsychiatric condition that involves dysregulation in both anxiety and ADHD domains. Treatment usually requires a combination of medication and psychotherapeutic intervention. Stimulant medications have been found most helpful so far compared with other medications, although atomoxetine is also being studied. There is limited evidence for selective serotonin reuptake inhibitors, and their potential for behavioral activation may be problematic in these children. Intensive behavior modification was shown to be beneficial in conjunction with medication for ANX + ADHD in a multimodal treatment study of children with ADHD. Cognitive-behavioral therapy has been used to address anxiety symptoms, but may need to be individualized in ANX + ADHD as cognitive limitations and ADHD behaviors may otherwise interfere. Parental anxious or ADHD traits and the child's developmental level must also be considered to optimize treatment.

Dennis CL, Ross LE, Grigoriadis S. · University of Toronto, Faculty of Nursing, 155 College Street, Toronto, Ontario, Canada, M5T 1P8. · Cochrane Database Syst Rev. · Pubmed #17636841 No free full text.

Abstract: BACKGROUND: Although pregnancy was once thought of as a time of emotional wellbeing for many women, conferring 'protection' against psychiatric disorders, a recent meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, non-pharmacological treatment options are needed. OBJECTIVES: The primary objective of this review is to assess the effects, on mothers and their families, of psychosocial and psychological interventions compared with usual antepartum care in the treatment of antenatal depression. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006), the Cochrane Collaboration Depression Anxiety and Neurosis Group's Trials Registers (CCDANCTR-Studies and CCDANCTR-References) (July 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to July 2006), EMBASE (1980 to July 2006) and CINAHL (1982 to July 2006). We also scanned secondary references and contacted experts in the field to identify other published or unpublished trials. SELECTION CRITERIA: All published, unpublished and ongoing randomised controlled trials of preventive psychosocial or psychological interventions in which the primary or secondary aim is to treat antenatal depression. We excluded quasi-randomised trials (for example, those randomised by delivery date, or odd versus even medical record numbers) from the analysis. DATA COLLECTION AND ANALYSIS: All review authors participated in the evaluation of methodological quality and data extraction. Results are presented using relative risk for categorical data and weighted mean difference for continuous data. MAIN RESULTS: One US trial was included in this review, incorporating 38 outpatient antenatal women who met Diagnostic and Statistical Manual for Mental Disorders-IV criteria for major depression. Interpersonal psychotherapy, compared to a parenting education program, was associated with a reduction in the risk of depressive symptomatology immediately post-treatment using the Clinical Global Impression Scale (one trial, n = 38; relative risk (RR) 0.46, 95% confidence interval (CI) 0.26 to 0.83) and the Hamilton Rating Scale for Depression (one trial, n = 38; RR 0.82, 95% CI 0.65 to 1.03). AUTHORS' CONCLUSIONS: The evidence is inconclusive to allow us to make any recommendations for interpersonal psychotherapy for the treatment of antenatal depression. The one trial included was too small, with a non-generalisable sample, to make any recommendations.

Lipsman N, Neimat JS, Lozano AM. · Division of Neurosurgery, Toronto Western Hospital, University Health Network and University of Toronto, Toronto, Canada. · Neurosurgery. · Pubmed #17621014 No free full text.

Abstract: Obsessive-compulsive disorder (OCD) is a common psychiatric disease that is marked by recurring, anxiety-provoking thoughts (obsessions) accompanied by repetitive and time-consuming behaviors (compulsions). Among the controversies in the OCD literature is the issue of the origin of the disease and whether brain changes observed with modern imaging techniques are the causes or results of OCD behaviors and thoughts. These issues remain unresolved; however, significant strides have been made in understanding the illness from both phenomenological and pathophysiological perspectives. The current staple of OCD management remains pharmacological in nature and often occurs in conjunction with cognitive behavioral therapy. Refractory cases, however, are occasionally referred for neurosurgical consultation, and several procedures have been examined. Success in the treatment of Parkinson's disease, the reversibility of the therapy, and a relatively safe side-effect profile have allowed deep brain stimulation (DBS) to be examined as an alternative treatment for some psychiatric conditions. Here we assess the possibility of applying DBS to the treatment of OCD. Morphological, functional metabolic, and volumetric data point to several brain regions that are important to the etiology and maintenance of OCD. Converging evidence from the genetics and neurocircuitry literature suggests that several subcortical structures play prominent roles in the disease. The functional modification of these structures could potentially provide symptom relief. Here, we review the ablative and DBS procedures for refractory OCD, and provide a research-driven hypothesis that highlights the ventromedial head of the caudate nucleus, and structures up- and downstream from it, as potential DBS targets for treatment-resistant disease. We hope that a research-driven approach, premised on converging evidence and previous experience, will lead to a safe and effective DBS procedure that will benefit patients who remain disabled despite presently available therapies.

McIntyre RS, Fallu A, Konarski JZ. · Mood Disorders Psychopharmacology Unit, University Health Network, University of Toronto, Toronto, Ontario, Canada. · Clin Ther. · Pubmed #17213009 No free full text.

Abstract: BACKGROUND: Mental disorders are highly prevalent, heterogeneous, and of multifactorial etiology. Collectively, they are associated with significant morbidity, mortality, and economic cost. Wellness is the optimal outcome in the management of chronic medical and psychiatric disorders. OBJECTIVES: This review provides a synopsis of definitions and operational criteria for remission in major depressive disorder, bipolar disorder, schizophrenia, anxiety disorders, and attention-deficit/hyperactivity disorder (ADHD). The overall goals were to propose a treatment framework that gives primacy to therapeutic outcomes and to provide a rationale for psychiatry to quantify and measure patient outcome. METHODS: Articles proposing definitions for remission were identified using a MEDLINE search (1966-April 2005) of the English-language literature (key terms: remission, anxiety disorders, bipolar disorder, major depressive disorder, attention-deficit/hyperactivity disorder, and schizophrenia). RESULTS: Operationalizing and quantifying critical end points in psychiatric disorders may help sharpen the focus of therapeutic activity and benefit patient outcome. In the absence of a validated biomarker of psychiatric illness activity, symptomatic remission and functional restoration are the only available markers of wellness in psychiatry. There is an emerging consensus regarding a definition for remission in major depressive disorder; several working definitions for bipolar disorder, schizophrenia, and anxiety disorders have been proposed. Developments in adult mood disorders-albeit incomplete-have been informative; managing psychiatric disorders that first appear in childhood (eg, ADHD) may also benefit by objectifying patient outcome. CONCLUSIONS: Research is needed to determine the impact of applying a remission-focused model of illness management--emphasizing quantifiable, objective, and measurable end points--on overall patient outcomes.

Hoch JS, Smith MW. · Centre for Research on Inner City Health and St. Michael's Hospital, Toronto, and the Department of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada. · J Trauma Stress. · Pubmed #17195977 No free full text.

Abstract: The authors introduce economic evaluation with particular attention to cost-effectiveness analysis. They begin by establishing why health care decisions should be guided by economics. They then explore different types of economic evaluations. To illustrate how to conduct and evaluate a cost-effectiveness analysis, a hypothetical study about the treatment of posttraumatic stress disorder with psychotherapy versus pharmacotherapy is considered. The authors conclude with recommendations for increasing the strength and relevance of economic evaluations.

McIntyre RS, Soczynska JK, Bottas A, Bordbar K, Konarski JZ, Kennedy SH. · Department of Psychiatry and Pharmacology, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada. · Bipolar Disord. · Pubmed #17156153 No free full text.

Abstract: CONTEXT: Epidemiological, clinical and familial studies indicate that anxiety disorders (ADs) are highly comorbid in persons with bipolar disorder (BPD). The phenomenological overlap between ADs and BPD is reported more frequently in individuals with female predominant bipolar presentations (e.g., bipolar II disorder). Anxiety comorbidity in the BPD population poses a serious hazard. For example, it is associated with an intensification of symptoms, non-recovery, substance use comorbidity and harmful dysfunction (e.g., suicidality). OBJECTIVE: The evidentiary base informing treatment decisions for the anxious bipolar patient is woefully inadequate. Several expert consensus and evidence-based treatment guidelines for BPD suggest various treatment avenues, although these have been insufficiently studied. The encompassing aim of this paper is to synthesize extant studies reporting on the co-occurrence of AD and BPD. Taken together, a compelling basis emerges for prioritizing the identification and management of anxiety symptomatology in the BPD population.

Ameis SH, Feinstein A. · University of Toronto, Sunnybrook Health Sciences Center, 2075 Bayview, Avenue, Toronto, Ontario, M4N 3M5, Canada. · Expert Rev Neurother. · Pubmed #17078794 No free full text.

Abstract: This article reviews the treatment of behavioral disturbances associated with multiple sclerosis. Pharmacological and psychotherapeutic treatment data, when available, are presented for five discrete conditions: major depression, bipolar affective disorder, anxiety, psychosis, pseudobulbar affect and cognitive dysfunction. Despite the paucity of empirical treatment data that characterizes all of these conditions, with the exception of pseudobulbar affect, the message from open-label trials and anecdotal experience is that therapy is often successful, leading to improvements in quality of life for patients. Thus, all health professionals involved in the care of multiple sclerosis patients should have a good working knowledge of the neurotherapeutics of multiple sclerosis-related behavioral disorders.

Ross LE, McLean LM. · Women's Mental Health and Addiction Research Section, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. · J Clin Psychiatry. · Pubmed #16965210 No free full text.

Abstract: OBJECTIVE: The postpartum period is recognized as a time of vulnerability to affective disorders, particularly postpartum depression. In contrast, the prevalence and clinical presentation of anxiety disorders during pregnancy and the postpartum period have received little research attention. In this article, we review the medical literature as it relates to the prevalence and clinical presentation of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder during pregnancy and the postpartum period. DATA SOURCES: MEDLINE (1966 to July 2005 week 1) and PsycInfo (1840 to July 2005 week 1) were searched using combinations of the following search terms: pregnancy, childbirth, postpartum, panic disorder, phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. STUDY SELECTION: All relevant papers published in English and reporting original data related to perinatal anxiety disorders were included. DATA EXTRACTION: Studies were examined for data related to the prevalence, presentation, predictors/risk factors, new onset, course, and treatment of anxiety disorders during pregnancy and the postpartum period. DATA SYNTHESIS: Anxiety disorders are common during the perinatal period, with reported rates of obsessive-compulsive disorder and generalized anxiety disorder being higher in postpartum women than in the general population. The perinatal context of anxiety disorders presents unique issues for detection and management. CONCLUSIONS: Future research is needed to estimate the prevalence of perinatal anxiety disorders more precisely, to identify potential implications of maternal anxiety disorders for maternal quality of life and child development, and to determine safe and effective treatment methods.

Woodside BD, Staab R. · Program for Eating Disorders and the Department of Psychiatry, Toronto General Hospital, Toronto, Ontario, Canada. · CNS Drugs. · Pubmed #16863270 No free full text.

Abstract: The eating disorders anorexia nervosa and bulimia nervosa present with comorbidity in a number of important areas, including depression, bipolar disorder, anxiety disorders (obsessive-compulsive disorder, panic disorder, social anxiety disorder and other phobias, and post-traumatic stress disorder) and substance abuse. The most important principle of treating comorbidity in these conditions is the recognition of the effect of starvation and unstable eating on both the diagnosis and response to treatment of the comorbidity. This article reviews the identification of the most common areas of comorbidity and describes treatment approaches for these conditions. When it occurs, clinicians should treat comorbidity in patients with eating disorders in the usual fashion, but must remain aware that the disturbed eating itself will negatively affect response to treatment.

Goldstein BI, Diamantouros A, Schaffer A, Naranjo CA. · Department of Psychiatry, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada. · Drugs. · Pubmed #16827599 No free full text.

Abstract: There has been an exponential increase in recent years of literature pertaining to the treatment of individuals with alcohol use disorders and co-morbid psychiatric disorders. Patients with mood and anxiety disorders in particular have a very high prevalence of alcoholism. Alcoholism confers significant morbid risks to patients with psychiatric disorders, and vice versa, including markedly increased risk of suicide. Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively. The first randomised, controlled trial involving subjects with co-morbid alcoholism and bipolar disorder was recently conducted, yielding promising results for valproate in this population. The literature regarding co-morbid alcoholism and anxiety disorders has also seen recent progress, particularly in the study of post-traumatic stress disorder (PTSD). A placebo-controlled study of sertraline suggests some benefit in terms of alcohol use among individuals with early-onset PTSD and less severe alcohol dependence. Atypical antipsychotics such as olanzapine and quetipaine have been examined in several open studies of subjects with alcoholism co-morbid with a variety of psychiatric conditions including bipolar disorder, PTSD and schizophrenia. This paper selectively reviews the evidence that is currently available for the pharmacological management of alcoholism among persons with co-morbid psychiatric illness. Effectiveness, safety and tolerability are considered, and directions for future study are discussed.