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Objectives: Military sexual trauma (MST) is a prevalent issue among actively serving members and Veterans, and is associated with adverse health outcomes including mental disorders. This study sought to identify correlates and protective factors for the development of mental disorders among Canadian MST survivors., Methods: We analyzed data from participants of the longitudinal 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) who experienced MST (rounded n  = 455; 9.6%). A semi-structured diagnostic interview assessed MST and mental disorders in accordance with DSM-IV criteria. Multivariable logistic regressions examined associations between sample characteristics (2002 and 2018) and psychosocial factors (at baseline [i.e., 2002] and 2018) and any mental disorder since 2002. Analyses were run among the full subsample of MST survivors and additionally stratified by sex, when possible., Results: Among MST survivors, 66.5% had a mental disorder since 2002. Among the total sample, those who were officers (odds ratio [OR] = 0.58) or on active duty (OR = 0.52) had reduced odds of any mental disorder since 2002. In addition, less frequent use of avoidance coping in 2002 and 2018 (adjusted odds ratio [AOR]: 0.86, 0.64), more frequent use of active coping in 2018 (AOR = 0.64), less frequent use of self-medication coping in 2018 (AOR = 0.79), greater perceived social support in 2018 (AOR = 0.94), and reduced work stress across various domains in 2018 (AOR: 0.67-0.87) were associated with reduced odds of any mental disorder since 2002. Some variability emerged according to sex (e.g., types of work stress or coping emerging as protective)., Conclusions: Results highlight certain sample characteristics and psychosocial factors that illustrated a protective relationship with mental disorders among MST survivors. Findings may inform targeted intervention strategies that could help mitigate adverse mental health impacts of MST., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Cannabis use among veterans in Canada is an understudied public health priority. The current study examined cannabis use prevalence and the relationships between child maltreatment histories and deployment-related traumatic events (DRTEs) with past 12-month cannabis use including sex differences among Canadian veterans., Method: Data were drawn from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (response rate 68.7%; veterans only n  = 1,992). Five child maltreatment types and 9 types of DRTEs were assessed in relation to the past 12-month cannabis use., Results: The prevalence of lifetime and past 12-month cannabis use was 49.4% and 16.7%, respectively. Females were less likely than males to report lifetime cannabis use (41.9% vs. 50.4%; odds ratio [OR] 0.71; 95% CI, - 0.59 to 0.86). No sex differences were noted for past 12-month cannabis use (14.1% vs. 17.0%; OR 0.80; 95% CI, 0.60 to 1.07). Physical abuse, sexual abuse, neglect, any child maltreatment, most individual DRTEs, and any DRTE were associated with increased odds of past 12-month cannabis use after adjusting for sociodemographic and military variables. Some models were attenuated and/or nonsignificant after further adjustments for mental disorders and chronic pain conditions. Sex did not statistically significantly moderate these relationships. Cumulative effects of having experienced both child maltreatment and DRTEs compared to DRTEs alone increased the odds of past 12-month cannabis use. Statistically significant interaction effects between child maltreatment history and DRTE on cannabis use were not found., Conclusions: Child maltreatment histories and DRTEs increased the likelihood of past 12-month cannabis use among Canadian veterans. A history of child maltreatment, compared to DRTEs, indicated a more robust relationship. Understanding the links between child maltreatment, DRTEs, and cannabis use along with mental disorders and chronic pain conditions is important for developing interventions and improving health outcomes among veterans., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Royal Canadian Mounted Police (RCMP) report extremely frequent and varied exposures to potentially psychologically traumatic events (PPTEs). While occupational exposures to PPTEs may be one explanation for the symptoms of mental disorders prevalent among serving RCMP, exposures occurring prior to service may also play a role. The objective of the current study was to provide estimates of lifetime PPTE exposures among RCMP cadets in training and assess for associations with mental disorders or sociodemographic variables., Methods: RCMP cadets ( n   =  772; 72.0% male) beginning the Cadet Training Program (CTP) completed a survey assessing self-reported PPTE exposures as measured by the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition-Extended. Binomial tests were conducted to compare the current results to previously collected data from the general population, a diverse sample of public safety personnel (PSP) and serving RCMP., Results: Cadets reported statistically significantly fewer PPTE exposures for all PPTE types than serving RCMP (all p' s < 0.001) and PSP (all p' s < 0.001) but more PPTE exposures for all PPTE types than the general population (all p' s < 0.001). Cadets also endorsed fewer PPTE types (6.00  ±  4.47) than serving RCMP (11.64  ±  3.40; p  < 0.001) and other PSP (11.08  ±  3.23) but more types than the general population (2.31  ±  2.33; p  < 0.001). Participants who reported being exposed to any PPTE type reported the exposures occurred 1-5 times (29.1% of participants), 6-10 times (18.3%) or 10  +  times (43.1%) before starting the CTP. Several PPTE types were associated with positive screens for one or more mental disorders. There were associations between PPTE types and increased odds of screening positive for post-traumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD) and social anxiety disorder (SAD) (all p's  < 0.05). Serious transport accident (11.1%), physical assault (9.5%) and sudden accidental death (8.4%) were the PPTEs most identified as the worst event, and all were associated with positive screens for one or more mental disorders., Conclusion: The current results provide the first information describing PPTE histories of cadets, evidencing exposure frequencies and types much higher than the general population. PPTE exposures may have contributed to the cadet's vocational choices. The current results support the growing evidence that PPTEs can be associated with diverse mental disorders; however, the results also suggest cadets may be uncommonly resilient, based on how few screened positive for mental disorders, despite reporting higher frequencies of PPTE exposures prior to CTP than the general population.

Background: Royal Canadian Mounted Police (RCMP) report diverse occupational stressors and repeated exposures to potentially psychologically traumatic events, which may increase the odds of screening positive for a mental disorder, and increase the risk of death by suicide. The current study was designed to provide prevalence information regarding suicidal behaviours (i.e., ideation, planning, attempts) and assess for sociodemographic differences among cadets at the start of the RCMP Cadet Training Program (CTP)., Method: Cadets ( n = 736, 74.0% male) were administered the structured Mini International Neuropsychiatric Interview by a mental health clinician or a supervised clinical psychologist trainee. The interview includes an assessment of past month suicidal ideation, planning, attempts and lifetime suicide attempts., Results: Within 1 month of starting the CTP, a small percentage of cadets reported past month suicidal ideation (1.6%) and no cadets reported any suicidal planning (0%) or attempts (0%). Lifetime suicide attempts were reported by (1.5%) of cadets., Conclusions: The current results provide the first information describing the prevalence of suicidal ideation, planning, and attempts among RCMP cadets starting the CTP. The estimates of suicidal behaviours appear lower than the general population and lower than reports from serving RCMP. Higher prevalence estimates of suicidal behaviours reported by serving RCMP, relative to lower estimates among cadets starting the CTP in the current study, may be related to age, cumulative experiences or protracted exposures to operational and organizational stressors, rather than insufficient screening of recruits.

Objective: Serving Royal Canadian Mounted Police (RCMP) have screened positive for one or more mental disorders based on self-reported symptoms with substantial prevalence (i.e., 50.2%). Mental health challenges for military and paramilitary populations have historically been attributed to insufficient recruit screening; however, cadet mental health when starting the Cadet Training Program (CTP) was unknown. Our objective was to estimate RCMP Cadet mental health when starting the CTP and test for sociodemographic differences., Method: Cadets starting the CTP completed a survey assessing self-reported mental health symptoms ( n  = 772, 72.0% male) and a clinical interview ( n  = 736, 74.4% male) with a clinician or supervised trainee using the Mini-International Neuropsychiatric Interview to assess current and past mental health., Results: The percentage of participants screening positive for one or more current mental disorders based on self-reported symptoms (15.0%) was higher than the diagnostic prevalence for the general population (10.1%); however, based on clinical interviews, participants were less likely to screen positive for any current mental disorder (6.3%) than the general population. Participants were also less likely to screen positive for any past mental disorder based on self-report (3.9%) and clinical interviews (12.5%) than the general population (33.1%). Females were more likely to score higher than males (all p s<.01; Cohen's d s .23 to .32) on several self-report mental disorder symptom measures., Conclusions: The current results are the first to describe RCMP cadet mental health when starting the CTP. The data evidenced a lower prevalence of anxiety, depressive, and trauma-related mental disorders than the general population based on clinical interviews, contrasting notions that more rigorous mental health screening would reduce the high prevalence of mental disorders among serving RCMP. Instead, protecting RCMP mental health may require ongoing efforts to mitigate operational and organizational stressors.

Introduction: Military sexual trauma (MST) is an ongoing problem. We used a 2002 population-based sample, followed up in 2018, to examine: (1) the prevalence of MST and non-MST in male and female currently serving members and veterans of the Canadian Armed Forces, and (2) demographic and military correlates of MST and non-MST., Methods: Data came from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (n = 2,941, ages 33 years + ). Individuals endorsing sexual trauma were stratified into MST and non-MST and compared to individuals with no sexual trauma. The prevalence of lifetime MST was computed, and correlates of sexual trauma were examined using multinomial regression analyses., Results: The overall prevalence of MST was 44.6% in females and 4.8% in males. Estimates were comparable between currently serving members and veterans. In adjusted models in both sexes, MST was more likely among younger individuals (i.e., 33-49 years), and MST and non-MST were more likely in those reporting more non-sexual traumatic events. Among females, MST and non-MST were more likely in those reporting lower household income, non-MST was less likely among Officers, and MST was more likely among those with a deployment history and serving in an air environment. Unwanted sexual touching by a Canadian military member or employee was the most prevalent type and context of MST., Interpretation: A high prevalence of MST was observed in a follow-up sample of Canadian Armed Forces members and veterans. Results may inform further research as well as MST prevention efforts.

Objective: Knowledge is limited regarding the longitudinal course and predictors of mental health problems, suicide, and physical health outcomes among military and veterans. Statistics Canada, in collaboration with researchers at the University of Manitoba and an international team, conducted the Canadian Armed Forces Members and Veterans Mental Health Follow-Up Survey (CAFVMHS). Herein, we describe the rationale and methods of this important survey., Method: The CAFVMHS is a longitudinal survey design with 2 time points (2002 and 2018). Regular Force military personnel who participated in the first Canadian Community Health Survey Cycle 1.2-Mental Health and Well-Being, Canadian Forces Supplement (CCHS-CFS) in 2002 ( N = 5,155) were reinterviewed in 2018 ( n = 2,941). The World Mental Health Survey-Composite International Diagnostic Interview was used with the Diagnostic and Statistical Manual of Mental Disorders , fourth edition ( DSM -IV) criteria., Results: The CAFVMHS includes 2,941 respondents (66% veterans; 34% active duty) and includes data on mental disorder diagnoses, physical health conditions, substance use, medication use, general health, mental health services, perceived need for care, social support, moral injury, deployment experiences, stress, physical activity, military-related sexual assault, childhood experiences, and military and sociodemographic information., Conclusions: The CAFVMHS provides a unique opportunity to further understand the health and well-being of military personnel in Canada over time to inform intervention and prevention strategies and improve outcomes. The data are available through the Statistics Canada Research Data Centres across Canada and can be used cross-sectionally or be longitudinally linked to the 2002 CCHS-CFS data.

Objective: The current study used the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) to (1) examine the incidence and prevalence of mental disorders and (2) estimate the comorbidity of mental disorders over the follow-up period., Method: The CAFVMHS (2018) is a longitudinal study with two time points of assessment. The sample is comprised of 2,941 Canadian Forces members and veterans who participated in the 2002 Canadian Community Health Survey: Canadian Forces Supplement. The World Health Organization Composite International Diagnostic Interview (WHO-CIDI) was utilized to diagnose Diagnostic and Statistical Manual -IV post-traumatic stress disorder (PTSD), major depressive episode (MDE), generalized anxiety disorder, social anxiety disorder (SAD), and alcohol abuse and dependence. Self-report health professional diagnoses were assessed for attention deficit hyperactivity disorder (ADHD), mania, obsessive compulsive disorder (OCD), and personality disorder. We established weighted prevalence of mental disorders and examined the association between mental disorders using logistic regression., Results: In 2018, lifetime prevalence of any WHO-CIDI-based or self-reported mental disorder was 58.1%. Lifetime prevalence of any mood or anxiety disorder or PTSD was 54.0% in 2018. MDE (39.9%), SAD (25.7%), and PTSD (21.4%) were the most common mental disorders. There was a substantial increase in new onset or recurrence/persistence of mental disorders between the two measurement points (16-year assessment gap); 2002-2018 period prevalences were 43.5% for mood and anxiety disorder and 16.8% for alcohol abuse or dependence. The prevalence of self-reported ADHD, OCD, any personality disorder, and mania were 3.3%, 3.0%, 0.8%, and 0.8%, respectively. Comorbidity between mental disorders increased over the follow-up., Conclusions: This study demonstrates a high burden of mental disorders among a large Canadian military and veteran cohort. These findings underscore the importance of prevention and intervention strategies to reduce the burden of mental disorders and alcohol use disorders in these populations.

Objectives: The present report is the first study of Canadian military personnel to use longitudinal survey data to identify factors that determine major depressive episodes (MDEs) over a period of 16 years., Methods: The study used data from the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) collected in 2018 ( n = 2,941, response rate 68.7%) and linked baseline data from the same participants that were collected in 2002 when they were Canadian Regular Force members. The study used structured interviews to identify 5 common Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition mental disorders and collected demographic data, as well as information about traumatic experiences, childhood adversities, work stress, and potential resilience factors. Respondents were divided into 4 possible MDE courses: No Disorder, Remitting, New Onset, and Persistent/Recurrent. Relative risk ratios (RRRs) from multinomial regression models were used to evaluate determinants of these outcomes., Results: A history of anxiety disorders and post-traumatic stress disorder (RRRs: 1.50 to 20.55), mental health service utilization (RRRs: 1.70 to 12.34), veteran status (RRRs: 1.64 to 2.15), deployment-associated traumatic events (RRRs: 1.71 to 2.27), sexual traumas (RRRs: 1.91 to 2.93), other traumas (RRRs: 1.67 to 2.64), childhood adversities (RRRs: 1.39 to 1.97), avoidance coping (RRRs 1.09 to 1.49), higher frequency of religious attendance (RRRs: 1.54 to 1.61), and work stress (RRRs: 1.05 to 1.10) were associated with MDE courses in most analyses. Problem-focused coping (RRRs: 0.73 to 0.91) and social support (RRRs: 0.95 to 0.98) were associated with protection against MDEs., Conclusions: The time periods following deployment and trauma exposure and during the transition from active duty to veteran status are particularly relevant for vulnerability to depression in military members. Interventions that enhance problem-focused coping and social support may be protective against MDEs in military members.

Objective: Mental health among military personnel is an important public health priority. It is known that military personnel experience a high prevalence of child maltreatment and deployment-related traumatic events (DRTEs) and both are related to mental health outcomes. However, few, if any, studies have examined the cumulative and interactive effects of child maltreatment and DRTEs on mental health disorders in a sample of active duty service members and military veterans., Methods: Data were from the Canadian Armed Forces (CAF) Members and Veterans Mental Health Follow-up Survey collected in 2018 ( N = 2,941, response rate = 68.7%), a 16-year follow-up survey of CAF Regular Force members interviewed in 2002. Five types of child maltreatment and 10 types of DTREs were assessed for impact on mental health. Mental disorders included past 12-month generalized anxiety disorder (GAD), panic disorder, social phobia, and major depressive episode (MDE). Past 12-month symptoms of posttraumatic stress disorder (PTSD) were also examined., Results: The prevalence of any exposure to child maltreatment and DRTEs was 62.5% and 68.6%, respectively. All types of child maltreatment were associated with increased odds of past 12-month PTSD symptoms and mental disorders with the exception of physical abuse and GAD as well as childhood exposure to intimate partner violence and panic disorder. Cumulative effects of having experienced both child maltreatment and DRTEs increased the odds of past 12-month PTSD symptoms, GAD, social phobia, and MDE. No interaction effects were significant., Conclusions: The prevalence of a child maltreatment history is high among active Canadian military and veterans. As well, child maltreatment may increase the likelihood of mental disorders across the life span. This may be especially true for individuals who also experience DRTEs. Understanding these relationships may provide insight into developing effective interventions for military personnel and veteran mental health outcomes.

Objective: This study examined baseline risk and protective predictors and interim correlates of the persistence/recurrence, remission, and onset of posttraumatic stress disorder (PTSD) in a 16-year prospective, nationally representative sample of Canadian Forces members and veterans., Methods: The 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey is a prospective study of 2,941 regular force service members and veterans who participated in the 2002 Canadian Community Health Survey on Mental Health and Wellbeing: Canadian Forces Supplement ( n = 5,155; ages 15 to 64 years; response rate 68%). PTSD diagnoses in 2002 and 2018 were used to create 4 groups: (1) no lifetime , (2) remitted , (3) new onset , and (4) persistent/recurrent PTSD. Multinomial regressions were conducted to identify predictors of PTSD courses., Results: Female sex, being a junior noncommissioned member (vs. officer), and land (vs. air) operations in 2002 were associated with all PTSD courses relative to no lifetime PTSD (relative risk ratio [RRR] range: 1.28 to 3.65). After adjusting for sociodemographic variables, baseline predictors of all PTSD courses included lifetime mental disorder, history of mental health care utilization, all trauma type categories (deployment-associated, sexual, "other"), and the number of lifetime traumatic events (RRR range: 1.14 to 8.95). New ("since 2002") traumas, transitioning to veteran status, and alcohol dependence were mostly associated with the new onset and persistent/recurrent PTSD courses (RRR range: 1.79 to 4.31), while mental health care utilization and greater avoidance coping were associated with all PTSD courses (RRR range: 1.10 to 17.87). Protective factors for several PTSD courses at one or both time points included social support, social network size, and problem-focused coping (RRR range: 0.71 to 0.98)., Conclusions: This is the first population-based survey to examine the longitudinal course of PTSD in Canadian Forces members. Prevention and intervention programs focused on bolstering social support and active coping strategies as possible protective factors/correlates may help mitigate the development and persistence of PTSD.

Objectives: To report on the perceived barriers surrounding the use of telepsychiatry for emergency assessments and our approach to overcoming those barriers to achieve successful implementation of a program to increase access to emergency psychiatric assessment in a Canadian urban setting., Methods: We conducted a survey of emergency care staff to inform the implementation of an emergency telepsychiatry program in the urban setting of Winnipeg, Manitoba, where hospitals have variable on-site emergency psychiatric coverage. We analyzed survey responses for perceived barriers we would need to address in implementation. We employed implementation strategies for each barrier and scaled the program to three sites over the first year. Data from the first year were collected including number of telepsychiatry assessments, reasons for referral, wait time, and percentage of patient transfers avoided., Results: Survey respondents ( N = 111) had little prior exposure to telepsychiatry, but the majority were open to its use for emergency psychiatric assessments in the region. We identified three categories of perceived barriers: clinical, logistical/technical, and readiness barriers. Implementation planning addressed each barrier, and a hub-and-spoke program was launched. After the first year, the program had one hub serving three spokes, and 243 emergency telepsychiatry assessments had been completed. After 12 months, we were avoiding 65% of patient transfers., Conclusions: By conducting a user survey to identify perceived barriers, and addressing these during implementation, we successfully scaled our emergency telepsychiatry program across our region. Our report of this experience may benefit others attempting to implement a similar program.

Objective: There is limited information to guide health-care service providers and policy makers on the burden of mental disorders and addictions across the Canadian provinces. This study compares interprovincial prevalence of major depressive disorder (MDD), bipolar disorder, generalized anxiety disorder (GAD), alcohol use disorder, substance use disorders, and suicidality., Method: Data were extracted from the 2012 Canadian Community Health Survey-Mental Health ( n = 25,113), a representative sample of Canadians over the age of 15 years across all provinces. Cross tabulations and logistic regression were used to determine the prevalence and odds of the above disorders for each province. Adjustments for provincial sociodemographic factors were performed., Results: The past-year prevalence of all measured mental disorders and suicidality, excluding GAD, demonstrated significant interprovincial differences. Manitoba exhibited the highest prevalence of any mental disorder (13.6%), reflecting high prevalence of MDD and alcohol use disorder compared to the other provinces (7.0% and 3.8%, respectively). Nova Scotia exhibited the highest prevalence of substance use disorders (2.9%). Quebec and Prince Edward Island exhibited the lowest prevalence of any mental disorder (8.5% and 7.7%, respectively). Manitoba also exhibited the highest prevalence of suicidal ideation (5.1%); however, British Columbia and Ontario exhibited the highest prevalence of suicidal planning (1.4% and 1.3%, respectively), and Ontario alone exhibited the highest prevalence of suicide attempts (0.7%)., Conclusions: Significant interprovincial differences were found in the past-year prevalence of mental disorders and suicidality in Canada. More research is necessary to explore these differences and how they impact the need for mental health services.

Objective: Posttraumatic stress disorder (PTSD) is often accompanied by other mental health conditions, including major depressive disorder (MDD), substance misuse disorders, and anxiety disorders. The objective of the current study is to delineate classes of comorbidity and investigate predictors of comorbidity classes amongst a sample of Canadian Armed Forces (CAF) Regular Force personnel., Methods: Latent class analyses (LCAs) were applied to cross-sectional data obtained between April and August 2013 from a nationally representative random sample of 6700 CAF Regular Force personnel who deployed to the mission in Afghanistan., Results: MDD was the most common diagnosis (8.0%), followed by PTSD (5.3%) and generalized anxiety disorder (4.7%). Of those with a mental health condition, LCA revealed 3 classes of comorbidity: a highly comorbid class (8.3%), a depressed-only class (4.6%), and an alcohol use-only class (3.1%). Multinomial logit regression showed that women (adjusted relative risk ratio [ARRR] = 2.77; 95% CI, 2.13 to 3.60; P < 0.01) and personnel reporting higher trauma exposure (ARRR = 4.18; 95% CI, 3.13 to 5.57; P < 0.01) were at increased risk of membership in the comorbid class compared to those without a mental health condition. When compared to those with no mental health condition, experiencing childhood abuse increased the risk of being in any comorbidity class., Conclusions: Results provide further evidence to support screening for and treatment of comorbid mental health conditions. The role of sex, childhood abuse, and combat deployment in determining class membership may also prove valuable for clinicians treating military-related mental health conditions.

Objective: This study sought to examine differences in sociodemographic risk factors, comorbid mental conditions, clinical presentations, and functional impairments associated with past-year generalized anxiety disorder (GAD) between Canadian Armed Forces (CAF) Regular Force personnel and the Canadian general population (CGP)., Method: Data were from 2 nationally representative surveys collected by Statistics Canada: 1) the Canadian Community Health Survey on Mental Health, collected in 2012 ( N = 25,113; response rate = 68.9%); and 2) the Canadian Forces Mental Health Survey, collected in 2013 ( N = 8,161; response rate = 79.8%)., Results: The prevalence of lifetime and past-year GAD was significantly higher in the CAF (12.1% and 4.7%) than in the CGP (9.5% and 3.0%). Comorbid mental disorders were strongly associated with GAD in both populations. Although the content area of worry and the GAD symptoms endorsed were similar, CAF personnel were significantly more likely to endorse specific types of worries (i.e., success at school/work, social life, mental health, being away from home or loved ones, and war or revolution) and specific symptoms of GAD (i.e., restless, keyed up, or on edge and more irritable than usual) than civilians, after adjusting for sociodemographic covariates and comorbid mental disorders. CAF personnel with past-year GAD reported significantly higher functional impairment at home than civilians with past-year GAD., Conclusion: GAD is a substantial public health concern associated with significant impairment and disability in both military and civilian populations. GAD in military and civilian populations shows similarities and differences: Key similarities include its extensive comorbidity and significant functional impairment, whereas key differences include the focus of worries and symptom profile.

This paper has been substantially revised by the Canadian Psychiatric Association's Research Committee and approved for republication by the CPA's Board of Directors on May 3, 2017. The original policy paper 1 was developed by the Scientific and Research Affairs Standing Committee and approved by the Board of Directors on November 10, 2008.

Background: Canadian public safety personnel (PSP; e.g., correctional workers, dispatchers, firefighters, paramedics, police officers) are exposed to potentially traumatic events as a function of their work. Such exposures contribute to the risk of developing clinically significant symptoms related to mental disorders. The current study was designed to provide estimates of mental disorder symptom frequencies and severities for Canadian PSP., Methods: An online survey was made available in English or French from September 2016 to January 2017. The survey assessed current symptoms, and participation was solicited from national PSP agencies and advocacy groups. Estimates were derived using well-validated screening measures., Results: There were 5813 participants (32.5% women) who were grouped into 6 categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with 1 (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures. There were significant differences across PSP categories with respect to proportions screening positive based on each measure., Interpretation: The estimated proportion of PSP reporting current symptom clusters consistent with 1 or more mental disorders appears higher than previously published estimates for the general population; however, direct comparisons are impossible because of methodological differences. The available data suggest that Canadian PSP experience substantial and heterogeneous difficulties with mental health and underscore the need for a rigorous epidemiologic study and category-specific solutions.

Background: Bill C-14 allows for medical assistance in dying (MAID) for patients who have intolerable physical or psychological suffering that occurs in the context of a reasonably foreseeable death. In Canada, psychiatrist support for MAID on the basis of mental illness and beliefs influencing level of support are unknown. The objectives of this research were to 1) determine if psychiatrists are supportive of MAID under certain conditions and on the basis of mental illness and 2) determine what factors are related to psychiatrist support for MAID on the basis of mental illness., Methods: This cross-sectional study was conducted among 528 psychiatrists in Canada using an online survey platform (February 19 to March 11, 2016)., Results: The response rate was 20.9% ( n = 528). Most psychiatrists supported the legalisation of MAID in some circumstances (72%); however, only 29.4% supported MAID on the basis of mental illness. Factors correlating with decreased support for MAID for mental illness were the belief that MAID for mental illness would change the psychiatrists' commitment to their patients through enduring suffering, having a personal faith, and having had past patients who would have received MAID for mental illness were it legal but instead went on to recover., Interpretation: This study found that most psychiatrists do not support the legalisation of MAID for mental illness, despite being quite supportive of MAID in general. Objections seemed to be based upon concern for vulnerable patients, personal moral objections, and concern for the effect it would have on the therapeutic alliance.

Objective: Worldwide, there has been substantial controversy with respect to whether military deployment is a risk factor for suicidal behaviour. The present study examined the relationship between lifetime exposure to deployment and deployment-related traumatic events (DRTEs) and past-year suicidal ideation (SI), suicidal plans (SP), and suicidal attempts (SA)., Method: Data were analysed from the 2013 Canadian Forces Mental Health Survey (8161 respondents; response rate, 79.8%; aged 18-60 years). A total of 12 individual items assessed exposure to DRTEs (e.g., combat, witnessing human atrocities, feeling responsible for the death of Canadian or ally personnel, knowing someone who was injured or killed). We examined each individual DRTE type as well as the number of types of DRTEs in relation to suicidal behaviour., Results: Lifetime deployment was not significantly associated with suicidal behaviour. In models adjusted for sociodemographic variables, most of the individual DRTE items and the DRTE count variable were significantly associated with suicidal behaviours (adjusted odds ratio ranged between 1.10 and 5.32). When further adjusting for child abuse exposure, these associations were minimally attenuated, and some became nonsignificant. In models adjusting for mental disorders and child abuse, most DRTEs and number of types of DRTEs became nonsignificant in relation to SI, SP, and SA., Conclusions: Active military personnel exposed to increasing number of DRTEs are at increased risk for SI, SP, and SA. However, most of the association between DRTEs and suicidal behaviour is accounted for by child abuse exposure and mental disorders.

Objective: This study attempted to determine if Housing First (HF) decreased suicidal ideation and attempts compared to treatment as usual (TAU) amongst homeless persons with mental disorders, a population with a demonstrably high risk of suicidal behaviour., Method: The At Home/Chez Soi project is an unblinded, randomised control trial conducted across 5 Canadian cities (Vancouver, Winnipeg, Toronto, Montreal, Moncton) from 2009 to 2013. Homeless adults with a diagnosed major mental health disorder were recruited through community agencies and randomised to HF ( n = 1265) and TAU ( n = 990). HF participants were provided with private housing units and received case management support services. TAU participants retained access to existing community supports. Past-month suicidal ideation was measured at baseline and 6, 12, 18, and 21/24 months. A history of suicide attempts was measured at baseline and the 21/24-month follow-up., Results: Compared to baseline, there was an overall trend of decreased past-month suicidal ideation (estimate = -.57, SE = .05, P < 0.001), with no effect of treatment group (i.e., HF vs. TAU; estimate = -.04, SE = .06, P = 0.51). Furthermore, there was no effect of treatment status (estimate = -.10, SE = .16, P = 0.52) on prevalence of suicide attempts (HF = 11.9%, TAU = 10.5%) during the 2-year follow-up period., Conclusion: This study failed to find evidence that HF is superior to TAU in reducing suicidal ideation and attempts. We suggest that HF interventions consider supplemental psychological treatments that have proven efficacy in reducing suicidal behaviour. It remains to be determined what kind of suicide prevention interventions (if any) are specifically effective in further reducing suicidal risk in a housing-first intervention.

Objective: Child abuse is associated with poor mental health outcomes in adulthood. However, little is known about how a history of child abuse may be related to perceived need for care (PNC) and mental health service use (MHSU) among Canadian military personnel. The objectives of this study were to determine 1) the relationship between child abuse history and PNC and 2) the relationship between child abuse history and MHSU in the Canadian military., Method: Data were drawn from the 2013 Canadian Forces Mental Health Survey ( n = 6692 Regular Force personnel between the ages of 18 and 60 years). Logistic regression was used to examine the relationships between individual child abuse types and PNC and MHSU while adjusting for sociodemographic variables, the presence of mental disorders, deployment-related variables, and other types of child abuse. Population attributable fractions (PAFs) were calculated to estimate the proportion of PNC and MHSU that may be attributable to child abuse., Results: Each individual child abuse type was associated with increased odds of PNC and MHSU after adjusting for all covariates (adjusted odds ratio ranging from 1.26 to 1.80). PAFs showed that if any child abuse did not occur, PNC and MHSU among Regular Force personnel may be reduced by approximately 14.3% and 11.3%, respectively., Conclusions: This study highlights that preenlistment factors, such as a history of child abuse, have an independent association with PNC and MHSU and hence need to be considered when assessing the mental health service needs of the Canadian Regular Force personnel.

Purpose: Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF., Methods: Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model., Results: In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not., Conclusion: While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: PG was on contract to the Mental Health Commission of Canada as the overall research lead. CA was on contract to the Mental Health Commission of Canada as the quantitative research lead. Their roles were otherwise the same as all other academic investigators. RB, BK, and SV were on contract to the Mental Health Commission of Canada for their contribution as analysts (RB, SV) or study research associate (BK).

Objective: Child abuse can have devastating mental health consequences. Fortunately, not all individuals exposed to child abuse will suffer from poor mental health. Understanding what factors are related to good mental health following child abuse can provide evidence to inform prevention of impairment. Our objectives were to 1) describe the prevalence of good, moderate, and poor mental health among respondents with and without a child abuse history; 2) examine the relationships between child abuse and good, moderate, and poor mental health outcomes; 3) examine the relationships between individual- and relationship-level factors and better mental health outcomes; and 4) determine if individual- and relationship-level factors moderate the relationship between child abuse and mental health., Method: Data were from the nationally representative 2012 Canadian Community Health Survey: Mental Health ( n = 23,395; household response rate = 79.8%; 18 years and older). Good, moderate, and poor mental health was assessed using current functioning and well-being, past-year mental disorders, and past-year suicidal ideation., Results: Only 56.3% of respondents with a child abuse history report good mental health compared to 72.4% of those without a child abuse history. Individual- and relationship-level factors associated with better mental health included higher education and income, physical activity, good coping skills to handle problems and daily demands, and supportive relationships that foster attachment, guidance, reliable alliance, social integration, and reassurance of worth., Conclusions: This study identifies several individual- and relationship-level factors that could be targeted for intervention strategies aimed at improving mental health outcomes following child abuse.

Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals., Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section is the first of six guidelines articles., Results: In Canada, the annual and lifetime prevalence of MDD was 4.7% and 11.3%, respectively. MDD represents the second leading cause of global disability, with high occupational and economic impact mainly attributable to indirect costs. DSM-5 criteria for depressive disorders remain relatively unchanged, but other clinical dimensions (sleep, cognition, physical symptoms) may have implications for depression management. e-Mental health is increasingly used to support clinical and self-management of MDD. In the 2-phase (acute and maintenance) treatment model, specific goals address symptom remission, functional recovery, improved quality of life, and prevention of recurrence., Conclusions: The burden attributed to MDD remains high, whether from individual distress, functional and relationship impairment, reduced quality of life, or societal economic cost. Applying core principles of care, including comprehensive assessment, therapeutic alliance, support of self-management, evidence-informed treatment, and measurement-based care, will optimize clinical, quality of life, and functional outcomes in MDD., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RWL has received honoraria for ad hoc speaking or advising/consulting or received research funds from Asia-Pacific Economic Cooperation, AstraZeneca, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Depression Research and Intervention Network, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Coast Capital Savings, Johnson & Johnson, Lundbeck, Lundbeck Institute, Medscape, Pfizer, St. Jude Medical, Takeda, University Health Network Foundation, and Vancouver Coastal Health Research Institute. DM has received honoraria for ad hoc speaking or advising/consulting or received research funds from Allergan, Bristol-Myers Squibb, Lundbeck, Janssen-Ortho, Otsuka, Pfizer, Shire, and Sunovion. JLW has no disclosures. MWE has no disclosures. TK has received speaker and/or advisory honoraria from AstraZeneca, Bristol-Myers Squibb, Eli Lilly Canada, Lundbeck, Lundbeck-Otsuka, Janssen-Ortho, Pfizer, and Sunovion. EEM has received advisory honoraria from Lundbeck. JS has no disclosures. WYS has received honoraria for ad hoc speaking or advising/consulting or research funds from AstraZeneca, Bristol-Myers Squibb, Canadian Psychiatric Association, Eli Lilly, Forrest Laboratories, Lundbeck, Ortho-Janssen, Pfizer, and Sunovion. SHK has received honoraria for ad hoc speaking or advising/consulting or research funds from Allergan, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Janssen, Lundbeck, Ontario Brain Institute, Pfizer, St. Jude Medical, Servier, and Sunovion. GMM has been on advisory board or speaker for Janssen, Lilly, Lundbeck, and Pfizer. RVM has received speaker and consultant honoraria or research funds from Allergan, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Network for Mood and Anxiety Treatments, Canadian Psychiatric Association, Eli Lilly, Johnson & Johnson, Lallemand, Lundbeck, Merck, Ontario Brain Institute, Ontario Mental Health Foundation, Otsuka, Paladin, Pfizer, Queen’s University, Sunovion, Takeda, the University Health Network Foundation, and Valeant. SVP has been a consultant to Bristol Myers Squibb, Lundbeck, and Takeda; has had a research contract with Assurex; and has equity in Mensante. AVR has received speaker and consultant honoraria or research funds from Bristol-Myers Squibb, Canadian Depression Research and Intervention Network, Canadian Foundation for Innovation and the Ministry of Economic Development and Innovation, Canadian Institutes of Health Research, Grand Challenges Canada, Janssen, Lundbeck, Ontario Mental Health Foundation, Pfizer, and Sunovion., (© The Author(s) 2016.)

Objective: The 2013 Canadian Forces Mental Health Survey (CFMHS) collected detailed information on mental health problems, their impacts, occupational and nonoccupational determinants of mental health, and the use of mental health services from a random sample of 8200 serving personnel. The objective of this article is to provide a firm scientific foundation for understanding and interpreting the CFMHS findings., Methods: This narrative review first provides a snapshot of the Canadian Armed Forces (CAF), focusing on 2 key determinants of mental health: the deployment of more than 40,000 personnel in support of the mission in Afghanistan and the extensive renewal of the CAF mental health system. The findings of recent population-based CAF mental health research are reviewed, with a focus on findings from the very similar mental health survey done in 2002. Finally, key aspects of the methods of the 2013 CFMHS are presented., Results: The findings of 20 peer-reviewed publications using the 2002 mental health survey data are reviewed, along with those of 25 publications from other major CAF mental health research projects executed over the past decade., Conclusions: More than a decade of population-based mental health research in the CAF has provided a detailed picture of its mental health and use of mental health services. This knowledge base and the homology of the 2013 survey with the 2002 CAF survey and general population surveys in 2002 and 2012 will provide an unusual opportunity to use the CFMHS to situate mental health in the CAF in a historical and societal perspective., (© The Author(s) 2016.)

Objective: Relatively little is known about the temporal relation between at-risk gambling or problem gambling (PG) and mental and substance use disorders (SUDs) in young adulthood. Our study aimed to examine whether past-year, at-risk, or PG is associated with incident mental disorders and SUDs (that is, depression, generalized anxiety disorder, obsessive-compulsive disorder [OCD], or alcohol dependence) and illegal drug use, and whether past-year mental disorders and SUDs and illegal drug use is associated with incident at-risk or PG., Method: Data for this longitudinal study were drawn from the Manitoba Longitudinal Study of Young Adults (MLSYA). Respondents aged 18 to 20 years in 2007 were followed prospectively for 5 years., Results: In cross-sectional analyses, at-risk or PG was associated with increased odds of depression, OCD, alcohol dependence, and illegal drug use. In longitudinal analysis at-risk or PG at cycle 1 was associated with incident major depressive disorder, alcohol dependence, and illegal drug use in the follow-up period. Only illegal drug use at cycle 1 was associated with incident at-risk or PG during follow-up., Conclusions: At-risk or PG was associated with more new onset mental disorders and SUDs (depression, alcohol dependence, and illegal drug use), compared with the reverse (illegal drug use was the only association with new onset at-risk or PG). Preventing at-risk or PG from developing early in adulthood may correspond with decreases in new onset mental disorders and SUDs later in adulthood., (© The Author(s) 2015.)

Objective: Identifying child and household characteristics that are associated with specific child maltreatment types and child functional impairment are important for informing prevention and intervention efforts. Our objectives were to examine the distribution of several child and household characteristics among substantiated child maltreatment types in Canada; to determine if a specific child maltreatment type relative to all other types was associated with increased odds of child functional impairment; and to determine which child and household characteristics were associated with child functional impairment., Method: Data were from the Canadian Incidence Study of Reported Child Abuse and Neglect (collection 2008) from 112 child welfare sites across Canada (n = 6163 children)., Results: Physical abuse, sexual abuse, and emotional maltreatment were highly prevalent among children aged 10 to 15 years. For single types of child maltreatment, the highest prevalence of single-parent homes (50.6%), social assistance (43.0%), running out of money regularly (30.7%), and unsafe housing (30.9%) were reported for substantiated cases of neglect. Being male, older age, living in a single-parent home, household running out of money, moving 2 or more times in the past year, and household overcrowding were associated with increased odds of child functional impairment., Conclusions: More work is warranted to determine if providing particular resources for single-parent families, financial counselling, and facilitating adequate and stable housing for families with child maltreatment histories or at risk for child maltreatment could be effective for improving child functional outcomes.

Objective: In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the distinction between nonsuicidal self-injury (NSSI) and suicidal behaviour disorder is highlighted in the section Conditions for Further Study. Diagnostic criteria classify NSSI and suicidal behaviour disorder as distinct disorders, with the latter including suicide attempt (SA). This study examined the prevalence and correlates of NSSI in emergency department (ED) settings and compared them to SA., Methods: Data came from adult referrals to psychiatric services in 2 EDs between January 2009 and June 2011 (n = 5336). NSSI was compared with SA, as well as no suicidal behaviour, across a broad range of demographic and diagnostic correlates., Results: NSSI was more highly associated with female sex, childhood abuse, anxiety disorders, major depressive disorder (MDD), aggression and impulsivity, age under 45, and substance use disorders (SUDs), compared with presentations without suicidal behaviour. Comparing NSSI and SA, no differences were observed on sex, age, history of child abuse, or presence of anxiety or SUDs. Recent life stressors (OR 1.44; 95% CI 1.05 to 1.99), active suicidal ideation (OR 8.84; 95% CI 5.26 to 14.85), MDD (OR 3.05; 95% CI 2.23 to 4.17), previous psychiatric care or SA (OR 1.89; 95% CI 1.36 to 2.64), and single marital status (OR 1.63; 95% CI 1.20 to 2.22) contributed to a higher SA rate. Among people with NSSI, 83.7% presented only once to an ED. Among people who presented multiple times, only 18.2% re-presented with NSSI., Conclusions: NSSI is associated with early life adversity and psychiatric comorbidity. Most people present only once to ED services, and self-harm presentations seemed to change over time. Future studies should continue to clarify whether NSSI and SA have distinct risk profiles.

Objective: To determine the degree of risk during the first year after diagnosis with a mental illness., Methods: We used propensity scoring to create a matched sample for all identified suicide attempts and suicide deaths in the province of Manitoba from 1996 to 2009. This study identified 2100 suicide deaths and 8641 attempted suicides. Three control subjects were identified for every case and matched on age, sex, income decile, region of residence, and marital status. Five categories of physician-diagnosed mental disorders were tested: schizophrenia, anxiety, depression, dementia, and substance abuse. Logistic regression was used to determine the risk for suicide attempts and suicide deaths overall, and within 3 time periods since initial diagnosis: 1 to 90 days, 91 to 364 days, and 365 or more days., Results: All disorders, except dementia, were independently related to death. All disorders were related to suicide attempts. The risk of dying by suicide was particularly high within the first 90 days after initial diagnosis for many disorders, including depression (adjusted odds ratio [AOR] 7.33; 95% CI 4.76 to 11.3), substance use disorders (AOR 4.07; 95% CI 2.43 to 6.82), and schizophrenia (AOR 20.91; 95% CI 2.55 to 172). Depression and anxiety disorders had elevated risk in the first year for suicide attempts., Conclusions: These data suggest that several mental disorders independently increase the risk of suicide attempts and death by suicide after controlling for all mental disorders and demographic risk factors. Clinicians should be aware of the heightened risk of suicide and suicidal behaviour within the first 3 months after initial diagnosis.

During the last 30 years, there has been a substantial increase in the study of posttraumatic stress disorder (PTSD). Several high-profile traumatic events, such as the wars in Afghanistan and Iraq, and the terrorist attacks of September 11 on the World Trade Center, have led to a greater public interest in the risk and protective factors for PTSD. In this In Review paper, I discuss some of the important advances in PTSD. The paper provides a concise review of the evolution of PTSD diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, impact of PTSD in the community, an overview of the established risk factors for developing PTSD, and assessment and treatment. Throughout the paper, controversies and clinical implications are discussed.

Objective: To compare major depressive disorder (MDD) symptomatology within men and women in a large, representative sample of Canadian military personnel and civilians., Method: We used the Canadian Community Health Survey: Mental Health and Well-Being (Cycle 1.2 and Canadian Forces Supplement) (n = 36 984 and n = 8441, respectively) to compare past-year MDD symptomatology among military and civilian women, and military and civilian men. Logistic regression models were used to determine differences in the types of depressive symptoms endorsed in each group., Results: Men in the military with MDD were at lower odds than men in the general population to endorse numerous symptoms of depression, such as hopelessness (adjusted odds ratio [AOR] 0.44; 99% CI 0.23 to 0.83) and inability to cope (AOR 0.53; 99% CI 0.31 to 0.92). Military women with MDD were at lower odds of thinking about their death (AOR 0.52; 99% CI 0.32 to 0.86), relative to women with MDD in the general population., Conclusion: Different MDD symptomatology among males and females in the military, compared with those in the general population, may reflect selection effects (for example, personality characteristics and patterns of comorbidity) or occupational experiences unique to military personnel. Future research examining the mechanisms behind MDD symptomatology in military personnel and civilians is required.

Objective: Although military interest in promoting psychological resilience is growing, resources protective against psychopathology have been understudied in female service members. Using a representative sample of Canadian Forces personnel, we investigated whether religious attendance, spirituality, coping, and social support were related to mental disorders and psychological distress in female service members, and whether sex differences occurred in these associations., Method: Religious attendance and spirituality were self-reported. Coping items were taken from 3 scales and produced 3 factors (active, avoidance, and self-medication). Social support was assessed with the Medical Outcomes Study Social Support Survey. Past-year mental disorders were diagnosed with the World Mental Health Composite International Diagnostic Interview. The Kessler Psychological Distress Scale assessed distress. Multivariate regression models investigated links between correlates and psychological outcomes within each sex. For associations that were statistically significant in only one sex, sex by correlate interactions were computed., Results: In female service members, inverse relations were found between social support and MDD, any MDD or anxiety disorder, suicidal ideation, and distress. No associations were found between religious attendance and outcomes, and spirituality was associated with an increased likelihood of some outcomes. Active coping was related to less psychological distress, while avoidance coping and self-medication were linked to a higher likelihood of most outcomes. Although several statistically significant associations were found in only one sex, only one sex by correlate interaction was statistically significant., Conclusions: Social support was found to be inversely related to several negative mental health outcomes in female service members. Few differences between men and women reached statistical significance. Future research should identify additional helpful resources for female service members.

Objective: To examine the association between a history of 5 types of childhood maltreatment (that is, physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect) and several substance use disorders (SUDs), including alcohol, sedatives, tranquilizers, opioids, amphetamines, cannabis, cocaine, hallucinogens, heroin, and nicotine, in a nationally representative US adult sex-stratified sample., Method: Data were drawn from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative US sample of adults aged 20 years and older (n = 34 653). Logistic regression models were conducted to understand the relations between 5 types of childhood maltreatment and SUDs separately among men and women after adjusting for sociodemographic variables and Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I and II mental disorders., Results: All 5 types of childhood maltreatment were associated with increased odds of all individual SUDs among men and women after adjusting for sociodemographic variables, with the exception of physical neglect and heroin abuse or dependence, emotional neglect, and amphetamines and cocaine abuse or dependence among men (adjusted odds ratio range 1.3 to 4.7). After further adjustment for other DSM Axis I and II mental disorders, the relations between childhood maltreatment and SUDs were attenuated, but many remained statistically significant. Differences in the patterns of findings were noted for men and women for sexual abuse and emotional neglect., Conclusions: This research provides evidence of the robust nature of the relations between many types of childhood maltreatment and many individual SUDs. The prevention of childhood maltreatment may help to reduce SUDs in the general population.

Objective: Our study examines the association between suicidal ideation and and self-reported symptoms of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and alcohol use disorder (AUD) in a sample of treatment-seeking Canadian combat and peacekeeping veterans; and identifies potential predictors of suicidal ideation., Methods: Actively serving Canadian Forces and Royal Canadian Mounted Police members and veterans seeking treatment at the Parkwood Hospital Operational Stress Injury Clinic (n = 250) completed measures including the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, the Alcohol Use Disorder Identification Test, and the PTSD Checklist-Military Version (PCL-M) between January 2002 and December 2010. Regression analyses were used to determine the respective impact of PTSD, and self-reported symptoms of MDD, GAD, AUD, and anxiety on suicidal ideation., Results: Most people met PCL-M screening criteria for PTSD (73.6%, n = 184), while 70.8% (n = 177) screened positively for a probable major depressive episode. PTSD symptom was significantly associated with suicidal ideation (β = 0.412, P < 0.001). After controlling for self-reported depressive symptom severity, AUD severity, and generalized anxiety, PTSD severity was no longer significantly associated with suicidal ideation (β = 0.043, P = 0.58)., Conclusions: Although PTSD alone is associated with suicidal ideation, after controlling for common comorbid psychiatric illnesses, self-reported depressive symptom severity emerged as the most significant predictor of suicidal ideation. These findings support the importance of screening for comorbidities, particularly an MDD, as potentially modifiable conditions that are strongly related to suicidal ideation in military personnel's endorsing criteria for PTSD.

Objective: Generic drugs are less expensive than their branded equivalents, but receive limited promotion. This study sought to examine how user rates of individual selective serotonin reuptake inhibitors (SSRIs) changed after the introduction of their generic equivalents., Method: Administrative health and census data were used to examine the rates of use of all 6 SSRIs from 1996 to 2009 in the province of Manitoba (population of 1.2 million). The primary outcome measure was a comparison of the rates of use in the pre- and post-generic periods, using generalized estimating equations. Secondary analyses were stratified by specialty of physician prescriber., Results: Escalating rates of use of branded SSRIs in the pre-generic period significantly decreased after generic versions became available (all Ps < 0.001). Incident use of sertraline and paroxetine continued to decrease throughout the post-generic period (1.5% and 1.9% quarterly decreasing rates, respectively). During the years when generic sertraline, fluoxetine, and fluvoxamine were available, their use declined while branded paroxetine and citalopram use continued to increase. Use of branded citalopram, sertraline, and paroxetine prescribed by general practitioners (GPs) increased at rates significantly higher than when prescribed by psychiatrists (all Ps < 0.001)., Conclusion: The introduction of cheaper generic alternatives of SSRIs paradoxically resulted in their use diminishing rather than increasing. With the exception of escitalopram, branded SSRIs tended to be preferentially used, compared with available less expensive generic SSRIs. These patterns were more pronounced for prescriptions by GPs.

Objective: To report the prescribing of antipsychotics to the youth population of the Canadian province of Manitoba during the course of a decade., Methods: Use of antipsychotics in children and adolescents (aged 18 years or younger) was described using data collected from the administrative health databases of Manitoba Health and the Statistics Canada census between the fiscal years of 1999 and 2008., Results: The prevalence of antipsychotic use in this segment of the population increased with the introduction of the second-generation antipsychotics (SGAs) from 1.9 per 1000 in 1999 to 7.4 per 1000 in 2008. The male-to-female antipsychotic usage ratio increased from 1.9 to 2.7 as the male youth population represented the fastest-growing subgroup of antipsychotic users in the entire population of Manitoba. The total number of prescriptions also increased significantly despite the lack of approved indications in this population. Proportion of use remained equally split between high- and low-income users. More than 70% of antipsychotic prescriptions to children and adolescents were written by general practitioners. The most common diagnoses linked to antipsychotic use were attention-deficit hyperactivity disorder and conduct disorders. Use of antipsychotics in combination with methylphenidate increased from 13% to 43%., Conclusion: Extensive off-label use of SGAs has been observed in the youth population of Manitoba for treatment of aggressive behaviours across a range of diagnoses. It is important to monitor antipsychotic prescribing to children as more reports of significant adverse events associated with antipsychotics become available.

Objective: To examine baseline mental disorders and other correlates among people who have not previously used drugs as potential risk factors for incident drug use at 3-years' follow-up., Method: Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (commonly referred to as the NESARC) Wave 2 (2004 to 2005; n = 34 653), a longitudinal nationally representative survey of mental illness in community-dwelling adults. The study group consisted of people who reported no history of any illicit drug use or prescription drug misuse at Wave 1 (2001 to 2002). Logistic regression analyses were used to compare people with first-episode drug use at Wave 2 (n = 1145) to those who remained abstinent (n = 25 790) across various Wave 1 correlates, including sociodemographic factors, mental disorders (including alcohol use disorders and nicotine dependence), childhood adversity, and family history of substance use disorders., Results: All measures of childhood adversity were associated with an increased risk of incident drug use, as were alcohol or drug problems in first-degree relatives. In models adjusted for childhood adversity and a family history of addiction, a pre-existing mood disorder (AOR 1.31; 95% CI 1.04 to 1.64), personality disorder (AOR 1.82; 95% CI 1.50 to 2.20), previous nicotine dependence (AOR 1.41; 95% CI 1.09 to 1.83), and alcohol abuse or dependence (AOR 1.96; 95% CI 1.48 to 2.60) were independently associated with new-onset drug use at follow-up., Conclusions: Specific mental disorders independently increase the risk of progression to incident drug use among people who were previously abstinent. Early-life adversities and addiction in family members accounts for some, but not all, of this observed relation.

Objective: There has been much debate as to whether nicotine is a risk factor for suicidal behaviour. This study sought to examine the relation between nicotine dependence and suicide attempts in a population-based sample of adults., Method: Our study used the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004-2005), a large (n = 34,653) nationally representative survey of community-dwelling American adults. Multiple logistic regression analyses examined the relation between suicide attempts and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, nicotine dependence, compared with nonusers of nicotine. Associations between suicide attempts and other measures of nicotine use (nicotine cessation, age of first use, frequency, and amount of use) were also examined., Results: Lifetime (AOR 1.78; 95% CI 1.48 to 2.15) and past-year nicotine dependence (AOR 1.77; 95% CI 1.02 to 3.06) were independently associated with lifetime and past-year suicide attempts, respectively, even after adjusting for sociodemographic factors, other mental disorders, and physical disease. Nicotine dependence cessation was associated with a decreased likelihood of suicide attempt compared with people currently dependent on nicotine (AOR 0.15; 95% CI 0.05 to 0.43). Greater amount of daily cigarette use was associated with suicide attempts in the model that adjusted for sociodemographic factors and other mental disorders (AOR 1.53; 95% CI 1.05 to 2.24)., Conclusions: Nicotine dependence is associated with suicide attempts, independently of comorbid mental disorders and physical disease. The association attenuates when a person ceases using nicotine, suggesting a state, rather than trait, effect. These findings provide evidence for additional concern regarding the deleterious health effects of tobacco.

Objective: To compare the rates of all Axis I and II mental disorders and suicide attempts in sexual orientation minorities with rates in heterosexuals using a nationally representative sample., Method: Data used were from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (n = 34 653, response rate = 70.2%). Cross-tabulations and multivariate logistic regression analyses were performed to determine differences in rates of mental disorders and suicide attempts by sexual orientation. All analyses were stratified by sex., Results: Compared with their heterosexual counterparts, lesbians and bisexual women demonstrated a 3-fold increased likelihood of substance use disorders, and gay and bisexual men showed twice the rate of anxiety disorders and schizophrenia and (or) psychotic illness, even after accounting for mental disorder comorbidity. Suicide attempts were independently associated with bisexuality, with odds 3 times higher than in heterosexuals., Conclusion: Findings from our study emphasize the fact that sexual orientation minorities are vulnerable to poor mental health outcomes, including suicide attempts. Clinicians need to be aware of these specific negative mental health consequences when assessing sexual orientation minorities.

Objectives: The ongoing global economic crisis may have affected people's mental health. This study aimed to, among a sample of the working population, estimate and compare the prevalence of depressive and anxiety disorders in different time intervals from January 2008 to October 2009 and to examine the demographic and socioeconomic correlates of mental disorders., Methods: From January 2008 to October 2009, 3579 employees in Alberta were recruited using the random digit dialing method. Mental disorders were assessed using the World Health Organization's Composite International Diagnostic Interview-Auto 2.1. The lifetime and 12-month prevalence of depressive and anxiety disorders in different time intervals were estimated and compared., Results: The 12-month prevalence of major depressive disorder (MDD) before September 1, 2008; between September 1, 2008, and March 1, 2009; and between March 1, 2009, and October 30, 2009, was 5.1%, 6.8%, and 7.6% (P = 0.03), respectively. The lifetime prevalence of dysthymia reported during the 3 periods was 0.4%, 0.7%, and 1.5% (P = 0.006), respectively. No changes in the 12-month prevalence of social phobia, panic disorder, and generalized anxiety disorder were found over time., Conclusions: The ongoing global economic crisis may have contributed to the increased prevalence of MDD. Future studies are needed to monitor the changes in the prevalence and to describe how the event may affect people's employment status, income, and health.

Objective: To systematically review the literature on the association between deployment to a peacekeeping mission and distress, mental disorders, and suicide., Methods: Peer-reviewed English publications were found through key word searches in MEDLINE, PsycINFO, Scopus, and Embase, and by contacting authors in the field. Sixty-eight articles were included in this review., Results: Some studies have found higher levels of postdeployment distress and posttraumatic stress disorder (PTSD) symptoms. Most studies have not shown an increased risk of suicide in former peacekeepers. Correlates of distress and PTSD symptoms included level of exposure to traumatic events during deployment, number of deployments, predeployment personality traits or disorder, and postdeployment stressors. Perceived meaningfulness of the mission, postdeployment social supports, and positive perception of homecoming were associated with lower likelihood of distress., Conclusions: Most peacekeepers do not develop high levels of distress or symptoms of PTSD. As postdeployment distress is consistently shown to be associated with high levels of exposure to combat during deployment, targeted interventions for peacekeepers who have been exposed to high levels of combat should be considered.

Objective: Most previous studies that have investigated the relation between abortion and mental illness have presented mixed findings. We examined the relation between abortion, mental disorders, and suicidality using a US nationally representative sample., Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization-Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental disorders., Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders--mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse)., Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

Objective: Canada experienced large-scale growth of the gambling industry during the 1990s. Clinical data have indicated that substantial proportions of people seeking help for gambling problems in Canada are women. A population health model was used to understand the relation between types and frequency of gambling activities and problem gambling among women in Canada., Method: Data used for the analysis were from the nationally representative Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2; n = 10,056, women aged 15 years and older; data collected in 2002)., Results: The types of gambling associated with the highest odds of problem gambling among women in Canada were video lottery terminals (VLTs) outside the casino (OR 2.37 to 53.73; P < 0.01), VLTs inside the casino (OR 2.84 to 36.19; P < 0.001), and other casino games (OR 4.01 to 24.15; P < 0.001)., Conclusions: These observations further our understanding of problem gambling among women in Canada and confirm that problem gambling among women is an important public health concern. Frequent VLT gambling, both outside and inside casinos, and other casino games are associated with the largest odds of problem gambling, which highlights an area of gambling in Canada that needs to be reassessed if problem gambling is to be prevented or reduced. Evidence-based research is necessary to inform healthy public policies on gambling in Canada. Findings from the current research have important research and policy implications.

Objectives: To determine the prevalence and sociodemographic correlates of negative attitudes toward help seeking for mental illness among the general population in the United States and Ontario., Methods: Two contemporaneous population-based surveys (aged 15 to 54 years) were analyzed: the US National Comorbidity Survey (NCS) (n = 5877) and the Ontario Health Survey (OHS) (n = 6902). Multiple logistic regression analyses were used to examine the correlates of a derived negative attitudes composite variable obtained from questions assessing probability, comfort, and embarrassment related to help seeking for mental illness., Results: Negative attitudes toward help seeking for mental illness were prevalent in both countries. Fifteen percent of OHS and 20% of NCS respondents stated they probably or definitely would not seek treatment if they had serious emotional problems. Almost one-half of recipients in both surveys stated they would be embarrassed if their friends knew about their use of mental health services. Negative attitudes toward help seeking were highest among socioeconomically challenged young, single, lesser-educated men in Ontario and the United States. In both countries, substance abuse or dependence and antisocial personality disorder were associated with greater negative attitudes, as was not having sought treatment in the past., Conclusions: Negative attitudes toward mental health service use are prevalent in Ontario and the United States. They are most common in young adults, especially those with lower education and socioeconomic resources, and those with substance abuse or dependence problems. This information can be used to target educational efforts aimed at improving willingness to seek care for mental health problems.

Objective: To examine the comorbidity of Axis I and II disorders within a community-based sample of adults with schizophrenia., Methods: The study was conducted using data from the National Epidemiologic Survey of Alcohol and Related Conditions. A diagnosis of schizophrenia was based on respondents' self-report that they had been diagnosed by a health professional with schizophrenia or a psychotic illness or episode (SPIE). Axis I disorders and Axis II personality disorders (PDs) were assessed using the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Mental and physical quality of life were assessed using the Medical Outcomes Study Short Form 12 questionnaire., Results: The prevalence of SPIE was 0.9%. We used multiple logistic regression to examine the association between the presence and absence of SPIE in Axis I and II mental disorders. Each of the Axis I and II mental disorders examined were significantly associated with a diagnosis of SPIE after controlling for age, sex, education, marital status, and household income., Conclusions: Clinicians should be aware of the patterns and extent of psychiatric comorbidities that may exist in schizophrenia. Possible mechanisms of these associations are discussed.