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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.

Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) last published clinical guidelines for the management of major depressive disorder (MDD) in 2016. Owing to advances in the field, an update was needed to incorporate new evidence and provide new and revised recommendations for the assessment and management of MDD in adults., Methods: CANMAT convened a guidelines editorial group comprised of academic clinicians and patient partners. A systematic literature review was conducted, focusing on systematic reviews and meta-analyses published since the 2016 guidelines. Recommendations were organized by lines of treatment, which were informed by CANMAT-defined levels of evidence and supplemented by clinical support (consisting of expert consensus on safety, tolerability, and feasibility). Drafts were revised based on review by patient partners, expert peer review, and a defined expert consensus process., Results: The updated guidelines comprise eight primary topics, in a question-and-answer format, that map a patient care journey from assessment to selection of evidence-based treatments, prevention of recurrence, and strategies for inadequate response. The guidelines adopt a personalized care approach that emphasizes shared decision-making that reflects the values, preferences, and treatment history of the patient with MDD. Tables provide new and updated recommendations for psychological, pharmacological, lifestyle, complementary and alternative medicine, digital health, and neuromodulation treatments. Caveats and limitations of the evidence are highlighted., Conclusions: The CANMAT 2023 updated guidelines provide evidence-informed recommendations for the management of MDD, in a clinician-friendly format. These updated guidelines emphasize a collaborative, personalized, and systematic management approach that will help optimize outcomes for adults with MDD., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Camelia Adams has nothing to disclose. Anees Bahji has nothing to disclose. Serge Beaulieu reports research grants, personal fees, and/or nonfinancial support from Abbvie, Boehringer-Ingelheim, Canadian Institutes for Health Research (CIHR), DiaMentis, Idorsia, Eisai, Janssen, and Otsuka-Lundbeck. Venkat Bhat reports research grants from the American Foundation for Suicide Prevention, AMS, Brain and Behaviour Research Foundation, CIHR, Department of Defense, Eisai, New Frontiers in Research Fund, Novartis, Ontario Ministry of Health, Roche, Royal College of Physicians and Surgeons of Canada, and the University of Toronto. Pierre Blier received research grants and/or personal fees from Abbvie, Allergan, CIHR, Janssen, Lundbeck, Merck, Ontario Brain Institute (OBI), Otsuka, Pfizer, University of Ottawa Medical Research Fund, and VilaNova. Daniel M. Blumberger reports research grants, nonfinancial support, and/or other support from Brain Canada, CIHR, Magventure, National Institutes of Health (NIH), and Welcony Inc. Elisa Brietzke reports research grants from Queen’s University Centre for Neuroscience and the PSI Foundation. Trisha Chakrabarty has nothing to disclose. Dr. André Do reports research grants and/or personal fees from AbbVie, CIHR, Janssen, and Otsuka. Benicio N. Frey has nothing to disclose. Dr. Peter Giacobbe reports research grants from CIHR and salary support from the Academic Scholars Fund, Department of Psychiatry, University of Toronto. David David Gratzer has nothing to disclose. Dr. Sophie Grigoriadis reports personal fees from the Canadian Pharmacists Association, Norton, and UptoDate. Jeffrey Habert reports research grants, personal fees and/or other support from Abbvie, Amgen, Astra-Zeneca, Bausch, Bayer, BMS, Boehringer-Ingelheim, Eisai, Eli-Lilly, Elvium, GSK, HLS, Idorsia, Janssen, Lundbeck, Novartis, Novo-Nordisk, Otsuka, Pfizer, and Valeo. M. Ishrat Husain reports research grants and/or other support from the Centre for Addiction and Mental Health (CAMH) Foundation, CIHR, COMPASS Pathfinder, MindSet Pharma, Psyched Therapeutics, University of Toronto, and Wake Network. Zahinoor Ismail reports personal fees from Lundbeck and Otsuka. Sidney H. Kennedy reports research grants, personal fees and/or other support from Abbott, Abbvie, Boehringer-Ingelheim, Brain Canada, Canada’s Strategy for Patient-Oriented Research (SPOR), CIHR, -, Janssen, Lundbeck, Merck, -, OBI, Otsuka, - Servier, and Sunovion. Raymond W. Lam reports research grants, personal fees and/or other support from AbbVie, Asia-Pacific Economic Cooperation (APEC), Bausch, BC Leading Edge Endowment Fund, Brain Canada, CANMAT, Carnot, CIHR, Grand Challenges Canada, Healthy Minds Canada, Janssen, Lundbeck, Michael Smith Health Research BC, MITACS, Neurotorium, OBI, Otsuka, Pfizer/Viatris, Unity Health, and VGH-UBCH Foundation. Alexander McGirr reports other support from Allergan Canada; he holds a patent 63/193,643 pending. Roger S. McIntyre reports research grants and/or personal fees from Abbvie, Alkermes, Atai Life Sciences, Axsome, Bausch, Biogen, Boehringer Ingelheim, Braxia Scientific Corp., CIHR, Eisai, Global Alliance for Chronic Diseases, Intra-Cellular, Janssen, Kris, Lundbeck, Milken Institute, Mitsubishi Tanabe, National Natural Science Foundation of China, Neumora Therapeutics, Neurocrine, NewBridge Pharmaceuticals, Novo Nordisk, Otsuka, Pfizer, Purdue, Sage, Sanofi, Sunovion, Takeda, and Viatris. Erin E. Michalak reports research grants from the Otsuka-Lundbeck Alliance. Roumen V. Milev reports research grants and/or personal fees from AbbVie, Allergan, Canadian Biomarker Integration Network in Depression (CAN-BIND), CIHR, Eisai, Janssen, KYE, Lallemand, Lundbeck, Neonmind, Nubiyota, OBI, Ontario Mental Health Foundation, Otsuka, and Sunovion. Daniel J. Müller reports research grants or personal fees from CAMH AFP Innovation Fund, CAMH Foundation, CIHR, Novagenic, Nubiyota, and OBI. Sagar V. Parikh is the Medical Director for the National Network of Depression Centers and reports research grants, honoraria and/or personal fees from Aifred, Boehringer Ingelheim, Janssen, Medscape, Mensante, Merck, Myriad/Assurex, Otsuka, and Sage; and private shares in Mensante. Lena S. Quilty has nothing to disclose. Arun V. Ravindran has nothing to disclose. Nisha Ravindran has nothing to disclose. Johanne Renaud has nothing to disclose. Joshua D. Rosenblat reports research grants and/or personal fees from Academic Scholars Award, Allergan, American Psychiatric Association, American Society of Psychopharmacology, Boehringer Ingelheim, Braxia Health (Chief Medical and Scientific Officer of Braxia Scientific; Medical Director of the Canadian Rapid Treatment Centre of Excellence [Braxia Health]), Brain and Cognition Discovery Foundation, Canadian Cancer Society, Canadian Psychiatric Association, CIHR, COMPASS, iGan, Janssen, Joseph M. West Family Memorial Fund, Labatt Brain Health Network, Lundbeck, Physician Services Inc. (PSI) Foundation, Sunovion, Timeposters Fellowship, University Health Network Centre for Mental Health, and University of Toronto. Zainab Samaan has nothing to disclose. Gayatri Saraf has nothing to disclose. Kathryn Schade has nothing to disclose. Ayal Schaffer reports personal fees from AbbVie, Lundbeck, and Otsuka. Mark Sinyor has nothing to disclose. Claudio N. Soares reports research grants and/or personal fees from Bayer, Boehinger-Ingelheim, Clairvoyant Therapeutics, Diamond Therapeutics, Eisai, OBI, and Otsuka, Jennifer Swainson reports personal fees, nonfinancial support, and/or other support from AbbVie, Bausch, Eisai, Idorsia, Janssen, Lundbeck, Newly Institute, and Otsuka. Valerie H. Taylor has nothing to disclose. Smadar V. Tourjman reports personal fees from AbbVie, Elvium, Esai, Idorsia, Janssen, Lundbeck, Otsuka, Pfizer, Sunovion, and Takeda. Rudolf Uher has nothing to disclose. Michael van Ameringen reports research grants, personal fees, and/or other support from Abbvie, Bausch Health, Biohaven, Boehringer Ingelheim, CIHR, Elvium (Purdue), Jazz, Lundbeck, Michael G. DeGroote Centre for Medicinal Cannabis Research, Otsuka, Sunovion, Takeda, UptoDate, and Vistagen. Gustavo Vazquez reports personal fees for Abbvie, Allergan, Asofarma, Elea/Phoenix, Eurofarma, Gador, Janssen, Lundbeck/Otsuka, NeonMind Biosciences, Psicofarma, Raffo, Sunovion, and Tecnofarma. Simone Vigod reports royalties from UpToDate. Daphne Voineskos holds the Labatt Family Professorship in Depression Biology, a University Named Professorship at the University of Toronto; she reports research grants from CIHR, CAMH, Centre for Mental Health at University Health Network, Department of Psychiatry at the University of Toronto, and the National Institute of Mental Health. Lakshmi N. Yatham reports research grants and/or personal fees from Abbvie, Alkermes, Allergan, Dainippon Sumitomo, Gedeon Richter, GSK, Intracellular Therapies, Merck, Sanofi, and Sunovion.

Background: Despite being critical to reducing the impacts of poverty internationally, synchronized monthly government income assistance payments are linked to intensified drug use and associated harms, including disrupted access to substance use-related services. This study evaluates whether alternative income assistance distribution schedules improve harm reduction (HR), pharmacotherapy and substance use service utilization., Methods: This exploratory, parallel group, unblinded, randomized controlled trial analyzed data from adults (n = 192) in Vancouver, Canada receiving income assistance, and reporting active, regular illicit drug use. Participants were randomly assigned on a 1:2:2 basis for six income assistance payment cycles to: (1) existing government schedules (control); (2) a "staggered" single monthly payment; or (3) "split & staggered" twice-monthly payments. Generalized linear mixed models analyzed secondary outcomes of HR, pharmacotherapy and substance use service utilization as well as barriers accessing these services., Results: Forty-five control, 71 staggered, and 76 split & staggered volunteers participated between 2015 and 2019. Multivariable modified per-protocol analyses demonstrate increased access to substance use services (Adjusted Odds Ratio [AOR] 1.64, 95% Confidence Interval [CI] 1.02-2.64) for split & staggered arm participants, and, conversely, increased barriers to HR for participants in the staggered (AOR 2.34, 95% CI 1.24-4.41) and split & staggered (AOR 2.16, 95% CI 1.08-4.35) arms. Results also showed decreased barriers to pharmacotherapy around government payments (AOR 0.23, 95% CI 0.06-0.90), pharmacotherapy around individual payments (AOR 0.12, 95% CI 0.02-0.58), and HR around individual payments (AOR 0.11, 95% CI 0.02-0.63) for staggered arm participants., Conclusion: Modifying payments schedules demonstrate improved access to overall substance use services, and reduced barriers to HR and pharmacotherapy around income assistance payments. However, increased overall barriers to HR access were also shown. These complex, predominantly beneficial findings support the exploration of offering alternative payment schedules to support service access., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Chronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients., Competing Interests: Financial/Nonfinancial Disclosures Members of the CTS COPD Guideline Panel declared potential conflicts of interest at the time of appointment, and these were updated throughout the process in accordance with the CTS Conflict of Interest Disclosure Policy. J. B. reports grants from McGill University, the McGill University Health Centre Foundation, the Canadian Institute Health Research, Grifols, Novartis, Sanofi, and the Respiratory Health Network of the Fonds de la recherche en santé du Québec; grants and personal fees from Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, and Trudell Canada Ltd; and personal fees from Pfizer Canada Ltd, and COVIS Pharma Canada Ltd, outside the submitted work. M. B. reports personal fees and grants outside the submitted work from AstraZeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Novartis, Sanofi-Genzyme, the Canadian Institute Health Research, CHEST, The Lung Association of Alberta, The University of Alberta Hospital Foundation, Alberta Innovates Health Solutions, Valeo, and Covis. P. H. reports grants from the Canadian Institute Health Research, the Lung Association of Nova Scotia, the Nova Scotia Health Authority Research Fund, Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, Cyclomedica, Grifols, Respivant, and Vertex; and personal fees from Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Janssen, Merck, Novartis, Sanofi-Aventis, and Trudell, outside the submitted work. S. D. A. receives grants from CIHR. He has received speaking honoraria or has participated on advisory boards for GSK, AZ, Chiesi, and Sanofi. M-F. B. reports grants and personal fees from the Cercle du doyen (Faculté de pharmacie, Université de Montréal) and Astra Zeneca Canada Ltd. A. D. reports receiving research, consulting and lecturing fees from GlaxoSmithkline, Sepracor, Schering Plough, Altana, Methapharma, AstraZeneca, ONO pharma, Merck Canada, Forest Laboratories, Novartis Canada/USA, Boehringer Ingelheim (Canada) Ltd, Pfizer Canada, SkyePharma, and KOS Pharmaceuticals and Almirall, Sanofigenzyme and TEVA Canada, Valeopharma Canada. F. M. reports grants from AstraZeneca and GlaxoSmithKline, Boehringer Ingelheim, GSK, Sanofi, and Novartis, and personal fees for serving on speaker bureaus and consultation panels from GlaxoSmithKline, Grifols, and Novartis. He is financially involved with Oxynov, a company which is developing an oxygen delivery system. S. M. reports grants outside the submitted work from Canadian Institute of Health Research and Canadian Lung Association in partnership with Boehringer Ingelheim Canada Ltd and Astra Zeneca Canada Ltd. E. P. reports personal fees from COVIS Pharma, Sanofi Genzyme, Boehringer Ingelheim Canada Ltd, Astra Zeneca Canada Ltd, GlaxoSmithKline Canada Ltd, and Novartis; and grants from the Canadian Institute Health Research, the Saskatchewan Research Foundation, the Respiratory Research Centre, and Astra Zeneca Canada Ltd, outside the submitted work. D. D. S. reports personal fees from GlaxoSmithKline Canada Ltd, Boehringer Ingelheim, and AstraZeneca outside of the submitted work. J. W. reports personal fees from GlaxoSmithKline Canada Ltd and Astra Zeneca Canada Ltd and a grant from Fisher & Paykel, outside the submitted work. B. L. W. reports personal fees from AstraZeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Novartis, Sanofi-Genzyme and Covis Pharma Canada, outside of the submitted work. D. D. M. reports consultancy work with Alberta Health Services, Health Canada, Lung Saskatchewan, Ontario Ministry of Health and Long-Term Care, Saskatchewan Health Authority, Saskatchewan Ministry of Health, Yukon Health and Social Services; reports grants (managed by University of Saskatchewan) from AstraZeneca, Boehringer Ingelheim, Canadian Institute of Health Research, GlaxoSmithKline, Grifols Therapeutics, Lung Saskatchewan, Novartis, Sanofi-Aventis, Saskatchewan Health Research Foundation, Syneos Health, Schering-Plough; employee/roles with University of Saskatchewan, Deputy Editor - CHEST Journal, Board Member - Saskatchewan Health Research Foundation; outside the submitted work. None declared (A. L., A. V. D., S. B. K., J. D. M.)., (Copyright © 2023 Canadian Thoracic Society and American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: Schizophrenia spectrum and other psychotic disorders often have their onset in adolescence. The sequelae of these illnesses can negatively alter the trajectory of emotional, cognitive, and social development in children and youth if left untreated. Early and appropriate interventions can improve outcomes. This article aims to identify best practices in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders.Methods: A systematic search was conducted for published guidelines for schizophrenia and schizophrenia spectrum disorders in children and youth (under age 18 years). Recommendations were drawn from the National Institute for Health and Care Excellence guidelines on psychosis and schizophrenia in children and youth (2013 and 2015 updates). Current guidelines were adopted using the ADAPTE process, which includes consensus ratings by a panel of experts.Results: Recommendations identified covered a range of issues in the pharmacotherapy management of children and youth with schizophrenia spectrum disorders. Further work in this area is warranted as we continue to further understand their presentation in the developing brain.Conclusions: Canadian guidelines for the pharmacotherapy management of children and youth with schizophrenia spectrum disorders are essential to assist clinicians in treating this vulnerable population. Ongoing work in this area is recommended. [ABSTRACT FROM AUTHOR]

Objective: The present guidelines address the pharmacotherapy of schizophrenia in adults across different stages, phases, and symptom domains.Method: Guidelines were developed using the ADAPTE process, which takes advantage of existing guidelines. Six guidelines were identified for adaptation, with recommendations extracted from each. For those specific to the pharmacotherapy of schizophrenia in adults, a working group selected between guidelines and recommendations to create an adapted guideline.Results: Recommendations can be categorized into 6 areas that include 1) first-episode schizophrenia, 2) acute exacerbation, 3) relapse prevention and maintenance treatment, 4) treatment-resistant schizophrenia, 5) clozapine-resistant schizophrenia, and 6) specific symptom domains. For each category, recommendations are made based on the available evidence, which is discussed and linked to other established guidelines.Conclusions: In most cases, evidence-based recommendations are made that can be used to guide current clinical treatment and decision making. Notably, however, there is a paucity of established evidence to guide treatment decision making in the case of clozapine-resistant schizophrenia, a subsample that represents a sizable proportion of those with schizophrenia. [ABSTRACT FROM AUTHOR]

The current diagnostic and treatment pathway for patients with fibromyalgia (FM) is lengthy, complex, and characterized by multiple physician visits with an average 2-year wait until diagnosis. It is clear that effective identification and appropriate treatment of FM remain a challenge in current clinical practice. Ideally, FM management involves a multidisciplinary approach with the preferable patient pathway originating in primary care but supported by a range of health care providers, including referral to specialist care when necessary. After the publication of individual clinical studies, high-quality reviews, and meta-analyses, recently published FM treatment guidelines have transitioned from an expert consensus to an evidence-based approach. Evidence-based guidelines provide a framework for ensuring early diagnosis and timely adoption of appropriate treatment. However, for successful outcomes, FM treatments must adopt a more holistic approach, which addresses more than just pain. Impact on the associated symptoms of fatigue and cognitive problems, sleep and mood disturbances, and lowered functional status are also important in judging the success of FM therapy. Recently published guidelines recommend the adoption of a symptom-based approach to guide pharmacologic treatment. Emerging treatment options for FM may be best differentiated on the basis of their effect on comorbid symptoms that are often associated with pain (e.g. sleep disturbance, mood, fatigue). The current review discusses the most recently published Canadian guidelines and the implications of the recent European League Against Rheumatism (EULAR) recommendations, with a focus on the challenges of implementing these guidelines in current clinical practice. [ABSTRACT FROM AUTHOR]

Background: Although psychotherapy is an important pillar in the treatment of bipolar disorders, alongside pharmacotherapy, non-drug and complementary procedures, there is no up to date evidence synthesis for inpatient psychotherapeutic treatment and work with caregivers., Objective: To review and evaluate the current study situation on evidence-based inpatient psychotherapy for bipolar disorders., Material and Methods: 1.Summary of the evidence for inpatient psychotherapy in adolescents and adults with bipolar disorders from current review articles and guidelines (German S3 guidelines, Australian, Canadian, and British NICE guidelines). 2. Systematic literature search (PRISMA) in Cochrane trials and Medline (via PubMed). 2a. Identification of original articles using the following search term: "bipolar fft" OR "bipolar ipsrt" OR "bipolar cbt" OR "bipolar cognitive remediation" OR "bipolar psychotherapy inpatient". 2b. Screening of n = 942 publications on the following inclusion criteria: randomized controlled efficacy trials, inpatient treatment/recruitment in the inpatient setting, adolescent or adult patients with bipolar disorder or caregivers., Results: The guidelines recommend a combination of pharmacotherapy and psychotherapy for the treatment of patients with bipolar disorders (so far no evidence-based presentation of inpatient psychotherapy). The results from reviews and original papers are heterogeneous. Recently described evidence-based psychotherapeutic approaches for inpatient treatment are family focused therapy (FFT), interpersonal and social rhythm therapy (IPSRT) and psychoeducation., Conclusion: Although the current evidence is heterogeneous and further systematic studies are necessary, the results indicate that psychotherapy should be started or initiated in the inpatient setting with inclusion of caregivers., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Aims: To compare the cost-effectiveness of immediate and 12-month delayed initiation of dapagliflozin treatment in patients with a history of hospitalization for heart failure (HHF) from the UK, Canadian, German, and Spanish healthcare perspectives., Methods and Results: A cost-utility analysis was conducted using a decision-analytic Markov model with health states defined by Kansas City Cardiomyopathy Questionnaire scores, type 2 diabetes mellitus status and incidence of heart failure (HF) events. Patient-level data for patients with prior HHF from the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure (DAPA-HF) trial were used to inform the model inputs on clinical events and utility values. Healthcare costs were sourced from the relevant national reference databases and the published literature. Compared to standard therapy, immediate initiation of dapagliflozin decreased HHF (187 events), urgent HF visits (32 events) and cardiovascular mortality (18 events). Standard therapy was associated with lifetime costs of £13 224 and 4.02 quality-adjusted life years (QALYs). Twelve-month delayed initiation of dapagliflozin was associated with total discounted lifetime costs and QALYs of £16 660 and 4.61, respectively, compared to £16 912 and 4.66, respectively, for immediate initiation. Compared to standard therapy, immediate and 12-month delayed initiation of dapagliflozin yielded an incremental cost-effectiveness ratio (ICER) of £5779 and £5821, respectively. Compared to 12-month delayed initiation, immediate initiation of dapagliflozin had an ICER of £5263. Results were similar from the Canadian, German, and Spanish healthcare perspectives., Conclusion: Both immediate and 12-month delayed initiation of dapagliflozin are cost-effective. However, immediate initiation provides greater clinical benefits, with almost 10% additional QALYs gain, compared to 12-month delayed initiation of dapagliflozin and should be considered standard of care., (© 2023 Health Economics and Outcomes Research, AstraZeneca and The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: The effects of direct oral anticoagulants (DOACs) among octogenarian patients with venous thromboembolism remains poorly understood. To address this knowledge gap, our study aimed to assess the effectiveness and safety of DOACs compared to vitamin K antagonists (VKAs) among octogenarians with venous thromboembolism., Methods: We conducted an international cohort study using administrative health care databases from Québec, Canada, and Germany. We assembled 2 population-based cohorts of octogenarians with incident venous thromboembolism initiating treatment with DOACs or VKAs. The study period spanned from January 2012 to the most recent date of data availability (Québec: December 2016; Germany: December 2019). Using an as-treated exposure definition, we compared use of DOACs to use of VKAs, applying inverse probability of treatment weighting based on high-dimensional propensity scores to balance exposure groups. Cox proportional hazards models estimated site-specific hazard ratios (HRs) and 95% confidence intervals (CIs) of recurrent venous thromboembolism, major bleeding, and all-cause mortality. The results were meta-analyzed using random-effects models., Results: Overall, our study included 6737 octogenarians with venous thromboembolism (Québec: n = 2556; Germany: n = 4181) who initiated use of DOACs (n = 3778) or VKAs (n = 2959). When compared to VKAs, DOACs were associated with similar risks of recurrent venous thromboembolism (weighted HR, 0.80; 95% CI, 0.43-1.46; I 2  = 0.00), major bleeding (weighted HR, 0.96; 95% CI, 0.57-1.63; I 2  = 0.59), and all-cause mortality (weighted HR, 1.04; 95% CI, 0.81-1.34; I 2  = 0.00)., Conclusions: Among octogenarians with venous thromboembolism, DOACs showed a comparable effectiveness and safety compared to VKAs. Our results support the use of DOACs in this high-risk group., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement. Method: A multidisciplinary consensus group used the Grading of Recommendations Assessment, Development and Evaluation approach for rating evidence quality and for grading recommendations. We conducted a systematic review of medications studied in placebo-controlled trials for treating disruptive and aggressive behaviour in children and adolescents with ADHD, ODD, or CD. We followed consensus procedures to make 1 of 4 recommendations for each medication: strong, in favour (↑↑); conditional, in favour (↑?); conditional, against (↓.?); and strong, against (↓↓). Results: For children and adolescents with disruptive or aggressive behaviour associated with ADHD, psychostimulants received a strong recommendation in favour of use, while atomoxetine and alpha-2 agonists received a conditional recommendation in favour of use. If these patients do poorly with ADHD medications, the medication with the most evidence is risperidone. Risperidone also has the most evidence for treating disruptive or aggressive behaviour in the absence of ADHD. However, given risperidone's major adverse effects, it received only a conditional recommendation in favour of use. We recommended against using quetiapine, haloperidol, lithium, or carbamazepine because of the poor quality of evidence and their major adverse effects. Conclusion: When severe disruptive or aggressive behaviour occurs with ADHD, medications for ADHD should be used first. Other medications have major adverse effects and, with the exception of risperidone, very limited evidence to support their use. [ABSTRACT FROM AUTHOR]

Osteoporotic fractures are a common and serious health problem for older adults living in nursing homes (NHs). Risk of fracture increases with age and dementia status, yet gaps in evidence result in controversies around when to start and stop treatment for osteoporosis in NH residents, particularly those who have high fracture risk but have limited life expectancy. In this article, we discuss these areas of controversy. We provide an overview of current guidelines that explicitly address osteoporosis treatment strategies for NH residents, review the evidence for osteoporosis medications in NH residents, and use these sources to suggest practical recommendations for clinical practice and for research. Three published guidelines (from the United States, Canada, and Australia) and several studies provide the current basis for clinical decisions about osteoporosis treatment for NH residents. Practical approaches may include broad use of vitamin D and selective use of osteoporosis medication based on risks, benefits, and goals of care. Clinicians still lack strong evidence to guide treatment of NH residents with advanced dementia, multimorbidity, or severe mobility impairment. Future priorities for research include identifying optimal approaches to risk stratification and prevention strategies for NH residents and evaluating the risk-benefit profile of pharmacologic treatments for osteoporosis NH residents across key clinical strata. In the absence of such evidence, decisions for initiating and continuing treatment should reflect a patient-centered approach that incorporates life expectancy, goals of care, and the potential burden of treatment., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Objective: The current study aims to assess the self-reported competence of graduating psychiatry residents in Canada to provide pharmacotherapy and psychotherapy for major depressive disorder as recommended in national practice guidelines., Methods: Canadian psychiatry residents who participated in an optional national review course to prepare for licensing were anonymously surveyed regarding their experience and competence in providing treatments recommended by the 2016 Canadian Network for Mood and Anxiety Treatments guidelines., Results: The majority (89%, 130/146) reported competence in ≥ 5 medication monotherapies (e.g., selective serotonin/norepinephrine reuptake inhibitors, bupropion, mirtazapine) and ≥ 3 adjuncts (e.g., mirtazapine, second-generation antipsychotics). While 76% expressed interest in practicing multiple psychotherapeutic modalities, only 47% reported self-assessed competence in delivering multiple modalities. Only 42% reported pharmacological competence (≥ 5 monotherapies, ≥ 3 adjuncts) and competence in ≥ 2 psychotherapies. Only 9% reported competence in offering medication, psychotherapy, and electroconvulsive therapy. Less than two-thirds endorsed sufficient didactic teaching (58%) or supervision in pharmacotherapy (50%) for treatment-resistant depression., Conclusions: Canadian psychiatry residents report competence in prescribing many first-line medications. However, only a minority report competence in prescribing medications and competence in psychotherapies and/or electroconvulsive therapy. Given known biases in assessments by self-report, real-world competence may be even lower. This study identifies gaps between national practice guidelines and the comfort of the emerging psychiatric workforce in delivering recommended treatments. These gaps in resident competence may lead to under-use of effective treatments for depression. Residency programs should consider how to improve resident competence in providing the full range of evidence-based treatments for depression., (© 2022. Academic Psychiatry.)

Objective:Individuals with substance use and psychiatric disorders have a high prevalence of tobacco use disorders and are disproportionately affected by tobacco-related morbidity and mortality. However, it is unclear how having co-occurring disorders affects tobacco cessation. Our aim was to examine smoking cessation outcomes and relevant predictors of smoking cessation among smokers with substance use and/or psychiatric disorders.Methods:Data from medical records of 674 participants in a tobacco treatment program within mental health and addictions services in Vancouver, Canada, were analyzed. The 26-week treatment program included an 8-week structured behavioral counseling group, an 18-week support group, and 26 weeks of no-cost pharmacotherapy. Information on demographics, tobacco use and history, type of pharmacotherapy received, nicotine dependence, importance of and confidence in quitting smoking, expired carbon monoxide level, substance use and psychiatric disorder history, and total program visits were gathered.Results:Approximately 67% (n= 449) of participants had co-occurring substance use and psychiatric disorders, while 20% (n= 136) had substance use disorder only, 10% (n= 67) had psychiatric disorder only, and 3% (n= 22) had tobacco dependence only. Rates of tobacco cessation (i.e., 7-day point prevalence of abstinence verified by expired carbon monoxide of ≤8 ppm) by group in the 522 people who completed treatment were as follows: 38.2% for those with co-occurring disorders, 47.1% for those with tobacco dependence only, 47.1% for those with substance use disorder only, and 41.8% for those with psychiatric disorder only. Length of treatment was a significant predictor of smoking cessation for those with co-occurring disorders and substance use disorder only. In the final stratified multivariate analysis, for individuals with co-occurring disorders, having an opiate use disorder (as compared to an alcohol use disorder) and higher nicotine dependence scores at baseline were predictive of poor cessation outcomes, while greater length of treatment was predictive of successful smoking cessation.Conclusions:Tobacco cessation treatment for individuals with co-occurring substance use and psychiatric disorders is likely to be as effective as for smokers with either disorder alone. Treatment duration predicts success among these smokers so strategies to enhance engagement and retention are needed. [ABSTRACT FROM AUTHOR]

Aim To investigate the cardiometabolic risk ( CMR) assessment and management patterns for individuals with and without type 2 diabetes mellitus ( T2DM) in Canadian primary care practices. Methods Between April 2011 and March 2012, physicians from 9 primary care teams and 88 traditional non-team practices completed a practice assessment on the management of 2461 patients >40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least one of the following risk factor- T2DM, dyslipidaemia or hypertension. Results There were 1304 individuals with T2DM and 1157 without. Pharmacotherapy to manage hyperglycaemia, dyslipidaemia and hypertension was widely prescribed. Fifty-eight percent of individuals with T2DM had a glycated haemoglobin ( HbA1c) ≤7.0%. Amongst individuals with dyslipidaemia, median low-density lipoprotein cholesterol ( LDL-C) was 1.8 mmol/l for those with T2DM and 2.8 mmol/l for those without. Amongst individuals with hypertension, 30% of those with T2DM achieved the <130/80 mmHg target, whereas 60% of those without met the <140/90 mmHg target. The composite glycaemic, LDL-C and blood pressure ( BP) target outcome was achieved by 12% of individuals with T2DM. Only 17% of individuals with T2DM and 11% without were advised to increase their physical activity. Dietary modifications were recommended to 32 and 10% of those with and without T2DM, respectively. Conclusions Patients at elevated CMR were suboptimally managed in the primary care practices surveyed. There was low attainment of recommended therapeutic glycaemic, lipid and BP targets. Advice on healthy lifestyle changes was infrequently dispensed, representing a missed opportunity to educate patients on the long-term benefits of lifestyle modification. [ABSTRACT FROM AUTHOR]

The government of Canada now plans to bring into force new federal drug pricing regulations on 1 July 2022. We do not take issue with the goal of medication affordability, which is vital in healthcare the world over. Our concern is that the new guidelines are being implemented without due consideration for three major unintended consequences: regulatory changes will lower the number of clinical trials for new medications in Canada, fewer clinical trials will mean lower research and development investments, and changes will reduce patients' access to new medications. Access to effective medications is a cornerstone of healthcare for Canadian patients. As physicians, our duty to patient care demands that we tell the government to protect the right of Canadians to timely access to life-changing medicines.

Objective: This study aimed to determine the associations between guideline-concordant pharmacotherapy for depression and the use of health services in the year following diagnosis.Method: This population-based, retrospective cohort study examined Quebec drug plans between 1999 and 2002. We included beneficiaries aged 18 to 64 years who were newly diagnosed with an episode of depression by primary care physicians and psychiatrists between October 1, 2000, and March 31, 2001, and who made at least one psychotropic pharmacy claim within 31 days of diagnosis. We defined guideline concordance as the receipt of recommended medication, starting dosage, and treatment duration as defined by the Canadian Network for Mood and Anxiety Treatments guidelines. We measured outcomes on use of ambulatory (number of visits to prescribing physician, other physicians, or emergency departments) and inpatient (hospitalization) services.Results: There were 2742 patients (mean age 42 years; 64% female patients) who met the study criteria. Of the 2047 (75%) patients to whom an antidepressant was dispensed, 1958 (71%) received a recommended first-line medication, 1297 (63%) received a recommended starting dosage, and 304 (15%) received a recommended duration. According to the 3 criteria, only 8% were treated appropriately; 21% received benzodiazepines rather than antidepressants. There were 2 median visits (inferquartile range [IQR] 1 to 3) to prescribing physicians, 0 visits (IQR 0 to 1) to other physicians, and 0 visits (IQR 0 to 0) to emergency departments; 497 (18%) patients were hospitalized. In separate multivariate models for repeated measures, recommended first-line medication, dosage, and duration were associated with more prescribing physician visits. Recommended first-line medication reduced the odds of hospitalization.Conclusion: Guideline concordance was associated with more visits to prescribing physicians and lower odds of hospitalization. [ABSTRACT FROM AUTHOR]

We set out to examine selected clinical characteristics of migraine patients referred to neurologists specializing in headache in Canada, and to document their pharmacological therapy both before and after consultation with the neurologist. Demographic, clinical and pharmacotherapy data were collected at the time of consultation for 606 patients referred to five headache clinics and who were given a migraine diagnosis by the neurologist. Data were analysed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The mean age of the migraine patients was 39.7 years; and 82.5% were female. The majority of patients suffered severe impact from their headaches. Prior to consultation, 48.7% were taking a triptan; after consultation, 97.2% were on a triptan. Before consultation, 30.9% were on a prophylactic drug; after consultation, 70.4% were. 20.8% of patients were medication overusers. Of these medication overusers, 42.4% were overusing an opiate, usually in combination with other analgesics; 21.6% were overusing a triptan. Medication changes made by the neurologists at consultation included a large increase in the use of both triptans and prophylactic medications. Medication overuse, particularly opiate overuse, remains a significant problem in patients with migraine in Canada. [ABSTRACT FROM AUTHOR]

Background. This evaluation of the 2000 Quit and Win campaign in the province of Quebec, Canada, assessed the use and effectiveness of pharmacological aids, social support, and support resources (clinic program, support groups, books, telephone support) among contest participants. The reach of the contest was 1.3% of adult smokers: 20,400 participants.Methods. Six months after the contest ended, 3,033 randomly selected participants completed telephone interviews about their smoking status and their use of nonform aids, social support, support resources, and pharmacological aids during their cessation attempt. Those who were abstinent from smoking were then reinterviewed 6 months later, that is, 12 months after the contest.Results. Cessation rates were 66% at contest end, 36% at 6 months, and 22% at 12 months. Heavier smokers were somewhat more likely to have quit. Overall, 41% of respondents used any form of aid (support resources and pharmacological aids) in the first 6 months; among these, 42% used bupropion and 38% used nicotine patches. Those using bupropion were more likely to successfully quit smoking. Successful quitters rated the social support received from their buddy as more useful than did relapsers, and social support was unrelated to the use of pharmacological aids.Conclusions. The results suggest that adequate investment in population-wide Quit and Win programs that provide a variety of appropriate aids to smokers, including social support and pharmacological products, can improve the reach of smokers. [Copyright &y& Elsevier]

Objectives: The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provided clinicians with pragmatic treatment recommendations for bipolar disorder (BD). While these guidelines included commentary on how mixed features may direct treatment selection, specific recommendations were not provided-a critical gap which the current update aims to address., Method: Overview of research regarding mixed presentations in BD, with treatment recommendations developed using a modified CANMAT/ISBD rating methodology. Limitations are discussed, including the dearth of high-quality data and reliance on expert opinion., Results: No agents met threshold for first-line treatment of DSM-5 manic or depressive episodes with mixed features. For mania + mixed features second-line treatment options include asenapine, cariprazine, divalproex, and aripiprazole. In depression + mixed features, cariprazine and lurasidone are recommended as second-line options. For DSM-IV defined mixed episodes, with a longer history of research, asenapine and aripiprazole are first-line, and olanzapine (monotherapy or combination), carbamazepine, and divalproex are second-line. Research on maintenance treatments following a DSM-5 mixed presentation is extremely limited, with third-line recommendations based on expert opinion. For maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy or combination) is first-line, and lithium and olanzapine identified as second-line options., Conclusion: The CANMAT and ISBD groups hope these guidelines provide valuable support for clinicians providing care to patients experiencing mixed presentations, as well as further influence investment in research to improve diagnosis and treatment of this common and complex clinical state., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Study Objectives: Concomitant patterns of sleep aid use may provide insight for understanding the transition to chronic sleep medication use. Therefore, we sought to characterize the trajectories of concomitant natural product (NP), over-the-counter (OTC), and prescribed (Rx) sleep aid use in a population-based sample over 12-months., Methods: Self-reported data on the use of NP, OTC, and Rx sleep aids were extracted from a Canadian longitudinal study on the natural history of insomnia (N = 3416, M age = 49.7 ± 14.7 years old; 62% women) at baseline, 6-month, and 12-month. Latent class growth modeling was used to identify latent class trajectories using MPlus Version 7. Participants completed a battery of clinical measures: Ford Insomnia Response to Stress Test, abbreviated Dysfunctional Beliefs and Attitudes about Sleep Scale, Beck Depression Inventory, Insomnia Severity Index and, the Pittsburgh Sleep Quality Index. Associations between class membership and baseline covariates were evaluated., Results: Concurrent sleep aid use fell into six distinct latent class trajectories over a 12-month period: Minimal Use (74.5%), Rx-Dominant (11.3%), NP-Dominant (6.3%), OTC-Dominant (4.3%), Rx-NP-Dominant (2.4%), and Rx-OTC-Dominant (1.1%). The three latent classes with prominent prescribed agent use predicted greater incidence of healthcare professional consultations for their sleep (p < 0.05), poorer sleep quality (p < 0.001), elevated dysfunctional sleep beliefs (p < 0.001), and sleep reactivity (p < 0.001). Compared to the other four latent classes, clinical profiles of Rx-NP-dominant and Rx-OTC-dominant groups endorsed greater severity across measures., Conclusions: Patterns of sleep aid use may provide insight for identifying individuals who may be vulnerable to inappropriate self-medicating practices., (© Sleep Research Society 2021. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To review the drug treatment of Alzheimer's disease (AD) and to provide guidelines for the physician on how to integrate these treatments into the overall management of this disorder.Method: A qualitative review of randomized, double-blind, placebo-controlled trials of medications used to treat cognitive deficits, disease progression, agitation, psychosis, or depression in AD. A computerized search of Medline was used to identify relevant literature published during the period 1968-1998. Key words used in the search were 'randomized controlled trials,' with 'dementia' and with 'Alzheimer's disease'.Results: Agents that are currently available in Canada to treat the cognitive deficits of AD include donepezil, ginkgo biloba, selegiline, and ergoloid mesylates. Donepezil and ginkgo biloba are associated with a statistically significant but clinically modest improvement in cognitive function in a substantial minority of patients with mild to moderate AD. Selegiline may have a mild beneficial effect on cognitive function in some patients with AD, but the data are inconclusive. Ergoloid mesylates have questionable efficacy in AD and can only be recommended as a last line of treatment. The results of a single trial suggest that vitamin E or selegiline (both have antioxidant properties) may slow the progression of AD. Antipsychotic medications can result in clinically significant improvement in agitation and psychosis. Carbamazepine also appears to be an effective treatment for agitation in AD, and there is preliminary evidence that the selective serotonin reuptake inhibitor citalopram reduces irritability in this disorder. There is no evidence that other nonneuroleptic medications are more efficacious than placebo in treating agitation in AD. Limited data indicate that depression in dementia responds to antidepressant medication.Conclusion: These data indicate that selected medications can be used to treat cognitive deficits, disease progression, agitation, psychosis, and depression in AD. However, there is considerable heterogeneity in patients' responses to these medications. Pharmacotherapy needs to be considered as a component of a package of care that also includes psychosocial and environmental interventions and support of the caregiver. [ABSTRACT FROM AUTHOR]

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective/background: Lemborexant is a dual orexin receptor antagonist approved in the United States, Japan, and Canada for the treatment of insomnia in adults. We report effectiveness and safety outcomes in subjects with insomnia who received up to twelve months of continuous lemborexant treatment in Study E2006-G000-303 (Study 303; SUNRISE-2)., Patients/methods: Study 303 was a twelve-month, global, multicenter, randomized, double-blind, parallel-group, Phase 3 study divided into two treatment periods. In Treatment Period 1 (first six months), subjects (n = 949, Full Analysis Set) were randomized to daily placebo, lemborexant 5 mg (LEM5) or lemborexant 10 mg (LEM10). In Treatment Period 2 (second six months), placebo subjects were rerandomized to LEM5 or LEM10, and subjects randomized to lemborexant continued their assigned treatment (LEM5, n = 251; LEM10, n = 226). Sleep onset and sleep maintenance endpoints were analyzed from daily electronic sleep diary data. Treatment-emergent adverse events (TEAEs) were monitored., Results: For all sleep parameters, the significant benefits observed with LEM5 and LEM10 versus placebo over six months were maintained at twelve months in subjects who received twelve continuous months of treatment. There was no evidence of rebound insomnia or withdrawal in either lemborexant group following treatment discontinuation. Over twelve months of lemborexant treatment, most TEAEs were mild/moderate; the most common TEAEs were nasopharyngitis, somnolence and headache., Conclusions: LEM5 and LEM10 had significant benefit on sleep onset and sleep maintenance compared with placebo, and importantly, lemborexant effectiveness persisted at twelve months, suggesting that lemborexant may provide long-term benefits for subjects with insomnia., Clinical Trial Registration: ClinicalTrials.gov, NCT02952820; ClinicalTrialsRegister.eu, EudraCT Number 2015-001463-39., (Copyright © 2021 Eisai Inc. Published by Elsevier B.V. All rights reserved.)

This paper presents an introduction to the phase two series of papers by the 14 nation International Obsessive-Compulsive Disorders Task Force (ATF) of the Canadian Institute for Obsessive Compulsive Disorders. These papers present evidence-based knowledge and competency standards developed by the ATF for specialized treatments for obsessive-compulsive disorder (OCD) through the lifespan, operationalized as clinician abilities. Specialty standards for OCD do not currently exist and are deemed by experts to be foundational to transformative improvement globally in quality and accessibility of evidence-based treatments for this crippling disorder. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to this disorder. The ATF standards encompass specialized cognitive behavior therapy, and pharmacotherapy, for pediatric and adult OCD. Evidence-based methodology with integration of expert opinion are described. Upcoming ATF phases three and four will involve development and implementation of training criteria and processes for certification (individual clinicians) and accreditation (clinical sites) based on the ATF standards. These standards will require periodic review and updating commensurate with advances in clinical research. We hope that this international initiative constitutes a significant step forward to inform and advance evidence-based specialized treatment and training for OCD., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Fasting from dawn to dusk during Ramadan, including abstaining from water and food, is 1 of the pillars of Islam and is observed by the majority of Muslims. Most research concerning diabetes and fasting during Ramadan originates from Middle Eastern or South Asian countries; however, differences exist in hours of work and fasting, pharmacotherapy and blood glucose monitoring between these countries and Canada., Methods: An expert forum of 7 Canadian experts and 1 international expert collaborated to develop Canadian guidelines using the same evidence-based principles, with the exception of an independent methods review used for the Diabetes Canada clinical practice guidelines. Diabetes Canada scientific leadership and Canadian health-care providers performed independent external reviews. Religious leaders endorsed the position statement and provided letters of support. An informed patient participated in the position-statement development. Each recommendation was approved with 100% consensus of the expert forum., Results: Recommendations for risk stratification, education, pharmacotherapy and blood glucose monitoring for adults with type 1 and type 2 diabetes who intend to fast during Ramadan have been developed., Conclusions: This is the first Canadian position statement on the topic of Ramadan fasting and diabetes. It was developed by an expert faculty and endorsed by Diabetes Canada, and provides guidance about pharmacotherapy and glucose monitoring for health-care providers so that they can assist Canadian Muslims living with diabetes to observe fasting during Ramadan safely., (Copyright © 2019. Published by Elsevier Inc.)

Objective: There is a lack of definitive pediatric literature on effective pharmacotherapy for persistent post-concussion headache symptoms. This study assessed whether acute metoclopramide treatment in the Emergency Department (ED) was associated with a reduction in persistent headache in children at 1- and 4-weeks post-concussion., Methods: Children aged 8-17years with acute concussion presenting to 9-Canadian Pediatric EDs were enrolled in a prospective cohort study, from August 2013-June 2015. Primary and secondary outcomes were persistent headache at 1- and 4-week post-injury respectively. Headache persistence was based on the one and four-week headache scores minus recalled pre-injury score using the Post-Concussion Symptom Inventory. The association between metoclopramide and headache persistence at 1- and 4-weeks were examined using unadjusted and adjusted regression and 1:4 propensity score matching model., Results: Baseline assessments were completed in 2095 participants; 65 (3.1%) received metoclopramide within 48-hours of injury. At 1- and 4-weeks, 54% (963/1808) and 26% (456/1780) of participants had persistent headache relative to baseline respectively. In unadjusted analysis, no association between metoclopramide and headache persistence at 1-week was found [treated vs. untreated: 1-week (53% vs. 53%; relative risk (RR)=1.0 (95%CI: 0.8, 1.3); 4-weeks (27.3% vs. 25.6%; RR=1.0 (95% CI: 0.9, 1.2)]. Metoclopramide was not associated with lower headache risk on propensity score matching [treated vs. untreated: 1-week, n=220 (52% vs. 59.4%; RR=0.8 (95%CI: 0.6, 1.2) and 4-weeks, n=225 (27.1% vs. 32.8%; RR=0.9 (95%CI: 0.8, 1.1)]., Conclusion: Metoclopramide administration was not associated with a reduction in headache persistence in children seeking ED care due to a concussion. Further research is necessary to determine which pharmacotherapies may be effective for acute and persistent post-concussive headache., (Copyright © 2018 Elsevier Inc. All rights reserved.)

To examine postpartum recurrence rates of depression comparing women receiving antidepressant treatment to women not being treated with psychotropic medication. This was a prospective study of 130 women with major depressive disorder (MDD) who attended a tertiary care perinatal clinic during and after pregnancy. Depression recurrence was defined as a score of 13 or more on the Edinburgh Postnatal Depression Scale (EPDS) or a score of greater than 13 on the Hamilton Depression Rating Scale (HDRS). Over half of women (56.9%) were not receiving medication during pregnancy to treat their mood disorder, with the rate of medication use increasing over the 1-year postpartum period. When comparing women being treated with antidepressant medication (monotherapy or combination therapy) to women receiving no psychotropic medication, no significant differences in recurrence rates were observed during the postpartum period. However, we did observe that the occurrence of depression in our sample fluctuated between rates comparable to general population estimates to rates that were at times more than twofold higher, regardless of treatment with antidepressant medication. The findings of this study align with research which suggests that the postpartum period is a particularly vulnerable time for recurrence of depression. Moreover, our results suggest that this remains the case regardless of antidepressant treatment.

The World Health Organization ranks obsessive compulsive disorder (OCD) among the leading causes of worldwide medical disability. Affecting approximately 3% of the population, OCD, with its damaging effect on psychosocial function, is among the most severe and impairing of mental disorders. In Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), OCD and related disorders form a separate classification, consistent with convergent research that indicates OCD is distinct from anxiety disorders in psychopathology and treatment requirements. Although evidence-based treatments have been developed for OCD, these are not accessible to many sufferers. Timely evidence-based treatment is recommended to avoid unnecessary progression to chronicity, disability, and intransigence of symptoms. Improvement in existing training models is needed to disseminate advanced specialty clinical skills to optimize illness recovery. This special series by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) Accreditation Task Force (ATF) critically reviews evidence-based psychological and pharmacological treatments for OCD throughout the lifespan. The ATF mandate is to establish specialty OCD certification/accreditation standards and competencies. This pioneering initiative aims to achieve transformational change in accessibility to evidence-based clinical care so urgently needed for young people and adults suffering from OCD., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Abstract: Background: In 2001, the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT) partnered to produce evidence-based clinical guidelines for the treatment of depressive disorders. A revision of these guidelines was undertaken by CANMAT in 2008–2009 to reflect advances in the field. Methods: The CANMAT guidelines are based on a question–answer format to enhance accessibility to clinicians. An evidence-based format was used with updated systematic reviews of the literature and recommendations were graded according to Level of Evidence using pre-defined criteria. Lines of Treatment were identified based on criteria that included Levels of Evidence and expert clinical support. This section on “Pharmacotherapy” is one of 5 guideline articles. Results: Despite emerging data on efficacy and tolerability differences amongst newer antidepressants, variability in patient response precludes identification of specific first choice medications for all patients. All second-generation antidepressants have Level 1 evidence to support efficacy and tolerability and most are considered first-line treatments for MDD. First-generation tricyclic and monoamine oxidase inhibitor antidepressants are not the focus of these guidelines but generally are considered second- or third-line treatments. For inadequate or incomplete response, there is Level 1 evidence for switching strategies and for add-on strategies including lithium and atypical antipsychotics. Limitations: Most of the evidence is based on trials for registration and may not reflect real-world effectiveness. Conclusions: Second-generation antidepressants are safe, effective and well tolerated treatments for MDD in adults. Evidence-based switching and add-on strategies can be used to optimize response in MDD that is inadequately responsive to monotherapy. [Copyright &y& Elsevier]