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Objective: Electroconvulsive therapy (ECT) is an effective treatment for mood and other psychiatric disorders. Despite widespread use, the specifics of ECT practice in Canada are largely unknown. A nationwide survey designed to document current delivery was therefore conducted., Method: One hundred seventy-five Canadian ECT delivery sites were identified. A detailed questionnaire (13 pages, 76 questions grouped in 11 subheadings) was developed, translated into French, piloted, and then forwarded to all ECT centers., Results: Return rate for the full questionnaire was 61%. Wide-ranging information pertaining to ECT was gathered. This article, which addresses the data specifically pertaining to ECT devices, electrical stimulus parameters and electrode placements, showed that many core aspects of ECT practice in Canada are in keeping with current recommendations. The use of old sine wave devices is virtually nonexistent. Electroencephalographic (EEG) monitoring of seizures is widespread., Conclusions: Specific concerns were identified, including the need for access to back-up devices at all centers, the lack of ECT credentialing requirements by Canadian hospitals, and a striking variation in dosing practices. An audit of Canadian practice and the development of a National Standards Document would be an essential next undertaking.

Neurocognitive impairments are observed in depression and associated with poor functioning. This study examined the efficacy and the effectiveness of cognitive remediation with supplemental Internet-based homework in treatment-resistant depression. Participants were randomized to treatment or wait list control conditions. Treatment consisted of 10 weeks of weekly group sessions and daily online cognitive exercises completed at home. The participants were assessed on cognitive, mood, motivation, and functioning measures. There was a significant time by treatment interaction for attention/processing speed and verbal memory. Changes in functioning were not significant, although improved cognition predicted improvements in functioning. Number of minutes of online exercise was associated with greater cognitive improvements. Cognitive deficits are malleable with behavioral treatment in a mood disorder characterized by severe and persistent symptoms.

Objectives: This study investigated the effect of ziprasidone augmentation therapy on sleep architecture in bipolar depression., Methods: We conducted a double-blind, randomized, placebo-controlled clinical pilot trial of ziprasidone versus placebo in Diagnostic and Statistical Manual of Mental Disorders, fourth edition bipolar disorder with current major depressive episode. The effects during acute (2-5 days) and continuation treatment (28-31 days) were measured. Main outcomes were sleep architecture variables including rapid eye movement sleep (REM) and slow wave sleep (SWS) measured by polysomnography. Secondary outcomes included subjective sleep quality measures and illness severity measures including the 17-item Hamilton Depression Rating Scale (HAMD-17), Montgomery Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Rating Scale (HAMA) and Clinical Global Illness Severity (CGI-S) scores., Results: The completer analysis comprised of 14 patients (ziprasidone, N = 8 and placebo, N = 6). Latency to REM, duration of SWS, duration of stage 2 sleep, total sleep time, onset to sleep latency, number of awakenings and overall sleep efficiency significantly improved in ziprasidone-treated participants over placebo. CGI-S and HAMA scores also significantly improved. No significant difference between treatment groups was seen on the HAMD-17, MADRS or in self-reported sleep quality. Increase in SWS duration significantly correlated with improvement in CGI-S, however, this finding did not withstand Bonferroni correction., Conclusion: Adjunctive ziprasidone treatment alters sleep architecture in patients with bipolar depression, which may partially explain its mechanism of action and merits further investigation.

Aim: The objective of this study was to present survey data on the teaching of electroconvulsive therapy (ECT) in health care centers across Canada., Methods: Of 1273 centers identified, 175 were found to practice ECT. These centers were asked to complete a questionnaire, and 107 (61%) of them answered 5 questions dealing specifically with ECT teaching. These questions were as follows: (1) Does your facility have an ECT teaching program for residents in psychiatry? (2) How is ECT taught to residents in psychiatry? (3) If direct supervision of the administration of ECT is a requirement of the psychiatry training program, is there a minimum number of supervised treatments or minimum duration of training period? (4) Do residents provide unsupervised ECT at your center? (5) Which other groups of learners, if any, are provided with orientation, teaching, or training in ECT?, Results: Sixty percent of respondents had no ECT teaching program for psychiatry residents. Pedagogical methods varied, ranging from direct observation of ECT treatments to directed readings. Few centers required a minimum number of supervised treatments. No resident-administered ECT is performed without direct supervision. Interestingly, various groups of health care professionals were often invited to participate in ECT training., Conclusions: The situation regarding ECT teaching continues to be a cause for concern given the noted absence of organized, structured, and mandatory programs. No resident administering ECT, however, goes unsupervised, which is in keeping with good practice. Electroconvulsive therapy is taught in many different ways, and teaching is accessible to different groups of health care professionals. However, much remains to be done to standardize ECT teaching to render this therapy available to all those who need it and to overcome the stigma and bias associated with it.

Treatment-resistant depression (TRD) refers to a condition where individuals with major depressive disorder have inadequate or no response to treatment. Although functional disability is a prominent and costly feature of treatment resistance, very little is known about the factors that contribute to and maintain functional impairment in TRD. This is the first study to report the neurocognitive profile of TRD and the relationships among neurocognition, symptoms, and functioning in this syndrome. Results indicated that patients with TRD (N = 33) exhibit mildly reduced performance across all neurocognitive domains with a superimposed moderate impairment in verbal working memory. Neurocognition was associated with functional competence (what one can do), whereas depressive symptoms were associated with functional performance (what one actually does). Understanding the psychological mechanisms related to functioning may help us move toward recovery in this chronically ill group.

The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options., (© 2012 John Wiley and Sons A/S.)

A bidirectional relationship exists between diabetes mellitus (DM) and major depressive disorder (MDD), with depression commonly reported in both type 1 DM (T1DM) and type 2 DM (T2DM), and depressive symptoms associated with a higher incidence of diabetes. However, how the two conditions are pathologically connected is not completely understood. Similar neurophysiological abnormalities have been reported in both DM and MDD, including elevated electroencephalographic (EEG) activity in low-frequency slow waves and increased latency and/or reduced amplitude of event-related potentials. It is possible that this association reflects some common underlying pathology, and it has been proposed that diabetes may place patients at risk for depression through a biological mechanism linking the metabolic changes of DM to changes in the central nervous system. In this review we will discuss EEG abnormalities in DM, as well as the biological mechanisms underlying various EEG parameters, in order to evaluate whether or not a common EEG biosignature exists between DM and MDD. Identifying such commonalities could significantly inform the current understanding of the mechanisms that subserve the development of the two conditions. Moreover, this new insight may provide the basis for informing new drug discovery capable of mitigating and possibly even preventing both conditions.

Background: Many people with mental illness experience stigma that has impacted their lives. In this study, we validated the Inventory of Stigmatizing Experiences (ISE) as a tool to help quantify the stigma experienced by patients with bipolar disorder and its impact on their lives. The ISE has two components, ie, the Stigma Experiences Scale (SES) and the Stigma Impact Scale (SIS), which were administered to a population of Argentinean patients with bipolar disorder. We characterized the differences between these two populations using the SES and SIS. Finally, we compared SES and SIS scores with those in a population of Canadian patients with bipolar disorder., Methods: The SES and SIS scales were administered to tertiary care patients with bipolar I and II disorder in Argentina (n = 178) and Canada (n = 214)., Results: In this study, we validated both SES (Kuder-Richardson coefficient of reliability, 0.78) and SIS (Cronbach's alpha, 0.91) scales in a population of Argentinean patients with bipolar disorder. There were no significant differences in stigma between patients with bipolar I or II disorder on SES or SIS. However, over 50% of all respondents believed that the average person is afraid of those with mental illnesses, that stigma associated with mental illness has affected their quality of life, and that their self-esteem has suffered due to stigma. In comparison with the Canadian population, Argentinean participants scored lower on both the SES and SIS, which may be due to cultural differences or to differences in population characteristics., Conclusion: Stigma associated with mental illness is serious and pervasive. If we are to find successful strategies to mitigate stigma, it is first important to understand how patients perceive such stigma. The ISE is a valuable tool which allows us to do this with high reliability among cultures.

Objectives: We report on the anesthesia subsection of a comprehensive nationwide survey (Canadian Electroconvulsive Therapy Survey/Enquête canadienne sur les electrochocs) on the practice of electroconvulsive therapy (ECT) in Canada., Methods: This comprehensive survey was sent to the 175 Canadian institutions identified as providers of ECT in 2007. Among other topics, 9 anesthesia-related questions were administered regarding anesthesiology consultation; high-risk patients; credentials of the anesthesia provider; monitoring, airway, and resuscitation equipment; anesthetic induction, muscle relaxant, vasoactive, and other perianesthetic drugs and practices; and postanesthetic discharge., Results: Sixty-one percent (107/175) of the institutions returned completed survey questionnaires. More than 70% of the sites reported pre-ECT anesthesiology consultation for all (61%) or most (11%) patients. In more than 90%, a Canadian Royal College-certified anesthesiologist, or equivalent, provided anesthetic care. Routine use of oximetry, electrocardiography, and blood pressure monitoring were reported by all but 2 sites; use of bite block was reported by all but 4 sites; and preoxygenation was reported by all but 7 sites. Dantrolene and capnography were not reported as readily available by 35% and 40%, respectively, with comparatively less frequent availability at non-operating room and lower-volume sites., Conclusions: These results suggest safe practices of anesthesia for ECT in Canada. Further attention needs to be paid to ready availability of dantrolene and capnography, particularly at non-operating room ECT sites. Improvements in anesthetic care of patients undergoing ECT may be realized through continued knowledge translation efforts and by expanding access to currently unavailable anesthetic induction agents and, in some settings, limited clinical anesthesiology resources.

Objective: To report the results of the policies and procedures subsection of a nationwide electroconvulsive therapy (ECT) survey: Canadian Electroconvulsive Therapy Survey/Enquête canadienne sur les electrochocs., Method: We contacted 1273 registered health care institutions in Canada and invited the 175 centres identified as providing ECT to complete a comprehensive postal questionnaire. Nonresponding sites were repeatedly reminded and then eventually contacted by telephone., Results: Sixty-one per cent (107/175) of the institutions returned survey questionnaires. Most (84%) of the responding sites have a written general policy for the delivery of ECT. Only 27% of respondents indicated having some written policy for managing concurrent medications during ECT, and practice was quite variable regarding individual psychotropics. Informed consent was usually obtained by the attending physician (88%), and most sites indicated conveying information before ECT by using interdisciplinary and multimodal means. Almost all of the sites (93%) discharged outpatients with accompaniment home by a responsible adult., Conclusions: It is reassuring to note that general ECT policies and procedures do exist in most Canadian ECT centres. Wider variations in practice were observed in several areas, such as the elements of consent provided to patients and families, the use of concurrent medications, and the degree of supervision on discharge home after outpatient ECT. However, adherence to these policies was not captured by the results of the survey. Based on experiences in other countries, establishing a Canadian ECT accreditation service could further improve standards of practice.

The management of depression remains a constant challenge in clinical practice. This is largely due to the fact that initial treatments frequently do not lead to remission and recovery. The current treatment approach involves lengthy trial-and-error periods. It would be beneficial to have early reliable predictors to determine whether patients will respond to treatment or not. Electroencephalography (EEG) derived biomarkers namely change in the activity of EEG frequency bands, hemispheric alpha asymmetry, theta cordance, the antidepressant treatment response index (ATR) and evoked potentials have all been shown to predict response to a variety of antidepressant medications. However, the neurobiology in support of this association has been largely unexplored. In this review, we discuss biological mechanisms for each EEG derived biomarker predictive of treatment response. Validating such biomarkers will not only greatly aid clinicians in selecting antidepressant treatment for individual patients but will also provide a critical step in drug discovery., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: Brain-derived neurotrophic factor (BDNF) levels are decreased in individuals with depression and increase following antidepressant treatment. The objective of this study is to compare pre- and post-treatment serum BDNF levels in patients with drug-resistant major depressive disorder (MDD) who received either electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS). It is hypothesized that non-pharmacological treatments also increase serum BDNF levels., Methods: This was a prospective, single-blind study comparing pre- and post-treatment serum BDNF levels of 29 patients with drug-resistant MDD who received ECT or rTMS treatment. Serum BDNF levels were measured 1 week prior to and 1 week after treatment using the sandwich ELISA technique. Depression severity was measured 1 week before and 1 week after treatment using the Hamilton Depression Rating Scale. Two-sided normal distribution paired t-test analysis was used to compare pre- and post-treatment BDNF concentration and illness severity. Bivariate correlations using Pearson's coefficient assessed the relationship between post-treatment BDNF levels and post-treatment depression severity., Results: There was no significant difference in serum BDNF levels before and after ECT, although concentrations tended to increase from a baseline mean of 9.95-12.29 ng/ml after treatment (p = 0.137). Treatment with rTMS did not significantly alter BDNF concentrations (p = 0.282). Depression severity significantly decreased following both ECT (p = 0.003) and rTMS (p < 0.001). Post-treatment BDNF concentration was not significantly correlated with post-treatment depression severity in patients who received either ECT (r = -0.133, p = 0.697) or rTMS (r = 0.374, p = 0.126). It is important to note that these results are based on the small number of patients included in this study., Conclusion: This study suggests that ECT and rTMS may not exert their clinical effects by altering serum BDNF levels in patients with drug-resistant MDD. Serum BDNF concentration may not be a biomarker of ECT or rTMS treatment response.

Identifying biological and clinical markers of treatment response in depression is an area of intense research that holds promise for increasing the efficiency and efficacy of resolving a major depressive episode and preventing future episodes. Collateral benefits include decreased healthcare costs and increased workplace productivity. Despite research advances in many areas, efforts to identify biomarkers have not revealed any consistently validated candidates. Studies of clinical characteristics, genetic, neuroimaging, and various biochemical markers have all shown promise in discrete studies, but these findings have not translated into a personalized medicine approach to treating individual patients in the clinic. We propose that an integrated study of a range of biomarker candidates from across different modalities is required. Furthermore, advanced mathematical modeling and pattern recognition methods are required to detect important biological signatures associated with treatment outcome. Through an informatics-based integration of the various clinical, molecular and imaging parameters that are known to be important in the pathophysiology of depression, it becomes possible to encompass the complexity of contributing factors and phenotypic presentations of depression, and identify the key signatures of treatment response.

Objectives: We sought to determine factors governing access to electroconvulsive therapy (ECT) in Canada., Methods: We contacted all 1273 registered health care institutions in Canada and invited the 175 centers identified as providing ECT to complete a comprehensive questionnaire. To determine geographic access to ECT, we used a geographic information system, population density data, and road network data. Responses to 5 questions from the questionnaire were used to identify local barriers to access., Results: Approximately 84% of the population in the 10 Canadian provinces live within a 1-hour drive of an ECT center, but 5% live more than 5 hours' drive away. There was significant province-to-province variation, with all of the citizens of Prince Edward Island living within 2 hours of an ECT center but 12.5% of those in Newfoundland and Labrador living more than 5 hours' distance away. There are no ECT services at all in the 3 territories, which contain 3% of the Canadian population. Nongeographic barriers to access included inadequate human resources, particularly, a lack of anesthesiologists, in 59% of the centers; logistical impedances (52%); space limitations (45%); strictures on the hiring of adequate staff (29%); imposed limits to number of treatments or to operating or postanesthetic room time (28%); and a lack of funds to purchase up-to-date ECT or related anesthesiology equipment (14%)., Conclusions: Electroconvulsive therapy is geographically accessible for most Canadians. Even when geography is not a factor, however, there are significant barriers to access resulting from inadequate availability of qualified professional staff, treatment areas, and funding.

Background: Major depressive disorder (MDD) is associated with significant impairment in quality of life and psychosocial functioning, including social and occupational/role functioning. Evaluation of clinical effectiveness of treatments for depression must include improvement in these important functional outcomes. However, clinical trials for depression have primarily focused on reduction in symptoms, as measured by symptom severity scales such as the HDRS and MADRS or by standard definitions of response and remission., Method: The rationale and necessity for accessing both symptom and functional outcomes in clinical trials for MDD are reviewed, and examples of validated scales for measuring QoL and social and occupational functioning are provided., Results: Emerging data suggest that treatment effects assessed with functioning scales may differ from those captured by symptoms scales. Many validated scales are available to measure global and specific aspects of functional outcomes, including QoL, psychosocial functioning and occupational functioning. Nevertheless, systematic reviews have shown that functional outcome scales are used in fewer than 5% of trials., Conclusions: Given the importance of psychosocial functioning for the individual with MDD as well as for society, greater attention must be focused on the assessment of functional outcomes in clinical trials for MDD, as well as in the clinical management of people with depression., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: The purpose of our study was to assess the knowledge, social distance and perception of social discrimination towards persons with schizophrenia in the general adult population of Buenos Aires, Argentina., Methods: One thousand two-hundred fifty-four persons were surveyed at different neighborhoods of the city of Buenos Aires. Their knowledge about schizophrenia, personal social distance and perception of social discrimination were assessed with several questions. Afterwards, a scale for each one of these measures was built., Results: Almost half of the general population believed that patients with schizophrenia suffer from split personality and that most of them are dangerous and violent. Knowledge about schizophrenia in the general population was moderate and it was associated with age and education. Almost 80% of the population had less than one-third of the maximum possible social distance score, but their perception of social discrimination was high. Social distance was greater in the elderly. Knowledge was correlated weakly with social distance. Respondents directly related with patients suffering from schizophrenia were more knowledgeable about the illness, but had the same social distance and perception of social discrimination than the rest of the general population., Conclusions: The persons surveyed felt their own attitudes are more favorable to people with schizophrenia than 'most other people's' attitudes. The elderly should be specifically addressed in specially designed anti-stigma campaigns.

Objective: To determine the effect of adjunctive quetiapine therapy on the sleep architecture of patients with bipolar or unipolar depression., Methods: This is a prospective, single-blind, repeated measures polysomnographic study. Sleep architecture was analyzed by overnight polysomnography, and subjective sleep quality was measured using the Pittsburgh Sleep Quality Index. The Hamilton Rating Scale for Depression, Montgomery Asberg Depression Rating Scale, Young Mania Rating Scale, and Clinical Global Impression-Severity Scale were employed to quantify changes in illness severity with adjunctive quetiapine treatment. Polysomnographs and clinical measures were administered at baseline, after 2-4 days of treatment, and after 21-28 days of quetiapine treatment. The average dose of quetiapine was 155 mg, ranging from 100-200 mg., Results: Adjunctive quetiapine therapy did not significantly alter sleep efficiency, sleep continuity, or Pittsburgh Sleep Quality Index scores. Respiratory Disturbance Index and percentage of total time in rapid eye movement (REM) sleep significantly decreased and the percentage of total time in non-REM sleep, and duration of Stage 2 and non-REM sleep significantly increased after 2-4 days of quetiapine treatment. Illness severity significantly decreased over time., Conclusions: Adjunctive quetiapine treatment alters sleep architecture in patients with major depressive disorder or bipolar disorder, which may partially explain its early antidepressant properties. Changes in sleep architecture are more robust and significant within two to four days of starting treatment.

Objective: To investigate the frequency of gambling in people who have been diagnosed with major depressive disorder (MDD) or bipolar disorder (BD). Secondary objectives were to examine: sex differences in the rates of gambling behaviour, the temporal relation between onset of mood disorders and problem gambling, psychiatric comorbidities associated with problem gambling, and the influences of problem gambling on quality of life., Method: People (aged 18 years and older) who met criteria for lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision-defined MDD or BD I or II, and were confirmed by the Mini International Neuropsychiatric Interview, were enrolled. Participants were recruited from 5 sites in Canada and 1 in the United States. Prevalence of past-year problem gambling was assessed with the Canadian Problem Gambling Index. Associated comorbidities with problem gambling are presented., Results: A total of 579 participants were enrolled (female: n = 379, male: n = 200). Prevalence of problem gambling did not differ significantly between the MDD (12.5%) and the BD (12.3%) groups. There was a significant difference in the prevalence of problem gambling between males (19.5%) and females (7.8%) in the BD group (chi-square = 8.695, df = 1, P = 0.003). Among people meeting criteria for problem gambling, the mood disorder was the primary onset condition in 71% of cases. People with a mood disorder with comorbid current panic disorder (OR = 1.96; 95% CI 1.02 to 3.75), obsessive-compulsive disorder (OR = 1.86; 95% CI 1.01 to 3.45), specific phobia (OR = 2.36; 95% CI 1.17 to 4.76), alcohol dependence (OR = 5.73; 95% CI 3.08 to 10.65), or lifetime substance dependence (OR = 2.05; 95% CI 1.17 to 3.58), had significantly increased odds of problem gambling. Problem gambling across MDD and BD populations was also associated with lower quality of life ratings., Conclusion: These results reaffirm a higher prevalence of gambling both in BD and in MDD populations, compared with previously published community samples. Our study also identifies risk factors for gambling behaviours within these populations.

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. There is renewed interest in refined approaches to brain stimulation, particularly for treatment resistant major depressive disorder (MDD)., 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 evidence and expert clinical support. This section on "Neurostimulation Therapies" is one of 5 guidelines articles., Results: Among the four forms of neurostimulation reviewed in this section, electroconvulsive therapy (ECT) has the most extensive evidence, spanning seven decades. Repetitive transcranial magnetic (rTMS) and vagus nerve stimulation (VNS) have been approved to treat depressed adults in both Canada and the United States with a much smaller evidence base. There is also emerging evidence that deep brain stimulation (DBS) is effective for otherwise treatment resistant depression, but this is an investigational approach in 2009., Limitations: Compared to other modalities for the treatment of MDD, the data based is limited by the relatively small numbers of randomized controlled trials (RCTs) and small sample sizes., Conclusions: There is most evidence to support ECT as a first-line treatment under specific circumstances and rTMS as a second-line treatment. Evidence to support VNS is less robust and DBS remains an investigational treatment.

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.

The Canadian Network for Mood and Anxiety Treatments (CANMAT) published guidelines for the management of bipolar disorder in 2005, with a 2007 update. This second update, in conjunction with the International Society for Bipolar Disorders (ISBD), reviews new evidence and is designed to be used in conjunction with the previous publications. The recommendations for the management of acute mania remain mostly unchanged. Lithium, valproate, and several atypical antipsychotics continue to be first-line treatments for acute mania. Tamoxifen is now suggested as a third-line augmentation option. The combination of olanzapine and carbamazepine is not recommended. For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. New data support the use of adjunctive modafinil as a second-line option, but also indicate that aripiprazole should not be used as monotherapy for bipolar depression. Lithium, lamotrigine, valproate, and olanzapine continue to be first-line options for maintenance treatment of bipolar disorder. New data support the use of quetiapine monotherapy and adjunctive therapy for the prevention of manic and depressive events, aripiprazole monotherapy for the prevention of manic events, and risperidone long-acting injection monotherapy and adjunctive therapy, and adjunctive ziprasidone for the prevention of mood events. Bipolar II disorder is frequently overlooked in treatment guidelines, but has an important clinical impact on patients' lives. This update provides an expanded look at bipolar II disorder.

Unlabelled: The antidepressant effects of repetitive transcranial magnetic stimulation (rTMS) are well documented, but studies to date have produced heterogeneous results in late-life depression., Objective: To address this matter, we evaluated the efficacy of both high- and low-frequency rTMS delivered to the prefrontal cortex of older adults with treatment-resistant major depression., Methods: Forty-nine older adults (69 +/- 6.7 years) with treatment-refractory major depressive disorders underwent a series of rTMS treatments as an adjuvant to pharmacotherapy. Patients received high-frequency rTMS delivered to the left dorsolateral prefrontal cortex, low-frequency stimulation to the right dorsolateral prefrontal cortex, or a combination thereof, at 80-110% of the motor threshold., Results: There was a modest, but statistically significant, mean reduction (24.7%) in Hamilton Depression Rating Scale (HDRS) scores from baseline to the end of treatment. Nine patients were classified as responders (50% HDRS reduction), and 4 patients reached remission status (final HDRS score <8). Similar improvements in HDRS scores were observed for high- and low-frequency rTMS. Treatment was generally well tolerated, and no serious adverse effects were reported., Conclusions: The findings support the contention that in older adults with treatment-refractory depression, rTMS can be an effective treatment alternative for some patients.

Primary polydipsia, excessive fluid intake without medical cause, is present in over 20% of seriously and persistently ill psychiatric inpatients. The long-term effects of primary polydipsia on longevity have not previously been examined. Inpatients in a psychiatric hospital were screened for polydipsia in 1985. Those identified to be polydipsic, the majority of whom suffered from schizophrenia, were re-evaluated in 2005 and compared with a control group of non-polydipsic patients. Chart reviews were conducted and follow-up data were obtained. Of 172 patients at the time of screening, 48 suffering from schizophrenia either had or went on to develop polydipsia; 42 non-polydipsic patients with schizophrenia from the original survey were randomly selected as controls. Primary polydipsia had a significant negative effect on longevity. The median age at death (age at which 50% of cases have died) was 59 years for polydipsic patients and 68 for non-polydipsic control patients. Adjusting for duration of schizophrenia, smoking, and diagnosis, a patient with polydipsia had a 74% greater chance of dying before a non-polydipsic patient (a hazard ratio of 2.84 [95% Confidence Interval (CI): 1.22-6.64]). Outcome was worst in patients with severe polydipsia: the median age at death was 57 years and a patient with severe polydipsia had a 75% greater chance of dying before a non-polydipsic patient (hazard ratio of 3.36 [95% CI: 1.31-8.60]). When polydipsia is associated with schizophrenia, mortality is increased in comparison to that in patients with schizophrenia who do not drink water to excess.

Background: Dementia in the elderly is a common, debilitating condition. Residents in long-term care facilities present with a number of challenging behaviors. Pharmacological management is not always helpful. Alternative approaches are needed., Methods: Multisensory stimulation (MSS) was developed to address sensory stimulation imbalance. In this pilot 24-week single-blinded, randomized controlled study, the authors examined the effect of MSS when given for 12 weeks in either 1 or 3 sessions per week with a control group., Results: There is a trend for better outcomes as measured by daily observation scales (DOS) or Clinical Global Impression-Improvement (CGI-I) with the increase of sessions of treatment per week. This became statistically significant at weeks 8 (DOS) and 12 (CGI). This difference continued for 12 additional weeks after treatment ended., Conclusions: MSS may be a useful addition to the care of elderly patients with dementia. A larger double-blind randomized control study is required.

Background: RTMS has been developed as a novel tool for treating depression but the clinical significance of this treatment has been variable, especially in the older depressed subjects., Methods: Medication-resistant depressed patients 60 years or older were treated for two weeks (10 sessions) with high-frequency rTMS delivered to the left dorsolateral prefrontal cortex at 100% of motor threshold. Each session consisted of 20 trains at 10Hz delivered in 8-second duration. The patients continued taking their psychotropic medications throughout the study., Results: Nineteen of the 20 subjects completed the trial. One subject dropped out after 8 sessions because of discomfort. The average age of our patients was 66.8 years (6 males and 14 females). Six patients responded and there was a 31.6% mean reduction in Hamilton Depression Rating Scale (HDRS) scores from baseline at the end of the treatment. There was statistically significant decrease from baseline in both HDRS and HARS scores at the end of treatment. rTMS was generally well tolerated., Conclusion: These preliminary finding suggests that rTMS may be an effective treatment alternative to a subpopulation of medication resistant older depressed patients.

Objectives: Bipolar disorder (BD) is a disabling and often chronic condition. Patients with BD suffer from depression at least one-third of the time, but they do not always respond well to conventional mood stabilizers. Attempts to treat them with antidepressants can provoke a switch to mania or increased cycling. Our open-label trial aimed to assess the long-term response of patients with bipolar depression to the addition of quetiapine to their usual treatment. Our study also sought to assess the safety and tolerability of quetiapine in patients with BD., Method: To meet inclusion criteria for the study, patients had a DSM-IV diagnosis of type I or II BD, were aged 18 years and older, currently suffered from depression with a score of > 18 on the Hamilton Depression Rating Scale (HDRS), and had no change in antidepressant use for at least 3 weeks prior to the study. We added quetiapine to patients' medication and attempted to increase the dosage to at least 400 mg daily. Outcome was measured at baseline and once monthly for 12 months on the HDRS, the Young Mania Rating Scale, the Clinical Global Impression Scale (CGI), and the Abnormal Involuntary Movement Scale., Results: There were 19 patients enrolled in the study (6 men and 13 women), 2 of whom dropped out because they could not tolerate the drug. Seventeen completed at least 2 assessments, and 7 patients completed the full 12-month trial. Data for the 17 patients (that is, last observation carried forward) at 12 months shows HDRS scores reduced from 27.2 to 12.1 and CGI scores reduced from 4.7 to 2.6., Conclusions: Quetiapine seems to be helpful to and relatively well tolerated by patients with bipolar depression when it is added to their usual treatment. There is, however, a need for controlled trials.

Purpose of Study: To investigate whether the addition of triiodothyronine (T3) helps relieve depressive symptoms in non-hypothyroid major depressive disorder patients who failed to respond to an adequate course of standard SSRI antidepressant treatments., Methods: Patients who fulfilled the DSM-IV criteria for non-psychotic major depression, able to give informed consent, and failed to show satisfactory antidepressant response after a minimum of six weeks adequate treatment were recruited. To enter the study their Hamilton Depression (17-item HAMD) score had to be 18 or more, thyroid-stimulating hormone (TSH) value within the normal range, and a normal thyrotropin releasing hormone-stimulation test (TRH-ST). All patients continued taking the same SSRI which they had been taking before they entered the study. At the completion of TRH-SH they were all started on 25 microg of T3 and the dose was increased to 50 microg within a week when tolerated; they continued the combination of T3 and the SSRI for a minimum of three weeks., Results: Twelve patients, comprising eight females and four males, entered the study. One female patient withdrew during the first week of side effects, eleven patients completed the trial. The patients ranged from 26 to 77 years of age, with the mean age for males and females being 52.3 and 45.1 years, respectively. Five patients were taking sertraline (mean dose = 130 mg/day) and 4 were taking citalopram (mean dose = 50 mg/day), two were on fluvoxamine (150 mg/day) and one patient was on 40 mg of paroxetine. The women took a mean daily dose of 40.6 microg of T3 for a mean duration of 3.75 weeks, while the men were on a mean daily dose of 43.8 mug of T3 for 3.5 weeks. T3 augmentation was associated with a statistically significant drop (p < .003) in the mean HAMD at end of the three weeks compared to baseline scores. Five patients (42%) showed >or=50% improvement on HAMD scores, with three achieving full remission (HAMD scores

Although maintenance electroconvulsive therapy (ECT) appears to be the logical choice for the prevention of relapses and recurrences in patients with refractory depression who have responded to a course of ECT, the perception of ECT's negative effect on memory continues to limit its wider use. This retrospective study of depressed patients maintained on ECT after an initial course revealed that maintenance ECT was effective in sustaining clinical improvement, particularly in patients who showed a satisfactory clinical response to the initial course of ECT, and that memory difficulties were limited and tolerable.

Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring., (Blackwell Munksgaard, 2005)

Objective: To review the literature for reported cases of mania related to discontinuing antidepressant treatment, as well as for possible explanations of this phenomenon, and to present a case report., Method: We undertook a literature review through the PubMed index, using the key words mania, antidepressant withdrawal, and antidepressants in bipolar disorder. We reviewed 11 articles featuring 23 cases. Where available, we noted and tabulated certain parameters for both bipolar disorder (BD) and unipolar depression. We use a case example to illustrate the phenomenon of mania induced by antidepressant withdrawal., Results: For patients with unipolar depression, we found 17 reported cases of mania induced by antidepressant withdrawal. Antidepressants implicated included tricyclic antidepressants (TCAs) (12/17), monoamine oxidase inhibitors (MAOIs) (2/17), trazodone (1/17), mirtazapine (1/17), and paroxetine (1/17). For patients with BD, we found 19 reported cases of mania induced by antidepressant withdrawal, including our own case example. Of these, selective serotonin reuptake inhibitors (SSRIs) (10/19), TCAs (4/19), MAOIs (2/19), and serotonin norepinephrine reuptake inhibitors (SNRIs) (2/19) were implicated., Conclusion: Our case report supports the observation of antidepressant withdrawal-induced mania in patients with BD. It is distinguishable from antidepressant-induced mania, physiological drug withdrawal, and mania as a natural course of the illness. Many theories have been put forward to explain this occurrence. Noradrenergic hyperactivity and "withdrawal-induced cholinergic overdrive and the cholinergic-monoaminergic system" are the 2 most investigated and supported models. The former is limited by poor clinical correlation and the latter by its applicability only to anticholinergic drugs.