Search

Background Multiple survey studies have demonstrated a mental health (MH) burden of COVID-19 globally. However, few studies have examined relevant risk factors for pandemic-related MH issues. Methods A link to an online survey was posted from April 8th - June 11th, 2020 which included questions regarding COVID-19 experience, perceived impact of the pandemic on life domains (e.g., social communication, finances), behavioural alterations (e.g., online activities, substance use), and MH treatment history. Current psychiatric symptom severity and impairment were evaluated using the Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and the Perceived Stress Scale. Results Overall, 632 individuals (82% female, mean age:42.04 ± 16.56) in Canada and the United States completed the survey. While few reported contracting COVID-19 (0.5%), the impact of the pandemic was evident, with a vast majority reporting anxiety around COVID-19 infecting loved ones (88%). Almost half (43%) reported previous MH treatment and 31% met criteria for GAD, 29% for MDD and 63% reported significantly high levels of stress. Female sex, younger age and past MH treatment emerged as significant predictors of these issues(p

Treatments for Adult ADHD include stimulants, two non-stimulant medications, as well as cognitive-behavioral therapy (CBT). These pharmacological agents are often associated with side effects, contributing to poor treatment adherence. Patients with ADHD have regularly stated that cannabis has helped improve their ADHD symptoms; however, scientific literature describing the effects of cannabis on symptoms of ADHD is scarce.We systematically searched MEDLINE, EMBASE, EMCARE, PsycINFO, Web of Science, Cochrane Library, and Clinicaltrials.gov. The searches included all publications in English up to June 27, 2022. We included both experimental and observational studies that assessed the effect of cannabis on ADHD symptomatology and neuropsychiatric outcomes. To synthesize our current understanding of the potential effects of cannabis use on ADHD symptoms and pathophysiology, and the effects of ADHD on cannabis use, data was extracted from each study regarding the characteristics of its population, methods used to assess both cannabis consumption and ADHD symptoms, and key findings.Our scoping review included a total of 39 studies. Only one study employed a randomized and placebo-controlled design to directly measure the effect of cannabis on ADHD, and no significant effect was observed for the study's primary outcome, the QbTest (Est = -0.17, 95% CI -0.40 to 0.07, p = 0.16). Most of the literature consists of cross-sectional studies that evaluate the association between ADHD severity and cannabis use. 15 studies addressed the neuropsychiatric effects of cannabis on ADHD by employing either a battery of neuropsychiatric tests or neuroimaging. The concentration and amount of THC and CBD used were not well measured in most of the studies. Although some studies indicated that cannabis improved ADHD symptoms, most studies indicated it worsened or had no effect on ADHD symptoms.Given the current evidence, cannabis is not recommended for people with ADHD. Limitations of the literature include the absence of objective measurements for cannabis exposure and ADHD symptoms, heterogenous definitions, oversampling, and small sample sizes.

Purpose: This study explores perceived stress (PS), mental health (MH) symptoms and internet use behaviors during early stages of the pandemic in Brazil. Methods: A questionnaire battery was posted on various internet platforms from April to July 2020. The questionnaires included various life domains, internet use behaviors, MH symptoms, PS and quality of life, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Perceived Stress Scale, Obsessive Compulsive Inventory – Revised, PTSD Checklist and Quality of Life Enjoyment and Satisfaction Questionnaire. Results: Majority of participants (n=519) reported changes to financial status (71%) and social communication (89%) and various internet use behaviors (79-89%). This sample reported elevated PS (x̄=17.09, SD=8.37, 62%), mild depression (x̄=6.44, SD=5.98) and anxiety (x̄=6.62, SD=5.37) and a significant proportion had clinically significant symptoms of MDD (25%), GAD (23%), OCD (14%), PTSD (18%) and elevated PS (62%). Elevated PS was predicted by younger age (β=-0.063, p=0.005), female sex (β=0.581. p=0.05), loss of employment (β=0.665, p=0.05), healthcare worker status (β=-0.589, p=0.005), past mental health treatment (β =0.739, p=0.005) increased social media use (β=0.591, p=0.05) and increased digital information seeking (β=0.697, p=0.05). Conclusion: Mental health providers should assess internet use habits and behaviors as a potential risk factor for heightened stress.

The mental health (MH) burden on healthcare practitioners (HCPs) is emerging as a significant cost of the pandemic, although few studies have compared the MH of HCPs in different countries.A link to an online survey was posted in the Spring of 2020 which included questions regarding perceived impact of the pandemic; current MH symptom severity and impairment was evaluated using validated scales.Overall, 1315 individuals (74% female, mean age: 42.9 + 16.4) in Canada, the United States, Brazil and Italy completed the survey. Nearly 26% met diagnostic thresholds for GAD and MDD; Italian respondents reported the lowest rates of disorder. Except for Canada, non-HCPs in each country reported higher symptom severity than HCPs. Amongst the HCPs, Canadian HCPs reported the highest rates of anxiety and depression as well as increases in alcohol and cannabis use, lower levels of perceived emotional support and more worry about themselves or their loved ones contracting COVID-19.Despite key infrastructural and COVID-19 mortality differences between the countries, the MH effects appeared to be quite similar. HCPs, with the exception of Canada, reported less impact on their mental health compared to the general population, suggesting resilience in the face of adversity.Key pointsRates of current mental health disorders were similar across Canada, the USA and Brazil but lower in Italy, yet much higher than pre-pandemic ratesNon-Healthcare Practitioners (HCPs) reported significantly higher severity on all MH scales in the overall sample. This was consistent within the USA, Brazil and Italy, however in Canada, HCPs reported higher anxiety, depression and stress symptom severity compared to Canadian non-HCPs.Canadian HCPs reported significantly higher anxiety and depression symptom severity than all other countriesCanadian HCPs also reported significantly greater increases in alcohol and cannabis use, lower levels of perceived emotional support and more worry about themselves or their loved ones contracting COVID-19 compared to HCPs in the other countries.

The global population is becoming increasingly reliant on mobile technology, with 3.5 billion smartphone users globally in 2020 with the widespread adoption of smartphones and tablets in combination with increased internet access present unique opportunities for mobile health (mHealth) applications (apps) to be utilized as novel interventions for medical conditions. Mobile apps refer to programs designed for smartphone, tablet, and other digital platforms, enabling such technologies to support medicine and public health practices (Van Ameringen, Turna, Khalesi, Pullia, & Patterson, 2017). Interest in mHealth apps has grown particularly for mental health (MH) conditions, which are becoming increasingly prevalent worldwide. The prevalence of mental illness is high in children and adolescents, ranging from 10% to 20% worldwide (World Health Organization, 2020). Unfortunately, treatment mental continuously suffers various degrees of distress and experience a lower quality of life. It is critical to overcome treatment barriers for the well-being of the global population. Improved access to MH care and alternative interventions are necessary from a public health standpoint, and mobile apps offer a promising solution. We identified six existing app evaluation models, frameworks and review sites. Results indicate there is some evidence for the efficacy of mobile MH apps, and there is evidence that these app interventions may be feasible and acceptable—however, the paucity of completed clinical trials focusing on outcomes, especially for young people, limits what we can determine about the effectiveness. Now it is repeatedly documented that these smartphone application interventions are feasible, the focus will shift to effectiveness.

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects approximately 2-7 % of children globally and is associated with a myriad of difficulties that have long-term consequences. Most children and adolescents live in low- and middle-income countries (LMICs), but there are few reports and no consolidation of findings on ADHD treatment outcomes in this population. We conducted a review of ADHD treatment literature for children and adolescents living in LMICs.Studies were identified using databases (PsychoINFO, Pubmed, MEDLINER, EMBASE, Global Health, Academic Search Complete, Google Scholar). The initial search produced 139 articles. These were filtered for language, title, abstract, and full-text keyword identification to yield a final 20 articles to be included in this review.Reports on outcomes of both psychological and pharmacological treatment were relatively sparse, particularly the former, which mostly referred to parent training and multimodal programs in pre-school children. Most evidence exists for the benefit of methylphenidate-IR with a few reports on other agents, including clonidine, atomoxetine, and lisdexamfetamine. Methylphenidate is the most common agent to treat ADHD in youth in LMICs. Younger age, combined subtype, and comorbid oppositional defiant disorder were associated with poorer treatment outcome.Access to treatment for ADHD is overall limited in LMICs and varied among individual countries. Pharmacological treatments were generally more available than psychological interventions. Several barriers including stigma, cost, and lack of resources were reported to impact treatment acceptance. More research in LMICs is needed to improve and expand mental health services in these regions.

A 23-year-old university student was initially seen for symptoms of long-standing social anxiety disorder (SAD). Her primary symptoms included excessive shyness and avoidance of peer-related activities, large family gatherings, speaking with authority figures, public speaking and class participation

The gut microbiome, the collection of microbes and their genetic material in the human gastrointestinal tract, has recently become a topic of interest in psychiatry. To date, animal studies have repeatedly shown behavior to be affected by alterations in the gut microbiota. Furthermore, studies in clinical psychiatric populations have also illustrated that microbial dysbiosis may play a role in these conditions, but results have been inconsistent. Given the existing animal and human literature providing evidence for a role of the microbiome in anxiety and depressive disorders, this review explores and develops similar lines of evidence in obsessive-compulsive disorder. Theoretical treatment options targeting the gut microbiome are also discussed. [ Psychiatr Ann. 2017;47(11):542–551.]

Purpose Generalized anxiety disorder (GAD) is one of the most common anxiety disorders, afflicting approximately 6% of the general population in their lifetime. It has a chronic and episodic course, requiring a long-term treatment approach. A variety of pharmacological agents and psychological treatments have been shown to be efficacious as GAD treatments; however, remission effect sizes for first-line treatments are small. This review aims to examine the existing evidence for next-step pharmacological and psychological treatments for individuals who remain symptomatic after first-line treatment. Recent Findings Relatively few studies have examined next-step treatments for treatment-resistant GAD (TR-GAD). The bulk of the available treatment-resistant literature has investigated augmentation with atypical antipsychotics or pregabalin. Summary Unfortunately, there is little information to guide clinicians in this area. The strongest evidence supports augmentation with pregabalin, however, this is based primarily upon one study. Approaches to consider when treating patients with TR-GAD are discussed.

Anxiety and related disorders are the most common mental conditions affecting the North American population. Despite their established efficacy, first-line antidepressant treatments are associated with significant side effects, leading many afflicted individuals to seek alternative treatments. Cannabis is commonly viewed as a natural alternative for a variety of medical and mental health conditions. Currently, anxiety ranks among the top five medical symptoms for which North Americans report using medical marijuana. However, upon careful review of the extant treatment literature, the anxiolytic effects of cannabis in clinical populations are surprisingly not well-documented. The effects of cannabis on anxiety and mood symptoms have been examined in healthy populations and in several small studies of synthetic cannabinoid agents but there are currently no studies which have examined the effects of the cannabis plant on anxiety and related disorders. In light of the rapidly shifting landscape regarding the legalization of cannabis for medical and recreational purposes, it is important to highlight the significant disconnect between the scientific literature, public opinion, and related policies. The aim of this article is to provide a comprehensive review of the current cannabis treatment literature, and to identify the potential for cannabis to be used as a therapeutic intervention for anxiety, mood, and related disorders. Searches of five electronic databases were conducted (PubMed, MEDLINE, Web of Science, PsychINFO, and Google Scholar), with the most recent in February 2017. The effects of cannabis on healthy populations and clinical psychiatric samples will be discussed, focusing primarily on anxiety and mood disorders.

Mental health apps are viewed as a promising modality to extend the reach of mental health care beyond the clinic. They do so by providing a means of assessment, tracking, and treatment through a smartphone. Given that nearly 2/3 of the American population owns a smartphone, mental health apps offer the possibility of overcoming treatment barriers such as geographic location or financial barriers. Unfortunately, the excitement surrounding mental health apps may be premature as the current supporting literature regarding their efficacy is limited. The app marketplace is littered with apps claiming to treat or assess symptoms, but even those created by reputable organizations or those incorporating components of evidence-based treatments have not yet been validated in terms of their efficacy. This review aims to provide a comprehensive review of the current state of the mental health app literature by examining published reports of apps designed for DSM-5 anxiety and mood disorders, OCD, and PTSD. The breadth of apps reviewed includes those oriented around assessment, symptom tracking, and treatment as well as "multipurpose" apps, which incorporate several of these components. This review will also present some of the most popular mental health apps which may have clinical utility and could be prescribed to clients. While we discuss many potential benefits of mental health apps, we focus on a number of issues that the current state of the app literature presents. Overall there is a significant disconnect between app developers, the scientific community and health care, leaving the utility of existing apps questionable.

Cannabis use for medical purposes has become increasingly common, including as treatment for mental health disorders such as anxiety. Unfortunately, the evidence examining its use in mental health has been slow to evolve, but is emerging. Given the widespread use of cannabis, it is important for both clinicians and those who suffer with anxiety to understand the effects of cannabis on symptoms of anxiety. In this review, we present recent, available evidence from animal models, clinical trials, and survey studies and evaluate the contribution of these studies to the current understanding of the role of cannabis in treating anxiety.In reviewing recent evidence, we observed significant inconsistencies across findings from preclinical studies. Large-scale surveys suggest that cannabis may be effective in reducing anxiety, however, these results stand in contrast to equivocal findings from clinical trials.The literature evaluating the efficacy of cannabis in anxiety disorders is in its infancy. The survey data is generally positive. Although, while some animal studies posit cannabis constituents to have anxiolytic effects, others suggest the opposite or null results. Few new clinical trials have been conducted recently, and the extant trials have significant flaws in methodology. Although anecdotal evidence from survey studies, and a small signal found in animal studies and single-dose clinical trials provide early support that cannabis may be effective for alleviating anxiety, ultimately, the current evidence is equivocal. More high-quality clinical trials must be published before sound conclusions regarding the efficacy of cannabis for treating anxiety can be drawn.

Background Anxiety and mood symptoms often co-occur with gastrointestinal problems, such as irritable bowel syndrome (IBS). The extent to which these relate to Obsessive-Compulsive Disorder (OCD) is unclear, despite anxiety being a prominent symptom of this disorder. The purpose of this analysis was to examine gastrointestinal symptoms in unmedicated, non-depressed adult OCD patients compared to age- and sex-matched community controls. Methods Twenty-one OCD patients and 22 controls were recruited from the community (Hamilton, ON, Canada) and enrolled in this cross-sectional study. In addition to a standardized psychiatric assessment, participants completed clinician- and self-rated psychiatric and gastrointestinal symptom severity measures. Presence of IBS was assessed using Rome III criteria. Results Gastrointestinal symptom severity (GSRS total; OCD = 8.67 ± 6.72 vs. controls = 2.32 ± 2.12) and prevalence of IBS (OCD = 47.6%; Controls = 4.5%) was higher in OCD patients than in controls. A comparison of OCD patients based on IBS status revealed greater depressive symptom severity (total MADRS: 12.60 ± 1.89 vs 6.91 ± 2.77), p Conclusions High prevalence and severity of gastrointestinal symptoms may be an important clinical consideration when treating OCD patients. More specifically, assessment of IBS and gastrointestinal symptoms may be useful when considering pharmacotherapeutic treatments options for patients. Given the high comorbidity noted with IBS, a disorder of the “gut-brain axis”, results may suggest a shared pathophysiological mechanism between psychiatric and gastrointestinal disorders which should be explored in future research.

Background A systematic review and meta-analysis was conducted to explore the efficacy of medication augmentation strategies compared to control treatments in patients who have had a partial or no response to initial treatment for generalized anxiety disorder, social anxiety disorder, and panic disorder. Methods Double-blind controlled trials of medication augmentation in adult treatment-resistant anxiety disorders conducted between January 1990 and January 2015 were systematically reviewed and evaluated by two independent raters. The search identified 625 articles; 610 were excluded following abstract review and 15 had full-text screening. Studies had to include a definition of treatment resistance, exclude concomitant medications, and have a parallel or crossover design. Data extraction forms were completed in duplicate. Results Six studies were included in the meta-analysis. Effect estimates were calculated using random effects modeling; heterogeneity was assessed and subgroup and sensitivity analyses were completed. Primary outcome was response, defined by Clinical Global Impression–Improvement score of ≤2. Augmentation was not associated with an increased risk of response, as compared with placebo (RR = 1.08, 95% CI = 0.94–1.24). A small significant effect was found in reduction in symptom severity: standard mean difference = –0.32, 95% CI = –0.56 to –0.08. No significant differences between augmentation with medication versus placebo were found in ratings of functional impairment and dropouts due to adverse events. Conclusions Augmentation does not appear to be beneficial in treatment-resistant anxiety disorders. These results may be limited by small study samples, and a small number of overall studies in the analysis.

Research in the past decade has shown that variations in the gut microbiome may influence behavior, and vice versa. As such, interest in the role of the gut microbiome in psychiatric conditions has drawn immense interest. This is evidenced by the recent surge in published studies examining microbial dysbiosis in clinical psychiatric populations, particularly autism spectrum disorder and depression. However, critical examination of these studies reveals methodological flaws in design and execution, suggesting that they may not be held to the same standards as other bodies of clinical research. Given the complex nature of the gut microbiome, this narrative review attempts to clarify concepts critical to effectively examine its potential role in psychopathology to appropriately inform mental health researchers. More specifically, the numerous variables known to affect the gut microbiome are discussed, including inflammation, diet, weight, and medications. A comprehensive review of the extant microbiome literature in clinical psychiatric populations is also provided, in addition to clinical implications and suggestions for future directions of research. Although there is a clear need for additional studies to elucidate the gut microbiome's role in psychiatric disorders, there is an even greater need for well-designed, appropriately controlled studies to truly impact the field.

Expanded partnership with the medical community is a promising strategy for reducing disparities in dental caries among young children. However, no validated caries risk instrument exists for use in primary health care settings. To help resolve this gap, a 52-item caries risk questionnaire was developed and targeted to primary caregivers (PCGs) to test in a 3-y prospective study. To begin to understand the validity of the questionnaire items, the purpose of this study was to compare responses to the questionnaire based on key demographic characteristics known to be associated with disparities in caries experience (e.g., race/ethnicity and insurance status). A total of 1,323 one-year-old children were recruited primarily through 3 medical research networks. Baseline questionnaire responses were analyzed via logistic regression. The sample was 49% female. Its racial/ethnic makeup was as follows: 13% Hispanic, 37% White, 37% Black, and 13% other or multiracial. Sixty-one percent were enrolled in Medicaid, and 95% resided in urban communities. Mothers represented 94% of PCGs. There were significant differences ( P < 0.05) in baseline responses based on Medicaid status and race/ethnicity. As compared with those not enrolled in Medicaid, children in the Medicaid group were significantly more likely (after adjusting for race/ethnicity) to 1) go to sleep while nursing or drinking something other than water, 2) eat sugary snacks between meals, 3) consume sugary drinks between meals, 4) receive topical fluoride from a health professional, 5) visit the dentist, and 6) not have an employed adult in the household. PCGs of children enrolled in Medicaid were significantly more likely to be the mother, have bleeding gums, eat sugary snacks between meals, consume sugary drinks between meals, eat or drink something other than water before going to bed, and not get regular dental checkups. In conclusion, there are significant differences in caries risk questionnaire responses based on Medicaid status and race/ethnicity that provide construct and criterion validity to the developed caries risk tool (ClinicalTrials.gov NCT01707797).

Cannabis is commonly used recreationally for its euphoric and relaxing effects, while its medical use is permitted in several jurisdictions. With only low-quality evidence suggesting anxiolytic effects of cannabis and strong public sentiment surrounding such purported effects, the purpose of this study was to examine the prevalence of cannabis for medicinal purposes (CMP) use for anxiety symptoms. An online survey was disseminated to CMP users registered with a Canadian licensed producer. Respondents completed demographic and validated self-report questionnaires (GAD-7, PHQ-9, MINI-SPIN, and panic disorder/agoraphobia DSM-5 criteria). Cannabis use behaviors were also discussed. Overall, 2032 completed responses with a verified user number were collected. Of the total sample, 888 (43.7%) reported CMP authorization to treat anxiety symptoms and completed all psychometric screening instruments. Rates of probable disorders were high (Generalized Anxiety Disorder: 45.6%, Social Anxiety Disorder: 42.4%, Major Depressive Disorder: 25.7%, Panic Disorder/Agoraphobia: 25.7%); 63.4% met screening criteria for ≥1 disorder. Most (92%) reported that cannabis improved their symptoms, despite continuing to endorse moderate-level severity. Nearly half (49%) reported replacing a non-psychiatric (53.7%) or psychiatric medication (46.3%) prescribed to them by their physician with CMP. Respondents endorsed daily CMP use and severity of anxiety (GAD-7, p 0.001) and depressive (PHQ-9, p 0.001) symptoms were positively associated with the amount of cannabis used/day. The vast majority perceived symptom improvement with CMP use and did not believe CMP use was associated with impairment or an inability to control use. Nevertheless, the possibility of cannabis use disorder cannot be ruled out as well as the possibility that improvements in non-psychiatric conditions were attributed to improvements in anxiety. These results highlight the need to systematically evaluate CMP use for mental illness.

Cloud computing and the Internet of Things (IoT) are currently the two dominant Internet technologies, but cloud computing embodies the maturity of the computing field with its clear path to software generation, transmission, distribution and control. The growth and popularity of cloud-virtualized resources (infrastructure, platform and software), have been accompanied with an increase in cloud performance evaluation that could be used for decision-making. As reported in the literature, most of the evaluations and simulations tend to be one-dimensional that focus on easily measurable criteria such as load balancing and response time. This preliminary paper presents a more holistic approach using the technique of balanced scorecard that analyses cloud computing with respect to finance, customer, internal processes, and learning and growth perspectives. A critical analysis shows that cost reduction is not enough to cause a customer to embrace cloud computing. Other factors such as value proposition, internal and growth perspectives also play a role.

Although many people use the internet to diagnose mental health problems, little is known about the relationship between internet self-diagnosis and treatment-seeking. The MACSCREEN (a validated, self-report screening tool for anxiety and depression) was posted on our clinic homepage and respondents were invited to take an anxiety test. Three months after completing the MACSREEN and a variety of symptom severity scales, respondents were emailed a follow up questionnaire asking about treatment-seeking behaviours. Of the 770 MACSCREEN respondents, 103 completed the follow-up questionnaire. Of these, 100% met criteria for at least one anxiety or mood disorder diagnosis and 51% sought treatment after completing the MACSCREEN. In the 49% who did not seek treatment, fear of medication (57%), discomfort talking to their doctor about anxiety (28%) and the belief that symptoms were not severe enough (28%) were cited as barriers. Compared to non-seekers, treatment-seekers were significantly more likely to meet screening criteria for Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Posttraumatic Stress Disorder and Depression. Higher Sheehan Disability Scale scores and being married (versus single) significantly increased the odds of treatment-seeking, suggesting that functional impairment and disease burden on the family may be stronger predictors of treatment seeking than overall severity of symptoms.

Introduction Practice-based research networks (PBRNs) conduct research in community settings, which poses quality control challenges to the integrity of research, such as study implementation and data collection. A foundation for improving research processes within PBRNs is needed to ensure research integrity. Methods Network directors and coordinators from seven U.S.-based PBRNs worked with a professional team facilitator during semiannual in-person meetings and monthly conference calls to produce content for a compendium of recommended research practices specific to the context of PBRNs. Participants were assigned to contribute content congruent with their expertise. Feedback on the draft document was obtained from attendees at the preconference workshop at the annual PBRN meeting in 2013. A revised document was circulated to additional PBRN peers prior to finalization. Results The PBRN Research Good Practices (PRGPs) document is organized into four chapters: (1) Building PBRN Infrastructure; (2) Study Development and Implementation; (3) Data Management, and (4) Dissemination Policies. Each chapter contains an introduction, detailed procedures for each section, and example resources with information links. Conclusion The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings.

An estimated 2–6% of the general population is thought to suffer from clinically significant hoarding symptoms, with 80–90% engaging in excessive acquisition. Minimal research has examined the excessive acquisition component of hoarding disorder (HD). Many individuals with HD have limited insight into their condition and are reluctant to seek help, making prevalence estimates difficult to obtain. Online classified advertisement networks provide a venue to list items for sale, often for free. We examined the prevalence of hoarding behaviours among users of online classified advertisements. A link to an online survey was posted between June 26, 2015—March 10, 2017. Participants provided demographic information and completed the Hoarding Rating Scale (HRS); individuals with clinically significant hoarding (High HRS) also completed the Saving Inventory-Revised (SI-R) and Clutter Image Rating (CIR). Feedback regarding hoarding behaviours was provided. The survey was completed by 729 adults and 12.3% (n = 90) self-identified as experiencing clinically significant hoarding as per the HRS (High HRS). Of those in the High HRS group, most (66.7%) were categorized to the ‘high acquisition’ group based on the SI-R excessive acquisition subscale. Overall this sample revealed high rates of significant hoarding behaviours, almost double that of community samples. Excessive acquisition was prominent and associated with greater hoarding severity, highlighting the need to further study this specifier.

Evaluate retention efforts in an ongoing longitudinal multi-site study to develop a self-administered, simple-to-score caries risk tool to identify young children at risk of developing dental caries through medical settings. Preliminary study data had suggested that expected retention rates within a year of follow up, without any intermediate contact, would be approx. 75% in the target population. 1,326 primary caregiver/infant (1 year ± 3 months) pairs were enrolled at baseline across three study sites (Duke University, Indiana University, University of Iowa). Children were …

A systematic review and meta-analysis was conducted to explore the efficacy of medication augmentation strategies compared to control treatments in patients who have had a partial or no response to initial treatment for generalized anxiety disorder, social anxiety disorder, and panic disorder.Double-blind controlled trials of medication augmentation in adult treatment-resistant anxiety disorders conducted between January 1990 and January 2015 were systematically reviewed and evaluated by two independent raters. The search identified 625 articles; 610 were excluded following abstract review and 15 had full-text screening. Studies had to include a definition of treatment resistance, exclude concomitant medications, and have a parallel or crossover design. Data extraction forms were completed in duplicate.Six studies were included in the meta-analysis. Effect estimates were calculated using random effects modeling; heterogeneity was assessed and subgroup and sensitivity analyses were completed. Primary outcome was response, defined by Clinical Global Impression-Improvement score of ≤2. Augmentation was not associated with an increased risk of response, as compared with placebo (RR = 1.08, 95% CI = 0.94-1.24). A small significant effect was found in reduction in symptom severity: standard mean difference = -0.32, 95% CI = -0.56 to -0.08. No significant differences between augmentation with medication versus placebo were found in ratings of functional impairment and dropouts due to adverse events.Augmentation does not appear to be beneficial in treatment-resistant anxiety disorders. These results may be limited by small study samples, and a small number of overall studies in the analysis.

For the publication of DSM-5, obsessive-compulsive disorder (OCD) was the subject of significant revisions to its classification and diagnostic criteria. One of these significant changes was the placement of OCD in a new category, "Obsessive-Compulsive and Related Disorders (OCRDs)," which also includes body dysmorphic disorder (BDD), trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, hoarding disorder, substance/medication-induced OCRD, OCRD due to another medical condition, and other specified OCRDs. Changes in the diagnostic criteria and grouping of these disorders may have significant clinical implications, and will be reviewed in this article.

Objective: It is unknown what next-step strategies are being used in clinical practice for patients with obsessive–compulsive disorder (OCD) who do not respond to first-line treatment. As part of a cross-sectional study of OCD, treatment and symptom information was collected. Method: Consecutive OCD out-patients in nine international centers were evaluated by self-report measures and clinical/structured interviews. OCD symptom severity was evaluated by the Yale Brown Obsessive Compulsive Scale (YBOCS) and Clinical Global Impression–Severity Scale (CGI-S). Clinical response to current treatment was evaluated by the CGI-Improvement Scale (CGI-I ≤ 2). Results: In total, 361 participants reported taking medication; 77.6% were taking a selective serotonin reuptake inhibitor; 50% reported use of at least one augmentation strategy. Antipsychotics were most often prescribed as augmenters (30.3%), followed by benzodiazepines (24.9%) and antidepressants (21.9%). No differences in OCD symptom severity were found between patients taking different classes of augmentation agents. Conclusions: Results from this international cross-sectional study indicate that current OCD treatment is in line with evidence-based treatment guidelines. Although augmentation strategies are widely used, no significant differences in OCD symptom severity were found between monotherapy and augmentation or between different therapeutic agents.

Multiple sclerosis (MS) is a neurodegenerative, inflammatory disease of the central nervous system, resulting in physical and cognitive disturbances. The goal of the current study was to examine the association between network integrity and composite measures of cognition and disease severity in individuals with relapsing-remitting MS (RRMS), relative to healthy controls. All participants underwent a neuropsychological and neuroimaging session, where resting-state data was collected. Independent component analysis and dual regression were employed to examine network integrity in individuals with MS, relative to healthy controls. The MS sample exhibited less connectivity in the motor and visual networks, relative to healthy controls, after controlling for group differences in gray matter volume. However, no alterations were observed in the frontoparietal, executive control, or default-mode networks, despite previous evidence of altered neuronal patterns during tasks of exogenous processing. Whole-brain, voxel-wise regression analyses with disease severity and processing speed composites were also performed to elucidate the brain-behavior relationship with neuronal network integrity. Individuals with higher levels of disease severity demonstrated reduced intra-network connectivity of the motor network, and the executive control network, while higher disease burden was associated with greater inter-network connectivity between the medial visual network and areas involved in visuomotor learning. Our findings underscore the importance of examining resting-state oscillations in this population, both as a biomarker of disease progression and a potential target for therapeutic intervention.

Panic attacks have been reported by patients with generalized anxiety disorder (GAD) in response to catastrophic worry. This has not been characterized in the literature. We examined the prevalence of GAD panic attacks in an anxiety disorders clinic sample. Charts of 254 patients with DSM-IV GAD were retrospectively evaluated. The presence and type of panic attacks were examined as well as correlates including comorbidity, baseline symptom severity, demographic variables, and family history. Twenty-one percent had GAD panic attacks, 21.7% had situationally predisposed attacks, 15.6% had situationally bound attacks, and 39.4% had unexpected panic attacks. The individuals who had GAD panic attacks had higher scores on the Anxiety Sensitivity Index compared with those who also had other types of panic attacks. One in five patients with GAD reported GAD panic attacks; however, these individuals did not differ significantly on the correlates that were evaluated. These findings require replication and further evaluation.

Background Evidence-based, first-line treatments for obsessive compulsive disorder, (OCD) include the serotonin reuptake inhibitors (SRI), however, 40–60% of OCD patients do not respond. A wide variety of agents have been examined as adjuncts to standard SRI treatment in cases of treatment resistance, however, no gold-standard approach has been identified. Glutamate dysfunction is now thought to have a role in OCD, and use of glutamatergic treatment agents may hold promise. N-acetylcysteine (NAC) is an amino acid derivative of cysteine, available as a health supplement. It has shown efficacy in OCD-spectrum disorders and in 1 case report of treatment resistant OCD. Method A retrospective chart review of 6 treatment resistant OCD patients, who had been treated with NAC for 6–12 weeks. Symptom severity was evaluated at regular clinic visits. Results Five of 6 patients took NAC for 12 weeks. The mean endpoint dose was 2833.3±408.2 mg/day. Only 1/6 patients responded to treatment with NAC; two patients reported a worsening of symptoms; no patients reported adverse events. Conclusions NAC was not effective in this sample of treatment-refractory OCD patients. Whether this result was a function of the mechanism of action of NAC or of the pathophysiology of treatment refractory OCD, remains unclear.

Mental health apps are viewed as a promising modality to extend the reach of mental health care beyond the clinic. They do so by providing a means of assessment, tracking, and treatment through a smartphone. Given that nearly 2/3 of the American population owns a smartphone, mental health apps offer the possibility of overcoming treatment barriers such as geographic location or financial barriers. Unfortunately, the excitement surrounding mental health apps may be premature as the current supporting literature regarding their efficacy is limited. The app marketplace is littered with apps claiming to treat or assess symptoms, but even those created by reputable organizations or those incorporating components of evidence-based treatments have not yet been validated in terms of their efficacy. This review aims to provide a comprehensive review of the current state of the mental health app literature by examining published reports of apps designed for DSM-5 anxiety and mood disorders, OCD, and PTSD. The breadth of apps reviewed includes those oriented around assessment, symptom tracking, and treatment as well as "multipurpose" apps, which incorporate several of these components. This review will also present some of the most popular mental health apps which may have clinical utility and could be prescribed to clients. While we discuss many potential benefits of mental health apps, we focus on a number of issues that the current state of the app literature presents. Overall there is a significant disconnect between app developers, the scientific community and health care, leaving the utility of existing apps questionable.

Current evidence suggests that the strength of the psychological control condition greatly impacts treatment outcomes. Psychological controls can be grouped into three general classes: no-treatment or waitlist (delayed treatment), attention placebo or the best available treatment comparison. Of these three, the use of the waitlist condition is the most common and is used in up to 73% of published psychological treatment studies. Many psychological interventions are in use today based on the efficacy demonstrated in waitlist controlled trials. In the field of anxiety disorders, cognitive behavioural therapy (CBT) is considered a first-line treatment. Meta-analyses in anxiety disorders have revealed that effect sizes for CBT compared to waitlist controls are much higher than those found using psychological placebos as comparators. Furthermore, waitlists have been associated with deleterious effects and have been described as "no-cebos" in related conditions such as major depressive disorder. Despite these findings, the use of waitlist controls continues to be a mainstay in the psychological anxiety disorders literature. The purpose of this paper is to examine the use of waitlists with a focus on the anxiety disorders. Methodological and ethical issues associated with waitlist controls will be explored, as well the use of alternative psychological placebos.

An extensive body of research defines the default-mode network (DMN) to be one of the critical networks of the human brain, playing a pivotal functional role in processes of internal mentation. Alterations in the connectivity of this network as a function of aging have been found, with reductions associated with functional ramifications for the elderly population. This study examined associations between integrity of the DMN and trait levels of mindfulness disposition, defined by our ability to exert attentional and emotional control in the present moment, and, thereby, bring awareness to immediate experiences. Twenty-five older adults participated in the study and underwent a brief functional magnetic resonance imaging session and filled out questionnaires related to their overall health and mindfulness disposition. Mindfulness disposition was associated with greater connectivity of the DMN, specifically, in the dorsal posterior cingulate cortex and the precuneus. Mindfulness disposition, thus, explains variance in the connectivity of one of the more intrinsic networks of the human brain, known to be critical for promoting self-relevant mental explorations and building cognitive and affective control.

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system, resulting in physical, cognitive and affective disturbances, with notable declines in the ability to learn and retain new information. In this study, we examined if higher levels of physical activity in MS individuals were associated with an increased resting-state connectivity of the hippocampus and cortex, resulting in better performance on a task of episodic memory. Forty-five individuals with a clinically definite diagnosis of MS were recruited for the study. Consistent with previous reports, hippocampus was functionally connected to the posteromedial cortex, parahippocampal gyrus, superior frontal gyrus, and the medial frontal cortex. Higher levels of physical activity in MS patients were associated with an increased coherence between the hippocampus and the posteromedial cortex (PMC). The increased connectivity between these two regions, in turn, was predictive of better relational memory, such that MS patients who showed an increased coherence between the left (not right) hippocampus and the PMC also showed better relational memory. Results of the study are interpreted in light of the challenge of disentangling effects of physical activity from effects of disease severity and its neuropathological correlates. (JINS, 2011, 17, 986–997)

It is well established that individuals with anxiety disorders experience significant impairments in social and occupational functioning. However, the impact of anxiety disorders on family members has not been adequately studied. The objective of the present study was to examine the burden experienced by relatives of anxiety disorder patients. In all, 74 outpatients and 74 family members participated in the study. Family members completed measures that assessed the impact of having an anxiety disordered relative. Results indicate that family members experience significant burden. The burden encompasses several domains including negative effects on physical health, psychological well-being, and family functioning. Burden was positively correlated with the severity of the patient's condition. The presence of a comorbid mood disorder in patients was associated with increased burden. Health-care professionals should assess the impact of anxiety disorders on the patient's family and provide interventions to reduce burden and improve the quality of life of family members.

Background: The Internet is a widely used resource for obtaining health information. Internet users are able to obtain anonymous information on diagnoses and treatment, seek confirmatory information, and are able to self-diagnose. We posted a self-report diagnostic screening questionnaire for DSM-IV anxiety and mood disorders (MACSCREEN) on our clinic website. Method: Three hundred and two individuals completed the MACSREEN. For those who qualified for a DSM-IV disorder, self-report symptom severity measures were completed for the specified disorder: Quick Inventory of Depressive Symptomatology, self-report, Social Phobia Inventory, GAD-7, Davidson Trauma Scale, Panic and Agoraphobia Scale, and Yale/Brown Obsessive Compulsive Scale, self-report. Cutoff scores for each self-report measure were used to evaluate clinically significant symptom severity. Respondents were also asked to complete a series of questions regarding their use of the Internet for health information. Results: The mean age of the MACSCREEN sample was 35.2 years (±13.9), where the majority (67.2%) were female. The most frequently diagnosed conditions were social phobia (51.0%), major depressive disorder (32.4%), and generalized anxiety disorder (25.5%). Sixty-five percent of the sample met criteria for at least one disorder. Most respondents reported completing the MACSCREEN, as they were concerned they had an anxiety problem (62.3%). The majority of respondents reported seeking health information concerning specific symptoms they were experiencing (54.6%) and were planning to use the information to seek further assessment (60.3%). Conclusion: Individuals with clinically significant disorder appear to be using the Internet to self-diagnose and seek additional information. Depression and Anxiety, 2010. © 2010 Wiley-Liss, Inc.

Background Hoarding disorder (HD) is a mental disorder that has been newly included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. It is estimated that 2-6% of adults in the general population suffer from clinically significant hoarding symptoms, with 80 to 90% engaging in excessive acquisition [1]. Little research has examined the excessive acquisition component of hoarding disorder(HD), although preliminary evidence suggests that buying and obtaining free things are markers of HD severity. [2] Classified ad networks on the web provide a way to list items for sale, often for free. Many individuals who suffer from HD have limited insight into their condition and are reluctant to seek help, making prevalence estimates difficult to obtain. We elected to examine the prevalence of hoarding behaviours among users of online classified advertisements. Methods A link to an online survey was posted on the following classified ad sites: Kijiji, Craigslist, Locanto, Reddit and postad.ca. The ads were posted in communities across Canada from June 26, 2015 to February 26, 2016. Following acknowledgment of a disclosure statement, participants were asked to complete a short demographics questionnaire and general questions regarding their use of online classified advertisements; no personal identifiers were collected. The Hoarding Rating Scale (HRS) was then completed; individuals with clinically significant hoarding (based on HRS) also completed the Saving Inventory-Revised(SI-R) and the Clutter Image Rating. Participants were provided with feedback on their hoarding behaviours. Results Seven hundred twenty-four individuals completed the survey; 69% of respondents came from Kijiji advertisements. The sample was 66% female, with a mean age of 39.9 ± 13.8 years; 55% were married, 29% were single, 9% were separated or divorced and 1% were widowed. Clinically significant hoarding behavior was identified in 11% (n=80) using the HRS (x 26.1 ± 5.2 versus x 9.9 ± 7.0 in those without significant hoarding, p Discussion This sample of individuals visiting online classified ad sites had high rates of clinically significant hoarding behaviours - double that found in the general population. The amount of time spent on online classified sites did not appear to be associated with hoarding. Online classified ad sites may represent a unique medium to study individuals with hoarding behaviours.

Purpose Internet addiction, is a term describing pathological, compulsive internet use and has an estimated prevalence of 6% among the general population and higher in students[1]. Extreme internet use may have significant public health importance as it has been attributed to several cardio-pulmonary deaths and at least one murder. While the pathological use of alcohol or drugs has been historically accepted as an addiction, questions remain concerning whether extreme internet use should be conceptualized as an addiction. The Internet Addiction Test (IAT) was developed in 1998, prior to the wide-spread use of Smartphone and other mobile devices, to detect internet addiction [2]. It is unclear whether this instrument is capable of capturing problematic modern internet use. The purpose of this study was to examine the construct of “internet addiction” in a sample of college aged internet users. Method A survey was administered to first year undergraduate students at McMaster University and posted to our centre website www.macanxiety.com . Following acknowledgment of a disclosure statement, participants completed several self-report scales detailing internet usage, symptoms of depression and anxiety, impulsiveness and executive functioning. Measures included: a short demographics questionnaire as well as a survey containing the IAT, sections from the Mini International Neuropsychiatric Interview for OCD, GAD, SAD, the Barkley Adult ADHD Rating Scale, the Barratt Impulsiveness Scale, the Depression, Anxiety and Stress Scale (DASS-21), the Barkley Deficits in Executive Functioning Scale (BDEFS) and the Sheehan Disability Scale (SDS). Individuals were also asked to complete the Dimensions of Problematic Internet Use (DPIU); a scale based on DSM-5 addiction criteria. Once the survey was complete, respondents were informed of their score and interpretation on the IAT. Results Two hundred and fifty-four participants completed all assessments. They had a mean age of 18.5±1.6 years and 74.5% were female. In total 12.5% (n = 33) met screening criteria for internet addition according to the IAT, while 107 (42%) met addiction criteria according to the DPIU. The most frequently reported dimensions of internet use where respondents had difficulty controlling their use were: video streaming services (55.8%), social networking (47.9%) and instant messaging tools (28.5%). Those screening positive on the IAT and on the DPIU had significantly higher levels of functional impairment (p Conclusion A high proportion of the sample met criteria for internet addiction. Participants meeting criteria for internet addiction had greater levels of psychopathology and functional impairment. With the exception of instant messaging tools, none of the dimensions of internet use differed between individuals who did and did not meet internet addiction criteria on the IAT. This study highlights that problematic internet use may be more widespread than once thought. Further studies are needed to understand the relationship between problematic internet use and psychopathology.

BACKGROUND Trichotillomania has been considered as part of the obsessive-compulsive disorder spectrum; however, trichotillomania treatment with obsessive-compulsive disorder medications has largely been unsuccessful. OBJECTIVE To determine whether a dopaminergic treatment as used in tics and Tourette's syndrome would be effective in trichotillomania. METHOD Twenty-five participants with DSM-IV trichotillomania participated in a 12-week, randomized, double-blind, placebo-controlled trial of flexible-dose olanzapine for trichotillomania. Recruitment occurred between August 2001 and December 2005, and follow-up was completed in February 2006. The primary outcome measure was the Clinical Global Impressions-Improvement (CGI-I) scale, and secondary measures of efficacy included the Yale-Brown Obsessive Compulsive Scale for Trichotillomania (TTM-YBOCS) and the Clinical Global Impressions-Severity of Illness (CGI-S) scale. RESULTS Eleven of 13 participants (85%) in the olanzapine group and 2 of 12 (17%) in the placebo group were considered responders according to the CGI-I (P = .001). There was a significant change from baseline to end point in the TTM-YBOCS (P < .01) and the CGI-S (P < .001). The mean ± SD dose of olanzapine at end point was 10.8 ± 5.7 mg/d. Twenty-one of 25 patients (84%) reported at least 1 adverse event, but no adverse events resulted in early withdrawal from the study. CONCLUSION Olanzapine seems to be a safe and effective treatment for primary DSM-IV trichotillomania. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00182507.

Adult Attention Deficit Hyperactivity Disorder (ADHD) is a life-long, chronic disorder, which has its onset in childhood and is associated with significant functional impairment. ADHD appears to be highly comorbid with other psychiatric disorders, however, literature is lacking concerning ADHD/anxiety comorbidity. To that end, we examined the prevalence of ADHD in an anxiety disorder sample. Consecutive patients referred to an anxiety disorders clinic completed a variety of anxiety disorder self-report measures as well as the Adult ADHD self-report scale and were clinically assessed using the Structured Clinical Interview for DSM-IV, and the ADHD module of the Mini International Neuropsychiatric Interview. Of the 129 patients assessed, the rate of adult ADHD was 27.9%. The mean age of the sample was 33.1 ± 12.5 years, and the mean baseline CGI-S was 4.6 ± 1.1 (moderate to marked severity). The majority of the sample was female (63.6%) and single (49.5%). The most common comorbid disorders associated with ADHD were major depressive disorder (53.8%), social phobia (38.5%), generalized anxiety disorder (23.1%), and impulse control disorders (30.8%). Individuals with ADHD had higher symptom severity scores for obsessive-compulsive disorder, (P≤ 0.05) and for GAD (P≤ 0.05) and reported a significantly earlier age of onset for depression as compared to those without (P≤ 0.05). The prevalence of adult ADHD was higher in our anxiety disorders clinic sample than found in the general population. Clinical implications of these findings are discussed.

The association between migraine and psychiatric disorders has been reported in both clinical and epidemiological studies. The prevalence of psychiatric disorders has been found to be increased among individuals with migraine. Studies assessing migraine in psychiatric patients are limited and the majority of these studies have focused solely on examining patients with major depression. In the present study, we examined the prevalence and characteristics of migraine headache in an anxiety disorders clinic sample in order to better understand the relationship between these commonly associated conditions. We evaluated 206 consecutive outpatients to an Anxiety Disorders Clinic for the prevalence of migraine. The presence of migraine was established using International Headache Society Criteria. Subjects completed a modified self-report version of the Headache Diagnostic Questionnaire. In order to assess the relationship between migraine and anxiety disorder symptom severity, subjects completed standardized measures of symptom severity. The prevalence of migraine in our anxiety disorder clinic sample was 67%. Anxiety disorder patients with migraine presented with a significantly greater number of comorbid psychiatric disorders than patients without migraine (P= 0.012). The prevalence of migraine was significantly higher in patients with a diagnosis of either panic disorder with agoraphobia (P= 0.048) or major depressive disorder/dysthymia (P= 0.008) compared to other psychiatric disorders. The severity of anxiety disorder symptoms was significantly higher in patients with migraine compared to patients without migraine. This study suggests that there is an increased prevalence of migraine headaches among anxiety disorder patients as compared to the general population. Migraine comorbidity may have important clinical implications, such that the treatment of one condition could potentially ameliorate the development or progression of the other. Further research is required to better understand the nature and implications of the association between migraine and psychiatric disorders.

Using peer learning strategies, seven experienced PBRNs working in collaborative teams articulated procedures for PBRN Research Good Practices (PRGPs). The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings. This paper describes the team science processes which culminated in the PRGPs. Skilled facilitators used team science strategies and methods from the Technology of Participation (ToP®), and the Consensus Workshop Method to support teams to codify diverse research expertise in practice-based research. The participatory nature of "sense-making" moved through identifiable stages. Lessons learned include (1) team input into the scope of the final outcome proved vital to project relevance; (2) PBRNs with diverse domains of research expertise contributed broad knowledge on each topic; and (3) ToP® structured facilitation techniques were critical for establishing trust and clarifying the "sense-making" process.

A 31-year-old woman presented to an anxiety disorders clinic with a history of intrusive thoughts, including concerns about illness and contamination, and being responsible for bad things happening to loved ones. Her primary concern involved intrusive images of harming her 2-year-old son and she was fearful of being alone with him, particularly at bedtime. This patient was extremely distressed by these symptoms. In addition, she reported experiencing intrusive images of accident scenes and had a number of checking rituals that she completed each day, lasting about 30–40 minutes in total. She also reported comorbid symptoms of social and performance anxiety, excessive worrying, panic attacks and agoraphobic avoidance. She had had previous treatment trials of the selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine, and her current treatment consisted of lorazepam 0.5 mg once daily when necessary and an oral contraceptive. Treatment was initiated with citalopram, titrated from 5 mg to 40 mg over a 12-week period. By week 16, the patient reported substantial improvement in her checking compulsions such that at times she was able to resist checking completely; when she did check, she went through her ritual only once. In addition, she reported substantial improvement in her social and performance anxiety, had had no panic attacks and was able to dismiss many of her worries about day to day issues. Unfortunately, the intrusive images of harming her son had not improved and continued to be very distressing and interfering. First-line pharmacological treatments for obsessive–compulsive disorder (OCD) are SSRIs with effect sizes ranging from 0.37 to 1.09.1 About 25%–60% of patients with OCD do not respond to initial SSRI treatment,2–4 making treatment-refractory OCD the norm rather than the exception. In cases of treatment resistance, clinicians generally adopt one of several strategies, including continuing with the chosen SSRI for an extended period of time, raising the dose to the highest tolerated level, switching to another first-line treatment agent (usually another SSRI), or augmenting the SSRI with an agent from a different drug class.2,5–7 The patient’s dose of citalopram was subsequently increased to 60 mg/d; however, she experienced excessive daytime somnolence and recurrent awakenings through the night. We reviewed potential augmentation strategies, including clomipramine, antipsychotics and anticonvulsants. The tricyclic antidepressant clomipramine has demonstrated efficacy as monotherapy for OCD;3,8 however, there is limited evidence to support clomipramine augmentation with an SSRI. Although the strongest evidence for SSRI augmentation in OCD is for anti-psychotics,3 the patient refused to take these agents for fear of metabolic syndrome. Over the past decade, the role of the neurotransmitter glutamate in OCD has attracted closer examination.9 Glutamate is the main excitatory neurotransmitter in the adult brain.10 Its primary function is on postsynaptic cells (Group I metabotropic and N-methyl-d-aspartate receptors); however, it also appears to have presynaptic action in the form of autoreceptor inhibitory feedback.11 Literature on glutamatergic pharmacological agents in OCD is limited but emerging. The glutamate-modulating agent riluzole has demonstrated positive effects as an augmentation agent to an SSRI in case reports and open-label studies of treatment-refractory comorbid OCD and major depressive disorder.12–14 However, there has been a negative randomized controlled trial (RCT) in children with OCD using riluzole.15 Lamotrigine has been reported to be beneficial in some case reports,16 but not in others.17 Topiramate is an anticonvulsant with a novel chemical structure. It has been used off label in clinical practice as an augmentation agent and as an alternative mood stabilizer in treating bipolar disorder, refractory depression, and binge-eating disorder. Augmentation with topiramate has shown some promise in the OCD literature in 1 RCT18 as well as case reports and 2 open-label studies;19,20 however, another RCT of adjunctive topiramate reported significantly improved compulsions, but not obsessions.21 Nevertheless, we elected to start a trial of topiramate, which was initiated at 25 mg/d for 1 week and was titrated by 25 mg/d/week until she had reached a dose of 50 mg twice daily. Following 8 weeks of adjunctive topiramate treatment, this patient reported improvement in her intrusive thoughts and was able to put her son to bed on her own. After 12 weeks, she had achieved a full response. She was no longer worried about harming her child and denied any impairment in her day to day functioning. Although adverse events with topiramate are not uncommon, (particularly difficulties with parathesia, word-finding problems and short-term memory), this patient tolerated the treatment well and has been maintained on this treatment combination for more than 1 year without recurrence of OCD symptoms.