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Objective: Prior studies have reported that major depressive episodes (MDEs) are associated with elevated mortality. However, the association has not always persisted after adjustment for other mortality risk factors. In our study, we examine this issue using data from a longitudinal Canadian study (the National Population Health Survey [NPHS]). The NPHS included a more comprehensive set of mortality determinants than prior studies, allowing a more comprehensive assessment of the effect of MDEs on mortality.Methods: The NPHS began data collection in 1994 and follow-up data were available to 2006 at the time of this analysis. The NPHS assessed depression using a short-form version of the Composite International Diagnostic Interview. Mortality was assessed as part of the cohort's follow-up, including linkage to vital statistics data.Results: During follow-up, 2019 deaths occurred in the eligible part of the NPHS cohort. Consistent with prior studies, MDEs were strongly predictive of mortality when basic adjustments were made for age and sex (hazard ratio [HR] 2.0, 95% CI 1.4 to 2.9). The association disappeared with adjustment for other variables that predict mortality risk (HR 1.1, 95% CI 0.7 to 1.7).Conclusions: MDE is a strong predictor of mortality in the general population. This analysis failed to identify an independent effect of MDE when adjustments were made for other risk factors. However, the lack of a strong independent effect on mortality does not preclude an etiologic impact of MDE. MDE itself is intertwined with health-related changes that predict mortality and its impact may be mediated by these variables. [ABSTRACT FROM AUTHOR]

Objective: Few studies have longitudinally followed trends in antidepressant prescribing for Canadian children following the Black Box warning issued in 2004. Using a national data source, we aim to describe trends in antidepressant recommendations for Canadian children ages 1-18 during 2012 to 2016. Methods: A database called the Canadian Disease and Therapeutic Index (CDTI), provided by IQVIA, was used to conduct analyses. The CDTI dataset collects a quarterly sample of pediatric antidepressant recommendations, projected using a weight procedure from a dynamic sample of 652 Canadian office-based physicians. The term "recommendations" is used because nonprescription drugs may be recommended and there is no confirmation in the database that the prescriptions were filled or medications taken. The data were collected from 2012 to 2016 and the sample population was projected by IQVIA to be representative of the entire Canadian pediatric population. Results: The total number of projected antidepressant recommendations for children increased from 2012 to 2016. Selective serotonin reuptake inhibitors were the most recommended class of antidepressants. Analysis indicated that fluoxetine was the most frequently recommended drug. Findings also suggest that recommendations for tricyclic antidepressants (TCAs) are increasing, but predominantly for reasons other than treatment of depression. Conclusions: Overall, antidepressant use in Canadian children increased over the study period. Unsurprisingly, fluoxetine was the most recommended antidepressant for Canadian children. However, the observed increase in TCA use for a pediatric population is unexpected. The data source is descriptive and lacks detailed measures supporting comprehensive explanation of the findings, therefore, further research is required.

Background: Suicide is a leading cause of death, particularly in younger persons, and this results in tremendous years of life lost., Objective: To compare the performance of recurrent neural networks, one-dimensional convolutional neural networks, and gradient boosted trees, with logistic regression and feedforward neural networks., Methods: The modeling dataset contained 3548 persons that died by suicide and 35,480 persons that did not die by suicide between 2000 and 2016. 101 predictors were selected, and these were assembled for each of the 40 quarters (10 years) prior to the quarter of death, resulting in 4040 predictors in total for each person. Model configurations were evaluated using 10-fold cross-validation., Results: The optimal recurrent neural network model configuration (AUC: 0.8407), one-dimensional convolutional neural network configuration (AUC: 0.8419), and XGB model configuration (AUC: 0.8493) all outperformed logistic regression (AUC: 0.8179). In addition to superior discrimination, the optimal XGB model configuration also achieved superior calibration., Conclusions: Although the models developed in this study showed promise, further research is needed to determine the performance limits of statistical and machine learning models that quantify suicide risk, and to develop prediction models optimized for implementation in clinical settings. It appears that the XGB model class is the most promising in terms of discrimination, calibration, and computational expense., Limitations: Many important predictors are not available in administrative data and this likely places a limit on how well prediction models developed with administrative data can perform., Competing Interests: Declaration of Competing Interest None, (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Suicide is a leading cause of death worldwide and results in a large number of person years of life lost. There is an opportunity to evaluate whether administrative health care system data and machine learning can quantify suicide risk in a clinical setting., Methods: The objective was to compare the performance of prediction models that quantify the risk of death by suicide within 90 days of an ED visit for parasuicide with predictors available in administrative health care system data.The modeling dataset was assembled from 5 administrative health care data systems. The data systems contained nearly all of the physician visits, ambulatory care visits, inpatient hospitalizations, and community pharmacy dispenses, of nearly the entire 4.07 million persons in Alberta, Canada. 101 predictors were selected, and these were assembled for each of the 8 quarters (2 years) prior to the quarter of death, resulting in 808 predictors in total for each person. Prediction model performance was validated with 10-fold cross-validation., Findings: The optimal gradient boosted trees prediction model achieved promising discrimination (AUC: 0.88) and calibration that could lead to clinical applications. The 5 most important predictors in the optimal gradient boosted trees model each came from a different administrative health care data system., Interpretation: The combination of predictors from multiple administrative data systems and the combination of personal and ecologic predictors resulted in promising prediction performance. Further research is needed to develop prediction models optimized for implementation in clinical settings., Funding: There was no funding for this study., Competing Interests: None., (© 2020 Published by Elsevier Ltd.)

Objective: To explore the association between major depressive episodes (MDE) and subsequent mortality in a representative sample of the general household population, with adjustment for other determinants of mortality., Method: The analysis used four datasets from the Canadian Community Health Survey (CCHS); the CCHS 1.1 (conducted in 2000 and 2001), the CCHS 1.2 (conducted in 2002), the CCHS 2.1 (conducted in 2003 and 2004) and the CCHS 3.1 (conducted in 2005 and 2006). Each survey included an assessment of past-year major depressive episodes (MDEs) and was linked to mortality data from the Canadian Mortality Database for January 1, 2000 to December 31, 2011. The hazard ratio (HR) for all-cause mortality was estimated in each survey sample. Random effects, individual-level meta-analysis was used to pool estimates from the four survey data sets. Estimates were adjusted for other determinants of mortality prior to pooling in order to help quantify the independent contribution of MDE to all-cause mortality., Results: The unadjusted HR was 0.77 (95% CI 0.63-0.95). A naïve interpretation of this HR suggests a protective effect of MDE, but the estimate was found to be strongly confounded by age (age adjusted HR for MDE: 1.61, 95% CI 1. 34-1.93) and by sex (sex adjusted HR for MDE: 1.15, 95% CI 0.75-1.77). The age and sex adjusted HR was: 1.70 (95% CI 1.45-2.00). No evidence of effect modification by any determinant of mortality was found, including sex. After adjustment for a set of mortality risk factors, the pooled HR was weakened, but remained statistically significant, HR = 1.29 (I-squared = < 1%, tau-squared < 0.001, 95% CI 1.10-1.51). Smoking was the strongest single confounding variable., Conclusions: MDE is associated with elevated mortality. The elevated risk is partially attributable to psychosocial, behavioral and health-related determinants. Since MDE itself may have caused changes to these variables, these estimates cannot fully quantify the independent contribution of MDE to mortality. However, these results suggest that clinical and public health efforts to counteract the effect of MDE on mortality may benefit from attention to a broad set of mortality risk factors e.g. smoking, physical activity, management of medical conditions., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To estimate the incidence and explore potential determinants of incidence of depression in MS., Methods: A prospective cohort study used a sample of 192 patients from the southern Alberta MS clinic registry. Participants completed baseline risk factor assessment questionnaires using either online, mail or telephone surveys, and completed the Patient Health Questionnaire every 2weeks for 6months to assess depressive symptoms in real time. Risk factors assessed included biopsychosocial variables such as socioeconomic status, illness-related factors, childhood risk factors, psychosocial factors, and health behaviors. Cox proportional hazard models were fit to estimate predictors of incidence., Results: 2-week incidence of depression for females was 0.019 (95% CI 0.013-0.029) and for males was 0.044 (0.026-0.074). Strongest predictor of depression incidence risk included fatigue impact, low mobility, resiliency, self-esteem, self-efficacy, and coping style., Conclusion: Depression in MS exhibits a risk factor profile similar to that of depression in the general population, with the additional impact of MS illness-related factors. Potentially modifiable risk factors, such as coping with stress and resiliency, present opportunities for focus of further research in depression in MS treatment and prevention efforts. Some differences in determinants of incidence were found compared to the prevalence risk factors, highlighting the danger of using cross-sectional data to make assumptions about risk. For example, the finding that depression incidence was higher for men is opposite to the higher depression prevalence estimates found for women as well as the consensus in the literature., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Depression is common in epilepsy, and is often under-detected and under-treated. The motivation to create a depression eHub for persons with epilepsy is to connect them to the best available online resources to effectively manage their depression. The study sought to: 1) identify facilitators and barriers to accessing resources related to management of epilepsy and/or depression and 2) discuss gaps in available resources (free and in the public domain) and 3) identify suggestions for future content., Methods: Semi-structured interviews were conducted with ten patients with epilepsy and a history of depression. Using inductive analysis, two team members engaged in a process of textual open-coding utilizing a conventional content analysis approach whereby content was conceptually clustered based on the research questions. A phenomenological framework was applied to describe the phenomenon of online health resource access and utilization from the perspective of people with epilepsy., Results: Facilitators to the use of online resources included information credibility, thoughtful organization, and accessibility of resources. Barriers included difficulties finding and piecing together information from many different sites. Patients reported difficulty having the motivation to seek out resources while depressed, which was compounded by feelings of stigma, social isolation, and lack of control. Gaps in resources included a lack of information about living with epilepsy day-to-day and resources for family and friends. Suggested content included information to raise awareness about epilepsy and depression; questionnaires to screen for symptoms of depression; stories of other patients with epilepsy and depression via video or moderated forums; current research and news; local community resources; and tools and strategies to manage depression in epilepsy., Conclusions: There is a gap in accessible resources for patients with epilepsy and depression as well as barriers that include epilepsy-related restrictions, depression-related impairments, lack of awareness, and stigmatization. These results should be used to guide the development of e-Health resources for patients with epilepsy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The purpose of this paper is to describe variation, over the months of the year, in major depressive episode (MDE) prevalence. This is an important aspect of the epidemiological description of MDE, and one that has received surprisingly little attention in the literature. Evidence of seasonal variation in MDE prevalence has been weak and contradictory. Most studies have sought to estimate the prevalence of seasonal affective disorder using cut-points applied to scales assessing mood seasonality rather than MDE. This approach does not align with modern classification in which seasonal depression is a diagnostic subtype of major depression rather than a distinct category. Also, some studies may have lacked power to detect seasonal differences. We addressed these limitations by examining the month-specific occurrence of conventionally defined MDE and by pooling data from large epidemiological surveys to enhance precision in the analysis., Method: Data from two national survey programmes (the National Population Health Survey and the Canadian Community Health Survey) were used, providing ten datasets collected between 1996 and 2013, together including over 500,000. These studies assessed MDE using a short form version of the Composite International Diagnostic Interview (CIDI) for major depression, with one exception being a 2012 survey that used a non-abbreviated version of the CIDI. The proportion of episodes occurring in each month was evaluated using items from the diagnostic modules and statistical methods addressing complex design features of these trials. Overall month-specific pooled estimates and associated confidence intervals were estimated using random effects meta-analysis and a gradient was assessed using a meta-regression model that included a quadratic term., Results: There was considerable sampling variability when the month-specific proportions were estimated from individual survey datasets. However, across the various datasets, there was sufficient homogeneity to justify the pooling of these estimated proportions, producing large gains in precision. Seasonal variation was clearly evident in the pooled data. The highest proportion of episodes occurred in December, January and February and the lowest proportions occurred in June, July and August. The proportion of respondents reporting MDE in January was 70% higher than August, suggesting an association with implications for health policy. The pattern persisted with stratification for age group, sex and latitude., Conclusions: Seasonal effects in MDE may have been obscured by small sample sizes in prior studies. In Canada, MDE has clear seasonal variation, yet this is not addressed in the planning of services. These results suggest that availability of depression treatment should be higher in the winter than the summer months.

Objective: To determine whether there is an association between latitude and annual major depressive episode (MDE) prevalence in Canada., Methods: Data from 2 national survey programs (the National Population Health Survey and the Canadian Community Health Survey) were used, providing 10 data sets collected between 1996 and 2013, together including 922,260 respondents, of whom 495,739 were assessed for MDE using 1 of 2 versions of the Composite International Diagnostic Interview, a short-form version (8 studies), and a Canadian adaptation of the World Mental Health version (2 studies). Approximate latitude was determined by linkage to postal code data. Data were analyzed using logistic regression and pooled across surveys using individual-level meta-analytic methods., Results: In models including latitude as a continuous variable, a statistically significant association was observed, with prevalence increasing with increasing latitude. This association persisted after adjustment for a set of known risk factors. The latitude gradient was modest in magnitude, a 1% to 2% increase in the prevalence odds of MDE per degree of latitude was observed. Due to sparse data, this gradient cannot be confidently generalized beyond major population centres, which tend to occur at less than 55° latitude in Canada., Conclusion: A latitude gradient has not previously been reported. If replicated, the gradient may have implications for the planning of services and generation of aetiological hypotheses. However, this cross-sectional analysis cannot confirm aetiology and could not evaluate the potential contributions of variables such as light exposure, weather patterns, or social determinants., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Major depressive disorder is an important contributor to disease burden. Anticipation of service needs is important, yet basic information is lacking. For example, there is no consensus as to whether major depressive episodes (MDE) are more or less prevalent in urban or rural areas. The objective of this study was to determine whether a difference exists in Canada., Method: A series of 11 Canadian national cross-sectional studies were examined from 2000 to 2014, providing much greater precision than prior analyses. Survey-specific MDE prevalence estimates were synthesized into a pooled odds ratio comparing urban to rural areas using meta-analytic methods., Results: Differences in the survey-specific estimates were not in excess of what would be expected due to sampling variability. This suggests that inconsistency in the prior literature is due to inadequate power and precision, an issue addressed by the meta-analytic pooling. The pooled odds ratio for Canada is 1.18 (95% confidence interval, 1.12 to 1.25), indicating that urban regions have higher MDE prevalence than rural regions. However, the difference is very small and of uncertain significance for policy and planning., Conclusions: Prevalence of MDE is approximately 18% higher in urban compared to rural regions of Canada. The difference is insufficient to impute differing need for services, but the result resolves an inconsistency in the existing literature and may play a role in future needs assessment., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Heavy drinking is a major factor in morbidity and mortality worldwide. Little information is available on trends in Canada regarding alcohol abuse. We sought to estimate abstinence, binge drinking and alcohol intake exceeding low-risk drinking guidelines in the Canadian population from 1996 to 2013., Methods: The data sources for this analysis were a series of cross-sectional national health surveys of the Canadian population carried out by Statistics Canada between 1996 and 2013. These were cross-sectional files from the National Population Health Surveys of 1996 and 1998, plus the Canadian Community Health Surveys from 2000 to 2013. Respondents were aged 18 years and older., Results: The proportion of binge drinkers increased steadily from 13.7% (95% confidence interval [CI] 13.2%-14.2%) in 1996 to 19.7% (95% CI 19.1%-20.3%) in 2013. The corresponding proportions for men were 20.8% (95% CI 19.9%-21.7%) in 1996, and 25.7% (95% CI 24.7%-26.6%) in 2013; for women, these proportions were 6.9% (95% CI 6.4%-7.5%) in 1996, and 13.8% (95% CI 13.1%-14.5%) in 2013. No significant increases were seen in the proportion of people who exceeded low-risk drinking guidelines or of abstainers during the same period., Interpretation: The rate of self-reported binge drinking in Canada has increased from 1996 to 2013, relatively more so among women than among men. No evidence of an increase in the proportion of people exceeding low-risk drinking guidelines or of abstainers was seen during the same period. These results suggest that binge drinking is of particular concern regarding intervention strategies aimed at improvement of public health., Competing Interests: Conflicts of Interest: None declared.

Objectives: Our primary aim was to validate the Patient Health Questionnaire (PHQ)-9 as a screening tool for suicidal ideation (SI)., Methods: Persons with epilepsy (n=188), migraine (n=208), multiple sclerosis (n=151), and stroke (n=122) completed questionnaires (e.g., PHQ-9) and the structured clinical interview for DSM-IV (SCID). Logistic regression was used to examine factors associated with SI [odds ratios (ORs) with 95% confidence intervals (CIs)]. The diagnostic accuracy of the PHQ-9 in identifying SI [sensitivity (Se), specificity (Sp), positive and negative predictive value (PPV and NPV)] was validated against the SCID., Results: The 2-week prevalence of SI ranged from 5.7% (stroke) to 12.7% (epilepsy). Factors most strongly associated with SI were depression [OR ranging from 14.6 (migraine) to 38.6 (stroke)] and anxiety [OR ranging from 8.6 (migraine) to 15.3 (epilepsy)] (see text for 95% CI). The PHQ-9 had good Se for SI in epilepsy (90%) and migraine (75.0%). PPV was poor while Sp and NPV were >90% for every condition., Conclusions: Screening for depression and anxiety is important in view of their strong association with SI. The PHQ-9 may be considered as a screening tool for SI, although it should not be relied on solely in view of its suboptimal PPV., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The Mental Health Experiences Scale is a measure of perceived stigma, the perception of negative attitudes and behaviours by people with mental disorders. A recent Canadian survey (Canadian Community Health Survey-Mental Health) included this scale, providing an opportunity to describe perceived stigma in relation to diagnosis for the first time in the Canadian general population., Methods: The survey interview began with an assessment of whether respondents had utilised services for an "emotional or mental health problem" in the preceding 12 months. The subset reporting service utilisation were asked whether others "held negative opinions" about them or "treated them unfairly" for reasons related to their mental health. The analysis reported here used frequencies, means, cross-tabulation, and logistic regression, all incorporating recommended replicate sampling weights and bootstrap variance estimation procedures., Results: Stigma was perceived by 24.4% of respondents accessing mental health services. The frequency was higher among younger respondents (<55 years), those who were not working, those reporting only fair or poor mental health, and the subset who reported having received a diagnosis of a mental disorder. Sex and education level were not associated with perceived stigma. People with schizophrenia reported stigmatization only slightly more frequently than those with mood and anxiety disorders., Conclusions: Stigmatization is a common, but not universal, experience among Canadians using services for mental health reasons. Stigmatization was a problem for a sizeable minority of respondents with mood, anxiety, and substance use disorders as well as bipolar and psychotic disorders., (© The Author(s) 2016.)

Objective: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a disability scale included in Section 3 of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a possible replacement for the Global Assessment of Functioning Scale (GAF). To assist Canadian psychiatrists with interpretation of the scale, we have conducted a descriptive analysis using data from the 2012 Canadian Community Health Survey-Mental Health component (CCHS-MH)., Methods: The 2012 CCHS-MH was a cross-sectional survey of the Canadian community (n = 23,757). The survey included an abbreviated 12-item version of the WHODAS 2.0. Mental disorder diagnoses were assessed for schizophrenia, other psychosis, major depressive episode (MDE), generalized anxiety disorder (GAD), bipolar I disorder, substance abuse/dependence, and alcohol abuse/dependence., Results: Mean scores ranged from 14.2 (95% CI, 14.1 to 14.3) for the overall community population to 23.1 (95% CI, 19.5 to 26.7) for those with schizophrenia, with higher scores indicating greater disability. Furthermore, the difference in scores between those with lifetime and past-month episodes suggests that the scale is sensitive to changes occurring during the course of these disorders; for example, scores varied from 23.6 (95% CI, 22.2 to 25.1) for past-month MDE to 14.4 (95% CI, 14.2 to 14.7) in the lifetime MDE group without a past-year episode., Conclusion: This analysis suggests that the WHODAS 2.0 may be a suitable replacement for the GAF. As a disability measure, even though it is not a mental health-specific instrument, the 12-item WHODAS 2.0 appears to be sensitive to the impact of mental disorders and to changes over the time course of a mental disorder. However, the clinical utility of this measure requires additional assessment., (© The Author(s) 2016.)

Aims: Accumulating evidence links childhood adversity to negative health outcomes in adulthood. However, most of the available evidence is retrospective and subject to recall bias. Published reports have sometimes focused on specific childhood exposures (e.g. abuse) and/or specific outcomes (e.g. major depression). Other studies have linked childhood adversity to a large and diverse number of adult risk factors and health outcomes such as cardiovascular disease. To advance this literature, we undertook a broad examination of data from two linked surveys. The goal was to avoid retrospective distortion and to provide a descriptive overview of patterns of association., Methods: A baseline interview for the Canadian National Longitudinal Study of Children and Youth collected information about childhood adversities affecting children aged 0-11 in 1994. The sampling procedures employed in a subsequent study called the National Population Health Survey (NPHS) made it possible to link n = 1977 of these respondents to follow-up data collected later when respondents were between the ages of 14 and 27. Outcomes included major depressive episodes (MDE), some risk factors and educational attainment. Cross-tabulations were used to examine these associations and adjusted estimates were made using the regression models. As the NPHS was a longitudinal study with multiple interviews, for most analyses generalized estimating equations (GEE) were used. As there were multiple exposures and outcomes, a statistical procedure to control the false discovery rate (Benjamini-Hochberg) was employed., Results: Childhood adversities were consistently associated with a cluster of potentially related outcomes: MDE, psychotropic medication use and smoking. These outcomes may be related to one another since psychotropic medications are used in the treatment of major depression, and smoking is strongly associated with major depression. However, no consistent associations were observed for other outcomes examined: physical inactivity, excessive alcohol consumption, binge drinking or educational attainment., Conclusions: The conditions found to be the most strongly associated with childhood adversities were a cluster of outcomes that potentially share pathophysiological connections. Although prior literature has suggested that a very large number of adult outcomes, including physical inactivity and alcohol-related outcomes follow childhood adversity, this analysis suggests a degree of specificity with outcomes potentially related to depression. Some of the other reported adverse outcomes (e.g. those related to alcohol use, physical inactivity or more distal outcomes such as obesity and cardiovascular disease) may emerge later in life and in some cases may be secondary to depression, psychotropic medication use and smoking.

Objective: The best screening questionnaires for detecting post-stroke depression have not been identified. We aimed to validate four commonly used depression screening tools in stroke and transient ischemic attack patients., Methods: Consecutive stroke and transient ischemic attack patients visiting an outpatient stroke clinic in Calgary, Alberta (Canada) completed a demographic questionnaire and four depression screening tools: Patient Health Questionnaire (PHQ)-9, PHQ-2, Hospital Anxiety and Depression Scale (HADS-D), and Geriatric Depression Scale (GDS-15). Participants then completed the Structured Clinical Interview for DSM-IV (SCID), the gold-standard for diagnosing major depression. The questionnaires were validated against the SCID and sensitivity and specificity were calculated at various cut-points. Optimal cut-points for each questionnaire were determined using receiver-operating curve analyses., Results: Among 122 participants, 59.5% were diagnosed with stroke and 40.5% with transient ischemic attack. The point prevalence of SCID-diagnosed current major depression was 9.8%. At the optimal cut-points, the sensitivity and specificity for each screening tool were as follows: PHQ-9 (sensitivity: 81.8%, specificity: 97.1%), PHQ-2 (sensitivity: 75.0%, specificity: 96.3%), HADS-D (sensitivity: 63.6%, specificity: 98.1%), and GDS-15 (sensitivity: 45.5%, specificity: 84.8%). Areas under the receiver operating characteristic curves were as follows: PHQ-9 86.6%, PHQ-2 86.7%, HADS-D 85.9%, and GDS-15 66.3%., Conclusions: The PHQ-2 and PHQ-9 are both suitable depression screening tools, taking less than 5 minutes to complete. The HADS-D does not appear to have any advantage over the PHQ-based scales, even though it was designed specifically for medically ill populations. The GDS-15 cannot be recommended for general use in a stroke clinic based on this study as it had worse discrimination due to low sensitivity., (© The Author(s) 2016.)

Objective: Major depressive episodes (MDE) make an important contribution to disease burden in Canada. The epidemiology of MDE in the national population has been examined in 2 mental health surveys, one conducted in 2002 and the other in 2012. Our objective was to compare selected variables from the 2 surveys to determine whether changes have occurred in the prevalence, treatment, and impact of MDE., Method: The World Health Organization World Mental Health Composite International Diagnostic Interview was used in both surveys and the MDE module (which was not modified) was scored using the same algorithm. Some variables assessing impact and management of MDE were also identical in the 2 surveys. The analysis was based on frequency estimates and associated 95% confidence intervals., Results: The annual prevalence of MDE was 4.7% (95% CI 4.3% to 5.1%) in 2012, nearly identical to 4.8% (95% CI 4.5% to 5.1%) in 2002. Receipt of potentially adequate treatment (defined as taking an antidepressant or 6 or more visits to a health professional for mental health reasons) increased from 41.3% in 2002 to 52.2% in 2012, mostly due to an increase in respondents reporting 6 or more visits. Use of second generation antipsychotics also increased. There was no evidence of diminishing prevalence or impact (as assessed by symptoms of distress)., Conclusions: There appears to have been an increase in receipt of treatment for people with MDE and a changing pattern of management. However, it was not possible to confirm that the impact of MDE is diminishing as a result., (© The Author(s) 2015.)

Background: Women have a higher prevalence of major depressive episodes (MDE) than men, and the annual prevalence of MDE declines with age. Age by sex interactions may occur (a weakening of the sex effect with age), but are easily overlooked since individual studies lack statistical power to detect interactions. The objective of this study was to evaluate age by sex interactions in MDE prevalence., Methods: In Canada, a series of 10 national surveys conducted between 1996 and 2013 assessed MDE prevalence in respondents over the age of 14. Treating age as a continuous variable, binomial and linear regression was used to model age by sex interactions in each survey. To increase power, the survey-specific interaction coefficients were then pooled using meta-analytic methods., Results: The estimated interaction terms were homogeneous. In the binomial regression model I (2) was 31.2 % and was not statistically significant (Q statistic = 13.1, df = 9, p = 0.159). The pooled estimate (-0.004) was significant (z = 3.13, p = 0.002), indicating that the effect of sex became weaker with increasing age. This resulted in near disappearance of the sex difference in the 75+ age group. This finding was also supported by an examination of age- and sex-specific estimates pooled across the surveys., Conclusions: The association of MDE prevalence with sex becomes weaker with age. The interaction may reflect biological effect modification. Investigators should test for, and consider inclusion of age by sex interactions in epidemiological analyses of MDE prevalence.

Background: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution., Methods: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol., Findings: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa., Interpretation: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks., Funding: Bill & Melinda Gates Foundation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development., Methods: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time., Findings: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries., Interpretation: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions., Funding: Bill & Melinda Gates Foundation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To estimate the prevalence of depression across a range of neurological conditions in a nationally representative sample., Methods: The data source was the Survey of Living with Neurological Conditions in Canada (SLNCC), which accrued its sample by selecting participants from the Canadian Community Health Survey. The point prevalence of depression was estimated by assessment of depressive symptoms with the Patient Health Questionnaire, Brief (Patient Health Questionnaire, 9-item)., Results: A total of n=4408 participated in the SLNCC. The highest point prevalence of depression (>30%) was seen in those with traumatic brain injury and brain/spinal cord tumors. Depression was also highly prevalent (18-28%) in those with (listed from highest to lowest) Alzheimer's disease/dementia, dystonia, multiple sclerosis, Parkinson's disease, stroke, migraine, epilepsy and spina bifida. The odds ratios for depression, with the referent group being the general population, were significant (from highest to lowest) for migraine, traumatic brain injury, stroke, dystonia and epilepsy., Conclusions: All neurological conditions included in this study are associated with an elevated prevalence of depression in community populations. The conditions with the highest prevalence are traumatic brain injury and brain/spinal cord tumors., (Copyright © 2015. Published by Elsevier Inc.)

Background: Depression is a common comorbid condition with multiple sclerosis (MS). Historically, however, it has been undertreated. Little is known about the characteristics of those who receive, or do not receive, treatment for depression in the MS population. This study evaluated depression treatment in patients with MS, associated patient characteristics, and probable determinants of antidepressant drug use in those with and without depression., Methods: A total of 152 patients with MS completed questionnaires and the Structured Clinical Interview for DSM-IV-TR (SCID) to determine depression status. Tabular analyses and a binary regression model were used to identify patient characteristics associated with antidepressant drug use., Results: Of participants with major depression according to the SCID, 65% were taking antidepressant medications. With adjustment for successful treatment (antidepressant drug use by those not currently depressed and currently depressed), the prevalence of treated depression increased to 85.7%. Of those receiving treatment for depression, 19% were receiving nonpharmacologic treatment alone, 38% were taking antidepressant drugs only, and 44% were receiving both pharmacologic and nonpharmacologic treatments. Demographic and clinical variables were not statistically significantly associated with antidepressant drug use in those with depression., Conclusions: A large proportion of participants with depression in MS are now receiving treatment, a change from previous reports. The adequacy of treatment has become a bigger question because many of the treated patients continued to have depressive symptoms. Further research is needed to identify ways to achieve better outcomes for depression.

Background: There is a role for brief assessment instruments in detection and management of major depression in MS. However, candidate scales have rarely been validated against a validated diagnostic interview. In this study, we evaluated the performance of several candidate scales: Patient Health Questionnaire (PHQ)-9, PHQ-2, Center for Epidemiologic Studies Depression rating scale (CES-D), and Hospital Anxiety and Depression Scale (HADS-D) in relation to the Structured Clinical Interview for DSM-IV (SCID)., Methods: The sample was an unselected series of 152 patients attending a multiple sclerosis (MS) clinic. Participants completed the scales during a clinic visit or returned them by mail. The SCID was administered by telephone within two weeks. The diagnosis of major depressive episode, according to the SCID, was used as a reference standard. Receiver-operator curves (ROC) were fitted and indices of measurement accuracy were calculated., Results: All of the scales performed well, each having an area under the ROC > 90%. For example, the PHQ-9 had 95% sensitivity and 88.3% specificity when scored with a cut-point of 11. This cut-point achieved a 56% positive predictive value for major depression., Conclusions: While all of the scales performed well in terms of their sensitivity and specificity, the availability of the PHQ-9 in the public domain and its brevity may enhance the feasibility of its use., (© The Author(s), 2015.)

Background: Considerable evidence now links childhood adversity to a variety of adult health problems. Unfortunately, almost all of these studies have relied upon retrospective assessment of childhood events, creating a vulnerability to bias. In this study, we sought to examine three associations using data sources that allowed for both prospective and retrospective assessment of childhood events., Methods: A 1994 national survey of children between the ages of 0 and 11 collected data from a 'person most knowledgeable' (usually the mother) about a child. It was possible to link data for n = 1977 of these respondents to data collected from the same people in a subsequent adult study. The latter survey included retrospective reports of childhood adversity. We examined three adult health outcomes in relation to prospectively and retrospectively assessed childhood adversity: major depressive episodes, excessive alcohol consumption and painful conditions., Results: A strong association between childhood adversities (as assessed by both retrospective and prospective methods) and major depression was identified although the association with retrospective assessment was stronger. Weaker associations were found for painful conditions, but these did not depend on the method of assessment. Associations were not found for excessive alcohol consumption irrespective of the method of assessment., Conclusions: These findings help to allay concerns that associations between childhood adversities and health outcomes during adulthood are merely artefacts of recall bias. In this study, retrospective and prospective assessment strategies produced similar results.

Objective: Current epidemiologic knowledge about bipolar disorder (BD) in Canada is inadequate. To date, only 3 prevalence studies have been conducted: only 1 was based on a national sample, and none distinguished between BD I and II. The objective of this study was to estimate the prevalence of BD I and II in Canada in 2012., Method: Data were obtained from the 2012 Canadian Community Health Survey: Mental Health and Well-being, a cross-sectional survey of a nationally representative sample of household residents ages 15 years and older (n = 25 113). The survey response rate was 68.9%. Interviews were based on the World Health Organization Composite International Diagnostic Interview (CIDI). Prevalence was estimated using generalized linear modelling. Prevalence of self-reported diagnosis of BD and use of lithium were also estimated., Results: The estimated lifetime prevalence of BD I and II (based on the CIDI) in Canada in 2012 was 0.87% (95% CI 0.67% to 1.07%) and 0.57% (95% CI 0.44% to 0.71%), respectively. Prevalence did not differ by sex. The estimated prevalence of self-reported BD was 0.87% (95% CI 0.65% to 1.07%). There was a lack of congruence between CIDI-defined and self-reported BD, and few people taking lithium were positive for BD on the CIDI, which raises some concerns about the validity of the CIDI's assessment of BD., Conclusions: These prevalence estimates align with those reported in prior literature. However, caution should be exercised when interpreting general population studies that use CIDI-defined BD owing to the possibility of misclassification.

Objective: The epidemiology of major depressive disorder (MDD) was first described in the Canadian national population in 2002. Updated information is now available from a 2012 survey: the Canadian Community Health Study-Mental Health (CCHS-MH)., Method: The CCHS-MH employed an adaptation of the World Health Organization World Mental Health Composite International Diagnostic Interview and had a sample of n=25 113. Demographic variables, treatment, comorbidities, suicidal ideation, and perceived stigma were assessed. The analysis estimated adjusted and unadjusted frequencies and prevalence ratios. All estimates incorporated analysis methods to account for complex survey design effects., Results: The past-year prevalence of MDD was 3.9% (95% CI 3.5% to 4.2%). Prevalence was higher in women and in younger age groups. Among respondents with past-year MDD, 63.1% had sought treatment and 33.1% were taking an antidepressant (AD); 4.8% had past-year alcohol abuse and 4.5% had alcohol dependence. Among respondents with past-year MDD, the prevalence of cannabis abuse was 2.5% and that of dependence was 2.9%. For drugs other than cannabis, the prevalence of abuse was 2.3% and dependence was 2.9%. Generalized anxiety disorder was present in 24.9%. Suicide attempts were reported by 6.6% of respondents with past-year MDD. Among respondents accessing treatment, 37.5% perceived that others held negative opinions about them or treated them unfairly because of their disorder., Conclusions: MDD is a common, burdensome, and stigmatized condition in Canada. Seeking help from professionals was reported at a higher frequency than in prior Canadian studies, but there has been no increase in AD use among Canadians with MDD.

Objective: To evaluate trends in the prevalence of major depressive episodes (MDEs) in Canada during the past 2 decades using data collected in a series of national surveys., Method: MDE prevalence has been assessed in national surveys that either used a short form version of the Composite International Diagnostic Interview Short Form for Major Depression (CIDI-SFMD) or an adaptation of the World Health Organization's (full-length) version, World Mental Health (WMH) CIDI. We applied meta-regression methods to adjust for instrument type while also addressing design effects in the individual data sets. Interprovincial differences that might have confounded estimation of national trends were also explored., Results: Interprovincial differences were not found to be significant, nor were time by province interactions. Estimates based on the WMH-CIDI were about 1% lower than those using the CIDI-SFMD. There was no evidence of changing prevalence over time, with slope for time, adjusted for assessment instrument, being nearly zero (β=0.0007, P=0.24)., Conclusion: An extensive collection of surveys conducted in Canada between 1994 and 2012 provide an opportunity to examine long-term trends in the prevalence of major depression. MDE prevalence has not changed during this period of time.

Objective: Epidemiologic studies typically assess mental health using diagnostic measures or symptom severity measures. However, perceptions are also important. The objective of our study was to evaluate trends in perceived mental health in Canada during the past 20 years using data collected in a series of surveys., Method: Perceived mental health status, the stressfulness of most days, and perceived general health, have been repeatedly measured in national surveys. In our study, the resulting frequencies and 95% confidence intervals were calculated. Distress was also assessed in the same surveys with the Kessler 6 Psychological Distress Scale, and analyzed using mean scores and frequencies based on cut-points. Data synthesis used forest plots. Time trends were assessed using random effects meta-regression models., Results: No detectable changes in distress were found. Similarly, self-rated general health remained stable. However, over time, Canadians became slightly more likely to report that their mental health was merely fair or poor. Conversely, they have been progressively less likely to perceive that their lives are quite a bit or extremely stressful., Conclusion: While these observations are ecological, the 2 trends may be related: distressing emotional experiences may increasingly be interpreted as evidence of a disturbance of mental health rather than a reaction to stressful circumstances. These changing perceptions should not be misinterpreted as an epidemic of poor mental health.

Objective: Large increases in the use of antidepressants (ADs) were reported in the past 2 decades in many countries, including Canada. Our objective was to determine whether this pattern of increasing use has continued, using data from a 2012 national mental health survey., Method: During the past 2 decades, a series of Canadian national health surveys have evaluated AD use in the household population. Some of these surveys have assessed past 2-day use whereas others have assessed self-reported past-month use. We applied meta-regression methods as a methodological strategy to address this heterogeneity and to examine long-term trends, incorporating 2012 data., Results: In keeping with prior reports, AD use rapidly increased in the 1990s and early 2000s. However, the 2012 data suggest that these increases have slowed or perhaps even stopped in recent years. A post hoc examination of longitudinal data from the National Population Health Survey reinforced the impression of a levelling off in the use of these medications., Conclusion: The frequency of AD use may now be stabilizing in the Canadian population. This emerging steady state may reflect a contemporary balance between the perceived need, perceived effectiveness, and acceptability of these medications in the general population.

Objective: Depression is a common comorbidity of epilepsy, and its timely identification in persons with epilepsy is essential. The use of screening tools to detect depression is common in epilepsy, but some scales in current use have not been validated using a gold standard in this population. The present study aims to validate three commonly used depression-screening scales and assess new cut points for scoring in those with epilepsy., Methods: Persons with epilepsy (n = 300) from the only epilepsy clinic in a large urban health region completed questionnaires (e.g., sociodemographics, adverse event profile) and three depression-screening tools (Hospital Anxiety and Depression Scale [HADS]; Patient Health Questionnaire [PHQ]-9 and PHQ-2). One hundred eighty-five patients participated in a gold-standard structured clinical interview to assess depression. The diagnostic accuracy of the depression scales was assessed comparing a variety of scoring cut points to the gold-standard diagnosis of depression., Results: The prevalence of current depression in this population, according to the gold-standard, was 14.6%. The scale with the highest sensitivity (84.6%) was the HADS with a cut point of 6 and the scale with the highest specificity (96.2%) was the PHQ-9 algorithm scoring method. Overall, the PHQ-9 at a cut point of 9 and the HADS at a cut point of 7 resulted in the greatest balance of sensitivity and specificity (area under the curve: 88% and 90%, respectively)., Significance: The PHQ-9 at a cut point of 9 and the HADS at a cut point of 7 had the best overall balance of sensitivity and specificity. However, for screening purposes the PHQ-9 algorithm method is ideal (optimizing specificity), whereas for case finding the HADS at a cut point of 6 performed best (optimizing sensitivity). Appropriate scale cut points should be chosen based on the study's goals and available resources. Disease-specific scale cut points are recommended for future studies assessing depression in persons with epilepsy., (Wiley Periodicals, Inc. © 2014 International League Against Epilepsy.)

Objective: Though depression is common in persons with epilepsy, it often remains undiagnosed and/or untreated. The current study aimed to determine the proportion of persons with epilepsy receiving depression-related treatment and to characterize the type of treatment received., Methods: Persons with epilepsy (n=185) from the only epilepsy clinic in a city of 1.2 million people completed questionnaires and the gold-standard Structured Clinical Interview for DSM Disorders (SCID) to assess current and past depression. Treatment for depression (pharmacological and nonpharmacological) was ascertained through patient self-report and chart review., Results: Of those with current depression (n=27), the majority (70.3%) were not on any depression-related treatment. In persons with current depression, nonpharmacological management was the most common treatment method, followed by treatment with psychotropic medications such as selective serotonin reuptake inhibitors. More individuals with a past history of depression but without a current episode (n=43) were treated (37.2%); it was more common for these individuals to be treated with pharmacological measures. After using an algorithm that adjusts the treated prevalence for those who are successfully treated, the adjusted proportion of depression treatment was 53.1%., Conclusions: The proportion of people treated for current depression in this cohort was very low. Future studies should investigate barriers to treatment and how depression treatment can be optimized for those with epilepsy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The prevalence of depression in multiple sclerosis (MS) is known to be elevated, but nearly all available studies have estimated period prevalence. The objective of this study was to estimate the point prevalence of depression in a representative community sample using the Patient Health Questionnaire, Brief (PHQ-9)., Methods: The data source for this study was the Survey of Living with Neurological Conditions in Canada, which was derived from a representative sample of household residents., Results: The sample included 630 respondents with MS. With application of the standard PHQ-9 cut point (10+), the prevalence of depression was 26.0% (95% confidence interval 18.9%-33.0%). Depressed subjects had lower quality of life; an increased frequency of suicidal ideation; and more often reported a negative disease course, high stress, low social support and stigmatization., Conclusions: This study adds to the existing literature by providing point prevalence data: in any 2-week period, about one quarter of community residents with MS experience substantial levels of depressive symptoms., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To estimate the prevalence, incidence and determinants of suicidal ideation in the multiple sclerosis (MS) population., Methods: A sample of 188 subjects were randomly selected from a community-based MS clinic registry and participated in as many as 13 interviews over 6 months. Thoughts of "being better off dead" or of "harming oneself" were assessed using item 9 on the Patient Health Questionnaire, Brief (PHQ-9)., Results: At baseline, the 2-week period prevalence of suicidal ideation was 8.3%. Over the course of 6 months, 22.1% of respondents reported having such thoughts at least once. Survival analysis incorporating baseline PHQ-8 scores as a covariate confirmed that being age 65 and over (HR=4.3, 95% CI 1.7-11.3) and having lower quartile self-efficacy ratings (HR=3.5, 95% CI 1.5-8.2) predicted suicidal ideation. Lower levels of task-oriented coping (treated as a continuous variable) also predicted suicidal ideation after adjustment for depressive symptoms (p=0.015), as did self-reported bladder or bowel symptoms (HR=2.6, 95% CI 1.1-6.0) and difficulties with speaking and swallowing (HR=2.9, 95% CI 1.3-6.8). Associations with MS symptoms were not confounded by depressive symptoms., Conclusion: This study identified several potentially modifiable factors that may be useful for preventing suicide in people with MS., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Preference-weighted HRQoL (utility) ratings are increasingly used to guide clinical and resource allocation decisions, but their performance has not always been adequately explored. We sought to examine patterns of health utility ratings in community populations with depressive disorders and painful conditions., Methods: We used two Canadian cross-sectional health surveys that obtained Comprehensive Health Status Measurement System/Health Utilities Index Mark 3 (HUI3) ratings and identified people with painful conditions and major depression. We estimated the frequency of item endorsements and mean utility ratings in these groups., Results: Interesting differences between health state ratings and diagnostic categories were noted. For example, 71% of those professionally diagnosed with migraine reported that they usually have "no pain." Despite this, utility ratings were lower in those respondents with depressive episodes and in those with painful conditions. Greater than additive reductions in HUI3 scores were noted in most instances where both depressive disorders and painful conditions were present., Conclusions: Health utility ratings confirm the clinical impression that painful conditions and depressive disorders magnify each other's impact. Despite weak alignment between the health state definitions incorporated into utility ratings and the diagnostic concepts examined, the HUI3 appeared to capture HRQoL decrements and negative synergies associated with the co-occurrence of depressive episodes and painful conditions.

Background: Major depressive episodes have a negative effect on health-related quality of life (HRQoL). The objective of this study was to determine whether recreational physical activity can ameliorate some of this negative impact., Methods: The data source for the study was the Canadian National Population Health Survey (NPHS). The NPHS is a longitudinal study that has collected data from a representative cohort of 15,254 community residents. Sixteen years of follow-up data are available. The NPHS included: an instrument to assess MDE (the Composite International Diagnostic Interview Short Form for Major Depression), an inventory of recreational activities (each associated with hours of participation and estimated metabolic expenditures), and a HRQoL instrument (the Health Utility Index, Mark 3, or HUI3). Proportional hazard and linear regression models were used in this study to determine whether MDE-related declines in HRQoL were lessened by participation in an active recreational lifestyle., Results: Consistent with expectation, major depression was associated with a significant decline in HRQoL over time. While no statistical interactions were observed, the risk of diminished HRQoL in association with MDE was reduced by physical activity. In a proportional hazards model, the hazard ratio for transition to poor HRQoL was 0.7 (95% CI: 0.6-0.8, p < 0.0001). In linear regression models, physical activity was significantly associated with more positive HRQoL (β = 0.019, 95% CI 0.004 to -0.034, p = 0.02)., Conclusion: Recreational physical activity appears to ameliorate some of the decline in HRQoL seen in association with MDE. Physical activity may be an effective tertiary preventive strategy for this condition.

Background: Clinical practice guidelines increasingly recognize the heterogeneity associated with major depressive episodes (MDE), e.g. through strategies such as watchful waiting. However, the implications of episode heterogeneity for long-term prognosis have not been adequately explored., Methods: In this project, we used data from a Canadian longitudinal study to evaluate recurrence risks for MDE after an initial episode in the mid-1990s. This study collected data from a community cohort between 1994/1995 and 2008/2009 using biannual interviews. Characteristics of the index episode: syndromal versus sub-syndromal, duration of symptoms, and indicators of seriousness (activity restriction, high distress or suicidal ideation) were recorded. The ability of these variables to predict MDE recurrence was explored using proportional hazards modeling. Additional analyses using generalized estimating equations were used to assess robustness., Results: Even brief, sub-syndromal episodes not characterized by indicators of seriousness were associated with an increased risk of subsequent MDE. However, episodes meeting diagnostic criteria for MDE, those lasting longer than four weeks and those associated with indicators of seriousness were associated with much higher recurrence risk. Sub-syndromal episodes associated with these characteristics generally predicted subsequent MDE as strongly as the occurrence of MDE itself., Limitations: The data source did not include assessment of all potentially relevant covariates. The assessment of MDE used an abbreviated instrument., Conclusions: Brief sub-syndromal episodes of depression are not usually targets of acute treatment, but such episodes have implications for subsequent MDE risk. Episode characteristics identify a range of outcomes that have potential implications for long-term management., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Patients with multiple sclerosis (MS) have a high prevalence of depression, but there are concerns regarding assessment of possible depression status using rating scales, such as the 9-item Patient Health Questionnaire (PHQ-9). The idea has been proposed that PHQ-9 scores are contaminated by the MS symptoms of fatigue and impaired concentration, decreasing the validity of measurement., Objectives: To determine the extent to which scores on the PHQ-9 are contaminated by patients reporting symptoms attributable to MS., Methods: Baseline PHQ-9 scores from an ongoing prospective cohort study of depression in patients with MS (N = 173) were compared with those of a general population sample (N = 3304). Depression prevalence estimates for the MS and general population samples were calculated using conventional algorithm and cutoff point scoring methods, as well as modified scoring methods, excluding fatigue and concentration deficits. Correlations between scores on adjusted scoring methods were analyzed. The proportion that each item contributed to total PHQ-9 scores was also calculated. A logistic regression model evaluated the relationship between symptom severity and MS status corrected for age, sex, and other depressive symptoms., Results: Conventional PHQ-9 algorithm and cutoff point scoring yielded 2-week prevalence estimates of 9.8% and 21.4%, respectively, in patients with MS, and 3.3% and 8.4%, respectively, in the general population. In both samples, conventional and modified scoring methods were strongly correlated (Spearman rank correlation coefficient > 0.9). The proportion of total scores contributed by fatigue and concentration items was not different between samples. With adjustment for other depressive symptoms, the MS sample had greater odds of endorsement for guilt (odds ratio, 2.17; P = 0.025) and fatigue (odds ratio, 1.51; P = 0.046)., Conclusion: Inclusion or exclusion of fatigue and concentration items on the PHQ-9 scale does not substantially alter the performance of the scale. With use of the PHQ-9 in MS populations, we find no evidence to suggest that modified approaches to scoring are necessary.

Background: In psychiatric epidemiology, symptoms are often assessed retrospectively. This raises concerns about the accuracy of the information recalled. In this study, we sought to examine the level of agreement between survey items assessing recent and more remote depressive episodes., Methods: Data from the Canadian National Population Health Survey (NPHS) were used. The NPHS is a prospective study following a representative cohort of household residents sampled in 1994 and 1995. Every 2 years, participants are administered the Composite International Diagnostic Interview Short Form for Major Depression (CIDI-SFMD). The 2004 NPHS interview also included items asking about past episodes of depression and diagnoses of depression done by health professionals. We used cross-tabulation and logistic regression to explore the relationship between these responses., Results: Approximately, 90% of respondents with CIDI-SFMD-defined major depressive episodes in the year preceding the 2004 interview also reported lifetime episodes or professional diagnoses of depression in 2004. However, responses to the 2004 lifetime items corresponded less closely to CIDI-SFMD results from the same individuals earlier in the longitudinal survey. Only 40.8% of respondents having the most recently identified episode in 1994 subsequently affirmed a past episode of depression in 2004., Conclusions: Reporting of depressive episodes diminishes with time, suggesting that retrospective assessment of such episodes may be vulnerable to inaccuracy.

Background: Reports of bidirectional associations between smoking and major depression (MD) have been interpreted as providing evidence for confounding by shared-vulnerability factors (SV) that predispose individuals to both conditions. If this is true, then smoking cessation may not reduce the risk of MD. From clinical practice and public health perspectives, the long-term outcomes associated with smoking persistence and cessation are potentially important and deserve exploration. To this end, the 12-year risk of MD in persistent heavy smokers and abstainers who were former-heavy smokers with and without adjustment for potential confounders were compared., Methods: Follow-up data from the National Population Health Survey (NPHS) was used. Multinomial logistic (ML) models were fit to identify potential confounders. Using proportional hazard (PH) models, unadjusted and adjusted hazard ratios (HRs) for MD outcome were estimated for different smoking patterns., Results: The unadjusted HR relating the risk of MD among current-heavy versus former-heavy smokers was 4.3 (95% CI: 2.6-6.9, p < 0.001). Current-heavy smoking predicted onset of MD (HR = 3.1, 95% CI: 1.9-5.2, p < 0.001) even after adjustment for age, sex and stress - the main confounders. However, this was not the case for the never, former-light, and current-light categories. Evidence of decreased risk of MD among former-heavy relative to current-heavy smokers as function of smoking cessation maintenance time was also found., Conclusions: Contrary to common beliefs about the benefits of smoking for mental health, our results suggest that current-heavy rather than ever-heavy smoking is a major determinant of MD risk and point towards the benefits of smoking cessation maintenance., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objectives: We examined trends in prescription recommendations for treatment of bipolar disorder (BD) in Canada during 2002-2010., Methods: Data collected by IMS Brogan in a database known as the Canadian Disease and Therapeutic Index were used for this analysis. These data are collected from a representative physician panel who record each drug recommendation and reason for recommendation in their practices for 2 consecutive days each calendar quarter of the year. Prescription patterns of medications for BD, including lithium, anticonvulsants, antipsychotic agents, anxiolytics, and antidepressants, were evaluated both for general practitioners and for specialists., Results: The number of prescription recommendations for BD increased by 72.1% from 2002 to 2009, and then dropped by 24.8% from 2009 to 2010. This increase from 2002 to 2009, and subsequent decrease from 2009 to 2010, was observed for all classes of medications. The overall increase from 2002 to 2010 was statistically significant for the atypical antipsychotics (P = 0.04). The largest change for an individual drug during this period was a 438% increase in recommendations for quetiapine (P = 0.01)., Conclusions: The number of prescription recommendations for BD increased substantially from 2002 to 2009 and sharply dropped in the following year. These results suggest that the influence of the concept of the bipolar spectrum and its promotion may have resulted in a substantial increase in treatment that has recently begun to wane.

Community-based studies are required to accurately describe the supportive services needed by people with multiple sclerosis (MS). Characteristics that influence (or result from) care-seeking may introduce bias into other types of studies. The Participation and Activity Limitation Survey (PALS) was a post-census survey conducted by Statistics Canada in association with a 2006 national census. The PALS collected data from a sample of 22,513 respondents having health-related impairments according to their census forms. The survey collected self-reported diagnostic data and obtained ratings for items assessing impairment as well as perceived met and unmet needs for care and support. It identified 245 individuals with MS, leading to an estimated (weighted) population prevalence of 0.2% (200 per 100,000). As expected, those with MS reported more-severe health problems than did those with other types of disability, particularly in the areas of mobility, dexterity, and cognition; they were also more likely to report having multiple caregivers. People with MS also reported more unmet health-care needs than did those with other forms of disability, particularly with respect to meal preparation, housework, shopping, and chores. Despite their more negative health status and greater reliance on caregivers, people with MS reported participation in society comparable to that of people without MS. Thus, people with MS report greater needs than do people with other forms of health-related disability and utilize supportive services more often. However, they also report higher levels of unmet needs. The substantial needs of people with MS are only partially addressed by existing services.

Background: Community-based studies can describe health status and related variables in people with Multiple Sclerosis (MS) while avoiding biases introduced by help-seeking in specific clinical settings., Objective: To describe general health status, stress perceptions and life satisfaction in people with MS, in comparison to those with other types of disabilities., Materials & Methods: The Participation and Activity Limitation Survey (PALS) was a post-censual survey conducted by Statistics Canada in association with the 2006 Canadian Census. PALS collected data from a random sample of n = 22,513 respondents identified as having health-related impairments. Frequencies and quartiles as well as mean values, along with associated 95% confidence intervals, were calculated in the analysis., Results: PALS identified 245 individuals with MS. Health status, both perceived and when weighted for societal preference, was markedly lower than that of other disabled groups. No differences in self-perceived stress were seen. People with MS reported lower levels of satisfaction with their health but slightly higher levels of satisfaction with their family and friends., Conclusions: People with MS report lower levels of general health status and more impairment than those with other disabling conditions. Higher levels of satisfaction with friends and family may reflect psychological adaptation to the illness.

Objective: Psychiatric conditions are known to have a detrimental impact on functioning and may therefore influence patterns of disability associated with MS. Population-based studies are needed to evaluate such interactions. The objective of this study was to describe the pattern of interaction of MS and mental disorders on health-related impairments., Methods: The Participation and Activity Limitation Survey (PALS) was a post-censual survey conducted by Statistics Canada in association with the 2006 Canadian Census. PALS collected detailed data from a random sample of n = 28,640 respondents with health-related impairments reported on their census form. The PALS interview collected self-reported diagnostic data and included scales to assess functioning and participation in society., Results: PALS identified 245 individuals with MS, leading to an estimated (weighted) population prevalence of 0.2% (200 per 100,000), consistent with other Canadian estimates. As expected, impaired agility, vision, communication, mobility, pain, and memory were strongly associated with MS. Mental disorders were also associated with impairment, but interactions between these conditions and MS were generally not evident., Conclusions: Mental disorders are associated with a higher level of disability in MS but, with the exception of communication, there was no evidence of synergistic interaction between mental disorders and MS in contributing to health-related impairments.