The Canadian Journal of Psychiatry

To review research, policy, and practice in psychiatric rehabilitation in the UK.

We undertook a literature review and review of government policy documents.

Most individuals with severe, disabling mental illnesses are cared for by generic community mental health services under the Care Programme Approach (CPA). Current government policy requires the introduction of assertive outreach and early psychosis services and is highly consistent with the adoption of the recovery paradigm within UK mental health services. Research and development activities have demonstrated the success of the UK hospital-closure program and have contributed to the worldwide resurgence of interest in psychosocial interventions in psychosis.

A need remains to focus research and practice on those who are most disabled by their illnesses and to improve the skills of the workforce in psychosocial interventions.

Chronic depressive disorders are common, accounting for approximately one-third of all cases of depression and posing a major public health problem. In the past, chronic depression has been thought to be treatment-resistant, and evidence suggests that it is currently underdiagnosed, misdiagnosed, and suboptimally treated.

To review the subtypes of chronic depression and the evidence-base concerning their optimal treatment and to discuss some key clinical issues and areas of future research.

We identified key studies and randomized controlled trials (RCTs) by systematically searching electronic databases and hand searching specialist journals and bibliographies.

Chronic depressive disorders respond well to standard pharmacologic interventions in the acute and maintenance phases of treatment. Standard psychotherapies alone may not be efficacious for chronic depression (especially dysthymia). Recent evidence suggests that treatment combining psychotherapy and medications may be superior to either treatment alone.

Chronic depressive disorders are amenable to treatment, provided that intervention is both thorough and intensive. Although our knowledge about the optimal treatment of chronic depression has developed rapidly, changes in clinical practice have been slower to evolve. Further research is required to assess the effectiveness of multimodal interventions for chronic depression in more naturalistic settings.

To discuss developments in Ontario mental health reform, describe general psychiatric services in contrast to tertiary services, describe guidelines for the training of general psychiatrists, and suggest what changes may be required to develop an integrated mental health system (IMHS).

We review the Ontario government's recent blueprint for mental health reform and the Canadian federal government's document on best practices in psychiatry, in the context of defining general psychiatric services and their relation to tertiary services. From this, we consider the education of general psychiatrists and make suggestions for their training.

General psychiatric services correspond to first-line and intensive psychiatric services delivered by community mental health agencies, community psychiatrists, and general hospitals for patients with moderate or serious mental illness. Many suggest that psychiatrists are not being trained to meet the needs of a reformed mental health system. An education program for general psychiatrists should include training in a wide range of community and general hospital settings, work within a multidisciplinary mental health team, and experience working in a shared care model with family physicians.

Along with training general psychiatrists better, we must also develop recruitment and payment incentives, which would allow general psychiatrists who are based in the community and general hospitals to work within an IMHS.

There are few Canadian prevalence studies of mental retardation (MR); those that do exist were conducted prior to the era of community integration. We undertook a population-based study to explore mental health disturbances in young persons with MR. The first requirement was to identify a population with MR and to establish its prevalence. Here, we report data on the prevalence of MR in a population aged 14 to 20 years.

We conducted the study in the Niagara Region of Ontario, which has a population base of around 400 000. Researchers worked closely with schools and with agencies providing services to persons with MR to identify the study group. We confirmed the functioning level of participants through standard tests of nonverbal intelligence and receptive language; teachers and other service personnel provided information relevant to the estimation of nonparticipants' functioning level.

We identified 255 individuals as having MR (IQ ≤ 75). Of these, 171 chose to participate (defined as “participants with MR”; the remaining 84 were “nonparticipants with MR”). Thus, the participation rate was 67% (171/255). Participants and nonparticipants with MR did not differ on age, sex, or IQ, although there were more nonparticipants in the lower social strata. Overall prevalence for MR was 7.18/1000. For mild mental retardation (MMR; that is, IQ = 50 to 75), prevalence was 3.54/1000, and for severe mental retardation (SMR; that is, IQ < 50), it was 3.64/1000.

Our prevalence estimate for SMR is similar to rates from previous studies conducted worldwide. Our estimate for MMR parallels the lower rates found in Scandinavian countries and contrasts with the higher rates generally reported in the US.

To systematically review the literature with respect to treatment-seeking rates for depression and associated mediating factors. This review focuses on adolescents and adults of all ages.

A structured literature review using Medline and PsychInfo databases revealed 38 relevant papers. Two trained reviewers independently and blindly assessed each study according to 4 inclusion criteria. A total of 17 papers met all 4 criteria.

Between 17.0% and 77.8% of individuals with depressive episodes or disorders sought treatment in these studies. We could explain the range in rates by diverse measures of depression, mediating factors that influence treatment-seeking, varied years in which the studies were done, and different time periods over which treatment-seeking was assessed.

Treatment-seeking rates for major depression appear to have increased over the years. Age, race, social supports, and clinical and psychiatric factors seem to influence treatment-seeking rates most. Public health initiatives can use this information to facilitate service access and delivery.

Previous proton magnetic resonance spectroscopy (¹H-MRS) studies in posttraumatic stress disorder (PTSD) report decreased hippocampal N-acetylaspartate (NAA), an indicator of neuronal integrity. However, other areas of the brain need to be explored. The objective of this study was to investigate the specificity of hippocampal NAA concentration changes in PTSD by also examining a control region, the occipital white matter (OWM).

Eight patients with PTSD and 5 control subjects underwent single-voxel ¹H-MRS of the hippocampi and bilateral OWM. Absolute neurometabolite concentrations were determined.

Trends toward reduced left hippocampal NAA and creatine (Cre) were found in the PTSD group. PTSD subjects also had reduced bilateral OWM Cre.

The preliminary results of our study in civilians with PTSD replicate previous MRS studies and are consistent with decreased hippocampal neuronal integrity without effects in the OWM. Replication of our findings is needed.

To examine the efficacy of atypical neuroleptics for decreasing craving and drug relapses during protracted withdrawal in individuals dually diagnosed with schizophrenia and cocaine dependence.

We conducted a 6-week, open-label pilot study comparing risperidone with typical neuroleptics in a sample of withdrawn cocaine-dependent schizophrenia patients.

Preliminary results suggest that individuals treated with risperidone had significantly less cue-elicited craving and substance abuse relapses at study completion. Further, they showed a trend toward a greater reduction in negative and global symptoms of schizophrenia.

Atypical neuroleptics may help reduce craving and relapses in this population. Future research should include more rigorous double-blind placebo-controlled studies with this class of medications.