Behavioural Medicine Manual

Photo/Video Consent Form

PATIENT CENTRED CARE LAB (PCCL)

In Family Medicine specialty training we use videotape review as one of the tools to improve communication and clinical skills. We appreciate your willingness to participate in this process. This recording will be used for the Resident’s learning purposes in a small, supervised teaching lab at the University of Calgary only, and will be deleted within eight weeks of today’s date.

Please note that physical examinations will not be recorded. If you change your mind about being recorded at any point in this video process, you are free to withdraw your consent or can ask to stop the recording without any effect to your health care.

Your signature on this form shows that you understand this process and agree to participate. The consent does not waive your legal rights, nor does it release us from our legal and professional responsibilities.

If you have any questions, comments and/or concerns about the collection or use of this recording, please do not hesitate to contact:

Dr. Todd Hill PhD, R. Psych Assistant Professor & Director of Behavioural Medicine Department of Family Medicine University of Calgary [email protected] (403) 943 - 5062

______Patient Name (CAPITALS)

______Patient Signature

______Resident Signature Date

Patient Centered Skills Form (PCSF)

Resident: Observer: Date: Directions: Track behaviours in the left column. Then, mark one box per row: Not observed, Attempted, Good or Excellent. Record important provider/patient comments and verbal/non-verbal cues in the notes. Residents: Use form to enhance your learning, vocabulary, and self-awareness. Ratings can be for individual interviews or to summarize several interactions. If requested, use this form to guide verbal feedback to someone you observe.

Not Behaviours, skill sets, and elements Good Excellent Observed Check only what you see or hear. Avoid giving benefit of the doubt. Attempted Notes Established rapport Introduces self, role and nature of interview Greets patient by name Acknowledges all in the room by name Demonstrates respect Uses eye contact Humour or non-medical interaction Strong verbal and / or non-verbal empathy Demonstrates mindfulness through curiosity, self-reflection or presence Established reason for consult Asks – “What are the issues you’d like to discuss in today’s visit?” and “is there anything else?” Until the patient states there are no other issues. Listens to patients’ list of concerns (polite interruption = eye contact. Lean in, hand gesture, apologize, reflect, explain) Summarizes list and confirms what is most important to patient (negotiates agenda) Sets an agenda (negotiates agenda) Acknowledges agenda items from other team member (e.g. nurse, MOA or EMR) Gathering information - disease Asks patient to tell ‘The Whole Story’ Starts with open-ended and moves to close-ended questions Facilitates responses by using verbal, paraverbal and nonverbals, silence, repetition, paraphrasing, interpretation Actively and attentively LISTENS without excessive interruptions, leaving patients time to think & speak Picks up on info via patient’s non-verbal cues / behaviours Uses summary statements (potential for ‘type & talk’) Uses clarifying statements Uses easily understood questions – No jargon Establishes a timeline Gathering information – illness experience Explores patient feelings Explores patient beliefs Explores impact of illness experience on patient’s functioning Elicits patient’s expectations for the visit Explores contextual influences: family, cultural, spiritual Electronic Medical Record use Signposts and describes use of EMR to patient Maintains eye contact with patient during majority of time while using EMR (opportunity for ‘type and talk’) Positions monitor to be viewed by patient (or positions patient to have better access to the clinician and the monitor) Points to screen using hand to point / not mouse or cursor

Not Behaviours, skill sets, and elements Good Excellent Observed Check only what you see or hear. Avoid giving benefit of the doubt. Attempted Notes Makes organization overt About visit organization, problem priorities, problem-solving (admits not-knowing &/or explores info with patient) Summarizes at the end of specific lines of inquiry to confirm resident understanding Progresses from one section to another using signposting / transition statements Structures the interview in a logical sequence Takes responsibility for efficient time management Physical Exam Prepares patient before physical exam actions and describes exam findings during the exam (“I am going to ____” then “your lungs sound healthy”) Providing the correct amount and type of information Assesses patient’s prior knowledge (APK) Chunks & checks information Asks what information the patient would like to know Saves explanation and treatment planning until the end Aiding accurate recall Organizes information Categorizes information (using labels i.e. “1, 2, 3” / “a, b, c”) Uses repetition and summarizing to reinforce information Avoids or explains medical jargon Uses visual aids / handouts Uses Teachback = Asking the patient to explain his/her understanding of the plan / Explicitly Checks pt understanding Co-creating a plan Achieving a shared understanding FIFE’s it back to the patient (creates connections between the patient’s illness experience and the explanation / treatment plan) • “So you have been concerned about . . . and these are our options . . .” • “You checked with Google – and were wondering whether it was . . . ”, • “We know that this is affecting your parenting, so . . .”, • or “You were hoping that we would be able to . .”) Provides opportunities for patient to contribute his / her opinion Responds to verbal and nonverbal signs of agreement, curiosity , engagement, disagreement, displeasure, etc Elicits patient’s beliefs about info and plan (does the patient feel you both are “on the right track?”) (‘Scales’ confidence or importance – i.e. on a scale from 0 – 10, how confident . . . ) Share d decision making Shares own opinion (based on evidence behind recommendations - when available) Involves patient / makes suggestions / uses inclusive language Offers choices Negotiates a mutually acceptable plan Checks with patient – if plan is acceptable / if concerns have been addressed Closure and follow-up Contracts with patient (Dr’s job, patient’s job, clinic’s job, etc.) Discusses red-flags / safety nets Summarizes the session Final Check - Asks for questions about today’s topics (does NOT end with an open “Is there anything else you would like to discuss with the doctor, today”)

Patient Centered Skills Form (PCSF)

PCCL – You are an individual Let’s hear more about that

CFPC Key and enabling competencies Professionalism 5. Demonstrates a commitment to reflective practice: 5.2 Demonstrates awareness of self and an understanding of how one’s attitudes, beliefs, assumptions, values, preferences, feelings, privilege and perspective impact their practice

Principle 1 of Relationship Centered care That relationships in health care should honour the individuality of the participants

Therefore, bring in something that you feel is representative of who you are.

Past have included: Wife and children (in real life) Tim Horton’s Donuts A cello A map of the world (traveller) Iranian poetry Video of dance performances Medical School Yearbook (Queen’s) Coca-Cola Beach sand Chinese pastry Seattle Seahawks’ jersey Asian tea – drink boxes Haggis Baklava Triathlon singlet A crucifix An eagle feather Team photos Family photos Samosa Bagels An African ceremonial drinking goblet

Come prepared to tell us a little about who you are & to discuss how some of your attitudes, beliefs, assumptions, values, preferences, feelings, privilege and perspective impact your practice.

For better and for . . . less better.

“Behavioural Medicine is an interdisciplinary field that aims to integrate the biological and psychosocial perspectives on human behaviour and to apply them to the practice of medicine. It also includes a behavioural approach to somatic disease, the mental disorders as they commonly appear in medical practice, issues in the clinician-patient relationship, and other important topics that affect the delivery of medical care, such as motivating behaviour change, maximizing adherence to medical treatment, complementary and alternative medicine, and the care of the dying”

Feldman & Christensen, 2008

1 Behavioural Medicine Completion Requirements

(PCCL) Patient Centered Care Lab:

Video Review PCSF PCSF PCSF

Task # 1 2 3 4 5 6 7 8 9 Self Videos Video Completed by Self learning Completed Reflection reviewed in reviewed colleague assessment by PCCL Show&Tell lab with preceptor(s) colleague

(FM-MHL)Family Medicine Mental Health Lab:

Case Presentations R1 R2

Task # 1 1 First Case must be Anxiety or based on anxiety Depression and/or depression

*All cases reviewed in FM-MHL must be sourced from a patient interaction in your FM clinic

1 PCCL

2 FM-MH Lab

3 Wellness

1 PATIENT CENTERED CARE LAB (PCCL)

Patient Centered Care Lab - PCCL

When: Monday or Friday afternoons 1:30pm-4:30pm (R1s only)

Where: Sunrdige Family Medicine Teaching Centre 2685 – 36th Street NE Calgary, AB T1Y 5S3

Who: Family Physicians, Psychologists and approximately 6 FMRs

How: 1x/week for 8 weeks during PGY1 during an FM MH/BM Block (= 1 A.C.E.)

What: The focus is on provision of Patient Centered Care – using Calgary Cambridge Communication Guide, mindfulness and self-reflection exercises as curriculum. The labs include videotape review of residents with any patients from their own Family Medicine clinics.

1st Lab: Please remember to refer to the instructions on your Block schedule specific to PCCL, and come adequately prepared to your first lab.

Please read pages 1-16 from your BEHMED binder prior to the start of the 1st PCCL session

Patient Centered Care Lab - PCCL

What’s the syllabus?

 Calgary Cambridge Communication Guide

 Mindfulness Training

 Self Reflection Exercise

Lab #1 – Intro to Mindfulness / Intro to Calgary Cambridge Guide (CCG)

Lab #2 – Mindful Practice / CCG – Information Gathering

Lab #3 – Mindfulness Practice / CCG – FIFE

Lab #4 – Mindfulness Practice / Making Organization Overt

Lab #5 – Mindfulness Practice / Explanation and Treatment Planning

Lab #6 – Mindfulness Practice / Shared Decision Making

Lab #7 – Mindfulness Practice / Shared Decision Making

Lab #8 – Mindfulness Practice / Closing Session

PGY1 – opportunity to attend 8 labs (must attend minimum of 6)

Recommended Record (at least) 12 patient interactions (must be from your home FM clinic) Review (at least) 8 of your interactions

Required Review 4 in PCCL (2X 5 mins of 1st half & 5 mins of 2nd half)

Review 1 with a colleague who has attended PCCL (current, past residents, preceptors) – full encounter – colleague must complete a PCSF

Patient Centered Care Lab - PCCL

Competency Targets / Objectives

The resident will:

 Display effective, professional and non-judgmental communication skills • Organize presenting complaints in a way that clearly identifies the main presenting problems • Gather a focused history regarding the main symptoms in a timely manner • Elicit the pertinent associated symptoms, red flags and risk factors • Convey to preceptors through the nature and sequence of questions that diagnostic hypotheses are being generated and tested • Employ rich mixture of techniques such as open-ended questions, direct questions, scaling, narrative • Employ flexible style to suit varying cultural, educational levels • Illustrate age-appropriate approach e.g. using play, humour with children • Communicate effectively and professionally to family members • Establish therapeutic relationship with patients and families

 Adopt a patient centered approach • Determine patient agenda and explore patient illness experience (i.e., FIFE) • Identify and articulate patient goals and priorities and negotiate patient priorities • Develop and monitor contracts with patients • Balance patient needs with desired treatment outcome • Clarify the patient’s understanding and develop mutually agreeable treatment plan • Demonstrate sensitivity to cultural, gender, sexuality and socioeconomic differences

3 4 5 6 7 8 9 10 11 12 13 RESEARCH EVIDENCE FIVE BASIC TASKS OF THE MEDICAL INTERVIEW Updated by the Communication Skills Program, Dalhousie Medical School, 2004

Research evidence relating to the Calgary-Cambridge Guide’s five basic communication tasks for the medical interview:

1. Initiating the Session 2. Gathering Information 3. Building the Relationship 4. Explanation and Planning 5. Closing the Session

Initiating the Session

• Only ¼ of patients (23 to 28%) completed their opening statement (Beckman & Frankel, 1984; Marvel et al, 1999). • Most patients who were allowed to complete their opening statement without interruption took less than 60 seconds and none longer than 150 seconds, even when encouraged to continue (Beckman & Frankel, 1984). Patients allowed to complete their opening statements of concerns used only 6 seconds more on average that those who were interrupted. (Marvel et al, 1999). • Doctors frequently interrupt patients, often preventing patients from disclosing all of their health problems. Studies have found physician interruption times vary: from 18 seconds (Beckman & Frankel, 1984) to 23.1 seconds (Marvel et al, 1999). Residents have been found to interrupt patients every 12 seconds (Rhoades, 2001). • Clarifying or closed questions were the most frequent cause of interruption (Beckman & Frankel, 1984). • Patients generally have more than one concern (average = 1.2 to 3.9), revealing the importance of identifying all concerns before hypothesis testing with clarifying questions (Beckman & Frankel, 1984). Patients with more than one unraised concern tend to be young, female, non-white, less educated and unmarried (Bell et al, 2001).

Gathering Information

• Doctors often pursue a ‘doctor-centered’, closed approach to information gathering that discourages patients from telling their story (Stewart el al, 2003). • Doctors rarely ask their patients to volunteer their ideas and often inhibit their expression (Stewart el al, 2003).

14 • Patient centred consultations were only one minute longer than physician- centred consultations (Abdel-Tawab and Roter, 2002). • The ratio of closed-ended to open-ended questions has been found to be 5.8 to 1 (Berry, 2003). • Without specific questions from physicians, the patient’s perspective on the illness (concerns, etc.) surfaces spontaneously in only about ¼ of medical interviews (Lang et. al, 2002). • Lack of recognition of patients’ ideas and beliefs about the illness can result in poor understanding, adherence, satisfaction and outcomes (Tuckett et al, 1985). When a patient-centred approach is employed, it is associated with a three-fold increase in the likelihood of client satisfaction and adherence (Abdel-Tawab and Roter, 2002). • Doctors were found to consistently use jargon that patients do not understand. (Hadlow and Pitts, 1991). However, a more recent study found that doctors don’t use jargon, but dominate the conversation with controlling language (Skelton and Hobbs, 1999). • Female residents interrupted their patients less often than did male physicians (Rhoades et al, 2001). • Residents interrupted female patients more than male patients (Rhoades et al, 2001). • Doctors can increase adherence to treatment regimes by explicitly asking patients about knowledge, beliefs, concerns and attitudes to their own illness (Maiman et al, 1988; Abdel-Tawab and Roter, 2002). • Discovering patients’ expectations leads to greater patient adherence to plans made, whether or not those expectations are met by the doctor (Eisenthal et al, 1990; Abdel-Tawab and Roter, 2002). • Third year medical students who received communication skills training outperformed those who did not receive the training in organization and time management, relationship development and maintenance, patient assessment, negotiation and shared decision-making (Yedidia et al, 2003).

Building the Relationship

• Better non-verbal communication skills are associated with significantly greater patient satisfaction (Griffith et al, 2003). • Computer use, verbal interruptions, a knock on the door and beeper interruptions all interfered with effective patient-doctor communication (Rhoades et al, 2001). • Female physicians participated in more psycho-social discussion, emotionally focused talk and positive talk (Roter et al, 2002; Bylund & Makoul, 2002).

15 Explanation and Planning

• In general, physicians give sparse information to their patients, with most patients wanting their doctors to provide more information (Beisecker, 1990, Pinder, 1990). Between ¼ and 1/3 of patients reported receiving less information than desired, particularly in relation to the risks and benefits of medical treatments (Ford, Schofield, and Hope, 2003). • Doctors were found to spend an average of 1.3 minutes of time devoted to information giving in interviews lasting an average of 15.5 minutes (Waitzkin 1985), and overestimated the time they devote to task by a factor of nine (Makoul et al, 1995). • Nine out of 10 patients do not receive good explanations on proposed treatments or tests (Braddock et al, 2000). • Concerning information, patients can be divided into ‘seekers’ (80%) and ‘avoiders’ (20%), with ‘seekers’ coping better with more information and ‘avoiders’ with less (Miller & Mangan, 1983; Deber, 1994). • A survey of 204 Nova Scotian adults indicated that patients were very satisfied with their family physician’s medical care, but somewhat less satisfied with their doctor’s communication skills – particularly in regard to explanation and planning. Items rated highest included an ability to put patients at ease, listen to complaints and create a good rapport. Items rated lowest included soliciting information about patient’s lives, providing enough information about the presenting complaint and actively involving patients in treatment plans (Laidlaw et al, 2001).

Closing the Session

• The average length of closure is 1.6 minutes. (White et al, 1994) • 86% of interview closures are initiated by the physicians. (White et al, 1994) • In 21% of closures, new problems arise that were not mentioned earlier in the visit (White et al, 1994). • Late rising concerns were most common when physicians did not solicit the patient’s concerns during the interview (Marvel et al, 1999) • Physicians’ behaviours in closure of the interview included: clarifying the plan (75%); orientating the patient to next steps of the visit (56%); providing information and counselling to the patient about the therapeutic regime (41%) and checking for patient understanding (34%) (White et al, 1994).

16 Bibliography: Abdel-Tawab, N, Roter D. "The relevance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience." Soc.Sci.Med. 2002; 54(9): 1357-68. Beckman HB, Frankel RM. The effect of physician behaviour on the collection of data. Ann Intern Med. 1984; 101: 692-6. Beisecker A, Beisecker T. Patient information-seeking behaviours when communicating with doctors. Med Care. 1990; 28: 19-28. Bell R et al. Unsaid but not forgotten: Patients’ unvoiced desires in office visits. Archives of Internal Medicine. 2001; 161: 1977-1984. Berry DL et al. “Clinicians communicating with patients experiencing cancer pain.” Cancer Invest. 2003; Jun 21(3): 374-81. Braddock CH, Edwards KA, Hasenber NM, Laidley TL, Levinson W. Informed decision-making in outpatient practice. JAMA. 2000; 282(24): 2313-20. Bylund C, Makoul G. Empathic communication and gender in the physician-patient encounter. Patient Educ & Counseling. 2002; 48: 207-216. Deber R. The patient-physician partnership: Changing roles and the desire for information. Can Med Assoc. 1994; 151: 171-6. Eisenthal S, Koopman C, Stoeckle JD. (1990). The nature of patients’ requests for physicians’ help. Academic Med.1990; 65: 401-5. Ford S, Schofield T, Hope T. “Are patients' decision-making preferences being met?” Health Expect. 2003; Mar 6(1): 72-80. Griffith C, Wilson J, Langer S et al. House staff non-verbal communication skills in standardized patient satisfaction. J of Internal General Medicine. 2003; 18: 170-4. Hadlow J, Pitts M. The understanding of common terms by doctors, nurses and patients. Soc Sci Med. 1991; 2: 18-30. Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary- Cambridge guides. Acad Med. 2003; Aug 78(8): 802-9.

Kurtz SM, Silverman JD, Draper J. Teaching and learning communication skills in medicine, Oxon: Radcliff Publishing, 2005. 2nd edition

Laidlaw T, Kaufman DM, Macleod H, Sargeant J, Langille D. Patient satisfaction with their family physician’s communication skills: a Nova Scotia survey. Academic Medicine. 2001; 76(10): S77-S79. Lang, F et al. "Sequenced questioning to elicit the patient's perspective on illness: effects on information disclosure, patient satisfaction, and time expenditure." Fam.Med. 2002; 34(5): 325-30. Maiman LA, Becker MH, Liptak GS et al. Improving pediatricians’ compliance-enhancing practices: A randomized trial. Am J Dis Child. 1988; 142: 773-9. Makoul G, Arnston P, Scofield T. Health promotion in primary care: Physician-patient communication and decision about prescription medications. Soc Sci Med.1995; 41: 1241-54. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA, 1999; 282(10): 942-3. Miller SM, Mangan CE. Interacting effects of information and coping styles in adapting to gynecological stress: Should the doctor tell all? J Personality and Soc Psychol. 1983; 45: 223-36. Pinder R. The management of chronic disease: Patient and doctor perspectives on Parkinson’s disease. Macmillan Press, London. 1990. Rhoades DR et al. “Speaking and interruptions during primary care office visits.” AO.Fam Med. 2001; 33(7): 528-32. Roter D, Hall J, Aoki Y. Physician gender effects in medical communication: A meta-analytic review. J of Am Med Assn. 2002; 288: 756-840. Skelton J.R, Hobbs F.D. “Concordancing: use of language-based research in medical communication.” Lancet. 1999. 353(9147): 108-11. Stewart MA, Belle Brown J, Wayne Weston W et al. Patient-centered medicine:Transforming the clinical method. Oxon: Radcliffe Medical Press. 2003. (2nd ed) Tuckett D, Boulton M, Olson C et al. Meetings between experts: An approach to sharing ideas in medical consultations. Tavistock, London. 1995. Waitzkin H. Information giving in medical care. J of Health & Soc Behavior. 1985, 26: 81-101. White J, Levinson W, Roter D. ‘Oh, by the way’: The closing moments of the medical interview. J Gen Intern Med. 1994; 9: 24-8. Yedidia M, Gillespie C, Kachur E et al. Affective communications training on medical student performance. JAMA. 2003; 290(9): 1157-65. G:\TL-lj\Conferences\McGill 2004\Research Evidence-Interviewing Tasks.doc

17 Questions to Explore the Illness Experience – FIFE

F – Feelings: What are you most concerned about?

Do you have any specific fears or worries right now? I imagine you have had many different feelings as you have coped with this illness.

Sometimes people have fears that they keep to themselves and don't tell their doctor. Can you tell me about any concerns you have?

I – Ideas: What do you think might be going on? What do you think this pain means?

Do you have ideas about what might have caused this illness? Most people have discussed their illness with family members or friends. I am interested to know what ideas you have come up with Before I tell you what I think is going on, I would like to hear your ideas

F – Effects on Day-to-Day Function: How has your illness affected you day-to-day?

What have you had to give up because of your illness? What goals do you have now in your life? How has your illness affected your goals?

How does this illness affect important people in your life?

Expectations of the doctor and the illness: What do you expect or hope I can do for you today?

Do you have expectations about how doctors can help?

What do you hope this treatment will do for you? What are your expectations about what might happen with this illness?

18 Communication Techniques and Behaviors Vol. 34, No.5 325

Sequenced Questioning to Elicit the Patient’s Perspective on Illness Effects on Information Disclosure, Patient a Satisfaction, and Time Expenditure

Forrest Lang, MD; Michael R. Floyd, EdD; Kathleen L.B. Beine, MD; Patricia Buck, MA

Table 1

Examples of Previously Referenced Sequenced Questions

Weston Brown, and Stewart1

• What do you think is causing the headaches? • Have any idea or theories about why you might be having them? • Do you think there is any relationship between headaches and current events in your life?

Yudkin24

• What is particularly bothering you about the condition? • What do you think might have caused the trouble?

Bass and Cohen9

• What are you concerned about? • Is there anything special about [your condition] that causes you concern?

Lipkin25

• What do you think is the matter with you? • What does the name of the disease mean to you? • What is your idea of what the sickness does to people? • Have you known anybody who had the same trouble? • What happened to that person?

Martin26

• How do you explain the illness? • What diagnosis have you thought of? • Are you concerned that this is cancer? • Has anyone you have known ever had similar symptoms?

Stoeckle and Barsky27

• Most people have had some ideas of their own about what brought on their sickness. • What does your husband, wife, or family think is the cause?

Figure 1

Sequenced Questions to Determine the Patient’s Perspective on Illness

When the history is complete, ask: Question 1

“What ideas or thoughts have you had about the possible cause of today’s problem?”

Patient discloses an attribution or concern, then ask: Patient denies specific attribution or concern, then ask;

Question 2A Question 2B

“That is very helpful. Besides that, did any other ideas “I know you may not know for sure the cause of your occur to you either of a serious or non-serious nature?” symptoms, but it would be helpful if you could share any ideas that may have crossed your mind.”

To further explore the patient perspective, ask:

Question 3

“Today, people hear, see, and read a lot about health problems. I wonder if there is anything you may have seen, read about, or heard someone mention that you connected with your symptoms?

Table 2

Patient Concerns Disclosed Spontaneously and In Response to Sequenced Questioning*

Spontaneous First Question Second Question Third Question No Disclosures 6 9 7 6 9

Patient concerns in response to Question 2 but not spontaneously and not to Question 1: • Infertility • Chest pain secondary to scar tissue • Gall bladder disease or gastrointestinal cancer • Heart attack • Inability to work • Pneumonia • Liver Problems

Patient concerns in response to Question 3 but not previously: • Fear that swelling of legs might cause congestive heart failure • The possibility of pancreatic cancer, like patient’s brother • Fear of stroke, like patient’s paternal grandfather • Fear of sudden infant death • Heart failure • Brain Tumor (the patient’s husband initiated this concern)

*n=27

20 Polite Interruption

Eye Contact Lean In Hand Gesture

Acknowledge and Apologize Empathize with the problem that is being interrupted Explain why you are interrupting, for example;

• Planning time use • Finishing an important topic )topic tracking) • Stopping to explore an important cue 21

Larry Mauksch M Ed University of Washington Department of Family Medicine Computer skills for the Calgary-Cambridge observation guide

Adapted by the iiCR team from the Guide (in: Silverman, Kurtz, Draper. Skills for Communicating with Patients. Radcliffe Medical Press. 1998 (p8)) and validated by Suzanne Kurtz. Building the relationship Developing rapport Use of notes: if reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport.

• Adapts behaviour to take into account relative position of doctor, patient and computer • Maintains open posture when using computer • Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen • Controls, or takes advantage of, the structure of the consultation in order to minimize risk of patient talking when doctor’s attention is on the computer * • Responds to patient cues when attending to the computer

Involving the patient

• Explains to patient why computer is being used • If the computer is being used as an information source, negotiates the use of such information with the patient • Lets the patient read information from the screen when appropriate

Explanation and planning Options

If using screen-based information (shared screen, PIL etc)

• Checks that patient can see the screen clearly • Remains quiet, and gives the patient time to read the text • Checks that patient has understood the text • Gives patient opportunity to ask questions • On a busy screen indicates (points etc) relevant information

22 Detailed description of the skills Developing rapport

Use of notes: if reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport.

• Adapts behaviour to take into account relative position of doctor, patient and computer • Maintains open posture when using computer • Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen • Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctor’s attention is on the computer • Responds to patient cues when attending to the computer

In this section we consider skills that allow use of the computer for a wide range of purposes. Many of these, such as generating a prescription or looking up records of previous consultations, are essential components of the consultation. In these instances computer use is no more than an analogue of the use of paper notes. Other uses of the computer, for instance as an information source or for decision support or prescribing support, require additional skills that are described in later sections. Adapts behaviour to take into account relative position of doctor, patient and computer Individual practitioners will have their own personal preference for the way that the desk and chairs are arranged in a consulting room. In many consulting rooms there are physical constraints that make some layouts of the desk impossible. Also many practitioners consult in a room that is not for their sole use and so they have to work with what is there. There is no single best solution either, each arrangement has some advantages and disadvantages. What is important for practitioners is to be aware of the restrictions of each room layout and to adapt their communication behaviour accordingly.

Layout A: computer screen and patient at opposite ends of the desk

23 In this set-up it is easy for the patient to see what is on the screen. As the practitioner has to turn away from the patient in order to see the screen, it should be clear to the patient where the practitioner’s attention is directed. If the mouse and keyboard are in front of the screen, the practitioner’s shoulders will be turned away from the patient, which may be interpreted by the patient as a cutting-off. When the practitioner is studying the screen, the patient is out of the practitioner’s sight-line: this means that cues from the patient’s eye or body movement or posture are not available to the practitioner during this time. Advantages to the practitioner of this set up are that the body movement required to turn to the screen serves as a signposting of where attention is focussed: this reduces reliance on verbal signposting. The other advantage is that the patient can easily read the screen, which makes it more likely that the screen will be used as a shared resource. Disadvantages are that eye contact is lost when the practitioner reads from the screen, and that all text on the screen is available to the patient. The practitioner must therefore be more prepared to respond to verbal cues when using the computer, and turn to face the patient if s/he speaks while the practitioner uses the computer. In addition it means that rapport needs to be re-established after each usage of the screen. Because the screen is so visible to the patient, it is important that the practitioner ensures that third party information is not present on the screen as well as making sure that all entries in the notes are appropriate for the patient to see.

Layout B: computer screen and patient at same end of the desk In this set up the practitioner can easily glance from patient to screen, without turning head or body. The patient cannot easily see the screen if s/he sits close to the desk. A tv type cathode ray monitor in this position is likely to dominate the patient’s space, which may be overbearing. Advantages to the practitioner of this set up mainly relate to the point that the patient is never out of view, so it is much easier to respond to non-verbal signals from the patient.

24 There are two main disadvantages. The first is that it is hard for the patient to know whether the practitioner is looking at them or at the screen: consequently verbal signposting and a commentary from the practitioner is much more important. The second is that if the patient is to see the screen, either the screen has to be turned towards them, or they have to lean forwards or move their chair.

Layout C: computer screen in middle of desk There are several different versions of this arrangement, all of which have the computer, the practitioner and the patient at apices of a triangle that is roughly equilateral. This is a compromise between layouts A and B. The position of the patient’s chair is the variable. If a flat screen is used, or a CRT screen mounted on a bracket at the back of the desk, then the patient can sit back round the corner of the desk and still see the screen. On the other hand, use of a narrow desk or a standard screen on a desk that is against a wall will force the patient’s position towards the one shown in the diagram. The advantage of this set up is that it is as easy for either party to see the screen and they can both do this without losing sight of each other. One disadvantage is that practitioner and or patient may both feel uncomfortable with the lack of a physical barrier between them. Both verbal and non-verbal signposting is required to signal changes in the practitioner’s focus of attention. Considerable rapport-building and rapport-maintaining skills are required to support this more open setting. There is an implicit acknowledgement in this layout that the computer is a full participant in the consultation: there will be some patients and some practitioners who are not ready to welcome this. Maintains open posture when using computer As we mentioned in the previous section, it is quite easy to be physically drawn towards the computer screen and keyboard when you are reading from the screen or typing. Consequently the practitioner can become hunched over the desk. This is uncomfortable for the practitioner in terms of posture, it also may make the patient feel isolated and so damage rapport in the consultation.

25 The position of screen and keyboard on the desk are often determined by the physical attributes of the room and these cannot be changed easily. One way to get round the problem is to use extension cables for screen keyboard and mouse. This allows the practitioner to sit back and still be able to use the screen. The aim should be to make the triangle of practitioner/ patient/ screen as near to equilateral as possible. This aids communication and rapport. Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen It is not possible to pay full attention to two different things at the same time, particularly if they involve spoken or written words. The consequence of this is that if you are paying full attention to some text on the computer screen, you will not be able to take in or respond appropriately to what the patient may be saying to you. We saw numerous instances of this problem in our work on the information in the consulting room project: the GP whose attention was fully engaged with the computer did not respond to what the patient said, or did not even notice that the patient had spoken. However, it is possible to use the computer during the consultation and maintain rapport with the patient, being aware of what they are doing and saying. Further, there is more than one strategy that successfully achieves this goal. The key is to apportion attention between the computer and the patient sequentially and not to try to attend to both at the same time. One way to do this is to make it clear to the patient when you are transferring your attention to the screen. If this is done clearly, then the patient is much less likely to try to communicate with you when you are distracted. The key communication skill is “signposting”. This is explained fully in Skills for communicating with patients. Some examples are given in the box. There are many other possible phrases that you could use: you should aim to be familiar with using one or two of them.

Signposting This can be done by verbal and non-verbal means, usually in combination.

Non-verbal: gestures, reaching for mouse, turning away from patient. Verbal: use of phrases that tell the patient what you are doing.

• “Just give me a minute while I look at the computer” • “I need to concentrate on the computer for a minute, do you mind?” • “Forgive me while I look at the screen” • “There is some information about this on the computer, I just need a moment to find it” • “Hold on while I do this on the computer”

Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctor’s attention is on the computer This skill is related to signposting, but is more concerned with the way that the practitioner manages the interaction with the patient. If you transfer your attention to the computer screen midway through a passage of dialogue you will either have to interrupt the patient in order to tell them what you are doing, or perhaps more likely you will not tell them and they will continue talking (with the attendant risk that what they say will not be heard). Much better to use breaks in the conversational flow as opportunities to transfer your attention to the screen. One strategy here is to wait for these breaks to occur naturally. The other is to engineer them. A number of practitioner behaviours encourage the patient to talk (these were described by Byrne and Long in 1976). These include use of open questions, non-verbal vocalisations (mm), short encouraging statements “yes”, “OK”, “go on”, leaving silent gaps, talking slowly. Using the opposite behaviours, and appropriate non-verbal behaviour too, will help bring a phase of the dialogue to an end.

Ways of creating a break in the dialogue

1. Use closed questions 2. Use statements or instructions 3. Speak quickly 4. Don’t leave gaps in the dialogue 5. Avoid prolonged eye contact

27 Filling the space Another strategy is to prevent the patient from talking by occupying the conversation space yourself. Some people do this by talking very slowly: another approach is to blather. By this we mean talk about low-challenge things like the weather or sport: many people can do this on ‘auto-pilot’ and leave their attention free for the computer. An alternative is to give a running commentary on what you are doing.

Blather This may be a running commentary on what the GP is doing

• “I just need to get into PRODIGY” • “The system is being slow today” • “I still need to take my time when I’m typing”

Responds to patient cues when attending to the computer This is a matter of self-discipline as much as anything. Some GPs we saw in the iiCR project used the computer almost casually without signposting, engineering gaps in the dialogue, or using blather. Their strategy is to turn back to the patient whenever they speak, cough or move. It is a very successful strategy and there was no loss of rapport in their consultations. To do this you need to be able to turn your attention away from the computer in midstream. It also relies on the patient being within your sightline, so it is not appropriate strategy if the position of the computer is such that you are turned completely away from the patient when looking at the screen. Involving the patient

In Skills For Communicating With Patients ‘Involving the patient’ appears as a skill in both the ‘Building the relationship’ and the ‘Explanation and Planning: Shared decision-making’ sections. This inter-relation between rapport, mutual understanding, and shared decisions is crucial to good outcomes in health terms. It is also crucial to successful communication of many sorts and to successful teaching in particular.

28 In the specific instance of using the computer as an information source in a medical consultation involving the patient features at three levels. The first is that if the patient knows what the practitioner is doing, there is more likely to be more common ground. The second is that allowing the patient to read the screen can let her/him see the source of information being used, and so increase his/her trust in that information. The third is that the decision to use the computer as an information source is best made as a shared decision, negotiated between practitioner and patient. Explains to patient why computer is being used This is largely a matter of good manners. It also allows the practitioner to explain why s/he is using the computer for information, rather than having everything at his/her fingertips. Also, the reasons for using the computer can vary and it helps the communication process if the reasons are explicit. Examples of phrases that could be used are:

• “This isn’t a problem I’ve come across before: I just want to look at the computer to get some more information” • “I’m pretty sure that this won’t affect the other tablets you are taking: I’d just like to check to make sure. Is it alright if we have a quick look at something on the computer?” • “This isn’t that easy to explain, there is something on Prodigy on the computer that we could both look at: I think that may help” • “I’m just going to use the computer to print out your prescription” • “If you give me a moment I’ll just look back at your records from when you last had this problem”

If the computer is being used as an information source, negotiates the use of such information with the patient Different people have different attitudes to knowledge and expertise. Some people expect practitioners to be knowledgeable in their field and not to need to look things up. Other people feel happier to see that personal knowledge and experienced is being backed up by authoritative sources. There is a wide range of information sources available to practitioners: the computer is one; books, journals, colleagues are others. These attitudes vary as much among doctors and nurses as they do in the rest of the population. In a consultation it is important to clarify a mutual understanding of each other’s views so that the decision to use the computer has a foundation on solid ground and so that both parties will accept the information and act on it. Techniques for doing this are explained in

29 detail in Skills For Communicating With Patients (p115 ff). Briefly the steps are:

• Share own thoughts • Encourage the patient to contribute their thoughts, ideas, suggestions • Negotiate a mutually acceptable plan • Check with patient

Clearly, this can be abbreviated if the practitioner and patient know each other well and if the patient is used to the practitioner’s way of working. Even so, the practitioner will do well to consider two questions before seeking information from the computer: “Why do I want to do this?” “How will it affect this patient?” Lets the patient read information from the screen when appropriate In the United Kingdom patients have a legal right to see their medical records, and it is sensible to write records with that in mind. In spite of this there may be third party references in a record, or the patient may have a relative or friend with them. These are reasons for being careful about the information that is visible on the screen in the consulting room. When it comes to information that you want the patient to see, and information that is helpful to the process of the consultation, then it does help if the patient can read what is on the screen. Examples are given in the box.

• Drug side effects/ dosages/ warnings in eBNF • Records of previous BP readings, blood test results • Prodigy shared screens • Patient Information Leaflets • Letters from hospital specialists • X ray reports

As we discussed in the previous sections, it is helpful to give a commentary as you set this up and also to negotiate or check with the patient that you both agree about the appropriateness.

• “I can show you this on the screen if you like” • “Would you like to see how your blood pressure has been since you started taking those tablets? • “Do you want to read the letter from the specialist?”

30 Detailed skills for enabling the patient to read from the screen are described in the next section. Explanation and planning

Options If using screen-based information (shared screen, PIL etc)

Checks that patient can see the screen clearly Obvious but important! One aspect is to make sure that the screen is in a position where it can be seen. If you are able to adjust the position or angle of the screen you should adjust it so that the patient has the clearest possible view: check too that there is not a disabling reflection from a light or a window. The other aspect is a simple question: “Can you see that OK?” As well as the clarification, the purpose here is to convey to the patient that you are concerned that they can see the screen properly, that this is important and not just you going through the motions. Remains quiet, and gives the patient time to read the text We have already talked about the problems of dividing attention and the need for the patient to be quiet while the practitioner is reading from the screen. This works both ways. Remember too that people have different reading speeds and if the text is unfamiliar it will take longer (perhaps two readings) to assimilate. Read through the text yourself, watch the patient’s eyes to see if they are still reading, ask “Have you had time to read that?” Checks that patient has understood the text

• “Have you got that?” • “Is that straightforward?” • “Is there anything you are not sure about?” • “Do you want me to explain any of that?” • “Do you need to know anything else?”

Gives patient opportunity to ask questions

31 If you have used one of the phrases in the previous section, or something similar, the patient they may be primed to ask you a question. Make sure that you give them time to ask and make sure that your body language communicates the fact that you are prepared to listen. You may choose to ask a second question or even take the direct approach: “Do you want to ask me anything?” The value of this is that it allows you to check that the patient has understood what they have read. You can judge from the question and the manner in which it is posed how well they have understood the text they have just read. On a busy screen indicates (points etc) relevant information Sometimes the information that you are showing the patient has been designed for shared viewing by practitioner and patient. The PRODIGY shared screens are an example of this. At other times the information that you want to show will occupy a small part of a complicated screen. Pointing manually, or with the mouse icon on screen are ways of drawing the patient’s attention to the text you want them to see. Some people find it helpful to read the text out loud while the patient is reading. This can be helpful, but care is needed. People can read more quickly than they can speak. This means that the reader may soon get ahead of the talker, and there is again the problem of divided attention, and possible confusion.

The key skills are

• Make sure the patient can see the screen • Use signposting to let the patient know what is expected • Don’t talk while they are reading • Give the patient opportunity to ask questions • Check that the patient has understood the message (ask them to summarise the information, or summarise it yourself and check that they agree with your summary)

References:

1. Silverman, Kurtz, Draper. Skills for Communicating with Patients. Radcliffe Medical Press. 1998 2. Byrne PS, Long BE. Doctors talking to patients. RCGP London 1976

FAMILY MEDICINE - 2 MENTAL HEALTH LAB (FM-MHL)

Family Medicine Mental Health Lab – FM-MHL

When: Thursdays (mornings and afternoons)

AM sessions from 9:00am – noon (R2s)

PM sessions from 1:00pm-4:00pm (R1s)

Where: Sheldon M. Chumir (Central Teaching Clinic) 1213 4th Street SW Calgary, AB T2R 0X7

Who: Family Physicians, Psychologists and approximately 8 FMRs

How: Residents are scheduled for one FM-MHL each Family Medicine Block (i.e. FM-Care of the Adult, FM-Care of the Child, FM-BM/MH, etc.) over the 2 years of the Program. FM-MHL

will appear as an experience on your Block schedule when you are to attend/present.

What: The focus is on Mental Health / Psychiatry in the Family Medicine context. The labs include case review of residents’ patients from their own Family Medicine Clinics, role plays and other counselling exercises.

Each Resident will present (at least) 1 patient case per year. Residents will be assigned case presentation dates via their Block schedules. Detailed instructions for case presentations will be provided.

*Cases reviewed in FM-MHL must be sourced from a patient interaction FROM FM CLINIC

*First case over two years must be related to anxiety and/or depression

Family Medicine Mental Health Lab – FM-MHL

Fam Med approach to managing Mental Health - Assess risk - Rule out organic causes - Explore possible contributions of substances - Explore possible psychosis - Explore mood - Explore anxiety - Explore other (somatic Sx, personality, etc) - PaLMS (Psychotherapy, Lifestyle, Medications, Stressor/Supports) - Trauma Informed Care

Case Presentation Format (Describe aspects of care that went well & less well) Resident Name, RLevel • Brief HPI • Pertinent past mental health Hx • Family Hx - past / present mental health issues • Substances / addictions • Psycho-Social context (i.e. living situation, work, relationships, income, activity level, interests / hobbies / ADLs, etc) • Medications (current & past) • Differentials  General medical condition  Substances and medications  Psychosis  Mood disorders  Anxiety disorders  Personality disorders, somatic symptom disorder, dissociative disorders, others • Address the ‘4 pillars’ of treatment: Psychotherapy, Lifestyle, Medications, Stressors/supports ∗ Develop a few questions for discussion + 3 teaching points. ∗ Come prepared to lead a clinical discussion re. your case.

Examples of Topics for FM-MH Lab cases (*remember - 1st case must be related to anxiety and/or depression)

Anxiety Disorders Depressive Disorders Bipolar disorder Psychosis Dementia Eating disorders Obsessive compulsive disorders Personality disorders Somatic symptom disorder Substance use disorder ADHD Sleep disorders Trauma and stress related disorders- including adjustment disorder and PTSD

Cases can be focused on any aspect of the case from diagnosis to management

Cases can also be focused on specific patient populations, i.e. paediatrics, geriatrics, perinatal mental health, etc.

Family Medicine Mental Health Lab – FM-MHL

Competency targets / Objectives

The resident will: – Recognize and diagnose mental health problems commonly found in family practice. • Demonstrate familiarity with the DSM diagnostic criteria for these common disorders (see list below) • Demonstrate ability to appropriately screen for these disorders utilizing evidence based screening tools when applicable • Recognize common presentations, features, and risk factors of these disorders • Take an appropriate history to generate differential diagnoses for symptoms which also include comorbid psychiatric conditions, medical causes and contributors, and rule out serious organic pathology • Assess patient's mental status and in particular focus on suicide risk, homicide risk and judgment

– Develop a management plan and provide appropriate follow up for the disorders listed, including the ability to: • Offer appropriate treatment in a way that promotes full discussion of options and patient's own decision-making • Use a multidisciplinary and multifaceted approach to treatment and management and refer appropriately (pharmacological and non-pharmacological – psychological, family and community supports, exercise, diet, etc) • Demonstrate knowledge of indications, risks, side effect profile, common interactions and monitoring requirements of psychopharmacological agents • Demonstrated knowledge of the benefits and appropriate applications of various therapies [e.g.: cognitive behaviour therapy, behaviour therapy, supportive counselling, couples and family therapy] • Regularly assess response to treatment (both pharmacological and non-pharmacological) using evidence-based tools/screening

List of common disorders – ADHD – adjustment disorders – anxiety disorders – developmental and behavioural disorder of childhood – eating disorders – mood disorders • depression – personality disorders – psychotic disorder – substance use disorders

Family Medicine Mental Health Lab – FM-MHL

Competency targets / Objectives

The resident will: – Develop the skills to manage difficult or emotionally intense situations or interactions • Work towards establishing common ground and an atmosphere of safety and trust • Explore life circumstances and functional status to better understand the patient’s frame of reference • Demonstrate awareness of and skills for discussing unexpected medical outcomes • Identify own attitudes and beliefs which may be contributing to emotional intensity and take appropriate measures to limit negative impact • Anticipate possible violent or aggressive behaviour and recognize the warning signs

– Demonstrate ability to recognize, explore and counsel non-DSM mental health and psychosocial issues commonly seen in a Family Medicine setting. • Demonstrate familiarity with non-DSM, mental health and psychosocial issues commonly seen in Family Medicine setting (see list below) • Demonstrate ability to explore and take an appropriate history of non-DSM, mental health and psychosocial issues commonly seen in Family Medicine setting • Demonstrate ability to engage in empathic and supportive counselling and to develop an appropriate care plan for non-DSM, mental health and psychosocial issues commonly seen in Family Medicine setting • Demonstrate ability to perform self assessment and assessment of patient characteristics (including clinician skill set, patient symptom severity, motivation and boundary issues) in order to determine when to counsel, when to refer and when to monitor. • Demonstrate effective motivational interviewing skills when counselling patients

– Be familiar with social service resources for patients • Mobilize services within the health care and community institutions on behalf of the patient. • Develop an effective long-term relationship with a cohort of patients and build on this relationship to improve health care • Demonstrate awareness of complex needs of and available resources for under-serviced / fragile populations

List of common issues – life and family transition issues – crisis – gender and sexuality issues – domestic violence – grief – family systems stressors – occupational stress

4 Diagnostic Codes linked to Health Service Code 08.19G V11 Personal history of mental disorder 290 Senile and presenile organic psychotic conditions V15 Other personal history presenting hazards to health 290.0 Senile dementia, simple type V15.4 Psychological trauma 290.1 Presenile dementia V17.0 Psychiatric condition 290.2 Senile dementia, depressed or paranoid type V40.0 Mental and behavioral problems 290.3 Senile dementia with acute confusional state V40.0 Problems with learning 290.4 Arteriosclerotic dementia V40.1 Problems with communication (including speech) 290.8 Other specified senile psychotic conditions V40.2 Other mental problems 290.9 Unspecified V40.3 Other behavioural problems 291 Alcoholic psychoses V40.9 Unspecified mental or behavioural problems 291.0 Delirium tremens V61 Other family circumstances 291.1 Korsakov's psychosis, alcoholic V61.0 Family disruption 291.2 Other alcoholic dementia V61. 1 Marital problems 291.3 Other alcoholic hullucinosis V61.2 Parent - child problems 291.4 Pathological drunkenness V61.3 Problems with aged parents or in-laws 291.5 Alcoholic jealousy V61.4 Health problems within family 291.8 Other specified alcoholic psychosis V61.5 Multiparity 291.9 Unspecified V61.6 Illegitimacy or illegitimate pregnancy 292 Drug psychoses V61.7 Other unwanted pregnancy 292.0 Drug withdrawal syndrome V61.8 Other specified family circumstances 292.1 Paranoid and/or hallucinatory states induced by drugs V61.9 Unspecified . 292.2 Pathological drug intoxication V62 Other psychosocial circumstances 292.8 Other specified drug-induced mental disorders V62.0 Unemployment 292.9 Unspecified V62.1 Adverse effects of work environment 293 Transient organic psychotic conditions V62.2 Other occupational circumstances or maladjustment 293.0 Acute confusional state V62.3 Educational circumstances 293.1 Subacute confusional state V62.4 Social maladjustment 293.8 Other specified transient organic mental disorders V62.5 Legal circumstances 293.9 Unspecified Refusal of treatment for reasons of religion or V62.6 294 Other organic psychotic conditions (chronic) conscience Other psychological or physical strain, not elsewhere V62.8 294.0 Korsakov's psychosis or syndrome (non-alcoholic) classified V62.9 Unspecified 294.1 Dementia in conditions-classified elsewhere V65.4 Other Counselling, not elsewhere classified 294.8 Other specified organic brain syndromes (chronic) Following psychotherapy and other treatment for V66.3 294.9 Unspecified mental disorder Following psychotherapy and other treatment for V67.3 295 Schizophrenic psychoses mental disorder V70 General medical examination 295.0 Simple type General psychiatric examination requested by the V70.1 295.1 Hebephrenic type authority General psychiatric examination other and V70.2 295.2 Catatonic type unspecified V71 Observation and evaluation for suspected conditions 295.2 Catatonic type V71.0 Mental 295.3 Paranoid type Special screening for mental disorders and V79 295.4 Acute schizophrenic episode developmental handicaps V79.0 Depression 295.5 Latent schizophrenia V79. 1 Alcoholism 295.6 Residual schizophrenia V79.2 Mental retardation 295.7 Schizoaffective type V79.3 Developmental handicaps in early childhood 295.8 Other specified types of schizophrenia Other specified mental disorders / developmental V79.8 295.9 Unspecified handicaps V79.9 Unspecified 296 Affective psychoses 5 Diagnostic Codes linked to Health Service Code 08.19G 296.0 Manic depressive psychosis, manic type 301.9 Unspecified 296.1 Manic-depressive psychosis, depressed type 302 Sexual deviations and disorders Manic-depressive psychosis, circular type, currently 296.2 302.0 Homosexuality manic Manic-depressive psychosis, circular type but 296.3 302.1 Bestiality currently depressed 296.4 Manic - depressive psychosis, circular type, mixed 302.2 Pedophilia Manic-depressive psychosis, circular type, current 296.5 302.3 Transvestism condition specified 296.6 Manic depressive psychosis, other and unspecified 302.4 Exhibitionism 296.8 Affective psychosis, other 302.5 Trans-sexualism 296.9 Unspecified 302.6 Disorders of psychosexual identity 297 Paranoid states 302.7 Frigidity and impotence 297.0 Paranoid state, simple 302.8 Other specified psychosexual disorders 297.1 Paranoia 302.9 Unspecified 297.2 Paraphrenia 303 Alcohol dependence syndrome 297.3 Induced psychosis 304 Drug dependence 297.8 Other specified paranoid states 304.0 Morphine type 297.9 Unspecified 304.1 Barbiturate type 298 Other nonorganic psychoses 304.2 Cocaine 298.0 Depressive type 304.3 Cannabis 298.1 Excitative type 304.4 Amphetamine type and other psychostimulants 298.2 Reactive confusion 304.5 Hallucinogens 298.3 Acute paranoid reaction 304.6 Other specified drug dependence 298.4 Psychogenic paranoid psychosis 304.7 Combinations of morphine type drug with any other 298.8 Other and unspecified reactive psychosis 304.8 Combinations excluding morphine type drug 298.9 Unspecified psychosis 304.9 Unspecified 299 Psychoses with origin specific to childhood 305 Nondependent abuse of drugs 299.0 Infantile Autism 305.0 Alcohol 299.1 Disintegrative psychosis 305.1 Tobacco 299.8 Other specified early childhood psychoses 305.2 Cannabis 299.9 Unspecified 305.3 Hallucinogens 300 Neurotic disorders 305.4 Barbituates and tranquillizers 300.0 Anxiety states 305.5 Morphine type 300.1 Hysteria 305.6 Cocaine type 300.2 Phobic state 305.7 Amphetamine type 300.3 Obsessive compulsive disorders 305.8 Antidepressants 300.4 Neurotic depression 305.9 Other, mixed or unspecified 300.5 Neurasthenia 306 Physiological malfunction arising from mental factors 300.6 Depersonalization syndrome 306.0 Musculoskeletal 300.7 Hypochondriasis 306.1 Respiratory 300.8 Other neurotic disorders 306.2 Cardiovascular 300.9 Unspecified 306.3 Skin 301 Paranoid personality disorder 306.4 Gastrointestinal 301.0 Personality disorders 306.5 Genitourinary 301.1 Affective personality disorder 306.6 Endocrine 301.2 Schizoid personality disorder 306.7 Organs of special sense 301.3 Explosive personality disorder 306.8 Other specified psychophysiological malfunction 301.4 Anankastic personality disorder 306.9 Unspecified 301.5 Hysterical personality disorder 307 Special symptoms/syndromes not elsewhere classified 301.6 Asthenic personality disorder 307.0 Stammering or stuttering Personality disorder with predominantly sociopathic 301.7 307.1 Anorexia nervosa or a social manifestation 301.8 Other personality disorders 307.2 Tics 6 Diagnostic Codes linked to Health Service Code 08.19G 307.3 Stereotyped repetitive movements 315 Specific delays in development 307.2 Tics 315.0 Specific reading retardation 307.3 Stereotyped repetitive movements 315.1 Specific arithmetical retardation 307.4 Specific disorders of sleep 315.2 Other specific learning difficulties 307.5 Other and unspecified disorders of eating 315.3 Developmental speech or language disorder 307.6 Enuresis 315.4 Specified motor retardation 307.7 Encopresis 315.5 Mixed development disorder 307.8 Psychalgia 315.8 Other specified delays in development 307.9 Other and unspecified 315.9 Unspecified 308 Acute reaction to stress 316 Psychic factors associated with diseases classified elsewhere 308.0 Predominant disturbance of emotions 317 Mild mental retardation 308.1 Predominant disturbance of consciousness 318 Other specified mental retardation 308.2 Predominant psychomotor disturbance 318.0 Moderate mental retardation 308.3 Other acute reactions to stress 318.1 Severe mental retardation 308.4 Mixed 318.2 Profound mental retardation 308.9 Unspecified 319 Unspecified mental retardation 309 Adjustment reaction 780.9 Other general symptoms 309.0 Brief depressive reaction 309.1 Prolonged depressive react on 309.2 With predominant disturbance of other emotions 309.3 With predominant disturbance of conduct 309.4 With mixed disturbance of emotions and conduct 309.8 Other specified adjustment reactions 309.9 Unspecified Specific nonpsychotic mental disorders following 310 organic brain damage 310.0 Frontal lobe syndrome 310.1 Cognitive or personality change of other type 310.2 Postconussinal syndrome 310.8 Other 310.9 Unspecified 311 Depressive disorder, not elsewhere classified 312 Disturbance of conduct not elsewhere classified 312.0 Unsocialized disturbance of conduct 312.1 Socialized disturbance of conduct 312.2 Compulsive conduct disorder 312.3 Mixed disturbance of conduct and emotions 312.8 Other 312.9 Unspecified 313 With anxiety and fearfulness Disturbance of emotions specific to childhood and 313.0 adolescence 313.1 With misery and unhappiness 313.2 With sensitivity, shyness and social withdrawal 313.3 Relationship problems 313.8 Other or mixed 313.9 Unspecified 314 Hyperkinetic syndrome of childhood 314.0 Simple disturbance of activity and attention 314.1 Hyperkinesis with developmental delay 314.2 Hyperkinetic conduct disorder

7 Service Code Psychiatric Notes Direct contact with an individual patient for psychiatric treatment Calls 1-10 per 15 mins. 08.19G (including medical psychotherapy and medication prescription), Need to use a psychiatric reassessment, patient education and/or general psychiatric diagnosis Psychiatric Visit psychiatric counselling code

Diagnosis code 780.5 – Does NOT work will be rejected

DO NOT USE 08.19GA (for psychiatrists only) Professional interview with relative(s) in connection with the Calls 1-8 per 15 mins, 08.19D management of a patient with a psychiatric disorder, but without billed under the patient the patient being present during the interview being discussed require Family visit for Psychiatric the name of family patient This service is to be claimed using the Personal Health Number of member or person Max 2 hours per patient, per the patient being discussed, NOT the person who is in the office. speaking with year regarding the patient. The relationship of the patient to the person interviewed must be RELATIVE(S) NAME NEEDED indicated.

Diagnosis code 780.5 – Does NOT work will be rejected Certification under the Mental Health Act 08.12A No Modifiers, No calls Mental Health Act - A physician may submit claims for group psychotherapy, psychiatric Certification management and/or indirect services for the same patient on the same day.

8 Service Code Visits Notes Direct management, reassessment, education and/or general CMGP 1-99 unit 03.05O counselling of a patient with chronic pain, per 15 minutes or represents 15 mins Chronic Pain portion thereof

Direct management, In those situations where the physician is not part of a reassessment, education comprehensive, coordinated, interdisciplinary chronic pain program, the patient must have been initially assessed at an interdisciplinary chronic pain program, the name of which must be identified in the patient's chart when the patient is referred back to the home community for ongoing treatment.

 Referring Doctor requests – verbal or written opinion and or CMGP 1-10 1st unit 03.07A advice of consultant represents 15 mins and Minor Referred consultation  History, Physical, may order lab or diagnostics after that it is per 10  Discuss treatment and advice with the patient and in some mins cases the referring doctor  Provides referring with written report about recommendations, treatment, and opinion.

 Referring Doctor requests – verbal or written opinion and or advice of consultant CMXC30 if longer than 03.08A  History, Physical, may order lab or diagnostics 30 min Major Referred consultation  Discuss treatment and advice with the patient and in some cases the referring doctor  Provides referring with written report about Only Once every 345 days recommendations, treatment, and opinion.  Comprehensive Consultation: An in-depth evaluation of a patient with a written report to the referring physician, audiologist, Alberta registered midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner. This service includes the recording of a complete history, performing a complete physical examination appropriate to the physician's specialty, an appropriate record and advice to the patient. It may include the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient and/or the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner.

9 Patient care advice provided to community mental health care workers

Health Service Code 03.01B

Patient care advice provided to community mental health care workers, child protection workers, group home staff, or educational personnel weekdays 0700 to 1700 hours in relation to the care and treatment of a patient receiving community mental health care services under the Alberta community mental health care program.

NOTE: Refer to notes following 03.01BB for further information.

Category: V Visit

Base rate: $17.23

AMA billing tips:

• This code may be claimed when the physician receives the request and or responds by fax, email or telephone. GR 1.26 Telecommunications means communication via telephone, facsimile or email.

Fee modifiers:

Type Code # of calls Explicit Action Amount

SKLL GNMH Replace Base $27.92

SKLL PSYC Replace Base $28.27

Health Service Code 03.01BA Patient care advice provided to community mental health care workers, child protection workers, group home staff, or educational personnel weekdays 1700 to 2200 hours, weekends and statutory holidays 0700 to 2200 hours in relation to the care and treatment of a patient receiving community mental health care services under the Alberta community mental health care program. NOTE: Refer to notes following 03.01BB for further information.

Category: V Visit

Base rate: $23.85

Fee modifiers:

Type Code # of calls Explicit Action Amount

SKLL GNMH Replace Base $29.56

SKLL PSYC Replace Base $29.93

10 Health Service Code 03.01BB

Patient care advice provided to community mental health care workers, child protection workers, group home staff, or educational personnel any day 2200 to 0700 hours in relation to the care and treatment of a patient receiving community mental health care services under the Alberta community mental health care program.

NOTE: 1. HSCs 03.01B, 03.01BA, 03.01BB are to be claimed using the Personal Health Number of the patient. 2. May only be claimed when the request for advice is initiated by the community mental health care worker, child protection worker, group home staff, or educational personnel. 3. May be claimed: • for advice provided in person or via telephone or other telecommunication methods. • in addition to visits or other services provided on the same day by the same physician. 4. A maximum of two (any combination of HSC 03.01B, 03.01BA, 03.01BB) claims may be claimed per patient, per physician, per day. 5. Documentation of the request and advice must be recorded by both the physician and the community mental health care worker in their respective patient records.

Category: V Visit

Base rate: $27.83

AMA billing tips:

• This code may be claimed when the physician receives the request and or responds by fax, email or telephone. GR 1.26 Telecommunications means communication via telephone, facsimile or email.

Fee modifiers:

Type Code # of calls Explicit Action Amount

SKLL GNMH Replace Base $34.48

SKLL PSYC Replace Base $34.92

11 Table 3: Common behavioural problems associated with borderline personality disorder encountered in the primary care setting and their management Clinical Scenario Management Strategy Follow-up with patient “Jane” With the patient’s help, pick the most urgent matter and address only that today. Review clinic policy requiring review of outside records before providing refills of psychoactive substances such as benzodiazepines. Set follow-up appointment for next week to address additional concerns. If patient’s use of suicidal statements increases, refer to the emergency room because she is an unfamiliar patient to you. The patient has called the clinic 7 times in one day demanding Remind the patient that you will see her the next day for her appointment. to speak to the doctor, and refusing to specify the reason for Speak in a calm and even tone, do not engage in arguing or admonishing her over the phone. Cut off calling. She has a regularly scheduled appointment for the next contact if patient escalates. day. She has engaged in abusive and threatening language with During her appointment remind her of the clinic policies about abusive language toward staff; remind her staff when they inquire her reason for calling. that abusive behaviour in the future will result in her termination from the clinic. Move on to discuss medical problems without further judgment or scolding tone. The patient requests a refill of Adderall “just this one time” Do not refill the prescription because this will set a precedent for further boundary limit testing in the that her psychiatrist normally prescribes because he is out of future. town and the hard copy of her prescription was stolen by a Tell patient it is clinic policy that you do not refill prescriptions written by another doctor no matter what friend. the circumstances, and that she will need to contact her psychiatrist when he is back in town.

The patient received a prescription for oxycodone after a visit Do not refill the prescription. to the emergency department for a migraine. She comes to the Acknowledge the patient’s distress (“you are very upset right now”). office in tears requesting a refill for the medication because Firmly state that it is against your policy to prescribe opioids for migraines. “this is the only medication that has ever helped my pain.”

The patient presents with symptoms she feels indicate a Briefly see and evaluate the patient and provide reassurance that there is no infection present. serious illness, despite a pattern or similar complaints leading Validate the patients that she is suffering and uncomfortable, and that you will continue to follow her to repeated evaluations without evidence of significant symptoms. pathology. When you attempt reassurance, she demands Schedule a regular follow-up appointment. Remind her ahead of time that you will only be available to her elaborate testing to confirm “I know there’s something during regularly schedules appointments. wrong.” Do not acquiesce to requests to repeat invasive medical tests or treatment that is not indicated.

You have secured an outpatient psychiatry consultation for the Discuss fears about seeing the psychiatrist including fear of abandonment by you (the primary care

12 patient, but she refuses to go “because they won’t understand provider); provide reassurance that you will continue to treat her despite another physician being me like you do.” involved. If recurrent maladaptive behaviour continues to disrupt the doctor-patient relationship, tell the patient that consultation is necessary if treatment is to continue. Managing borderline personality disorder can be difficult and confusing. Because of their instability in the multiple areas of interpersonal relationships, self-image, affects, and impulsivity, these patients can present with a wide range of symptoms, including depression, anger, paranoia, extreme dependency, self-mutilation, and alternating idealization and devaluation of the physician. Their lives tend to be chaotic. They transfer many of their dysfunctional feelings and conflicts to the physician and the medical encounter. A somewhat detached professional stance and clear limit setting in terms of availability, appointment frequency, appropriate behaviour, and medication use are necessary to manage these patients successfully. It is crucial to monitor one’s own feelings, and to refrain from responding inappropriately to verbal attacks and manipulation. The development of a formal behavioural treatment plan and insistence on participation in psychiatric care may be necessary to establish an effective working relationship.

RANDY K. WARD, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin Am Family Physician. 2004 Oct 15; 70(8):1505-1512.

13 Basic Counselling Skills for Family Medicine (FM-MH Lab)

B – background A – affect (welcome it) T – what’s ‘troubling’ the most H – what’s been most ‘helpful’ E – express empathy

Listen Understand Acknowledge (reflect / summarize) Validate (encourage / praise / normalize) Empathize Attend to Boundaries (don’t try harder than your patient)

Motivational Interviewing O – open-ended questions D – develop discrepancies A – affirmations E – express empathy R – reflections A – aim for ambivalence S – summaries R – roll-with-resistance S – support self efficacy

Basic CBT for Family Medicine

1. Ask for permission 2. Provide 3. Set an Agenda 4. Basic CBT Rationale i) setting up for referral Cognitive Distortions ii) basic CBT techniques Triple Column

Feelings iii) psychotherapy Worry Time Goalification Efforts & Rewards

Thoughts Behaviours 14

Listen More / Speak Less

LISTEN MORE THAN WE USUALLY DO USUALLY WE THAN MORE LISTEN USUALLYSPEAK THANDO LESS WE ended questions

- • • Motivational Interviewing (MI): Interviewing Motivational (OARS) or Open Reflect Affirmations Summarize

• • • •

DEARS

Ambivalence Interviewing otivational

efficacy M evelop Discrepancy evelop im at im oll with Resistance oll with

elf-

mpathy D E R S A

• • • • •

16 Motivational Interviewing: Readiness Rulers

0 5 10

How important is making this change to you – at present?

Why didn’t you choose lower? Why didn’t you choose higher? What would make this more important you?

How confident are you that you are presently able to

17 make this change?

What would make you more confident? What might your next steps be? What is your plan? 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Assessment to Management of Adult Insomnia | Dec 2015

APPENDIX A

Clinical Practice Guideline Page 28 of 35 Appendix A 32 Assessment to Management of Adult Insomnia | Dec 2015

ASSESSMENT The essential elements of an insomnia diagnosis (as described in the DSM-5 definition below) are a complaint of difficulty initiating or maintaining sleep despite adequate opportunity for sleep, and associated distress or impairment of daytime functioning. For patients whose sleep complaint is consistent with this definition, an evaluation of sleep using a sleep diary is recommended. It is important to rule out other sleep disorders. Specific tools are discussed below (see Useful Clinical Tools for Practice).

DIAGNOSTIC CRITERIA Note: for the purposes of clarity and simplicity, acute insomnia is differentiated from chronic insomnia in this CPG. Acute insomnia is common in practice but no longer defined as such in the DSM-5. Insomnia disorder is the new DSM-5 terminology. The DSM-5 definition of an insomnia disorder is: Dissatisfaction with sleep quality or quantity along with a complaint of difficulty initiating sleep (initial insomnia), maintaining sleep (middle insomnia) and/or waking up too early in the morning (late insomnia)

The DSM-5 criteria are: The sleep disturbance causes clinically significant distress or impairment in functioning;

 It occurs at least three nights per week.  It is present for at least three months.  It occurs despite adequate opportunity for sleep.  It is not better explained by another sleep-wake disorder.  It is not attributable to the physiological effects of a substance. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

FOR THIS CPG THE FOLLOWING DEFINITIONS APPLY:

ACUTE INSOMNIA Acute insomnia has also been known as short term or adjustment insomnia and is an abrupt onset of difficulty initiating and maintaining sleep that is associated with an identifiable trigger. It is less than three months in duration. Acute insomnia is most commonly the result of stressful event(s), environmental disturbances (such as noise, extreme temperatures or caring for a newborn), or a disruption of the sleep/wake cycle due to jet lag.

CHRONIC INSOMNIA Chronic insomnia is defined as insomnia that has persisted for at least three months. Unlike acute insomnia, chronic insomnia is likely to be sustained by factors that are distinct from the initial triggers for the sleep difficulty. Although stressful life events are usually present when insomnia

Clinical Practice Guideline Page 8 of 35 Background 33 Assessment to Management of Adult Insomnia | Dec 2015

TREATMENT Whether acute or chronic insomnia, the following non-pharmacologic and pharmacologic treatments may apply depending on the individual patient and circumstances. Sleep hygiene-related education generally includes practices and environmental factors that may positively or negatively affect sleep (see Appendix E for patient resources). Although these strategies can be useful and effective for those with acute insomnia, they are ineffective as a monotherapy for chronic insomnia.

NON-PHARMACOLOGIC TREATMENT

COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA (CBT-I) Cognitive behavioural therapy for insomnia (CBT-I) is the treatment of choice especially for chronic insomnia13,41 and can also can be used for acute insomnia depending on individual circumstances. The efficacy of this treatment is well established for adults with insomnia, including older adults and patients with comorbid conditions (such as chronic pain, depression, cancer).43,44 CBT-I is a multi-component intervention that includes sleep restriction therapy (reducing time in bed in order to build up the homeostatic sleep drive), stimulus control therapy (strengthening the association between the bed and sleep), cognitive therapy (addressing key concerns about insomnia thereby reducing distress and arousal), and relaxation techniques (reducing physiological arousal).

CBT-I IN PRIMARY CARE A comprehensive CBT-I program is considered the best approach. It is typically offered to patients as sessions once a week for four to eight weeks and conducted by a clinician trained in behavioural sleep medicine and is effective in the primary care setting when provided by a psychologist or a trained nurse.45,46 Many PCNs in Alberta now offer doctoral level psychologist services and/or CBT programs. It is important for primary care providers to inquire about the availability of CBT-I within their own PCN. An abbreviated, two-session version of CBT-I can be effective for primary care patients47 if a comprehensive CBT-I program is not available. There is preliminary evidence that an intervention consisting of sleep restriction alone, provided directly by the primary care physician in two sessions, may be helpful.48 For most primary care providers in general practice, the time requirement to learn and offer CBT-I themselves is likely not feasible. Until brief physician-administered methods have been adequately tested, or there are more behavioural sleep professionals on the primary care team, a reasonable compromise based on expert opinion is to offer some behavioural advice to patients based on the principles of CBT-I. See Table 1.

Clinical Practice Guideline Page 10 of 35 Background 34 Assessment to Management of Adult Insomnia | Dec 2015

CBT-I Strategy Rationale

 Don’t go to bed too early. Go to bed when you are sleepy.  Helps build up the homeostatic sleep drive, and counters the unproductive  Maintain a regular sleep schedule. strategy of going to bed early in an  Minimize bright light before going to bed, including all attempt to gain more sleep technology.

 Keep a constant rise time seven days a week, regardless  Strengthens the circadian rhythm of sleep of how little sleep you have had. regulation

 Wake up (and get out of bed) at the same time every day, including weekends.

 Expose yourself to bright light in the morning to help wake up.

 Your bed is for sleep.  Strengthens the association of the bed and bedroom with sleep and sleepiness  Get out of bed when not sleeping. Go to another room. Return when sleepy.

 Remove electronic devices from the bedroom.  Take time to unwind and relax before bed.

 Relax the body using deep breathing, relaxation  Relaxation exercises should be done in techniques or visualization. the early evening, not in bed.

 Calm racing thoughts by:  Reduces hyper-arousal and makes it easier for sleep to arrive o Writing down worrisome issues and find temporary solutions for them so that you have dealt with them  Visual imagery can be used in bed to take for the night the mind away from worry or racing thoughts. o Using meditation (e.g., mindfulness) to calm the mind

 Identify any sleep-related worries and make sure your thoughts are realistic and not catastrophic.

 Do not check or watch the clock.

Table 1: Strategies from CBT-I and the Rationale for Use Note: Based on expert opinion

Clinical Practice Guideline Page 11 of 35 Background 35 Assessment to Management of Adult Insomnia | Dec 2015

APPENDIX D

SLEEP DIARY Printable Sleep Diary (visit: http://www.topalbertadoctors.org/cpgs/8640793)

GENERAL INSTRUCTIONS FOR PATIENT What is a Sleep Diary? A sleep diary will gather information about your daily sleep pattern. How often and when do I fill out the sleep diary? Complete your sleep diary every day and it is best to complete it within one hour of getting out of bed in the morning. What should I do if I miss a day? If you forget or are unable to finish recording each section, leave the diary blank for that day. What if something unusual affects my sleep or how I feel in the daytime? If your sleep or daytime functioning is affected by some unusual event (such as an illness, or an emergency) make a note in the “comments” section of your diary. What do the words “bed” and “day” mean on the diary? This diary is for people who are awake or asleep at unusual times. The word “day” means the time of day when you choose or must wake up. The term “bed” means the place where you usually sleep. Will answering these questions about my sleep keep me awake? This is not usually a problem. Do not worry about exact times and do not watch the clock. Just provide your best estimate.

ITEM INSTRUCTIONS Use the guide below to help you fill in each item of the Sleep Diary. Date: Write the date of the morning you are filling out the diary. What time did you get into bed? Write the time that you got into bed. This may not be the time that you began “trying” to fall asleep What time did you try to go to sleep? Record the time that you began “trying” to fall asleep How long did it take you to fall asleep? Beginning at the time you wrote in question 2, how long did it take you to fall asleep. How many times did you wake up, not counting your final awakening? How many times did you wake up between the time you first fell asleep and your final awakening? In total, how long did these awakenings last? What was the total time you were awake between the time you first fell asleep and your final awakening. For example, if you woke 3 times for 20 minutes, 35 minutes, and 15 minutes, add them all up (20+35+15= 70 min or 1 hour and 10 min). What time was your final awakening? Record the last time you woke up in the morning. What time did you get out of bed for the day? What time did you get out of bed with no further attempt at sleeping? This may be different from your final awakening time (e.g., you may have woken up at 6:35 a.m. but did not get out of bed to start your day until 7:20 a.m.) How would you rate the quality of your sleep? “Sleep Quality” is your sense of whether your sleep was good or poor. Comments: If you have anything that you would like to say that is relevant to your sleep, write it here

Clinical Practice Guideline Page 32 of 35 Appendix D 36 Assessment to Management of Adult Insomnia | Dec 2015

SAMPLE ID/Name: John Doe

Today’s date Mon Nov 5 2014 1. What time did you get into 10:15 p.m. bed?

2. What time did you try to go 1 :30 p.m. to sleep?

3. How long did it take you to 55 min fall asleep?

4. How many times did you 3 times wake up, not counting your final awakening? 5. In total, how long did these 1 hour 10 awakenings last? min

6. What time was your final 6:35 a.m. awakening?

7. What time did you get out 7:20 a.m. of bed for the day?

8. How would you rate the ❑Very poor ❑Very poor ❑Very poor ❑Very poor ❑Very poor quality of your sleep? Poor ❑Poor ❑Poor ❑Poor ❑Poor ❑Fair ❑Fair ❑Fair ❑Fair ❑Fair ❑Good ❑Good ❑Good ❑Good ❑Good

9. Comments (if applicable) I have a cold

Permission to use the Consensus Sleep Diary is restricted to clinical use only. Research use requires permission from first author. Carney CE et al. Sleep 2012;35(2):287-302.

Clinical Practice Guideline Page 33 of 35 Appendix D 37 Sleep Efficiency = Total Time Asleep / Total Time in Bed

38 Assessment to Management of Adult Insomnia | Dec 2015

Medication/Drug Suggested Considerations Classification Dosing zopiclone (Imovane®) 3.75 – 7.5mg  Should allow at least eight hours in bed Non-BZD (Max 5.0 mg for  Metallic after-taste most common adverse Specific GABAA agonist elderly; pt with reaction kidney/liver  Complex sleep related behaviors can be induced disease or taking  Risk of physical tolerance and dependence other medications) zolpidem (Sublinox®) 5 - 10 mg  Less chance of morning hang-over effect Non-BZD  Rapid onset of action Specific GABAA agonist  Should allow at least eight hours in bed  Complex sleep related behaviors can be induced  Risk of physical tolerance and dependence doxepin (Silenor®) 3 - 6 mg  Indicated only for sleep maintenance tricyclic (H1 antagonist)  No fall risk or cognitive side effects seen  Minimal risk of physical tolerance/ dependence  Higher doses doxepin appear to have traditional TCA side effect profile58,59 temazepam (Restoril®) 15 - 30 mg  Risk of physical tolerance and dependence BZD  Intermediate half-life carries a low-moderate risk of morning hang-over Non-Specific GABAA agonist Note: flurazepam, oxazepam, triazolam are indicated for, but not recommended for primary insomnia trazodone (Desyrel®) 25 - 100 mg  Short half-life provides lower risk of morning hang-over effect phenylpiperazine  Minimal risk of tolerance/dependence 5-HT2/H1 antagonist  Risk of orthostatic hypotension  Rare risk of priapism and cardiac conduction issues  Multiple mechanisms of promoting sleep Additional information to aid decision making regarding Z-drugs can be found at Alberta College of Family Physicians Tools for Practice: https://www.acfp.ca/tools-for-practice/articles/details/?id=126&title=Z- drugs+for+sleep%3A+Should+we+%E2%80%9CCatch+Some+Z%E2%80%99s%E2%80%9D%3F

Table 2: Commonly Used Medications

Clinical Practice Guideline Page 14 of 35 Background 39 Assessment to Management of Adult Insomnia | Dec 2015

Agent Suggested Dose Considerations Melatonin* 0.3-5mg Some evidence of:  Increased effectiveness in older patients but higher risk of adverse effects such as daytime sleepiness in amounts >4mg60 shift workers, jet lag, delayed sleep phase. Modest effect overall. Need to determine use of melatonin, i.e., shift circadian rhythm? If yes take lower dose four to five hours before bed. If used as a hypnotic take 30-90 min before bed. No apparent physical tolerance and dependence Purity of source is often questionable. Only mild adverse effects for general population, such as dizziness, headache, nausea and sleepiness have been reported in studies to date.60 L-Tryptophan 500mg to 2g Conflicting evidence of benefit Valerian 400-900 mg Some evidence suggesting effect in insomnia, especially in menopause and for medical illness.61 Purity of source is often questionable *Additional information to aid decision making regarding Melatonin can be found at Alberta College of Family Physicians Tools for Practice https://www.acfp.ca/tools-for- practice/articles/details/?id=120&title=Melatonin+for+sleep%3A+Exhausted+by+other+options%3F Table 3: Non-prescription “Natural” Agents

OVER-THE-COUNTER (OCT) AGENTS Diphenhydramines (Benadryl®, Sleep Eze®, Simply Sleep®, Nytol®, Unisom®), dimenhydrinate (Gravol®) and doxylamine (Unisom 2®) should not be prescribed to patients because of the potential harms that may outweigh benefits. All have potentially serious side effects arising from anticholinergic properties, especially in elderly. Rapid tolerance and cognitive impairment may occur.

OFF LABEL AGENTS Numerous medications have sedating side effects such as sedating antidepressants, antihistamines, anticonvulsants, anti-psychotics, other benzodiazepines and muscle relaxants. These drugs should not be used as sleep agents for insomnia alone because of lack of evidence, as well as harms that could outweigh the benefit. These agents may be helpful if the patient has insomnia in addition to another significant comorbid condition for which the medication is being prescribed. See Appendix F for additional information.

SPECIAL POPULATIONS

OLDER ADULTS Elderly patients present particular challenges with insomnia. The aging process reduces the robustness of the sleep state and this combined with an increased likelihood of medical and mental health comorbidities, polypharmacy, drug interaction with sedative/hypnotic medication and the

Clinical Practice Guideline Page 15 of 35 Background 40 Assessment to Management of Adult Insomnia | Dec 2015 potential for cognitive impairment due to sedating medication all require special attention when treating the elderly who present with insomnia. CBT-I has been shown to be superior to medication in the short and long term management of insomnia in older adults8 as in other populations. It has been shown to be as successful in older adults as it is in younger adults.62-64 Special care must be taken when prescribing sleep medications for older adults due to the potential for increased falls, drug interactions, and increased potency.65 For these reasons, nonpharmacological interventions are the preferred treatment option. If a medication is to be used, the safest and best studied sleep medication for use in the elderly is Silenor.61,66,67 Other medications that can be considered are melatonin or a short acting GABA-A agonist such as Sublinox.42

PREGNANT AND LACTATING WOMEN

TREATMENT OF INSOMNIA DURING PREGNANCY AND POSTPARTUM It is important to screen for a physiological sleep disorder, a medical condition or a psychiatric illness that may be affecting sleep during pregnancy or postpartum. The patient’s sleep may be affected by their use of caffeine, alcohol and nicotine. Child care without adequate spouse/ family support can also result in sleep deprivation.

NON-PHARMACOLOGIC TREATMENT There are no studies examining the efficacy of CBT-I during pregnancy and the postpartum period but based on expert opinion and experience, CBT-I principles can be effective and if available used as a first approach to managing insomnia based on the patient’s individual situation. CBT-I can be used, even in those patients for whom physical or mental health factors play a role. Women often believe their insomnia is negatively impacting their baby’s growth and development. This can be addressed using CBT-I and there is no evidence that, in the absence of other medical or psychiatric factors, insomnia results in fetal damage. Primary care providers should normalize the sleep disturbance and minimize the anxiety for these women.

PHARMACOLOGIC TREATMENT IN PREGNANCY AND POSTPARTUM Most women resist using sleep medication while pregnant or breastfeeding. However, when insomnia is having a severe impact, the use of a sleep aid may be warranted. Benzodiazepines (BZDs) are frequently used to treat insomnia in the general population but their use in pregnancy remains controversial until more conclusive data regarding adverse effects is available. Studies to date suggest that use of BZDs and the hypnotic benzodiazepine receptor agonists (HBRAs) (Zopiclone, Zaleplon and Zolipdem) may cause adverse pregnancy outcomes such as low birth weight infants, preterm deliveries, SGA infants, and cesarean delivery, albeit of marginal significance and confounding factors not accounted for in these studies.68 However, these drugs no longer appear to have the strong teratogenic potential as once thought.69-71 If a BZD must be prescribed, lorazepam is preferred during pregnancy since it lacks active metabolites and is less likely to be associated with a withdrawal syndrome in the neonate. Regarding breastfeeding, lorazepam has low levels in breast milk and does not appear to cause any adverse

Clinical Practice Guideline Page 16 of 35 Background 41 Assessment to Management of Adult Insomnia | Dec 2015 effects in breastfed infants with usual maternal dosages. Of sixty-four mothers who reported taking lorazepam while breastfeeding, none reported sedation in the infant.72 The tricyclic antidepressant nortriptyline has considerable sedating properties but does not appear to have major teratogenic effects and is considered safe for use in pregnancy.73 As with other antidepressants, there is a risk of neonatal (withdrawal) adaptation syndrome, a transient syndrome in most cases, and not associated with long term neurodevelopmental delays in the neonate/child.74 When used during lactation, infants exposed through breast milk have low or undetectable concentrations of nortriptyline and its metabolites.75 The antidepressant trazodone may be beneficial for reducing sleep-onset latency.76 No difference in pregnancy outcome (including rate of major malformations and gestational age at birth) has been reported among patients taking trazodone during the first trimester when compared with women taking other non-teratogenic antidepressants or other non-teratogenic drugs (e.g., sumatriptan, dextromethorphan), matched for age, smoking, and alcohol use.76 Although both antidepressant groups had a trend toward a higher rate of spontaneous abortion, the difference was not statistically significant. According to a review published in 2015, there is a paucity of human studies supporting either clinical benefit or risk of adverse events with use of exogenous melatonin in pregnancy. The authors suggest avoiding use of melatonin until more data is forthcoming.60 Excellent quality and current information regarding the use of medications during pregnancy and lactation is available at the following websites.  http://toxnet.nlm.nih.gov  www.reprotox.org  www.motherisk.org There is also an excellent review paper by Okun et al,77 addressing sleep-promoting medications during pregnancy for more detailed information.

Clinical Practice Guideline Page 17 of 35 Background 42 Current Symptoms: Connecting Neurotransmitters and Scales 43

Created b Tom Janzen,M.D. Adapted from Stephen Stahl, Essential Psychopharmacoi9QY, March 2008 Monoamine Binding Affinities of First Line Antidepressants

+++++ 0.1-1 ++++ 1-10 +++ 10-100 ++ 100-1000 + 1000-10000

Blocks SHT2A,SHT2c,SHT3,a 2 Reversibly blocks the breakdown of SHT,NE,DA

• K; Values are gathered from multiple labs and presented as published in the Clinical Handbook of Psychotropic Drugs, 2009

44 • This chart is not intended to imply any specific difference in clinical efficacy or tolerability but merely to highlight the fact that these antidepressants have mechanistic differences. Adapted from Virani et al. Cilnical Handbook of Psychotropic Drugs Online 2012. Created by Tom Janzen,M.D. RW. Lam et al. Journal of Affective Disorders 117 (2009) S26-S43 Adapted from Stephen Stahl, EssentialPsychopharmacology,March 2008,Clinical Handbook of Psychotropic Drugs TAILORING ANTIDEPRESSANT CHOICE TO PATIENT PROFILE Eric Teboul M.D. Feb-17 [email protected]

(SR, XL) PROFIL DU PATIENT

Fetzima ® Venlafaxine Quetiapine XR VortioxetineLevomilnacipran ER FluoxetineProzac Fluvoxamine® Luvox ®Paroxetine Paxil (CR)® SertralineZoloft ® CitalopramCelexa Escitalopram ® Cipralex Bupropion ® Wellbutrin Mirtazapine ® Remeron ® Effexor Duloxetine XR ®Cymbalta Desvenlafaxine ® Pristiq ® Seroquel XR ® Trintellix ® Fatigue/ lack of energy or motivation X O O XX O O O XX O DEPRESSION requires a sedative antidepressant O XX OO OO FEATURES if pt at high risk of attempting suicide by overdose X XX X XX would not tolerate weight gain O O XX O X O OO XX O O O XX O would not tolerate sexual adverse effects XOXXXO OO O X O O O O O PT PREFERENCES / wants to quit smoking O LIFESTYLE frequently forgets meds ( risk of withdrawal sx ) O X XX O substantial alcohol consumption / binge drinker X O OO X generalized anxiety disorder OO OO OO O O OO panic disorder OO O OO O X O OO O social anxiety disorder OOOO OO XO PSYCHIATRIC obsessive-compulsive disorder OOOOOOXOO COMORBIDITIES post-traumatic stress disorder O OOOOXOOO O attention deficit / hyperactivity disorder OO OOO bulimia O O OO O paraphilia or hypersexuality O OO patient is taking Risperidone XX XX XX X X X MEDICATION patient is taking multiple meds XX XX XX X O O X OO O X OO XX X INTERACTIONS pt is taking a 1A2 inhibitor ( Cipro, cimetidine, ticlopidine) X X chronic headache OX XO OOO CHRONIC PAIN fibromyalgia O O OO O SYNDROMES depression with pain of unknown origin O diabetic neuropathic pain O O OO irritable bowel syndrome O O OO O OO vulnerable to nausea/vomiting XXX OO XX X Diabetic OXXXOOOX O tremors XXXX OO X OO O OO MEDICAL long QT interval or taking meds which prolong QT int X X O OO COMORBIDITIES heart disease or uncontrolled hypertension O OO OOXOO OX liver disease or insufficency XXOOX XOX severe renal insufficiency XXXX X X X menopause-related hot flashes O O OO OOOOO age < 18 y.o. (caution re: risk of covert bipolarity) OO O OO O OO O O pregnant or planning to be X X XX O O O X XXX X SPECIAL SITUATIONS breastfeeding XO OO OO XOOOXO O Covered by provincial med insurance (Québec) OOOOOXOOOXX O XX

45 LEGEND: O = use of this antidepressant is particularly advantageous for this patient or good evidence of efficacy in this situation X = use of this antidepressant is particularly disadvantageous or contraindicated for this patient X = use of this antidepressant is particularly disadvantageous or contraindicated for this patient b = Reflecting concerns of possible QT interval prolongation, Health Canada issued an advisory warning that Citalopram and Escitalopram are contraindicated for pts with congenital long QT syndrome or a known long QT interval (>500 msec) and recommending that doses not exceed Cit 40 mg, Escit 20 mg (or Cit 20, Escit 10 if hepatic insuff, in pts ≥ 65 y.o., and in pts taking CYP2C19 inhibitors like cimetidine or who are CYP2C19 slow metabolisers). However, a very large cohort study found no ↑ risks of ventric. arrhythmia or all-cause, cardiac, or noncardiac mortality with Cit doses > 40 mg/day, casting doubt on the merits of these warnings (Zivin K et al. Am J Psychiatry. 2013;170:642-650). The FDA notes that escit was NOT associated with a significantly ↑ QT interval (03/2012) c = Health Canada and the makers of Venlafaxine XR issued an advisory (Oct. 23 2008) re: case reports of fatal acute overdoses with as little as approximately 1000 mg of venlafaxine alone d = at doses of 150 - 225 mg/day References ( list not complete ) Ahn JH, Patkar AA. Escitalopram for the treatment of major depressive disorder in youth. Expert Opinion on Pharmacotherapy 2011;12(14): 2235-44 Alberti S, Chiesa A, Andrisano C, Serretti A. Insomnia and somnolence associated with second-gen antidepressants during the treatment of major depression. J Clin Psychopharmacol 2015;35:296-303 Ansari A. The efficacy of newer antidepressants in the treatment of chronic pain: a review of the current literature. Harvard Rev Psychiatry 2000;7:257-277 Arsenault P, Neron A. Le syndrome de l'intestin irritable -1. Le Médecin du Québec 2008;4(5):85-88 Bandelow B et al. Efficacy of treatments for anxiety disorders: a meta-analysis.International Clinical Psychopharmacology 2015;30:183-192 Beaulieu S et al. CANMAT task force recommendations for the management of patients with mood disorders and comorbid substance use disorders. Ann Clin Psychiatry 2012;24(1):23-37 Berle J, Spigset O. Antidepressant use during breastfeeding.Current Women's Health Reviews 2011;7:28-34 Boulenger JP et al. Efficacy and safety of vortioxetine 15 and 20 mg/day: a randomized double-blind, plac-cont, dulox-ref study in the acute treatment of adult pts with MDD. Int Clin Psychopharmacol 2013 Bradford JMW. The neurobiology, neuropharmacology and pharmacological treatment of the paraphilias and compulsive sexual behavior. Can J Psychiatry 2001;46:26-34 Brecht et al. Efficacy and safety of duloxetine 60 mg once daily in the treatment of pain in patients with MDD and at least moderate pain of unknown etiology.... J Clin Psychiatry 2007;68:1707-1716 Calandra C et al. Bupropion Versus Sertraline in the Treatment of Depressive Patients with Binge Eating Disorder: Retrospective Cohort Study. Psychiatric Quarterly (Sept 2011) Cheeta S et al. Antidepressant-related deaths and antidepressant prescriptions in England and Wales, 1998-2000. Br J Psychiatry 2004;184:41-47 Clauw DJ. Pharmacotherapy for patients with fibromyalgia. J Clin Psychiatry 2008;69(suppl 2):25 - 29 Clayton A et al. Changes in sexual functioning associated with duloxetine, escitalopram and placebo in the treatment of patients with major depressive disorder. J Sex Med 2007;4:917-929 Dent R, Gervais A. Weight gain induced by psychotropic agents. CMAJ 2013. DOI:10.1503/cmaj.121044(Appendix) Deshauer D. Venlafaxine (effexor): concerns about increased risk of fatal outcomes in overdose. CMAJ 2007;176(1):39-40 Dunlop BW et al. Symptomatic and functional improvement in employed depressed patients: A double-blind clinical trial of desvenlafaxine versus placebo. J Clin Psychopharmacol 2011;31(5):569-76 Dyskant M et al. SSRIs in the treatment of panic disorder: a systematic review of placebo-controlled studies. Expert Rev Neurother 2010;10(8):1285-1293 Ede M. Renseignements importants en matière d'innocuité approuvé par Santé Canada concernant Remeron / Remeron RD (mirtazapine) [Lettre: 28 mars 2014] Figueroa R. Use of Antidepressants During Pregnancy and Risk of Attention-Deficit/Hyperactivity Disorder in the Offspring. J Dev Behav Pediatr. 2010 Jul 6. [Epub ahead of print] Findling RL et al. Safety and Tolerability of Desvenlafaxine in Children and Adolescents with Major Depressive Disorder. J Child Adolesc Psychopharmacol 2014;24(4):201-209 Freire RC, Machado S, Arias-Carrión O, Nardi AE1. Current Pharmacological Interventions in Panic Disorder. CNS Neurol Disord Drug Targets. 2014 Jun 12. Gaynes et al. Does the presence of accompanying symptom clusters differentiate the comparative effectiveness of second-line med strategies for treating depression? Depression and Anxiety 2011;0:1-10 Goodnick PJ et al.Psychotropic drugs and the ECG : Focus on the QT interval. Expert Opin Pharmacother 2002;3(5):479-498 Grigoriadis S et al. Antidep. exposure during pregnancy and congenital malformations: is there an association? A syst. review and meta-analysis of the best evidence. J Clin Psychiatry 2013;74:e293–308 Grover M, Camilleri M.J Effects on gastrointestinal functions and symptoms of serotonergic psychoactive agents used in functional gastrointestinal diseases. Gastroenterol. 2013 Feb; 48(2):177-81. Guerdjikova AI et al. Duloxetine in the treatment of binge eating disorder with depressive disorders: A placebo-controlled trial. International Journal of Eating Disorders (Jul 2011) Hallberg P, Sjöblom V. The use of SSRIs during pregnancy and breastfeeding. J Clin Psychopharmacology 2005;25:59-73 Hawton K, et al. Toxicity of antidepressants: rates of suicide relative to prescribing and non-fatal overdose. Br J Psychiatry. 2010 May;196(5):354-8. Joffe H et al. Treatment of depression and menopause-related symptoms with the serotonin-norepinephrine reuptake inhibitor duloxetine. J Clin Psychiatry 2007;68:943-950 Kunz NR et al. Diabetic neuropathic pain management with venlafaxine XR. Eur Neuropsychopharmacol 2000;10(suppl 3):S389 Larsen ER et al. Use of psychotropic drugs during pregnancy and breastfeeding. Acta Psychiatrica Scandinavica. 2015:132(Suppl. 445):1-28 Ma D et al. Comparative efficacy, acceptability, and safety of med, CBT, and pbo treatments for acute MDD in children and adolescents: a multiple-tx meta-analysis. Curr Med Res Opin. 2014;30(6):971-995 Mago R et al. Cardiovascular adverse effects of newer antidepressants. Expert Review of Neurotherapeutics. 2014;14(5): 539-551 Mallinckrodt CH et al. Differential antidepressant symptom efficacy: placebo-controlled comparison of duloxetine and SSRIs (fluoxetine, paroxetine, escitalopram). Neuropsychobiology 2007;56:73-85 Maneeton N et al. Bupropion for adults with attention-deficit hyperactivity disorder: Meta-analysis of randomized, placebo-controlled trials. Psychiatry and Clinical Neurosciences 2011;65 (7), 611-7 McIntyre RS et al. Quetiapine XR efficacy and tolerability as monotherapy and as adjunctive treatment to conventional antidepressants.. Expert Opin Pharmacother. 2009;10 (18) :3061-3075 Nakhai-Pour HR et al. Use of antidepressants during pregnancy and the risk of spontaneous abortion. CMAJ 2010;182(10):1031-7 Nelson HD et al. Nonhormonal therapies for menopausal hot flushes: systematic review and meta-analysis. JAMA 2006;295:2057-2071 Patil AS, Kuller JA, Rhee EHJ. Antidepressants in pregnancy: a review of commonly prescribed medications. Obstetrical & Gynecological Survey 2011;66 (12), 777-87 Reefhuis J et al. Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports. BMJ 2015;351:h3190 Schutters SI, et al. Mirtazapine in generalized social anxiety disorder: a randomized, double-blind, placebo-controlled study. Int Clin Psychopharmacol. 2010 Sep;25(5):302- Schweitzer I et al. Sexual side effects of contemporary antidepressants: review. Australian and New Zealand Journal of Psychiatry 2009;43:795-808 Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol 2009; 29(3): 259-266 Serretti A, Mandelli L. Antidepressants and body weight: a comprehensive review and meta-analysis. J Clin Psychiatry 2010;71(10)1259-1272 Soares CC et al. A pilot, 5-week, placebo lead-in trial of quetiapine XR for depression in mid-life women. J Clin Psychopharmacol 2010;30:612-615 St-André M. Antidépresseurs et grossesse: informer, accompagner, prescrire judicieusement. Le Spécialiste 2009;11(3):40-41 Taylor D. Antidepressant drugs and cardiovascular pathology: a clinical overview of effectiveness and safety. Acta Psychiatr Scand 2008;118:434-442

46 Thase ME et al. Effects of levomilnacipran ER on motivation/energy and functioning in adults with major depressive disorder. Int Clin Psychopharmacol 2016;31:332-340 Voican CS, Corruble E, Naveau S, Perlemuter G. Antidepressant-induced liver injury: a review for clinicians. Am J Psychiatry. 2014 Apr 1; 171(4):404-15. Volpe FM. An 8-week, open-label trial of duloxetine for comorbid major depressive disorder and chronic headache. J Clin Psychiatry 2008;69:1449-1454 Walderburg E et al. Effects of duloxetine in treatment-refractory men with PTSD. Pharmacopsychiatry 2010;43(20:45-9 Wenzel-Seifert K et al. QTc prolongation by psychotropic drugs and the risk of torsade de pointes. Dtsch Arztebl Int 2011;108(41):687-93 www. fda.gov/Safety/Medwatch www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2012/13674a-eng.php; www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2012/14672a-eng.php La Revue Canadienne de Psychiatrie 61(9) 551

Select and iniate a ﬁrst-line andepressant (Table 3)

Early No 2 Consider factors for improvement a er 2-4 switch vs. adjunct weeks? (Table 11)

4 3 Yes Switch to Switch to a second- another 1st ndepressant Add an adjuncve line or third-line line a , with medicaon andepressant preferably superior eﬃcacy (Table 11) (Table 3) (Table 6)

Early No improvement a er 2-4 weeks?

Yes Connue treatment for 6-8 weeks

❶

No 6 7 Symptom remission?

Yes

Risk factors No for Maintain treatment recurrence? for 6-9 months (Table 10)

Yes

Maintain treatment for 2 years or longer

Figure 2. Summary algorithm for managing inadequate response to an antidepressant. (1) Monitor outcomes using measurement-based care. (2) Depending on tolerability, first optimize antidepressant by increasing dose. (3) For early treatment resistance, consider adjunctive use of psychological and neurostimulation treatments. (4) After failure of 1 or more antidepressants, consider switch to a second-line or third-line antidepressant. (5) For more resistant depressions, consider longer evaluation periods for improvement. (6) Depending on tolerability, increase dose if not at maximal doses. (7) For more chronic and resistant depressions, consider a chronic disease management approach, with less emphasis on symptom remission and more emphasis on improvement in functioning and quality of life.

47 Canadian Psychiatric Association

Association des psychiatres CANMAT Guidelines du Canada

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(9) 524-539 Canadian Network for Mood and Anxiety ª The Author(s) 2016 Reprints and permission: Treatments (CANMAT) 2016 Clinical sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716659418 Guidelines for the Management of Adults TheCJP.ca | LaRCP.ca with Major Depressive Disorder: Section 2. Psychological Treatments

Sagar V. Parikh, MD, FRCPC1,2, Lena C. Quilty, PhD2, Paula Ravitz, MD2, Michael Rosenbluth, MD2, Barbara Pavlova, PhD3, Sophie Grigoriadis, MD, PhD2, Vytas Velyvis, PhD4, Sidney H. Kennedy, MD2, Raymond W. Lam, MD5, Glenda M. MacQueen, MD, PhD6, Roumen V. Milev, MD, PhD7, Arun V. Ravindran, MB, PhD2, Rudolf Uher, MD, PhD3, and the CANMAT Depression Work Group8

Abstract Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) has revised its 2009 guidelines for the management of major depressive disorder (MDD) in adults by updating the evidence and recommendations. The target audiences for these 2016 guidelines are psychiatrists and other mental health professionals. Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. ‘‘Psychological Treatments’’ is the second of six sections of the 2016 guidelines. Results: Evidence-informed responses were developed for 25 questions under 5 broad categories: 1) patient characteristics relevant to using psychological interventions; 2) therapist and health system characteristics associated with optimizing outcomes; 3) descriptions of major psychotherapies and their efficacy; 4) additional psychological interventions, such as peer interventions and computer- and technology-delivered interventions; and 5) combining and/or sequencing psychological and pharmacological interventions. Conclusions: First-line psychological treatment recommendations for acute MDD include cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and behavioural activation (BA). Second-line recommendations include computer-based and telephone-delivered psychotherapy. Where feasible, combining psychological treatment (CBT or IPT) with antidepressant treatment is recommended because combined treatment is superior to either treatment alone. First-line psychological treatments for maintenance include CBT and mindfulness-based cognitive therapy (MBCT). Patient preference, in combination

1 Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 2 Department of Psychiatry, University of Toronto, Toronto, Ontario 3 Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia 4 CBT Associates, Toronto, Ontario 5 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia 6 Department of Psychiatry, University of Calgary, Calgary, Alberta 7 Department of Psychiatry, Queen’s University, Kingston, Ontario 8 Members of the CANMAT Depression Work Group are listed here: www.canmat.org/workgroups

Corresponding Author: Sagar V. Parikh, MD, FRCPC, University of Michigan, Ann Arbor, 4250 Plymouth Road, Room 1303, Ann Arbor, Michigan, USA, 48109-2700. Email: [email protected]

48 La Revue Canadienne de Psychiatrie 61(9) 525 with evidence-based treatments and clinician/system capacity, will yield the optimal treatment strategies for improving individual outcomes in MDD.

Keywords major depressive disorder, clinical practice guidelines, evidence-based medicine, meta-analysis, systematic reviews, psychotherapy, biopsychosocial, cognitive-behavioural therapy, interpersonal therapy, mindfulness-based interventions

In 2009, the Canadian Network for Mood and Anxiety Treat- marital therapy for MDD coinciding with a severe marital ments (CANMAT), a not-for-profit scientific and educa- dispute) are not evaluated, since such therapies do not gen- tional organization, published a revision of evidence-based eralize to the average person with depression. Indications for clinical guidelines for the treatment of depressive disorders.1 a specific therapy, as well as the choice of either psycholo- CANMAT has updated these guidelines in 2016 to reflect gical treatment or pharmacotherapy alone or in combination, new evidence in the field. are reviewed in a number of the following questions, along The scope of these guidelines remains the management with discussion of self-help approaches and peer support. of adults with unipolar major depressive disorder (MDD). The recommendations are presented as guidance for clini- CANMAT, in collaboration with the International Society cians who should consider them in the context of individual for Bipolar Disorders, has published separate guidelines for patients and not as standards of care. bipolar disorder.2 This section on Psychological Treat- ments is 1 of 6 CANMAT guidelines articles; other sections of the guidelines expand on burden and principles of care, Methods pharmacological treatments, neurostimulation treatments, The full methods have been previously described,3 but in complementary and alternative medicine treatments, and summary, relevant studies in English published from Janu- special populations. ary 1, 2009, to December 31, 2015, were identified using We use the term psychological treatment rather than computerized searches of electronic databases (PubMed, psychotherapy as a broader term that involves treatment PsychInfo, Cochrane Register of Clinical Trials), inspection of psychiatric and behavioural disorders through a method of bibliographies, and review of other guidelines and major of communicating that invokes a psychological model of reports. Each recommendation includes the level of evidence illness. This method of communication begins with a for each graded line of treatment, using specified criteria patient who seeks alleviation of current symptoms or pre- (Table 1). The level of evidence criteria now reflect the vention of recurrence of symptoms. With the advent of primacy of meta-analysis because of its increasing use in the computer, Internet, self-help, phone, and mobile apps, the evaluation of evidence. relationship is now between the patient and the psycholo- Because of the very large number of randomized- gical model, with an implicit link to the ‘‘therapist’’ who controlled trials (RCTs), this psychological treatments designed the therapy. This guideline summarizes depression- section will primarily focus on systematic reviews and indi- specific psychotherapies as well as newer therapies that are vidual and network meta-analyses. Although meta-analyses promising and seeks to clarify the evidence and usefulness have advantages in summarizing data, they still have limita- of each major treatment. tions that can lead to erroneous or conflicting results Psychological treatments for MDD share many common depending on the comprehensiveness of the review, criteria components: 1) the goal of treatment is alleviation of the core for study selection and quality and generalizability of the symptoms of depression; 2) there is careful attention to a included studies, and various types of bias.4 One additional specific method to deliver the therapy (typically a manual); limitation of both RCTs and subsequent meta-analyses 3) the psychotherapy focuses on the current problems of the needs to be highlighted: recruitment of individuals in stan- patient; 4) high levels of activity are expected from both the dard MDD RCTs often excludes people with current suici- therapist and the patient (who frequently has ‘‘homework’’); dality, substance use, and other comorbidities.5 This limits 5) careful symptom monitoring, preferably with rating scales, the generalizability of these studies. We have included sep- is expected; 6) psychoeducation about the illness is a frequent arate sections on depression with various comorbidities to component; and 7) the treatment is generally time-limited, specifically highlight findings in those clinical conditions. often paralleling the time course for pharmacotherapy. Furthermore, many of these therapies have been modified to be delivered in a group format. While a group approach 2.1. When Is Psychological Treatment Indicated? may allow for integration of new techniques involving peer In addition to patients’ attitudes and preferences, a clinician feedback and may be more cost-effective, the core of the must consider the availability of high-quality evidence- psychotherapy remains unchanged, so group interventions based psychological treatment and the risk from delay in are not evaluated in these guidelines as a separate ‘‘group treatment initiation. In more severe and high-risk cases, it therapy.’’ Similarly, context-specific therapies (such as is imperative to start a treatment that is immediately

49 526 The Canadian Journal of Psychiatry 61(9)

Table 1. Criteria for Level of Evidence and Line of Treatment. different subtypes of depression, including atypical depression, melancholic depression, and anxious depression.9,10 In Criteria addition, a large individual-level meta-analysis confirmed Level of evidencea that men and women derive similar benefits from CBT and 1 Meta-analysis with narrow confidence intervals from antidepressants.11 In persistent depressive disorder and/or 2 or more RCTs with adequate (PDD), medication treatment or combination of medication sample size, preferably placebo controlled with psychological treatment provides more benefit than 2 Meta-analysis with wide confidence intervals psychological treatment alone.12,13 and/or 1 or more RCTs with adequate sample size 3 Small-sample RCTs or nonrandomized, Severity. Early findings that CBT as a treatment for severe 14 controlled prospective studies or case series depression was less effective than medication were followed or high-quality retrospective studies by evidence of comparable efficacy for CBT and medica- 4 Expert opinion/consensus tion.15 A subsequent meta-analysis confirmed that severity Line of treatment of depression does not differentially predict outcomes of First line Level 1 or Level 2 Evidence, plus clinical treatment with antidepressants and CBT.16 As in the case of supportb Second line Level 3 Evidence or higher, plus clinical antidepressant medication, the magnitude of benefit for psy- supportb chological treatment appears to increase with increasing 17 Third line Level 4 Evidence or higher, plus clinical severity, although there is evidence that psychological treat- supportb ments are beneficial even for subthreshold depressive symptoms.18 However, since the time course of improvement is RCT, randomized controlled trial. aNote that Level 1 and 2 Evidence refer specifically to treatment studies in typically faster with pharmacological than psychological 19 which randomized comparisons are available. Recommendations involving treatment, pharmacotherapy may still be preferred as the epidemiological or risk factors primarily arise from observational studies, initial treatment in severe and high-risk cases. and hence the highest level of evidence is usually Level 3. Higher order recommendations (e.g., principles of care) reflect higher level judgement of the strength of evidence from various data sources and therefore are primarily Level 4 Evidence. 2.3. How Do Co-occurring Psychiatric and Medical bClinical support refers to application of expert opinion of the CANMAT committees to ensure that evidence-supported interventions are feasible Conditions Affect the Efficacy of Psychological and relevant to clinical practice. Therefore, treatments with higher levels of Treatments? evidence may be downgraded to lower lines of treatment due to clinical issues such as side effects or safety profile. Psychiatric comorbidities. This question was addressed by a CANMAT task force in 201220 with individual studies on available and to consider all treatment modalities, including anxiety disorders,21 attention-deficit/hyperactivity disorder neurostimulation. In moderately severe and low-risk cases, (ADHD),22 substance use disorders,23 and personality the choice of initial treatment between psychological treat- disorders.24 There is insufficient evidence to define formal ment and antidepressants may be determined by the balance treatment recommendations, so instead only evidence is of patient preferences and availability of each treatment summarized. modality. In addition, special circumstances may need to In summary, Level 2 Evidence supports a negative prog- be taken into account. For example, women who are plan- nostic impact of comorbid personality disorder on treatment ning to conceive or are pregnant may be preferentially con- outcomes, including psychological treatments, in depression sidered for psychological treatment, because of concerns that (Table 2). Insufficient evidence is available to support a use of antidepressants in pregnancy may affect the fetus.6,7 positive or negative effect of anxiety symptoms or disorders On the other hand, psychological therapies are not indicated on depression outcomes, but CBT may be more effective for individuals with psychotic depression, who require phar- than other treatments. CBT is also effective for depressive macotherapy with antidepressants and antipsychotics8 or symptoms in substance use disorders, and Level 2 Evidence electroconvulsive therapy. supports integrated psychosocial treatment of alcohol misuse and depression. For ADHD, CBT can improve both depressive and ADHD symptoms. 2.2. Which Individuals with Depression Are Most Likely Medical comorbidities. The CANMAT task force also to Benefit from Psychological Treatment? addressed the management of mood disorders and comorbid Demographic factors. Psychological treatments benefit men medical conditions.20,25,26 There is insufficient evidence to and women to the same extent; psychological treatments are define formal treatment recommendations, so instead only equally suitable for individuals of all ages, levels of educa- evidence is summarized. tion, and cultural and ethnic backgrounds.9 Psychological Several key limitations exist in summarizing this litera- treatments in general and cognitive-behavioural therapy ture: 1) the comorbid medical disorders themselves represent (CBT) in particular appear to be equally effective for a variety of illnesses grouped according to organ system

50 La Revue Canadienne de Psychiatrie 61(9) 527

Table 2. Impact of Comorbid Psychiatric Disorders on Psycholo- Table 3. Impact of Comorbid Medical Disorders on Psychological gical Treatments in Major Depressive Disorder. Treatments in Major Depressive Disorder.

Comorbid Level of Comorbid Level of Disorder Summary Findings Evidence Disorder Summary Findings Evidence

Anxiety Anxiety may not complicate or reduce Conflicting/ Cancer Evidence varies by type of Level 2 responses to psychological insufficient psychological intervention and treatments. evidence phase of cancer treatment, but CBT more beneficial than other Level 2 multiple small positive RCTs24 psychological treatments. Cardiovascular Effectiveness shown with CBT, IPT, Level 2 Substance CBT improves both depression and Level 2 disease and PST, alone or with abuse substance abuse symptoms. antidepressants Integrated treatment is effective but Level 2 Multiple Various psychological treatments Level 2 with small effect size. sclerosis studied, primarily CBT; all Personality Personality disorders have negative Level 2 beneficial impact on depression outcomes. HIV CBT effective, most delivered in Level 1 ADHD CBT for ADHD helps both disorders, Level 2 group format; IPT effective but for CBT as adjunct to medications. with limited studies Level 2 for IPT ADHD, attention-deficit/hyperactivity disorder; CBT, cognitive-behavioural Epilepsy Limited research, using CBT Level 3 therapy. primarily, with moderate benefit for depressive symptoms (e.g., cancer includes a variety of diseases), 2) the medical Migraines Various psychological treatments Level 3 have moderate benefit for disorders themselves include patients at varying stages or depressive symptoms severity of medical illness, and 3) most studies measure Parkinson’s CBT effective for reducing depressive Level 2 improvement in depressive symptoms as opposed to only disease symptoms improvement of those with a full diagnosis of MDD. Hepatitis C Psychological treatments may be Level 3 In summary, there is Level 2 Evidence for treatment of useful depression with co-occurring cardiovascular disease for CBT, cognitive-behavioural therapy; HIV, human immunodeficiency virus; CBT, interpersonal therapy (IPT), and problem-solving ther- IPT, interpersonal therapy; PST, problem-solving therapy; RCT, randomized- 25,27-29 apy (PST). Level 2 Evidence also exists for a variety controlled trial. of psychological treatments in cancer patients, but these are studied by cancer type and stage as noted in Table 3.25,30 In many pregnant women prefer psychological treatment and the presence of human immunodeficiency virus (HIV), Level report fear of potential adverse effects of antidepressants on 1 Evidence supports a variety of psychological treatments, the developing fetus or on their newborn via lactation, gen- particularly CBT31 and, importantly, improved adherence to eral worries about a negative outcome, and fears of depen- medical interventions as well as improvement in depression.32 dency as well as balancing concerns about their own health 41,42 For a variety of neurological disorders, psychological treat- or the fetus. Treatment for adolescents is addressed else- ments (almost always CBT) have been tested for comorbid where; for further advice, see the American Academy of 43 depression or depressive symptoms, with Level 2 Evidence of Child and Adolescent Psychiatry. Similarly, psychological efficacy for multiple sclerosis and Parkinson’s disease, and treatments may have increased relevance in the elderly, since Level 3 Evidence for epilepsy and migraines.25,33,34 Finally, older patients with depression are more vulnerable to med- for the strikingly high rates of depression accompanying hepa- ication side effects and drug interactions, as many may titis C, only Level 3 Evidence exists for psychological treat- already be taking multiple medications for comorbid medi- ments, based primarily on expert recommendations with a cal disorders. Treatment of depression in youth/adolescents, 44 single trial using both CBT and IPT approaches.25,35 women, and those in late life is reviewed in Section 6.

2.4. How Do Gender and Age Influence the 2.5. What Are the Key Therapist Factors That Decision to Use Psychological Treatment? Improve Clinical Outcomes? More women than men prefer psychological treatment over Recommendations from the American Psychological Associ- medication treatment.36 Considerations for women during ation Task Force on psychotherapy relationships45 concluded childbearing years include exposure of the fetus during that the best outcomes are likely to come from the concurrent gestation or neonate during lactation. The scope of evidence use of evidence-based therapy relationships, not just for psychological treatment is broader for postpartum rather evidence-based treatments. These conclusions were described than during pregnancy, with Level 1 Evidence to support as ‘‘demonstrably effective,’’ ‘‘probably effective,’’ and ‘‘pro- psychological treatment as first-line for perinatal women mising, but insufficiently researched’’ (Table 4).46,47 These with mild to moderate depressive illness.37-40 Moreover, recommendations are based on literature reviews and process

51 528 The Canadian Journal of Psychiatry 61(9)

Table 4. Evidence-based Therapy Relationships: Therapist Factors not exclusively focused on patients with depression. Thera- That Improve Clinical Outcomes.45,47,48,50,162-167 pist experience, adherence, and ability to be responsive to individual patient differences are associated with better Elements of a Therapeutic Relationship outcomes.54,55 Most importantly, the evidence for psycho- Demonstrably effective Alliance in individual logical therapies for depression is based on studies with psychotherapy—a collaborative highly competent therapists, hence the second-line recom- stance predicated on agreement mendation (Level 3 Evidence) that psychological therapies on goals, with consensus on the for depression should be delivered by trained and proficient therapeutic tasks, and an emotional bond therapists, although even less-trained therapists can have Empathy—understanding with efficacy in treating depression and indeed may be the only 56 communicative attunement source of treatment. Collecting patient feedback— monitoring treatment response with standardized scales 2.6. How Do You Choose a Psychological Treatment for MDD? Probably effective Goal consensus—congruent understanding, agreement, and Choosing a specific type of psychological treatment should commitment to goals consider treatment efficacy, quality, and availability, as well Collaboration—mutual as patient preference. Comparisons of different psychologi- cooperative involvement of cal treatments are fewer in number and quality, as well as patient and therapist Positive regard—in which patient complicated by methodological challenges, including lack of feels respected and appreciated blinding and the effects of allegiance to a particular model. Table 5 lists recommendations for acute and mainte- Promising but insufficient Congruence/genuineness— nance psychological treatments (respectively) for depres- research to judge therapist awareness and sion, with the evidence level conveying the efficacy in authentic use of his or her comparison to control conditions, not to alternative psycho- internal in-session experiences logical treatments. When choosing psychological treatment with the patient for a patient with depression, we recommend preferentially Repairing alliance ruptures— recognizing and resolving selecting from first-line treatments. Second-line treatments tensions or impasses in the should be used if first-line treatments have failed or are therapeutic alliance to restore unavailable. Third-line treatments should be reserved for collaboration, understanding, or use in specialist centres where first- and second-line treat- communication ments are also available. All high-quality evidence in psy- Managing countertransference— chotherapy research is based on studies where extensively therapist awareness and self- trained therapists receive regular supervision and adhere to management of strong feelings precipitated by the patient’s principles of the given therapeutic model with high fidelity. manner of relating and/or the Therefore, the evidence-based recommendations do not therapist’s unresolved conflicts extend to psychological treatments that eclectically use elements of different models. Adapted with permission from Norcross (2011). research using secondary analyses, rather than experimental 2.7. How Do Psychological Treatments for MDD trials of the specific principles; thus, they are supported by Level 3 Evidence and are recommended as a first-line treat- Compare in Efficacy? ment practice. Three evidence-based common factors found Some meta-analytic comparisons between specific models to predict positive outcomes are establishing a strong thera- of psychological treatment have shown no significant differ- peutic alliance, using empathy, and collecting client feedback ences in efficacy,57 with others showing modest differ- (Table 4).46-49 Therapist characteristics that promote a thera- ences.58 When only bona-fide therapies (defined as peutic alliance include being genuinely respectful and inter- delivered by trained therapists, based on psychological prin- ested in the well-being and safety of the patient, with empathy ciples, and designed to be a viable treatment) were consid- for subjective experience.50 The collecting of patient feedback ered, there were no differences between CBT and IPT, but helps to track symptoms, experience of treatment, and func- CBT was more effective than other psychotherapies consid- tioning using validated scales (e.g., the Patient Health Ques- ered as a group59; using a different definition of bona-fide tionnaire–9 [PHQ-9]51) such that changes can be made if therapy, supportive therapy was less effective than other patients are not improving. types of therapy, with no differences between CBT, IPT, and Additionally, therapist supervision and feedback can psychodynamic psychotherapy (PDT).60 Short-term psycho- improve patient outcomes,52,53 although the research was dynamic psychotherapy (STPP) compared to other types of

52 La Revue Canadienne de Psychiatrie 61(9) 529

Table 5. Recommendations for Psychological Treatments for (BA) to first-line treatment.70,71 The evidence base for STPP Acute and Maintenance Treatment of Major Depressive Disorder. has expanded with recent studies, including comparisons with CBT72 and antidepressant medication73 and a recently Maintenance 61 Acute Treatment (Relapse updated meta-analysis. A key limitation of the STPP liter- Treatment Prevention) ature is the conflation of different models of psychodynamic therapy (PDT) into the broad term STPP, whereby no single Cognitive-behavioural First line First line (Level 1) model has a replicated large RCT with positive findings for therapy (CBT) (Level 1) MDD, unlike CBT and IPT. Consequently, STPP is recom- Interpersonal therapy (IPT) First line Second line (Level 2) (Level 1) mended as a second-line therapy with Level 2 Evidence. Behavioural activation (BA) First line Second line (Level 2) While long-term PDT is not within the scope defined earlier (Level 1) of an acute treatment for depression, there is limited evi- Mindfulness-based cognitive Second line First line (Level 1) dence of efficacy for acute MDD treatment.74 Thus, the therapy (MBCT) (Level 2) limited evidence base confines general PDT—as separate Cognitive-behavioural analysis Second line Second line (Level 2) from specific STPP—as a third-line treatment. While the system of psychotherapy (Level 2) amount of evidence for the cognitive-behavioural analysis (CBASP) Problem-solving therapy Second line Insufficient evidence system of psychotherapy (CBASP) has increased, results of (PST) (Level 2) the most recent large trial (N ¼ 491 in 3 conditions) are Short-term psychodynamic Second line Insufficient evidence inconsistent with previous results and do not support the psychotherapy (STPP) (Level 2) efficacy of CBASP.75 Therefore, CBASP remains a Telephone-delivered CBT and Second line Insufficient evidence second-line treatment for chronic depression. An updated IPT (Level 2) meta-analysis of acceptance and commitment therapy (ACT) Internet- and computer- Second line Insufficient evidence concluded that there is insufficient evidence of efficacy76; assisted therapy (Level 2) Long-term psychodynamic Third line Third line (Level 3) therefore, ACT remains a third-line treatment. The evidence psychotherapy (PDT) (Level 3) status for other types of psychotherapies has not changed Acceptance and commitment Third line Insufficient evidence significantly since the 2009 guidelines. therapy (ACT) (Level 3) Videoconferenced Third line Insufficient evidence psychotherapy (Level 3) 2.8. Does Group or Individual Format for Psychological Motivational interviewing (MI) Third line Insufficient evidence (Level 4) Treatment Influence Outcome? Meta-analyses that evaluated efficacy of group psychological therapy for depression concluded that it is more effec- psychotherapies resulted in slightly worse outcomes on some tive than treatment as usual.77,78 However, group therapy measures of depression at the end of treatment.61 was less effective than individual therapy at the end of Individual psychological treatments are discussed in more treatment and had a higher dropout rate, although no dif- detail in the following, but in summary, CBT remains the ferences were found at follow-up.77 While efficacy evi- most established evidence-based, first-line treatment for dence may slightly favour individual therapy, other depression, both acute and maintenance. With more than factors, including availability, cost, and patient preference, 40 original reports and meta-analyses published on CBT for are still important factors in choosing between group and MDD or PDD since 2009, there is substantial evidence of individual treatments. Finally, given the gap between efficacy even in severely affected individuals and in those needed and available psychological treatments, group psy- who had not responded to treatment with antidepres- chotherapy could improve access to treatment. sants.62,63 Similarly, there is evidence across populations (adult, adolescents, perinatal women) to support IPT as an alternative strong first-line treatment for acute MDD and 2.9. How Many Sessions of Psychological Treatment second-line as a maintenance treatment.64-66 Mindfulness- based cognitive therapy (MBCT) has new evidence to qualify Are Required to Be Effective? as a second-line acute treatment. With several meta-analyses Recent research has examined shorter durations for various demonstrating efficacy67,68 and a large, high-quality RCT psychotherapies. Overall, there is Level 1 Evidence that brief (N ¼ 424)69 demonstrating equal efficacy of MBCT to interventions can be effective. A number of trials have medication as maintenance treatment for recurrent MDD, demonstrated the efficacy of an 8-session CBT interven- MBCT has emerged as a first-line maintenance treatment tion.79,80 A review of 4 small trials of an 8-session brief IPT adjunctive to medication. intervention in depressed women also found efficacy,81 while While there are new studies using Internet- or 2 other meta-analyses looking at brief (8 or fewer sessions) of smartphone-delivered treatment, a single additional face- CBT, MBCT, and PST noted significant efficacy in symptom to-face study together with a new meta-analysis including reduction.82,83 Studies comparing 8 versus 16 or more ses- many older, small studies elevate behavioural activation sions are rare but suggestive of similar effectiveness.84-86

53 530 The Canadian Journal of Psychiatry 61(9)

In the absence of definitive ‘‘dose-finding’’ trials, insuffi- who discontinued medication. There was no difference, cient evidence exists to state a minimum dose; it is recom- however, between the CBT group and those who continued mended that after selecting a first- or second-line pharmacotherapy at 1-year follow-up.57 A meta-analysis of psychological treatment, the specific treatment manual be 10 trials demonstrated a reduction in the risk of relapse by followed. In several RCTs,15,62,86,87 treatment was offered 21% in the first year and by 28% in the first 2 years.90 In a twice weekly for the first 2 to 8 weeks. Furthermore, in a subsequent meta-analysis, which included more heteroge- recent analysis of 70 controlled studies (N ¼ 5403), which neous studies, CBT delivered during remission decreased account for natural recovery, there was no association the likelihood of relapse by 32%. The comparison with between clinical improvement and the number of psycholo- pharmacotherapy did not show a significant difference.91 gical treatment sessions or hours; however, a strong positive To prevent depressive relapse/recurrence, CBT versus association was found for increased frequency of psycholo- pharmacotherapy delivered during the acute phase offers gical treatment sessions per week and increased size of clin- better protection. During maintenance phase treatment, ical improvement.12 Thus, more frequent treatment sessions, CBT and pharmacotherapy provide comparable prevention particularly at the start of therapy, should be considered of relapse. In summary, CBT has Level 1 Evidence and is (Level 3 Evidence). recommended as a first-line maintenance therapy, whether the CBT is delivered either in the acute or maintenance phase of MDD. 2.10. What Is Cognitive-Behavioural Therapy (CBT) and Its Efficacy in the Acute and Maintenance Phases of MDD Treatment? 2.11. What Is Mindfulness-Based Cognitive Therapy (MBCT) and Its Efficacy in the Acute and Maintenance CBT is an intensive, time-limited, symptom-focused psychological treatment built on the premise that depression is Phases of MDD Treatment? maintained by unhelpful behaviours and by inaccurate MBCT for MDD was formally developed as an 8-week group thoughts and beliefs about oneself, others, and the future. treatment designed to teach patients how to disengage from Behavioural interventions are aimed at increasing the maladaptive cognitive processes through an integration of patients’ participation in activities that promote a sense of mindfulness meditation training and cognitive-behavioural pleasure and achievement and thus lift their mood. Patients techniques.92 MBCT improves clinical outcomes via changes also assess the impact of various behaviours on their mood. in mindfulness, rumination, worry, compassion, and meta- The cognitive techniques help patients evaluate the accuracy awareness, consistent with underlying theory.93 of their negative thoughts and beliefs. Practising the new MBCT was originally developed to prevent relapse in skills outside the therapy room (i.e., homework) is crucial remitted patients. Clinical trials have supported its therapeu- for the effectiveness of therapy. tic value as an adjunct to treatment as usual94,95 and its Since 2009, several meta-analyses have been pub- comparability to maintenance antidepressant medication69,96 lished57,88,89 using the same database (www.evidencebasedp in this context. Of note, evidence has accrued to suggest that sychotherapies.com). The authors found that CBT is as MBCT may only be efficacious or advantageous over other effective as antidepressant medication,88 and the combina- forms of aftercare for those patients with greater vulnerabil- tion of CBT and an antidepressant is more effective than ity, in the form of recurrent depression,97,98 unstable remis- either alone.57,88,89 Results of a recent RCT62 suggested that sion,99,100 or a history of childhood trauma98 (although see when both CBT and pharmacotherapy are of high quality, also Geschwind et al.101). the addition of CBT to pharmacotherapy increases recovery MBCT has been increasingly applied to treatment of resi- rates. When participant characteristics were taken into dual depressive symptoms following treatment and more account, this effect was limited to participants with severe recently to depressive symptoms in the context of a full nonchronic depression. CBT is also effective for people with MDD, particularly in patients who have not responded to treatment-resistant depression (i.e., those who did not an earlier treatment. MBCT has exhibited efficacy as an respond to at least 2 adequate antidepressant trials). An RCT augmentation to treatment as usual in a heterogeneous sam- of 469 primary care patients with depression with poor ple of both currently and remitted depressed outpatients, response to medication found CBT improved response and albeit with modest effect sizes.102,103 MBCT has also exhib- remission,63 with sustained effects at 3-year follow-up.89 In ited superior efficacy to a psychoeducation control treat- summary, CBT has Level 1 Evidence of efficacy and con- ment104 and comparable efficacy to group CBT,105 tinues to be recommended as a first-line treatment for acute although a brief follow-up period and small sample size, treatment of MDD. respectively, were notable in these studies. Regarding maintenance treatment, a meta-analysis of 9 In summary, MBCT is recommended as a second- RCTs comparing CBT and pharmacotherapy concluded line adjunctive treatment (Level 2 Evidence) for acute that after 1 year, those who received CBT in the acute phase depression and as a first-line maintenance treatment of depressive illness had a lower rate of relapse than those (Level 1 Evidence).

54 La Revue Canadienne de Psychiatrie 61(9) 531

2.12. What Is Interpersonal Therapy (IPT) and Its psychotherapies at posttreatment.61 Overall, the literature Efficacy in the Acute and Maintenance Phases of MDD shows increasing evidence of a variety of improvements in Treatment? outcomes related to STPP, but an absence of replication of specific models leaves evidence of efficacy at Level 2, and IPT focuses on patients’ relational stressors involving losses, STPP models designed for depression should be considered changes, disagreements, or interpersonal sensitivity, which second-line treatment. There is insufficient evidence to rec- are associated with the onset or perpetuation of present symp- ommend STPP or PDT as a maintenance treatment for toms. The 4 focal interpersonal problem areas (i.e., bereave- MDD. ment, social role transitions, social deficits with interpersonal sensitivity, and disputes) each have a set of therapeutic guidelines.106,107 The goals of IPT are to alleviate suffering, remit 2.14. What Is the Overall Level of Efficacy for symptoms, and improve functioning. Motivational Interviewing (MI) in the Acute and A meta-analysis (16 RCTs, N ¼ 1472) compared IPT Maintenance Phases of MDD Treatment? to a control group for depression or depressive symptoms, Motivational interviewing (MI) was originally designed for with an effect size of 0.63.65 A subsequent systematic engaging and treating patients with substance use disor- review of comparative outcomes between IPT and other ders110 and takes the view that people approach change with psychological treatments (8 studies, N ¼ 1233) concluded ambivalence along a continuum of readiness.111 There are no that differences were small.66 Finally, specific examina- trials of MI as a stand-alone treatment for MDD; however, it tion of IPT versus CBT for adults with MDD (7 trials, has been used in conjunction with CBT, IPT, or medications N ¼ 741) found no differences between them.64 In sum- to improve treatment engagement or adherence and for treat- mary, Level 1 Evidence supports IPT as a first-line treatment of depression and comorbid substance misuse. For ment for acute depression. patients less likely to engage in or respond to unmodified For maintenance treatment, a meta-analysis demonstrates treatments, it is worth considering integration of MI.112 In that combined IPT with pharmacotherapy treatment was the absence of specific MDD studies, evidence remains at more effective than pharmacotherapy alone.65 However, het- Level 4 (expert opinion), and MI receives a third-line treat- erogeneity among the treatment formats (individualized vs. ment recommendation. group) and small sample size in the studies reduce evidence to Level 2, and therefore IPT combined with medication is recommended as a second-line maintenance treatment for 2.15. What Is the Overall Level of Efficacy for depression. Cognitive-Behavioural Analysis System of Psychotherapy (CBASP) in the Acute and Maintenance Phases of MDD Treatment? 2.13. What Are Short-Term Psychodynamic Psychotherapy (STPP) and Long-Term Psychodynamic CBASP was developed specifically for the treatment of chronic depression.113 It involves cognitive, behavioural, Therapy (PDT) and Their Efficacy in the Acute and and interpersonal strategies and is focused on helping Maintenance Phases of MDD Treatment? patients to recognize how maladaptive cognitions and Gunderson and Gabbard108 have defined PDT as ‘‘a therapy behaviours influence each other and lead to and perpetuate that involves careful attention to the therapist/patient inter- negative outcomes. Since the first CBASP trial published in 114 action with carefully timed interpretation of transference and 2000, 5 CBASP studies have been published that provide 75,115-118 resistance embedded in a sophisticated appreciation of the only mixed results supporting CBASP. Overall, therapist’s contribution to the two-person field.’’ PDT has Level 2 Evidence supports CBASP as a second-line contributed deeply to understanding the importance of rela- monotherapy, or in combination with antidepressants, for tionship/alliance issues (Table 4). Similarly, in the treatment partial-responding or nonresponding patients, in the treat- of the depressed patient with comorbid personality disorder, ment of PDD. PDT may have particular utility.24 However, there is only weak evidence, and only after prolonged treatment, for effi- 2.16. What Is Acceptance and Commitment cacy of long-term PDT for acute treatment of MDD.74,109 Hence, PDT is considered a third-line treatment for acute Therapy (ACT) and Its Efficacy? MDD. The aim of ACT is to mindfully increase acceptance of For STPP, a meta-analysis identified 54 studies (33 distressing experiences by taking an observer perspective RCTs).61 STPP was significantly more effective than waitlist and by clarifying and orienting behaviour towards valued or treatment-as-usual control conditions, but some analyses directions, instead of struggling against or trying to indicated STPP was similar to other psychotherapies in out- control perceived suffering.119 Since 2009, there have comes while other findings noted STPP was significantly been 3 meta-analyses with a comparison of ACT to less effective on depressive symptoms than alternative CBT.120-122 In 16 studies of various diagnoses, there was

55 532 The Canadian Journal of Psychiatry 61(9) improvement in depressive symptoms and anxiety with effective when training includes both positive problem ACT, although less than with CBT. ACT may also have orientation and problem-solving skills.138 particular value in the presence of comorbid medical con- PST has been tested most extensively in primary care ditions.122 In the absence of specific large trials in MDD, settings in individuals with a variety of depressive symptoms evidence remains at Level 3 and ACT is recommended as spanning subclinical depression, adjustment disorders, and a third-line treatment for MDD. MDD, with clear efficacy in reducing depressive symptoms. Both telephone-delivered and in-person PST were effective for treating MDD in low-income homebound older adults.139 2.17. What Is Behavioural Activation (BA) for Two separate meta-analyses found that the use of PST as an Depression and Its Efficacy? acute treatment for late life depression resulted in a significant reduction of depressive symptoms as well as disability The rationale for BA is that depression is caused and main- 138,140 tained by escape and avoidance of aversive emotions and in comparison to control treatments. stimuli that become self-reinforced and also prevents Overall, since most studies include a focus on depressive positive reinforcement of nondepressive behaviour, conse- symptoms rather than formal MDD, PST is recommended as quently causing longstanding patterns of inertia, avoidance, a second-line acute treatment in primary care and geriatric and social withdrawal.123 Manuals are available to address depression (Level 2 Evidence); there is insufficient evidence techniques to be applied in BA.124-126 to recommend PST as a maintenance treatment. One meta-analysis (34 studies, N > 2000 patients with depressive symptoms, but not necessarily MDD)127 found similar large effect sizes for BA and CBT compared to con- 2.20. What Is Bibliotherapy and What Is Its Efficacy? trol conditions, as well as a similar effect to CBT. Subse- Bibliotherapy, the reading and use of self-help materials quent clinical trials evaluating BA in MDD have almost such as books to treat depression, has been tested in many exclusively involved Internet- or smartphone-delivered older trials, particularly as RCTs involving a waitlist control treatments as opposed to in-person therapy.70,128,129 A sub- compared to use of the book Feeling Good by David sequent meta-analysis (26 RCTs, N ¼ 1524) that incorpo- Burns.141 With the expansion of computer/Internet rated older studies, the Internet/smartphone studies, and 1 approaches to self-help, very few bibliotherapy trials have recent face-to-face trial reported a large effect size of BA been published since 2009. Although 1 RCT142 highlighted compared to control conditions.130,131 Overall, Level 1 Evi- the need for physician guidance to ensure active engage- dence supports BA as a first-line treatment for acute depres- ment, an RCT evaluating usual care versus prescription for sion, with modest evidence that BA in acute depression Feeling Good found no difference in patient outcomes.143 provides protection against future relapse (Level 2), suggest- Overall, bibliotherapy has practical utility due to ease of use ing its role as a second-line treatment for maintenance. and low cost, may be useful for people waiting to be seen for clinical care, and remains a second-line treatment, either alone or as an adjunct to medication, ideally with clinician 2.18. What Are Peer Interventions and Their encouragement and monitoring. Efficacy for Depression? Peer interventions for depression include self-help groups and peer-run organizations and services.132 Peer support can 2.21. How Effective Is Internet- and Computer- be beneficial either alone or as a complement to clinical care. Delivered Therapy for Depression? Guidelines from the Mental Health Commission of Canada Meta-analyses and reviews of computer-based psychological provide direction to decision makers, program leaders, and 133 treatment for the treatment of MDD, whether delivered over the public about peer support training and practice. the Internet or as a stand-alone program, confirm effi- An initial meta-analysis of peer support for depression 144-150 134-136 cacy. Internet- and computer-delivered therapy was positive, but subsequent results are mixed. Given (I/CT) can also be helpful in relapse prevention.151 I/CT the general benefits of social and peer support, as well as the 137 studies usually use adaptations of CBT, but 1 trial compared widespread availability of this resource, peer interven- updated versions of CBT and IPT with the established tions are recommended as a second-line adjunctive treatment ‘‘MoodGym’’ online version of CBT with over 600 partici- for MDD (Level 2 Evidence). pants in each of the 3 groups; self-guided IPT was similar to the other treatments in reducing depressive symptoms.152 2.19. What Is Problem-Solving Therapy (PST) When the Internet therapy is guided by a clinician, both adherence and efficacy are much more substantial.88 Across and Its Efficacy? psychiatric disorders, 1 meta-analysis153 found that guided PST is a structured brief, empirically tested intervention Internet CBT was no different in outcomes from face-to-face focusing on the adoption of adaptive problem-solving atti- CBT, while a noninferiority study154 specifically for depres- tudes and skills to treat MDD. It has been shown to be more sion also found no differences between the 2 approaches.

56 La Revue Canadienne de Psychiatrie 61(9) 533

I/CT remains a second-line treatment for depression, with 2.24. Is Combined Psychological Treatment with improved efficacy if the I/CT is actively guided by a clinician. Medication Superior to Medication Alone? A recent meta-analysis shows that psychological treatment 2.22. How Effective Is Remote Interactive combined with antidepressants is more effective than anti- Psychological Treatment for Depression (Phone, Video, depressants alone.159 The evidence is primarily based on Internet) Compared to Face-to-Face Therapy? studies where individual CBT or IPT was combined with Psychological treatments with a live therapist are being SSRIs or TCAs. The effect size of the difference was mod- increasingly mediated by technology, whether by phone, erate, suggesting that combined treatment should be offered videoconferencing, or live interaction over the Internet. In in preference to antidepressants alone to individuals with addition to CBT, a significant number of studies have eval- moderate to severe depression. uated other methods of telephone-delivered support and disease management. Telephone-delivered psychological treatment remains 2.25. Is Sequential Treatment Superior to the most studied model. In one of the first large trials Monotherapy? (600 patients starting antidepressants in primary care A meta-analysis of 8 studies found that psychological treat- offices), both 8-session CBT and disease management by ment after antidepressant treatment reduces the likelihood of phone improved clinical efficacy and satisfaction, compared relapse by 20%, compared to treatment as usual, which 79 to medication alone. The same 8-session CBT phone inter- included discontinuation of antidepressants.161 Although the vention added to an antidepressant improved work perfor- meta-analysis aimed to examine the effect of any type of 80 mance and satisfaction compared to antidepressant alone. psychological treatment, the evidence was limited to CBT Collectively, telephone-delivered CBT has Level 1 Evi- and MBCT.161 In addition, a large pragmatic trial found that dence, while other therapies have Level 2 Evidence, posi- a course of up to 18 sessions of face-to-face individual CBT tioning telephone-delivered therapy as a second-line significantly reduced depressive symptoms and increased treatment. the likelihood of therapeutic response to antidepressants in Videoconferencing approaches to psychological treat- treatment-resistant depression.63 Another large primary care ment may include use of traditional videoconference suites trial compared the effects of group MBCT and maintenance with television cameras in 2 different locations or, more antidepressant therapy on time to relapse; while there recently, Internet technologies on personal computing were no significant differences between the 2 conditions, the devices, including Skype, Medeo, FaceTime, and many risk of relapse was greater in those who had prematurely others. The broader application of such technologies to discontinued antidepressant treatment.69 In contrast, PDT psychiatry has been extensively reviewed and found to be (up to 60 sessions over 18 months) did not significantly acceptable and generally equivalent to face-to-face care for increase the likelihood of remission.74 155,156 many psychiatric conditions. Relatively few studies In summary, CBT or MBCT is recommended as sequen- have been done using videoconferencing for MDD, but tial first-line treatment (Level 1 Evidence) after a course of there is limited evidence of efficacy in several small antidepressants, and MBCT is recommended as a second- 156-158 RCTs, suggesting that videoconferenced psychologi- line alternative to long-term maintenance antidepressant cal treatment for depression may be considered a promising treatment (Level 2 Evidence). third-line treatment.

2.23. Is Combined Psychological Treatment with Disclosures Medication Superior to Psychological Treatment Alone? The guidelines process and publication were funded entirely by internal CANMAT funds; no external support was sought or Accumulated evidence shows that combined psychological received. No honoraria were paid to authors and no professional and antidepressant treatment is more effective than psycho- editorial assistance was used. All members of the CANMAT logical treatment alone or psychological treatment with pla- Depression Work Group disclosed potential conflicts of interest cebo.159,160 The evidence is mostly based on studies where (available at www.canmat.org). CANMAT is a project-driven either CBT or IPT was delivered alone and combined with organization governed by a volunteer, unpaid advisory board, selective serotonin reuptake inhibitors (SSRIs) or tricyclic with no permanent staff or dedicated offices. CANMAT has a antidepressants (TCAs). There was a trend for SSRIs and conflict of interest policy that includes disclosures by all participants, and all continuing professional development (CPD) proj- IPT to be less effective in combinations than TCAs, CBT, ects are accredited by academic institutions. CANMAT has and other psychotherapies. The small to moderate effect size diverse funding, but in the past 5 years (2011-2015), sources of of the differences suggests that combined treatment should CANMAT revenue (excluding CIHR and research funding) be offered to individuals with moderate to severe depression included national/international scientific conferences (28% of based on a consideration of benefit-burden balance and pre- revenue), publications (26%), industry-supported CPD projects ferences of a given patient. (26%), and academic projects (18%).

57 Canadian Psychiatric Association

Association des psychiatres CANMAT Guidelines du Canada

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(9) 540-560 Canadian Network for Mood and Anxiety ª The Author(s) 2016 Reprints and permission: Treatments (CANMAT) 2016 Clinical sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716659417 Guidelines for the Management of Adults TheCJP.ca | LaRCP.ca with Major Depressive Disorder: Section 3. Pharmacological Treatments

Sidney H. Kennedy, MD1*, Raymond W. Lam, MD2*, Roger S. McIntyre, MD1, S. Vale´rie Tourjman, MD3, Venkat Bhat, MD4, Pierre Blier, MD, PhD5, Mehrul Hasnain, MD6, Fabrice Jollant, MD, PhD4, Anthony J. Levitt, MD1, Glenda M. MacQueen, MD, PhD7, Shane J. McInerney, MB, MSc1, Diane McIntosh, MD2, Roumen V. Milev, MD, PhD8, Daniel J. Mu¨ller, MD, PhD1, Sagar V. Parikh, MD1,9, Norma L. Pearson, BSc (Pharm)10, Arun V. Ravindran, MB, PhD1, Rudolf Uher, MB, PhD11, and the CANMAT Depression Work Group12

1 Department of Psychiatry, University of Toronto, Toronto, Ontario 2 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia 3 Department of Psychiatry, L’Universite´ de Montreál, Montreál, Quebec 4 Department of Psychiatry, McGill University, Montreál, Quebec 5 Department of Psychiatry, University of Ottawa, Ottawa, Ontario 6 Department of Psychiatry, Memorial University, St. John’s, Newfoundland 7 Department of Psychiatry, University of Calgary, Calgary, Alberta 8 Department of Psychiatry, Queen’s University, Kingston, Ontario 9 Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 10 Canadian Pharmacists Association, Ottawa, Ontario 11 Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia 12 Members of the CANMAT Depression Work Group are listed here: www.canmat.org/workgroups. *Co-first authors.

Corresponding Author: Sidney H. Kennedy, MD, Department of Psychiatry, University Health Network, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. Email: [email protected]

58 La Revue Canadienne de Psychiatrie 61(9) 541 frequent monitoring, and assessing clinical and functional outcomes with measurement-based care; 2) comparative aspects of antidepressant medications based on efficacy, tolerability, and safety, including summaries of newly approved drugs since 2009; 3) practical approaches to pharmacological management, including drug-drug interactions and maintenance recommendations; and 4) managing inadequate response and treatment resistance, with a focus on switching antidepressants, applying adjunctive treatments, and new and emerging agents. Conclusions: Evidence-based pharmacological treatments are available for first-line treatment of MDD and for management of inadequate response. However, given the limitations of the evidence base, pharmacological management of MDD still depends on tailoring treatments to the patient.

Keywords major depressive disorder, pharmacotherapy, clinical practice guidelines, antidepressants, evidence-based medicine, meta- analysis, antipsychotics, clinical trials, randomized controlled trial

In 2009, the Canadian Network for Mood and Anxiety Treat- generalizability of the included studies.4 We also focus on ments (CANMAT), a not-for-profit scientific and educa- second-generation antidepressants because there is little new tional organization, published a revision of evidence-based information on the older tricyclic antidepressants (TCAs) and clinical guidelines for the treatment of depressive disorders.1 monoamine oxidase (MAO) inhibitors. CANMAT has updated these guidelines in 2016 to reflect new evidence in the field. The scope of these guidelines remains the management of 3.1. Who Should be Treated with Pharmacotherapy? adults with unipolar major depressive disorder (MDD) with a Despite earlier reports questioning the efficacy of antidepres- target audience of psychiatrists and other mental health pro- sants,5 subsequent meta-analyses have continued to support fessionals. CANMAT, in collaboration with the Interna- the efficacy of antidepressants in MDD.6 The 2009 CANMAT tional Society for Bipolar Disorders, has published guidelines identified most second-generation antidepressants separate guidelines for bipolar disorder.2 This section on as first-line treatments for patients with a major depressive ‘‘Pharmacological Treatments’’ is 1 of 6 CANMAT guide- episode (MDE) of moderate or greater severity (as determined lines articles; other sections of the guidelines expand on by symptom scales and/or functional impairment), and this burden and principles of care, psychological treatments, neu- recommendation is unchanged. First-line treatments for indi- rostimulation treatments, complementary and alternative viduals with depression of mild severity include psychoedu- medicine treatments, and special populations. These recom- cation, self-management, and psychological treatments. mendations are presented as guidance for clinicians who Pharmacological treatments can be considered for mild should consider them in the context of individual patients depression in some situations, including patient preference, and not as standards of care. Some medications discussed previous response to antidepressants, or lack of response to may not be available in Canada or other countries. nonpharmacological interventions.

Methods 3.2. Which Antidepressants Are Newly Approved? The full methods have been previously described,3 but in Several new antidepressants have been approved in Canada, summary, relevant studies in English and French published the United States, and elsewhere since the publication of the from January 1, 2009, to December 31, 2015, were identified 2009 CANMAT guidelines. using computerized searches of electronic databases Levomilnacipran is an active enantiomer of the racemic (PubMed, PsychInfo, Cochrane Register of Clinical Trials), drug, milnacipran, a serotonin and noradrenaline reuptake inspection of bibliographies, and review of other guidelines inhibitor (SNRI). Levomilnacipran has greater selectivity and major reports. Each recommendation includes the level for noradrenaline than for serotonin reuptake inhibition of evidence for each graded line of treatment, using specified compared to other SNRIs. It is available as an extended- criteria (Table 1). The level of evidence criteria now reflect release formulation for once-daily administration. There the primacy of meta-analysis because of its increasing use in are no published meta-analyses for levomilnacipran, but the evaluation of evidence. a pooled analysis of 5 placebo-controlled RCTs (N ¼ 2598) Because of the very large number of randomized- confirmed its efficacy for response and remission.7 One controlled trials (RCTs), this section will primarily focus on relapse-prevention study did not show significant differ- systematic reviews and individual and network meta-analyses. ences between levomilnacipran and placebo.8 There are Although meta-analyses have advantages in summarizing no comparison studies of levomilnacipran with other data, they still have limitations that can lead to erroneous antidepressants. or conflicting results depending on the comprehensiveness Vilazodone is a multimodal antidepressant that acts as a of the review, criteria for study selection and quality, and serotonin reuptake inhibitor and a partial agonist at 5-HT1A

59 542 The Canadian Journal of Psychiatry 61(9)

Table 1. Criteria for Level of Evidence and Line of Treatment. Table 2. Principles of Pharmacotherapy Management.

Criteria Recommendations (Level 4 Evidence)

Level of evidencea Conduct a detailed clinical assessment, including evaluation 1 Meta-analysis with narrow confidence intervals of suicidality, bipolarity, comorbidity, concomitant and/or 2 or more RCTs with adequate medications, and symptom specifiers/dimensions. sample size, preferably placebo controlled Discuss evidence-based pharmacologic and 2 Meta-analysis with wide confidence intervals nonpharmacologic treatment options. and/or 1 or more RCTs with adequate Elicit patient preference in the decision to use sample size pharmacological treatment. 3 Small-sample RCTs or nonrandomized, Evaluate previous treatments, including dose, duration, controlled prospective studies or case series response, and side effects of antidepressant and related or high-quality retrospective studies medications. 4 Expert opinion/consensus Where clinically indicated, refer for laboratory testing, Line of treatment including lipids, liver function tests, and electrocardiograms. First line Level 1 or Level 2 Evidence, plus clinical Reassess patients for tolerability, safety, and early supportb improvement no more than 2 weeks after starting a Second line Level 3 Evidence or higher, plus clinical medication. Further follow-up may be every 2 to 4 weeks. supportb Follow measurement-based care by using validated rating Third line Level 4 Evidence or higher, plus clinical scales to monitor outcomes and guide clinical decisions. supportb

RCT, randomized controlled trial. aNote that Level 1 and 2 Evidence refer specifically to treatment studies in 3.3. How Do You Select an Antidepressant? which randomized comparisons are available. Recommendations involving General principles of depression management are reviewed epidemiological or risk factors primarily arise from observational studies, 3 and hence the highest level of evidence is usually Level 3. Higher order in Section 1. Table 2 summarizes principles as they apply to recommendations (e.g., principles of care) reflect higher level judgement pharmacological treatment. The process of selecting an anti- of the strength of evidence from various data sources and therefore are depressant should involve both physician expertise and primarily Level 4 Evidence. bClinical support refers to application of expert opinion of the CANMAT patient perceptions and preferences. committees to ensure that evidence-supported interventions are feasible The selective serotonin reuptake inhibitors (SSRIs), and relevant to clinical practice. Therefore, treatments with higher levels of SNRIs, agomelatine, bupropion, and mirtazapine remain evidence may be downgraded to lower lines of treatment due to clinical first-line recommendations for pharmacotherapy for MDD issues such as side effects or safety profile. (Table 3). Vortioxetine is also a first-line recommendation. Recommended second-line agents include TCAs, quetiapine and trazodone (owing to higher side effect burden), moclo- receptors. Published meta-analyses are lacking, but 4 pub- bemide and selegiline (potential serious drug interactions), lished and 8 unpublished or recently completed RCTs were levomilnacipran (lack of comparative and relapse-prevention identified.9-11 A review of the clinical basis for approval has data), and vilazodone (lack of comparative and relapse- also been published.12 Although 5 early-phase vilazodone prevention data and the need to titrate and take with food). trials failed to show efficacy, 4 subsequent studies (phases Third-line recommendations include MAO inhibitors III and IV) reported efficacy for vilazodone 20 mg and 40 (owing to higher side effect burden and potential serious mg over placebo. There are no published relapse-prevention drug and dietary interactions) and reboxetine (lower data for vilazodone or comparison studies with other anti- efficacy). depressants. Vilazodone must be taken with food to ensure Many clinical features and medication characteristics adequate absorption and a titration dose schedule (10 mg/d influence the choice of a first-line antidepressant (Table 4). for 7 days, 20 mg/d for 7 days, then 40 mg/d if needed) is There are no absolutes, and relative differences between recommended to avoid adverse gastrointestinal effects.9 medications are small. Hence, selecting an antidepressant Vortioxetine, another multimodal antidepressant, acts as involves an individualized needs assessment for each a serotonin reuptake inhibitor, an agonist at 5-HT recep- 1A patient. Figure 1 shows a summary algorithm. The questions tors, a partial agonist at 5-HT receptors, and an antagonist 1B that follow summarize the evidence for selection factors. at 5-HT1D, 5-HT3A, and 5-HT7 receptors. In 1 meta-analysis (12 RCTs, N ¼ 4947), vortioxetine was superior to placebo in standardized mean difference and in odds ratios for 3.4. What Clinical Factors Influence Antidepressant response and remission.13 Vortioxetine also has positive effects on neuropsychological performance in multiple cog- Selection? nitive domains in patients with MDD.14-17 A relapse-preven- Several clinical features, including increasing age, presence tion study showed superiority of vortioxetine over placebo.18 of anxiety, and long episode duration are associated with Comparator studies are published for vortioxetine and ago- poorer response to medications.19-22 However, few clinical melatine, duloxetine, and venlafaxine. features have high-quality evidence to support specific

60 La Revue Canadienne de Psychiatrie 61(9) 543

Table 3. Summary Recommendations for Antidepressants.

Antidepressant (Brand Name(s)) Mechanism Dose Range

First line (Level 1 Evidence) a Agomelatine (Valdoxan) MT1 and MT2 agonist; 5-HT2 antagonist 25-50 mg Bupropion (Wellbutrin)b NDRI 150-300 mg Citalopram (Celexa, Cipramil) SSRI 20-40 mg Desvenlafaxine (Pristiq) SNRI 50-100 mg Duloxetine (Cymbalta) SNRI 60 mg Escitalopram (Cipralex, Lexapro) SSRI 10-20 mg Fluoxetine (Prozac) SSRI 20-60 mg Fluvoxamine (Luvox) SSRI 100-300 mg a Mianserin (Tolvon) a2-Adrenergic antagonist; 5-HT2 antagonist 60-120 mg Milnaciprana (Ixel) SNRI 100 mg c Mirtazapine (Remeron) a2-Adrenergic antagonist; 5-HT2 antagonist 15-45 mg Paroxetine (Paxil)d SSRI 20-50 mg 25-62.5 mg for CR version Sertraline (Zoloft) SSRI 50-200 mg Venlafaxine (Effexor)e SNRI 75-225 mg f Vortioxetine (Brintellix, Trintellix) Serotonin reuptake inhibitor; 5-HT1A agonist; 5-HT1B partial 10-20 mg agonist; 5-HT1D, 5-HT3A, and 5-HT7 antagonist Second line (Level 1 Evidence) Amitriptyline, clomipramine, and others TCA Various Levomilnacipran (Fetzima)f SNRI 40-120 mg Moclobemide (Manerix) Reversible inhibitor of MAO-A 300-600 mg Quetiapine (Seroquel)e Atypical antipsychotic 150-300 mg Selegiline transdermala (Emsam) Irreversible MAO-B inhibitor 6-12 mg daily transdermal Trazodone (Desyrel) Serotonin reuptake inhibitor; 5-HT2 antagonist 150-300 mg f Vilazodone (Viibryd) Serotonin reuptake inhibitor; 5-HT1A partial agonist 20-40 mg (titrate from 10 mg) Third line (Level 1 Evidence) Phenelzine (Nardil) Irreversible MAO inhibitor 45-90 mg Tranylcypromine (Parnate) 20-60 mg Reboxetinea (Edronax) Noradrenaline reuptake inhibitor 8-10 mg

5-HT, 5-hydroxytryptamine (serotonin); MAO, monoamine oxidase; MT, melatonin; NDRI, noradrenaline and dopamine reuptake inhibitor; SNRI, serotonin and noradrenaline reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant. aNot available in Canada. bAvailable as sustained-release (SR) and extended-release (XL) versions. cAvailable as rapid-dissolving (RD) version. dAvailable as controlled-release (CR) version eAvailable as extended-release (XR) version. fNewly approved since the 2009 Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines.

Table 4. Factors to Consider in Selecting an Antidepressant. clinical dimensions, including cognitive dysfunction, sleep disturbance, and somatic symptoms (e.g., pain, fatigue), are Patient Factors Medication Factors proposed.3 Many antidepressants have been studied for these Clinical features and Comparative efficacy depressive subtypes, but most studies only examine efficacy dimensions Comparative tolerability against placebo, and there are few comparative studies to Comorbid conditions (potential side effects) suggest differential antidepressant efficacy. Table 5 sum- Response and side effects Potential interactions marizes the recommendations for these specifiers/ during previous use of with other medications dimensions. antidepressants Simplicity of use Large trials examining response with DSM-IV specifiers Patient preference Cost and availability (melancholic, atypical, anxious) found no differences in efficacy between escitalopram, sertraline, and venlafaxine XR or antidepressant recommendations. For example, there is no between escitalopram and nortriptyline.24,25 The US consistent evidence that age, sex, race, or ethnicity predicts STAR*D study also did not find differences in remission rates outcomes using specific antidepressants. with citalopram in atypical or melancholic subtypes.26,27 The fifth edition of the Diagnostic and Statistical Manual For psychotic depression, a Cochrane meta-analysis (12 of Mental Disorders (DSM-5)23 uses episode and course studies, N ¼ 929) found that an antidepressant-antipsychotic specifiers to subtype clinical presentations of MDD. Other combination was more effective than placebo (2 RCTs),

61 544 The Canadian Journal of Psychiatry 61(9)

Consider clinical No factors in selecng Is paent on concomitant an andepressant medicaons? (Tables 3 and 4)

Yes

Consider potenal No for drug-drug Avoid parcular interacons side eﬀects? (Tables 8 and 9)

Yes

Consider tolerability diﬀerences (Table 7)

Select and iniate a ﬁrst-line andepressant (Table 3)

Figure 1. Summary algorithm for selecting an antidepressant. antidepressant monotherapy (3 RCTs), and antipsychotic trazodone also have the highest adverse event rates of som- monotherapy (4 RCTs).28 There is no evidence to address nolence and daytime sedation.32 the question of how long individuals should remain on com- There are few comparative studies of antidepressants for bination treatment once the psychotic depressive episode has somatic symptoms such as pain and fatigue.33 SNRIs, espe- remitted. cially duloxetine,34 are efficacious for painful conditions, Mixed features is a new DSM-5 specifier for MDD, and including neuropathic pain and fibromyalgia.35 There are no trials have used these DSM-5 criteria. In studies of MDE no comparative studies on fatigue or low energy. with variants of mixed symptoms similar to DSM-5 mixed features, monotherapy with lurasidone and with ziprasidone 3.5. How Do Psychiatric and Medical Comorbidities was efficacious compared with placebo.29,30 For cognitive dysfunction, a systematic review (35 stud- Influence Antidepressant Selection? ies) found low-quality evidence that SSRIs, bupropion, There is limited evidence to guide antidepressant choice in duloxetine, moclobemide, and tianeptine (an antidepressant the management of MDD with comorbid conditions. A com- with limited availability) improve cognitive domains such as prehensive review was conducted by a CANMAT task force learning, memory, and executive function.31 In a meta- in 2012.36 Readers are referred to their summary recommen- analysis (17 studies, N ¼ 3653) reviewing the cognitive dations for mood disorders and comorbid anxiety,37 atten- effects of antidepressants based on neuropsychological tests, tion-deficit/hyperactivity disorder,38 substance use vortioxetine had the largest effects on processing speed, disorders,39 personality disorders,40 metabolic conditions, executive control, and cognitive control, while duloxetine and common medical conditions.41-43 had the largest effects on delayed recall.17 The quality of these data is limited by small samples sizes and heterogene- 3.6. How Do Second-Generation Antidepressants ity in cognitive testing. There were few differences between individual or classes of antidepressants, but those compari- Compare in Efficacy? sons were also limited by small sample sizes. The 2009 CANMAT guidelines identified that, based on Some antidepressants, including agomelatine, mirtaza- evidence from RCTs and early meta-analyses, some antide- pine, and trazodone, and the atypical antipsychotic, quetia- pressants had superior efficacy, although differences were pine, have shown superior effects on subjective or objective small. Since then, meta-analyses with individual compari- sleep measures. However, mirtazapine, quetiapine, and sons (see Suppl. Table S1) have reported superiority of

62 La Revue Canadienne de Psychiatrie 61(9) 545

Table 5. Recommendations for Clinical Specifiers and Dimensions of Major Depressive Disorder.

Specifiers/ Dimensions Recommendations (Level of Evidence) Comments

With anxious Use an antidepressant with efficacy in No differences in efficacy between SSRIs, SNRIs, and distressa generalized anxiety disorder (Level 4) bupropion (Level 2) With catatonic Benzodiazepines (Level 3) No antidepressants have been studied featuresa With melancholic No specific antidepressants have TCAs and SNRIs have been studied featuresa demonstrated superiority (Level 2) With atypical No specific antidepressants have Older studies found MAO inhibitors superior to TCAs featuresa demonstrated superiority (Level 2) With psychotic Use antipsychotic and antidepressant Few studies involved atypical antipsychotics featuresa cotreatment (Level 1) With mixed Lurasidoneb (Level 2) No comparative studies featuresa Ziprasidoneb (Level 3) With seasonal No specific antidepressants have SSRIs, agomelatine, bupropion, and moclobemide have been patterna demonstrated superiority (Level 2 and 3) studied With cognitive Vortioxetine (Level 1) Limited data available on cognitive effects of other dysfunction Bupropion (Level 2) antidepressants and on comparative differences in efficacy Duloxetine (Level 2) SSRIs (Level 2)b Moclobemide (Level 3) With sleep Agomelatine (Level 1) Beneficial effects on sleep must be balanced against potential disturbances Mirtazapine (Level 2) for side effects (e.g., daytime sedation) Quetiapine (Level 2) Trazodone (Level 2) With somatic Duloxetine (pain) (Level 1) Few antidepressants have been studied for somatic symptoms Other SNRIs (pain) (Level 2) symptoms other than pain Bupropion (fatigue) (Level 1) Few comparative antidepressant studies for pain and other SSRIsb (fatigue) (Level 2) somatic symptoms Duloxetineb (energy) (Level 2)

MAO, monoamine oxidase; SNRI, serotonin and noradrenaline reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant. aDSM-5 specifiers. bComparisons only with placebo. agomelatine (over sertraline), citalopram (over paroxetine venlafaxine over fluoxetine. In the indirect treatments anal- and reboxetine), escitalopram (over citalopram), fluoxetine ysis, there was superior response to escitalopram over dulox- (over milnacipran), mirtazapine (over SSRIs as a class and etine and escitalopram over fluoxetine. The differences in venlafaxine), paroxetine (over fluoxetine), and sertraline response rates were modest, ranging from 5% to 6%.46 A (over fluoxetine). Unfortunately, many drug comparisons network meta-analysis of only head-to-head trials found that are not represented in these meta-analyses because of lack agomelatine, escitalopram, mirtazapine, and venlafaxine of head-to-head RCTs. were superior to fluoxetine.47 Additionally, mirtazapine and Network meta-analysis (also known as multiple or mixed- venlafaxine were superior to duloxetine, paroxetine, and ser- treatments meta-analysis) provides additional comparative traline, and agomelatine was superior to sertraline. A information because it uses both direct (comparing 2 drugs multiple-treatments meta-analysis of 10 antidepressants, head to head) and indirect (comparing 2 drugs based on their including only studies conducted in primary care settings, comparisons to a common third drug) comparisons.44 Sev- found that escitalopram had superior remission rates.48 In eral network meta-analyses have been conducted since 2009 contrast, a network meta-analysis examining only classes (see Suppl. Table S2). Cipriani and colleagues45 examined of antidepressants in primary care found few differences in 12 second-generation antidepressants in a network meta- response, although SSRIs and TCAs were superior to mian- analysis and found superior response for escitalopram, mir- serin/mirtazapine and moclobemide.49 tazapine, sertraline, and venlafaxine. In direct head-to-head In summary, meta-analyses continue to show that some trials, Gartlehner et al.46 found superior response of escita- antidepressants have modest superiority for treatment lopram over citalopram, sertraline over fluoxetine, and response, particularly escitalopram, mirtazapine, sertraline,

63 546 The Canadian Journal of Psychiatry 61(9)

Table 6. Antidepressants with Evidence for Superior Efficacy show a qualitative profile of side effects for each antide- Based on Meta-Analyses. pressant (Table 7). Because sexual side effects are inconsistently and inade- Level of Antidepressant Evidence Comparator Medications quately reported, clinical trial data are not reliable for assessing antidepressant-associated sexual dysfunction. A Escitalopram Level 1 Citalopram, duloxetine, fluoxetine, network meta-analysis of second-generation antidepressants fluvoxamine, paroxetine 53 (63 studies, N > 26,000) found low-quality evidence that Mirtazapine Level 1 Duloxetine, fluoxetine, fluvoxamine, bupropion had statistically lower rates of sexual side effects paroxetine, sertraline, venlafaxine Sertraline Level 1 Duloxetine, fluoxetine, fluvoxamine, and that escitalopram and paroxetine had higher rates com- paroxetine pared to other antidepressants. In studies that used standar- Venlafaxine Level 1 Duloxetine, fluoxetine, fluvoxamine, dized rating scales or interviews, which are more likely to paroxetine reliably detect sexual side effects, agomelatine, bupropion, Agomelatine Level 2 Fluoxetine, sertraline desvenlafaxine, mirtazapine, vilazodone, and vortioxe- Citalopram Level 2 Paroxetine 54 tine demonstrated lower risk. and venlafaxine (Table 6). There is more limited evidence 3.9. Are Antidepressants Associated with Suicidality? for the superiority of agomelatine and citalopram. Although Suicidal ideation and acts are important risks associated with considered small effects, 5% to 6% differences in response MDD and require diligent assessment, monitoring and man- rate may be clinically relevant from a population basis. agement during psychiatric treatment (see Section 13). A signal for increased suicidality in adolescents and young adults 3.7. How Do Antidepressants Compare on Measures in antidepressant clinical trials led many regulatory agencies to issue ‘‘black box’’ warnings in 2004. Since 2009, 3 large of Functional Outcomes? meta-analyses have addressed the effect of antidepressants on CANMAT recommendations for assessment of functional out- suicidal ideas or behaviour. The first included data from 372 comes highlighted the critical impact of depressive symptoms RCTs comparing 12 antidepressants to placebo and reported a on social, occupational, and physical functioning and that reduced risk of suicidal ideas or acts in those aged 25 to 64 recovery from depression involves both relief of symptoms and years and a reduced risk of suicidal acts in those older than 65 50 improvement of functioning. Systematic reviews show that years.55 A meta-analysis of fluoxetine and venlafaxine functional outcomes are only modestly correlated with symp- showed no difference in suicidality compared to placebo, tom outcomes, and functional improvement may lag behind while another meta-analysis showed a trend toward reduced 51 symptom improvement. Few studies of antidepressants risk of suicidal ideas or acts with paroxetine versus placebo in assess functional outcomes. A systematic review (247 studies) the same age groups.56,57 A systematic review of observa- found that 80% of treatment studies reported only symptom tional studies involving more than 200,000 patients with mod- 52 outcomes. Another systematic review (35 studies) examined erate to severe depression found that exposure to SSRIs the relationships between antidepressants, cognitive dysfunc- reduced the risk of suicide by more than 40% among adults 31 tion, and functional ability. Antidepressants were generally and more than 50% among elderly people.58 associated with improvement in cognitive domains, but there In contrast, exposure to SSRIs almost doubled (odds ratio was no conclusive evidence that improved cognition led to ¼ 1.92) the risk of suicide and suicide attempts among ado- improved overall functioning. In the absence of high-quality lescents in these observational studies.58 It is possible that studies comparing the efficacy of individual antidepressants on only the most severely ill adolescents would have been pre- functional outcomes in MDD, no medication can be cited as scribed antidepressants, and so this observational sample demonstrating superior functional improvement. may well have had a particularly high risk for suicide actions. Nevertheless, caution and close monitoring are rec- 3.8. What Is the Comparative Tolerability ommended when antidepressants are prescribed in this age group (see Section 659). Large observational studies have not of Second-Generation Antidepressants? shown differences in suicide risk with particular antidepres- Comparing tolerability is challenging to assess by RCTs, and sants or classes of antidepressants, and therefore caution meta-analyses have found few differences in tolerability should be exercised for all antidepressants. between antidepressants (see Suppl. Tables S1 and S2). CANMAT chose to illustrate differences in side effect pro- 3.10. What Are Uncommon but Serious Adverse files of antidepressants by using the summary information contained in product monographs, which is reported in a Effects of Antidepressants? standard format from the evidence submitted to regula- Prolongation of the corrected QT interval (QTc), a surrogate tory authorities. While this information is not placebo- marker for Torsade de Pointes (TdP) arrhythmia, has been adjusted and is not based on direct comparisons, it can the subject of warnings by regulatory agencies for

64 Table 7. Prevalence of Adverse Events among Newer Antidepressants: Unadjusted Frequency (%) of Common Adverse Events as Reported in Product Monographs.

Dry Increased Weight Nausea Constipation Diarrhea Mouth Headaches Dizziness Somnolence Nervousness Anxiety Agitation Insomnia Fatigue Sweating Asthenia Tremor Anorexia Appetite Gain

Citalopram 21 8 19 3 3 2 5 11 8 4 Escitalopram 15 4 8 7 3 6 4 2 2 8 5 3 2 2 2 Fluoxetine 21 10 13 14 12 16 8 9 10 11 Fluvoxamine 37 18 6 26 22 15 26 2 2 16 14 11 5 11 15 Paroxetine 26 14 11 18 18 13 23 5 5 2 13 11 15 8 1 Sertralinea 26 8 18 16 20 12 13 3 3 6 16 11 8 11 3 1 Desvenlafaxineb 22 9 11 13 4 <1 3 9 7 10 2 Duloxetine 20 11 8 15 8 7 3 11 8 6 3 Levomilnacipran 17 9 10 17 8 2 6 9 Milnacipran 12 7 9 10 4 7 3 4 3 Venlafaxine IR 37 15 8 22 25 19 23 13 6 2 18 12 12 5 11 Venlafaxine XR 31 8 8 12 26 20 17 10 2 3 17 14 8 5 8 Agomelatinec CC C CC C C CCC Bupropion SRd 11 7 4 13 28 7 3 5 5 2 8 2 2 3 Bupropion XL 13 9 26 34 65216 3 Mirtazapine 13 25 7 54 8 7 17 12 Moclobemide 5 4 2 9 8 5 4 4 3 5 7 3 2 1 5 Vilazodonee 24 29 7 14 8 5 6 3 3 2 Vortioxetinef 23 4 5 6 5 3 3 3 2

When data from multiple doses were reported separately, the data from the minimum therapeutic dose were used (indicated by footnotes). Data sources and references are available in Supplemental Table S3. Clear cells represent 0% to 9%; shaded cells, 10% to 29%; and black cells, 30% and higher. aData from all indications. bData from 50-mg dose. cC, common effects, 1% and <10%. dData from 100- to 150-mg dose. eData from 40-mg dose. fData from 10-mg dose. 65 547 548 The Canadian Journal of Psychiatry 61(9) citalopram, escitalopram, and quetiapine.60 However, TdP is a careful risk-benefit assessment (taking into account poten- often an idiosyncratic event, and its associations with anti- tial loss of efficacy) should be conducted prior to switching depressants, medication dose, and QTc prolongation remain to a generic version. unclear.61 For example, a systematic review of antidepressants, QTc prolongation, and TdP found that 95% (36 of 38) 3.12. What Are Clinically Relevant Drug-Drug of published case reports of QTc prolongation associated Interactions? with antidepressants had 1 or more additional risk factors for TdP.61 Most cases of TdP occurred at therapeutic doses Many patients with MDD take other medications for comor- of the antidepressant, and several cases of TdP occurred with bid psychiatric and medical conditions. Drug-drug interac- QTc interval within the normal range.61 Accordingly, in the tions can potentially reduce the efficacy of an antidepressant absence of other known risk factors for TdP, the use of or other medications and increase adverse effects. Antide- citalopram, escitalopram, and other antidepressants at ther- pressants and antipsychotics are primarily metabolized apeutic doses carries only a very low risk of TdP and other through the cytochrome P450 (CYP) enzyme metabolic arrhythmias.60,61 pathway.72,73 Most antidepressants are substrates for several The long-term use of SSRI antidepressants has been CYP enzymes (Tables 8 and 9), but agomelatine and dulox- associated with increased risk of falls and fractures that is etine are metabolized primarily via the CYP1A2 pathway unrelated to postural hypotension. Systematic reviews and and should not be coadministered with drugs that potently meta-analyses of observational studies indicate a small inhibit CYP1A2, such as cimetidine, ticlopidine, and cipro- increased relative risk for fractures associated with SSRIs, floxacin. Similarly, vilazodone is metabolized primarily with the highest risk in the first 6 weeks of exposure.62-64 through CYP3A4 and should be used with caution when Hyponatremia is also associated with SSRI use, primarily in prescribed with CYP3A4 inhibitors such as ketoconazole. elderly patients with other risk factors for hyponatremia.65 Several antidepressants and atypical antipsychotics act as SSRIs can inhibit platelet aggregation by altering platelet inhibitors of specific CYP isoenzymes (Table 9). Clinically serotonin receptors and modestly increase the risk of gastro- relevant drug-drug interactions are usually caused by agents intestinal bleeding, but this risk may be doubled with con- that are potent CYP inhibitors, including fluoxetine comitant use of nonsteroidal anti-inflammatory drugs (CYP2D6), paroxetine (CYP2D6), and fluvoxamine (NSAIDs).66 Concomitant use of acid-suppressing drugs can (CYP1A2, 2C19, and 3A4). Drug-drug interactions with significantly reduce the risk of gastrointestinal bleeding.67 moderate CYP inhibitors, including bupropion, duloxetine, Elevation of liver enzymes is uncommonly seen with and sertraline (CYP2D6), are rarely clinically relevant most antidepressants, and routine testing is not required. except at higher doses. However, regulatory agencies in countries where agomela- P-glycoprotein is an important component of the blood- tine is approved have mandated regular liver function testing brain barrier and the intestinal barrier and affects efflux of owing to the drug’s potential to elevate liver enzymes (1.3%) medications, including psychotropic, cardiac, and cancer and sporadic cases of toxic hepatitis.68 agents.74 However, there is no consistent evidence of clinically relevant P-glycoprotein interactions with antidepres- 74,75 3.11. Are There Differences in Formulations of Specific sants or antipsychotics. Although not a pharmacokinetic drug-drug interaction, ser- Antidepressants? otonin syndrome and/or hypertensive crisis can occur when A systematic review and network meta-analysis (7 studies serotonergic or sympathomimetic drugs are combined with for direct comparisons and 68 studies for indirect) found no MAO inhibitors, including the reversible MAO-A inhibitor, differences in efficacy or tolerability with extended-release moclobemide, and the irreversible MAO-B inhibitor, selegi- antidepressants compared to immediate-release formula- line (Table 9). Serotonin syndrome is rare except in cases of tions, although there was some evidence that adherence was overdose, but it can also occur with combination use of multi- lower with the immediate-release agents.69 Extended-release ple serotonergic medications (e.g., SSRIs, SNRIs, tramadol).76 antidepressants should be considered if adherence or compliance to medication is an issue. 3.13. Can Pharmacogenetic Testing or Therapeutic Generic substitution for branded medications is a com- Drug-Level Monitoring Help to Select or Optimize mon practice in some countries and may involve alternative drug formulations.70 The Canadian and US regulatory agen- an Antidepressant? cies define pharmacokinetic similarity for generics as bioe- Pharmacogenetic testing for CYP enzymes is now available quivalence between 80% and 125% of brand-name agents. in many regions, and comprehensive recommendations for Bioinequivalence, which may result in loss of efficacy or antidepressants have been suggested by the Clinical Pharma- increased side effects, can occur and in some cases led to cogenetics Implementation Consortium (CPIC).77 Since withdrawal of an approved generic agent.71 Although gen- large-scale RCTs to examine the utility of pharmacogenetic eric medications are safe and reliable for most patients, for tests are still lacking,78 CANMAT does not recommend rou- some who are well and maintained on a branded medication, tine use of pharmacogenetic testing.

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Table 8. Some Clinically Significant Drug-Drug Interactions Resulting from Inhibition of Cytochrome P450 (CYP) Isoenzymes.

Cytochrome P450 Inhibition of Increases Serum Levels of These CYP Substrates

CYP1A2 Agomelatine Naproxen Caffeine Olanzapine Clozapine Risperidone Duloxetine Tacrine Mexiletine Theophylline Warfarin

CYP2C19 Antiarrhythmics Omeprazole Antiepileptics (diazepam, phenytoin, Primidone phenobarbital) Propanolol Indomethacin Warfarin

CYP2D6 Tricyclic antidepressants Risperidone Beta-blockers (metoprolol, propranolol) Vortioxetine Codeine and other opioids (reduces effect) Tamoxifen (reduces effect) Olanzapine Tramadol

CYP3A4 Amiodarone Levomilnacipran Antiarrhythmics (quinidine) Macrolide antibacterials (clarithromycin, erythromycin) Antihistamines (astemizole, chlorpheniramine) Methadone Calcium channel antagonists (e.g., diltiazem, Phenothiazines verapamil) Quetiapine Haloperidol Sildenafil HIV protease inhibitors Tamoxifen Statins Vilazodone Immune modulators (cyclosporine, tacrolimus)

This is only a limited selection of interactions. For more comprehensive lists, see references in the text. Psychotropic medications in bold. HIV, human immunodeficiency virus.

Table 9. Potential Drug-Drug Interactions Involving Newer Antidepressants and Atypical Antipsychotics.

Potential for Drug-Drug Interaction Antidepressants Atypical Antipsychotics

Minimal or low potential Citalopram Paliperidone Desvenlafaxine Escitalopram Mirtazapine Venlafaxine Moderate potential Agomelatine (1A2 substratea) Aripiprazole (2D6, 3A4 substrate) Bupropion (2D6 inhibitor) Olanzapine (1A2 substrateb) Duloxetine (2D6 inhibitor; Risperidone (2D6, 3A4 substrate) 1A2 substratea) Levomilnacipran (3A4 substrate) Sertraline (2D6 inhibitor) Vilazodone (3A4 substrate) Vortioxetine (2D6 substrate) Higher potential Fluoxetine (2D6, 2C19 inhibitor) Clozapine (3A4, 1A2 substrate) Fluvoxamine (1A2, 2C19, 3A4 inhibitor) Lurasidone (3A4 substrate) Moclobemide (MAO inhibitor precautionsc) Quetiapine (3A4 substrate) Paroxetine (2D6 inhibitor) Selegiline (MAO inhibitor precautionsc)

Moderate and higher potential interactions are noted in parentheses. MAO, monoamine oxidase. aCoadministration with CYP1A2 inhibitors (e.g., cimetidine, ciprofloxacin and other fluoroquinolone antimicrobials, ticlopidine) should be avoided because serum antidepressant levels will be higher, leading to increased potential for side effects. bAlso metabolized through the uridine diphosphate glucuronosyltransferase (UGT) pathway. cPrecautions similar to those of older MAO inhibitors. Avoid coadministration of other antidepressants, serotonergic drugs (e.g., meperidine), and sympathomimetic drugs (e.g., pseudoephedrine, stimulants).

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Similarly, CANMAT does not recommend routine ther- Table 10. Risk Factors to Consider Longer Term (2 Years or apeutic drug-level monitoring (TDM) for second-generation Longer) Maintenance Treatment with Antidepressants (Level 3 and antidepressants because the poor correlation between blood 4 Evidence). antidepressant levels and clinical response limits TDM util- Frequent, recurrent episodes ity. Pharmacogenetic testing and/or TDM may be helpful in Severe episodes (psychosis, severe impairment, suicidality) individual circumstances, including inability to tolerate min- Chronic episodes imum doses (i.e., to detect poor metabolizers), repeated fail- Presence of comorbid psychiatric or other medical conditions ure to respond to high doses (i.e., to detect ultrarapid Presence of residual symptoms metabolizers), and to detect nonadherence. Difficult-to-treat episodes

3.14. How Long Do You Wait for a Response sensory disturbances, hyperarousal), may be experienced by from an Antidepressant? up to 40% of patients when antidepressants are stopped 87,88 Early improvement (defined as >20%-30% reduction from abruptly. These are generally mild and transient, but baseline in a depression rating scale after 2-4 weeks) is corre- more severe symptoms have been described. Immediate- lated with response and remission at 6 to 12 weeks.79 The lack release formulations of paroxetine and venlafaxine are the of early improvement at 2 to 4 weeks is also a predictor of later most likely to be associated with discontinuation effects while long half-life agents such as fluoxetine and vortioxe- antidepressant nonresponse/nonremission. However, there is 89 only low-quality evidence to support early switching at 2 or tine are the least likely. Unless there are clinical reasons 4 weeks for nonimprovers to an initial antidepressant.80,81 otherwise, we recommend slowly tapering the dose over CANMAT recommends increasing the antidepressant dose for several weeks when discontinuing antidepressants. nonimprovers at 2 to 4 weeks if the medication is tolerated and switching to another antidepressant if tolerability is a problem. 3.16. How Do You Manage Inadequate Response to an Antidepressant? 3.15. How Long Do You Continue an Antidepressant? Figure 2 shows an algorithm for inadequate response to an The CANMAT guidelines identify 2 phases of depression initial antidepressant. If a patient has partial (e.g., 25%-49% treatment: an acute phase (getting to symptomatic remission) reduction in symptom scores) or no response (e.g., <25% and a maintenance phase (preventing relapse and recurrence) reduction) to the initial treatment, clinicians should ensure the (see Section 13). The 2009 guidelines recommended that treatment is optimized.90,91 There is substantial evidence that patients maintain treatment with antidepressants for 6 to 9 many patients receive subtherapeutic doses and/or inadequate months after achieving symptomatic remission, while those duration of treatment, and up to 20% may have poor adher- with risk factors for recurrence extend antidepressant treat- ence.92 The clinician should then reevaluate the diagnosis and ment to 2 years or more.82 New evidence continues to sup- consider treatment issues that may be affecting response.93 port this recommendation for antidepressant maintenance. A Psychotherapy and neurostimulation approaches should also meta-analysis found significant benefit of antidepressants be considered for patients with an inadequate antidepressant over placebo in maintenance studies of 1 to 12 months (72 response (see Section 294 and Section 495 respectively). trials, N ¼ 14450) and 12 months (35 trials, N ¼ 7253).83 Research on strategies for inadequate response to an ini- Similarly, a review of all 16 maintenance RCTs (N > 4000) tial antidepressant has been hampered by a lack of consensus submitted to the Food and Drug Administration (FDA) found on the concept and definition of treatment-resistant depres- a 2-fold difference in recurrence during 24- to 52-week sion (TRD). The most commonly employed definition is follow-up with antidepressants versus placebo (18% vs inadequate response to 2 or more antidepressants.91 How- 37%, respectively).84 The drug-placebo benefit also nar- ever, this definition does not take into account adjunctive rowed after 6 months, consistent with meta-analyses show- strategies, nor does it differentiate between patients who ing higher relapse/recurrence risk when antidepressants are have had partial response versus those who have had no discontinued within 6 months.85 response. Additionally, few studies address residual symp- Few RCTs have specifically evaluated risk factors to toms (e.g., 50% improvement but symptom score is not in guide longer term treatment. In 1 study, patients with recur- remission range). rent MDD were less likely to experience recurrence and In 2012, the United States Agency for Healthcare more likely to have improved psychosocial outcomes with Research and Quality (AHRQ) published a comparative 2 years of maintenance treatment with venlafaxine ER ver- effectiveness review examining the various strategies to treat sus 1 year.86 The recommendation to extend maintenance depression following inadequate response to an SSRI.96 It treatment to 2 years or beyond in the presence of clinical concluded there was insufficient evidence to differentiate risk factors (Table 10) is based on Level 3 and 4 Evidence. between monotherapy switch within the SSRI class or Discontinuation symptoms, described by the FINISH switching to a non-SSRI agent. There was low strength of mnemonic (flu-like symptoms, insomnia, nausea, imbalance, evidence, indicating that augmenting with an atypical

68 552 The Canadian Journal of Psychiatry 61(9) antipsychotic was more effective than antidepressant mono- stronger efficacy estimates for aripiprazole and quetiapine therapy. There was also insufficient evidence about the ben- than for lithium and thyroid hormone.102 There were no sig- efits of individual atypical antipsychotics or other adjunctive nificant differences between the active treatments, but the agents. The following questions summarize subsequent evi- network meta-analysis was limited due to few head-to-head dence for these strategies. comparisons, which reduces the power of indirect comparisons and the reliability of the results. This is apparent when examining the evidence base for lithium and triiodothyronine 3.17. How Effective Are Switching Strategies? relative to other agents (summarized below). The 2009 CANMAT guidelines summarized evidence showing that switching nonresponders to another antidepressant Atypical antipsychotics. Adjunctive treatment with atypical results in good response and remission rates. Studies with antipsychotic medications has the most consistent evidence newer antidepressants support this finding. Switching has for efficacy in TRD. Four independent meta-analyses103-106 also been studied as a control condition in RCTs of adjunc- comprising 12 to 17 trials (N ¼ 3208-3807) and a network tive treatments, with several studies demonstrating benefit of meta-analysis107 (18 trials, N ¼ 4422) all found superior the switch compared to placebo.97,98 However, there are few efficacy when compared to placebo for adjunctive aripipra- RCTs comparing a switch strategy to continuing the same zole, olanzapine, quetiapine, and risperidone, with small to antidepressant. A systematic review identified only 3 RCTs medium effect sizes. The network meta-analysis did not find (N ¼ 495), all of which investigated adjunctive strategies as evidence for differences in efficacy among the atypical anti- the primary aim but included conditions for switching to a psychotics studied.107 Although not included in these meta- new antidepressant and continuing on the original antide- analyses, placebo-controlled RCTs have also shown efficacy pressant.99 There were no differences in response or remis- for adjunctive brexpiprazole108,109 and for ziprasidone.110 sion rates between switch and continuing strategies and no All the meta-analyses and RCTs also found evidence for consistent evidence of differential efficacy between switch- worse tolerability compared to placebo. ing within class (e.g., from one SSRI to another SSRI) or across classes of antidepressants.99 Antidepressants. The adjunctive strategy of adding another The value of switching between classes or within classes antidepressant to an existing one for TRD was examined of antidepressants remains controversial.100 A previous in a systematic review, but only 5 placebo-controlled RCTs meta-analysis (4 studies, N ¼ 1496) found a modest, but (N ¼ 565) were identified: 3 trials with mirtazapine/mian- statistically significant, remission advantage for patients on serin and 2 trials with low-dose desipramine added to an an SSRI switched to an antidepressant in a different class SSRI.111 The studies were too heterogeneous to conduct a (bupropion, mirtazapine, venlafaxine) versus a second SSRI meta-analysis, but there was a signal for efficacy of adjunc- trial (28% vs. 23.5%, respectively).101 These results are dif- tive mirtazapine/mianserin.111 A meta-analysis (23 studies, ficult to interpret because specific antidepressants have N ¼ 2435) focusing on adverse effects found that adjunctive shown superior efficacy within both SSRI and non-SSRI antidepressant use was associated with increased side effects classes (see 3.6., ‘‘How Do Second-Generation Antidepres- compared to monotherapy, especially when adding mirtaza- sants Compare in Efficacy?’’). Consequently, CANMAT pine/mianserin or TCAs to SSRIs.112 continues to recommend switching to an antidepressant with Combinations of antidepressants have also been investi- evidence of superior efficacy (Table 5). gated as comedications in the initial treatment of MDD. While initial pilot studies were encouraging,113,114 large- sample RCTs found no differences in efficacy with the com- 3.18. How Effective Are Adjunctive Strategies? bination of bupropion þ escitalopram over each agent An adjunctive strategy refers to the addition of a second alone115 or with the combinations of escitalopram þ bupro- medication to an initial medication. The term adjunctive is pion SR and mirtazapine þ venlafaxine XR over escitalo- preferred over terms such as combination (adding a second pram alone.116 In addition, adverse effects were higher in the antidepressant to the first) or augmentation (adding another combination treatments. A combination of antidepressants at medication that is not an antidepressant, e.g., triiodothyro- initiation of treatment is not recommended. nine) because some augmentation agents (e.g., lithium, quetiapine) also have antidepressant effects as monotherapy. Other medications. A systematic review of lithium augmen- Recommendations for adjunctive agents are based on effi- tation trials concluded that it was effective but acknowl- cacy and tolerability (Table 11). A network meta-analysis of edged that extant studies mostly involved lithium in RCTs (48 trials, N ¼ 6654) examined the comparative adjunc- combination with TCAs in trials with small sample tive effects of aripiprazole, bupropion, buspirone, lamotri- sizes.117 This was highlighted in a meta-analysis of gine, lithium, methylphenidate, olanzapine, pindolol, placebo-controlled RCTs (9 trials, N ¼ 237) that identified quetiapine, risperidone, and thyroid hormone with each other only 3 trials (N ¼ 74) of adjunctive lithium with SSRIs118; and with placebo.102 Only aripiprazole, lithium, quetiapine, while the overall comparison and the SSRI-only compari- and triiodothyronine were more effective than placebo, with son were both significant, the confidence intervals were

69 La Revue Canadienne de Psychiatrie 61(9) 553

Table 11. Recommendations for Adjunctive Medications for Nonresponse or Partial Response to an Antidepressant.

Recommendation Adjunctive Agent Level of Evidence Dosing

First line Aripiprazole Level 1 2-15 mg Quetiapine Level 1 150-300 mg Risperidone Level 1 1-3 mg Second line Brexpiprazolea Level 1 1-3 mg Bupropion Level 2 150-300 mg Lithium Level 2 600-1200 mg (therapeutic serum levels) Mirtazapine/mianserin Level 2 30-60 mg Modafinil Level 2 100-400 mg Olanzapine Level 1 2.5-10 mg Triiodothyronine Level 2 25-50 mcg Third line Other antidepressants Level 3 Various Other stimulants (methylphenidate, Level 3 Various lisdexamfetamine, etc.) TCAs (e.g., desipramine) Level 2 Various Ziprasidone Level 3 20-80 mg bid Experimental Ketamine Level 1 0.5 mg/kg, single intravenous doseb Not recommended Pindolol Level 1 (lack of efficacy) Not applicable

TCA, tricyclic antidepressant. aNewly approved since the 2009 Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines. bFor acute treatment. wide, indicating Level 2 Evidence for efficacy. There have A meta-analysis (5 trials, N ¼ 154) examined adjunctive been no studies of triiodothyronine augmentation since the use of the beta-blocker pindolol. There was no significant systematic review in 2008 that identified only 2 placebo- benefit for pindolol versus placebo in combination with controlled RCTs.119 The STAR*D trial, although not SSRI therapy and no differences in tolerability or safety placebo-controlled, is the largest RCT (N ¼ 142) to between the 2 groups.131 Pindolol is not recommended as compare the 2 strategies.120 There were no significant an adjunct treatment. differences in remission rates, but triiodothyronine was better tolerated than lithium and had lower dropout rates. A meta-analysis of modafanil, an atypical stimulant, in 3.19. How Do you Choose between Switching to MDD identified 4 trials (N ¼ 568), but only 2 (N ¼ 211) were adjunctive studies.121 After excluding an outlier Another Antidepressant and Adding an Adjunctive study, there was only marginal evidence for efficacy in Agent? modafinil-treated patients compared to placebo on both An RCT (N ¼ 101) found that adjunctive aripiprazole was response and remission rates. Adverse effects did not superior to antidepressant switch on efficacy outcomes, 121 appear to differ from placebo. Two placebo-controlled including response and remission.132 In a retrospective com- RCTs of lisdexamfetamine, a stimulant, found evidence of parison of the STAR*D switch and adjunctive studies, efficacy as an adjunctive agent for partial responders to patients who tolerated citalopram and who had partial 122,123 SSRIs ; however, 2 unpublished phase III trials response were more likely to benefit from adjunctive strate- (N ¼ 830) of adjunctive lisdexamfetamine were negative, gies compared to switching.133 A few studies have addressed 124 and the clinical development program was discontinued. residual symptoms, such as fatigue or sexual dysfunc- To date, other stimulants (e.g., methylphenidate) have only tion.134,135 However, there is no consistent evidence to sup- 125 negative studies. port specific adjunctive agents to target specific residual Several meta-analyses have shown that single doses of symptoms or side effects. intravenous ketamine, which preferentially target In summary, given the limited evidence, a pharmacologic N-methyl-D-aspartate (NMDA) receptors, have rapid anti- approach for TRD would include diagnostic reevaluation, 126-128 depressant effects in TRD. However, ketamine is consideration of previous medication trials (including degree associated with psychotomimetic adverse effects, carries of response and tolerability), rational use of adjunctive med- potential for abuse, and still has very limited data on safety ications, discontinuation of medications that have not been 126,129,130 and efficacy with longer term use. CANMAT beneficial, and careful monitoring of symptoms, side effects, considers ketamine an experimental treatment and recom- and functioning to evaluate outcomes. The decision between mends its use be limited to academic depression treatment switching and adjunctive strategies should be individualized centres. based on clinical factors (Table 12).

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Table 12. Factors to Consider in Choosing between Switching to 3.21. What Novel Treatments Are Being Investigated? Another Antidepressant Monotherapy or Adding an Adjunctive Medication (Level 3 Evidence). The link between the rapid antidepressant effect of ketamine and the glutamate system has stimulated drug development Consider switching to another antidepressant when: on related compounds, including esketamine (the S- It is the first antidepressant trial. enantiomer of ketamine, delivered intranasally),139 lanice- There are poorly tolerated side effects to the initial mine, and memantine.140 Other promising compounds antidepressant. 141 There is no response (<25% improvement) to the initial include GluN2B antagonists (e.g., CERC-301) ; GLYX- antidepressant.a 13, which targets the glycine coagonist site on the NMDA There is more time to wait for a response (less severe, less receptor142; and basimglurant, which targets the metabotro- functional impairment). pic glutamate (mGlu) receptors.143 Other potential candi- Patient prefers to switch to another antidepressant. dates for antidepressant actions include drugs that target Consider an adjunctive medication when: the endocannabinoid system and drugs with neuroplasticity There have been 2 or more antidepressant trials. mechanisms, which are thought to play a role in sustained The initial antidepressant is well tolerated. 144 There is partial response (>25% improvement) to the initial antidepressant effects. antidepressant. Preliminary studies have shown promise for several cur- There are specific residual symptoms or side effects to the rently available medications with diverse effects. In a meta- initial antidepressant that can be targeted. analysis (4 studies, N ¼ 150) of adjunctive celecoxib, higher There is less time to wait for a response (more severe, more response and remission rates and lower dropout rates were functional impairment). reported with the NSAID compared to placebo.145 In con- Patient prefers to add on another medication. trast, a subsequent small trial (N ¼ 30 female patients with aFor the initial antidepressant trial. In subsequent trials, lack of response first episode of MDD) did not demonstrate efficacy of (<25% improvement) may not be a factor for choosing between switch and adjunctive celecoxib with sertraline.146 Preliminary studies adjunctive strategies. of pramipexole, a dopaminergic D2, D3, and D4 receptor agonist that has evidence for efficacy in bipolar depres- 3.20. How Do You Manage Persistent and Chronic sion,147 found some benefit in TRD.148,149 Other investiga- Depression? tional drugs for MDD include novel atypical antipsychotics such as cariprazine.150 The DSM-5 has added a new diagnosis of persistent depressive disorder (PDD) that subsumes the DSM-IV diagnoses of Acknowledgements dysthymic disorder and chronic MDD (see Section 13). A systematic review and network meta-analysis examined effi- We thank Cindy Woo and Trehani Fonseka for assisting in preparation of this manuscript. cacy (response) and acceptability (all-cause discontinuation) of treatments for PDD (depression >2 years’ duration) with a Disclosures network of 45 RCTs (N ¼ 5804) involving 28 drugs.136 Most of the studied drugs were more effective than placebo, The guidelines process and publication were funded entirely by internal CANMAT funds; no external support was sought or including fluoxetine, paroxetine, sertraline, moclobemide, received. No honoraria were paid to authors, and no professional and imipramine, with no differences in acceptability com- editorial assistance was used. All members of the CANMAT pared to placebo. The only differences between treatments Depression Work Group disclosed potential conflicts of interest were superior efficacy of sertraline over imipramine and (available at www.canmat.org). CANMAT is a project-driven orga- 136 superior acceptability of moclobemide over fluoxetine. nization governed by a volunteer, unpaid advisory board, with no These results confirmed a meta-analysis (20 trials, N ¼ permanent staff or dedicated offices. CANMAT has a conflict of 2918) of chronic depression showing that SSRIs were similar interest policy that includes disclosures by all participants, and all in efficacy but superior in tolerability compared with TCAs.137 continuing professional development (CPD) projects are accredited The network meta-analysis also identified differences in by academic institutions. CANMAT has diverse funding; in the past effects between combined psychotherapy þ medication and 5 years (2011-2015), sources of CANMAT revenue (excluding medication-only studies in dysthymia studies compared to CIHR and research funding) included national/international scientific conferences (28% of revenue), publications (26%), industry- studies of chronic MDD, suggesting that the new diagnosis 136 supported CPD projects (26%), and academic projects (18%). of PDD may not have homogeneous treatment response. The CANMAT guidelines are not officially endorsed by the Although there are positive results in treating chronic Canadian Psychiatric Association. depression and PDD with antidepressants, some experts have argued that patients with repeated treatment failures and a Declaration of Conflicting Interests chronic course of depression require a chronic disease man- The author(s) declared the following potential conflicts of interest agement approach (i.e., with less emphasis on remission of with respect to the research, authorship, and/or publication of this symptoms and cure, greater emphasis on improving func- article: tioning and quality of life, and greater use of psychothera- SHK has received honoraria for ad hoc speaking or advising/ peutic and nonmedication treatments).138 consulting or received research funds from Allergan, Brain Canada,

71 Canadian Psychiatric Association

Association des psychiatres CANMAT Guidelines du Canada

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(9) 561-575 Canadian Network for Mood and Anxiety ª The Author(s) 2016 Reprints and permission: Treatments (CANMAT) 2016 Clinical sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716660033 Guidelines for the Management of Adults TheCJP.ca | LaRCP.ca with Major Depressive Disorder: Section 4. Neurostimulation Treatments

Roumen V. Milev, MD, PhD1, Peter Giacobbe, MD, MSc2, Sidney H. Kennedy, MD2, Daniel M. Blumberger, MD, MSc2, Zafiris J. Daskalakis, MD, PhD2, Jonathan Downar, MD, PhD2, Mandana Modirrousta, MD, PhD3, Simon Patry, MD4, Fidel Vila-Rodriguez, MD, MSc5, Raymond W. Lam, MD5, Glenda M. MacQueen, MD, PhD6, Sagar V. Parikh, MD2,7, Arun V. Ravindran, MB, PhD2, and the CANMAT Depression Work Group8

Abstract Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. ‘‘Neurostimulation Treatments’’ is the fourth of six sections of the 2016 guidelines. Results: Evidence-informed responses were developed for 31 questions for 6 neurostimulation modalities: 1) transcranial direct current stimulation (tDCS), 2) repetitive transcranial magnetic stimulation (rTMS), 3) electroconvulsive therapy (ECT), 4) magnetic seizure therapy (MST), 5) vagus nerve stimulation (VNS), and 6) deep brain stimulation (DBS). Most of the neurostimulation treatments have been investigated in patients with varying degrees of treatment resistance. Conclusions: There is increasing evidence for efficacy, tolerability, and safety of neurostimulation treatments. rTMS is now a first-line recommendation for patients with MDD who have failed at least 1 antidepressant. ECT remains a second-line treatment for patients with treatment-resistant depression, although in some situations, it may be considered first line. Third-line recommendations include tDCS and VNS. MST and DBS are still considered investigational treatments.

1 Department of Psychiatry, Queen’s University, Kingston, Ontario 2 Department of Psychiatry, University of Toronto, Toronto, Ontario 3 Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba 4 Department of Psychiatry, L’Universite´ Laval, Que´bec City, Que´bec 5 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia 6 Department of Psychiatry, University of Calgary, Calgary, Alberta 7 Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 8 Members of the CANMAT Depression Work Group are listed here: www.canmat.org/workgroups.

Corresponding Author: Roumen V. Milev, MD, PhD, Queen’s University, 752 King Street West, Kingston, ON K7L 4X3, Canada. Email: [email protected]

72 562 The Canadian Journal of Psychiatry 61(9)

Keywords major depressive disorder, clinical practice guidelines, evidence-based medicine, neurostimulation, repetitive transcranial magnetic stimulation, electroconvulsive therapy, deep brain stimulation, meta-analysis, systematic reviews

In 2009, the Canadian Network for Mood and Anxiety Treat- Transcranial Direct Current ments (CANMAT), a not-for-profit scientific and educa- Stimulation (tDCS) tional organization, published a revision of evidence-based clinical guidelines for the treatment of depressive disorders.1 4.1. What Is tDCS and How Is It Delivered? CANMAT has updated these guidelines in 2016 to reflect tDCS is a form of brain stimulation that delivers a contin- new evidence in the field. uous low-amplitude electrical current to a specified cortical The scope of these guidelines remains the management of region using scalp electrodes. Anodal stimulation over the adults with unipolar major depressive disorder (MDD). cortex increases cortical excitability through depolarization CANMAT, in collaboration with the International Society of neuronal membrane potential. By contrast, cathodal sti- for Bipolar Disorders, has published separate guidelines for mulation decreases cortical excitability through hyperpolar- 2 bipolar disorder. This section on ‘‘Neurostimulation Treat- ization of the membrane potential.4 Repeated use of tDCS ments’’ is 1 of 6 guidelines articles; other sections of the may lead to neuroplasticity effects similar to long-term guidelines will expand on disease burden and principles of potentiation and/or long-term depression, perhaps mediated 4 care, psychological treatments, pharmacological treatments, via N-methyl-D-aspartate receptor-dependent mechanisms. complementary and alternative medicine treatments, and Potential advantages of tDCS include ease of use, low cost, special populations. These recommendations are presented portability and potential for home-based use, ability for com- as guidance for clinicians who should consider them in con- bination use with other treatments, and low potential for text of individual patients and not as standards of care. adverse effects. Neurostimulation, or neuromodulation, is an expanding area of research and clinical interest, driven in part by the increasing knowledge base on the neurocircuitry of depres- 4.2. What Are the Delivery Parameters for tDCS? sion. Neurostimulation treatments use electrical or mag- There is no cohesive summary evaluating the optimal stimu- netic stimulation targeting specific brain regions with lus parameters, frequency, or duration of tDCS for the treat- noninvasive techniques, such as transcranial direct current ment of MDD. Studies to date have used an electrode stimulation (tDCS), repetitive transcranial magnetic stimu- montage consisting of anodal stimulation over the left dor- lation (rTMS), electroconvulsive therapy (ECT), and mag- solateral prefrontal cortex (DLPFC) with the cathode used as netic seizure therapy (MST), as well as invasive surgical a ground over a noncortical region or a montage combining techniques, such as vagus nerve stimulation (VNS) and left DLPFC anodal stimulation with right DLPFC cathodal deep brain stimulation (DBS). Most of these neurostimula- stimulation.5 The exact frequency and duration of stimulation treatments have been studied and are used in patients tion have not been established, but it seems that a minimum with treatment-resistant depression (TRD) who have failed stimulation with 2 milliamperes (mA) for at least 30 minutes to respond to standard treatments. per day for 2 weeks is necessary to observe an antidepressant effect.6 The largest randomized-controlled trial (RCT) to date (N ¼ 120 in 4 conditions) using these parameters found Methods higher remission rates at 6 weeks when combining tDCS The full methods have been previously described,3 but in with sertraline (47%) compared to tDCS (40%) or sertraline summary, relevant studies in English published from Janu- alone (30%),7 which suggests that tDCS may have an addi- ary 1, 2009, to December 31, 2015, were identified using tive or enhancing effect to other antidepressant treatments.8 computerized searches of electronic databases (PubMed, Furthermore, preliminary data suggest that tDCS may also PsychInfo, Cochrane Register of Clinical Trials), inspection enhance psychotherapeutic modalities.9 of bibliographies, and review of other guidelines and major reports. Each recommendation includes the level of evidence 4.3. How Effective Is tDCS in Acute for each graded line of treatment, using specified criteria (Table 1). The level of evidence criteria now reflect the and Maintenance Treatment of MDD? primacy of meta-analysis because of its increasing use in the Studies evaluating the efficacy of tDCS have demonstrated evaluation of evidence. mixed results. One meta-analysis (6 trials, N ¼ 200) found Table 2 presents the overall neurostimulation treatment no significant differences with tDCS compared to sham recommendations. More details for each modality are pre- treatments,10 while a subsequent meta-analysis (7 trials, sented in the following questions. Because there is no con- N ¼ 269) demonstrated modest differences between active sensus definition for TRD, we have specified the degree of and sham conditions with a small overall effect size of 0.37.6 treatment resistance whenever possible. An individual patient-level meta-analysis (6 trials, N ¼ 289)

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Table 1. Criteria for Level of Evidence and Line of Treatment. examining tDCS and sertraline 50 mg/d, hypomania (3 patients, 10%) and mania (2 patients, 7%) were reported with Criteria the combined treatment compared to tDCS and sertraline 7 Level of evidencea alone (both with hypomania reported in 1 patient, 3%). 1 Meta-analysis with narrow confidence intervals Adverse effects have not led to differences in dropout rates and/or 2 or more RCTs with adequate (*3%) between active and sham conditions across the sample size, preferably placebo controlled RCTs.5,6 There are no studies examining safety and toler- 2 Meta-analysis with wide confidence intervals ability over long-term use. and/or 1 or more RCTs with adequate sample size 3 Small-sample RCTs or nonrandomized, controlled prospective studies or case series Repetitive Transcranial Magnetic or high-quality retrospective studies 4 Expert opinion/consensus Stimulation (rTMS) Line of treatment 4.5. What Is rTMS and How Is It Delivered? First line Level 1 or Level 2 Evidence, plus clinical supportb Second line Level 3 Evidence or higher, plus clinical supportb rTMS uses powerful (1.0-2.5 Tesla), focused magnetic field Third line Level 4 Evidence or higher, plus clinical supportb pulses to induce electrical currents in neural tissue noninva- sively, via an inductor coil placed against the scalp.12 Ther- RCT, randomized controlled trial. apeutic rTMS is usually delivered by a trained technician or aNote that Level 1 and 2 Evidence refer specifically to treatment studies in which randomized comparisons are available. Recommendations involving nurse, under physician supervision. Unlike ECT, no anaes- epidemiological or risk factors primarily arise from observational studies, thesia is required. The therapeutic mechanism of rTMS is and hence the highest level of evidence is usually Level 3. Higher order still under investigation, with mechanisms proposed at both recommendations (e.g., principles of care) reflect higher level judgement 13 of the strength of evidence from various data sources and therefore are cell-molecular and network levels. primarily Level 4 Evidence. Standard protocols deliver rTMS once daily, 5 days/week bClinical support refers to application of expert opinion of the CANMAT (Table 3). Three-times-weekly stimulation has been reported committees to ensure that evidence-supported interventions are feasible as similarly effective, albeit with slower improvement and a and relevant to clinical practice. Therefore, treatments with higher levels of 14 evidence may be downgraded to lower lines of treatment due to clinical similar number of sessions required overall. ‘Accelerated’ issues such as side effects or safety profile. protocols with multiple daily sessions (2-10/days) are being explored to complete the course more rapidly.15,16

11 Repeated rTMS sessions can exert therapeutic effects found a similar effect size (b ¼ 0.347). The most recent lasting several months. Clinical trials and naturalistic studies meta-analysis (10 trials, N ¼ 393) also found superiority for have found maximal effects at 26 to 28 sessions.17,18 Clinical tDCS over sham conditions with a small but significant 5 experience concurs in suggesting 20 sessions before declar- effect size (g ¼ 0.30). There are no controlled studies of ing treatment failure, with extension to 25 to 30 sessions if tDCS for maintenance treatment or relapse prevention. His- improvements occur. There is currently no validated biomar- tory of treatment resistance has been associated with poorer 19 5,6,11 ker for predicting rTMS outcome in individuals and responses to tDCS. limited evidence for clinical features to suggest rTMS- tDCS is thus recommended as a third-line treatment responsive depression. for MDD. It has Level 2 Evidence for acute efficacy (Table 2), but given the small number of studies with heterogeneous methodologies and the inconsistent results 4.6. What Are the Delivery Parameters for rTMS? from meta-analyses, further research is needed to estab- rTMS parameters include stimulation intensity, frequency, lish the optimal parameters of stimulation and the effi- pattern, and site (Table 3). Conventional figure-8 or circular cacy of tDCS as monotherapy or combination therapy for rTMS coils can target brain regions 1 to 4 cm deep to acute treatment of MDD. the scalp; helmet-shaped ‘deep’ rTMS coils can stimulate slightly deeper structures. For coil navigation, magnetic reso- nance imaging (MRI) guidance is the most precise method; 4.4. What Are the Side Effects Associated with tDCS? however, scalp-based navigation is most common. Stimulus Most studies have found that tDCS is well tolerated. Red- intensity is based on individually determined resting motor dening of the skin, itching, burning, heat, and tingling sensa- threshold (RMT, minimum intensity to elicit muscle twitches tions at the site of stimulation are the most common reported at relaxed upper or lower extremities, by visual inspection or adverse events with tDCS in more than half of patients.5,6 electromyography). The most common intensity in all trials to Headaches, blurred vision, ringing in the ears, brighter or date is 110% RMT20; most recent large trials have employed illuminated vision, fatigue, nausea, mild euphoria, reduced 120% RMT. Stimulation above this level falls outside con- concentration, disorientation, insomnia, and anxiety have ventional safety guidelines.21 Newer theta-burst stimulation also been reported but at low rates with minimal difference (TBS) protocols are more commonly delivered at lower inten- between active and sham stimulation.5 In the RCT sities (e.g., 70%-80% active motor threshold).

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Table 2. Summary of Neurostimulation Treatment Recommendations for Major Depressive Disorder.

Acute Maintenance Safety and Neurostimulation Overall Recommendation Efficacy Efficacy Tolerability rTMS First line (for patients who have failed at least 1 antidepressant) Level 1 Level 3 Level 1 ECT Second line Level 1 Level 1 Level 1 First line in some clinical situations (see Table 5) tDCS Third line Level 2 Level 3 Level 2 VNS Third line Level 3 Level 2 Level 2 DBS Investigational Level 3 Level 3 Level 3 MST Investigational Level 3 Not known Level 3

DBS, deep brain stimulation; ECT, electroconvulsive therapy; MST, magnetic seizure therapy; rTMS, repetitive transcranial magnetic stimulation; tDCS, transcranial direct current stimulation; VNS, vagus nerve stimulation.

Table 3. Summary of Treatment Parameters for Repetitive Table 4. Recommendation for rTMS Stimulation Protocols. Transcranial Magnetic Stimulation (rTMS). Level of Intensity, frequency, and site Recommendation Evidence Stimulate at 110%-120% of resting motor threshold (70%-80% for theta-burst stimulation) (Level 1) First line Select stimulation frequency and site (Table 4) High-frequency rTMS to left DLPFC Level 1 Treatment course Low-frequency rTMS to right DLPFC Level 1 Perform stimulation 5 times weekly (Level 1) Second line Deliver initial course until symptom remission is achieved, Bilateral rTMS to DLPFC (left high-frequency and Level 1 up to 20 sessions (4 weeks) (Level 1) right low-frequency) Extend course to 30 sessions (6 weeks) in responders who Low-frequency rTMS to right DLPFC Level 3 have not achieved symptom remission (Level 3) (in nonresponders to high-frequency Maintenance course left DLPFC-rTMS) or high-frequency rTMS to Use rTMS as needed to maintain response (Level 3) left DLPFC (in nonresponders to low-frequency right DLPFC-rTMS) TBS protocols Level 3 Intermittent TBS to left DLPFC Different stimulation frequency and patterns exert differ- Left intermittent and right continuous TBS to ent effects. Conventionally, high-frequency rTMS (5-20 Hz) DLPFC is considered excitatory, while low-frequency stimulation Intermittent TBS to bilateral DMPFC (1-5 Hz) is inhibitory. Conventional stimulation is delivered Third line in 2- to 10-second trains at 10- to 60-second intervals, in 15- High-frequency rTMS to bilateral DMPFC Level 3 to 45-minute sessions. TBS protocols require only 1 to 3 DLPFC, dorsolateral prefrontal cortex; DMPFC, dorsomedial prefrontal minutes of stimulation and may achieve comparable or cortex; rTMS, repetitive transcranial magnetic stimulation; TBS, theta- stronger effects.22 Intermittent TBS (iTBS) is considered burst stimulation. excitatory and continuous TBS (cTBS) inhibitory. both high-frequency left DLPFC and low-frequency right 4.7. How Effective Is rTMS as an Acute DLPFC are first-line rTMS protocol recommendations. Low-frequency rTMS has the advantage of shorter treatment Antidepressant Therapy? time. Published studies also suggest that nonresponders to More than 30 systematic reviews and meta-analyses have high-frequency left DLPFC rTMS may respond to low- been conducted on rTMS in depression, with most studies frequency right DLPFC rTMS17 and vice versa.26 Hence, a involving patients with some degree of treatment resistance second-line recommendation is to switch nonresponders to (i.e., having failed at least 1 or 2 antidepressant trials). Over- the other stimulation protocol. all, rTMS is considered a first-line treatment for MDD for Bilateral stimulation combines high-frequency left and patients who have failed at least 1 antidepressant treatment low-frequency right DLPFC rTMS and has not shown super- (Table 2). Table 4 lists recommendations for rTMS stimula- iority over unilateral rTMS in meta-analyses.27-29 Because tion protocols. bilateral stimulation requires more intensive setup without Both high-frequency (10 Hz) rTMS of the left DLPFC efficacy or safety advantages, it is considered a second-line and low-frequency (1 Hz) rTMS of the right DLPFC have rTMS protocol. demonstrated efficacy in numerous meta-analyses,20,23-25 The efficacy of rTMS is established even in patients with with no differences in outcomes between them.20 Hence, TRD defined by stringent criteria.30 The most recent

75 La Revue Canadienne de Psychiatrie 61(9) 565 meta-analysis of high-frequency left DLPFC rTMS for TRD maintenance sessions over 3 days, once monthly, extending (23 trials, N ¼ 1156) found significant efficacy of rTMS relapse times to a mean 10.8 months among the 25 patients over sham, with a weighted mean difference of 2.31 and who relapsed.43 As yet, there is insufficient evidence to sup- an effect size of 0.33.31 For left DLPFC rTMS, RCTs with port any one particular schedule of maintenance sessions adequate sessions (20-30) and treatment durations of 4 over another. weeks or more achieved *40% to 55% response and *25% to 35% remission rates, and a real-world effective- 4.9. How does rTMS Compare to ECT? ness study reported 58% response and 37% remission rates.18 Similarly, a meta-analysis (8 trials, N ¼ 263) found rTMS and ECT differ in mechanism, tolerability, and accept- that low-frequency right DLPFC rTMS had superior remis- ability by patients and may be best understood as comple- sion rates compared to sham (35% vs. 10%, respectively, mentary rather than competing techniques. That said, several P < 0.0001).32 meta-analyses28,31,44-46 evaluating a similar number of stud- Excitatory rTMS of the dorsomedial prefrontal cortex ies have consistently found that rTMS is less effective than (DMPFC) has shown antidepressant effects in a small ECT, particularly in patients with psychosis.44 The most sham-controlled trial (N ¼ 45 in 3 conditions)33 and several comprehensive meta-analysis (9 trials, N ¼ 425) found sig- larger case series.22,34,35 The sham-controlled RCT directly nificant superiority of ECT over left DLPFC rTMS in compared DMPFC- and DLPFC-rTMS, reporting slightly response and remission rates but no significant difference better outcomes for DMPFC-rTMS.33 A large case series in weighted mean difference, in contrast to the other meta- (N ¼ 98) of open-label DMPFC-rTMS reported 50% analyses that found large differences in favour of ECT for all response and 36% remission rates, not significantly different outcomes.28,31,45,46 Likewise, rTMS response rates are poor from iTBS (N ¼ 87).22 Based on this Level 3 Evidence, in patients where ECT has failed.35 These findings indicate stimulation to bilateral DMPFC is recommended as a that rTMS should be considered prior to pursuing ECT and third-line rTMS protocol. that patients who have not responded to ECT are unlikely to Randomized pilot studies of TBS protocols for DLPFC respond to rTMS. have shown superiority over sham for left iTBS36 but not for 36,37 right cTBS, while bilateral stimulation (left iTBS and 4.10. What Are the Adverse Effects Associated with right cTBS) had positive results in one study36 but not in another.38 For TBS of bilateral DMPFC, a retrospective case rTMS? series found that iTBS achieved equivalent outcomes to lon- The most common adverse effects for rTMS are scalp pain ger conventional 10-Hz rTMS protocols.22 Randomized during stimulation (*40%) and transient headache after sti- comparisons of conventional rTMS and TBS are in progress mulation (*30%), both of which diminish steadily over but have not yet been published. Hence, TBS protocols are treatment, typically respond to over-the-counter analgesia, recommended as second line with Level 3 Evidence (Table 4). and result in low rates of discontinuation.47,48 The cognitive safety profile of rTMS appears benign. A 4.8. How Effective Is Maintenance Treatment systematic review (22 studies, N ¼ 659) of cognitive performance with rTMS found no worsening in cognitive domains Post-rTMS? but also little evidence of improvement, with no differences Without maintenance treatment, relapse is common follow- in cognitive performance between active rTMS and sham ing successful rTMS. One naturalistic study (N ¼ 204) conditions.49 reported median relapse time at 120 days, with relapse rates The most serious rTMS adverse event is seizure induc- of 25%,40%,57%,and77% at 2, 3, 4, and 6 months, tion. To date, fewer than 25 cases of rTMS-induced seizure respectively.39 With maintenance rTMS, long-term out- have been reported worldwide.50 Seizure incidence with comes appear more favourable. In a naturalistic study (N rTMS is estimated at *0.01% to 0.1% versus 0.1% to ¼ 257), maintenance rTMS sessions as needed over 12 0.6% on antidepressant medications and 0.07% to 0.09% months sustained remission in 71% of rTMS remitters and spontaneous incidence in the general population. High- response in 63% of rTMS responders.40 Another study found frequency rTMS is contraindicated in patients with a history that without maintenance, 38% of rTMS responders relapsed of seizures. Safety of low-frequency rTMS has been demon- within 24 weeks, at a mean of 109 days posttreatment.41 strated in patients with epilepsy,21 but safety in patients with With reintroduction of rTMS as needed, 73% met response depression and seizures has not been formally established. and 60% met remission criteria at 24 weeks.41 Most rTMS practitioners currently consider a history of Various rTMS maintenance schedules have been pro- seizures an absolute contraindication. posed. An observational study (N ¼ 59) compared a 20- Consensus safety guidelines for therapeutic rTMS21 list week gradual taper of maintenance rTMS (from 3 sessions/ metallic hardware (e.g., cochlear implants, brain stimulators week down to 1 session/month) to no maintenance; relapse or electrodes, aneurysm clips) anywhere in the head, except rates were 38% with maintenance versus 82% without main- the mouth, as an absolute contraindication. Relative contra- tenance.42 Another study (N ¼ 35) provided 5 ‘clustered’ indications include the presence of a cardiac pacemaker,

76 566 The Canadian Journal of Psychiatry 61(9) implantable defibrillator, a history of epilepsy, or the pres- Table 5. Clinical Indications for Electroconvulsive Therapy as a ence of a brain lesion (vascular, traumatic, neoplastic, infec- First-Line Treatment for Major Depressive Disorder. tious, or metabolic). Acute suicidal ideation (Level 1) Psychotic features (Level 1) 4.11. Should rTMS be Combined with Other Treatment-resistant depression (Level 1) Repeated medication intolerance (Level 3) Antidepressant Medications? Catatonic features (Level 3) Most rTMS studies have delivered rTMS as an add-on to the Prior favourable response to ECT (Level 3) preexisting antidepressant regimen. There is no evidence that Rapidly deteriorating physical status (Level 3) discontinuing antidepressants prior to rTMS will improve out- During pregnancy, for any of the above indications (Level 3) Patient preference (Level 4) comes. However, a meta-analysis (6 trials, N ¼ 392) found that starting a new antidepressant with rTMS resulted in 51 higher response and remission rates than rTMS alone. Table 6. Recommendations for Delivery of Electroconvulsive Therapy.

Level of Electroconvulsive Therapy (ECT) Recommendation Evidence

4.12. What Is ECT and How Is It Delivered? First line ECT is a therapeutic procedure that entails induction of a BP RUL (at 5-6 times seizure threshold) Level 1 seizure by applying an electrical stimulus to the brain. It is an BP BF (at 1.5-2.0 times seizure threshold) Level 1 effective and well-established treatment method for depres- Second line UBP RUL (up to 8 times seizure threshold) or UBP BF Level 1 sive and other mental disorders. ECT is delivered in a con- (at 1.5-2.0 times seizure threshold) trolled clinical setting, after induction of general anaesthesia BP BT (at 1.5-2.0 times seizure threshold) Level 1 and application of a muscle relaxant. There are no absolute Twice-weekly ECT sessions have similar efficacy to Level 2 contraindications for ECT. The following conditions may be thrice-weekly but have longer duration of treatment associated with an increased safety risk: space-occupying cer- If no response to RUL after 4 to 6 treatments, switch Level 3 ebral lesion, increased intracranial pressure, recent myocar- to bilateral ECT (BT or BF) dial infarction, recent cerebral haemorrhage, unstable vascular For maintenance pharmacotherapy post-ECT, use an Level 2 antidepressant that has not been tried prior to ECT aneurysm or malformation, pheochromocytoma, and class 4 or nortriptyline plus lithium or venlafaxine plus lithium or 5 anaesthesia risk. The exact mechanism of action is still Maintenance use of ECT is as effective as Level 2 under investigation, but the main hypotheses include seizure- pharmacotherapy in preventing relapse/recurrence induced changes in neurotransmitters, neuroplasticity, and after an acute course of ECT functional connectivity. For example, ECT can increase levels BF, bifrontal; BP, brief pulse; BT, bitemporal; ECT, electroconvulsive ther- of brain-derived neurotrophic factor (BDNF), which may con- apy; RUL, right unilateral; UBP, ultrabrief pulse. tribute to the antidepressant effect.52 ECT is generally recommended as a second-line treatment for MDD because of adverse effects (Table 2), but ECT and bilateral treatments. UBP may be associated with less can be considered a first-line treatment in some clinical short-term cognitive impairment and specifically the loss of situations (Table 5). autobiographical memory.54 However, UBP may have slower Table 6 summarizes the recommendations for delivery of speed of improvement and require more treatments than BP.55 ECT. Current treatment parameters for ECT include electrode A systematic review56 concluded there was no advantage of position, electrical intensity, and pulse width. The most com- UBP over BP in RUL or bilateral ECT, and a meta-analysis mon electrode placements are bilateral, either bitemporal (6 trials, N ¼ 689) found that BP RUL had a small efficacy (BT) or bifrontal (BF), or right unilateral (RUL). The electri- advantage and required fewer treatments than UBP but led to cal intensity is based on the minimum intensity to produce a more cognitive impairment after an acute course.57 Hence, generalized seizure, called the seizure threshold (ST). Bilat- UBP RUL is recommended as a second-line ECT treatment, eral treatments (both BT and BF) most often use 1.5 to 2.0 especially to minimize short-term cognitive impairment. times ST and RUL 5 to 6 or even 8 times ST. A meta-analysis The number of ECT treatments required to achieve (8 trials, N ¼ 617) found that BT, BF, and RUL have the same response and/or remission, referred to as the index course, efficacy but may adversely affect specific cognitive domains ranges between 6 and 15. ECT is usually delivered 2 to 3 differently.53 Both BF and RUL ECT are first-line recommen- treatments per week during the index course. More than 3 dations, but BT is recommended as second line because of treatments per week are not recommended, as they are asso- higher rates of short-term cognitive adverse effects. ciated with higher frequency of cognitive side effects. A ECT generally uses brief pulse (BP) width, but in the past meta-analysis (8 studies, N ¼ 214) found that twice- decade, there has been clinical and research interest into weekly ECT had similar efficacy compared to thrice- ultrabrief pulse width (UBP, pulse width below 0.5 ms) RUL weekly ECT but had longer duration of treatment.58

77 La Revue Canadienne de Psychiatrie 61(9) 567

4.13. How Effective Is ECT as an Acute Treatment? prospective RCT of continuation ECT versus continuation pharmacotherapy with nortriptyline and lithium.67 Hence, ECT is one of the most effective treatments for MDD. maintenance ECT also can be used as a relapse-prevention Response rates can reach 70% to 80%, with remission rates strategy after an acute course of ECT. There are no studies 40% to 50% or higher, depending on the patient population investigating optimal frequency of c/mECT, so the schedule and type of stimulus used. For example, 1 multicentre RCT should be adjusted to the needs of an individual patient. The (N ¼ 230) reported remission rates of 55% for RUL, 61% for most commonly used schedule in studies of c/mECT BF, and 64% for BT in a mixed sample of patients with involves weekly treatments for 4 weeks, then biweekly for unipolar (77%) and bipolar (23%)depression.59 The stron- 8 weeks, and then monthly. If signs of relapse occur, more gest predictor of nonresponse to ECT is the degree of resis- frequent sessions are usually provided. tance to previous treatments. In patients with greater There has been a paucity of evidence regarding psy- degrees of resistance to pharmacological and psychological chotherapeutic strategies to prevent post-ECT relapse.68 treatments, response rates with ECT approximate 50%, A small RCT found that cognitive-behavioural group ther- compared to 65% in patients without a previous treatment apy plus continuation medication (n ¼ 17) demonstrated a failure.60 Highest response rates have also been observed lower relapse rate at 6 and 12 months compared to conti- when patients are older, have psychotic features, have a nuation of UBP ECT plus medication (n ¼ 25) and conti- shorter episode duration, and, possibly, have lesser depres- nuation of medication alone (n ¼ 18).69 There is sive severity.61 insufficient evidence to recommend psychotherapy for The relapse/recurrence rate following an acute course of maintenance treatment post-ECT. ECT, with or without maintenance treatment, is also high. A meta-analysis of 32 studies from 1962 to 2013 (N ¼ 1706 patients) that assessed relapse rates following successful 4.15. What Are the Adverse Effects Associated treatment with ECT reported that relapse rates are highest with ECT? within the first 6 months post-ECT (37.7%).62 Even in those The use of general anaesthesia, muscle relaxants, oxygena- receiving maintenance treatment post-ECT, relapse rates of tion, and monitoring has minimized the risks associated with 51.1% and 50.4% have been observed at 1 and 2 years, ECT, and the mortality rate has been estimated to be less respectively. Baseline medication resistance is not associ- than 1 death per 73,440 treatments.70 No clinical studies ated with relapse, but lower relapse rates have been observed have demonstrated damage to the brain structures related in cohorts with a greater percentage of psychotic patients and to the administration of ECT. The most common adverse older patients.62 effects occur during a treatment course, are transient, and can be treated symptomatically: headaches (45%), muscle 4.14. How Effective Is Maintenance Treatment soreness (20%), and nausea (1%-25%). In a small number (7%), there can be a switch into a manic or mixed state. Post-ECT? Subjective and objective cognitive impairment are the Medications are most commonly used for maintenance after adverse effects that have received the greatest attention. an acute treatment course of ECT. The use of antidepressant Cognitive effects include transient disorientation when reco- medication post-ECT reducedrelapseratesbyapproxi- vering from an ECT session (in part due to postictal confu- mately half (relative risk of relapse on medication ¼ sion and effects of general anaesthesia), retrograde amnesia 0.56).62 However, there has been little study of specific (difficulty recalling information learned before a course of medication strategies to minimize post-ECT relapse, and ECT, such as autobiographical memories), and anterograde there is no clear evidence of the superiority of a specific amnesia (difficulty in retaining learned information after a antidepressant or class of medication. In RCTs, the combi- course of ECT). There is mild, short-term impairment in nation of nortriptyline and lithium was superior to both nor- memory and other cognitive domains during and immedi- triptyline monotherapy and placebo in reducing relapse ately following a course of ECT. Clinical factors, including rates,63 and the combination of venlafaxine and lithium was preexisting cognitive impairment, older age, and use of BT found to be equally efficacious as nortriptyline and ECT, are associated with greater cognitive impairment, lithium.64 In summary, the recommendation for pharma- while use of UBP RUL ECT is associated with less impair- cotherapy post-ECT is to use an antidepressant that has not ment. However, these impairments are usually transient, been tried prior to ECT, or nortriptyline plus lithium, or with recovery of cognitive functioning occurring within venlafaxine plus lithium. weeks and months after an acute course of ECT, and no Continuation/maintenance ECT (c/mECT) is also a safe eventual cognitive differences between ECT parameters, and effective strategy to reduce relapse/recurrence.65,66 including electrode placement and pulse width.71,72 For Studies in which continuation ECT was used yielded com- example, 1 meta-analysis (84 studies, N ¼ 2981) examined parable relapse-prevention results at 6 months as studies of 24 cognitive variables (including processing speed, working pharmacological strategies (relapse rates: 37.2% vs. 37.7%, memory, anterograde memory, and executive function) and respectively).62 This has also been demonstrated in a found recovery or improvement in all neuropsychological

78 568 The Canadian Journal of Psychiatry 61(9)

Table 7. Factors Associated with Higher Rates of Short-Term is elicited under general anaesthesia with assisted ventilation Adverse Cognitive Effects of Electroconvulsive Therapy Versus and EEG monitoring, but MST has the potential for fewer Those Associated with Lower Rates. side effects such as cognitive dysfunction.76 Level of The equipment used in MST consists of a neurostimulator Factors Evidence and coil that is placed in direct contact with the skull. When electrical current passes through the coil, a strong focal mag- Bitemporal electrode placement versus bifrontal or Level 1 netic field is generated (in the order of 2 Tesla). This magnetic unilateral placement field crosses the skull and soft tissue unimpeded to reach brain Brief pulse width (1.0-1.5 ms) versus ultrabrief pulse Level 2 width (0.3-0.5 ms) tissue, inducing an electrical current that causes neuronal Suprathreshold stimulation versus lower electrical dose Level 2 depolarization and eventually triggering a generalized seizure. Treatment 3 times a week versus twice a week Level 2 Concomitant use of lithium or agents with independent Level 3 4.18. What Are the Delivery Parameters of MST? adverse cognitive effects versus reducing doses or discontinuing these agents The optimal delivery parameters for MST are still being inves- Use of high doses of anaesthetic medications versus Level 4 tigated. Most studies have used a coil placement at the vertex lower doses (i.e., Cz in 10-20 electroencephalogram [EEG] system) with a frequencyofstimulationof100Hz,pulsewidth of0.2 to 0.4 ms, andstimulationdurationof10seconds.AsummaryofMST 72 measures within 3 to 15 days after completing ECT. There parameters used in studies is listed in Supplemental Table S1. is less consistent information about retrograde amnesia, with MST has been given on a similar schedule as ECT, usually 2 to some studies suggesting persistent effects, while a systema- 3 times per week, with an index course of 12 treatments. tic review (15 studies, N ¼ 1128) found that objective tests of autobiographical memory did not show effects beyond 6 4.19. How Effective Is MST Compared to ECT? months post-ECT.73 Patient self-reports indicate some persistent cognitive dysfunction, especially retrograde amnesia, There are no studies comparing MST versus sham stimula- but self-reports of cognitive dysfunction are usually highly tion. One small RCT (N ¼ 20) comparing MST to RUL ECT correlated with persistent depressive symptoms and are not found no significant differences in response rates (60% vs. correlated with objective testing.73,74 Table 7 lists some of 40%, respectively) or remission rates (30% vs. 40%, respec- the factors that are associated with higher or lower rates of tively).77 In addition, the largest MST case series (N ¼ 26, short-term adverse cognitive effects. which included the 10 patients who received MST in the randomized trial) reported an overall response rate of 69% 78 4.16. Should ECT Be Combined with Other and remission rate of 46%, which would be similar to those obtained with ECT. There are no studies of relapse following Antidepressant Treatments? MST or of relapse prevention strategies. As a result, MST is Lower relapse rates have been reported in studies where recommended as an investigational treatment alternative for concurrent antidepressant medication was permitted during ECT based on Level 3 Evidence (Table 2). the course of ECT compared to studies where maintenance pharmacotherapy was begun following the course of ECT 4.20. What Are the Adverse Effects Associated (29.2% vs. 41.6%, respectively), suggesting that improved with MST Compared to ECT? long-term outcomes are achieved with the use of concurrent, rather than sequential, use of ECT and medication.62 MST seems to be associated with lower rates of headaches and There is some evidence that concomitant use of lithium muscle aches than ECT. In addition, MST has not shown a and ECT may increase cognitive side effects, encephalopa- significant impact on anterograde or retrograde amnesia, and thy, and spontaneous seizures, whereas benzodiazepines and reorientation time (the time it takes after the seizure and emer- anticonvulsants may raise the seizure threshold and decrease gence from anaesthesia to be fully oriented to person, place, seizure efficacy, although lamotrigine may be less proble- and time) appears to be significantly shorter in patients receiv- matic than other anticonvulsants.75 ing MST compared to ECT (2-7 minutes vs. 7-26 minutes, respectively).76 However, the 1 randomized comparison of MST versus RUL ECT (N ¼ 20) found no significant differ- Magnetic Seizure Therapy (MST) ences in neuropsychological testing after 12 treatments.77 4.17. What Is MST and How Is It Delivered? MST is a noninvasive convulsive neurostimulation therapy Vagus Nerve Stimulation (VNS) that relies on the principle of electromagnetic induction to induce an electric field in the brain strong enough to elicit a 4.21. What Is VNS and How Is It Delivered? generalized tonic-clonic seizure. Currently, MST is being VNS is an implantable neurostimulation technology origi- investigated as an alternative to ECT. Like ECT, the seizure nally approved in 1997 for the treatment of drug-resistant

79 La Revue Canadienne de Psychiatrie 61(9) 569 epilepsy. The VNS system comprises an implantable pulse maintained response at 12 months and 24 months, respec- generator (IPG), which is surgically inserted underneath the tively.85 Hence, the longer term results with VNS appear skin of the chest, connected to an electrode placed in one of encouraging, and VNS can be considered for patients with the vagus nerves in the neck. The vagus nerve is a cranial chronic depression, particularly in situations where treat- nerve that largely consists of fibers that transmit nerve ment adherence may be an issue. impulses from the periphery to the brain. Electrical stimulation of the vagus nerve provides stimulation to the 4.25. What Are the Adverse Effects Associated with nucleus tractus solitarius, which in turn is able to modulate VNS? multiple regions of the brain via its neuronal connections to anatomically distributed subcortical and cortical regions of Most patients with VNS are also on antidepressant medica- the brain.79 tions, so adverse effects are for the combined treatment. The most commonly reported adverse effects after 1 year of VNS for TRD are voice alteration (69.3%), dyspnea (30.1%), pain 4.22. What Are the Delivery Parameters for VNS? (28.4%), and increased cough (26.4%).83 Voice alteration Optimal treatment parameters for VNS remain a research and increased cough are often direct effects of VNS being question. In an RCT of open-label VNS (N ¼ 331) compar- actively delivered and can immediately improve by turning ing low (0.25 mA current, 130 ms pulse width), medium the stimulation off. The tolerability of VNS appears to (0.5-1.0 mA, 250 ms), or high (1.25-1.5 mA, 250 ms) elec- improve over time with diminishing rates of adverse events trical outputs, higher electrical charges were correlated with reported by patients during their long-term treatment with better improvement in depressive symptoms.80 More sus- VNS.83 The reported rates of serious adverse psychiatric tained antidepressant responses and less frequent suicide events have included suicide or attempted suicide (4.6%) attempts were reported in the medium- and high- and treatment-emergent hypomania or mania (2.7%).80 A stimulation groups than the low-dose group. lower all-cause mortality rate, including suicide, has been observed in patients with TRD treated with adjunctive VNS compared to TAU.86 4.23. How Effective Is VNS in Acute Treatment? VNS was approved by the Food and Drug Administration Deep Brain Stimulation (DBS) (FDA) in the United States in 2005 for the adjunct long-term treatment of chronic or recurrent depression for adult 4.26. What Is DBS and How Is It Delivered? patients experiencing a major depressive episode who had DBS is an invasive neurosurgical procedure involving the failed to respond to 4 or more adequate antidepressant treat- implantation of electrodes under MRI guidance into discrete ments. A meta-analysis of open-label studies (7 studies, N ¼ brain targets. The electrodes are internalized and connected 81 426) found a response rate of 31.8%. However, only 1 RCT to an IPG that is typically implanted into the chest below the (N ¼ 235) has evaluated the efficacy of VNS versus a sham- right clavicle. Similar to cardiac pacemakers and VNS, the control condition, with no significant differences in efficacy IPG in DBS can be accessed using a handheld device, allow- 82 between the conditions at 12 weeks. Therefore, VNS is ing the stimulation parameters to be monitored and/or pro- recommended as a third-line acute treatment with Level 3 grammed remotely. Modifiable DBS parameters include Evidence for efficacy (Table 2). pulse width, frequency, and amplitude (voltage or current), whichcanbeprogrammedbythetreatingphysicianand 4.24. How Effective Is VNS During Extended titrated to clinical effect. Currently, the most common indi- Treatment? cations for DBS are movement disorders (most specifically Parkinson’s disease),87 but DBS for difficult-to-treat psy- Recent systematic reviews and meta-analyses of open-label chiatric disorders, including TRD, is a growing research studies have suggested that the antidepressant effects of field. VNS may accrue over time. A patient-level meta-analysis (6 trials, N ¼ 1460) of all randomized and open-label data 4.27. How Effective Is DBS as an Acute Treatment in with VNS found significantly higher odds ratios (ORs) for response (OR, 3.19) and remission (OR, 4.99) for VNS plus TRD? treatment as usual (TAU) compared to TAU alone.83 How- DBS is still considered an experimental treatment, with ever, absolute rates were low (e.g., remission rates for VNS Level 3 Evidence supporting efficacy (Table 2). Evidence plus TAU at 12, 24, 48, and 96 weeks were 3%,5%,10%, for effectiveness of DBS has been based on nonrandomized, and 14%, respectively, vs. 1%,1%,2%, and 4% for TAU open-label trials with small sample sizes (fewer than 20 alone).83 The median time to response with VNS was esti- patients each) of patients with antidepressant-, mated to be 9 months in 1 study.84 In another VNS study psychotherapy-, and, often, ECT-refractory depression. The (N ¼ 74), only 35% of patients had achieved a response by main anatomical targets for TRD are subcallosal cingulate 3 months, but 61.5% and 50% of these 3-month responders (SCC) white matter, ventral capsule/ventral striatum

80 Canadian Psychiatric Association

Association des psychiatres CANMAT Guidelines du Canada

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(9) 588-603 Canadian Network for Mood and Anxiety ª The Author(s) 2016 Reprints and permission: Treatments (CANMAT) 2016 Clinical sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716659276 Guidelines for the Management of Adults TheCJP.ca | LaRCP.ca with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly

Glenda M. MacQueen, MD, PhD1, Benicio N. Frey, MD, MSc, PhD2, Zahinoor Ismail, MD1, Natalia Jaworska, PhD3, Meir Steiner, MD, MSc, PhD2, Ryan J. Van Lieshout, MD, PhD2, Sidney H. Kennedy, MD4, Raymond W. Lam, MD5, Roumen V. Milev, MD, PhD6, Sagar V. Parikh, MD4,7, Arun V. Ravindran, MB, PhD4, and the CANMAT Depression Work Group8

Abstract Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. This section on ‘‘Special Populations’’ is the sixth of six guidelines articles. Results: Recent studies inform the treatment of MDD in children and adolescents, pregnant and breastfeeding women, women in perimenopause or menopause, and the elderly. Evidence for efficacy of treatments in these populations is more limited than for the general adult population, however, and risks of treatment in these groups are often poorly studied and reported. Conclusions: Despite the limited evidence base, extant data and clinical experience suggest that each of these special populations can benefit from the systematic application of treatment guidelines for treatment of MDD.

Keywords major depressive disorder, clinical practice guidelines, evidence-based medicine, meta-analysis, child and adolescent psychiatry, geriatric psychiatry, maternal health, perinatal, postpartum, systematic reviews

1 Department of Psychiatry, University of Calgary, Calgary, Alberta 2 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario 3 Department of Psychiatry, McGill University, Montre´al, Quebec 4 Department of Psychiatry, University of Toronto, Toronto, Ontario 5 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia 6 Department of Psychiatry, Queen’s University, Kingston, Ontario 7 Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 8 Members of the CANMAT Depression Work Group are listed here: www.canmat.org/workgroups.

Corresponding Author: Glenda M. MacQueen, MD, PhD, University of Calgary, 7D18, TRW Building, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada. Email: [email protected]

81 La Revue Canadienne de Psychiatrie 61(9) 589

In 2009, the Canadian Network for Mood and Anxiety Treat- Table 1. Criteria for Level of Evidence and Line of Treatment. ments (CANMAT), a not-for-profit scientific and educa- Criteria tional organization, published a revision of evidence-based 1 clinical guidelines for the treatment of depressive disorders. Level of evidencea CANMAT has updated these guidelines in 2016 to reflect 1 Meta-analysis with narrow confidence intervals new evidence in the field. and/or 2 or more RCTs with adequate The scope of these guidelines remains the management of sample size, preferably placebo controlled adults with unipolar major depressive disorder (MDD), with 2 Meta-analysis withwide confidence intervals and/ or 1 or more RCTs with adequate sample size a target audience of psychiatrists and mental health special- 3 Small-sample RCTs or nonrandomized, ists. This section covers the treatment of depressive disorders controlled prospective studies or case series in children and adolescents, women in the perinatal and or high-quality retrospective studies menopausal stages, and the elderly, recognizing that these 4 Expert opinion/consensus life stages carry distinct challenges for treatment. The sec- Line of treatment First line Level 1 or Level 2 Evidence, plus clinical supportb tion is 1 of 6 guidelines articles; other sections expand on b principles of care and psychological, pharmacological, neu- Second line Level 3 Evidence or higher, plus clinical support Third line Level 4 Evidence or higher, plus clinical supportb rostimulation, and complementary and alternative medicine treatments. Treatment recommendations in this section will RCT, randomized controlled trial. a emphasize differences from the general guidelines for adults. Note that Level 1 and 2 Evidence refer specifically to treatment studies in which randomized comparisons are available. Recommendations involving These recommendations are presented as guidance for clin- epidemiological or risk factors primarily arise from observational studies, icians who should consider them in context of individual and hence the highest level of evidence is usually Level 3. Higher order patients and not as standards of care. recommendations (e.g., principles of care) reflect higher level judgement of the strength of evidence from various data sources and therefore are primarily Level 4 Evidence. Methods bClinical support refers to application of expert opinion of the CANMAT committees to ensure that evidence-supported interventions are feasible The full methods have been previously described,2 but in and relevant to clinical practice. Therefore, treatments with higher levels of summary, relevant studies in English published from Janu- evidence may be downgraded to lower lines of treatment due to clinical ary 1, 2009, to December 31, 2015, were identified using issues such as side effects or safety profile. computerized searches of electronic databases (PubMed, 5 PsychInfo, Cochrane Register of Clinical Trials), inspection 24 years reported mood disorders. Most of the randomized- of bibliographies, and review of other guidelines and major controlled trials (RCTs) of youth assess antidepressant effec- reports. Each recommendation includes the level of evidence tiveness in 12- to 18-year-old participants, despite the rapid for each graded line of treatment, using specified criteria maturational changes during this period and the fact that a (Table 1). The level of evidence criteria now reflect the 12-year-old is developmentally distinct from an 18-year- 6 primacy of meta-analysis because of its increasing use in the old. Some studies also combine children (<12 years) and evaluation of evidence. adolescents (12-18 years); when recommendations are In special populations, consideration of harm becomes a intended for a specific age group (pediatric or adolescent), more prominent concern than in general adult populations, this is explicitly stated. because of the unique vulnerabilities of these developmental windows. The recommendations for various treatment 6.1. What is the Initial Approach to a Child or approaches therefore reflect an attempt to balance treatment benefit and potential risks in a way that is acceptable to Adolescent with Suspected Depression? clinicians and patients. As studies examining harm in the Use of standardized depression screening tools is recom- treatment of MDD are often of low quality,3 the confidence mended for assessing children and youth; different screening of the treatment recommendations in these groups may be tools exist for these age groups.7,8 When feasible, health care lower than in sections focused on general adult populations. providers should use a semistructured approach to diagnostic The following sections provide an overview of the treatment assessment of children and adolescents who screen positive challenges and options for children and adolescents; preg- for MDD (e.g., Kiddie Schedule for Affective Disorders nant, postpartum, and menopausal women; and the elderly. [K-SADS]). Given that a semistructured interview requires both time and training, this may be difficult in some settings Childhood and Adolescence: A Unique but should be attempted (e.g., by appointing trained personnel for this purpose). Although diagnostic criteria for MDD Neurodevelopmental Period are the same for children and adolescents, presenting symp- In 2014, 11.4% ofAmericanyouthaged12to17years toms may differ by age group; adolescents typically report reported at least 1 major depressive episode (MDE) in the more hypersomnia, fewer appetite and weight changes, and past year.4 Canadian statistics are limited, but 2012 Statistics fewer psychotic symptoms than children.9 As such, the Canada data found that 8.2% of surveyed youth aged 15 to patient’s age should be taken into account when assessing

82 590 The Canadian Journal of Psychiatry 61(9) children/youth, selecting treatments, and tracking Table 2. Treatment of Major Depressive Disorder in Children/ response.10 Best clinical practice includes the use of various Youth. sources for diagnosis and symptom severity assessments, Level of including a clinical interview and auxiliary information Recommendation Treatment Evidence (i.e., from parents, teachers). Supportive clinical care may be sufficient to reduce First line CBT or IPT Level 1 depression symptoms of a mild MDE. Supportive Internet-based psychotherapy Level 1 approaches include psychoeducation, active and empathetic (for milder severity, if in-person is not possible) listening, and lifestyle advice, including the benefits of good 11 Second line Fluoxetine Level 1 sleep hygiene, proper eating habits, and exercise. Escitalopram, sertraline, citaloprama Level 2 Third line Venlafaxine,b TCAb Level 2 6.2. Is Psychotherapy an Effective Treatment for Minimal or nonresponse Depressed Children/Adolescents? First line Add SSRI to psychotherapy Level 1 Second line Switch to another SSRI Level 2 Previous meta-analyses found that psychotherapy, largely in (if unresponsive to fluoxetine) b the form of cognitive-behavioural therapy (CBT), Third line Venlafaxine Level 2 b confers modest antidepressant effects in depressed children/ TCA Level 3 adolescents relative to comparison conditions (e.g., waitlist, Treatment resistant minimally-treated, active placebo), with more evidence for First line SSRI þ psychotherapy Level 2 its use in adolescents.12,13 A recent review of psychothera- Second line Switch to another SSRI Level 2 (if unresponsive to fluoxetine) peutic interventions in children/adolescents (52 studies, b Third line Venlafaxine Level 2 N ¼ 3805) found that interpersonal therapy (IPT) retained TCAb Level 3 superiority over both the short and long term compared with Neurostimulation treatment Level 3 control interventions (waitlist, no treatment, treatment as usual, (ECTb or rTMSb) psychological placebo).14 However, both CBT and IPT retained Suicide/adverse events must be monitored during SSRI treatment; weekly superiority over the short term compared with control condi- follow-ups recommended during first 4 weeks. CBT, cognitive-behavioural 14 tions. When focusing on children (8-12 years), results are therapy; ECT, electroconvulsive therapy; IPT, interpersonal therapy; SSRI, mixed; 1 meta-analysis (10 RCTs, N ¼ 523) found CBT to be selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant; rTMS, repetitive transcranial magnetic stimulation. modestly superior to control conditions (largely waitlist a 15 Not recommended in those with congenital long QT syndrome, congenital controls), although outcome heterogeneity was sizable, while heart disease, or hepatic impairment. another meta-analysis (7 RCTs) reported inconclusive evidence bOnly recommended for adolescents (older than 12 years). for the effectiveness of psychotherapy, mainly CBT, in depressed children (control: waitlist, no treatment, or medication).16 The effectiveness of Internet-based psychotherapeutic (vs. pharmacotherapy) in achieving remission.20 Similarly, interventions in children/adolescents has also been explored. another meta-analysis (5 trials) found that CBT conferred One meta-analysis found no significant benefit to Internet- limited additional benefit to pharmacological treatment in based interventions in 7- to 25-year-olds on depression depressed adolescents,21 but the combination did reduce symptoms (although anxiety was reduced) compared with functional impairment in the short term,21 which is consis- waitlist controls.17 Others found that computer/Internet- tent with previous work.11 Another Cochrane meta-analysis based CBT in children and youth was more effective than (9 trials, N ¼ 882) assessed the effectiveness of psychologi- comparison conditions (e.g., waitlist, no treatment) in alle- cal and pharmacological interventions in preventing relapse viating depression symptoms, particularly in adoles- or recurrence of depression after an initial episode in chil- cents.18,19 As such, these interventions may be a promising dren and youth up to 25 years of age, and found no difference treatment alternative when in-person/face-to-face treatment in outcomes with either approach.22 Finally, CBT for suicide is not feasible or available. Most Internet-based interven- prevention combined with pharmacotherapy resulted in tions have a considerable component of parental and/or greatest improvements in depressed youth who had recently teacher involvement, as well as guidance from a therapist. attempted suicide; these improvements appear comparable Therefore, Internet-based therapies may be better conceived to those in nonsuicidal adolescents with MDD.23 as a piece within a therapeutic intervention strategy rather Table 2 summarizes the treatment recommendations for than a stand-alone approach. MDD. In summary, as there is no clear comparative advan- A Cochrane meta-analysis (11 trials, N ¼ 1307) evaluated tage for pharmacotherapy or psychotherapy in treating the effectiveness of psychotherapy and antidepressant med- children/youth with non-treatment-resistant MDD, psy- ication, alone and in combination, for treating MDD in 6- to chotherapy should be the first line of treatment in mild to 18-year-old participants.20 There were no significant group moderate MDD. CBT and IPT should be considered ahead of differences on most outcome measures and limited evidence other types of psychotherapies in treating depressed pediatric favouring pharmacotherapy or combination treatment and adolescent populations.

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6.3. What Antidepressant Medication Should Be Used Canadian Psychiatric Association also recommends that in Depressed Children/Adolescents? appointments or telephone contacts should be scheduled at least weekly within the first month of treatment for children Selective serotonin reuptake inhibitors (SSRIs) are the most and adolescents.31 When starting antidepressant pharma- extensively studied medications for the treatment of MDD in cotherapy in youth, the initial dose is generally at the low children/youth. A Cochrane review (19 trials, N ¼ 3335) end of the therapeutic range and continues for a minimum of examined efficacy and adverse outcomes of newer genera- 4 weeks before a dose increase is considered. If the patient tion antidepressants (SSRIs and others vs. placebo) in parti- 24 continues to show only a partial response after 12 weeks cipants 6 to 18 years of age. Overall, antidepressant-treated despite adequate dosing, a change in treatment is children/youth had lower depression severity scores and warranted.8,9 higher response/remission rates than placebo-treated individuals, although the effect size was small.24 Fluoxetine is superior to placebo in pediatric/adolescent cohorts and is the 6.5. How Long Should Children/Adolescents Be recommended first-choice pharmacological treatment.24,25 Treated with Pharmacotherapy? Some studies have demonstrated escitalopram superiority 24 Relatively little is known about antidepressant maintenance over placebo on functioning and depression scores, strategies in children/adolescents. Based primarily on adult although this may be more pronounced in adolescent cohorts research, maintenance treatment for 1 year or more is rec- rather than children.26 Paroxetine has not shown efficacy in 24 ommended in children/youth with a history of at least 2 this age group. There is some evidence that sertraline may depressive episodes or 1 severe or chronic episode.9 In indi- be superior to placebo, but the effects are small; finally, there viduals with no MDD history, maintenance strategies should is little evidence for antidepressant effects of citalopram in persist for 6 to 12 months. Antidepressant discontinuation children or adolescents, although remission rates tended to 24 should consist of a slow taper and occur during a relatively be higher compared with placebo. Children/adolescents stress-free time (e.g., summer months). with congenital long QT syndrome should not be treated with citalopram; those with congenital heart disease or hepatic impairment should be treated with caution.27 6.6. How Should Treatment-resistant Depression or Tricyclic antidepressants (TCAs) are not useful in treat- Comorbidity Be Approached in Children or Adolescents? ing depression in children, and there is only marginal evi- 28 If a child/adolescent is unresponsive to first-line treatment, the dence to support their use in adolescents. Monoamine possibility of a misdiagnosis (e.g., undetected bipolar disorder, oxidase inhibitors (MAOIs) are not recommended for comorbid medical or psychiatric disorder) should be consid- depressed children/youth because there has been limited ered prior to a treatment switch. Treatment nonadherence assessment of MAOI effectiveness in this population and should also be considered, as should psychosocial factors because of the side effect burden as well as potential for (e.g., bullying, sexual identity concerns, and family conflict). difficulties with the tyramine-free diet. Based largely on findings from the Treatment of Resistant In summary, if psychotherapy is not accessible, accepta- Depression in Adolescents (TORDIA) study, following an ade- ble, or effective, pharmacotherapy should be considered in quate course with an initial SSRI, children/adolescents show- youth with depressive episodes of moderate severity ing minimal response (<20% decrease in symptoms) should be (Table 2). Pharmacotherapy should be considered as a switched to another SSRI. Although participants in the TOR- first-line intervention in more severe cases of depression. DIA trial were equally responsive to the serotonin and Fluoxetine is considered a first-choice antidepressant in chil- norepinephrine reuptake inhibitor (SNRI) venlafaxine as to dren/youth while escitalopram, sertraline, and, to a lesser another SSRI, venlafaxine was associated with a higher rate extent, citalopram are generally considered second-choice of self-harm events in those with higher suicidal ideation; ven- antidepressants. Paroxetine is not recommended. TCAs and lafaxine is therefore less preferable than switching to another MAOIsshouldonlybeconsideredintreatment-resistant SSRI.30 For youth with SSRI-resistant depression, combined depression. treatment (antidepressant þ psychotherapy) decreases the number of days with depression and may be cost-effective.32 6.4. How Should Children/Adolescents Be Monitored There is limited evidence for the use of neurostimulation treatments and other modalitiesintreatingdepressionin following Initiation of Pharmacotherapy? pediatric/adolescent populations. Repetitive transcranial The United States Food and Drug Administration (FDA) magnetic stimulation (rTMS) may hold some promise,33 recommends that patients be seen on a weekly basis during although large-scale randomized, sham-treatment controlled the first 4 weeks of treatment, followed by visits every 2 studies are lacking. Similarly, RCTs of electroconvulsive weeks for a month, and then after 12 weeks of treatment to therapy (ECT) in children/adolescents are lacking, although monitor adverse events/suicidality.29 This is especially true ECT parameters in adolescents exist.34 Case series indicate in more severely depressed patients, those with high suicidal that ECT is effective in alleviating depression symptoms in ideation, and those experiencing family conflict.30 The adolescents with treatment-resistant MDD, although some

84 592 The Canadian Journal of Psychiatry 61(9) individuals did report long-term cognitive/memory impair- of pregnancy and the postnatal period. The DSM-5 defines ments.35 Given the potential side effect profiles and lack of the peripartum onset specifier as an MDE that emerges dur- evidence, ECT is not recommended in children (<12 years of ing pregnancy or in the first 4 weeks after delivery, an age) and is only recommended with extreme caution in ado- acknowledgement that up to 40% of postpartum MDEs begin lescents with treatment-resistant and severe MDD (Table 2). during pregnancy. Finally, the presence of a comorbid psychiatric disorder Up to 7.5% of women will have a unipolar MDE during may complicate treatment. There are sparse data to guide pregnancy, and 6.5% will experience one in the first 3 treatment of MDD in the context of psychiatric comorbidity months postpartum. When cases of minor depressive disor- in individuals younger than 18 years. Some limited evidence der are considered, these rates increase to 18.4% and 19.2%, supports the use of fluoxetine in depressed youth with mild respectively.42,43 If left untreated, MDEs can affect infant to moderate alcohol use disorders36 and with oppositional development, future depression risk, and family and voca- symptoms.37 In the TORDIA study, remission from depres- tional functioning. Timely treatment is therefore essential to sion, regardless of treatment, was associated with a greater optimizing outcomes for women and their families. reduction in measures of anxiety, attention-deficit/hyperac- 38 tivity disorder (ADHD), and oppositional symptoms. 6.8. What Are the Principles of Management for Although the evidence is limited, treating depression in children/adolescents may reduce comorbid disorder(s) Perinatal Depression? symptoms. Up to 50% of pregnancies are unplanned.44 Discussions about a woman’s intent to become pregnant and the safety 6.7. What Are the Safety Concerns for Antidepressant of selected treatment strategies if a pregnancy (planned or Medications in Children/Adolescents? unplanned) occurs should therefore comprise a part of the assessment and documentation of all depressed women of Health Canada has not approved any antidepressant medica- childbearing age. tions for use in individuals younger than 18 years. Fluoxetine The treatment of MDD during pregnancy and the post- is the only antidepressant approved by the FDA for preado- partum period is marked by a number of unique challenges. lescents (8 years and older), but both fluoxetine and escita- These include the known risks of fetal and infant exposure to lopram are FDA-approved for children 12 years and older. pharmacologic treatments during pregnancy and lactation, as The FDA issued a black-box warning in 2003 on SSRI well as those posed by untreated depression. Unfortunately, use in those younger than 24 years; other regulatory agen- the evidence upon which our understanding of these risks is cies, including Health Canada, followed suit. The Cochrane based remains limited. The DSM-5 defines perinatal depres- review of newer generation antidepressants (SSRIs and oth- sion as a unitary diagnostic concept, but given these uncer- ers) found that median baseline risk of suicide-related out- tainties and the unique risks posed by depression and its comes (behaviour and ideation) rose from 25/1000 to 40/ treatment during the perinatal period, we have developed 1000.24 These results were consistent with the FDA meta- separate sets of recommendations for pregnancy and the analysis that showed an *1.5- to 2-fold risk of increased postpartum period, as well as for MDEs of mild to moderate suicidal thoughts/behaviours (no suicide deaths reported) for severity, and for severe episodes. Severity of depressive epi- newer antidepressants.39 While epidemiological data do not sodes is defined according to the DSM-5. demonstrate a relationship between prescriptions of antide- 40 pressants and suicide deaths in large populations of youth, 6.9. How Should Depression during Pregnancy Be a systematic review of observational studies found a higher risk (odds ratio ¼ 1.92) of suicidal acts (suicide and Treated? attempted suicide) with SSRI exposure in adolescents but a Decision making around the treatment of depression during reduced risk in older age groups.41 Given that these were pregnancy must balance the risks associated with fetal med- observational studies, it is possible that the adolescents with ication exposure with those of untreated depression. Left SSRI exposure were more severely depressed and at higher untreated, MDEs during pregnancy are not only associated risk of suicidality. While recognizing the risks associated with poorer nutrition and prenatal medical care, smoking, with SSRI use, the consequence of untreated depression in and recreational substance misuse,45,46 but also with signif- children/adolescents is more likely to result in harm; there- icant suffering for women. Depression is linked to an fore, treatment with SSRIs may be appropriate with careful increased risk of poor obstetrical outcomes,47 small neonates monitoring. for gestational age,48 neonatal intensive care unit admission,49 increased rates of neonatal complications,50 impairments in mother-infant bonding, infant sleep difficulties,51 Perinatal Depression mild developmental delays,52 and cognitive, behavioural, Unipolar MDEs occurring during pregnancy and in the first and emotional problems in offspring.53 year postpartum are frequently referred to as perinatal The recommendations for MDD in pregnancy are sum- depression and are among the most common morbidities marized in Table 3. The efficacy of first-line treatments for

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Table 3. Treatment of Mild to Moderate Major Depressive Dis- In keeping with recommendations in general population order during Pregnancy. samples, the use of antidepressants in the perinatal period should continue until 6 to 12 months after remission in low- Level of Recommendation Treatment Evidence risk women, although treatment for longer periods of time should be considered in those at high risk of relapse. First line CBT (individual or group) Level 1 IPT (individual or group) Level 1 Second line Citalopram, escitalopram, sertraline Level 3 6.10. What Is the Approach to Treating Severe Third line Structured exercise, acupuncture Level 2 Depression during Pregnancy? (depression specific), bright-light therapy For severe depression during pregnancy, pharmacotherapy Bupropion, desvenlafaxine, duloxetine Level 3 with particular agents is a first-choice treatment, either alone fluoxetine, fluvoxamine, or or in combination with CBT or IPT. The remaining SSRIs mirtazapine, TCAs (caution with Level 4 (except paroxetine), newer generation antidepressants, and clomipramine), venlafaxine TCAs are second line. ECT can also be considered.57 Com- ECT (for severe, psychotic, or Level 3 bination pharmacotherapy (see Section 3)58 may be cau- treatment-resistant depression) Therapist-assisted Internet CBT, Level 4 tiously considered, but little is known about short- and mindfulness-based CBT, long-term risks to the fetus with this approach. supportive psychotherapy, couples therapy, psychodynamic psychotherapy, rTMS 6.11. What Are the Risks of Using Antidepressant Combination SSRI þ CBT or IPT Level 4 Medications in Pregnancy?

For severe major depressive disorder, pharmacotherapies each move up Unfortunately, studies examining the risks of antidepressants one recommendation line (e.g., second line becomes first line), despite a during pregnancy are limited by the presence of exposures paucity of treatment trials in pregnant women. Psychotherapy and comple- (e.g., maternal depression, substance or prescription misuse, mentary and alternative medicine therapies as monotherapy are not rec- poor prenatal care, maternal physical health problems) that ommended. ECT remains third line. CBT, cognitive-behavioural therapy; ECT, electroconvulsive therapy; IPT, interpersonal therapy; SSRI, selective confound associations between antidepressants and these serotonin reuptake inhibitor; TCA, tricyclic antidepressant; rTMS, repeti- risks. Available studies cannot fully adjust for these factors, tive transcranial magnetic stimulation. and so the magnitude and specific nature of the risks associated with antidepressants are not completely understood.59 mild to moderate depression, including CBT and IPT deliv- Most antidepressants have not been linked to an increased ered in either individual or group format, is supported by risk of major congenital malformations. An increased risk of meta-analyses.54,55 Given the established efficacy of SSRIs CV malformations (odds ratio *1.5) has been found with as first-line treatments in MDD outside of the perinatal first-trimester paroxetine exposure,59 although a number of period, citalopram, escitalopram and sertraline are recom- these complications resolve spontaneously and do not pose mended based on efficacy and safety; combination treatment significant functional impairment.60 Reports have linked with an SSRI and CBT or IPT can also be considered. Other fluoxetine use early in pregnancy to a small increase in con- SSRIs (except paroxetine) and newer antidepressants are less genital malformations as well.61 Significant evidence has not preferred options given the relative absence of reproductive yet accrued that supports increased risks with the other data and limited antenatal clinical use. Despite increased SSRIs, bupropion, mirtazapine, SNRIs, or TCAs (except for risks of fetal cardiovascular (CV) malformations (outlined clomipramine, which may be associated with an elevated risk below), paroxetine and clomipramine may be discussed with of CV malformations). However, antidepressant risk is an women where there is a compelling reason to consider it, active area of study, and discussions with patients should take such as a previous good response or ongoing stability on the into account the most recent data. Consultation by patients medication. Doxepin should be avoided during pregnancy and/or physicians with Motherisk (www.motherisk.org) given its high rate of passage into breast milk and accom- can support these conversations. panying complications. MAOIs are not recommended during There may be a very modest link between gestational pregnancy given their propensity to interact with certain SSRI use and clinically recognized spontaneous abortion analgesic and anaesthetic agents. When MAOIs must be (odds ratio *1.5).62 However, neither this nor the risk of used, early consultation with anaesthesia is recommended. malformations is in excess of the 2-fold increase in risk that Other treatments, including neurostimulation and com- is accepted as clinically significant in the field.63 Studies plementary and alternative medicine strategies, can also be have also linked SSRIs to a 4-day shortened gestational considered as third-line recommendations.56 Recognizing duration and reduced birth weight (74 grams).62 the need for rapid treatment during pregnancy, interventions At delivery, fetuses exposed to SSRI antidepressants in the that have previously been effective for that woman may be third trimester are at elevated risk of developing a syndrome worth discussing as potential second-line strategies, as long of poor neonatal adaptation marked by jitteriness, irritability, as they are not contraindicated. tremor, respiratory distress, and excessive crying. Occurring

86 594 The Canadian Journal of Psychiatry 61(9) in 15% to 30% of infants, these symptoms are most often Table 4. Treatment of Mild to Moderate Postpartum Depression time-limited (typically resolving in 2-14 days), are not asso- during Breastfeeding. ciated with an increased risk of mortality or longer-term neu- Level of rodevelopmental problems, and resolve with supportive Recommendation Treatment Evidence care.64 This risk may be highest with paroxetine, venlafaxine, and fluoxetine.64 Limited data also suggest that SSRIs taken First line CBT (individual or group) Level 1 late (but not early) in pregnancy may be associated with an IPT (individual or group) Level 1 increased risk of persistent pulmonary hypertension of the Second line Citalopram, escitalopram, sertraline Level 2 Combination SSRI þ CBT or IPT Level 2 newborn (PPHN). The absolute risk is 2.9 to 3.5 per 1000 65 Third line Structured exercise, acupuncture Level 2 infants compared to a general population risk of 2 per 1000. (depression specific), therapist- The limited data on the longer-term postnatal effects of assisted Internet CBT, or fetal intrauterine exposure to SSRIs report no lasting cogni- behavioural activation tive, language, emotional, or behavioural problems in off- Fluoxetine, fluvoxamine, paroxetine Level 2 spring.66 Finally, despite the fact that a small number of TCAs (except doxepin) studies have suggested that fetal SSRI exposure may be Bupropion, desvenlafaxine, duloxetine, Level 3 mirtazapine, venlafaxine, TMS, associated with autism-spectrum disorder in offspring, these bright-light therapy studies have significant methodological limitations, have ECT (for severe, psychotic, or Level 3 wide confidence intervals, and require further replication treatment-resistant depression) before evidence-based recommendations can be made.67 Mindfulness-based CBT, supportive Level 4 psychotherapy, couples therapy, psychodynamic psychotherapy 6.12. How Is Depression Treated during the Postpartum Period? For severe postpartum depression, pharmacotherapies each move up one recommendation line (e.g., second line becomes first line), despite a paucity The deleterious effects of untreated postpartum depression of treatment trials in this population. Psychotherapy and complementary (PPD) on women and their families can be significant. PPD and alternative medicine treatments as monotherapy are not recom- 68 mended. ECT remains third line. CBT, cognitive-behavioural therapy; ECT, has been linked to impaired mother-infant attachment and electroconvulsive therapy; IPT, interpersonal therapy; SSRI, selective sero- cognitive, emotional, and behavioural problems in off- tonin reuptake inhibitor; TCA, tricyclic antidepressant; TMS, transcranial spring.69 Successful treatment of maternal depression may magnetic stimulation. reduce these risks.70 Breastfeeding is not contraindicated during treatment with latter because of its association with CV malformations in an antidepressant medication. Concerns about breastfeeding subsequent pregnancies. Other second-generation antide- during medication treatment include short-term adverse reac- pressants are categorized as third-line treatments because tions and longer-term neurodevelopmental effects. Treatment of limited evidence in lactating women. Among the TCAs, recommendations for PPD are given for use in women who nortriptyline has the most evidence in the postpartum setting are breastfeeding. Women with PPD who are not breastfeed- and a solid track record in lactation.78 Doxepin should be ing should follow the general CANMAT guidelines. avoided in the postpartum period because of reports of sig- For women with a mild to moderate PPD who are breast- nificant adverse reactions in infants with breastfeeding.79,80 feeding, first-line recommendations again include IPT and Finally, rTMS79,81 and bright-light therapy81,82 may be CBT54,55 (Table 4). Second-line treatments include citalo- effective for mild to moderate PPD. pram, escitalopram, and sertraline, which have data for effectiveness during the postpartum period, minimize risk during 6.13. What Is the Approach to Treating Severe PPD? lactation, and pose the least known risk during the childbearing years.70 Structured exercise and depression-specific acu- For severe PPD, pharmacotherapy should be used first line, with puncture are complementary and alternative treatments that or without psychotherapy. First-choice medications are citalo- have some evidence in the postpartum period.71-73 An increas- pram, escitalopram, and sertraline. Other antidepressants are ing body of evidence also supports the use of therapist-assisted second-choice treatments for women who are more severely Internet-based behavioural activation and CBT, whereas the depressed. ECT is also an effective treatment that is listed as third effectiveness of unsupported Internet-based psychotherapeu- line because of its side effect profile, but it can be considered a tic interventions has not been established.74-76 While not first-choice treatment for severe depression, especially with psy- extensively studied in the postpartum period, mindfulness- chosis; women can also continue to breastfeed during ECT.83 based CBT and supportive, couples, and psychodynamic psychotherapy may have a role for selected women. 6.14. What Are the Risks of Antidepressants during Despite the presence of RCT support for fluoxetine and paroxetine, they are recommended as third-line choices, the Breastfeeding? former because of its long half-life and slightly higher rates Exposure to antidepressants in breastfed infants is 5 to 10 of minor adverse reactions in breastfed infants,77 and the times lower than exposure in utero. Serum levels in preterm

87 La Revue Canadienne de Psychiatrie 61(9) 595 infants or those with liver and/or kidney impairment may be Table 5. Current Evidence for Treatment of Perimenopausal higher, and so consultation with a pediatrician should help Depression. guide decisions in these cases. Relative infant doses (RID) of Level of medication <10% are generally safe, and all of the SSRIs and Recommendation Treatment Evidence SNRIs tested to date appear to meet this criterion.84 Sertra- line, fluvoxamine, and paroxetine have the lowest RID and First line Desvenlafaxine Level 1 CBT Level 2 ‘‘milk-to-plasma’’ ratios. Minor reactions have been noted in a case studies of over 200 infants with breastfeeding exposure Second line Transdermal estradiol Level 2 Citalopram, duloxetine, Level 3 to sertraline or paroxetine. Citalopram and fluoxetine have had escitalopram, mirtazapine, higher rates of infant reactions (4%-5%), but these are quetiapine XR, venlafaxine XR reversible and generally limited to short-lived increases in Omega-3 fatty acids, fluoxetine, Level 4 irritability, restlessness, somnolence, or insomnia.78 Given its nortriptyline, paroxetine, relatively low relative infant dose, nortriptyline can be a good sertraline choice if women prefer or require treatment with a TCA. Third line Mindfulness-based CBT, supportive Level 4 Unfortunately, next-to-no data exist on MAOIs during lacta- psychotherapy tion. There is a paucity of data on the long-term neurodeve- CBT, cognitive-behavioural therapy. lopmental outcomes of infants who receive antidepressants in aWomen with an intact uterus should also be prescribed concomitant breast milk, but there is currently no evidence of significant progesterone. long-term neurodevelopmental effects.77

studies of antidepressants in menopausal women. Based on Perimenopausal Depression these limited data, the recommendations for antidepressants The transition to menopause (or perimenopause, the begin- in peri- or postmenopausal depression do not differ from ning of ovarian failure) starts when menstrual cycles become those in the general adult population. 7 days longer or shorter than usual and extends to the early 85 postmenopausal years. Perimenopause is a period of 6.16. Are Hormonal Agents Effective as Monotherapy increased risk for depression compared to premenopausal years. Notably, in epidemiological studies, both increased or Adjunctive Treatment with Antidepressants? depressive symptoms and diagnosis of an MDE occurred Transdermal estradiol has been evaluated as both monother- more frequently in perimenopausal relative to premenopau- apy and adjunctive posttherapy to treat perimenopausal sal women.86-89 Perimenopause is associated with risk for depression. In a comparative trial of 3 hormone replacement both depressive recurrence and new-onset depression.87,88 therapies as adjuncts to venlafaxine XR in postmenopausal Along with increased rates of depression and anxiety, this women, methyltestosterone but not estradiol was superior to period is also associated with emergence of menopausal placebo.94 In 2 other small RCTs, estrogen augmentation symptoms such as hot flashes, night sweats, decreased was superior to placebo in perimenopausal women,95,96 libido, vaginal dryness, sleep disturbances, and memory while there was no difference between transdermal estradiol complaints, all of which may negatively affect mood. Hot and placebo in late postmenopausal women.97 Hormonal flashes and night sweats have been identified as independent agents are recommended as second-line agents for women predictors of perimenopausal depression.90 who understand the risks and have no contraindications to Table 5 summarizes the current evidence for treatment of hormonal therapy. MDD in perimenopausal women. 6.17. Are There Effective Nonpharmacologic 6.15. Is Antidepressant Medication Effective during Treatments for Depression during Menopause? Menopause? Only 1 study (N ¼ 50) investigated the use of CBT in peri- Only desvenlafaxine has been specifically evaluated through menopausal women with depression.98 Group CBT signifi- randomized, placebo-controlled trials for antidepressant effi- cantly decreased mean scores on the Beck Depression cacy in peri- and postmenopausal depressed women; the 2 Inventory-II in both pre- and perimenopausal women with trials found that desvenlafaxine (50 mg daily, N ¼ 43491; depression, but no change was observed in the waitlist con- 100 mg and 200 mg daily, N ¼ 38792) was superior to pla- trol group. These results are consistent with a post-hoc anal- cebo. Importantly, a post-hoc analysis of these RCTs showed ysis of a large open-label trial (N ¼ 353) showing no no differences in treatment response to desvenlafaxine differences in treatment response to cognitive therapy between peri- and postmenopausal women.93 Otherwise, between premenopausal, perimenopausal, and postmeno- small-sample, open-label studies have shown the benefit of pausal women.99 citalopram, duloxetine, escitalopram, mirtazapine, quetia- In contrast, adjunctive acupuncture conferred no advan- pine XR, and venlafaxine XR. There are no comparative tage when added to self-care versus self-care alone for the

88 596 The Canadian Journal of Psychiatry 61(9) treatment of hot flashes and depressive symptoms in post- old-old (75 years) can be helpful, with a greater degree of menopausal women.100 vigilance required in treating the old-old. Overall, there are pharmacokinetic changes with aging that may decrease the rate of absorption, modify bioavailability, increase Late-Life Depression half-life for lipid-soluble drugs, and increase relative 110 Late-life depression (LLD) can be defined as MDD occur- concentration for water-soluble drugs and metabolites. ring in adults 60 years and older. When discussing LLD, it is As comorbid medical burden and polypharmacy expand, the important to differentiate early adult-onset depression recur- risk for pharmacokinetic and pharmacodynamic drug inter- 58 ring in late life from late-onset depression. Compared to actions increases (see Section 3). In addition, rare antide- patients with earlier onset of MDD, late-onset depression pressant side effects in adults such as bone loss, serotonin has a worse prognosis, a more chronic course, a higher syndrome, extrapyramidal side effects, and neuroleptic 111 relapse rate, and higher levels of medical comorbidity, cog- malignant syndrome are more common in the elderly. nitive impairment, and mortality.101 The vascular depression Particular attention should be paid to falls, hyponatremia, hypothesis posits that cerebrovascular disease predisposes, and gastrointestinal bleeding, which are associated with 112,113 precipitates, or perpetuates some depressive syndromes in SSRIs in general and to QTc prolongation with citalo- 114 older age. This vascular burden affects fronto-striatal circui- pram. Standard principles of conservative prescribing 115 try, resulting in depression and associated cognitive impair- should be applied to minimize adverse drug outcomes. ment, especially executive dysfunction.102,103 Evidence also Meta-analyses also suggest that longer antidepressant treat- 116 suggests that late-onset depression or depressive symptoms ment trials (10-12 weeks) are required in LLD. may be a prodrome for dementia; hence, monitoring of cog- 104,105 nition at initial assessment and over time is warranted. 6.20. What Is the Pharmacological Approach to LLD? 6.18. What Is the Role of Nonpharmacological An inherent paradox in the treatment of LLD stems from the dissonance between routine clinical practice and RCT evi- Treatments in LLD? dence. For example, while citalopram and escitalopram are Meta-analyses have demonstrated efficacy for psychological generally considered by clinicians to be first-line treatments treatments of depression in older adults,106 with even higher for LLD due to tolerability and fewer drug interactions,117- effect sizes when minor depression and dysthymia were 119 none of the RCTs involving these drugs demonstrated included.107 Newer meta-analyses have addressed some superiority over placebo in the elderly,120-122 with the excep- methodological issues in earlier studies—namely, the need tion of citalopram in a subset of old-old (>75 years) patients for randomization of treatment and the need to assess the with severe depression (Hamilton Depression Rating Scale effect of the type of control group on the magnitude of psy- score > 24).120 In fact, a meta-analysis of 7 studies demon- chotherapy effects. A meta-analysis of 27 RCTs including strated no difference between citalopram and other antide- 2245 participants demonstrated great variability in standar- pressants for depression remission or trial withdrawal for dized mean differences of 0.05 to 1.36 depending on the adverse effects.123 In contrast, geriatric clinicians are reluc- control group.108 In this meta-analysis, psychotherapies tant to prescribe paroxetine due to anticholinergic effects and (including bibliotherapy) yielded large effects compared fluoxetine due to drug interactions, yet these same SSRIs with waitlist and attention controls but small to moderate have positive RCT evidence in the treatment of LLD.124,125 effects compared with supportive therapy or treatment as Thus, treatment recommendations for LLD have been evi- usual. The authors suggested that supportive therapy best dence-informed, rather than evidence-based.119 controlled for the nonspecific elements of psychotherapy and Overall, recent systematic reviews and meta-analyses should be used as the control for future studies and that support the efficacy of antidepressants in LLD, with no problem-solving therapy (PST) has the strongest evidence difference between SSRI and SNRI classes,126 and in base using supportive therapy as a control.108 A recent adult-onset MDD where episodes recurred in LLD.127 A meta-analysis assessed the efficacy of PST in MDD in older subsequent meta-analysis, in adult and geriatric populations, adults, demonstrating that PST significantly reduced depres- demonstrated that antidepressants are efficacious for depression rating scale scores and reduced disability. The authors sion in adults 55þ years of age.128 However, drug-placebo also noted that PST is one of the few therapies studied in differences for studies with an entry criterion of 65þ years older people with cognitive impairment and executive were modest and nonsignificant. Heterogeneity, small study dysfunction.109 number, physical comorbidity, and chronicity were all considered to affect the ability of a trial to separate drug from 128 6.19. What Are the Principles of Pharmacological placebo effects. A recent network meta-analysis, with response as an outcome (>50% reduction in depression score Treatment of LLD? from baseline), demonstrated relative risks compared to pla- The adage of ‘‘start low and go slow (and keep going)’’ is cebo of greater than 1.2 for only 3 drugs: sertraline, parox- relevant in LLD. Divisions into young-old (<75 years) and etine, and duloxetine.129 A meta-analysis of moderators of

89 La Revue Canadienne de Psychiatrie 61(9) 597 treatment response in LLD suggests older adults with longer efficacy for depressive symptoms irrespective of baseline illness duration and moderate to severe depression benefit sleep, anxiety, or pain.138 from antidepressants compared to placebo, whereas short When prescribed for dementia, antipsychotic medica- illness duration does not show antidepressant response.130 tions are associated with increased risk of all-cause mor- Furthermore, executive dysfunction, especially in the sub- tality, with greater risks for typical than atypical domains of planning and organization, has been associated antipsychotics; the risk is less well elucidated in cogni- with poor antidepressant treatment response in LLD, which tively intact elderly populations.139 Antipsychotic medi- may be a factor in trial heterogeneity.131 One can speculate cations may be considered in selected elderly individuals, that vascular depression, associated with executive dysfunc- recognizing that the risk profile in cognitively intact indi- tion, may be more resistant to traditional pharmacotherapeu- viduals has not been confirmed. tic approaches, and may be related to depressive syndromes that are in fact early manifestations of dementia. These are important considerations when assessing lack of response to 6.22. What Is the Recommended Sequential Approach initial treatment approaches. Among new antidepressants, vortioxetine and agomelatine have been evaluated in LLD. to Pharmacological Treatment of LLD? An RCT (N ¼ 453) comparing vortioxetine, duloxetine, and There is support for a stepwise approach to treatment of LLD placebo demonstrated significant reduction of depression in providing the best likelihood of achieving response and scores with both comparators versus placebo in adults remission.119 In 2 large studies, IMPACT140,141 and PROS- (aged 65þ years) with depression. Additionally, both med- PECT,142,143 elderly depressed patients randomized to a ications improved verbal learning, with vortioxetine stepwisealgorithmicapproachweremuchmorelikelyto demonstrating an additional improvement in processing improve than if they were randomized to usual care. Specif- speed.132 Agomelatine was associated with improved ically, the odds ratio for IMPACT versus usual care was 3.45 depressive symptoms and better treatment response than (response rate 45% vs. 19%; P < 0.001), and for PROSPECT placebo but did not separate from placebo for remission.133 versus usual care, the odds ratio was 2.13 (likelihood of There is also evidence to support efficacy of continuation remission, 43% vs. 28%; P < 0.05). and maintenance treatment in LLD. A meta-analysis of 8 A systematic review and meta-analysis of treatment- double-blind RCTs found antidepressants effective in pre- resistant depression (defined as failure to respond to at least venting relapses and recurrences in the elderly, with similar 1 treatment) in adults aged >55 years identified a dearth of tolerability for TCAs and SSRIs.134 randomized trial data for this patient population. Half of the participants responded to a switch or augmentation strategy, with lithium augmentation demonstrating the most consis- 144 6.21. Is There a Role for Atypical Antipsychotic tent data for all approaches. Of all studies included in the analysis, a sequential treatment strategy provided the highest Medication in LLD? response rates.145 In a post-hoc analysis pooling clinical trial data of the 61- to For LLD, RCT data generally only assess an individual 67-year age group, adjunctive aripiprazole and antidepres- step in an algorithmic or stepwise approach. Given the chal- sants showed a large effect size of 0.8 compared to placebo; lenges in interpreting the evidence in LLD, therefore, an the most common side effects were akathisia and dizzi- evidence-informed sequential treatment approach is recom- ness.135 A recent National Institute of Mental Health–funded mended, rather than simply extrapolating from individual RCT (N ¼ 181) reported on aripiprazole augmentation (10- trials (Table 6). While good clinical judgement suggests 15 mg) in older adults (aged 60þ years) with late and early choosing antidepressants to avoid mechanisms that may be onset LLD who were nonremitters to venlafaxine XR mono- harmful in the elderly (e.g., avoiding anticholinergic antide- therapy. For remission, aripiprazole was superior to placebo pressants to minimize confusion and delirium risk), there is (40/91 [44%] vs. 25/90 [29%], respectively). The most com- yet little evidence over the long term to support ad-hoc tai- mon adverse events were akathisia (26%) and Parkinsonism loring of antidepressant choices to target symptom clusters (17%). Serious adverse events were reported in 4% of or to leverage specific side effects for therapeutic benefit. patients on aripiprazole and 2% on placebo, with 6% dis- For example, evidence does not necessarily support that continuation on aripiprazole and 9% with placebo.136 using a sedating medication to optimize sleep in a depressed An RCT (N ¼ 338) of older adults (aged 65þ years) with patient improves overall outcomes over the course of treat- MDD found that quetiapine XR monotherapy (median dose ment or longer. It is possible, for example, that when depres- 158.7 mg) demonstrated efficacy versus placebo in depression has remitted and sleep has normalized that the ongoing sion scores, response, and remission rates.137 However, sub- sedating effects of medications contribute to noncompliance group analysis of participants aged 75þ years demonstrated or lack of tolerability. Hence, use of medications in a con- only a trend-level significance for depression score reduction sistent and algorithmic manner is suggested, leveraging the (P ¼ 0.068). Dropout rates were 9.6% for quetiapine XR extensive evidence for this approach to optimize depression versus 4.1% for placebo.137 Post-hoc analysis demonstrated outcomes.119

90 598 The Canadian Journal of Psychiatry 61(9)

Table 6. Algorithmic Pharmacological Treatment of Late-Life professional development (CPD) projects are accredited by Depression. academic institutions. CANMAT has diverse funding, but in the past 5 years (2011-2015), sources of CANMAT revenue Level of Recommendation Treatment Evidence (excluding CIHR and research funding) included national/ international scientific conferences (28% of revenue), pub- First line Duloxetine, mirtazapine, Level 1 lications (26%), industry-supported CPD projects (26%), nortriptyline and academic projects (18%). Bupropion, citalopram/escitalopram, Level 2 The CANMAT guidelines are not officially endorsed by desvenlafaxine, duloxetine, sertraline, venlafaxine, the Canadian Psychiatric Association. vortioxetine Declaration of Conflicting Interests Second line Switch to Nortriptyline Level 1 The author(s) declared the following potential conflicts of interest Moclobemide, phenelzine, Level 2 with respect to the research, authorship, and/or publication of this quetiapine, article: trazodone GMM has been on advisory boards or a speaker for Janssen, Bupropion Level 3 Lilly, Lundbeck, and Pfizer. Combine with BNF has received honoraria for ad hoc speaking or advising/ Aripiprazole, lithium Level 1 consulting or received research funds from Alternative Funding Methylphenidate Level 2 Plan Innovations Award, AstraZeneca, Brain & Behavioral Foun- Third line Switch to dation, Bristol-Myers Squibb, Canadian Institutes of Health Amitriptyline, imipramine Level 2 Research, Canadian Network for Mood and Anxiety Treatments, Combine SSRI or SNRI with Canadian Psychiatric Association, Daiichi Sankyo, Eli Lilly, Bupropion, SSRI Level 3 Hamilton Health Sciences Foundation, J. P. Bickell Foundation, Lundbeck, Lundbeck International Neuroscience Foundation, SNRI, serotonin and norepinephrine reuptake inhibitor; SSRI, selective ser- Ontario Brain Institute, OMHF, Ontario Ministry of Research and otonin reuptake inhibitor. Innovation, NSERC, Pfizer, Servier, Society for Women’s Health Research, Sunovion, and the Teresa Cascioli Charitable Foundation. Summary ZI has received honoraria for ad hoc speaking or advising/con- Depression is common across the life span. While special sulting or received research funds from Canadian Biomarker Inte- populations (children and youth, women in the perinatal or gration Network for Depression, Canadian Consortium for menopausal period, and older adults) bring unique chal- Neurodegeneration and Aging, Canadian Institutes of Health lenges, the essential approach to depressive episodes is sim- Research, Janssen, Joan and Clifford Hatch Foundation, Katthy Taylor Chair in Vascular Dementia, Lundbeck, National Institute ilar to that of the general adult population. Careful diagnosis, of Aging, Ontario AFP Innovation Fund, Otsuka, Pfizer, and evidence-based evaluation of the risk-benefit ratios of spe- Sunovion. cific treatment strategies, and careful monitoring of out- NJ has no financial conflicts to declare. comes are universal elements of optimal treatment. MS has no financial conflicts to declare. Evidence for efficacy of treatments in these populations is RJV has no financial conflicts to declare. often more limited than for the general population, and risks SHK has received honoraria for ad hoc speaking or advising/ of treatment in these groups are often poorly studied and consulting or received research funds from Allergan, Brain Canada, reported. Despite the limited evidence base, extant data and Bristol-Myers Squibb, Canadian Institutes of Health Research, clinical experience suggest that each of these special popula- Janssen, Lundbeck, Ontario Brain Institute, Pfizer, St. Jude Medi- tions can benefit from the systematic application of treat- cal, Servier, and Sunovion. ment guidelines for treatment of depression. RWL has received honoraria for ad hoc speaking or advising/ consulting or received research funds from Asia-Pacific Economic Cooperation, AstraZeneca, Brain Canada, Bristol-Myers Squibb, Canadian Institutes of Health Research, Canadian Depression Disclosures Research and Intervention Network, Canadian Network for Mood The guidelines process and publication were funded entirely and Anxiety Treatments, Canadian Psychiatric Association, Coast by internal CANMAT funds; no external support was sought Capital Savings, Johnson & Johnson, Lundbeck, Lundbeck Insti- or received. No honoraria were paid to authors, and no pro- tute, Medscape, Pfizer, St. Jude Medical, Takeda, University fessional editorial assistance was used. All members of the Health Network Foundation, and Vancouver Coastal Health Research Institute. CANMAT Depression Work Group disclosed potential con- RVM has received speaker and consultant honoraria or research flicts of interest (available at www.canmat.org). CANMAT funds from Allergan, Bristol-Myers Squibb, Canadian Institutes of is a project-driven organization governed by a volunteer, Health Research, Canadian Network for Mood and Anxiety Treat- unpaid advisory board, with no permanent staff or dedicated ments, Canadian Psychiatric Association Eli Lilly, Johnson & John- offices. CANMAT has a conflict of interest policy that son, Lallemand, Lundbeck, Merck, Ontario Brain Institute, Ontario includes disclosures by all participants, and all continuing Mental Health Foundation, Otsuka, Paladin, Pfizer, Queen’s

91 From CADDRA (Canadian ADHD Resource Alliance - Third Edition)

CHAPTER 1: DIAGNOSIS AND OVERVIEW OF VISITS

The Management of Uncomplicated ADHD From Diagnosis to Treatment We are well aware that a busy family or primary paediatric practice may not have the luxury of time to carry out the longer assessment typical of a specialist paediatric or psychiatric visit. With this in mind, we have piloted this visit schedule with family doctors and community paediatricians in Canada for feedback and we are confident it is user-friendly, although remuneration schedules in some regions may make this schedule difficult to implement. We feel the comprehensive nature of the assessment adds credibility to the diagnosis. The work can be done in multiple visits that are as effective – if not more – than a single, longer one.

In Canada, paediatricians and family physicians are on the front line in screening for, assessing, and initiating treatment for ADHD in children, while adult psychiatrists and family doctors assess and manage adults with ADHD. However, since ADHD is the most common childhood psychiatric disorder11, adequate levels of service delivery for ADHD are only going to be feasible when it becomes a disorder that primary care providers are trained to deal with, and when they can access specialist care when needed.

This outline is organized around proposed assessment and treatment visits. Physicians can use this as a guide. The objective of our summary is to allow physicians to know how to screen for ADHD across the lifespan, to conduct a reasonable assessment in simpler cases, and to know when to refer.

In complicated cases of ADHD (ADHD Complex) – where there are comorbid conditions, differential diagnosis and management with often multiple interventions and multiple medications – assessment and treatment of ADHD may be more difficult. It is the view of the CAP-G Committee that in such cases the patient should be referred to a specialist. However, once the patient is assessed and treatment initiated, it is reasonable for follow-up to be conducted by family doctors and primary care pediatricians.

CADDRA ADHD Assessment Toolkit (CAAT) – Overview The CADDRA ADHD Assessment Toolkit is broken into CAAT Forms and CAAT Handouts sections (see index at the start of each). The required assessment templates, questionnaires and handouts are within each section. These tools are free to download from www.caddra.ca and print or duplicate as long they are not altered and the CADDRA logo and the appropriate credits remain intact. This toolkit is designed to support clinicians familiar with ADHD. Clinicians not familiar with ADHD are urged to attend training programs (including those hosted by CADDRA) or to go to the website for online training programs when they become available. Further information can be obtained from www.caddra.ca.

The assessment templates can be photocopied and used as follows: 1. The CADDRA ADHD Assessment Form and the CADDRA Patient ADHD Medication Form (to record somatic symptoms present prior to treatment) allow the doctor to document his/her findings during the interview itself and therefore provide a permanent record of the history and the supporting information for diagnosis. Should a report ever be required, the CADDRA ADHD Assessment Form allows for easy review/dictation in a logical format, even when the interview itself ran in different directions. 2. Rating scales and questionnaires can be used as an efficient way to obtain information from the patient and collateral sources. They are NOT diagnostic. They remain a part of the medical record and document change over time. It is important to remember that these tools measure the presence of symptoms but not their cause. Clinical judgement is mandatory for the interpretation of the results.

Chapter 1 92 1.1 Reasons For Assessment or Referral Patients may come to you or are referred for a wide variety of reasons: 1. someone close to the patient has learned about ADHD and recognizes traits in the patient (e.g. a relative, teacher, employer, colleague or friend) 2. the patient (typically an adolescent or an adult) has learned about ADHD and recognizes the relevant symptoms 3. a relative has already been diagnosed with ADHD and this triggers an awareness of ADHD within the patient (e.g. a child is diagnosed and one or both the parents think they may also have ADHD) 4. there are functional difficulties that the patient presents with (such as behavioural or attention problems, academic issues, difficulty with paperwork, time management, driving, smoking or marital problems) and the clinician postulates ADHD as a possible explanation.

Some physicians may be wary of patients self-referring with a possible ADHD diagnosis. They may suspect that the patient is looking for drugs, adaptations or an explanation/excuse for other problems. Clinical experience indicates this is an infrequent occurrence.

Practice Point: Keep in mind that self-referral neither guarantees nor eliminates a diagnosis of ADHD.

VISIT 1: SCREENING VISIT AND/OR TELEPHONE SCREEN

Presenting Complaint and Documentation Initiation Review with the parents/patient their concerns, the reason for referral and the parents'/patient’s hopes for the assessment.

Practice Point: Simple questions to ask (any one should trigger concern). With an adult, clarify if the symptoms have been present since they were young. 1. Do you find it harder to focus, organize yourself, manage time and complete paperwork than most people? 2. Do you get into trouble for doing impulsive things you wish you had not? 3. Do you find you are always on the go, or that you are constantly restless or looking for something exciting to do? 4. Do you find it really difficult to get motivated by boring things, though it is easier to do the things you enjoy? 5. Do people complain that you are annoying or are easily annoyed, unreliable or difficult to deal with?

If there is any suspicion of ADHD, begin to complete the CADDRA ADHD Assessment Form. Physicians may be somewhat reluctant to complete the semi-structured interview and scales we have provided for assessment since it is their usual practice to take notes as they go. They may feel patients will find this process tedious or that it interferes with their ability to “create a relationship”. We would suggest that patients are more likely to be pleased to know their doctor is conducting a full and systematic evaluation. The interview is designed to document all necessary information and it can be inserted directly into your medical records to document care.

1.2 Version: November 2014. Refer to www.caddra.ca for latest updates. 93 Practice Point: Make sure you review the patient’s strengths NOT just his or her areas of weakness. This establishes a rapport with a child, adolescent or adult and their family that makes future visits easier and can aid intervention planning. A useful rule of thumb is to ensure that each interview ends with a statement about the courage and coping skills that the patient and/or family have used to work with difficult circumstances, outlining and affirming the importance and value of these efforts.

ACTION At the END of the Screening Visit: 1. give the patient the relevant inventories necessary for the next visit (see age group below) 2. ask the patient to bring all documentation from their past (e.g. school report cards, assessments, etc.) 3. obtain written consent to release information for institutional documentation 4. book the next appointment.

It is recommended that physicians complete an assessment form (A), a screener (S) and at least one rating scale (R). For children, the CADDRA Teacher Assessment Form (T) is also suggested; for adults, a collateral rating scale is useful. Follow-up forms (F) are also recommended, but a baseline of the chosen forms must be carried out initially.

Children and Adolescents (age 6 to 18): 1. CADDRA Information and Resources (Handout) 2. ADHD Checklist (R) (F) 3. Weiss Symptom Record (WSR) (S) for parents, teachers and adolescents in high school 4. Weiss Functional Impairment Rating Scale for Parents (WFIRS-P) (R) 5. CADDRA Teacher Assessment Form (T) to be completed by the teacher who knows the patient best 6. SNAP-IV-26 (R) 7. CADDRA Child or Adolescent Assessment Instructions 8. CADDRA Teacher Instructions.

Adults: 1. CADDRA Information and Resources (Handout) 2. ADHD Checklist (R) (F) to document child symptoms by patient and other, can also be used to document current symptoms 3. Adult ADHD Symptom Rating Scale (ASRS) (R) 4. Weiss Symptom Record (WSR) (S) for the patient and their significant other, close friend or parent 5. Weiss Functional Impairment Rating Scale – Self Report (WFIRS-S) (R) 6. CADDRA Adult Assessment Instructions

Practice Point: Adults are not very good at bringing back forms so it might be better for them to fill out the relevant questionnaires in the office before they leave.

Chapter 1 94 1.3 VISIT 2: MEDICAL HISTORY AND PHYSICAL EXAM

Objectives for this Visit 1. collect the documentation from past records 2. obtain the relevant questionnaires for scoring before visit 3 3. determine if there is any missing information from the previous session 4. continue the CADDRA ADHD Assessment Form to: ■ complete the physical examination (or document that a physical examination was completed by a colleague)

■ ensure that there are no other medical causes of the symptoms of ADHD

■ review the possible medical consequences of having ADHD (e.g. accidents, sleep, poor nutrition)

■ ensure that there are no medical contraindications to the use of medications for the impairing ADHD symptoms.

Practice Point: If there are any signs or symptoms of a physical illness that may be a factor in explaining the clinical symptoms, this takes precedence in the evaluation. Only when these factors are ruled out should the following steps be taken.

ACTION At the END of this Visit: 1. review the list of documents required. Remind the patient of what is missing and give them a list 2. order any relevant clinical tests based on the physical findings to rule out medical causes and risk factors 3. obtain written consent to release information for institutional documentation (if more required) 4. make referrals for medical assessments if necessary (e.g. occupational therapist if there are coordination problems; speech and language therapist for expressive or receptive language problems) 5. book the next appointment and, if patient is an adult, arrange to obtain information from a collateral source that knows the patient’s early childhood experiences (such as parents, if possible).

Practice Point: If parents strongly object to involving a child's school, the physician should let the parent know that without an understanding of whether there are ADHD difficulties in the classroom he/she will only be able to provide a limited assessment. We have not encountered any problems with regard to schools refusing to complete the forms and have designed them to be as efficient as possible for the teacher. If this issue were to arise, it would be important to provide the parent with your telephone number and request that the parent ask the teacher or principal to call so that the matter can be discussed.

1.4 Version: November 2014. Refer to www.caddra.ca for latest updates. 95 VISIT 3: ADHD INTERVIEW (Over several visits if needed)

Practice Point: Begin the interview by talking about the patient’s strengths that were uncovered in the first session. The patient may not show clinical symptoms in your office setting. If there are obvious symptoms of motor hyperactivity, impulsivity and inattention, it suggests that the symptoms are more severe. Part of an ADHD assessment is observing not only the nature of the impairment and symptoms but the triggers that allow them to become apparent.

The Objectives for this Visit(s)

■ Do a complete review of the childhood developmental history for adults and a review for children/ adolescents, determining that relevant symptoms were there before the age of seven

■ Assess whether there are any life events that were of emotional concern in childhood (e.g., abuse, deaths, major changes)

Practice Point: ADHD is a biologically-based disorder. Try to separate out symptoms caused by psychosocial stressors. This can be very difficult, particularly when the patient has suffered significant loss or trauma.

■ Obtain collateral information from the patient’s mother/father or from a close relative that knows the patient’s childhood story

Practice Point: Some parents tend to dismiss problems in their adult children but will be able to tell stories about their behaviour if asked. It is also useful to establish the patient’s temperament as a child.

■ Review the CAAT Rating Scales: ADHD Checklist, Weiss Symptom Record, WFIRS-P, the CADDRA Teacher Assessment Form (for children/adolescents) and WFIRS-S (for adults)

Practice Point: It is useful to make your clinical impression BEFORE you look at the results of the questionnaires. Then see if the data from the questionnaires supports or refutes your conclusions.

ACTION At the END of the Interview Section: 1. make necessary referrals for specialty assessment (e.g. to a psychologist; for an adult, to a psychiatrist or neurologist; for a child/adolescent to a developmental paediatrician, child and adolescent psychiatrist or paediatric neurologist) 2. make any necessary referrals based upon clinical findings 3. request a psychoeducational assessment if indicated (see Chapter 6; Supporting Documents 6A) 4. continue to emphasize the need for them to learn about ADHD and ensure they are aware of the relevant websites for more information 5. provide them with any handouts from the toolkit or supporting documents 6. arrange for the feedback and treatment appointment.

Chapter 1 96 1.5 Practice Point: Some students will be able to access psychoeducational assessment through their school system. For patients who can afford a private assessment, it is useful to have a list of local psychologists who offer assessment of learning and support needs in the context of ADHD, including strategies for successful accommodations at school. Sometimes local colleges and universities offer psychometric assessments at a reduced rate as they need subjects for their psychology interns. This may help reduce costs.

VISIT 4: FEEDBACK AND TREATMENT RECOMMENDATIONS

Only proceed to feedback and treatment if the patient:

■ has well documented evidence of impairment

■ meets the thresholds for ADHD on the assessment batteries

■ shows no other medical problems that would contraindicate further treatment

■ has uncomplicated ADHD, i.e., no comorbid disorders (except Oppositional Defiant Disorder)

■ is motivated to learn about ADHD (adult) or has parent(s)/guardian(s) that are motivated.

If the patient does not meet this threshold then:

■ backtrack to see where the problem may have arisen and clarify using appropriate interventions

■ pursue referrals to ADHD specialists.

Feedback of the Diagnosis 1. Review the threshold rating scales to determine if they meet criteria for ADHD. Look for consistency between the rating scales and between observer comments 2. Review the developmental history, identifying impairments which are often associated with ADHD, symptoms noted clinically and on the Weiss Functional Impairment Rating Scale (WFIRS) 3. For children/adolescents review the CADDRA Teacher Assessment Form 4. Review all other documentation, such as report cards and prior assessments, to determine if there is consistency 5. Give feedback related to the interview and collateral sources 7. Based on the findings above, present the diagnosis and any other concerns that might be relevant.

Dispelling Myths Many patients come into an assessment for ADHD with false information or beliefs. Examples are:

■ I am just lazy and looking for an excuse

■ I don’t want to take medication that could change my personality

■ I am not the one with the problem, my spouse/employer/parent/teacher/school system is the problem

■ I had it as a child but it went away

■ I don’t have all of the clinical symptoms

■ ADHD is just a current fad

■ and more ….

1.6 Version: November 2014. Refer to www.caddra.ca for latest updates. 97 Practice Point: This is a diagnosis that arouses a lot of emotion. It is very important to ensure that the patient and their family's concerns are heard and not dismissed. This is a collaborative process. This is even truer when there are differences between the patient and the person who initiated the referral. When there are conflicts, it is useful to focus on the person's strengths and to avoid blaming. Often the negative emotion emanates from fear and the loss of control. Empowerment is healing.

Feedback of the Treatment Plan12 1. Ask the patients for their feelings, questions and reactions 2. Explain the impact of the diagnosis in school/vocational settings. E.g. documentation on the official diagnosis may be critical in order to receive various benefits (e.g. special funding) and accommodations 3. Review the areas of impairment, trying to narrow down the major symptom that is troubling the individual 4. Explain the multimodal treatment agenda:

■ The need for more education

■ Psychosocial treatments explaining the behavioural–lifestyle agenda, the school/vocational accommodations required, and the psychological interventions to deal with self-esteem and life stressors

■ Medication agenda – using medications to support the psychosocial agenda. 5. Relay the diagnosis through your report to stakeholders (with the patient’s consent) 6. Arrange for follow-up, referrals, consultations, laboratory work or other interventions as needed.

ACTION At the END of this Visit: 1. give the patient the necessary handouts related to the treatment plan for them to review, including the psychosocial and medical treatment information 2. make the necessary referrals for the psychosocial agenda or schedule the patient with you if you are the provider 3. book the next appointment for the medication discussion.

VISIT 5: MEDICAL TREATMENT AND ADVOCACY

Objectives for this Visit (Go to Chapter 7 for a detailed review of medications) 1. Discuss the medical treatment options 2. Select the initial medication and review the dosing strategy. Begin with the minimum dose recommended in these Guidelines and increase slowly in order to assure the optimum comfort on medication.

Practice Point: Sometimes the medical treatment is in response to a short-term emergency (e.g. aggression) but the long-term objective is improving functioning with a better quality of life and long-term maintenance.

Chapter 1 98 1.7 ACTION At the END of this Visit provide:

■ a prescription if clinically indicated and the patient is ready and requests to start medication

■ the 26 item ADHD Checklist (to be completed by patient, teacher or significant other before and for the period during which the patient is on optimal medication)

■ the CADDRA Patient ADHD Medication Form should be filled out by the patient or parent(s) before medication is started and then regularly (see Practice Point) based on current symptoms

■ an appointment for follow-up regarding the medication effects. Remind the patient/parent(s)/ guardian(s) that they are to bring the CADDRA Patient ADHD Medication Forms, the ADHD Checklist and, where relevant, the CADDRA Teacher Assessment Form to each visit.

Practice Point: While adjusting the medication, we suggest the patient or parent completes the CADDRA Patient ADHD Medication Form every Wednesday and Saturday evening based on the day’s symptoms. Collecting information in the middle of the week and at the weekend gives a better view of everyday symptom control and medication tolerability.

Follow-up Visits

■ Follow-up every three to four weeks is necessary until medication is optimized. A telephone call or secured email communication may be sufficient in the interim to ensure the patient has access to the doctor in case of questions related to efficacy or side effects.

■ Once an optimal dose has been determined, the ideal medication follow-up would be every three months.

Drug "Holidays" CB

■ Non-stimulant medications are usually given continuously as they rely on a blood level being sustained to establish treatment efficacy as mentioned in product monographs. However, for all medications, a trial of dose reduction or discontinuation is necessary at some point to determine if they are needed, and what positive and negative effect they are having

■ Drug "holidays" for children with ADHD have been controversial. It has been argued that the risks of medication discontinuation exceed any potential benefits. More recently, the finding from the Multimodal Treatment of ADHD13 study (that intermittent use of medication diminishes loss of height and weight) again brought the topic to the forefront, with physicians asking if drug "holidays" may have the same effect. Drug "holidays" have been described as having other important advantages. For example, they ensure that the patient and physician continue to monitor benefits and risks of medication or continued need for medication. In the event of deterioration, medication can be restarted. For children and adolescents, drug "holidays" may have an educational function in allowing them to be able to report subtle psychiatric side effects or to recognize beneficial effects they were not aware of. It is also not currently known if time off medication may minimize tolerance, dose increases, or total lifetime dose of exposure. At this time, there is no data to provide a definite recommendation on drug "holidays" and our consensus CB recommendation is that the risks, benefits and alternative coping strategies be discussed with each family and that an individualized approach be taken.

1.8 Version: November 2014. Refer to www.caddra.ca for latest updates. 99 SUPPORTING DOCUMENT 7A SUPPORTING DOCUMENT 7A: CANADIAN MEDICATION TABLES PER AGE GROUP Children's Medical Treatment Options (6-12 years)

Table 1. MEDICAL TREATMENT FOR ADHD UNCOMPLICATED – CHILDREN Alphabetically Listed – Refer to product monographs for complete prescribing information.

Brand Name Dosage Form Starting Dose* Titration Schedule Maximum per day1 (active chemical) Every 7 days (up to 40 kg child)

Per product Per CADDRA Per Product Per CADDRA Monograph Board Monograph Board*

FIRST LINE AGENTS – long-acting preparations

Adderall XR® 5, 10, 15, 20, 5-10 mg q.d. a.m.* r 5-10 mg r 5 mg 30 mg 30 mg (amphetamine mixed salts) 25, 30 mg cap

Biphentin® 10, 15, 20, 30, 40 10-20 mg r 10 mg r 5-10 mg 60 mg 60 mg (methylphenidate HCl) 50, 60, 80 mg cap q.d. a.m.

Concerta® 18, 27, 36, 54 18 mg q.d. a.m. r 18 mg r 9-18 mg 54 mg 72 mg (methylphenidate HCl) mg tab

Vyvanse® 20, 30, 40, 20-30 mg By clinical r 10 mg 60 mg 60 mg (lisdexamfetamine dimesylate) 50, 60 mg cap q.d. a.m. discretion

CB Doses per CADDRA Board that are over or under product monograph maximum or minimum doses should be considered off-label use. *CADDRA recommends generally starting at the lowest dose available. Young children should be started at the lower end of the recommended CADDRA dose and titrated slowly, e.g. Concerta: 18, 27, 36 and Biphentin 10, 15, 20 mg. A consensus decision has been made based on clinical use and research data.

SECOND LINE/ADJUNCTIVE AGENTS – long-acting preparations Non psychostimulant - selective norepinephrine reuptake inhibitor

CB Indications for use: Monotherapy for the treatment of ADHD in children aged 6-12 years (off-label: prescribed as an adjunctive therapy). Strattera® 10, 18, 25, 0.5 mg/kg/day Maintain dose for Maintain dose for lesser of lesser of a min. of 7-14 days a min. of 7-14 days (atomoxetine) 40, 60, 80, before adjusting to before adjusting to 1.4 mg/kg/day 1.4 mg/kg/day 100 mg cap 0.8 mg/kg/day then 0.8 mg/kg/day then or 60 mg/day or 60 mg/day 1.2 mg/kg/day 1.2 mg/kg/day SECOND LINE/ADJUNCTIVE AGENTS – long-acting preparations

Non psychostimulant - selective Alpha2A-adrenergic receptor agonist

CB Indications for use: Monotherapy and as an adjunctive therapy to psychostimulants for the treatment of ADHD in children aged 6-12 years with a sub-optimal response to psychostimulant.

Maintain dose for Maintain dose for Intuniv XR® 1, 2, 3, 4 mg tab 1 mg a min. of 7-14 days a min. of 7-14 days 4 mg 4 mg (guanfacine XR) before increasing by before increasing by no more than 1 mg no more than 1 mg

per week up to a per week up to a max. 4 mg daily dose max. 4 mg daily dose

Chapter 7 100 7.11 TABLE 1. MEDICAL TREATMENT FOR ADHD UNCOMPLICATED – CHILDREN (CONTINUED) Alphabetically Listed – Refer to product monographs for complete prescribing information.

Brand Name Dosage Form Starting Dose* Titration Schedule Maximum per day1, 2 (active chemical) Every 7 days (>40 kg)

Per Product Per CADDRA Per Product Per CADDRA Monograph Board Monograph Board*

SECOND LINE/ADJUNCTIVE AGENTS – short-acting and intermediate-acting preparations

CB Indications for use: a) p.r.n. for particular activities; b) to augment long-acting formulations early or late in the day, or early in the evening and c) when LA agents are cost prohibitive. To augment Adderall XR® or Vyvanse®, short-acting and intermediate-acting dextro-amphetamine products can be used. To augment Biphentin® or Concerta® short-acting MPH products can be used. b.i.d. refers to qam and qnoon and t.i.d. refers to qam, qnoon and q4pm.

Dexedrine® 5 mg tab 2.5-5 mg b.i.d. r 2.5-5 mg r 2.5-5 mg 40 mg 20 mg (dextro-amphetamine sulphate)

Dexedrine® Spansule2 10, 15 mg cap 10 mg q.d. a.m. r 5 mg r 2.5-5 mg 40 mg 30 mg (dextro-amphetamine sulphate)

Ritalin® 10, 20 mg tab 5 mg b.i.d. r 5-10 mg r 5 mg 60 mg 60 mg (methylphenidate) to t.i.d.

Ritalin® SR3 20 mg tab 20 mg q.d. a.m. r 20 mg r 20 mg 60 mg 60 mg (methylphenidate HCl)

1 The maximum daily dose can be split into once daily (q.d.), twice daily (b.i.d.) or three times daily (t.i.d.) doses except for once a day formulations. Refer to the adolescent table for children over 40kg. 2 Dexedrine® Spansule may last 6-8 hours 3 Ritalin® SR may help cover the noon period but clinical experience suggests an effect similar to short-acting preparations. An increased dose could be spread out to include q2pm dose with a daily maximum of 60 mg. * CADDRA recommends generally starting at the lowest starting dose available.

GENERIC MEDICATIONS PMS® or Ratio®- 5, 10, 20, 5 mg q.d. a.m. r 5 mg r 5 mg 60 mg 60 mg methylphenidate mg tab and noon (add q4pm dose) Novo-MPH ER-C® 18, 27, 36, 54 18 mg q.d. a.m. r 18 mg r 9-18 mg 54 mg 72 mg (methylphenidate) mg tab

THIRD LINE AGENTS These medications (except for clonidine) should only be initially or first prescribed by a specialist.

7.12 Version: November 2014. Refer to www.caddra.ca for latest updates. 101 Medication for Adolescents with ADHD

TABLE 2. MEDICAL TREATMENT FOR ADHD UNCOMPLICATED – ADOLESCENTS Alphabetically Listed – Refer to product monographs for complete prescribing information.

Brand Name Dosage Form Starting Dose* Titration Schedule Maximum per day1, 2 (active chemical) Every 7 days (>40 kg)

Per Product Per CADDRA Per Product Per CADDRA Monograph Board Monograph Board*

FIRST LINE AGENTS – long-acting preparations

Adderall XR® 5, 10, 15, 20, 5-10 mg q.d. am r 5-10 mg r 5 mg 20-30 mg 50 mg (amphetamine mixed salts) 25, 30 mg cap

Biphentin® 10, 15, 20, 30, 40 10-20 mg r 10 mg r 5-10 mg 60 mg 80 mg3 (methylphenidate HCl) 50, 60, 80 mg cap q.d. am

Concerta® 18, 27, 36, 54 18 mg r 18 mg r 9-18 mg 54 mg 90 mg (methylphenidate HCl) mg tab q.d. am (54 + 36 mg)

Vyvanse® 20, 30, 40, 20-30 mg By clinical r 10 mg 60 mg 70 mg (lisdexamfetamine 50, 60, mg cap q.d. am discretion dimesylate)

CB * Doses per CADDRA Board that are over or under product monograph maximum or minimum doses should be considered off-label use. Note: CADDRA recommends generally starting at the lowest starting dose available. A consensus decision has been made based on clinical use and research data.

SECOND LINE/ADJUNCTIVE AGENTS – long-acting preparations Non psychostimulant - selective norepinephrine reuptake inhibitor

CB Indications for use: a) Monotherapy for the treatment of ADHD (off-label: prescribed as an adjunctive therapy). Strattera® 10, 18, 25, 0.5 mg/kg/day Maintain dose for a Maintain dose for a lesser of lesser of min. of 7-14 days min. of 7-14 days (atomoxetine) 40, 60, 80 before adjusting before adjusting 1.4 mg/kg/day 1.4 mg/kg/day 100 mg cap 0.8 mg/kg/day then 0.8 mg/kg/day then or 100 mg/day or 100 mg/day 1.2 mg/kg/day for 1.2 mg/kg/day for patients <70kg4 patients <70kg4 SECOND LINE/ADJUNCTIVE AGENTS – short-acting and intermediate-acting preparations

Dexedrine® 5 mg tab 2.5-5 mg b.i.d. r 5 mg r 2.5-5 mg 40 mg 30 mg (dextro-amphetamine sulphate)

Dexedrine® Spansule5 10, 15 mg cap 10 mg q.d. a.m. r 5 mg r 2.5-5 mg 40 mg 30 mg (dextro-amphetamine sulphate)

Ritalin® 10, 20 mg tab 5 mg b.i.d. to r 5-10 mg r 5 mg 60 mg 60 mg (methylphenidate HCl) t.i.d.

Ritalin® SR6 20 mg tab 20 mg q.d. am r 20 mg (add r 20 mg (add 60 mg 80 mg (methylphenidate HCl) q2pm dose) q2pm dose)

1 Maximum off label doses have been published in the AACAP Practice Parameters14 but the off label maximums are either the same or lower in the CAP-G based on CB 2 The maximum daily dose can be split into once daily (q.d.), twice daily (b.i.d.) or three times daily (t.i.d.) doses except for once a day formulations 3 While the theoretical maximum off label dose for Biphentin® could be 100 mg, clinical practice currently suggests that 80 mg is the maximum that is used 4 For adolescents greater than 70 kg, use the adult dose titration schedule 5 Dexedrine Spansule® may last 6-8 hours 6 Ritalin SR® may help cover the noon period but clinical experience suggests an effect similar to short-acting preparations.

Chapter 7 102 7.13

Table 2. MEDICAL TREATMENT FOR ADHD UNCOMPLICATED – ADOLESCENTS (continued) Alphabetically Listed – Refer to product monographs for complete prescribing information.

Brand Name Dosage Form Starting Dose* Titration Schedule Maximum per day* (active chemical) Every 7 days

Per product Per CADDRA Per Product Per CADDRA Monograph Board Monograph Board

GENERIC MEDICATIONS

PMS® or Ratio®- 5, 10, 20, 5 mg q.d. a.m. r 5 mg r 5 mg 60 mg 60 mg methylphenidate mg tab and noon (add q4pm dose) Novo-MPH ER-C® 18, 27, 36, 54 18 mg q.d. a.m. r 18 mg r 9-18 mg 54 mg 90 mg (methylphenidate) mg tab

THIRD LINE AGENTS These medications (except clonidine) should only be initiated or first prescribed by a specialist.

7.14 Version: November 2014. Refer to www.caddra.ca for latest updates. 103 Medication for Adults with ADHD

TABLE 3. MEDICAL TREATMENT FOR ADHD UNCOMPLICATED – ADULTS Alphabetically Listed – Refer to product monographs for complete prescribing information.

Brand Name Dosage Form Starting Dose* Titration Schedule Maximum per day1, 2 (active chemical) Every 7 days

Per Product Per CADDRA Per Product Per CADDRA Monograph Board Monograph Board*

FIRST LINE AGENTS – long-acting preparations

Adderall XR® 5, 10, 15, 20, 10 mg r 10 mg r 5 mg 20-30 mg 50 mg (amphetamine mixed salts) 25, 30 mg cap q.d. a.m.

Biphentin® 10, 15, 20, 30, 40 10-20 mg r 10 mg r 5-10 mg 80 mg 80 mg3 (methylphenidate HCl) 50, 60, 80 mg cap q.d. a.m.

Concerta® 18, 27, 36, 54 18 mg q.d. a.m. r 18 mg r 9-18 mg 72 mg 108 mg (methylphenidate HCl) mg tab

Vyvanse® 20, 30, 40, 20-30 mg By clinical r 10 mg 60 mg 70 mg (lisdexamfetamine 50, 60 mg cap q.d. a.m. discretion dimesylate)

CB * Doses per CADDRA Board that are over or under product monograph maximum or minimum doses should be considered off-label use. Note: CADDRA recommends generally starting at the lowest dose. A consensus decision has been made based on clinical use and research data.

SECOND LINE/ADJUNCTIVE AGENTS – long-acting preparations Non psychostimulant - selective norepinephrine reuptake inhibitor

CB Indications for use: Monotherapy for the treatment of ADHD (off-label: prescribed as an adjunctive therapy).

4 Maintain dose for a Maintain dose for a Strattera® 10, 18, 25, 40 mg q.d. min. of 7-14 days min. of 7-14 days Lesser of Lesser of (atomoxetine) 40, 60, 80, for 7-14 days before adjusting to before adjusting to 1.4 mg/kg/day 1.4 mg/kg/day 100 mg cap 60 then 80 mg/day 60 then 80 mg/day or 100 mg/day or 100 mg/day max dose/day max dose/day 1.4 mg/kg/day or 1.4 mg/kg/day or 100 mg5 100 mg5

SECOND LINE/ADJUNCTIVE AGENTS – short-acting and intermediate-acting preparations

Dexedrine® 5 mg tab 2.5-5 mg b.i.d. r 5 mg r 2.5-5 mg 40 mg 50 mg (dextro-amphetamine sulphate)

Dexedrine® Spansule5 10, 15 mg cap 10 mg q.d. a.m. r 5 mg r 2.5-5 mg 40 mg 50 mg (dextro-amphetamine sulphate)

Ritalin® 10, 20 mg tab 5 mg b.i.d. to r 5-10 mg r 5 mg 60 mg 100 mg (methylphenidate HCl) t.i.d., consider q.i.d.

Ritalin® SR6 20 mg tab 20 mg q.d. a.m. r 20 mg (add r 20 mg (add 60 mg 100 mg (methylphenidate HCl) q2pm dose) q2pm dose)

1 Maximum off label doses have been published in the AACAP Practice Parameters14 but the off label maximums are either the same or lower in the CAP-G based on CB 2 The maximum daily dose can be split into once daily (q.d.), twice daily (b.i.d.) or three times daily (t.i.d.) doses except for once a day formulations 3 While the theoretical maximum off label dose for Biphentin® could be 100 mg, clinical practice currently suggests that 80 mg is the maximum that is used since no published study has researched doses higher than 80mg 4 Some adults may better tolerate a lower starting dose of 25 mg 5 Strattera titration schedule applies to children and adolescents over 70 kg body weight and adults. 6 Dexedrine Spansule® may last 6-8 hours 7 Ritalin SR® may help cover the noon period but clinical experience suggests an effect similar to short-acting preparations. Chapter 7 104 7.15

Table 3. MEDICAL TREATMENT FOR ADHD UNCOMPLICATED – ADULTS (continued) Alphabetically Listed – Refer to product monographs for complete prescribing information.

Brand Name Dosage Form Starting Dose* Titration Schedule Maximum per day (active chemical) Every 7 days

Per product Per CADDRA Per Product Per CADDRA Monograph Board Monograph Board

GENERIC MEDICATIONS

PMS® or Ratio®- 5, 10, 20, 10 mg q.d. a.m. r 10 mg r 5 mg 60 mg 100 mg methylphenidate mg tab and noon CADDRA: 5 mg b.i.d. to t.i.d., consider q.i.d. (add q4pm dose)

Novo-MPH ER-C® 18, 27, 36, 54 18 mg q.d. a.m. r 18 mg/wk r 9-18 mg/wk 54 mg 108 mg (methylphenidate) mg tab

THIRD LINE AGENTS These medications (except clonidine) should only be initially or first prescribed by a specialist.

7.16 Version: November 2014. Refer to www.caddra.ca for latest updates. 105

ADHD Checklist Instructions

Scoring Instructions The ADHD Checklist is a list of the nine DSM items of attention and the nine DSM items of hyperactivity/ impulsivity. Attention and impulsive-hyperactive items are grouped together so that the clinician can easily differentiate with a glance which area is primarily impaired. The number of items rated pretty much (2) or very much (3) are an indicatation that these areas are clinically problematic. Add up the numbers of clinically significant items and determine whether the client has met the threshold which is stated in next to the section heading (e.g. Attention > 6/9). If physicians are suspect but are unsure of whether ADHD is a possibility, the Checklist can be completed in the waiting room prior to assessment.

Comparison to Other Scales The items are also almost identical to those of the SNAP-IV scale, with the exception that the statement "Often ..." and then rating frequency as sometimes, often or very often has been deleted. Items have also been made generic enough to be appropriate to all age groups and so that they can be completed by any informant and for the past or present. The correlation between the DSM-IV checklists is very high (>.8). Therefore, if a clinician wishes to use an alternative checklist, the rating of number of positive items can be entered into the assessment form in the same way, noting the checklist used.

If Only ADHD The items on the ADHD Checklist are identical with the attention, hyperactive, and oppositional items at the beginning of the Weiss Symptom Record. This is so that the WSR can be given at baseline, but if the primary disorder is ADHD, follow-up assessments can be done by just using the Checklist and allowing for comparison.

The Checklist Used by Other Informants The Checklist can also be completed to identify ADHD in adults in childhood, or completed by a collateral informant as well as the patient.

Toolkit 106 8.19

Patient Name: Date of Birth: MRN/File No: Physician Name: Date:

Retrospective assessment of childhood symptoms Current symptoms ADHD CHECKLIST Current medication:

SYMPTOMS: Check the appropriate box Not at all Somewhat Pretty much Very much Diagnoses (0) (1) (2) (3) ATTENTION 314.00 (≥6/9) SEVERITY TOTAL Fails to give close attention to details, careless mistakes

Difficulty sustaining attention in tasks or fun activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish work

Difficulty organizing tasks and activities

Avoids tasks that require sustained mental effort (boring)

Losing things

Easily distracted _/9

Forgetful in daily activities ≥6/9 HYPERACTIVE/IMPULSIVE 314.01 (≥6/9) Fidgety or squirms in seat

Leaves seat when sitting is expected

Feels restless

Difficulty in doing fun things quietly

Always on the go or acts as if "driven by a motor"

Talks excessively

Blurts answers before questions have been completed

Difficulty awaiting turn ≥6/9

Interrupting or intruding on others _/9 OPPOSITIONAL DEFIANT DISORDER 313.81 (>4/8) Loses temper

Argues with adults

Actively defies or refuses to comply with requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehavior

Touchy or easily annoyed by others

Angry or resentful ≥4/8

Spiteful or vindictive _/8 COMMENTS

8.20 Version: November 2014. Refer to www.caddra.ca for latest updates. 107

SNAP-IV 26 RATING SCALE: SCORING INSTRUCTIONS

The SNAP-IV is a revision of the Swanson, Nolan and Pelham (SNAP) questionnaire (Swanson et al. 1983). The items from the DSM-IV criteria for Attention Deficit Hyperactivity Disorder (ADHD) are included for the two following subsets of symptoms: inattention (items 1 to 0) and hyperactivity/impulsivity (items 10 to 18). The scale also includes the DMS-IV criteria for Oppositional Defiant Disorder (items 19 to 26) since this is often present in children with ADHD.

The SNAP-IV is based on a 0 to 3 rating scale: Not at all = 0, Just a little = 1, Often = 2, and Very often = 3. Sub scale scores on the SNAP-IV are calculated by summing the scores on the subset and dividing by the number of items in the subset. The score for any subset is expressed as the Average Rating-Per-Item, as shown for ratings on the ADHD-Inattentive (ADHD-I) subset:

Not at all Just a little Often Very often (0) (1) (2) (3) Score 1. Makes careless mistakes * 2 2. Difficulty sustaining attention * 3 3. Does not listen * 3 4. Fails to finish work * 2 5. Disorganized * 1 6. Can’t concentrate * 3 7. Loses things * 1 8. Easily distracted * 3 9. Forgetful * 0 Total ADHD-Inattention = 18 Average = 18/9 = 2.0

ADHD-Inattention ADHD-Hyperactivty/Impusivity Oppositional Defiant Disorder

#1 #10 #19

#2 #11 #20

#3 #12 #21

#4 #13 #22

#5 #14 #23

#6 #15 #24

#7 #16 #25

#8 #17 #26

#9 #18

Total Total Total

Average Average Average Toolkit 108 8.21

Patient Name: Date of Birth: MRN/File No: Physician Name: Date:

SNAP-IV 26 – Teacher and Parent Rating Scale Name: ______Gender: ______Age: ______

Grade: ______Ethnicity: African-American Asian Caucasian Hispanic Other: ______Completed by: ______Type of Class: ______Class size: ______

For each item, check the column which best describes this child: Not At All Just A Little Quite A Bit Very Much

1. Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

7. Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books)

8. Often is distracted by extraneous stimuli

9. Often is forgetful in daily activities

10. Often fidgets with hands or feet or squirms in seat

11. Often leaves seat in classroom or in other situations in which remaining seated is expected

12. Often runs about or climbs excessively in situations in which it is inappropriate

13. Often has difficulty playing or engaging in leisure activities quietly

14. Often is “on the go” or often acts as if “driven by a motor”

15. Often talks excessively

16. Often blurts out answers before questions have been completed

17. Often has difficulty awaiting turn

18. Often interrupts or intrudes on others (e.g. butts into conversations/ games)

19. Often loses temper

20. Often argues with adults

21. Often actively defies or refuses adult requests or rules

22. Often deliberately does things that annoy other people

23. Often blames others for his or her mistakes or misbehavior

24. Often touchy or easily annoyed by others

25. Often is angry and resentful

26. Often is spiteful or vindictive 8.22 Version: November 2014. Refer to www.caddra.ca for latest updates. 109

ADULT ADHD SELF-REPORT SCALE (ASRS-V1.1) SYMPTOM CHECKLIST INSTRUCTIONS

Description: The Symptom Checklist is an instrument consisting of the 18 DSM-IV-TR criteria. Six of the 18 questions were found to be the most predictive of symptoms consistent with ADHD. These six questions are the basis for the ASRS-V1.1 screener and are also Part A of the Symptom Checklist. Part B of the Symptom Checklist contains the remaining 12 questions.

Instructions: Symptoms 1. Ask the patient to complete both Part A and Part B of the Symptom Checklist by marking an X in the box that most closely represents the frequency of occurrence of each of the symptoms. 2. Score Part A. If four or more marks appear under Often/Very Often then the patient has symptoms highly consistent with ADHD in adults and further investigation is warranted. 3. The frequency scores on Part B provide additional cues and can serve as further probes into the patient’s symptoms. Pay particular attention to marks appearing under Often/Very Often. The frequency-based response is more sensitive with certain questions. No total score or diagnostic likelihood is utilized for the 12 questions. It has been found that the six questions in Part A are the most predictive of the disorder and are best for use as a screening instrument.

Impairments 1. Review the entire Symptom Checklist with your patients and evaluate the level of impairment associated with the symptom. 2. Consider work/school, social and family settings. 3. Symptom frequency is often associated with symptom severity, therefore the Symptom Checklist may also aid in the assessment of impairments. If your patients have frequent symptoms, you may want to ask them to describe how these problems have affected the ability to work, take care of things at home, or get along with other people such as their spouse/significant other.

History 1. Assess the presence of these symptoms or similar symptoms in childhood. Adults who have ADHD need not have been formally diagnosed in childhood. In evaluating a patient’s history, look for evidence of early-appearing and long-standing problems with attention or self-control. Some significant symptoms should have been present in childhood, but full symptomology is not necessary.

References: 1. Schweitzer JB et al. Med Clin North Am. 2001;85(3),10-11:757-777. 2. Barkley RA. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. 1998. 3. Biederman J, et al. Am J Psychiatry. 1993;150:1792-1798. 4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders.Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association. 2000:85-93. © 2003 World Health Organization. Reprinted with permission. Toolkit 110 8.23 Patient Name: Date of Birth: MRN/File No: Physician Name: Date: ADULT ADHD SELF-REPORT SCALE (ASRS-V1.1) SYMPTOM CHECKLIST

Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during your appointment Never Rarely Sometimes Often often Very

PART A

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

2. How often do you have difficulty getting things in order when you have to do a task that requires organization?

3. How often do you have problems remembering appointments or obligations?

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

PART B

7. How often do you make careless mistakes when you have to work on a boring or difficult project?

8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

10. How often do you misplace or have difficulty finding things at home or at work?

11. How often are you distracted by activity or noise around you?

12. How often do you leave your seat in meetings or in other situations in which you are expected to stay seated?

13. How often do you feel restless or fidgety?

14. How often do you have difficulty unwinding and relaxing when you have time to yourself?

15. How often do you find yourself talking too much when you are in social situations? 16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish it themselves?

17. How often do you have difficulty waiting your turn in situations when turn taking is required?

18. How often do you interrupt others when they are busy?

8.24 Version: November 2014. Refer to www.caddra.ca for latest updates. ADULT ADHD SELF-REPORT SCALE111 1/1 WEISS FUNCTIONAL IMPAIRMENT RATING SCALE (WFIRS) INSTRUCTIONS

Purpose

■ ADHD symptoms and actual impairment overlap but are distinct concepts. It is important to measure both since some patients are highly symptomatic but not impaired or vice versa

■ This scale contains those items that are most likely to represent the patient's target of treatment. Therefore, the use of the scale before and after treatment can allow the clinician to determine not only if the ADHD has improved, but if the patient's functional difficulties are also better.

■ This instrument has been translated into 18 languages. It has been used in many studies and is psychometrically validated. This is the only measure of functional impairment that looks at specific domains and has been validated in the ADHD population.

Design and Validation Information Scoring The instrument uses a Likert scale such that any item rating 2 or 3 is clinically impaired. The scale can be scored by looking at the total score or by creating a mean score for the total score/number items for each domain, omitting those rated not applicable. For clinical purposes, when defining impairment for DSM-IV, clinicians can consider that any domain with at least two items scored 2, one item scored 3 or a mean score >1.5 is impaired.

Validation The scale has been psychometrically validated with an internal consistency >.8 for each domain and for the scale as a whole. It has moderate convergent validity (0.6) with other measures of functioning (i.e. Columbia Impairment Scale and the Global Assessment of Functioning (GAF). It has moderate discriminating validity (0.4) from symptoms pre-treatment (i.e. ADHD-Rating Scale) and quality of life (CHIP). The domains have been confirmed by factor analysis, although the domain of school functioning separates into learning and behaviour. The scale is highly sensitive to change with treatment and, in particular, significantly correlated to change in ADHD symptoms (40% change) and overall psychopathology. Each anchor point on the Likert scale represents approximately one standard deviation(SD). A total score change of 13 would be considered a significant improvement or about half a SD. The change obtained in treatment is typically one full SD. The mean score for risky behaviour in children is 0.5 but increases with age. For adolescents the mean score is 1.

Copyright Information This scale is copyrighted by Margaret Danielle Weiss, MD PhD, at the University of British Columbia. The scale can be used by clinicians and researchers free of charge and can be posted on the internet or replicated as needed. Please contact Dr. Weiss at [email protected] if you wish to post the scale on the internet, use it in research or plan to create a translation.

Toolkit 112 8.25 8.26 Version: November 2014. Refer to www.caddra.ca for latest updates. 113

Patient Name: Date of Birth: MRN/File No: Physician Name: Date:

WEISS FUNCTIONAL IMPAIRMENT RATING SCALE – SELF REPORT (WFIRS-S) Work: Full time Part time Other ______School: Full time Part time Circle the number for the rating that best describes how your emotional or behavioural problems have affected each item in the last month.

Never or Sometimes Often or Very often or not at all or somewhat much very much n/a A FAMILY 1 Having problems with family 0 1 2 3 n/a 2 Having problems with spouse/partner 0 1 2 3 n/a 3 Relying on others to do things for you 0 1 2 3 n/a 4 Causing fighting in the family 0 1 2 3 n/a 5 Makes it hard for the family to have fun together 0 1 2 3 n/a 6 Problems taking care of your family 0 1 2 3 n/a 7 Problems balancing your needs against those of your family 0 1 2 3 n/ 8 Problems losing control with family 0 1 2 3 n/a B WORK 1 Problems performing required duties 0 1 2 3 n/a 2 Problems with getting your work done efficiently 0 1 2 3 n/a 3 Problems with your supervisor 0 1 2 3 n/a 4 Problems keeping a job 0 1 2 3 n/a 5 Getting fired from work 0 1 2 3 n/a 6 Problems working in a team 0 1 2 3 n/a 7 Problems with your attendance 0 1 2 3 n/a 8 Problems with being late 0 1 2 3 n/a 9 Problems taking on new tasks 0 1 2 3 n/a 10 Problems working to your potential 0 1 2 3 n/a 11 Poor performance evaluations 0 1 2 3 n/a C SCHOOL 1 Problems taking notes 0 1 2 3 n/a 2 Problems completing assignments 0 1 2 3 n/a 3 Problems getting your work done efficiently 0 1 2 3 n/a 4 Problems with teachers 0 1 2 3 n/a 5 Problems with school administrators 0 1 2 3 n/a 6 Problems meeting minimum requirements to stay in school 0 1 2 3 n/a 7 Problems with attendance 0 1 2 3 n/a 8 Problems with being late 0 1 2 3 n/a 9 Problems with working to your potential 0 1 2 3 n/a 10 Problems with inconsistent grades 0 1 2 3 n/a D LIFE SKILLS 1 Excessive or inappropriate use of internet, video games or TV 0 1 2 3 n/a 2 Problems keeping an acceptable appearance 0 1 2 3 n/a 3 Problems getting ready to leave the house 0 1 2 3 n/a 4 Problems getting to bed 0 1 2 3 n/a 5 Problems with nutrition 0 1 2 3 n/a Toolkit 114 8.27 Never or Sometimes Often or Very often or not at all or somewhat much very much n/a 6 Problems with sex 0 1 2 3 n/a 7 Problems with sleeping 0 1 2 3 n/a 8 Getting hurt or injured 0 1 2 3 n/a 9 Avoiding exercise 0 1 2 3 n/a 10 Problems keeping regular appointments with doctor/dentist 0 1 2 3 n/a 11 Problems keeping up with household chores 0 1 2 3 n/a 12 Problems managing money 0 1 2 3 n/a E SELF-CONCEPT 1 Feeling bad about yourself 0 1 2 3 n/a 2 Feeling frustrated with yourself 0 1 2 3 n/a 3 Feeling discouraged 0 1 2 3 n/a 4 Not feeling happy with your life 0 1 2 3 n/a 5 Feeling incompetent 0 1 2 3 n/a F SOCIAL 1 Getting into arguments 0 1 2 3 n/a 2 Trouble cooperating 0 1 2 3 n/a 3 Trouble getting along with people 0 1 2 3 n/a 4 Problems having fun with other people 0 1 2 3 n/a 5 Problems participating in hobbies 0 1 2 3 n/a 6 Problems making friends 0 1 2 3 n/a 7 Problems keeping friends 0 1 2 3 n/a 8 Saying inappropriate things 0 1 2 3 n/a 9 Complaints from neighbours 0 1 2 3 n/a G RISK 1 Aggressive driving 0 1 2 3 n/a 2 Doing other things while driving 0 1 2 3 n/a 3 Road rage 0 1 2 3 n/a 4 Breaking or damaging things 0 1 2 3 n/a 5 Doing things that are illegal 0 1 2 3 n/a 6 Being involved with the police 0 1 2 3 n/a 7 Smoking cigarettes 0 1 2 3 n/a 8 Smoking marijuana 0 1 2 3 n/a 9 Drinking alcohol 0 1 2 3 n/a 10 Taking "street" drugs 0 1 2 3 n/a 11 Sex without protection (birth control, condom) 0 1 2 3 n/a 12 Sexually inappropriate behaviour 0 1 2 3 n/a 13 Being physically aggressive 0 1 2 3 n/a 14 Being verbally aggressive 0 1 2 3 n/a

SCORING: DO NOT WRITE IN THIS AREA A. Family 1. Number of items scored 2 or 3 B. Work or 2. Total score C. School or D. Life skills 3. Mean score E. Self-concept F. Social G. Risk Total

This scale is copyrighted by Margaret Danielle Weiss, MD PhD, at the University of British Columbia. The scale can be used by clinicians and researchers free of charge and can be posted on the internet or replicated as needed. Please contact Dr. Weiss at [email protected] if you wish to post the scale on the internet, use it in research or plan to create a translation. 8.28 Version: November 2014. Refer to www.caddra.ca for latest updates. WFIRS-S115 2/2

Patient Name: Date of Birth: MRN/File No: Physician Name: Date:

WEISS FUNCTIONAL IMPAIRMENT RATING SCALE – PARENT REPORT (WFIRS-P)

Your name: ______Relationship to child: ______

Circle the number for the rating that best describes how your child's emotional or behavioural problems have affected each item in the last month.

Never or Sometimes Often or Very often or not at all or somewhat much very much n/a

A FAMILY 1 Having problems with brothers & sisters 0 1 2 3 n/a

2 Causing problems between parents 0 1 2 3 n/a

3 Takes time away from family members’ work or activities 0 1 2 3 n/a

4 Causing fighting in the family 0 1 2 3 n/a

5 Isolating the family from friends and social activities 0 1 2 3 n/a

6 Makes it hard for the family to have fun together 0 1 2 3 n/a

7 Makes parenting difficult 0 1 2 3 n/a

8 Makes it hard to give fair attention to all family members 0 1 2 3 n/a

9 Provokes others to hit or scream at him/her 0 1 2 3 n/a

10 Costs the family more money 0 1 2 3 n/a

B SCHOOL

Learning

1 Makes it difficult to keep up with schoolwork 0 1 2 3 n/a

2 Needs extra help at school 0 1 2 3 n/a

3 Needs tutoring 0 1 2 3 n/a

4 Receives grades that are not as good as his/her ability 0 1 2 3 n/a

Behaviour

1 Causes problems for the teacher in the classroom 0 1 2 3 n/a

2 Receives ”time-out” or removal from the classroom 0 1 2 3 n/a

3 Having problems in the school yard 0 1 2 3 n/a

4 Receives detentions (during or after school) 0 1 2 3 n/a

5 Suspended or expelled from school 0 1 2 3 n/a

6 Misses classes or is late for school 0 1 2 3 n/a

C LIFE SKILLS

1 Excessive use of TV, computer, or video games 0 1 2 3 n/a

2 Keeping clean, brushing teeth, brushing hair, bathing, etc. 0 1 2 3 n/a

3 Problems getting ready for school 0 1 2 3 n/a Toolkit WFIRS-P116 1/2 8.29 Never or Sometimes Often or Very often or not at all or somewhat much very much n/a

4 Problems getting ready for bed 0 1 2 3 n/a

5 Problems with eating (picky eater, junk food) 0 1 2 3 n/a

6 Problems with sleeping 0 1 2 3 n/a

7 Gets hurt or injured 0 1 2 3 n/a

8 Avoids exercise 0 1 2 3 n/a

9 Needs more medical care 0 1 2 3 n/a

10 Has trouble taking medication, getting needles or visiting the doctor/dentist 0 1 2 3 n/a

D CHILD'S SELF-CONCEPT

1 My child feels bad about himself/herself 0 1 2 3 n/a

2 My child does not have enough fun 0 1 2 3 n/a

3 My child is not happy with his/her life 0 1 2 3 n/a

E SOCIAL ACTIVITIES

1 Being teased or bullied by other children 0 1 2 3 n/a

2 Teases or bullies other children 0 1 2 3 n/a

3 Problems getting along with other children 0 1 2 3 n/a

4 Problems participating in after-school activities (sports, music, clubs) 0 1 2 3 n/a

5 Problems making new friends 0 1 2 3 n/a

6 Problems keeping friends 0 1 2 3 n/a

7 Difficulty with parties (not invited, avoids them, misbehaves) 0 1 2 3 n/a

F RISKY ACTIVITIES

1 Easily led by other children (peer pressure) 0 1 2 3 n/a

2 Breaking or damaging things 0 1 2 3 n/a

3 Doing things that are illegal 0 1 2 3 n/a

4 Being involved with the police 0 1 2 3 n/a

5 Smoking cigarettes 0 1 2 3 n/a

6 Taking illegal drugs 0 1 2 3 n/a

7 Doing dangerous things 0 1 2 3 n/a

8 Causes injury to others 0 1 2 3 n/a

9 Says mean or inappropriate things 0 1 2 3 n/a

10 Sexually inappropriate behaviour 0 1 2 3 n/a

DO NOT WRITE IN THIS AREA SCORING: A. Family B. School 1. Number of items scored 2 or 3 or Learning 2. Total score Behaviour or C. Life skills 3. Mean score D. Child's self-concept E. Social activities F. Risky activities Total

This scale is copyrighted by Margaret Danielle Weiss, MD PhD, at the University of British Columbia. The scale can be used by clinicians and researchers free of charge and can be posted on the internet or replicated as needed. Please contact Dr. Weiss at [email protected] if you wish to post the scale on the internet, use it in research or plan to create a translation. 8.30 Version: November 2014. Refer to www.caddra.ca for latest updates. WFIRS-P117 2/2

Patient Name: Date of Birth: MRN/File No: Physician Name: Date:

CADDRA Teacher Assessment Form Adapted from Dr Rosemary Tannock's Teacher Telephone Interview. Reprinted for clinical use only with permission from the BC Provincial ADHD Program.

Student's Name: Age: Sex:

School: Grade:

Educator completing this form: ______Date completed: ______

How long have you known the student? ______Time spent each day with student: ______

Student's Placement: ______Special Ed: Yes No Hrs per week: ______

Student's Educational Designation: ______None

Does this student have an educational plan?: Yes No

Well Below Somewhat Below At Grade Somewhat Above Well Above ACADEMIC PERFORMANCE Grade Level Grade Level Level Grade Level Grade Level n/a

READING a) Decoding

b) Comprehension

c) Fluency

WRITING

d) Handwriting

e) Spelling

f) Written syntax (sentence level)

g) Written composition (text level)

MATHEMATICS

h) Computation (accuracy)

i) Computation (fluency)

j) Applied mathematical reasoning

Well Below Well Above CLASSROOM PERFORMANCE Average Below Average Average Above Average Average n/a

Following directions/instructions

Organizational skills

Assignment completion

Peer relationships

Classroom Behaviour

Toolkit CADDRA TEACHER ASSESSMENT FORM118 1/3 8.31 CADDRA Teacher Assessment Form

Strengths: What are this student's strengths? ______

Education plan: If this student has an education plan, what are the recommendations? Do they work? ______

Accommodations: What accommodations are in place? Are they effective? ______

Class Instructions: How well does this student handle large-group instruction? Does s/he follow instructions well? Can s/he wait for a turn to respond? Would s/he stand out from same-sex peers? In what way? ______

Individual seat work: How well does this student self-regulate attention and behaviour during assignments to be completed as individual seat work? Is the work generally completed? Would s/he stand out from same-sex peers? In what way? ______

Transitions: How does this student handle transitions such as going in and out for recess, changing classes or changing activities? Doe s/he follow routines well? What amount of supervision or reminders does s/he need? ______

Impact on peer relations: How does this student get along with others? Does this student have friends that seek him/ her out? Does s/he initiate play successfully? ______

Conflict and Aggression: – Is s/he often in conflict with adults or peers? How does s/he resolve arguments? Is the student verbally or physically aggressive? Is s/he the target of verbal or physical aggression by peers? ______

Academic Abilities: We would like to know about this student's general abilities and academic skills. Does this student appear to learn at a similar rate to others? Does this student appear to have specific weaknesses in learning? ______

Self-help skills, independence, problem solving, activities of daily living: ______

8.32 Version: November 2014. Refer to www.caddra.ca for latest updates. CADDRA TEACHER ASSESSMENT FORM119 2/3 Motor Skills (gross/fine): Does this student have problems with gym, sports, writing? If so, please describe. ______

Written output: Does this student have problems putting ideas down in writing? If so, please describe. ______

Primary Areas of concern: What are your major areas of concern/worry for this student? How long has this/these been a concern for you? ______

Impact on student: To what extent are these difficulties for the student upsetting or distressing to the student him/ herself, to you and/or the other students? ______

Impact on the class: Does this student make it difficult for you to teach the class? ______

Medications: If this student is on medication, is there anything you would like to highlight about the differences when s/he is on medication compared to off? ______

Parent involvement: What has been the involvement of the parent(s)? ______

Are the problems with attention and/or hyperactivity interfering with the student's learning? Peer relationships? ______

Has the student had any particular problems with homework or handing in assignments? ______

Is there anything else you would like us to know? If you feel the need to contact the student's clinician during this assessment please feel free to do so. ______

Toolkit CADDRA TEACHER ASSESSMENT FORM120 3/3 8.33

Patient Name: Date of Birth: MRN/File No: Physician Name: Date:

CADDRA CLINICIAN ADHD BASELINE/FOLLOW-UP FORM

Patient Name: ______Date of Birth: ______Date seen: ______Other person present during interview: ______

Clinician: Other therapist(s) involved:

Current medication(s): Dose & schedule Therapeutic Effects Side Effects

Adherence to treatment (took medications as directed): FULL PARTIAL (missed doses, did not take all medication) NONE (Discontinued medication for at least a week)

Developments since last appointment:

Height: Weight: BP: Pulse: Observations:

Opinion:

Psychiatric Diagnosis: ADHD, Combined Oppositional Defiant Anxiety Disorder Depression Learning Disorder ADHD, Inattentive Conduct Disorder Tic Disorder Language Disorder Personality Disorder/Traits Intellectual Disability Other

Medical Diagnosis (physical abnormalities):

Stressors: Mild Moderate Severe Extreme

Impairment Severity: Borderline Mild Moderate Marked Severe Extreme

Very much Much Minimally No change Minimally Much worse Very much improved improved improved worse worse

Treatment Plan:

Medication: No change Decrease Increase Switch

Psychological/Other:

School/Work:

Follow-up plan:

Signature: Date:

Copy to be sent to:

8.34 Version: November 2014. Refer to www.caddra.ca for latest updates. 121

Patient Name: Date of Birth: MRN/File No: Physician Name: Date:

CADDRA PATIENT ADHD MEDICATION FORM Please complete and bring to your next appointment

Patient name: ______Date form is completed: ______

Person completing this form (if not the patient): ______Mother Father Other

Medication usage since (decided with doctor): Current Medication List: ______(date) ______Medication not started yet ______Takes medication regularly, as prescribed ______Forgets/skips doses occasionally ______Takes medication irregularly ______Medication stopped ______

Instructions to use the quadrant below:

1. Place a mark on the horizontal black line indicating the level of current symptom control between -3 and +3. 2. Place a mark on the vertical black line indicating current side effect levels, between -3 to +3 3. Draw an X where lines from the marks made on each line would meet to show current patient status

NO SIDE EFFECTS - GOOD QUALITY OF LIFE COMMENTS: ______+ ______+3 ______+2 ______

+1 ______POOR - -3 -2 -1 +1 +2 +3 + GOOD CONTROL CONTROL ______-1 ______-2 ______

-3 ______- ______SIDE EFFECTS WITH IMPACT ON QUALITY OF LIFE

What changes have occurred since medication started?

Not applicable: no medication taken No change Marked Improvement Small deterioration Improvement Deterioration Small improvement Marked deterioration

Toolkit CADDRA PATIENT ADHD MEDICATION FORM122 1/2 8.35 Please indicate below the frequency of any side effects experienced since the last medical appointment (mark with an X). Please contact your physician if side effects are significant.

SIDE EFFECT FREQUENCY

Not at all Sometimes Often All the time Comments Headache

Dryness of the skin

Dryness of the eyes

Dryness of the mouth

Thirst

Sore throat

Dizziness

Nausea

Stomach aches

Vomiting

Sweating

Appetite reduction

Weight loss

Weight gain

Diarrhea

Frequent urination

Tics

Sleep difficulties

Mood instability

Irritability

Agitation/excitability

Sadness

Heart palpitations

Increased blood pressure

Sexual dysfunction

Feeling worse or different when the medication wears off (rebound)

Other:

Things to discuss at the next medical appointment: ______

8.36 Version: November 2014. Refer to www.caddra.ca for latest updates. CADDRA PATIENT ADHD MEDICATION FORM123 2/2 DIAGNOSIS AND TREATMENT FOR CHILDREN An ADHD assessment includes a general mental health screening (to consider comorbidities and differential diagnoses). In addition to a diagnostic interview, CADDRA recommends tools such as the WSR II. This eToolkit contains an optional guided assessment tool, the CADDRA ADHD Assessment Form. The step-by-step flowchart below applies after general mental health screening has been completed and ADHD is suspected. All the tools documented in this flowchart are free to download and use. Other assessment tools (e.g. Vanderbilt, Conners, Strengths and Difficulties Questionnaire - SDQ, Wender Utah Rating Scale) can be used in place of those proposed below. Further information on these steps can be found in Chapter 1, Canadian ADHD Practice Guidelines, 4th Edition.

ADHD SUSPECTED

STEP 1 - INITIAL INFORMATION GATHERING

QUESTIONNAIRES FOR PARENTS/CAREGIVERS QUESTIONNAIRES FOR TEACHERS ► SNAP-IV ► SNAP-IV Consider also using a functional impairment scale (e.g. WFIRS·P - Weiss ► CADDRA TEACHER ASSESSMENT FORM Functional Impairment Rating Scale Parent)

STEP 2 - MEDICAL REVIEW

EXCLUDE ANY MEDICAL CAUSES THAT CAN REVIEW NUTRITION AND LIFESTYLE HABITS: EVALUATE POTENTIAL CONTRAINDICATIONS MIMIC OR AGGRAVATE ADHD SIGNS OR Sleep, exercise, screen time, high-risk activities, TO ADHD MEDICATIONS SYMPTOMS substance use, sexual activity (if applicable), accidents

STEP 3 - ADHD SPECIFIC INTERVIEW

DISCUSS PATIENT’S REVIEW DEVELOPMENTAL REVIEW THE CONSIDER CONTRIBUTIONS OF OTHER STRENGTHS AND HISTORY AND OBTAIN QUESTIONNAIRES USED IN PSYCHIATRIC, PSYCHOSOCIAL FACTORS OR OBSERVE PATIENT COLLATERAL INFORMATION ASSESSMENT LEARNING DISORDERS TO THE PRESENTING DURING INTERVIEW FROM PARENTS/CAREGIVERS SYMPTOMS

Consider specialist referral if necessary.

STEP 4 - FEEDBACK AND TREATMENT RECOMMENDATIONS

EDUCATION ON ADHD FEEDBACK ON TREATMENT OPTIONS (Continuing process) DIAGNOSIS Discuss and initiate treatment + adaptation measures (school/work Feedback to patient and accommodations, daily strategies) Provide information and resources, including: family on ADHD symptoms & ► EDUCATIONAL ACCOMMODATION LETTER TEMPLATE impairments ► CADDRA ADHD Information Handout Links to useful websites: ● CADDAC (Canada: www.caddac.ca) ● PANDA (Quebec: www.associationpanda.qc.ca) ● CHADD (USA: www.chadd.org) NON-PHARMACOLOGICAL STRATEGIES PHARMACOLOGICAL STRATEGIES Support document: Support document:

► CADDRA Psychosocial Chart ► CADDRA Medication Chart

FOLLOW-UP VISITS • ADHD is a chronic disorder that needs longterm, regular follow-up, whether or not medication is prescribed. • Follow-up will be more frequent when adjusting medications and during life transitions. • Document changes over time with the rating scales that are most significant for the patient (e.g. SNAP-IV, WFIRS·P).

ADHD SUSPECTED

STEP 1 - INITIAL INFORMATION GATHERING

QUESTIONNAIRES FOR PATIENTS QUESTIONNAIRES FOR SOMEONE QUESTIONNAIRES FOR SOMEONE WHO WHO KNOWS THE PATIENT WELL (e.g. KNEW THE PATIENT AS A CHILD (if ► ASRS [Adult ADHD self -Report Scale] spouse, other) possible) Consider also using a functional impairment scale (e.g. ► ASRS [Adult ADHD Self-Report] ► SNAP-IV WFIRS-S) {Weiss Functional Impairment Rating Scale - Self}

STEP 2 - MEDICAL REVIEW

EXCLUDE ANY MEDICAL CAUSES REVIEW NUTRITION AND LIFESTYLE HABITS: EVALUATE POTENTIAL THAT CAN MIMIC OR AGGRAVATE Sleep, exercise, screen time, high-risk activities, substance use. sexual activity CONTRAINDICATIONS TO ADHD SIGNS OR SYMPTOMS (if applicable), accidents ADHD MEDICATIONS

STEP 3 - ADHD SPECIFIC INTERVIEW

DISCUSS PATIENT’S REVIEW DEVELOPMENTAL HISTORY REVIEW THE CONSIDER CONTRIBUTIONS OF OTHER PSYCHIATRIC, STRENGTHS AND AND OBTAIN COLLATERAL QUESTIONNAIRES PSYCHOSOCIAL FACTORS OR LEARNING DISORDERS OBSERVE PATIENT INFORMATION FROM PARENTS/CLOSE USED IN TO THE PRESENTING SYMPTOMS DURING INTERVIEW RELATIVES ASSESSMENT Consider specialist referral if necessary.

STEP 4 - FEEDBACK AND TREATMENT RECOMMENDATIONS

Links to useful websites: ● CADDAC (Canada: www.caddac.ca) ● PANDA (Quebec: www.associationpanda.qc.ca) NON-PHARMACOLOGICAL STRATEGIES PHARMACOLOGICAL STRATEGIES ● CHADD (USA: www.chadd.org) Support document: Support document:

► CADDRA Psychosocial Chart ► CADDRA Medication Chart

FOLLOW-UP VISITS ● ADHD is a chronic disorder that needs longterm, regular follow-up, whether or not medication is prescribed. ● Follow-up will be more frequent when adjusting medications and during life transitions. ● Document changes over time with the rating scales that are most significant for the patient (e.g. ASRS, WFIRS·S).

Other forms to track changes: ► CADDRA PATIENT ADHD MEDICATION FORM ► CADDRA CLINICIAN ADHD BASELINE/FOLLOW-UP FORM The CADDRA PATIENT TRANSITION FORM can be used when a patient is transferring to new healthcare professionals. The JEROME DRIVING QUESTIONNAIRE can be used to assess driving. 125 DIAGNOSIS AND TREATMENT FOR ADOLESCENTS An ADHD assessment includes a general mental health screening (to consider comorbidities and differential diagnoses). In addition to a diagnostic interview, CADDRA recommends tools such as the WSR II. This eToolkit contains an optional guided assessment tool, the CADDRA ADHD Assessment Form. The step-by-step flowchart below applies after general mental health screening has been completed and ADHD is suspected. All the tools documented in this flowchart are free to download and use. Other assessment tools (e.g. Vanderbilt, Conners, Strengths and Difficulties Questionnaire - SDQ, Wender Utah Rating Scale) can be used in place of those proposed below. Further information on these steps can be found in Chapter 1, Canadian ADHD Practice Guidelines, 4th Edition.

ADHD SUSPECTED

STEP 1 - INITIAL INFORMATION GATHERING

QUESTIONNAIRES FOR PARENTS/CAREGIVERS QUESTIONNAIRES FOR TEACHERS SELF-ASSESSMENT (when appropriate) ► SNAP-IV ► SNAP-IV ► ASRS - Adult ADHD Self-Report Scale Consider also using a functional impairment scale ► CADDRA TEACHER ASSESSMENT FORM Consider also using a functional impairment (e.g.WFIRS-P) [Weiss Functional Impairment Rating scale e.g. WFIRS·S [Weiss Functional Scale Parent] Impairment Rating Scale - Self]

STEP 2 - MEDICAL REVIEW

EXCLUDE ANY MEDICAL CAUSES THAT CAN REVIEW NUTRITION AND LIFESTYLE HABITS: EVALUATE POTENTIAL MIMIC OR AGGRAVATE ADHD SIGNS OR Sleep, exercise, screen time, high-risk activities, CONTRAINDICATIONS TO ADHD SYMPTOMS substance use, sexual activity (if applicable), MEDICATIONS accidents

STEP 3 - ADHD SPECIFIC INTERVIEW

DISCUSS PATIENT’S REVIEW DEVELOPMENTAL REVIEW THE CONSIDER CONTRIBUTIONS OF OTHER STRENGTHS AND OBSERVE HISTORY AND OBTAIN QUESTIONNAIRES USED PSYCHIATRIC, PSYCHOSOCIAL FACTORS OR PATIENT DURING COLLATERAL INFORMATION IN ASSESSMENT LEARNING DISORDERS TO THE PRESENTING INTERVIEW FROM PARENTS/CAREGIVERS SYMPTOMS Consider specialist referral if necessary.

STEP 4 - FEEDBACK AND TREATMENT RECOMMENDATIONS

EDUCATION ON ADHD FEEDBACK ON DIAGNOSIS TREATMENT OPTIONS (Continuing process) Feedback to patient and Discuss and initiate treatment + adaptation measures (school/work accommodations, daily strategies) Provide information and resources, including: family on ADHD symptoms & impairments ► EDUCATIONAL ACCOMMODATION LETTER TEMPLATE ► CADDRA ADHD Information Handout ► EMPLOYMENT ACCOMMODATION LETTER TEMPLATE

Links to useful websites: ● CADDAC (Canada: www.caddac.ca) ● PANDA (Quebec: www.associationpanda.qc.ca) ● CHADD (USA: www.chadd.org) NON-PHARMACOLOGICAL STRATEGIES PHARMACOLOGICAL STRATEGIES Support document: Support document:

► CADDRA Psychosocial Chart ► CADDRA Medication Chart

Other forms to track changes: ► CADDRA PATIENT ADHD MEDICATION FORM ► CADDRA CLINICIAN ADHD BASELINE/FOLLOW-UP FORM The CADDRA PATIENT TRANSITION FORM can be used when a patient is transferring to new healthcare professionals, including child and adolescent patients to adult services. The JEROME DRIVING QUESTIONNAIRE can be used to assess driving. 126 QUICK REFERENCE TO PSYCHIATRIC MEDICATIONS® DEVELOPED BY JOHN PRESTON, PSY.D., ABPP To the best of our knowledge recommended doses and side effects listed below are accurate. However, this is meant as a general reference only, and should not serve as a guideline for prescribing of medications. Please check the manufacturer’s product information sheet or the P.D.R. for any changes in dosage schedule or contraindications. (Brand names are registered trademarks.) ANTIDEPRESSANTS Usual Selective Action On NAMES Daily Dosage Neurotransmitters2 Generic Brand Range Sedation ACH1 NE 5-HT DA imipramine Tofranil 150-300 mg mid mid + + +++ 0 desipramine Norpramin 150-300 mg low low +++++ 0 0 amitriptyline Elavil 150-300 mg high high ++ ++++ 0 nortriptyline Aventyl, Pamelor 75-125 mg mid mid +++ ++ 0 clomipramine Anafranil 150-250 mg high high 0 +++++ 0 trazodone Oleptro 150-400 mg mid none 0 ++++ 0 nefazodone Generic Only 100-300 mg mid none 0 +++ 0 fluoxetine Prozac4, Sarafem 20-80 mg low none 0 +++++ 0 bupropion Wellbutrin4 150-400 mg low none ++ 0 ++ sertraline Zoloft 50-200 mg low none 0 +++++ + paroxetine Paxil 20-50 mg low low + +++++ 0 venlafaxine Effexor4 75-350 mg low none +++ +++ + desvenlafaxine Pristiq 50-400 mg low none +++ +++ + fluvoxamine Luvox 50-300 mg low low 0 +++++ 0 mirtazapine Remeron 15-45 mg mid mid +++ +++ 0 citalopram Celexa 10-40 mg low none 0 +++++ 0 escitalopram Lexapro 5-20 mg low none 0 +++++ 0 duloxetine Cymbalta 20-80 mg low none +++ +++ 0 vilazodone Viibryd 10-40 mg low low 0 +++++ 0 atomoxetine Strattera 60-120 mg low low +++++ 0 0 vortioxetine Brintellix 10-20 mg mid none 0 +++++ + levomilnacipran Fetzima 40-120 mg low none +++ ++ 0 MAO INHIBITORS phenelzine Nardil 30-90 mg low none +++ +++ +++ tranylcypromine Parnate 20-60 mg low none +++ +++ +++ selegiline Emsam (patch) 6-12 mg low none +++ +++ +++

1ACH: Anticholinergic Side Effects 2NE: Norepinephrine, 5-HT: Serotonin, DA: Dopamine (0 = no effect, + = minimal effect, +++ = moderate effect, +++++ = high effect) 3Uncertain, but likely effects 4Available in standard formulation and time release (XR, XL or CR). Prozac available in 90mg time released/weekly formulation BIPOLAR DISORDER MEDICATIONS 1 NAMES Daily Serum1 NAMES Daily Serum Generic Brand Dosage Range Level Generic Brand Dosage Range Level lithium carbonate Eskalith, Lithonate 600-2400 0.6-1.5 divalproex Depakote 750-1500 50-100 olanzapine/ lamotrigine Lamictal 50-500 (2) fluoxetine Symbyax 6/25-12/50mg4 (2) oxcarbazepine Trileptal 1200-2400 (2) Note: Many antipsychotic medications are used to treat various aspects carbamazepine Tegretol,Equetro 600-1600 4-10+ of bipolar disorder (see page two for a list) 1Lithium levels are expressed in mEq/l, carbamazepine and valproic acid levels express in mcg/ml. 2Serum monitoring may not necessary 3Not yet established 4Available in: 6/25, 6/50, 12/25, and 12/50mg formulations ANTI-OBSESSIONAL PSYCHO-STIMULANTS NAMES NAMES Generic Brand Daily Dosage1 Generic Brand Dose Range1 methylphenidate3 Ritalin 5-50 mg clomipramine Anafranil 150-300 mg methylphenidate3 Concerta2 18-54 mg 1 fluoxetine Prozac 20-80 mg methylphenidate3 Metadate 5-40 mg sertraline Zoloft1 50-200 mg methylphenidate3 Methylin 10-60 mg paroxetine Paxil1 20-60 mg methylphenidate3 Daytrana (patch) 15-30 mg fluvoxamine Luvox1 50-300 mg methylphenidate3 Quillivant XR (liquid)2 10-60 mg citalopram Celexa1 10-40 mg dexmethylphenidate Focalin 5-40 mg escitalopram Lexapro1 5-30 mg dextroamphetamine Dexedrine 5-40 mg vilazodone Viibryd1 10-40 mg lisdexamphetamine Vyvanse 30-70 mg d- and l-amphetamine Adderall 5-40 mg vortioxetine Brintellix 10-20 mg modafinil Provigil, Sparlon 100-400 mg armodafanil Nuvigil 150-250 mg 1often higher doses are required to control obsessive-compulsive symptoms than the doses generally used to treat depression. 1Note: Adult Doses. 2Sustained release 3Note: Many generic brands have emerged recently. Included here are the most common. © Copyright 2015, John Preston, Psy.D and P.A. Distributors 127 ANTIPSYCHOTICS

NAMES ACH Generic Brand Dosage Range1 Sedation Ortho2 EPS3 Effects4 Equivalence5

LOW POTENCY chlorpromazine Thorazine 50-800 mg high high + + ++++ 100 mg clozapine Clozaril 300-900 mg high high 0 +++++ 50 mg quetiapine Seroquel 150-600 mg mid mid +/0 + 50 mg HIGH POTENCY perphenazine Trilafon 8-60 mg mid mid ++++ ++ 10 mg loxapine Loxitane 50-250 mg low mid +++ ++ 10 mg fluphenazine Prolixin 3-45 mg low mid +++++ ++ 2 mg haloperidol Haldol 2-40 mg low low +++++ + 2 mg pimozide Orap 1-10 mg low low +++++ + 1-2 mg risperidone Risperdal 4-16 mg low mid + + 1-2 mg paliperidone Invega 3-12 mg low mid + + 1-2 mg olanzapine Zyprexa 5-20 mg mid low +/0 + 1-2 mg ziprasidone Geodon 60-160 mg low mid +/0 ++ 10 mg iloperidone Fanapt 12-24 mg mid mid + ++ 1-2 mg asenapine Saphris 10-20 mg low low + + 1-2 mg lurasidone Latuda 40-80 mg mid mid + + 10 mg aripiprazole Abilify 15-30 mg low low ++ + 2 mg brexpiprazole Rexulti 1-4 mg low low + + 1 mg cariprazine Vraylar 1.5-6 mg low low + + 1 mg

1Usual daily oral dosage. 2Orthostatic Hypotension. Dizziness and falls. 3Acute: Parkinson’s, dystonias, akathisia. Does not reflect risk for tardive dyskinesia. All neuroleptics may cause tardive dyskinesia, except clozapine. 4Anticholinergic Side Effects. 5Dose required to achieve efficacy of 100 mg chlorpromazine. 6In recent times a number of second generation antipsychotics have been developed in injectable form for acute treatment and longer term prophylaxis. These are not mentioned in this quick reference. 7Note: Many antipsychotic medications are approved for the treatment of various phases of bipolar disorder.

ANTI-ANXIETY HYPNOTICS NAMES Single Dose NAMES Single Dose Generic Brand Dosage Range Equivalence1 Generic Brand Dosage Range BENZODIAZEPINES temazepam Restoril 15-30 mg diazepam Valium 2-10 mg 5 mg triazolam Halcion 0.25-0.5 mg chlordiazepoxide Librium 10-50 mg 25 mg zolpidem Ambien 5-10 mg clonazepam Klonopin 0.5-2.0 mg 0.25 mg zolpidem Intermezzo 1.75 mg lorazepam Ativan 0.5-2.0 mg 1 mg zaleplon Sonata 5-10 mg eszopiclone Lunesta 1-3 mg alprazolam Xanax 0.25-2.0 mg 0.5 mg ramelteon Rozerem 4-16 mg OTHER ANTIANXIETY AGENTS diphenhydramine Benadryl 25-100 mg buspirone BuSpar 5-20 mg doxepin Silenor 3-6 mg gabapentin Neurontin 200-600 mg suvorexant Belsomra 15-40 mg hydroxyzine Atarax, Vistaril 10-50 mg propranolol Inderal 10-80 mg OVER THE COUNTER atenolol Tenormin 25-100 mg Name Daily Dose 1, 2 guanfacine Tenex, Intuniv 0.5-3 mg St. John’s Wort 600-1800 mg SAM-e3 400-1600 mg clonidine Catapres, Kapvay 0.1-0.3 mg Omega-34-EPA 1-2 g pregabalin Lyrica 25-450 mg Folic Acid7 400-800 mcg prazosin2 Minipress 5-20 mg L-methylfolate7, 8 7. 5 -15 mg N-acetylcysteine5 1200-2400 mg Chamomile6 200-1500 mg 5-HTP7 300-600 mg 1Treats depression and anxiety 5 For trichotillomania 1Doses required to achieve efficacy of 5 mg of diazepam 2 May cause significant drug-drug interactions 6Treats anxiety 7 2For treatment of nightmares and day time anxiety 3Treats depression Treats depression 4Treats depression and bipolar disorder 8Note: also available as Deplin 1-methylfolate (prescription) 7.5-15 mg REFERENCES and RECOMMENDED BOOKS Quick Reference & Bipolar Medications • Free Books • Free Downloads Website: www.PsyD-fx.com Handbook of Clinical Psychopharmacology For Therapists Clinical Psychopharmacology Made Bipolar Medications Child and Adolescent (2013) Preston, O’Neal and Talaga Ridiculously Simple 8th Edition A Concise Guide Psychopharmacology Made Simple (2016) New Drugs added (2016) Preston and Johnson (2016) Preston: Free Download (2015) Preston, O’Neal, Talaga 128 Monitoring of Antipsychotics and Mood Stabilizers Medication Typical (First Atypical Antipsychotics Lithium Divalproex Lamotrigine Carbamazepine Generation) Antipsychotics Adverse Effects EPS Agitation Hypothyroidism Thrombocytopenia Leukopenia Ataxia, nystagmus Requiring Monitoring Sedation Depression DI Pancreatitis Thrombocytopenia Leukopenia, Orthostatic Sedation Arrythmia PCOS Pancytopenia pancytopenia Hepatotoxicity hypotension Hypotension Weight gain Hepatotoxicity Hyponatremia Metabolic effects QTc prolongation Hepatotoxicity Hyperprolactinema Seizures Pneumonia Hyperprolactinemia LETHAL/ SEROIUS TD Metabolic effects Lithium toxicity SJS SJS RISKS NMS TD TEN TEN (esp HLA-B1502) NMS Agranulocytosis (clozapine) BMI, Waist 1 mo, 3mo, then 1 mo, 3mo, then circumference, annually annually AIMS BP, HgbA1C, lipids Baseline, 3mo, then Baseline, 3mo, then annually annually Drug levels q1-2wk until stable, q1-2wk until stable, then q1-2wk until stable, then then q3-6mo or sooner q3-6mo or sooner with q3-6mo or sooner with with dose changes dose changes dose changes CBC Clozapine – q1wk X 6/12, q1mo X 2/12 then q3- q1mo X 2/12 then q3- q1mo X 2/12 then q3- then q2wk X 6/12 then 12mo 12mo 12mo q4wk LFT’s q1mo X 2/12 then q3- q1mo X 2/12 then q3- q1mo X 2/12 then q3- 12mo 12mo 12mo Cr, lytes, u/a q2-3 mo X 6/12, then Baseline, then q6-12 mo periodically TSH q2-3 mo X 6/12, then q6-12 mo PRL As indicated As indicated ECG Baseline then q6-12 mo

129 Antipsychotics and Mood Stabilizers in Pregnancy and Lactation Medication Typical (First Atypical Lithium Divalproex Lamotrigine Carbamazepine Generation) Antipsychotics Antipsychotics Pregnancy Limited data – Limited data – Cardiac HIGHEST RISK Cleft palate 3.4-8.7% risk of probably safe probably safe malformations 8/1000 NTD, CHD, fetal 8/1000 carbamazepine Ebstein;s syndrome anomaly 10/20000 Lactation Limited data – Limited data – Relative infant OK Infant serum OK probably safe probably safe dose 0.87 – 30% level 30% Lowest relative - watch for maternal level – infant dose in lethargy, ensure watch for rash Quetiapine infant (0.02-0.1%), hydration. highest in Monitor infant’s Risperidone serum levels, (92.8-9.1%) also check infant’s Cr, lytes, TSH starting at 6 weeks

130 Table 27 Recommendations for pharmacotherapy for OCD

First-line Escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Adjunctive: aripiprazole, risperidone Second-line Citalopram, clomipramine, mirtazapine, venlafaxine XR Adjunctive: memantine, quetiapine, topiramate Third-line IV citalopram, IV clomipramine, duloxetine, phenelzine, tramadol, tranylcypromine Adjunctive: amisulpride, celecoxib, citalopram, granisetron, haloperidol, IV ketamine, mirtazapine, N- acetylcysteine, olanzapine, ondansetron, pindolol, pregabalin, riluzole, ziprasidone Not recommended Clonazepam, clonidine, desipramine Adjunctive: buspirone, clonazepam, lithium, morphine

Table 15 Recommendations for pharmacotherapy for panic disorder

First-line Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine XR Second-line Alprazolam, clomipramine, clonazepam, diazepam, imipramine, lorazepam, mirtazapine, reboxetine Adjunctive: alprazolam ODT, clonazepam Third-line Bupropion SR, divalproex, duloxetine, gabapentin, levetiracetam, milnacipran, moclobemide, olanzapine, phenelzine, quetiapine, risperidone, tranylcypromine Adjunctive: aripiprazole, divalproex, olanzapine, pindolol, risperidone Not recommended Buspirone, propranolol, tiagabine, trazodone

Table 30 Recommendations for pharmacotherapy for core symptoms of PTSD

First-line Fluoxetine, paroxetine, sertraline, venlafaxine XR Second-line Fluvoxamine, mirtazapine, phenelzine Adjunctive: eszopiclone, olanzapine, risperidone Third-line Amitriptyline, aripiprazole, bupropion SR, buspirone, carbamazepine, desipramine, duloxetine, escitalopram, imipramine, lamotrigine, memantine, moclobemide, quetiapine, reboxetine, risperidone, tianeptine, topiramate, trazodone Adjunctive: aripiprazole, clonidine, gabapentin, levetiracetam, pregabalin, quetiapine, reboxetine, tiagabine Not recommended Alprazolam, citalopram, clonazepam, desipramine, divalproex, olanzapine, tiagabine Adjunctive: bupropion SR, guanfacine, topiramate, zolpidem

131 Table 21 Recommendations for pharmacotherapy for SAD

First-line Escitalopram, fluvoxamine, fluvoxamine CR, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR Second-line Alprazolam, bromazepam, citalopram#, clonazepam, gabapentin, phenelzine Third-line Atomoxetine, bupropion SR, clomipramine, divalproex, duloxetine, fluoxetine, mirtazapine, moclobemide, olanzapine, selegiline, tiagabine, topiramate Adjunctive: aripiprazole, buspirone, paroxetine, risperidone Not recommended Atenolol*, buspirone, imipramine, keppra, propranolol*, quetiapine Adjunctive: clonazepam, pindolol *Beta-blockers: successful in clinical practice for performance situations #Note: although there is limited evidence for citalopram in SAD, it is likely as effective as the other SSRIs, in contrast there are negative trials of fluoxetine in SAD suggesting it may be less effective than other SSRIs [382,449].

Table 24 Recommendations for pharmacotherapy for GAD

First-line Agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR Second-line Alprazolam*, bromazepam*, bupropion XL*, buspirone, diazepam*, hydroxyzine, imipramine, lorazepam*, quetiapine XR*, vortioxetine Adjunctive: pregabalin Third-line Citalopram, divalproex chrono, fluoxetine, mirtazapine, trazodone Adjunctive: aripiprazole, olanzapine, quetiapine, quetiapine XR, risperidone Not recommended Beta blockers (propranolol), pexacerfont, tiagabine Adjunctive: ziprasidone *Note: These have distinct mechanisms, efficacy and safety profiles. Within these second-line agents, benzodiazepines would be considered first in most cases, except where there is a risk of substance abuse, while bupropion XL would likely be reserved for later. Quetiapine XR remains a good choice in terms of efficacy, but given the metabolic concerns associated with atypical antipsychotic, it should be reserved for patients who cannot be provided antidepressants or benzodiazepines. Please refer to text for further rationale for the recommendations.

132

Mental Health Act of Alberta Formal Patient Certification

See Key Points for reference details A-N (over). This Chart is one of three, only explanations specific to this chart are included.

Seek Judge’s Warrant (Form 8) Person shows signs of Physically (Expiry 7 days) Consider a mental disorder (A) and available for NO or CTO certification is being examination by Peace Officer's Statement (Form 10) considered physician? (B) YES YES

Apprehend and “Facility” means a place or part of a Examined by a physician Meets NO place designated in the Mental Health convey to facility criteria Regulation as a facility, otherwise for CTO known as designated facility

Meets ALL NO OR Discharge 3 criteria? (C)

Willing to NO accept treatment YES in facility? Within 24 hours of exam physician issues an Admission Certificate (Form 1) (D) YES

Examination by a physician Admitted as on staff at facility within voluntary • Person may access MH Patient 24 hours of arrival at facility patient Advocate services at any time after first Form 1

• Review Panel hearing may be requested anytime once person Patient is a Formal Patient Meets ALL NO or Other applies 3 criteria? NO • Automatic Review Panel Hearing for Review Panel to (C) 6 months after admission or challenge since last review certification YES YES

• A second Admission Certificate (Form 1) (D) issued within 24 hours of arrival at facility Review Panel Hearing: • Becomes a Formal Patient (valid for one month) within 21 days (G)

• Patient and Others informed of Formal Patient status and rights under MHA (E) (F)

Interventions to control While YES For additional patient to prevent waiting for Hearing, Continues as information refer to serious bodily objects to Formal Patient Formal Patient harm are treatment? Competency & permitted (H) Consent for Treatment Decisions NO

Review Panel YES Meets ALL NO 3 criteria? decision to continue (C) Formal status?

NO YES

Each renewal; 2 physicians must complete Formal Certificates separate exams and Renewal Certificates cancelled (Form 2), at least one must be a psychiatrist and one a facility staff physician Continue st 1 renewal: 1 month as a voluntary Continues as nd 2 renewal: 1 month patient Formal Patient 3rd and subsequent renewals: 6 months or discharge If not renewed Formal status expires

Material appearing in this resource may be reproduced or copied in full for education and program development purposes or not-for-profit, non-commercial activities without permission 13-Jan-16

Mental Health Act of Alberta Formal Patient Certification - Key Points A. Definition of Mental Disorder  Name and address of review panel chair

(see MHA 1(g))  Notice of discharge from facility or expiry / Additional Information

cancellation of certificates A substantial disorder of thought, mood, perception,  Formal Patient Certificates (admission / renewal) How orientation, or memory that grossly impairs: are cancelled on the issuance of a Community judgment, behavior, capacity to recognize reality or  Provide copies of certificates  Use verbal and written explanations Treatment Order. (MHA 9.1(3)) ability to meet the ordinary demands of life.  On admission as a formal patient, the Community  Use simple language B. Apprehension by Warrant or Peace  An interpreter must be provided if necessary to Treatment Order should be cancelled (MHA 9.6(4c)) Officers Statement (see MHA 10 and 12) facilitate understanding  Mental Health Patient Advocate services  Provide pamphlets about rights and copies of all available at any time To apprehend a person to conduct an examination, documents to patient / SDM’s the Judge and/or the Peace Officer must have  “Facility” means a place or part of a place reasonable and probable grounds to believe that the * Additional notice to Family Doctor - upon designated in the Mental Health Regulation as a person is in a condition likely to cause harm to the discharge, along with discharge summary including facility, otherwise known as designated facility person or others or to suffer substantial mental or recommendations for treatment physical deterioration or serious physical impairment # Form Name Completed by and: F. Documentation Judges Warrant: (section 10, Form 8) 1 Admission Certificate 2 Physicians o There is no other way to arrange for an examination.  Patient’s and Others’ receipt of: 1 Physician 2 Renewal Certificate o Application supported by sworn information o Certificates 1 Psychiatrist that the person is suffering from mental Verbal and written information about formal o Board’s disorder status: reasons, duration and legal rights, date Order to Return a Formal 3 Delegate e.g. Peace Officer: (section 12, Form 10) completed Patient to a Facility  Physician o The person is suffering from a mental disorder Patient’s awareness and apparent understanding of formal status and legal rights Minister of o The person should be examined for their own  Response to information, behavior & mental Certificate of Transfer into Health and safety or the safety of others. 4 status Alberta Wellness or o Circumstances are such that proceeding under section 10 would be dangerous  If an appeal is being made designate  Patient’s consent or refusal of treatment Minister of C. Three Criteria for Formal Patient Transfer of Formal Patient to Health and Not documented = Not done 5 Certification (see MHA 2(a-c)) a Facility Outside Alberta Wellness or

 Suffering from a mental disorder G. Review Panel (see MHA 34-43) designate  In a condition likely to cause harm to the person Board’s  or others or to suffer substantial mental or Composed of a chair or vice-chair (must be a Memorandum of Transfer to Delegate e.g. 6 physical deterioration or serious physical lawyer), a psychiatrist, a physician, a member of Another Facility Physician, at impairment the general public (see MHA 34-36). Review sending facility  Unsuitable for admission to a facility other than panel members may not be on staff at the facility as a formal patient and must not be treating or have treated the 7 Information Informant patient.  D. Admission Certificates The applicant and the applicant’s representative 8 Warrant Judge have a right to be present during presentation of Effect of One Admission Certificate evidence (see MHA 4(1))  Use Form 12 to apply for review panel hearing 9 Extension of Warrant Judge

 A board (usually delegated to a physician) may Gives sufficient authority to: Statement of Peace Officer apply on behalf of a formal patient (MHA 38(2)) 10 Peace Officer  Care for, observe, assess, detain and control, on Apprehension  apprehend and convey to a facility within 72 A board or attending physician may apply to A) Physician & hours of issue review panel for treatment order (MHA 29 (2))  B) Rep of  Care for, observe, assess, detain and control the Any decision or order of the review panel may be Certificate of Incompetence 11 Facility Board, person during apprehension and conveyance appealed to the Court of Queen’s Bench to Make Treatment Decisions usually a  Care for, observe, examine, assess, treat, detain Physician and control the person for up to a maximum of 24 H. Control (see MHA 30) hours after arrival at facility unless a 2nd Control is the minimal use of reasonable force, by Application for Review Panel Patient / SDM / certificate is written 12 mechanical means or medication - without patient’s Hearing Board / Anyone Effect of Two Admission Certificates consent – as necessary to prevent serious bodily (see MHA 7(1,2)) harm to the person or another person. Notice of Hearing Before Review Panel 13  Gives sufficient authority to If interventions / medications, are used to control the Review Panel Chair o Care for, observe, examine, assess, treat, behavior, not to treat patient, staff must document detain and control the person named on the behavior requiring control and measures used. Decision of Review Panel certificate for up to one month after issuing of Regarding Mental Review Panel 14 the certificates I. Mental Competency (see MHA 28) Incompetence to Make Chair  One certificate must be signed by a physician on Treatment Decisions staff at the facility Competency means that the person is able to  If needed, Renewal Certificates must be understand the subject-matter relating to, and the Decision of Review Panel Review Panel 15 completed prior to expiry of existing certificates consequences of, making treatment decisions or regarding Treatment Chair giving consent & the consequences of not doing so. E. Informing Patient and Others (see MHA 14) Treatment decisions may be made on behalf of a Decision of Review Panel Review Panel formal patient when the patient is a minor or is not 16 regarding Transfer back to a Who* Chair mentally competent by (in the following priority order): Correctional Facility  Patient  Patient’s agent, substitute decision maker (SDM) (a) agent of the patient (under personal  Patient’s nearest relative (unless patient objects) directive) Decision of Review Panel  Patient may designate one person s. 14 (1) & (4) (b) guardian of the patient Regarding Admission Review Panel 17 Certificates, Renewal Chair What (c) nearest relative as defined in section 1(i)(i), Certificates or CTO  The reason for issuance of the certificates or  The authority for detention and the period of it (d) the Public Guardian (last resort)

 Function of the review panel Decision of Review Panel The authorized person shall make the treatment Regarding Renewal Review Panel  Notice of the right to apply for a review panel 18 decisions in accordance with what they believe to be Certificates & CTO’s Chair hearing to appeal treatment orders, certificates the best interests of the patient. or finding of incompetence (Deemed Application)

DISCLAIMER: This document is intended as a guide and should not be used as a legal reference or advice. Please consult a lawyer if in need of clarification or legal advice. The information herein is not fully comprehensive; for complete details please refer to Alberta's Mental Health Act and the accompanying regulations. AHS is not liable in any way for actions based on the use of information contained herein. 1/13/2016

3 WELLNESS Calgary Resource Guide Compiled by Mobile Response Team - Revised March 2016 Crisis Services Hospitals and Medical Clinics *(Unless otherwise noted all numbers are in the 403 area code) Sheldon M. Chumir Health Centre 955-6200 Emergency 911 1213 4th St SW Distress Center Alberta Children’s Hospital 955-7211 • (24 hr Crisis Line) 266-4357 Claresholm Care Centre 625-8500 Mobile Response Team (MRT) 266-4357 CUPS 221-8780 • 9:30 a.m. – 9:30 p.m. Foothills Medical Center 944-1110 South Health Campus Psychiatric Peter Lougheed Center 943-4555 Outreach Response Team (PORT) Rockyview General Hospital 943-3000 • South of Anderson Rd. 266-4357 South Health Campus 956-1111 Community Resource Team (CRT) South Calgary Health Centre 943-9300 • Child & Adolescent Crisis 299-9699 31 Sunpark Plaza S.E. Police (Non emergency) 266-1234 STI Clinic 955-6700 Ambulance (Non emergency) 261-4000 Health Link 943-5465 Shelters Poison Information 944-1414 Avenue 15 (Youth 12-17) 938-15th Ave S.W. 543-9651 Red Cross 541-6100 Awo Taan Native Women’s Shelter 531-1972 Calgary and Area Child and Alpha House 234-7388 Family Services (24 hr) 297-2995 Brenda’s House 242-8575 Alberta Works 297-2094 Calgary Drop-In Society 266-3600 After Hours: 1-866-644-5135 Calgary Women’s Emergency Shelter 234-SAFE(7233) SPCA-Safe Keeping Program 403-723-6025 or 403- Discovery House 277-0718 205-4455(Emergency) Exit Youth Shelter (Wood’s- Youth 12-17) 509-2323 Connect: www.connectnetwork.ca Inn from the Cold 263-8384 Sexual Abuse/Sexual Assault 237-5888 Kerby Rotary House (Seniors) 265-0661 Domestic and Relationship Abuse 234-7233 Kerby- 24 hr line 705-3250 Children’s Cottage 233-2273 Sheriff King Home 266-0707 (Family emergency respite) The Mustard Seed 102–11th Ave S.E. 269-1319 The Salvation Army (Center of Hope) 410-1111 420-9th Ave S.E. Counseling Services Wheat Land Shelter, Strathmore (Abuse) 934-6634 Access Mental Health 943-1500 Calgary Counseling Centre 691-5991(intake) th Mental Health #200, 940 – 6 Ave S.W. Aboriginal Mental Health 955-6645 Calgary Women’s Health Collective 265-9590 ACCESS Mental Health 943-1500 Carya (Calgary Family Services) 269-9888 Bridging the Gap (16-24yr) 216-0660 -Functional Family Therapy 205-5899 Canadian Mental Health Association 297-1700 -Post Partum support 205-5177 Family Support Program 297-1704 Catholic Family Services 233-2360 Calgary Association of Self Help CCASA Calgary Communities 1019 – 7th Ave S.W. 266-8711 Against Sexual Abuse 237-5888 Children & Adults with ADHD (CHADD) 225-8512 Credit Counseling Services 265-2201 Community Geriatric MH Services 955-6155 Distress Centre Counseling 266-4357 Community Disaster Outreach Team (CDOT) 955-6019 th #300, 1010 – 8 Ave S.W. Developmental Disabilities - PDD 297-5011 Eastside Family Center (Mon-Sat) Emotions Anonymous 247-5381 th #255, 495 – 36 St N.E. 299-9696 Mental Health Help Line (24 hours) 1- 877-303-2642 Calgary Family Therapy Centre 802-1680 Men’s Line 266-4357 Grief Support Program 955-8011 Operational Stress Injury Clinic (Carewest) 216-9860 Jewish Family Services 287-3510 Organization for Bipolar Affective Disorder 263-7408 Native Counseling Services 237-7850 Potential Place 216-9250 Alberta Association of Social Work Schizophrenia Society 264-5161 www.acsw.ab.ca/public 1-800-661-3089 Suicide Services 297-1744 Psychologists’ Association of Alberta Street Outreach & Stabilization Team (SOS) 297-1700 www.psychologistsassociation.ab.ca Support Works http://supportworks.ca/ 246-TALK (8255)

Calgary Addiction Resources Community Services 1835 House/Recovery Acres (men) 245-1196 Information 211 Youth Addiction Services 297-4664 AIDS Calgary 508-2500 Adult Addiction Services (AADAC) 297-3071 AISH Office 297-8511 Addictions Center 944-2025 Alberta Youth Care and Custody Network 474-1344 Aspen Family Services 219-3477 Al-Anon / Al-Ateen 266-5850 Calgary Immigrant Women Assoc 263-4414 Alberta Adolescent Recovery Centre 253-5250 Calgary Outlink (Center for Gender and Sexual Diversity) Alcoholics Anonymous 777-1212 www.calgaryoutlink.ca 234-8973 Alpha House 203 – 15th Ave S.E. 234-7388 Calgary Urban Project (CUPS) 1001 10 AVE SW 221-8780 Aventa (Villa for Women) 245-9050 Calgary Workers’ Resource Centre 264-8100 Cocaine Anonymous 568-8008 Centre For Newcomers 569-3325 DOAP Team 998-7388 Champions Career Center 265-5374 Dream Center 243 5598 Child Abuse Hotline 1-800-387-5437 Fresh Start (men) 387-6266 Children’s Cottage 233-2273 City of Calgary Information Line 311 Gambling Help Line 1-866-332-2322 Early Start (24hr) 244-8351 Narcotics Anonymous 569-3427 Elder Abuse Resource Line 705-3250 Opiate Dependence Program 297-5118 Employmecalgary.ca 1-888-388-4217 Oxford House Intake 287-8771 Exit Community Outreach 262-9953 Renfrew Recovery Center 297-3337 Families Matter (Postpartum Support) 205-5178 Safeworks (Needle exchange) 232-3838 Family Caregiver Centre (Support for Caregiver) 303-6027 Salvation Army (Addiction Treatment) 410-1150 Government Services 310-0000 Servants Anonymous Society (Women) 237-8477 Home Care 943-1600 Simon House (Men) 247-2050 Immigrant Aid Society 265-1120 Infant Essentials 220-0432 Smart Recovery 619-4210 Inform Alberta informalberta.ca Sunrise Native Addiction Services 261-7921 Interfaith Food Bank 253-2055 Victory Outreach Foundation (Women) 264-0598 Interfaith Thrift Association 235-6881 Women for Sobriety 253-9063 Kerby Center (Seniors) 265-0661 Youville Residence 242-0244 Living Well with a Chronic Condition 943-2584 Louise Dean Center 777-7630 Neighbour Link 209-1930 North of McKnight Community Resource Centre 293-0424 Housing PDD (Developmental Disabilities) 297-5011 Accessible Housing Society 282-1872 CHR Patient Representatives 944-2080/944-2077 Calgary Housing 221-9100 Public Health 943-2288 Calgary Drop-In Society 266-3600 Pregnancy Care Center 269-3110 http://www.thedi.ca/services/affordable -housing/ Prospect (Employment) 273-2822 East Village Place 264-3455 SABIS (Brain Injury Society) 521-5212 SIDS Calgary Society 265-7437 Forest Lawn (working only) 248-0213 Self Help 266-8711 Giammarco and Company 269-4897 Seniors Resource Society 266-6200 Holy Cross 209-4780 Servants Anonymous 237-8477 Kerby Center (seniors) 265-0661 Sexual and Reproductive Health Clinic 955-6500 Lamda Apartments 242-7740 Sleep Disturbance Centre 944-2404 Landlord & Tenant service 1-877-427-4088 The Doorway (Youth) 269-6658 Langin Place (men) 237-5435 The Way Inn (403-SENIORS) 736-4677 Murdoch Manor 234-9311 Victims Assistance - V.A.S.T. 428-8398 Métis Housing (native) 569-9030 Women’s Center (Various drop in supports) 264-1155 Doctors accepting new patients : http://www.cpsa.ab.ca Off Campus Housing (students) 220-6553 www.calgaryareadocs.com Peter Coyle Place Housing 252-6000 Potential Place Housing 216-9254 Salvation Army (men only) 410-1184 Transitional & Supportive Housing 297-1700 Legal Support (Canadian Mental Health) URSA Universal Rehab Service Agency for Mental Health Warrant – Family Court 297-3471 th th Dependant Handicap 272-7722 7 Floor, 601 – 5 Street S.W. YWCA Mary Dover House 263-1550 Calgary Legal Guidance 234-9266 SORCe (Safe Communities Opportunity and Resource Calgary Diversion Service 410-1132 Centre) http://www.scorce.ca/ 316 – 7 Ave. SE Calgary Workers’ Resource Centre 264-8117 Low cost rent: http://www.lowcostrent.org Dial-A-Law 234-9022 Elizabeth Fry Society 294-0737 John Howard Society 266-4566 Legal Aid Society of Alberta 297-2260 Student Legal Assistance Society 220-6637

2 Community Counselling Services

Walk-In Counselling

Walk-in counselling is individual, couple, or family therapy on a first come, first served basis. There is no fee for this service. You may go as often as you wish, however you will see a different therapist each time.

Eastside Family Centre Suite 225, 495 - 36th Street NE

Phone: 403-299-9696 www.woodshomes.ca

Hours: Monday - Thursday 11:00 AM to 7:00 PM Closed Sunday and Statutory Friday 11:00 AM to 6:00 PM Holidays Saturday 11:00 AM to 2:00 PM

COMMENTS: Focused Counselling (up to 5 sessions with the same therapist) may be available primarily for youth and their families

South Calgary Walk-In Counselling 31 Sunpark Plaza SE

Phone: 403-943-9374 www.albertahealthservices.ca

Hours: Monday - Thursday 4:00 PM to 7:00 PM Closed Saturdays, Sundays, Friday 10:00 AM to 1:00 PM and Statutory Holidays

COMMENTS: Use the North entrance and proceed to the 2nd floor

Short Term Counselling

Individual, couple, or family therapy which has a limited number of scheduled sessions with the same therapist. Therapy is focused on a specific crisis and there is no fee.

Distress Centre Suite 300, 1010 - 8th Avenue SW

Phone: 403-266-4357 (request counselling intake) www.distresscentre.com

SESSION LIMIT: 5-6 COMMENTS: Evening and emergency appointments may be available. Individuals must not be involved with any other type of counselling (either individual or group).

Benefits / Private Counselling

Most benefit plans (Blue Cross, Sunlife) will reimburse a portion of the cost per session for clients who see a registered psychologist (see below). Some employers work with specific counselling agencies (Shepell fgi, Homewood) with no out-of-pocket expense to the employee. Contact your HR department for details.

Psychologists' Association of Alberta 403-246-8255 www.psychologistsassociation.ab.ca

3 Longer Term Counselling

Individual, couple, or family therapy scheduled with the same therapist. All of the agencies listed offer a sliding fee scale which is based on ability to pay and can be negotiated with the therapist.

Calgary Counselling Centre Suite 200, 940 - 6th Avenue SW

Phone: 403-265-4980 www.calgarycounselling.com

INTAKE PROCEDURE: 15 minute phone interview OR online questionaire COMMENTS: Individual counselling. Group sessions are available but require individual counselling first.

Carya (former Calgary Family Services) Suite 220, 1000 - 8th Avenue SW

Phone: 403-269-9888 www.caryacalgary.ca

INTAKE PROCEDURE: 5-10 minute phone intake by calling 403-205-5244 COMMENTS: Numerous locations throughout the city. Counselling may be available in several languages. Only accepting referrals for clients parenting children under 22 years old who reside in the home. They will see children & adolescents. Will not accept referrals for domestic violence or active substance use.

Catholic Family Services Suite 250, 707 - 10th Avenue SW

Phone: 403-205-5294 www.cfs-ab.org

INTAKE PROCEDURE: Phone intake by calling 403-205-5294 COMMENTS: Numerous locations throughout the city. Individual counselling. Group sessions available for social support, anxiety/depression and self-esteem

Jewish Family Services 420, 5920 - 1A Street SW

Phone: 403-287-3510 www.jfsc.org

INTAKE PROCEDURE: COMMENTS: Individual counselling. Group sessions are available. Evening appointments are available

Calgary Family Therapy Centre Suite 300, 2204 2nd Street SW

Phone: 403-802-1680 www.familytherapy.org

INTAKE PROCEDURE: Contact the Centre's main line APPROPRIATE FOR: Families concerned about a family member who is 18 years of age or younger. COMMENTS: Occasional evening appointments may be negotiated. Centre is a teaching facility with the Faculty of Medicine at the U of C. There is no fee.

Other Counselling Options

Most universities and colleges have counselling available to full-time students.

Other mental health programs and services may be available through Alberta Health Services. Contact Access Mental Health at 403-943-1500 for more information.

Updated January 1, 2014

4 WELLNESS BASICS CURRICULUM, 2E. (2018) University of Calgary Family Medicine Residency (Calgary Program)

Authors: Resident Project Leads: Jeffrey McCarthy, Leia Hoffman, Lauren Bilinsky, Jahan Lakhani, Toni Morris, Molly Whalen-Browne, Venessa Shaneman Faculty Project Leads: Dr. Todd Hill, Dr. Lindsay Jantzie

5 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 1 Wellness BASICS Curriculum – Important Definitions and Concepts: To begin, we must define wellness. Per the CFMS 2010 guide Embracing Wellness: • Wellness: “both a decision and a process. A conscious effort to make informed choices on a daily basis is necessary so that we may stay physically, mentally, and socially fit for different life challenges. Habits relating to stress management, sleep, exercise, nutrition, relationships, and work-life balance – to name a few – contribute to determining a person’s level of wellness. Additionally, optimal wellness is total wellness, which cannot be achieved in any one limited aspect or dimension. To embrace health as defined by the World Health Organization – not merely the absence of disease but a complete sense of physical, mental and social wellbeing – we need to embrace the different aspects and components of wellness.”1 Two end-points often associated with Wellness include Burnout and Engagement: • Burnout: Defined by Emotional exhaustion (feelings of being emotionally overextended and exhausted at one’s work), Depersonalization (interpersonal disengagement – unfeeling and impersonal response toward recipients of one’s service, care, treatment, or instruction); and low sense of personal accomplishment (feelings of incompetence and lack of achievement). Often measured by the Maslach Burnout Inventory Scale. Per the Resident Doctors of Canada, implications of burnout include decreased career satisfaction, decreased professionalism, suboptimal patient care, physical illness, substance abuse, depression, and suicidal ideation.2 • Engagement: “The positive antithesis of burnout,” engagement “embodies a state of high energy, strong involvement, and a sense of efficacy or a persistent positive state of fulfillment with vigor, dedication and absorption.”3 This concept is sometimes referred to as Professional Fulfillment4. Wellness can be understood in terms of 3 closely linked concepts – personal resilience, efficiency of practice & culture of wellness4:

• Personal Resilience: “The ability of an individual to respond to stress in a healthy, adaptive way, such that personal goals are achieved at minimal psychological and physical cost.”5 o Set of individual skills, behaviors and attitudes contributing to personal physical, emotional and social well-being, including prevention of burnout. o An internalized professional duty to pursue healthy behaviors. 푉푎푙푢푒 푎푑푑푒푑 푐푙𝑖푛𝑖푐푎푙 푤표푟푘 푎푐푐표푚푝푙𝑖푠ℎ푒푑 • Efficiency of Practice: 푇𝑖푚푒 & 퐸푛푒푟𝑔푦 푠푝푒푛푡 o Examples of Determinants of Efficiency of Practice: EMR Usability; Adequate Staffing (Physicians spending more time doing work they are uniquely trained for); Mitigation of documentation and regulatory burden; Maximized user-friendly decision support; Reliable care coordination. o How Efficiency of Practice Connects to Wellness: Increasing personal capacity to engage in positive health behaviors, while also contributing to a culture of wellness through healthier interpersonal interactions and encouraging others to engage in positive health behaviors. • Culture of Wellness: Normative values, attitudes and behaviors promoting self-care, personal and professional growth, and compassion for colleagues/patients/self. o Examples of Culture of Wellness: ▪ Expectation that physicians attend to their own well-being and view of self-care as a professional core competency – self-care and patient care are NOT competing interests. ▪ Culture of appreciation, support and compassion, along with deep sense of community. ▪ All Team members feeling safe when pointing out problems, rather than fearing retaliation or other negative reactions from colleagues or superiors.

6 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 2 Importantly, this definition recognizes both individuals and the organizations they work in have an important part to play in sustainable wellness, prevention of burnout and promotion of engagement. While the Wellness BASICS Modules focus on personal skill development towards sustainable wellness and personal resiliency, it is important to think critically about the culture of wellness and efficiency of practice in your place of work. A recent paper identified both intrinsic and modifiable barriers to wellness in residency in an Internal Medicine context, brainstorming possible interventions to address each modifiable barrier8. Similarly, in the context of your work while in residency, you can be an active participant in those broader organizational discussions in a number of ways, including:

• Submit evaluation feedback via One45 • Speak to your Co-Chief Residents about concerns with your residency experience and ideas to improve • Speak to your Curriculum Representatives about concerns with particular areas of the curriculum • Speak to your Site Lead (or Divisional Co-Chief Resident) about concerns with your home clinic site • Get involved in the Resident Leadership Committee to have a voice on both internal and external advocacy committees, organize resident programming, and more. • Have conversations about sustaining wellness when in independent practice with your mentors, including your primary preceptor when discussing your SMART Goals for each BASICS Module. The Wellness BASICS Modules that follow, along with the dedicated half-days allocated for residents to complete each module, are themselves the product of student engagement to address modifiable barriers to wellness in residency. The work seen here represents the second iteration of that effort, with changes made based on resident feedback via One45 evaluations. If you would like to be involved in a future module update, please contact your Divisional Chief Resident! References: 1. CFMS Wellness Program. 2010. Embracing Wellness: Healthy Medical Students for a Healthy Healthcare System. 2. https://residentdoctors.ca/wp-content/uploads/2017/10/RDoC-resiliency-CMA-GC-EN-FINAL.pdf. Accessed May 13, 2018. 3. Robb, M. 2017. Fulfillment vs. Burnout. Journal of American Physicians and Surgeons, 22 (4): 101-104 4. Bohman et al. 2017. Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness and Personal Resilience. NEJM Catalyst. https://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience/. Accessed May 13, 2018. 5. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2016/residents-and-resiliency. Accessed May 13, 2018. 6. Edmondson, E. Anupam, K.; Smith, S. 2018. Creating a Culture of Wellness in Residency. Academic Medicine. https://goo.gl/fBh4co. Accessed May 13, 2018.

7 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 3 Wellness BASICS Curriculum – Introduction to Process: Element When It Happens Process Description Wellness BASICS R1 – Foundations Block 1 • Intro session to key Wellness Concepts, and practice writing SMART Goal. Intro Session Wellness BASICS R1 – 3 BASICS Half-Days KEY IDEA: Each BASICS Half-Day generates a personalized Wellness SMART Goal Half-Day R2 – 3 BASICS Half-Days (Specific, Measurable, Actionable, Realistic, Time-Sensitive). • Before each BASICS Half-Day: Think about what you would change in your approach to wellness. To help turn these reflections into actions, create a SMART goal for your BASICS Half-Day. • During each BASICS Half-Day: Of the 5-10 activities, readings and modules presented, choose 2 of them. Each option includes a set of Thinking Questions to help you think back on the chosen activity. You do NOT need to write out detailed answers to Thinking Questions. Focus your energy on developing a SMART Goal that resonates with you, that you can come back to and see how you’re doing as you progress through the Program. By the end of each BASICS Half-Day, you should have a Wellness SMART Goal written on a field note. • After each BASICS Half-Day: As a measure of accountability, discuss your SMART Goal with a preceptor who will sign off on your BASICS Field Note. For most, this will be their Primary preceptor; for others, a faculty advisor or a mentor physician you’ve worked with would be great choices. Strike up a conversation about how they sustain Wellness in independent practice. Wellness Check- R1 – End of Block 3, 7, 11 • Opportunity to check-in with your primary preceptor around Resident Ins at 8-Week R2 – End of Block 2, 6, 10 Wellness and Career Planning, including follow-up on your BASICS SMART Midterm Reviews Goals (if applicable). • Tabulate number of Wellness BASICS Field Notes and half-days captured during current Midterm Review period. One45 Evaluation Periodic Evaluations • The Wellness BASICS Program began as a student-led initiative, and it has continued to evolve based on student input. When you are sent a One45 Eval for the Wellness BASICS curriculum, consider sharing ideas for activities or resources to add to the different modules; and on the flip side, let us know is a specific activity really did not meet your needs as well!

8 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 4 R1 Wellness BASICS – Module 1 – BODY: This first module focuses on the body and the effect that stress, our environment, our activity and our food choices have on our overall physical wellness1. In residency, time is at a premium and physical health often takes a backseat. Consider the following quote: “Medical training includes significant experience of self-denial. Physicians learn to go without sleep, meals, recreation and time with family and friends as a matter of routine while acquiring the vast amount of knowledge and skill required to practice medicine. Many will continue to deny their own personal needs while serving those of others in medical practice.”2 – Does this resonate with you? Through this module we encourage you to reflect on your own physical well-being and focus on making small but sustainable changes that can be reasonably incorporated into a busy residents’ life to help sustain physical wellness. Choose Your Adventure: Choose 2 of the following Options to help focus your Half-Day: • Reminder – Each Half-Day Should Generate a Wellness SMART Goal: Think about what you would change in your approach to wellness. To help turn your reflections into actions, create a SMART (Specific, Measurable, Actionable, Realistic, Time-Sensitive) goal for your Wellness BASICS Half-Day. Category Adventure Options Activities Option 1 – Exercise: • Do time-intensive work-out (consider apps from Resources to track progress) • Try a new activity (e.g. hiking, skiing, snowshoeing, etc. – check out Resources for groups to join!) • Try a Drop-In Sport (see Resources) Option 2 – Nutrition: • Take a cooking class; Weekly meal planning/cooking session • Make some healthy meals/snacks, even freeze some for later. Option 3 – Personal/Medical Care: • Find a Family Doctor (or allied health professional) if you don’t already have one. Consider making an intro visit appointment for this half-day. Thinking Question (Options 1-3): • How is your body wellness influenced by your nutrition, your exercise, or your approach to seeking personal medical care? Readings Option 4 – Nutrition: • Explore Dietitians of Canada Nutrition Articles, Meal Planning/Shopping Guides: https://goo.gl/wRGgzC; https://goo.gl/JcWWT6 • Take Dietitians of Canada Self-Assessment: https://goo.gl/a8T27j Thinking Questions (Option 4): • How do your eating, meal planning, shopping, etc. habits compare to what is recommended by the Dietitians of Canada? Are their suggestions realistic in your lifestyle? • Were the results of your self-assessment expected? Is there anything within your nutritional habits you’d like to change? What is one step you could take towards those changes? Option 5 – Fatigue Management: • Read ‘Effects of Chronic Exercise on Feelings of Energy and Fatigue: A Quantitative Synthesis’: https://goo.gl/FUP52z • Read ‘Using caffeine strategically to combat fatigue’ – Alexandra Holmes, Fatigue Management Specialist: https://goo.gl/4qYV5x Thinking Questions (Option 5): • How does the concept of ‘chronic exercise’ make you feel (e.g. excited, dread), and why? • How does your experience as a resident compare to that of an airline pilot? Are the strategies outlined for caffeine use applicable to you? Did you take anything away from these readings that you plan to try?

9 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 5 Readings Option 6 – Sleep Hygiene: • Explore MIT Sleep Resources: https://goo.gl/a1mM3U • Complete the Epworth Sleepiness Scale: https://goo.gl/XZYHhm Thinking Questions (Option 6): • Were there articles or resources on MIT site that caught your eye? Which ones, and why? • How did you score on the Epworth Sleepiness Scale? Is this your baseline? What does it tell you about your sleep habits? Modules Option 7 – Physical or Mental Health: • Watch ‘The Surprisingly Dramatic Role of Nutrition in Mental Health’ by Julia Rucklidge: https://goo.gl/Ki6KL3 • Watch ‘Why We All Need to Practice Emotional First Aid’ by Guy Winch: https://goo.gl/oTSwqx Thinking Questions (Option 7): • Can you relate to the videos’ connections drawn between physical & mental health? Why or why not? • What do you think about the idea of emotional first aid? Do you have a regular emotional hygiene practice? What would your ‘emotional first aid’ look like? Option 8 – Critical Thinking About Physical health: • Watch ‘Is the Obesity Crisis Hiding a Bigger Problem’ by Peter Attia: https://goo.gl/w4y9qM • Watch ‘Own Your Body’s Data’ by Talithia Williams: https://goo.gl/VAYWT4 Thinking Questions (Option 8): • Can you think of a time when your own personal biases about a person were related to their physiology? How did this affect the care you provided, if at all? How does it make you feel about your own body (ashamed, pressured, etc.)? • How aware do you think you are about your own body’s rhythms – do you know how healthy or unhealthy you are? What do others say? Do others think you ‘push yourself too hard’? Option 9 – Sleep: • Watch ‘Why Do We Sleep’ by Russell Foster: https://goo.gl/bgaMXg • Watch ‘How to Succeed? Get More Sleep’ by Arianna Huffington: https://goo.gl/KpR9zs • Watch ‘One More Reason to Get a Good Night’s Sleep’ by Jeff Iliff: https://goo.gl/CiN4mz • Watch ‘Our Natural Sleep Cycle is Nothing Like What We Do Now’ by Jessa Gamble: https://goo.gl/MPmvBg Thinking Questions (Option 9): • Are you getting an adequate amount of sleep? If so, what are you doing that works? If not, what is one thing you could change or try to improve it (within the confines of a resident’s schedule)? • What are some things that keep you from sleeping more? o Common examples include: You need ‘down time’ between when you stop working and start sleeping; You feel guilty not working; You have trouble falling asleep – and so avoid the ‘lying in bed awake’ feeling as much as you can; Environmental factors – partner is a ‘bed hog’ / snores, room is a mess, bedroom is noisy. • What do your answers to the above questions tell you about yourself?

10 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 6 Resources: Category Resources Nutrition • Cooking Classes in Calgary: https://goo.gl/y8Btuw • Meal Planning Resources: o Canadian Living Online (Includes How-To Videos): https://goo.gl/8p2363 o Food Network Canada (Includes Recipe Videos): https://goo.gl/kHpWmw • Meal Delivery Services (Delivering Meal Kits): o HelloFresh: https://goo.gl/kJebxA o Chefs Plate: https://goo.gl/4RV2xN o Jolly Table: https://goo.gl/GXHx7h o Healthy Chef: https://goo.gl/cKSo7d • Grocery Delivery Services: o Spud: https://www.spud.ca/ o Save-On-Foods: https://www.saveonfoods.com/shop-online-how-it-works/ Exercise • Fitness Facilities & Yoga Studios Offering UofC or AHS Student/Staff Discounts (e.g. UofC Active Living costs $37.70 per semester, tax included, for Residents?) - https://goo.gl/AsVwa4 • UofC Main Campus Drop-In Rates: https://goo.gl/meAFjD • UofC Kinetix FMC Drop-In Rates: https://goo.gl/qyFbph • Running Routes Around FMC / UofC: https://goo.gl/fzUzWL • Calgary Indoor Climbing Centers: http://www.calgaryclimbing.com/ • Calgary Outdoor Club: https://www.calgaryoutdoorclub.com/ • Hiking & Camping: http://www.albertawow.com/; https://www.trailpeak.com/; https://goo.gl/KmAepf (Kananaskis Trail App on iTunes) • Winter Mountain Sports – Skiing/Snowboarding: https://goo.gl/pd4yQi • Winter Mountain Sports – Cross-Country Skiing: https://goo.gl/8if1MA • Winter Mountain Sports – Snowshoeing: https://goo.gl/v9xbHf • Calgary Recreation Drop-In Schedules: https://goo.gl/Ez8TCo • Exercise Apps (Many Exist, A Small Sampling Here): o Carrot - https://goo.gl/qimiHX; iPerformance (Apple) - https://goo.gl/6eqf9T o Map My Run - https://www.mapmyrun.com/app/; Moves App - https://www.moves-app.com/ o Nike Running Club - https://goo.gl/584jyo; Nike Training - https://goo.gl/N2pWwo o Strava - https://www.strava.com/ ; 7-Minute Workout - https://7minuteworkout.jnj.com/

11 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 7

Category Resources Supports Resource – AMA Physician and Family Support Program (PFSP): for • Included in your AMA membership. You and your immediate family members (spouse/partner, dependent Residents children) may contact PFSP toll-free 1-877-SOS-4MDS (1-877-767-4637), 24 hours a day, 7 days a week, 365 in Distress days a year. As part of this program, PFSP will cover the cost of up to six counseling hours for you over a 12- month period, and up to an additional six hours total per family. They can also help you find your own family doctor. Find out more at: https://www.albertadoctors.org/services/pfsp. Resource – AHS Employee and Family Assistance Program (EFAP): • The AHS Employee and Family Assistance Program provides free access thru AHS, including residents and their immediate family members, to a variety of mental wellness resources, including individualized counseling both in person and via email or online chat. EFAP is completely confidential within the limits of the law. No one, including your employer, will ever know that you have used the service unless you choose to tell them. You can contact EFAP at 1-877-273-3134, 24 /7/365. Find out more at: https://goo.gl/xZ7P68 Resource – UC Wellness Centre: • The campus Wellness Centre offers massage and chiropractic to all students, residents, staff, and public. • Important Note: Residents do NOT have access to counseling services and medical support thru the Wellness Centre, as they are covered via the AMA PFSP and AHS EFAP (see above). They do provide these services for U of C Medical Students, and would be an important resource to recommend to medical students you work with. Find out more at: http://www.ucalgary.ca/wellnesscentre/ Resource – Chief Residents: • An important part of the role of your Co-Chief Residents (1 for each division) is to support wellbeing and morale of fellow Residents; provide a consistent level of support for concerns and issues; advocate for their needs; and work collaboratively in ongoing development and evolution of Family Medicine Residency. If you identify a problem within the program or your residency experience, consider reaching out for confidential support. Resource – Ombudsperson: • The Department of Family Medicine Residency Program Ombudsperson is a Family Physician who serves as an impartial third party in conflict resolution. The Ombudsperson acts as a resource to residents who may have personal issues or difficulties in the Program, where they don't feel comfortable going to their home program. Anything discussed with them is confidential and will not affect evaluations or reputation. • The current Ombudsperson for Calgary Family Medicine is Dr. Rita Dahlke (email: [email protected]). Resource – Office of Professionalism, Equity and Diversity (OPED), Cumming School of Medicine: • OPED acts as a resource for issues relating to professionalism, equity and diversity, and develops fair policies, practices and collaborative relationships to support various needs and circumstances. The office triages matters relating to mental health and will assist you in navigating the healthcare system. The office will hear matters concerning conflict in the workplace in accordance with established faculty protocols. All concerns brought to the office are confidential and will be treated with dignity and respect. • To reach out with concerns relating to Mental Health, Conflict Resolution, Harassment, and Professionalism breaches where you don’t feel comfortable going to your home program, please reach Dr. Beverly Adams at [email protected] (confidential email) Important Policies: • PGME Resident Safety Policy: https://goo.gl/PEbeyq • U of C Family Medicine Resident Wellness Policy: https://goo.gl/bfbg7B • U of C Family Medicine Resident Safety Policy: https://goo.gl/jnRkHm References: 1. http://www.docsmbwellness.org/wp-content/uploads/2014/10/TheBasics-full-version.pdf 2. http://www.black-bile.com/resources/00+Kaufman+OMA+Physician+Suicide+Prevention.pdf

HAVE AN IDEA FOR ACTIVITY/READING/MODULE FOR NEXT YEAR? INCLUDE IN ONE45 EVAL

12 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 8 R1 Wellness BASICS – Module 2 – AFFECT: Consider the following quotes:

• “I have a tendency to subscribe to the belief that my work performance should be perfect. This belief makes it difficult for me to accept compliments because perfect performance is the baseline expectation I set for myself. That makes a grievance about me an enormous affront that creates feelings of anger, self-doubt and irritation. Turns out I have some choice about that.”1 – Does this resonate with you? • “During the same shift…two patients on the same ward had died within 20 minutes of each other. The first patient’s wife was not accepting that he had really gone. I felt apprehensive. I felt a bit anxious. A few minutes later, the phone rang and I answered. It was an elderly man enquiring how his brother, the [other] recently deceased patient, was keeping. This totally caught me off guard. There was a silence which felt like an eternity to me as I struggled to dredge up from the back of my mind the breaking bad news training. I then had to go to another ward to attend to tasks there so I was no longer able to dwell upon what had just happened.”2 – How do you manage emotionally challenging situations like this while at work? • “I was quite upset about the situation. I was very fortunate that the nurses on the ward that evening were very experienced so I managed to discuss with them, we came up with a plan, we saw the family and we got it sorted. Unfortunately, the emotional impact of this was quite high for me, I was very upset. I was crying on the ward for quite a lengthy period of time. It was very difficult for me to deal with. I felt very isolated and left alone.”2 – Who do you turn to for emotional support in-the-moment of a stressful work situation? When the day is over? Residency is a stressful journey with significant physical and emotional demands. It is often easy to be caught up in patients’ health and neglect one’s own emotional and mental health. The goal of this module is promoting emotional health and emotional regulation by considering one’s personal attitudes, thought processes, and self-awareness. These behaviors modify our responses to situations in ways that range from unconscious, passive reaction to deliberate self-management. We can control our own thoughts and behavior but have less control over the culture in which we work. In this module, it is acknowledged that there are inherent challenges to behavior change within the culture of medicine and within the “hidden curriculum”. Perfectionism is often celebrated, self-sacrifice is subtly encouraged. To the extent possible, the aim of this module is to enable personal skills with acknowledgement of systemic challenges. Resources are included at the end of this module if you are in distress or when in need of support. Choose Your Adventure: Choose 2 of the following Options to help focus your Half-Day: • Reminder – Each Half-Day Should Generate a Wellness SMART Goal: Think about what you would change in your approach to wellness. To help turn your reflections into actions, create a SMART (Specific, Measurable, Actionable, Realistic, Time-Sensitive) goal for your Wellness BASICS Half-Day. Category Adventure Options Activities Option 1 – Exercises for Emotion Regulation: • Read the handout “Exercises for Emotion Regulation” found at: https://goo.gl/hsRCJX. During your Wellness Half-Day, practice a strategy listed that you haven’t used before. Thinking Questions (Option 1): • What strategies do you use during emotionally challenging moments at work? Which strategies do you find work well? Which do you find unhelpful and would like to change? • Which of the strategies listed do you already use? Which would you try in stressful work situations? Option 2 – Taking a Break: • Take time to do an activity that helps you relax or unwind. For example, physical activity, family time, meditation, phoning a parent, etc. Consider how often your mind returns to medicine during this activity. For example: Do your thoughts often return to your patients? Unfinished work? Remembering “mistakes”? Celebrating successes? • Review the Mental Health Continuum developed by the Canadian Armed Forces (summary table at the bottom of webpage) located at: https://goo.gl/ccjoDn

13 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 9 Thinking Questions (Option 2): • Do you give yourself permission to relax? How often do your thoughts return to medicine? • How often do you participate in this, or similar de-stressing activities? DO you omit these activities in times of high stress? If so, what are the consequences of doing so? • Where do I fit on the continuum: today, on average, on my worst days? If I am in the orange or red zone, who/where do I turn to for support? (For additional resources, see end of module) Readings Option 3 – Perfectionism Reading & Reflection: • Read the 1st handout on Perfectionism found at: https://goo.gl/BrkBgf. • Read the 2ndHandout on Perfectionism found at: https://goo.gl/br5A1q. Thinking Questions (Option 3): • What are some aspects of perfectionism you recognize in yourself? When in your life is perfectionism beneficial? When can it be harmful? • Have you used any of the four techniques (Using Realistic Thinking; Perspective-Taking; Looking at the Big-Picture; Compromising) to challenge perfectionist tendencies when they become harmful? Option 4 – Reading on Perfectionism, The Imposter Phenomenon and Psychological Adjustment: • Read the Article Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students by Henning, Ey and Shaw found at: https://goo.gl/RNUegJ Thinking Questions (Option 4): • When have I experienced the “Imposter Phenomenon” during residency? • Do I think I can challenge these feelings? Consider asking yourself, “What would I say to a friend who said they felt like this?”; and “Are my thoughts true? What is the evidence I have for/against this belief?” Modules Option 5 – When Perfect Isn’t Good Enough: • Watch the TedX Talk ‘When Perfect Isn’t Good Enough” by Martin Antony: https://goo.gl/Lsc9g5 • Watch the TedX Talk ‘Getting Stuck in the Negatives (And Getting Unstuck)’ by Alison Ledgerwood: https://goo.gl/U2vWsN Thinking Questions (Options 6): • What perfectionist traits do I see in myself (i.e. Fear of Failure; Fear of Making Mistakes; Fear of Disapproval; All-or-nothing (Black & White) thinking; Overemphasis on “Should” Statements)? • Choose one trait that can have negative effects – consider how you can challenge it in the future. • Write down 3 things that you are grateful for from the past day/week. • How do you work on seeing the upside in your day? Option 7 – The Gift and Power of Emotional Courage • Watch “The Gift and Power of Emotional Courage” by Susan David: https://goo.gl/7h2CdU Thinking Questions (Option 7): • The presenter describes her journaling of emotions as a “secret, silent correspondence with myself”. What strategies do you use to identify and to process your emotions? Would you consider journaling? • The presenter speaks of emotional agility as “the ability to be with your emotions with curiosity, compassion, and especially the courage to take values-connected steps”. She closes with the thought that “courage is not an absence of fear; courage is fear walking.” Think back to mentors or peers that demonstrated emotional courage in difficult work situations. What did they do to demonstrate this? What can we do to be more accepting of emotional courage in our medical workplace culture?

Resources: Category Resources Apps The following apps, many of which are focused on meditation and mindfulness, are also endorsed by the CFMS Longitudinal Wellness Initiative (https://goo.gl/oCRQZU) • Headspace (www.headspace.com); Calm (www.calm.com); Aura (www.aurahealth.io); 10% Happier (www.10percenthappier.com); Happify (www.happify.com) Books • When Perfect Isn’t Good Enough: Strategies for Coping With Perfectionism by Martin Antony & Richard Swinson (2009): https://goo.gl/T5zppn • Overcoming Perfectionism: The Key To Balanced Recovery by Ann W. Smith (1990): https://goo.gl/uvcvoZ • There is Nothing Wrong With You: Going Beyond Self-Hate by C. Huber (2001): https://goo.gl/Y24CaF

14 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 10 Supports Resource – AMA Physician and Family Support Program (PFSP): for • Included in your AMA membership. You and your immediate family members (spouse/partner, dependent Residents children) may contact PFSP toll-free 1-877-SOS-4MDS (1-877-767-4637), 24 hours a day, 7 days a week, 365 in Distress days a year. As part of this program, PFSP will cover the cost of up to six counseling hours for you over a 12- month period, and up to an additional six hours total per family. They can also help you find your own family doctor. Find out more at: https://www.albertadoctors.org/services/pfsp. Resource – AHS Employee and Family Assistance Program (EFAP): • The AHS Employee and Family Assistance Program provides free access thru AHS, including residents and their immediate family members, to a variety of mental wellness resources, including individualized counseling both in person and via email or online chat. EFAP is completely confidential within the limits of the law. No one, including your employer, will ever know that you have used the service unless you choose to tell them. You can contact EFAP at 1-877-273-3134, 24 /7/365. Find out more at: https://goo.gl/xZ7P68 Resource – UC Wellness Centre: • The campus Wellness Centre offers massage and chiropractic to all students, residents, staff, and public. • Important Note: Residents do NOT have access to counseling services and medical support thru the Wellness Centre, as they are covered via the AMA PFSP and AHS EFAP (see above). They do provide these services for U of C Medical Students, and would be an important resource to recommend to medical students you work with. Find out more at: http://www.ucalgary.ca/wellnesscentre/ Resource – Chief Residents: • An important part of the role of your Co-Chief Residents (1 for each division) is to support wellbeing and morale of fellow Residents; provide a consistent level of support for concerns and issues; advocate for their needs; and work collaboratively in ongoing development and evolution of Family Medicine Residency. If you identify a problem within the program or your residency experience, consider reaching out for confidential support. Resource – Ombudsperson: • The Department of Family Medicine Residency Program Ombudsperson is a Family Physician who serves as an impartial third party in conflict resolution. The Ombudsperson acts as a resource to residents who may have personal issues or difficulties in the Program, where they don't feel comfortable going to their home program. Anything discussed with them is confidential and will not affect evaluations or reputation. • The current Ombudsperson for Calgary Family Medicine is Dr. Rita Dahlke (email: [email protected]). Resource – Office of Professionalism, Equity and Diversity (OPED), Cumming School of Medicine: • OPED acts as a resource for issues relating to professionalism, equity and diversity, and develops fair policies, practices and collaborative relationships to support various needs and circumstances. The office triages matters relating to mental health and will assist you in navigating the healthcare system. The office will hear matters concerning conflict in the workplace in accordance with established faculty protocols. All concerns brought to the office are confidential and will be treated with dignity and respect. • To reach out with concerns relating to Mental Health, Conflict Resolution, Harassment, and Professionalism breaches where you don’t feel comfortable going to your home program, please reach Dr. Beverly Adams at [email protected] (confidential email) Important Policies: • PGME Resident Safety Policy: https://goo.gl/PEbeyq • U of C Family Medicine Resident Wellness Policy: https://goo.gl/bfbg7B • U of C Family Medicine Resident Safety Policy: https://goo.gl/jnRkHm References: 1. http://www.docsmbwellness.org/wp-content/uploads/2014/10/TheBasics-full-version.pdf 2. Lundin et al. 2018. “I’d been like freaking out the whole night”: Exploring Emotion Regulation Based on Junior Doctors’ Narratives. Adv. In Health Sci Educ. 23: 7-28.

HAVE AN IDEA FOR ACTIVITY/READING/MODULE FOR NEXT YEAR? INCLUDE IN ONE45 EVAL

15 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 11 R1 Wellness BASICS – Module 3 – SOCIAL: “It is our first nature to be connected,” says Psychologist Petruska Clarkson in her book The Bystander. Human beings, doctors included, are social creatures and need social contact. Leading a busy lifestyle, however, like going through Medical School, living through residency and being a physician – can sometimes take a toll on people’s social lives and result in feelings of isolation. Consider the following quote: “Try this exercise: think back to everyone you would have included in your personal support system when you were in high school. Include family members as well as friends, team-mates, fellow club members, and so on. Count them up. Repeat the exercise a few more times considering the years spent in university, medical school, residency, and beyond. What has happened to the total number of individuals in your support system over time? Has it decreased? For many in medicine, the years of rigorous training will take their toll upon social connections causing a robust network to shrink and fray.”1 – Does this resonate with you? When considering wellness, it is important to shine some light on our social wellness, how important it is to us, and things we can do to make sure we are feeling connected to the people in our lives, and to continue to reach out and invite new people into our lives as well. Through this module, we encourage you to reflect on the important social relationships in your life, and strategies to try to grow and to strengthen these important connections. Choose Your Adventure: Choose 2 of the following Options to help focus your Half-Day: • Reminder – Each Half-Day Should Generate a Wellness SMART Goal: Think about what you would change in your approach to wellness. To help turn your reflections into actions, create a SMART (Specific, Measurable, Actionable, Realistic, Time-Sensitive) goal for your Wellness BASICS Half-Day. An example SMART Goal for the Social Domain Might Look Like This: o Specific: I will contact a friend and make a commitment to go hiking and skiing this year o Measurable: I will contact a friend and make arrangements for 3 hikes, 2 ski days o Actionable: I will text and email my friend about hiking & skiing plans o Realistic: Weather permitting, we will book Dec. 21st for skiing; if weather looks sketchy, we’ll text on 20th and come up with alternate plans for 21st (e.g. hike) or raincheck dates. o Time-Sensitive: I will contact my friend within the next two weeks. Category Adventure Options Activities Option 1 – EcoMap: On a blank piece of paper, draw an Ecomap that includes all (or most) of the important & people and objects in your life. To draw this, the circle for “ME” is at center, and each person/object you add Readings surrounds you with lines connecting as follows: A. Size of Circle → Importance → B. Proximity of Circle Current Proximity/influence C. Arrow towards you → Positive Relationship

D. Arrow away from you → Negative Relationship

E. Arrow at both ends → Relationship both Positive and Negative F. Flag people you wish you reached out to more (e.g. with a highlighter) G. Write a line about 3-5 people you’ve included on how your relationship with them is +ve or -ve, and what things contribute to the nature of that positive/negative energy.

Option 2 – Hang Out: If you know someone is free or has the flexibility – go out for a coffee/tea/walk/get- together and chat. If possible, don’t make it about doing something (you can save your Squash game for ‘Body’ wellness). Find out how someone else is doing, and let them know how you’re doing.

Option 3 – Change Things Up: Meet someone at a time when you don’t usually (i.e. picking your kids up from

school, meeting your partner after work) and do something different (e.g. go for a walk, meet with other friends/families for play date, or coffee, or drink, or impromptu potluck, or dine-out/take-out).

16 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 12 Activities Option 4 - Structuring Social Time: Schedule 4 social activities for the upcoming month. Whether a 10-minute & walk, or a phone call with a friend, or coordinating going to a gym class or a drop-in sport with someone, or a date Readings with your partner. Have something to look forward to socially, each week. Some Social Wellness Challenge Ideas include: Become active in a club/group/organization; Call or write to far-away friends or family; Cultivate new friendships outside your family; Turn off the TV/Computer and interact with people; Maintain regular contact with a lonely person.

Option 5 – Phones Off: Lots of people when in public (waiting for a gym class, meeting their partner or friends at dinner) go on their phones. Try for a day (or week) not going on your phone when waiting for someone/something and instead, look around and possibly interact with someone near you.

Option 6 – Social Supports: Approach an important person in your life, and start a conversation about your respective needs in the coming year. For example, ask: ‘I realize I am going to be very busy over the next 2 years with residency, can we discuss how we’re going to approach this?’

Option 7 – Social Supports: Read the following article from heretohelp.bc.ca: https://goo.gl/QrvWKM. Thinking Questions (Options 1 – 7): • How are you doing at nurturing your most valued relationships? • How are you doing at reaching out to build new relationships? Are there people whom you would like to reach out to, but you aren’t? Why not? What barriers stop you? Are those barriers insurmountable? • Are there relationships with which you’d like to set better boundaries? • Are there relationships that are taking a toll on you? • Are there relationships which you would identify as unhealthy? o NOTE: If you identify you are in an abusive relationship, please reach out. Example warning signs of abuse can be found at: https://goo.gl/26Ege5. One resource for the Calgary Area with a number of links is run by the Calgary Police Service, found at https://goo.gl/iPnfHH. Modules Option 8 – Connected, But Alone: • Watch ‘Connected, but Alone?’ by Sherry Turkle: https://goo.gl/M8Nev8 Thinking Questions (Option 8): • How are you doing with the balance between being ‘connected’ to people in your life and ‘having relationships’ with them? Is this a struggle for you? • What are your thoughts about the role that technology plays in the ways that humans interact with each other? List a few aspects of relationships that you think are made better by social technologies. List a few things that you think are made worse by them. Option 9 – Importance of Vulnerability: • Watch ‘The Power of Vulnerability’ by Brene Brown: https://goo.gl/JYegtf Thinking Questions (Option 9): • What are your thoughts on Brene Brown’s thesis about the centrality of vulnerability in relationships? • What are some of the relationships in your life that you think could be made better by you allowing yourself to be a bit more vulnerable in? What’s stopping you? Option 10 – The Walk From No to Yes: • Watch ‘The Walk from “No” to “Yes”’ by William Ury: https://goo.gl/mC7czi Thinking Questions (Option 10): • Do you sometimes find yourself feeling it’s more important to be ‘right’ than ‘happy’? Why? • What are some things that you can do to make a change in this regard?

17 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 13 Resources: Category Resources Supports Resource – AMA Physician and Family Support Program (PFSP): for • Included in your AMA membership. You and your immediate family members (spouse/partner, dependent Residents children) may contact PFSP toll-free 1-877-SOS-4MDS (1-877-767-4637), 24 hours a day, 7 days a week, 365 in Distress days a year. As part of this program, PFSP will cover the cost of up to six counseling hours for you over a 12- month period, and up to an additional six hours total per family. They can also help you find your own family doctor. Find out more at: https://www.albertadoctors.org/services/pfsp. Resource – AHS Employee and Family Assistance Program (EFAP): • The AHS Employee and Family Assistance Program provides free access thru AHS, including residents and their immediate family members, to a variety of mental wellness resources, including individualized counseling both in person and via email or online chat. EFAP is completely confidential within the limits of the law. No one, including your employer, will ever know that you have used the service unless you choose to tell them. You can contact EFAP at 1-877-273-3134, 24 /7/365. Find out more at: https://goo.gl/xZ7P68 Resource – UC Wellness Centre: • The campus Wellness Centre offers massage and chiropractic to all students, residents, staff, and public. • Important Note: Residents do NOT have access to counseling services and medical support thru the Wellness Centre, as they are covered via the AMA PFSP and AHS EFAP (see above). They do provide these services for U of C Medical Students, and would be an important resource to recommend to medical students you work with. Find out more at: http://www.ucalgary.ca/wellnesscentre/ Resource – Chief Residents: • An important part of the role of your Co-Chief Residents (1 for each division) is to support wellbeing and morale of fellow Residents; provide a consistent level of support for concerns and issues; advocate for their needs; and work collaboratively in ongoing development and evolution of Family Medicine Residency. If you identify a problem within the program or your residency experience, consider reaching out for confidential support. Resource – Ombudsperson: • The Department of Family Medicine Residency Program Ombudsperson is a Family Physician who serves as an impartial third party in conflict resolution. The Ombudsperson acts as a resource to residents who may have personal issues or difficulties in the Program, where they don't feel comfortable going to their home program. Anything discussed with them is confidential and will not affect evaluations or reputation. • The current Ombudsperson for Calgary Family Medicine is Dr. Rita Dahlke (email: [email protected]). Resource – Office of Professionalism, Equity and Diversity (OPED), Cumming School of Medicine: • OPED acts as a resource for issues relating to professionalism, equity and diversity, and develops fair policies, practices and collaborative relationships to support various needs and circumstances. The office triages matters relating to mental health and will assist you in navigating the healthcare system. The office will hear matters concerning conflict in the workplace in accordance with established faculty protocols. All concerns brought to the office are confidential and will be treated with dignity and respect. • To reach out with concerns relating to Mental Health, Conflict Resolution, Harassment, and Professionalism breaches where you don’t feel comfortable going to your home program, please reach Dr. Beverly Adams at [email protected] (confidential email) Important Policies: • PGME Resident Safety Policy: https://goo.gl/PEbeyq • U of C Family Medicine Resident Wellness Policy: https://goo.gl/bfbg7B • U of C Family Medicine Resident Safety Policy: https://goo.gl/jnRkHm References: 1. http://www.docsmbwellness.org/wp-content/uploads/2014/10/TheBasics-full-version.pdf

HAVE AN IDEA FOR ACTIVITY/READING/MODULE FOR NEXT YEAR? INCLUDE IN ONE45 EVAL 18 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 14 R2 Wellness BASICS – Module 4 – INTELLECT: The author of ‘The BASICS’1 discusses the role of intellect in a physician’s medical career, and as part of who they are as a person. For some, intellectual activities outside of medicine (e.g. reading and learning about history, philosophy, etc.) can be engaging and act as a nice distraction from the study of medicine. For others, intellectual diversion is attained by personal hobbies, social interaction, creativity, or perhaps almost anything that is NOT medicine. The habits of resilient physicians have been studied, and important themes have emerged, including the ability to engage in regular ‘resilience practices’, whatever they may be.

By reading and reflecting on the experiences of physicians who have achieved work-life integration and who are able to remain resilient within a challenging profession, we can learn strategies and how to set realistic goals for long term wellness. Those physicians who are able to accept the things they cannot control, and accept change when it inevitably is required, embody healthy adaptability. Self-reflection is paramount in predicting those who will avoid burnout, and who will seek help when necessary. This module encourages you to reflect on how your chosen daily activities, sense of control, openness to change, and recognition of choice shape who you are and how you cope. The associated activities will help you to engage in self-reflection, to take stock of where you’re at, and where you hope to go next.

Choose Your Adventure: Choose 2 of the following Options to help focus your Half-Day: • Reminder – Each Half-Day Should Generate a Wellness SMART Goal: Think about what you would change in your approach to wellness. To help turn your reflections into actions, create a SMART (Specific, Measurable, Actionable, Realistic, Time-Sensitive) goal for your Wellness BASICS Half-Day. Category Adventure Options Activities Option 1 – Self-Determined Activity: Engage in a leisure or self-care activity, which can be anything but work. You could try an activity you’ve enjoyed in the past, or try something new! Examples include: • Photography; Arts/Crafts; Reading; Going to a Gallery/Museum/Zoo; Outdoor Activities; Cooking; Attending Events (Sports, Music, etc.); Playing Music; Writing (see Resources below). Thinking Questions (Option 1): • What is it you like about your hobby (thinking beyond “I just like it”) – do you like solving problems? Being creative? That it helps cultivate a part of you that otherwise gets ignored? • Are there other things that can help you achieve small bits of your hobby? For example, if you like playing music, could you listen to music in the car on your way to work? If you like art, could you doodle while you’re in meetings? Could you take ½ of your lunch to do something creative once a week? Readings Option 2 – If Every Fifth Physician is Affected by Burnout, What About the Other Four? • Read If Every Fifth Physician is Affected by Burnout, What About the Other Four? Resilience Strategies of Experienced Physicians by J. Zwack and J. Schweitzer (2013), found at: https://goo.gl/y5ZmDX Thinking Questions (Option 2): • What were your resilience practices as a child, as a teenager, as a university student, as a med student, and what are they today? Have they changed, or stayed the same? • What are the main barriers (if any) to engaging in your resilience practices regularly? What are some alternatives, or things you could try that might work better given your current set of responsibilities? • What do you hope your resilience practices will be after residency? • What are the benefits and drawbacks to focusing primarily on individual resiliency skills to address wellness in medicine? Option 3 – Physician Resilience; What It Means, Why It Matters, and How to Promote It. • Read Physician Resilience: What It Means, Why It Matters, and How To Promote It by R. Epstein and M. Krasner (2013), found at: https://goo.gl/As6uV7. This article is a commentary on the Article in Option 2. Thinking Questions (Option 3): • What would YOUR perfect work-life balance day look like? How far off are you? • What is 1 small change you could make (e.g. 1 evening per month) that you would like to make? Can you start today/tonight? • What are the benefits and drawbacks to focusing primarily on individual resiliency skills to address wellness in medicine? 19 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 15 Readings Option 4 – Powerlessness, Control, and Complexity • Read Powerlessness, Control, and Complexity: The Experience of Family Physicians in a Group Model HMO by L. Gask (2004), found at: https://goo.gl/bjUPak. Thinking Questions (Option 4): • What are some things you like about the way your home clinic operates (re. work-life balance)? • What are some things you don’t like about the way your home clinic operates (re. work-life balance)? • How would (will) you change your future practice to improve on your current clinic situation? • What sorts of things might you do if your future practice provides you with some extra time? Option 5 – Adaptability or Resilience, What Is More Beneficial? • Read the Blog Post Adaptability or Resilience – What Is More Beneficial by S. Taylor (2014), found at: https://goo.gl/Dr4Nru. Thinking Questions (Option 5): • Explore this blog, and choose 2-3 (or more) entries to read. Any general thoughts about this blog? • What are the benefits and drawbacks to focusing primarily on individual resiliency skills to address wellness in medicine? Modules Option 6 – Control: • Watch Smart Empathy: Raising Resilient Children and Teenagers by W. Mogel, found at: https://goo.gl/uMev1E Thinking Questions (Option 6): • What does this remind you of about your own childhood? • What would you do (as a parent or potential parent) the same, and different? • What in your life do you have control over? Does a sense of control bring you strength or stress? What happens when you don’t have control of a situation, feeling, thought, etc.? • If lack of control makes you uncomfortable, what are some ways that you cope with this? • What are some examples within your medical practice where you are required to let go of control? Option 7 – Joining the Medical Tribe: • Watch Joining the Medical Tribe by M. Barnes, found at: https://goo.gl/86oCng. It is a behind-the- scenes article by a documentary filmmaker (0-20:00 Med School Yr1-2; 20:00-43:00 Med School Yr3-4; 43:00-60:00 Match Day/Residency; 60:00-End Staff Years). Thinking Questions (Option 7): • What do you remember about match day? How did it compare to feelings you had on graduation day? • What do you think of the idea of junior residency as a form of self-abuse? Comment on this thought: “I hope life after internship is nothing like internship.” Do you agree? Why or why not? • Can you relate to a spouse’s description of seeing “a shell” of her partner when he comes home from work? What are some ways you cope with the inability to be everything to everyone at this time in life? • What do you think about the description of the behaviors at work not translating to behaviors at home (e.g. spouse objecting to being ‘delegated’)? • What are the advantages/disadvantages of having a spouse in the medical field versus outside? • Another doctor talked about ‘becoming this person I don’t like’. How do you feel about the person you are as a resident (versus before or after residency)? • Thinking ahead to where you’ll be in 20 years, what do you think will be different (about your life, your hobbies, your family)? What will be the same? • When you think about work-life integration in 20 years, which parts of your life will have more of your time? For example, if you have 16 hours in a day to dedicate to work, to family, to hobbies and to self- care, how do the hours get parsed out? Option 8 – How to Make Work-Life Balance Work: • Watch How to Make Work-Life Balance Work by N. Marsh, found at: https://goo.gl/BBrXwy Thinking Questions (Option 8): • If you had a year off work, what would you do? (Given enough money to get by, pay bills, travel cheap). • What would your perfect work day look like? – How many hours would you work? How much free time would you have? What would you be able to ‘fit in’? • What is one small change you can commit to – that will make a difference in your life?

20 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 16 Modules Option 9 – Try Something New For 30 Days: • Watch Try Something New For 30 Days by M. Cutts, found at: https://goo.gl/sw7JPn Thinking Questions (Option 9): • What would you like to do for the next 30 days? • What are some of the challenges you may encounter? • What are some strategies for managing those challenges? • This was a short video – start now. Why not?

Resources: Category Resources Resources • Calgary City Parks: https://goo.gl/Pn16Ex • City of Calgary Events Calendar: https://goo.gl/8EPfVF - also sorts by Map Location and includes Kid-Friendly Events. • Calgary Farmer’s Market: https://goo.gl/ChL1MC • Calgary Zoo: https://goo.gl/P83FVD • Calgary Religious Communities Listing: https://goo.gl/1rkKiA • Opportunities to get involved in Calgary local politics: https://goo.gl/1rkKiA • U of C Intramural Sports: https://goo.gl/McfNHj

21 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 17 Resources: Category Resources Supports Resource – AMA Physician and Family Support Program (PFSP): for • Included in your AMA membership. You and your immediate family members (spouse/partner, dependent Residents children) may contact PFSP toll-free 1-877-SOS-4MDS (1-877-767-4637), 24 hours a day, 7 days a week, 365 in Distress days a year. As part of this program, PFSP will cover the cost of up to six counseling hours for you over a 12- month period, and up to an additional six hours total per family. They can also help you find your own family doctor. Find out more at: https://www.albertadoctors.org/services/pfsp. Resource – AHS Employee and Family Assistance Program (EFAP): • The AHS Employee and Family Assistance Program provides free access thru AHS, including residents and their immediate family members, to a variety of mental wellness resources, including individualized counseling both in person and via email or online chat. EFAP is completely confidential within the limits of the law. No one, including your employer, will ever know that you have used the service unless you choose to tell them. You can contact EFAP at 1-877-273-3134, 24 /7/365. Find out more at: https://goo.gl/xZ7P68 Resource – UC Wellness Centre: • The campus Wellness Centre offers massage and chiropractic to all students, residents, staff, and public. • Important Note: Residents do NOT have access to counseling services and medical support thru the Wellness Centre, as they are covered via the AMA PFSP and AHS EFAP (see above). They do provide these services for U of C Medical Students, and would be an important resource to recommend to medical students you work with. Find out more at: http://www.ucalgary.ca/wellnesscentre/ Resource – Chief Residents: • An important part of the role of your Co-Chief Residents (1 for each division) is to support wellbeing and morale of fellow Residents; provide a consistent level of support for concerns and issues; advocate for their needs; and work collaboratively in ongoing development and evolution of Family Medicine Residency. If you identify a problem within the program or your residency experience, consider reaching out for confidential support. Resource – Ombudsperson: • The Department of Family Medicine Residency Program Ombudsperson is a Family Physician who serves as an impartial third party in conflict resolution. The Ombudsperson acts as a resource to residents who may have personal issues or difficulties in the Program, where they don't feel comfortable going to their home program. Anything discussed with them is confidential and will not affect evaluations or reputation. • The current Ombudsperson for Calgary Family Medicine is Dr. Rita Dahlke (email: [email protected]). Resource – Office of Professionalism, Equity and Diversity (OPED), Cumming School of Medicine: • OPED acts as a resource for issues relating to professionalism, equity and diversity, and develops fair policies, practices and collaborative relationships to support various needs and circumstances. The office triages matters relating to mental health and will assist you in navigating the healthcare system. The office will hear matters concerning conflict in the workplace in accordance with established faculty protocols. All concerns brought to the office are confidential and will be treated with dignity and respect. • To reach out with concerns relating to Mental Health, Conflict Resolution, Harassment, and Professionalism breaches where you don’t feel comfortable going to your home program, please reach Dr. Beverly Adams at [email protected] (confidential email) Important Policies: • PGME Resident Safety Policy: https://goo.gl/PEbeyq • U of C Family Medicine Resident Wellness Policy: https://goo.gl/bfbg7B • U of C Family Medicine Resident Safety Policy: https://goo.gl/jnRkHm References: 1. http://www.docsmbwellness.org/wp-content/uploads/2014/10/TheBasics-full-version.pdf

HAVE AN IDEA FOR ACTIVITY/READING/MODULE FOR NEXT YEAR? INCLUDE IN ONE45 EVAL

22 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 18 R2 Wellness BASICS – Module 5 – COMMUNITY: What does community mean to you? The dictionary can provide a static definition of community, but it is really a dynamic word: interpretation will vary between individuals and even within ourselves the meaning changes depending on context. Perhaps your idea of community focuses on those close to you, like your family or neighborhood. Perhaps it’s based around a common interest or aspect of your identity: your sports community, medical community, religious community etc. Perhaps you go geographically further and consider connections on a provincial, national, or even international level. As family physicians we work in and for our communities at the same time as we may be members ourselves in these communities. Conversely, we may feel socially excluded or isolated at times. This module focuses on how we connect with others - from a professional or personal perspective - and the role we can have in shaping these social dynamics. Thinking more simply: “Where do we belong? What do we belong to? Each of us has a personal connection to the idea of belonging. It reaches deep. It’s influenced by our experiences with the people, places and identities to which we feel connected. Strengthening our sense of belonging is at the heart of building more resilient communities and a better country.”2 The following module encourages you to explore how a sense of community, or lack thereof, either reinforces or inhibits your own health and wellness as a physician. Choose Your Adventure: Choose 2 of the following Options to help focus your Half-Day: • Reminder – Each Half-Day Should Generate a Wellness SMART Goal: Think about what you would change in your approach to wellness. To help turn your reflections into actions, create a SMART (Specific, Measurable, Actionable, Realistic, Time-Sensitive) goal for your Wellness BASICS Half-Day. Category Adventure Options Activities Option 1 – Self-Directed Community Engagement Activities: Spend your Wellness Half-Day Volunteering (e.g. Support Groups, Activism/Community Initiatives, and Fundraisers). Or, make a plan to check out an upcoming event in the local community. Find some examples of opportunities in the Resource Section below. Thinking Questions (Option 1): • What does community mean to you? Does the definition in the intro feel incomplete, and in what way? • How does working towards a common goal of community wellness make you feel? Why do you think it makes you feel this way? In what ways (if any) are you planning on being involved in your community (neighborhood, religious, sport-specific, medical, ethnic, etc.) once you enter independent practice? Readings Option 2 – CFPC Stories in Family Medicine: The CFPC publishes stories written by family docs about the meaning of being a family physician, and the contributions of family medicine and family physicians to the history of medicine, health care and life in Canada. Consider writing for them during your own career! • Visit their website at https://goo.gl/nbSvQr. Search under the Theme Community, and choose a minimum of 3 stories to read from the community theme. Thinking Questions (Option 2): • How does the author’s community of practice compare to your home clinic? • How does the community context in your practice affect your abilities and experiences as a doctor? • Does reflecting on the individual physician experiences change the way you view community practice? • Optional Writing Activity: Drawing on your experiences as a physician within your own community (personal or professional), write your own “Story in Family Medicine” (MAX 500-word). Modules Option 3 – The Art of Living Every Minute of Your Life (~60 minutes of videos): • Watch video The Art of Living Every Minute of Your Life by R. Naomi, found at: https://goo.gl/vo3BTj Thinking Questions (Option 3): • Name up to 3 things that struck you, or made you reflect on your own experience. Talk about how, if at all, this may inform your practice and/or life going forward. Option 4 – Social Justice in Medicine: • Watch Why Your Doctor Should Care about Social Justice by M. Bassett, found at: https://goo.gl/ouPAFR. • Watch Medicine on the Margins, Health Services the Homeless by A. O’Carroll, found at: https://goo.gl/MTffQx. 23 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 19 Thinking Questions (Option 4): • Mary Bassett notes “As health professionals in our daily work, whether in the clinic or doing research, we are witness to great injustice: the homeless person who is unable to follow medical advice because he has more pressing priorities; the transgender youth who is contemplating suicide because our society is just so harsh; the single mother who has been made to feel that she is responsible for the poor health of her child. Our role as health professionals is not just to treat our patients but to sound the alarm and advocate for change. Rightfully or not, our societal position gives our voices great credibility, and we shouldn't waste that.” What are your thoughts about this call to action? • Austin O’Carroll states “The existence and extent of homelessness in our society today is our political choice. We have chosen to place our fellow citizens in peril of losing their lives and their health.” What are your thoughts about this statement? • What resources are available in the Calgary community to vulnerable and underserved populations? How can you gain more exposure to this Domain of Care during your residency? Once in practice? Resources: Category Resources Resources • Calgary City Parks: https://goo.gl/Pn16Ex • City of Calgary Events Calendar: https://goo.gl/8EPfVF - also sorts by Map Location incl. Kid-Friendly Events. • Calgary Farmer’s Market: https://goo.gl/ChL1MC • Calgary Zoo: https://goo.gl/P83FVD • Calgary Religious Communities Listing: https://goo.gl/1rkKiA • Opportunities to get involved in Calgary local politics: https://goo.gl/1rkKiA • U of C Intramural Sports: https://goo.gl/McfNHj

24 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 20 Category Resources Supports Resource – AMA Physician and Family Support Program (PFSP): for • Included in your AMA membership. You and your immediate family members (spouse/partner, dependent Residents children) may contact PFSP toll-free 1-877-SOS-4MDS (1-877-767-4637), 24 hours a day, 7 days a week, 365 in Distress days a year. As part of this program, PFSP will cover the cost of up to six counseling hours for you over a 12- month period, and up to an additional six hours total per family. They can also help you find your own family doctor. Find out more at: https://www.albertadoctors.org/services/pfsp. Resource – AHS Employee and Family Assistance Program (EFAP): • The AHS Employee and Family Assistance Program provides free access thru AHS, including residents and their immediate family members, to a variety of mental wellness resources, including individualized counseling both in person and via email or online chat. EFAP is completely confidential within the limits of the law. No one, including your employer, will ever know that you have used the service unless you choose to tell them. You can contact EFAP at 1-877-273-3134, 24 /7/365. Find out more at: https://goo.gl/xZ7P68 Resource – UC Wellness Centre: • The campus Wellness Centre offers massage and chiropractic to all students, residents, staff, and public. • Important Note: Residents do NOT have access to counseling services and medical support thru the Wellness Centre, as they are covered via the AMA PFSP and AHS EFAP (see above). They do provide these services for U of C Medical Students, and would be an important resource to recommend to medical students you work with. Find out more at: http://www.ucalgary.ca/wellnesscentre/ Resource – Chief Residents: • An important part of the role of your Co-Chief Residents (1 for each division) is to support wellbeing and morale of fellow Residents; provide a consistent level of support for concerns and issues; advocate for their needs; and work collaboratively in ongoing development and evolution of Family Medicine Residency. If you identify a problem within the program or your residency experience, consider reaching out for confidential support. Resource – Ombudsperson: • The Department of Family Medicine Residency Program Ombudsperson is a Family Physician who serves as an impartial third party in conflict resolution. The Ombudsperson acts as a resource to residents who may have personal issues or difficulties in the Program, where they don't feel comfortable going to their home program. Anything discussed with them is confidential and will not affect evaluations or reputation. • The current Ombudsperson for Calgary Family Medicine is Dr. Rita Dahlke (email: [email protected]). Resource – Office of Professionalism, Equity and Diversity (OPED), Cumming School of Medicine: • OPED acts as a resource for issues relating to professionalism, equity and diversity, and develops fair policies, practices and collaborative relationships to support various needs and circumstances. The office triages matters relating to mental health and will assist you in navigating the healthcare system. The office will hear matters concerning conflict in the workplace in accordance with established faculty protocols. All concerns brought to the office are confidential and will be treated with dignity and respect. • To reach out with concerns relating to Mental Health, Conflict Resolution, Harassment, and Professionalism breaches where you don’t feel comfortable going to your home program, please reach Dr. Beverly Adams at [email protected] (confidential email) Important Policies: • PGME Resident Safety Policy: https://goo.gl/PEbeyq • U of C Family Medicine Resident Wellness Policy: https://goo.gl/bfbg7B • U of C Family Medicine Resident Safety Policy: https://goo.gl/jnRkHm References: 1. http://www.docsmbwellness.org/wp-content/uploads/2014/10/TheBasics-full-version.pdf 2. https://communityfoundations.ca/wp-content/uploads/2015/10/cfc_vitalsignsreport_oct05_FA_digital.pdf

HAVE AN IDEA FOR ACTIVITY/READING/MODULE FOR NEXT YEAR? INCLUDE IN ONE45 EVAL

25 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 21 R2 Wellness BASICS – Module 6 – SPIRITUAL: Spirituality is a complex and multidimensional aspect of human experience. Common themes include: a belief in a power operating in the universe that is greater than oneself; a sense of interconnectedness with all living creatures; and an awareness of the purpose and meaning of life and the development of personal, absolute values. The author of BASICS notes several spiritual practices that enhance resilience, including: Being Humble; Giving of Yourself; Being Mindful; Prayer; Walking on Uneven Ground; Joining Spiritual/Religious Communities; Playing; Enjoying Music; Reading; Creating; and Seeing Life Through The Lens of Awe and Wonder1. Consider the following quote: “The individual must be viewed as a whole. What affects one dimension will affect all the other dimensions…Just as each individual is a unique biological creation, each individual is also unique in the sense of [their] own perception of the cosmos because it is dependent upon the inner and outer experiences of that individual.”2 – Does this resonate with you? Reflecting back on your Wellness BASICS experience thus far, how does Spirituality influence the other Wellness Dimensions in your own life? This module focuses on spiritual wellness, including developing ideas around purpose, happiness, and connectivity with both oneself and others, and through this helps to develop personal, absolute values and how these influence their resiliency, practice, and personal life. Choose Your Adventure: Choose 2 of the following Options to help focus your Half-Day: • Reminder – Each Half-Day Should Generate a Wellness SMART Goal: Think about what you would change in your approach to wellness. To help turn your reflections into actions, create a SMART (Specific, Measurable, Actionable, Realistic, Time-Sensitive) goal for your Wellness BASICS Half-Day. Category Adventure Options Activities Option 1 – Mindfulness & Meditation Exercises: • Guided Meditation – Website 1: http://marc.ucla.edu/mindful-meditations • Guided Meditation – Website 2: https://goo.gl/unCp3w Option 2 – Learn about a religion or spiritual practice that is different from your own (for example, do you have patients or friends that practice spirituality or religion that you would like to learn more about?) Option 3 – Attend a Religious Service (either your own or something different) Option 4 – Flexible Option: If you identify as a spiritual and/or religious person and spirituality is a familiar concept to you, use this time as an opportunity to do an activity that is spiritual for you and write a brief paragraph reflecting on that activity. Readings Option 5 – Spirituality and Stress Relief – Make the Connection: • Explore Mayo Clinic’s section on Spirituality and Stress Relief, found at: https://goo.gl/WUzeM6 Modules Option 7 – How to Know Your Life Purpose in 5 Minutes: • Watch the video How to Know Your Life Purpose in 5 Minutes by A. Leipszig, found at: https://goo.gl/RtaUNm. Option 8 – The Art of Stillness: • Watch the video The Art of Stillness by P. Iyer, found at: https://goo.gl/isouus. Option 9 – Want to Be Happy? Be Grateful: • Watch the video Want to Be Happy? Be Grateful by D. Steindl-Rast, found at: https://goo.gl/jj8rgS. Option 9 – The Faith Project • Explore the website The Faith Project by the National Film Board of Canada with 7 short films (5 minutes each), found at: https://goo.gl/b7PwqS. Thinking Questions (ALL OPTIONS): • Prior to starting this activity, how would define your spiritual wellness? How is your current spiritual wellness state? What do you hope to understand about your personal spirituality by going through this exercise? • What were three things you learned about your spirituality/spiritual wellness by going through this activity? Did you learn something new about yourself? • How do you see what you experienced and learned benefiting your overall wellness and your ability to practice medicine? What aspects of spirituality do you feel you were exposed to that can help you better serve your patients and yourself?

26 July 2018 Wellness BASICS Curriculum – Updated May 2018 Page 22 Resources: Category Resources Books This is by no means a complete or representative list of books, but some contemporary works to consider exploring further. If you have an idea for a resource that should be included here (or for any other module), please include this in your One45 Evaluation. • Eckhart Tolle: The Power of Now or A New Earth; The Secret: Rhonda Byrne; • The Alchemist: Paulo Coelho; The Seven Laws of Spiritual Success: Deepak Chopra; • Tuesday’s with Morrie: Mitch Albom; When Breath Becomes Air: Paul Kalanithi Supports Resource – AMA Physician and Family Support Program (PFSP): for • Included in your AMA membership. You and your immediate family members (spouse/partner, dependent Residents children) may contact PFSP toll-free 1-877-SOS-4MDS (1-877-767-4637), 24 hours a day, 7 days a week, 365 in Distress days a year. As part of this program, PFSP will cover the cost of up to six counseling hours for you over a 12- month period, and up to an additional six hours total per family. They can also help you find your own family doctor. Find out more at: https://www.albertadoctors.org/services/pfsp. Resource – AHS Employee and Family Assistance Program (EFAP): • The AHS Employee and Family Assistance Program provides free access thru AHS, including residents and their immediate family members, to a variety of mental wellness resources, including individualized counseling both in person and via email or online chat. EFAP is completely confidential within the limits of the law. No one, including your employer, will ever know that you have used the service unless you choose to tell them. You can contact EFAP at 1-877-273-3134, 24 /7/365. Find out more at: https://goo.gl/xZ7P68 Resource – UC Wellness Centre: • The campus Wellness Centre offers massage and chiropractic to all students, residents, staff, and public. • Important Note: Residents do NOT have access to counseling services and medical support thru the Wellness Centre, as they are covered via the AMA PFSP and AHS EFAP (see above). They do provide these services for U of C Medical Students, and would be an important resource to recommend to medical students you work with. Find out more at: http://www.ucalgary.ca/wellnesscentre/ Resource – Chief Residents: • An important part of the role of your Co-Chief Residents (1 for each division) is to support wellbeing and morale of fellow Residents; provide a consistent level of support for concerns and issues; advocate for their needs; and work collaboratively in ongoing development and evolution of Family Medicine Residency. If you identify a problem within the program or your residency experience, consider reaching out for confidential support. Resource – Ombudsperson: • The Department of Family Medicine Residency Program Ombudsperson is a Family Physician who serves as an impartial third party in conflict resolution. The Ombudsperson acts as a resource to residents who may have personal issues or difficulties in the Program, where they don't feel comfortable going to their home program. Anything discussed with them is confidential and will not affect evaluations or reputation. • The current Ombudsperson for Calgary Family Medicine is Dr. Rita Dahlke (email: [email protected]). Resource – Office of Professionalism, Equity and Diversity (OPED), Cumming School of Medicine: • OPED acts as a resource for issues relating to professionalism, equity and diversity, and develops fair policies, practices and collaborative relationships to support various needs and circumstances. The office triages matters relating to mental health and will assist you in navigating the healthcare system. The office will hear matters concerning conflict in the workplace in accordance with established faculty protocols. All concerns brought to the office are confidential and will be treated with dignity and respect. • To reach out with concerns relating to Mental Health, Conflict Resolution, Harassment, and Professionalism breaches where you don’t feel comfortable going to your home program, please reach Dr. Beverly Adams at [email protected] (confidential email) Important Policies: • PGME Resident Safety Policy: https://goo.gl/PEbeyq • U of C Family Medicine Resident Wellness Policy: https://goo.gl/bfbg7B • U of C Family Medicine Resident Safety Policy: https://goo.gl/jnRkHm References: 1. http://www.docsmbwellness.org/wp-content/uploads/2014/10/TheBasics-full-version.pdf 2. Banks, R. 1980. Health and the Spiritual Dimension: Relationships and Implications for Professional Preparation Programs. The Journal of Social Health, 50 (4): 195-202. HAVE AN IDEA FOR ACTIVITY/READING/MODULE FOR NEXT YEAR? INCLUDE IN ONE45 EVAL 27 Wellness and Professionalism Resource List

The University of Calgary Wellness Centre offers primary-care and counseling services at http://www.ucalgary.ca/wellnesscentre/counselling/self-help to all residents and their families, while they are enrolled at U of C.

Physician and Family Support Program offer 24 hr assistance at 1-877-767-4637 and https://www.albertadoctors.org/services/physicians/your-health/pfsp/we- are-here-for-you

PFSP will provide you with the name of a family physician if you would like to access one outside the Wellness Centre. However, you will only be given 1 name, no matter the location in the city. https://www.albertadoctors.org/services/physicians/pfsp/when-i-call.

There is a special webpage for residents at https://www.albertadoctors.org/services/residents/health

The University of Calgary Office of Equity and Professionalism is at http://medicine.ucalgary.ca/equity/ Dr. Janet de Groot is the Associate Dean, and she deals with issues such as intimidation, harassment, and unprofessional behavior.

There is a confidential email address: [email protected] www.ePhysicianHealth.com offers modules on weight/nutrition; substance use disorders; depression, burnout and suicide; boundaries; and 5 modules on disruptive behavior. The Resilience module offers 2 Mindfulness exercises at the end of the Spirituality section.

The Physician Health Program of the OMA offers several brief Mindfulness exercises at http://www.php.oma.org/Mindfulness.html

Dr. Doug Maclean teaches Mindfulness and MBSR, at www.practicalwellbeing.ca

Adjust the light on your computer so it is easier to fall asleep after working at night at http://stereopsis.com/flux/

DFM Ombudsperson: http://calgaryfamilymedicine.ca/residency/index.php/current- residents/support-wellbeing?id=290

28 Review

Physician wellness: a missing quality indicator

Jean E Wallace, Jane B Lemaire, William A Ghali

Lancet 2009; 374: 1714–21 When physicians are unwell, the performance of health-care systems can be suboptimum. Physician wellness might See Editorial page 1653 not only benefi t the individual physician, it could also be vital to the delivery of high-quality health care. We review the Department of Sociology, work stresses faced by physicians, the barriers to attending to wellness, and the consequences of unwell physicians to Faculty of Social Sciences the individual and to health-care systems. We show that health systems should routinely measure physician wellness, (Prof J E Wallace PhD), and discuss the challenges associated with implementation. Department of Medicine, Faculty of Medicine (Prof J B Lemaire MD, Introduction review the potential consequences of self-neglect by Prof W A Ghali MD), and “Healthy citizens are the greatest asset any country physicians, both individually and at the level of health- Department of Community care systems. We also address why health systems Health Sciences, Faculty of can have.” Medicine (Prof W A Ghali), Sir Winston Churchill should routinely measure physician wellness as an University of Calgary, Calgary, indicator of health-system quality in view of the growing AB, Canada Physicians are important citizens of health-care systems, recognition that suboptimum physician wellness Correspondence to: and evidence indicates that many physicians are unwell. adversely aff ects system performance. We discuss some Prof Jean E Wallace, Department Physicians who are aff ected by the stresses of their work of the measurement and operational challenges of Sociology, University of Calgary, 2500 University Drive NW, may go on to experience substance abuse, relationship associated with implementation of this missing quality 1–4 Calgary, AB, Canada, T2N 1N4 troubles, depression, or even death. Results of emerging indicator, and raise several issues that will need to be [email protected] research show that physicians’ stress, fatigue, burnout, addressed to achieve the desired outcomes of improved depression, or general psychological distress negatively physician wellness and system quality. aff ects health-care systems and patient care.5–12 Thus when physicians are unwell, the performance of the health-care Risk of physician ill health system can be sub optimum. The corollary is that physician Practising medicine is stressful to many physicians. For wellness might not only benefi t the individual physician, example, authors of a Canadian study reported that 64% of but also be vital to the delivery of high-quality health care.5,8 physicians feel that their workload is too heavy, and 48% We use the term wellness to capture the complex and multifaceted nature of physicians’ physical, mental, and Search strategy and selection criteria emotional health and wellbeing. Much research reports We searched Medline and the Cochrane Library for review physicians’ distress or ill health in terms of burnout (when articles (January, 1985–July, 2009) and original articles individuals feel emotionally overwhelmed by the demands (January, 2004–July, 2009) using several search terms to of their job), emotional exhaustion or withdrawal, fatigue, capture: physician demographics (eg, internship and depression, anxiety, suicide, substance abuse, or residency, health personnel, medical staff , women physicians, impairment. We also consider the positive side of being medical students, general practitioners, internist, pediatrician, 5,13 14 well; Shanafelt and colleagues noted “Wellness goes surgeon); wellness indicators (eg, burnout, suicide, fatigue, beyond merely the absence of distress and includes being impaired or psychological distress, stress or wellbeing, work challenged, thriving, and achieving success in various hours, work shifts, workload, anxiety, cognition, depression); aspects of personal and professional life.” negative medical consequences of physician impairment (eg, Traditionally, health-care organisations assess professional or diagnostic errors, fatigue, medical errors, sick programme performance from several patient-based leave, sleep deprivation, work schedule tolerance); and indicators of the quality of care received (panel 1). By health-care organisational perspectives on physician wellness considering the relation between physician distress and (eg, occupational health, personnel staffi ng and scheduling, patient perceptions of care, we have the opportunity to personnel turnover). We focused on reports published in the draw attention to physician wellness. Unfortunately, such past 5 years, but did not exclude frequently referenced and indicators of quality of patient care and quality within highly regarded reports published more than 5 years ago. We health-care systems often seem to overlook or ignore the also searched reference lists of reports identifi ed by this search issue of physician wellness. But expansion of assessments strategy and selected those we judged relevant. Our reference to explicitly include physician wellness could lead to list was modifi ed on the basis of comments from peer improvements in wellness. reviewers. We identifi ed an extensive number of studies, In this Review, we present evidence from published many of which could not be meaningfully acknowledged in reports to underscore the extent to which physicians this report; our report is not intended to cover all present face stressful working conditions. We discuss how and knowledge of physician wellness. Therefore, we strategically why physicians are unwell, and supply possible selected a subset of high-quality studies that we judged to be explanations for the profession’s poor record of self- most eff ective and relevant to draw attention to and support care, a practice that is diffi cult to revoke because of the central themes of this report. individual, pro fessional, and organisational barriers. We

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stress and burnout. 46% of physicians surveyed in one Panel 1: Patient-based indicators for quality of care study reported medical practice to be very or extremely According to the US Institute of Medicine, such indicators stressful.37 Cohen and Patten38 recorded that 17% of include health-care processes (eg, periodic blood and urine resident doctors rated their mental health as fair or poor, tests for patients with diabetes), patient outcomes (eg, which is more than double the amount reported in the 60-day survival rate of patients receiving cardiac bypass), general population. Burnout seems to be common in patient perceptions of care (eg, experience with physicians, aff ecting an estimated 25–60%,26,39–41 and up patient–provider communication), and the ability to provide to 75% in some studies.7,9 high-quality care associated with organisational structure The consequences of long periods of excessive work and systems (eg, entry systems for drug ordering).15 stress and burnout could have serious outcomes for the wellness of individual physicians (eg, substance abuse, relationship troubles, depression, or even death).1–4,42,43 have had an increase in their workload in the past year.16 However, prevalence statistics associated with Additionally, surveys consistently document that doctors physicians’ mental and emotional health vary work many hours, averaging 50–60 h per week when not substantially because such wellness indicators are on call.17 When physicians frequently work shifts longer diffi cult to quantify and estimate. Some studies clearly than 24 h, the resulting fatigue is associated with negative document that physicians have greater job stress and consequences for physicians, both personally and emotional distress than do the general population.38,44–46 professionally. Personally, they have increased risk of Other studies report that physicians have similar burnout,7 percutaneous needle stick injuries,18 and motor- wellness to the general population,3,5,47 but that vehicle crashes or near-miss incidents when driving depression is heightened in female physicians, medical home.19 Professionally, physicians have signifi cantly more students, and residents.9,42,44,48 Suicide rates for physicians failures of attention than do those working shifts shorter are estimated to be six times higher than in the general than 16 h,11 and make more serious medical errors than do population, their cardiovascular mortality is higher those working shifts shorter than 24 h.10 than average, and about 8–12% of all practising Beyond the eff ects of workload and fatigue, physicians physicians are expected to develop a substance-abuse might be aff ected by other stressors specifi c to medicine. disorder at some point in their career.20,49,50 Irrespective For example, physicians work in emotionally-charged of whether physician distress is similar to that of the situations, associated with suff ering, fear, failures, and general population, or if most doctors are happy,51 death, which often culminate in diffi cult interactions recognition of the potentially harmful eff ects of stressful with patients, families, and other medical personnel.20,21 work on physician wellness is important. Furthermore, excessive cognitive demands caused by the need for quick processing of overwhelming amounts Suboptimum attention to self-wellness by of information for long periods can negatively aff ect physicians work quality.22 Physician wellness is complex and multifaceted: Moreover, rapid and recent changes to the practice of individual, professional, and organisational factors might medicine—eg, increased patient-care demands, remun- aff ect a physician’s ability to be well. In terms of individual eration issues, growing bureaucracy associated with factors, research suggests that physicians are not very medical practice, increased accountability, and confl ict good at tending to many of their wellness needs or between the needs of the organisation and patients—are seeking help from others.20,52–55 Arnetz20 refers to the all potential threats to physician well ness.21,23–26 In view “ignorance, indiff erence and carelessness of physicians of these organisational shifts, much research has towards their own health”; physicians neglect to have focused on the substantial decline in physicians’ physical examinations and procrastinate when seeking autonomy because of increased managerial and cost medical treatment. This pattern of behaviour seems to be control by governments, employers, and patients.24,27,28 universal. For example, of 18% of Canadian physicians For example, quality-of-care interventions attempting to who were identifi ed as depressed, only 25% considered standardise care protocols are proven to provide getting help and only 2% actually did.16 Many physicians improved care based on evidence,29–31 but physicians who do not have family doctors. For example, Pullen and encounter these organ isational restrictions on their colleagues53 reported that only 42% of Australian decision making and autonomy often report increased physicians studied had a general practitioner, and most job dissatisfaction and stress.32–35 Similarly, the rise of had self-prescribed drugs. Uallachain56 recorded that 30% managed care in countries such as the USA and Israel of young Irish physicians had not been to a general has raised concerns because physicians fear that such practitioner in the previous 5 years, 65% felt unable to care will be of lower quality for patients, and reduce take time off from work when they were ill, 92% had self- physicians’ income and autonomy.28,35,36 prescribed drugs at least once, and 49% felt that they Excessive workloads, chronic work-related stress, and neglected their own health. Similarly, Thompson and restricted autonomy lead to high occurrence of physician colleagues55 reported that most British doctors are aware www.thelancet.com Vol 374 November 14, 2009 30 1715 Review

that they are not very good at taking care of themselves; applicants.64 Some licensing boards undertake investi- most said that they work when unwell and they also gations if physicians seek treatment, which can lead to expect their colleagues to do so, even though they would sanctions irrespective of whether there is any evidence of not place the same expectations on their patients. impaired functioning.66 The idea that physicians fear Moreover, doctors often rely on denial and avoidance as damaging their careers or putting their medical licence coping strategies, which are not very eff ective;49,52 the in jeopardy if they seek treatment for such problems is problem is exacerbated by the medical profession’s poor gradually receiving increased attention by published record for giving mutual support and feedback.57 The reports, and underscores an important consequence of conspiracy of silence deters doctors from talking about stigmatism with respect to physician ill health.67 their colleagues’ distress or their concerns for their own The culture of the medical profession has been personal health.20 Furthermore, a perceived stigma is recognised as a key factor that might deter doctors from associated with seeking help. Doctors might feel taking care of themselves. In a study of physicians’ uncomfortable in the role of patient, and fear that others attitudes towards their own health, Thompson and will interpret their need for help as an indicator of their colleagues55 identifi ed that general practitioners feel inability to cope.55,56 Findings show, however, that pressure from both their patients and colleagues to appear physicians who receive support from their colleagues or physically well, even when they are sick, because they spouse are more successful in achieving wellness.58 believe their health is interpreted as an indicator of their Other predictors of physician wellness at the individual medical competence. Similarly, McKevitt and colleagues68 level include physicians’ personality traits and gender. reported that more than 80% of the general practitioners Certain prevalent physician personality traits (eg, and hospital doctors in their study worked through their perfectionism, workaholism, and type A personalities) illness. Their results from interviews with doctors showed are associated with adverse health outcomes, including that professional and organisational barriers, which burnout, depression, anxiety, eating disorders, and reinforce one another, could contribute to reluctance to cardiovascular disease.59 McManus and colleagues60 take sick leave or discuss health concerns with colleagues.68 showed that physicians’ personalities and learning styles Moreover, Baldwin and colleagues69 have shown that are associated with their stress, burnout, and attitudes to trainee doctors are adopting the same behaviour that has work. Furthermore, female physicians often face greater been previously reported in older, more established challenges than do male physicians with respect to doctors. When questioned about their response to balancing work and family responsibilities, resulting in hypothetical illnesses, 61% of junior doctors would go to increased work–family confl ict and stress.61 work and wait and see if they were vomiting all night, 83% The eff ect of professional factors on wellness is if they had blood in their urine, 76% if they had a suspected exacerbated by the historical tendency of the profession stomach ulcer, and 73% if they had severe anxiety.69 to ignore indicators of distress.49 Many doctors face the Health-care organisations might also falter in ethical dilemma of choosing to protect the privacy of provision of even basic resources for physician wellness their impaired colleagues or patients’ safety. Farber and and self-care, such as adequate rest, recovery, and colleagues62 presented hypothetical scenarios to doctors nutrition.70 Despite these shortcomings, certain aspects and showed that most doctors are more likely to report a of physician wellness are being addressed by health-care physician with a substance-abuse disorder than one who systems and professional medical organisations. Many is emotionally or cognitively impaired. Roberts and countries, including Canada, Australia, and the UK, are colleagues63 noted that preserving confi dentiality between developing programmes to identify and treat impaired colleagues is a dominant factor, even when hypothetical or disruptive physicians, and some health-care doctors are at risk of suicide or patient care is organisations are targeting prevention and promoting compromised. They proposed that a contributing factor wellness (panel 2). These are worthy beginnings. could be the present approach to educating physicians, However, at present there are no standards to dictate which rewards individual achievement, self-reliance, how to promote physician wellness, enforce these independent judgment, industry, and self-sacrifi ce; mandates, or measure success. unintentionally, this approach could “inculcate the notions that the best doctors have few needs, make no Unwell physicians negatively aff ect health-care mistakes and are never ill”.63 systems Physicians could also be deterred from seeking help for Growing evidence points to important negative physical, mental health, or substance-abuse problems consequences of physician ill health to health-care because many licensing boards discriminate against systems by aff ecting recruitment and retention of these physicians, even if they have received eff ective physicians, workplace productivity and effi ciency, and treatment and the diagnosis has no eff ect on their quality of patient care and patient safety. The worldwide professional skills and abilities.50,64,65 Many medical shortage of physicians in primary health care makes licensing applications include questions that ask about physician wellness especially important for recruitment the physical health, mental health, and substance use of and retention to the medical profession.74,75 Medical

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The cost of replacing a physician is estimated to be Panel 2: Programmes run by health-care organisations to US$150 000–300 000, dependent on the time taken to improve physician wellness search for, screen, and interview candidates, and revenue In the UK, the National Clinical Assessment Service aims to lost to the health centre (eg, retaining a locum to replace “help to clarify the performance concerns [of doctors], the departing physician).82 This estimate does not include understand what is leading to them and support their additional expenses of signing bonuses, moving resolution in order to, where possible, restore safe and valued expenses, or promotion costs. practice”.71 The organisation off ers online resource materials At the organisational level, physician burnout is asso- such as access to the Practitioner Health Programme that ciated with reduced workplace productivity and effi ciency. provides a free confi dential service for doctors who have Such an eff ect is related to increased absenteeism, job mental or physical health concerns or addictions. turnover, interest in early retirement, and probability of ordering unnecessary tests or procedures, and reduced The Canadian Medical Association has a dedicated centre for practice revenue and time with patients.83 Physicians physician health and wellbeing, and every provincial medical with mental health problems are costly to organisations association within Canada has a physician wellness portfolio. because of sickness absences, suspensions, and early In addition to providing support to distressed physicians and retirement.59 their families, the Alberta Medical Association Physician and Perhaps of even greater concern is the direct eff ect of Family Support Program is engaged in several wellness physician wellness on quality of care and patient safety.5–8,84 educational activities, such as promotion of adequate sleep Firth-Cozens and Greenhalgh,6 examined physicians’ and workplace nutrition, and support for dealing with perceptions of the link between work-related stress and adverse events, complaints, and medical legal litigation. patient care. 57% of participants believed that tiredness, In the USA, the Joint Commission accreditation for hospitals exhaustion, or sleep deprivation negatively aff ected patient mandates that the medical staff “implement a process to care, and another 28% believed that pressures from being identify and manage matters of individual health for licensed overworked were negatively related. Work-related stress independent practitioners which is separate from actions led to 50% reporting reduced standards of patient care (eg, taken for disciplinary purposes“.72 The organisation also off ers taking short cuts, not following procedures), 40% reporting educational materials for dealing with issues such as the irritability or anger, 7% reporting serious mistakes not disruptive health professional.73 leading to patient death, and 2·4% reporting incidents in which the patient died. Tiredness and overwork were most school training is extremely stressful and often has often judged to be responsible for these outcomes, negative eff ects on students’ mental health,48,76 which especially the most serious ones. Di Matteo and colleagues85 could deter individuals from entering the profession, undertook a 2-year longitudinal study of 196 physicians to completing their medical training, or entering certain assess the eff ect of practice characteristics, practice styles, medical specialties. According to fi ndings from Cohen and job satisfaction on more than 20 000 patients with and Patten’s38 study, 22% of physician residents beginning diabetes, hypertension, and heart disease. Physicians’ their careers as doctors would not pursue medicine if overall job satisfaction had a positive eff ect on patients’ given the opportunity to relive their career. Young adherence to treatment and actions in managing their physicians report nearly twice the occurrence of burnout chronic diseases. Williams and Skinner’s8 narrative review compared with their older colleagues, and burnout could of outcomes of physician job dissatisfaction support these begin as early as residency training.7 Although physician results: more dissatisfi ed physicians tend to have riskier shortages can be partly off set by increased reliance on prescribing profi les, less adherent patients, and less international medical graduates, immigrant doctors are satisfi ed patients, all of which might indicate reduced likely to face additional stressors and strains above and quality of patient care. beyond those that they share with their local colleagues. Findings from several studies of residents clearly show Excessive job stress, burnout, and dissatisfaction are the link between physician distress, in terms of burnout closely related to job and career turnover.8,77,78 Physicians and depression, and the eff ect on patient care, especially who are highly dissatisfi ed with their work have increased medical errors. Shanafelt and colleagues7 reported that probability of changing jobs within medicine or leaving more than 75% of their study participants met the criteria medicine entirely. From a survey of University of Ottawa for burnout, and these residents had two to three times physicians, 50% thought about leaving academic increased probability of reporting that they had provided medicine every week and 30% thought of leaving suboptimum patient care at least monthly or weekly. Some medicine altogether.16 Such professional malaise impedes of the suboptimum practices included: failure to fully recruitment of the best and the brightest individuals into discuss treatment options or answer patient questions, medicine and to some medical specialties.79–81 Moreover, treatment or medication errors that were not due to lack of as workloads and stress increase, we expect turnover knowledge or inexperience, and reduced attentiveness or rates to rise and contribute to the increasing costs caring behaviour towards their patients. Similarly, associated with recruitment and retention of physicians. Fahrenkopf and colleagues9 recorded that 20% of residents www.thelancet.com Vol 374 November 14, 2009 32 1717 Review

studied were depressed and 75% were burned out, and Physician wellness as an indicator of those who were burned out or depressed, or both, had health-system quality signifi cantly increased risk of making medication errors. In view of the eff ect of suboptimum physician wellness on From a prospective longitudinal study, West and health systems, measurement of provider wellness as a colleagues’12 identifi ed that residents’ self-perceived health-system quality indicator could be highly benefi cial. medical errors were signifi cantly and adversely associated For eff ective improvement in health-system quality and with overall quality of life, burnout, and the likelihood of performance, however, quality indicators need to be both screening positive for depression. measurable and actionable.15 We need valid and reliable Factors such as overwork, inadequate sleep, and methods to measure provider wellness as an indicator of exhaustion, compounded with feelings of guilt, often result health-system quality, and evidence about how best to inter- in poor care that could contribute to a cycle of stress and vene if suboptimum system performance is identifi ed. diminishing quality of patient care.41,52,86 Sleep deprivation Fortunately, physician wellness is measurable. Despite can be more incapacitating than a high blood-alcohol methodological challenges, existing instruments can concentration,87 and call-associated fatigue is related to assess physician wellness at a system level. For example, increased error rates in the cognitive skill domain for Arnetz93 used a standardised questionnaire—the quality surgeons.88 Halbesleben and Rathert’s89 fi ndings showed of work competence survey—to assess ten core that the depersonalisation dimension of physician burnout components of organisational and staff wellbeing that was associated with decreased patient satisfaction and included mental energy, work climate, work tempo, work- lengthened recovery time after discharge. Furthermore, related exhaustion, skills development, organisational research fi ndings suggest that medical students and effi cacy, and leadership. From these components, he physicians who have a poor personal health profi le are less computed an overall weighted score that represented a likely than are those who are healthy to recommend any global, composite measure of the overall health of the kind of evidence-based screening to their patients90 or organisation. Arnetz94 suggests that subjective indicators counselling for healthy lifestyle such as moderate alcohol from employees can be used to gauge and improve use.91 In turn, physician wellness and satisfaction are organisational performance and wellness. He argues that important contributors to patients’ adherence to treatment improvement of physician wellness can improve the and satisfaction.5,8,84,86,92 organisation’s wellbeing and health, and that physician

Workplace stressors • Workload • Work hours • Fatigue • Emotional interactions • Cognitive demands • Restricted autonomy • Structural and organisational changes to practice

Contextual factors Physician outcomes Health-care system outcomes • Confidentiality issues • Feelings of stress • Recruitment and retention issues • Licensing board responses • Burnout • Lowered productivity and efficiency • Culture of medicine supporting neglect of • Depression • Suboptimum quality of patient care self-care and indifference to personal wellness • Relationship • Reduced patient adherence and satisfaction • Health-care organisations’ failure to troubles • Increased risk of medical errors provide basic resources for physician • Substance abuse wellness • Risk of suicide

Physician characteristics • Indiﬀerence to personal wellness • Neglect of self-care • Coping by denial and avoidance • Conspiracy of silence • Predisposing personality traits

Potential interventions

Workplace and profession Physician self-care Physician treatment Improved patient care awareness, management, and prevention and recovery and system outcomes and prevention

Figure: A model of physician ill health and the links with health-care system outcomes, and potential interventions to improve physician and system outcomes Solid lines are empirically supported; broken lines are potential links.

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wellness should receive the same priority as patient care stakeholders (physician groups, health-system decision and fi nancial viability. That is, individual physician makers, payers, and the general public) about the wellness is a valid indicator for organisational health. components needed in such a quality-indicator system Measures of physician wellness also seem to be to best measure physician and organisational wellness, actionable: in situations of suboptimum physician and the interventions needed to improve physician and wellness, eff ective interventions have been imple- organisational wellness. Assessment of physician mented.95–98 In a study by Dunn and colleagues,95 three wellness as an indicator of an organisation’s quality of interventions were introduced to a primary care group health care is only the fi rst step. Increased awareness of consisting of six sites and 32 physicians. The interventions the importance of physician wellness, both individually were designed to enhance physicians’ control over their and organisationally, is needed by physicians, their work environment, improve effi ciency in offi ce design patients, and their employers. A shift in the culture of and quality of staff , and contribute to a sense of satisfaction care and wellness of physicians is necessary. If these and meaning derived from patient care. The results groups do not recognise the crucial importance of showed clinically and statistically signifi cant decreases in physician wellness, there is little reason to expect that emotional and work-related exhaustion—key indicators of physicians and their employers will invest in taking burnout—during the study, and other improvements in better care of physicians, or that the public will support physician wellbeing were noted. In a study of stressed and appreciate such eff orts. physicians to assess the eff ect of a counselling intervention Ultimately, individual physicians will personally on burnout, Rø and colleagues99 showed clinically and benefi t from taking better care of themselves. Such statistically signifi cant reductions in emotional exhaustion eff orts would probably lead to increased job satisfaction and sick leave at 1-year follow-up in the 185 physicians and overall wellbeing, and reduced likelihood of who completed the study. physicians experiencing an overwhelming sense of Although interventions could improve physician stress and burnout. The organisations employing wellness, very little research has directly examined the physicians will benefi t by having more productive and eff ect of such interventions on patient care or health- effi cient health-care providers in conjunction with system performance. Although much is known about reduced absenteeism, job turnover, and recruitment and physician distress and the negative eff ect on patient care, retention issues. And perhaps the patients themselves little is known about whether interventions directed at will benefi t by receiving better quality of care. 25 physician wellness will also improve patient care. Contributors However, Jones and colleagues’100 study did suggest that JEW was mainly responsible for the search of published work. All stress management interventions could be benefi cial to authors contributed equally to writing of the report. both physicians and their patients. They showed a strong Confl icts of interest relation between a stressful workplace and malpractice We declare that we have no confl icts of interest. risk in both medical departments and hospitals. Acknowledgments Furthermore, they recorded signifi cant reductions in JEW was supported by a Killam Resident Fellowship at the University of Calgary during writing of this report. WAG is supported by a Canada medication errors and malpractice claims after Research Chair in Health Services Research and by a Senior Health introduction of stress-management programmes to Scholar Award from the Alberta Heritage Foundation for Medical 22 hospitals; by contrast, rates for the 22 hospitals in the Research. We thank John Conly, Chair of the Department of Medicine, control group (matched on bed numbers, frequency of University of Calgary, for his vision and support of physician wellness research through the creation of JBL’s departmental appointment of claims, and rural vs urban) remained unchanged. Vice-Chair in this domain, and JEW’s adjunct position in the Nevertheless, further research is needed to explore how Department of Medicine. We also thank research librarian interventions designed to improve physician wellness are Diane Lorenzetti for her expert assistance, and Garielle Brown and also benefi cial to patients and the organisations that Michael DeSouza for their help in preparation of the report. support such interventions. Studies that identify both References 1 Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and individual and organisational wellness interventions, and coping among orthopaedic surgery residents and faculty. that assess the eff ects of such interventions on patient J Bone Joint Surg Am 2004; 86: 1579–86. care, effi ciency, and productivity, will be important to 2 Firth-Cozens J. Individual and organizational predictors of support both the promotion of wellness programmes and depression in general practitioners. Br J Gen Pract 1998; 48: 1647–51. 3 Frank E, Dingle AD. Self-reported depression and suicide attempts the inclusion of physician wellness as a quality indicator. among U.S. women physicians. Am J Psychiatry 1999; The fi gure proposes a model to show the empirically 156: 1887–94. established links between physician ill health described 4 Graham J, Albery IP, Ramirez AJ, Richards MA. How hospital consultants cope with stress at work: implications for their mental in our Review, and the potential interventions that could health. Stress Health 2001; 17: 85–89. improve physician and system outcomes. 5 Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among Conclusion internal medicine residents. J Gen Intern Med 2005; 20: 559–64. 6 Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links The fi rst step to incorporation of physician wellness as a between stress and lowered clinical care. Soc Sci Med 1997; quality indicator is to promote dialogue among key 44: 1017–22. www.thelancet.com Vol 374 November 14, 2009 34 1719 Review

7 Shanafelt TD, Bradley KA, Wipf JW, Back AL. Burnout and self- 30 O’Connor C, Adhikari NK, DeCaire K, Friedrich JO. Medical reported patient care in an internal medicine residency program. admission order sets to improve deep vein thrombosis prophylaxis Ann Intern Med 2002; 136: 358–67. rates and other outcomes. J Hosp Med 2009; 4: 81–89. 8 Williams ES, Skinner AC. Outcomes of physician job satisfaction: 31 Ozdas A, Speroff T, Waitman LR, Ozbolt J, Butler J, Miller RA. a narrative review, implications and directions for future research. Integrating “best of care” protocols into clinicians’ workfl ow via care Health Care Manage Rev 2003; 28: 119–40. provider order entry: impact on quality-of-care indicators for acute 9 Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication myocardial infarction. J Am Med Inform Assoc 2006; 13: 188–96. errors among depressed and burnt out residents: prospective cohort 32 Duff y RD, Richard GV. Physician job satisfaction across six major study. BMJ 2008; 336: 488–91. specialties. J Vocat Behav 2006; 68: 548–59. 10 Landrigan CP, Rothschild JM, Cronin JW, et al. Eff ect of reducing 33 Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new interns’ work hours on serious medical errors in intensive care medical career: the case of the hospitalist physicians. units. N Engl J Med 2004; 351: 1838–48. J Health Soc Behav 2002; 43: 72–91. 11 Lockley SW, Cronin JW, Evans EE, et al, for the Harvard Work 34 Sundquist J, Johansson SE. High demand, low control, and impaired Hours, Health and Safety Group. Eff ect of reducing interns’ weekly general health: working conditions in a sample of Swedish general work hours on sleep and attentional failures. N Engl J Med 2004; practitioners. Scand J Public Health 2008; 28: 123–31. 351: 1829–37. 35 Warren MG, Weitz R, Kulis S. Physician satisfaction in a changing 12 West CP, Huschka MM, Novotny PJ, et al. Association of perceived health care environment: the impact of challenges to professional medical errors with resident distress and empathy: a prospective autonomy, authority, and dominance. J Health Soc Behav 1998; longitudinal study. JAMA 2006; 296: 1071–78. 39: 356–67. 13 Weiner EL, Swain GR, Wolf B, Gottlieb M, Spickard A. A qualitative 36 Hoff TJ. The physician as worker: what it means and why now? study of physicians’ own wellness-promotion practices. West J Med Health Care Manag Rev 2001; 34: 53–70. 2001; 174: 19–23. 37 Henry J. OMA membership survey results confi rm overwhelming 14 Shanafelt TD, Sloan JA, Haberman TM. The well being of level of frustration among Ontario physicians. Ont Med Rev 2004; physicians. Am Med J 2003; 114: 513–17. 71: 1–6. 15 Committee on Redesigning Health Insurance Performance 38 Cohen JS, Patten S. Well being in residency training: a survey Measures, Payment, and Performance Improvement Programs, examining resident physician satisfaction both within and outside of Institute of Medicine of the National Academies. Pathways to residency training and mental health in Alberta. BMC Med Educ quality health care. Performance measurement: accelerating 2005; 5: 21. improvement. Washington, DC: National Academies Press, 2006. 39 Panagopoulou EA, Montgomery A, Benos A. Burnout in internal 16 Canadian Medical Association. Guide to physician health and well medicine physicians: diff erences between residents and specialists. being: facts, advice and resources for Canadian doctors. Ottawa, Eur J Intern Med 2006; 17: 195–200. ON: Canadian Medical Association, 2003. 40 Renzi C, Tabolli S, Ianni A, Di Petro C, Puddu P. Burnout and job 17 Williams ES, Rondeau KV, Xiao Q, Francescutti LH. Heavy satisfaction comparing healthcare staff of a dermatological hospital physician workloads: impact on physician attitudes and outcomes. and a general hospital. J Eur Acad Dermatol Venereol 2005; 19: 153–57. Health Serv Manage Res 2007; 20: 261–69. 41 Goitein L, Shanafelt TD, Wipf JE, Slatore CG, Back AL. The eff ects of 18 Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the work-hour limitations on resident well being, patient care, and risk of self-reported percutaneous injuries in interns. JAMA 2006; education in an internal medicine residency program. 296: 1055–62. Arch Intern Med 2005; 165: 2601–06. 19 Barger LK, Cade BE, Ayas NT, et al, for the Harvard Work Hours, 42 Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal Health, and Safety Group. Extended work shifts and the risk of motor ideation among U.S. medical students. Ann Intern Med 2008; vehicle crashes among interns. N Engl J Med 2005; 352: 125–34. 149: 334–41. 20 Arnetz BB. Psychosocial challenges facing physicians of today. 43 Van Der Heijden F, Dillingh G, Bakker A, Prins J. Suicidal thoughts Soc Sci Med 2001; 52: 203–13. among medical residents with burnout. Arch Suicide Res 2008; 21 McMurray JE, Williams E, Schwartz MD, et al. Physician job 12: 344–46. satisfaction: developing a model using qualitative data. 44 Hsu K, Marshall V. Prevalence of depression and distress in a large J Gen Intern Med 1997; 12: 711–14. sample of Canadian residents, interns, and fellows. Am J Psychiatry 22 Levin S, Aronsky D, Hemphill R, Han J, Slagle J, France D. 1987; 144: 1561–66. Shifting toward balance: measuring the distribution of workload 45 Tyssen R, Hem E, Gude T, Gronvold NT, Ekeberg O, Vaglum P. among emergency physician teams. Ann Emerg Med 2007; Lower life satisfaction in physicians compared with a general 50: 419–23. population sample: a 10-year longitudinal, nationwide study of course 23 Umehara K, Yukihiro O, Kawakami N, Tsutsumi A, Fujimura M. and predictors. Soc Psychiatry Psychiatr Epidemiol 2009; 44: 47–54. Association of work-related factors with psychosocial job stressors 46 Wall TD, Bolden RI, Borrill CS, et al. Minor psychiatric disorder in and psychosomatic symptoms among Japanese pediatricians. NHS trust staff : occupational and gender diff erences. Br J Psychiatry J Occup Health 2007; 49: 467–81. 1997; 171: 519–23. 24 Dunstone DC, Reames HR. Physician satisfaction revisited. 47 McManus IC, Winder BC, Gordon D. Are UK doctors particularly Soc Sci Med 2001; 52: 825–37. stressed? Lancet 1999; 354: 1358–59. 25 Shanafelt TD, Novotny P, Johnson ME, et al. The well being and 48 Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of personal wellness promotion strategies of medical oncologists in the depression, anxiety, and other indicators of psychological distress North Central Cancer Treatment Group. Oncology 2005; 86: 23–32. among U.S. and Canadian medical schools. Acad Med 2006; 26 Goehring C, Bouvier Gallacchi M, Kunzi B, Bovier P. Psychosocial 81: 354–73. and professional characteristics of burnout in Swiss primary care 49 Baldisseri MR. Imparied healthcare professional. Crit Care Med 2007; practitioners: a cross-sectional survey. Swiss Med Wkly 2005; 35 (suppl): S106–16. 135: 101–08. 50 Center C, Davis M, Detre T, et al. Confronting depression and suicide 27 Landon BE, Reschovsky J, Blumenthal D. Changes in career in physicians: a consensus statement. JAMA 2003; 289: 3161–66. satisfaction among primary care and specialist physicians, 51 Nylenna M, Gulbrandsen P, Forde R, Aasland OG. Unhappy doctors? 1997–2001. JAMA 2003; 289: 442–49. A longitudinal study of life and job satisfaction among Norwegian 28 Gross R, Tabenkin H, Brammli-Greenberg S. Factors aff ecting doctors 1994–2002. BMC Health Serv Res 2005; 5: 44. primary care physicians’ perceptions of health system reform in 52 Firth-Cozens J. Interventions to improve physicians’ well being and Israel: professional autonomy versus organizational affi liation. patient care. Soc Sci Med 2001; 52: 215–22. Soc Sci Med 2007; 64: 1450–62. 53 Pullen D, Lonie CE, Lyle DM, Cam DE, Doughty MV. Medical care 29 Franke CA, Dickerson LM, Carek PJ. Improving anticoagulation of doctors. Med J Aust 1995; 162: 481–84. therapy using point-of-care testing and a standardized protocol. 54 Taub S, Morin K, Goldrich MS, Ray P, Benjamin R. Physician Ann Fam Med 2008; 6: S28–32. health and wellness. Occup Med 2006; 56: 77–82.

1720 www.thelancet.com Vol 374 November35 14, 2009 Review

55 Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T. 79 Keeton K, Fenner DE, Johnson RB, Hayward RA. Predictors of Challenge of culture, conscience, and contract to general physician career satisfaction, work-life balance, and burnout. practitioners’ care of their own health: qualitative study. BMJ 2001; Obstet Gynecol 2007; 109: 949–55. 323: 728–31. 80 Dorsey ER, Jarjoura D, Ruteki GW. Infl uence of controllable 56 Uallachain GN. Attitudes towards self-health care: a survey of GP lifestyle on recent trends in specialty choice by US medical trainees. Ir Med J 2008; 100: 489–91. students. JAMA 2003; 290: 1173–78. 57 Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: what are the 81 McMurray J, Linzer M, Konrad T, Douglas J, Shugerman R, causes and what can be done? BMJ 2002; 324: 835–38. Nelson K. The work lives of women physicians: results from the 58 Wallace JE, Lemaire J. On physician well being-you’ll get by with a physician work life study. J Gen Intern Med 2000; 15: 372–80. little help from your friends. Soc Sci Med 2007; 64: 2565–77. 82 Shi L. Managing human resources in health care organizations, 59 Firth-Cozens J, King J. Are psychological factors linked to 1st edn. Sudbury, MA: Jones and Bartlett Publishers, 2006. performance? In: Firth-Cozens J, King J, Hutchinson A, McAvoy P, 83 Linzer M, Kondrad TR, Douglas J, et al. Predicting and preventing eds. Understanding doctors’ performance. Oxford: Radcliff e physician burnout: results from the United States and Publishing, 2006: 61–70. Netherlands. Am J Med 2001; 111: 170–75. 60 McManus IC, Keeling A, Paice E. Stress, burnout and doctors’ 84 Wetterneck TB, Linzer M, McMurray J, et al. Worklife and attitudes to work are determined by personality and learning style: a satisfaction of general internists. Arch Intern Med 2002; twelve year longitudinal study of UK medical graduates. BMC Med 162: 649–56. 2004; 2: 29. 85 Di Matteo MR, Sherbourne CD, Hays RD, et al. Physicians 61 Robinson G. Stresses on women physicians: consequences and characteristics infl uence patients’ adherence to medical treatment: coping techniques. Depress Anxiety 2003; 17: 180–89. results from the medical outcomes study. Health Psychol 1993; 62 Farber NJ, Gilibert SG, Aboff BM, Collier VU, Weiner J, Boyer EG. 12: 93–102. Physicians’ willingness to report impaired colleagues. Soc Sci Med 86 Parthasarathy S. Sleep and the medical profession. 2005; 61: 1772–75. Curr Opin Pulm Med 2005; 11: 507–12. 63 Roberts LW, Warner TD, Rogers M, Horwitz R, Redgrave G. Medical 87 Williamson AM, Feyer AM. Moderate sleep deprivation produces student illness and impairment: a vignette-based survey study impairments in cognitive and motor performance equivalent to involving 955 students at 9 medical schools. Compr Psychiatry 2005; legally prescribed levels of alcohol intoxication. Occup Environ Med 46: 229–37. 2000; 57: 649–55. 64 Schroeder R, Brazeau CM, Zackin F, et al. Do state medical board 88 Gerdes J, Kahol K, Smith M, Leyba MF, Ferrara JJ. Jack Barney applications violate the Americans with disabilities act? Acad Med award: the eff ect of fatigue on cognitive and psychomotor skills of 2009; 84: 776–81. trauma residents and attending surgeons. Am J Surg 2008; 65 Worley LLM. Our fallen peers: a mandate for change. Acad Psychiatry 196: 813–19. 2008; 32: 8–12. 89 Halbesleben JR, Rathert C. Linking physician burnout and patient 66 Hampton T. Experts address risk of physician suicide. JAMA 2005; outcomes: exploring the dyadic relationship between physicians 294: 1189–91. and patients. Health Care Manage Rev 2008; 33: 29–39. 67 Hendin H, Reynolds C, Fox D, et al. Licensing and physician mental 90 Cornuz J, Ghali WA, Di Carlantonio D, Pecoud A, Paccaud F. health: problems and possibilities. J Med Licensure Discipline 2007; Physicians’ attitudes towards prevention: importance of 93: 6–11. intervention-specifi c barriers and physicians’ health habits. 68 McKevitt C, Morgan M, Dundas R, Holland WW. Sickness absence Fam Pract 2001; 17: 535–40. and ‘working through’ illness: a comparison of two professional 91 Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and groups. J Public Health Med 1997; 19: 295–300. alcohol counseling behavior among US medical students: cohort 69 Baldwin PJ, Dodd M, Wrate RM. Young doctors’ health—II. Health study. BMJ 2008; 337: a2155. and health behavior. Soc Sci Med 1997; 45: 41–44. 92 Haas JS, Cook EF, Puopolo AL, Burstin HR, Clearly PD, 70 Winston J, Johnson C, Wilson S. Barriers to healthy eating by Brennan TA. Is the professional satisfaction of general internists National Health Service (NHS) hospital doctors in the hospital associated with patient satisfaction? J Gen Intern Med 2000; setting: results of a cross-sectional survey. BMC Res Notes 2008; 1: 69. 15: 122–28. 71 National Patient Safety Agency. National Clinical Assessment Service. 93 Arnetz BB. Staff perception of the impact of health care Practitioner Health Programme. http://www.ncas.npsa.nhs.uk/ transformation on quality of care. Int J Qual Health Care 1999; health/practitioner-health-programme (accessed Sept 14, 2009). 11: 345–51. 72 The Joint Commission. Comprehensive accreditation manual for 94 Arnetz BB. Subjective indicators as a gauge for improving hospitals: the offi cial handbook, 2009. Oakbrook Terrace, IL: Joint organizational well being: an attempt to apply the cognitive Commission Resources, 2009: 26. activation theory to organizations. Psychoneuroendocrinology 2005; 30: 1022–26. 73 The Joint Commission. Sentinel event alert: behaviors that undermine a culture of safety. http://www.jointcommission.org/ 95 Dunn PM, Arnetz BB, Christensent JF, Homer L. Meeting the SentinelEvents/SentinelEventAlert/sea_40.htm (accessed July 15, imperative to improve physician well being: assessment of an 2009). innovative program. J Gen Intern Med 2007; 22: 1544–52. 74 Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and 96 Gardiner M, Lovell G, Williamson P. Physician you can heal demographic trends signal an impending physician shortage. yourself! Cognitive behavioral training reduces stress in GPs. Health Aff (Millwood) 2002; 21: 140–54. Fam Pract 2004; 21: 545–51. 75 Virtanen P, Oksanen T, Kivimäki M, Virtanen M, Pentti J, Vahtera J. 97 Le Blanc PM, Hox JJ, Schaufeli WB, Taris TW, Peeters MCW. Take Work stress and health in primary health care physicians and care! The evaluation of a team-based burnout intervention hospital physicians. Occup Environ Med 2008; 65: 364–66. program for oncology care providers. J Appl Psychol 2007; 92: 213–27. 76 Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. 98 Rowe MM. Teaching health-care providers coping: results of a J Bone Joint Surg Am 2004; 86: 1579–86. two-year study. J Behav Med 1999; 22: 511–51. 77 Gardiner M, Sexton R, Durbridge M, Garrard K. The role of 99 Rø KEI, Gude T, Tyssen R, Aasland OG. Counselling for burnout psychological well being in retaining rural practitioners. in Norwegian doctors: one year cohort study. BMJ 2008; Aust J Rural Health 2005; 13: 149–55. 337: a2004. 78 Grunfeld E, Whelan TJ, Zitzelsberger L, Willan AR, Montesanto B, 100 Jones JW, Barge BN, Steff y BD, Fay LM, Kunz LK, Wuebker LJ. Evans WK. Cancer care workers in Ontario: prevalence of burnout, Stress and medical malpractice: organizational risk assessment job stress and job satisfaction. CMAJ 2000; 163: 166–69. and intervention. J Appl Psychol 1988; 73: 727–35.

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COGNITIVE BEHAVIOURAL THERAPY IN PRIMARY CARE

1. The Cognitive Triangle

Feelings

Thoughts Behaviours

2. Goal (ification)_

3. Scale (ification)

1 5 10

4. Planning to Meet Your Goals

Mon Tues Wed Thurs Fri Sat Sun Efforts

Rewards

Unhelpful thinking habits

How to Write a Worry Script / List

A helpful tool in managing your excessive worries involves writing a worry script or list. This skill is most useful for worries about hypothetical situations over which you have little to no control. Examples of these types of worries include: Worries about you or a loved one developing a serious illness Worries about you or a loved one being in an accident, getting injured, abducted or killed Worries about failure or loss in your future (e.g. losing your job, getting divorced) These worries take up a lot of time and energy, and they probably cause you a great deal of anxiety. In general, the best way to get over fears is to face the fear through gradual exposure. The problem is that although this kind of exposure is very helpful for getting over a fear of dogs for example, it is not very useful when your fear is of a negative event in the future that has not happened, and may never happen. In this case, the best way to deal with your worries is to write a worry script or list. It is similar to a journal or diary entry, where you write out in great detail your worst fear every day for 2 weeks.

Why is a Worry Script / List Helpful? Research shows us that people with Generalized Anxiety Disorder (GAD) have a hard time dealing with their negative emotions, such as sadness or fear. They either try to push the negative feelings away, or they keep switching worry topics. Unfortunately, neither of these techniques work. Why not? Pushing bad thoughts and feelings away: If you have ever tried to push a bad feeling or thought away, you probably noticed that it didn’t work at all or that the thoughts and feelings came back pretty quickly. Trying to push something out of our minds is a little like trying to push a beach ball under water: it takes a lot of work to keep it down, and the minute you let it go, it pops right back up again. Switching worry topics: Research on worry has found that people often “hop” from one worry topic to another. They think about one worry, which makes them feel anxious, and then they switch to another worry. The problem with this approach is that you never get to fully “digest” your fear, and really clearly see what it is that you are afraid of. Instead, you are avoiding upsetting thoughts and feelings by constantly “switching” your worries. The problem with this strategy is that avoidance doesn’t work in the long run. So how is a worry script or list different? Rather than putting all of your energy into avoiding upsetting thoughts and images, you can instead face your fears head on! By writing about your biggest worry, you will be facing those negative thoughts and bad feelings. You will also get a clear picture of what it is you are really afraid of, which will give you a chance to “digest” your anxiety and change how you think about your fear. People who write a worry script or list for a few weeks report that they feel less anxious and worried about the worry topic they were working on. How to Write a Worry Script or List Your worry script should be about the worst-case scenario for one of your worries. For example, if you are worried about a loved one being in a car accident, you would write about your loved one actually being in a car accident. Your script should be vivid and visual. That is, it should include the 5 senses as much as possible (touch, taste, sight, smell, hearing), as well as your feelings and reactions. If you were writing about a loved one in a car accident, you might describe the sound of ambulance sirens, the smell of burning tires, and feeling like you might pass out. Your worry list can be a long catalogue of all the things you can / do worry about. You can elaborate on a worry, or just write the worry down – and keep writing.

IMPORTANT REMINDER: If you are feeling anxious, upset or tearful while writing your script, you are on the right track. Your worry script is about your worst-case scenario, so it is supposed to be upsetting. Remember that this exercise is designed to help you get over your worries and anxiety in the long-term. When it comes to anxiety, in order to get a long-term gain you will always experience some short-term pain. You should write your worry script for 30 minutes every day. Set aside time in your day to do it, and eliminate distractions: turn off the ringer on your phone and the television, and go into a room by yourself to write it. Write a new worry script every day. For example, in one script you might write about how the loss of a loved one would affect your family, or you might write about your fears for the future after the loss of a loved one. DON’T FORGET: If you get upset and tearful while writing your script, you are on the right track! Expect to write about the same worry topic for 30 minutes every day for 2 weeks. KEEP IN MIND: Sometimes when people write a worry script, they find that they worry more about the topic or generally feel more anxious during the day. This reaction is normal, and will pass. Just keep at it, and you will see that writing about your fears and negative emotions is a better strategy in the long run.

One final point Some people who face their worries by writing a worry script are afraid that writing it down will make the worst-case scenario actually happen, or that doing this type of exposure means that they will no longer care if it happens. This is not true. 1. Just writing about something bad will not make it happen (e.g. “fortune – telling” usually doesn’t work). If that were true, you could write a script about having millions of dollars and the next day you would win the lottery. You have probably been thinking and worrying about your worst-case scenario for years. The only difference now is that you are writing it down so that you can start to let the worry go. 2. The goal of the worry script is to reduce your worry, not to make you no longer care (e.g. thinking about things in “black-and-white” can often be both inaccurate and unhelpful). If you write out your worry script every day for 2 weeks, you will find you spend less time and energy worrying about fears. However, this does not mean that you don’t care about them. It simply means that you don’t spend hours worrying about it every day.

Monitoring of Antipsychotics and Mood Stabilizers Medication Typical (First Atypical Antipsychotics Lithium Divalproex Lamotrigine Carbamazepine Generation) Antipsychotics Adverse Effects Requiring Monitoring LETHAL/ SEROIUS RISKS

BMI, Waist circumference, AIMS BP, HgbA1C, lipids

Drug levels

CBC

LFT’s

Cr, lytes, u/a

TSH

PRL

ECG

Antipsychotics and Mood Stabilizers in Pregnancy and Lactation Medication Pregnancy

Lactation

Motivational Interviewing in Primary care FM-MHL (2018)

Stages of Change Pre-Contemplation − < 30 seconds − Provide concerned, caring, evidence-based advice − Leave the door open (“If you ever want to . . .”) − Signpost ongoing monitoring

Contemplation Motivational Interviewing

Preparation − SMART Goal setting S-pecific − Resources M-easurable − Support A-ction oriented Action R-ealistic − Support / Encouragement / Reward − Track Progress T-ime-Limited

Maintenance / Relaps Prevention − Support / Encouragement / Reward − Identify Triggers − Brainstorm replacement behaviours − Relapse Plan

Activity #1 MAKING IT PERSONAL

Think of 1 thing that you have thought about changing either more than once or for a long time (i.e. years) – we’ll call this your ‘Change Target’

(Examples: lose weight, learn a new language, get more organized, learn an instrument, take up a new hobby/ fitness activity, achieve a greater work / life balance)

Your Contemplation ‘Change Target’ is

Activity #2 AMBIVALENCE

#1 – write down (at least) 3 reasons why changing would be good #2 – write down (at least) 3 reasons why NOT changing would be good (i.e. less energy, less stress, less costly, less inconvenience) #3 – write down some of the feelings associated with this ambivalence (i.e. it’s frustrating, or annoying, or you feel impatient, or embarrassed, or guilty, etc)

Why change would be Why not changing Ambivalent good would be good feelings

Motivational Interviewing in Primary care FM-MHL (2018)

O – Open-ended questions A – Affirmations R – Reflections S – Summaries

Activity #3 OARS SKILLS PRACTICE

• Get into groups of 3 • Each of you is going to be ‘The Changer’, ‘The Clinician’ and ‘The Observer’

The Changer – talk about your ‘Change Target’ The Clinician – try to practice each of the OARS skills The Observer – keep track of which OARS skills have been used Clinician– use ‘time out’ hand signal & ask for help 3 mins + 2 mins for feedback / each

D evelop Discrepancy E mpathy A mplify Ambivalence R oll with Resistance S elf – Efficacy

Activity #4 DEARS SKILLS PRACTICE

• Get into another group of 3 • Each of you is going to be ‘The Changer’, ‘The Clinician’ and ‘The Observer’

The Changer – talk about your ‘Change Target’ The Clinician – try to practice each of the DEARS skills The Observer – keep track of which DEARS skills have been used Clinician– use ‘time out’ hand signal & ask for help 3 mins + 2 mins for feedback / each

Motivational Interviewing in Primary care FM-MHL (2018)

Activity #5 OARS + DEARS + READINESS RULERS PRACTICE

• Get into another group of 3 • Each of you is going to be ‘The Changer’, ‘The Clinician’ and ‘The Observer’

The Changer – talk about your ‘Change Target’ The Clinician – try to practice each of the OARS, DEARS and READINESS RULERS skills The Observer – keep track of which skills have been used Clinician– use ‘time out’ hand signal & ask for help 4 mins + 2 mins for feedback / each

Readiness Rulers

How important is making this change to you – at present?

0 5 10

If < 6 ask “why not lower” If > 7 ask: 1) what makes it a 7?, ii) how high does it need to be to act?, iii) why not lower?

How confident that you are presently able to make this change?

0 5 10

If < 6 ask “why not lower” If > 7 ask: 1) what makes it a 7?, ii) how high does it need to be to act?, iii) why not lower?

Motivational Interviewing in Primary care FM-MHL (2018)

Exercise #6 MAKING IT PERSONAL

Consider 1 technique or skill that you might consider changing with regards your practice (OARS, DEARS, Readiness Rulers)

Find a partner – 1 person tell the other person a specific OARS, DEARS or Readiness Ruler Skill you are seriously thinking about trying

Partner - Do a Readiness Ruler + OARS, DEARS

If partner is Pre-contemplative (Importance = 0) • < 30 seconds • Provide concerned, caring evidence-based advice • Leave the door open • Signpost ongoing monitoring

If partner is in Preparation (Importance > 0, ready to make a commitment, wants to make a plan -> Set a SMART goal

If partner is Contemplation (Importance > 0, NOT ready to make a commitment yet) • OARS, DEARS them

References

Britt, E., Hudson, S. & Blampied, N. M. (2004). Motivational interviewing in health settings: A review. Patient Education and Counselling, 53, 147 – 155.

Jensen (1996). Enhancing motivation to change in pain treatment. In Psychological approaches to pain management: a practitioner’s handbook. Gatchel & Turk (Eds.)

Lussier, M.& Richard, C. (2007). The motivational interview: In practice. Canadian Family Physician, 53, 2117 – 2118.

Miller, W. & Rollnick, S. (2002). Motivational Interviewing: preparing people for change.

Rollnick, S., Kinnersley, P. & Stott, N. (1993). Methods of helping patients with behaviour change. BMJ, 307, 188 – 190.

Rollnick, S., Mason, P. & Butler, C., (1999). Health behaviour change: A guide for practitioners. Sydney: Churchill Livingstone.

Rubak, S., Sandaek, Lauritzen, T. and Christensen, B. (2005). Motivational Interviewing: a systematic review and meta- analysis. British Journal of General Practice, April.

Sellman, J. D., Sullivan, P. F., Dore, D. M., Adamson, S. J. & MacEwan, I. (2001). A randomized controlled trial of motivational enhancement therapy (MET) for mild-moderate alcohol dependence. J Stud Alcohol, 63, 389 – 396.

Stotts, A. L., DiClemente, C. C., & Dolan-Mullen, P. (2002). A motivational intervention for resistant pregnant smokers. Addictive Behaviors, 27, 275 – 292.

SAMPs CASE: DEPRESSION Source: http://www.cfpc.ca/SAMPs/ then click on ‘SAMPs Website Demo’ (July 2018)

A 45 year old female presents at your office. She is worried that she might be depressed. She describes a three-month history of low mood, irritability, fatigue, indecisiveness, difficulty sleeping, and feeling distant from her husband and teenage daughter. In addition to experiencing these symptoms, for the past two weeks she has also had feelings of worthlessness most of the day nearly every day.

QUESTION 1: In terms of safety issues, what are your priorities in assessing the patient at this time?

List TWO. 1. 2.

QUESTION 2: Apart from a major depressive episode or disorder, what other psychiatric conditions should you consider?

List TWO. 1. 2.

QUESTION 3: A diagnosis of a major depressive disorder is made and you feel that outpatient management is safe. Apart from pharmacotherapy, what are the components of an appropriate management plan?

List THREE. 1. 2. 3.

QUESTION 4: Although she is compliant with her medication and adheres to the management plan for two months, her depression fails to improve. Other than referring to a psychiatrist, what are your next steps in management?

List FOUR. 1. 2. 3. 4. CORRECT ANSWERS According to the CFPC Website

QUESTION 1: ● The risk of suicide ● Homicidal risk

QUESTION 2: ● Bipolar disorder ● Substance abuse (Accept alcohol abuse, drug abuse, narcotic abuse, etc.)

QUESTION 3: ● Appropriate follow-up management/Monitoring response to therapy ● Psychotherapy/Counselling ● Contract for safety/Seeking help if suicidal

QUESTION 4: ● Consider an alternative diagnosis ● Look for co-morbid conditions ● Augment medication with second drug ● Increase / adjust dosage of present medication / Switch to alternate medication / antidepressant