The Canadian Journal of Psychiatry

To examine the usage of a standardized screening tool bundle in guiding care recommendations within a regional coordinated access service (1Call1Click.ca) for children, youth and their families seeking mental health, addictions, and substance use health (MHASUH) care. To explore how the screening tools align with each other and with Level of Need, an assigned designation used to indicate acuity, needs, and guide service recommendations.

Between May 31, 2021, and December 31, 2023, 8,280 clients aged 6–21 were administered the CASH screening tool bundle (CASH is an acronym for the included screening tools, the CRAFFT, Ask Suicide Questions {ASQ}, HEADS-ED (Over 6 and Under 6) and assigned a Level of Need (used to describe acuity and guide referrals). We describe the most common needs, correlations between Level of Need and each screening tool, and agreement between the HEADS-ED Domains of Suicidality and Drugs and alcohol with the ASQ and CRAFFT screening tools.

We observe a significant moderate correlation (r(8,280) = .507, p < .001) between the total HEADS-ED score and the assigned Level of Need and significant differences in HEADS-ED total score between each Level of Need (F(4, 8,275) = 766.810, p < .001). Additionally, ASQ and CRAFFT results align with the Suicidality and Drugs and alcohol domains of the HEADS-ED. Referrals were accepted by services at a rate of 94.4%.

The CASH screening tool bundle is effective for screening child and youth MHASUH concerns. The HEADS-ED can give a non-specialist healthcare provider an overview of the nature and acuity of child and youth MHASUH and guide the application of more specialized tools included in the bundle. Used as described in this manuscript, the standardized screening bundle is a useful means for assessing needs and guiding referrals to specialized care, including in-depth specialized assessments.

Screening tools are questionnaires that can help identify individuals at heightened risk for mental health, addictions, and substance use (MHASUH) challenges so they can be prioritized for more in-depth assessment and treatment. We examined the use of a set of screening tools (The CASH Bundle) in combination with each other. The CASH Bundle includes screening tools for substance use (the CRAFFT), suicide risk (the Ask Suicide Questions (ASQ)), and a general assessment screening tool for children and youth (the HEADS-ED (Over 6 and Under 6)).

The CASH bundle is used at 1Call1Click.ca, a program for infants, children, and youth struggling with MHASUH concerns to find the service that matches their needs. When someone contacts 1Call1Click.ca, they speak to a healthcare provider who uses the CASH Bundle to determine their Level of Need (a measure of severity that is linked to treatment types). The provider uses this information to connect the client directly to a local MHASUH treatment resource. This study included 8280 1Call1Click.ca clients aged 6 to 21 who were screened with the CASH bundle and assigned a Level of Need.

Our results showed that each of the tools in the CASH Bundle supported the healthcare providers' assessment of the clients' Level of Need.

The CASH Bundle can help healthcare providers quickly gain an overview of the client's MHASUH needs and determine which type and level of care those clients will benefit from the most. This is important because care resources are both limited and in high demand. Assigning care resources quickly, efficiently, and appropriately is critical to making the best use of available resources and making sure that people receive the care they need as quickly as possible.

Medical students are known to face significant psychological distress, making them vulnerable to substance use. There are few data on alcohol and drug consumption among medical students. The aim was to assess the prevalence of substance use, especially alcohol, in French medical students.

This cross-sectional nationwide study was conducted online from 10 June to 28 July 2024. A survey link was sent to French medical students and residents via official administrative emails. We assessed substance use (alcohol, tobacco, cannabis, cocaine, amphetamine, LSD, psilocybin, heroine, poppers, nitrous oxide and other). For alcohol consumption, we used the Alcohol Use Disorders Identification Test (AUDIT). Data analysis was performed, including recoding missing responses as zeros. Univariate and multivariate binary logistic regressions were performed with AUDIT as the dependent variable, categorized as binary (cutoff ≥8).

We included 8,312 students: 11% met criteria for hazardous drinking, and 5.5% for probable dependence according to the AUDIT; 23.3% respondents reported tobacco use, while cannabis use was reported by 13.4% with 1% using it more than 2 or 3 times a week. Among other substances, poppers (23.5%) and nitrous oxide (11.2%) were the most commonly reported. Multivariate analysis identified several factors associated with problematic alcohol use, such as male sex, younger age, financial difficulties, exposure to humiliation, harassment or sexual assault.

Alcohol and psychoactive substance use remain prevalent among French medical students, at levels broadly comparable to those reported internationally. These findings underscore the need for targeted preventive and supportive actions within medical schools.

Emerging evidence suggests overlap in brain areas implicated in the pathophysiology of bipolar I disorder (BD-I) and vestibular activity in the brainstem, potentially underlying the postural instability observed in BD-I. Computerized Dynamic Posturography (CDP), a validated tool that quantifies the functional contributions of somatosensory, visual, and vestibular inputs, as well as the central mechanisms responsible for integrating these inputs, was employed to examine the sensory processing and postural control in BD-I.

To investigate the integrity of dynamic postural control and the contributions of somatosensory, visual, and vestibular sensory systems to postural stability in individuals with BD-I in remission

Thirty participants aged 18–50 years with BD-I in remission (ICD-11; female = 12), not on known vestibular suppressants, and 30 matched controls (female = 13) underwent CDP, which included the Sensory Organization Test (SOT), adaptation test, Motor Control Test (MCT), fall risk test, and Optokinetic test (OKN). The differences between the groups were assessed using an independent samples t-test.

BD-I participants showed significantly poorer scores on SOT, fall risk test, and OKN test (all p < 0.005). We did not find significant differences in the adaptation test and MCT.

BD-I subjects exhibited greater postural alterations compared to healthy controls, indicating impaired sensory integration, especially when visual input was altered. Fall risk and OKN tests suggest central deficits in processing vestibular and proprioceptive input. These findings support postural control assessment as a potential biomarker for BD-I, though medication effects remain an important consideration.

The priorities of people with mental health challenges should be reflected in the research conducted on their behalf. Quantifying alignment of priorities with the unmet needs of people with lived experience is challenging, and to our knowledge, such alignment has not been extensively studied in bipolar disorder (BD). Natural language processing approaches comparing common topics derived from public forums to those of biomedical research could help in identifying topics that are underaddressed.

We contrasted 5 years of lived experience questions posed during a Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST.BD) “Ask Me Anything” (AMA) event hosted via Reddit (2019–2023) with topics labelled from abstracts extracted from PubMed with the search term BD during the same period. We applied topic modelling using BERTopic to identify dominant themes within each corpus and compared their semantic similarity using vector-based cosine similarity analyses.

The Reddit AMA data included 6159 comments, and the medical literature from this period included 9188 abstracts. Topic modelling and similarity analyses indicated that shared and frequent topics in both corpuses were sleep, BD medication safety in pregnancy, and lithium treatment. Topics with comparatively higher frequency in the Reddit forums than in medical research included BD misdiagnosis, marijuana and BD, and coping with daily challenges.

Notwithstanding limitations, comparing a corpus of lived experience questions with contemporaneous medical literature revealed areas of overlap, but some lived experience queries were not well covered in the biomedical literature. Natural language processing of public forums may facilitate identifying unmet priorities in BD.

To estimate the prevalence of comorbid postpartum depression (PPD) and postpartum anxiety (PPA) in birthing parents seeking treatment for PPD in Ontario, Canada and who were enrolled in 1 of 9 randomized controlled trials (RCTs) of cognitive behavioural therapies (CBT) for PPD.

Secondary analysis of 9 pooled RCTs containing baseline data from 1920 birthing parents and conducted between 2017 and 2025. All participants were living in Ontario, Canada with Edinburgh Postnatal Depression Scale (EPDS) Scores ≥10 and infants <12 months old. Comorbid anxiety was assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale, the Penn State Worry Questionnaire (PSWQ) and/or the Mini International Neuropsychiatric Interview (MINI).

Sixty-six percent of participants with PPD (EPDS scores ≥10) had moderate to severe anxiety (GAD-7 scale score ≥10; 95% confidence interval (CI) 63–68%, 7 studies, n = 1654), and 69% with PPD met the cutoff for probable GAD (PSWQ scale score ≥61; 95% CI [63–74%], 2 studies, n = 254). Seventy percent of participants with MINI-defined current major depressive disorder (MDD) met Diagnostic and Statistical Manual of Mental Disorders—4th Edition-based criteria for any anxiety disorder (95% CI [64–76%], 6 studies, n = 448). Nearly 60% of participants with current MDD met criteria for GAD on the MINI (95% CI [52–61%], n = 448).

More than two-thirds of treatment-seeking individuals with PPD have clinically significant anxiety. Those with PPD, their families, and healthcare professionals should be aware of the high prevalence of anxiety in these individuals so that treatment plans can be optimized to best meet their needs.

ClinicalTrials.gov (https://clinicaltrials.gov/): NCT03039530, NCT03654261, NCT03285139, NCT04485000, NCT04928742, NCT04934488, NCT04913584, NCT05314361 and NCT05044455.

To evaluate changes in antipsychotic treatment patterns and healthcare utilization before and after initiation of long-acting injectable antipsychotics (LAI-APs) in a large Québec population cohort, comparing individuals with schizophrenia (SCZ) to those with other psychotic disorders (non-SCZ).

We conducted a retrospective cohort study using linked Québec administrative databases (RAMQ, MED-ECHO, and public drug insurance) to identify 6,221 adults who initiated a LAI-AP between April 2013 and December 2016, after a 12-month LAI-free period. Participants were followed for 12 months before and after the index date. The cohort was stratified into SCZ and non-SCZ, and were further divided by regimen at initiation (LAI only; LAI + clozapine; LAI + other oral antipsychotic). Antipsychotic exposure and health-service usage (hospitalizations, emergency visits, outpatient and community care) trajectories were analyzed weekly using state-sequence analysis; pre- versus post-initiation comparisons used paired statistical tests.

Of 6,221 patients (63.4% male; mean age 41.6 years), initial treatments consisted of paliperidone LAI (55.7%), aripiprazole LAI (21.5%), risperidone LAI (6.9%), first-generation LAI (15.6%), and LAI combinations (0.2%); 40% received LAI only, 5% LAI + clozapine, 55% LAI + an oral antipsychotic. SCZ patients were more often male, economically disadvantaged, and more likely to receive clozapine. After LAI initiation, hospital days fell sharply by almost 70% and outpatient and community-care visits increased substantially. Use of oral antipsychotics decreased overall post-initiation, except for clozapine (which rose) and first-generation oral drugs (which remained stable).

In this real-world Québec cohort, LAI-AP initiation was followed by a marked reduction in hospitalizations and a shift toward outpatient and community care, regardless of diagnosis. Observed differences in sociodemographic and clinical profiles between SCZ and non-SCZ patients—and among SCZ treatment subgroups—suggest the need for tailored care pathways. These findings support LAI-AP effectiveness in reducing healthcare utilization and inform resource planning.

Clinical practice guidelines support evidence-based care but are often underused due to complexity, time constraints, and navigation challenges. We investigated whether a conversational agent (chatbot) using an open-weight large language model (LLM) with retrieval-augmented generation (RAG) could provide guideline-consistent answers for bipolar disorder management based on the full 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and ISBD guidelines, comparing against a system using only the base LLM.

We developed a multi-step RAG-based chatbot that retrieves relevant guideline sections and generates responses using Llama 3.3 70B. Twenty-one clinical vignettes spanning all guideline sections were created. Six expert psychiatrists generated queries and were presented with paired responses without labels from 2 systems: one using the base Llama 3.3 70B model, the other RAG-enhanced. Responses were rated for guideline consistency on a 3-point scale, and were analyzed using mixed-effects ordinal logistic regression.

Experts evaluated 126 responses, of which 110 (87.3%) were rated as correct as or more correct than the baseline system. The RAG system produced 80 answers (63.5%) rated fully consistent with the guidelines versus 24 (19.0%) for baseline, and only 10 answers with major deviation (7.9%) versus 48 (38.1%) for baseline. Ordinal regression showed RAG responses were significantly more likely to be more correct (OR = 9.1, 95% CI [5.3-16.3], P < 0.001), which was consistent across all raters. Preference ratings favoured RAG answers in 78.7% of cases. Performance varied by vignette, with some errors in both retrieval and reasoning.

The use of RAG with an open-weight model helped produce answers consistent with the CANMAT guidelines across vignettes that required adapting or combining guideline text, suggesting a proof-of-concept of a bipolar guideline chatbot. We identified areas to improve results and evaluation. Future work should explore additional retrieval strategies and LLMs, and test in more naturalistic settings.

We evaluated the effectiveness of an AI system at answering treatment questions from the bipolar disorder medical guidelines.

Persons involved in compulsory mental health treatment—including clinicians, lawyers, service users, and family members—frequently express dissatisfaction with how the system is regulated and administered. Policy discussions on improving the system often fail to consider the voices of service users and family members. Policy development must also grapple with the contested values of autonomy and wellbeing, and the associated disjuncture in professional views. Community treatment orders (CTOs) are a key mechanism of compulsory mental health treatment in Ontario, and many other jurisdictions. We studied views on CTOs in Ontario to identify agreement across groups about where and how the system ought to be improved.

We conducted semi-structured individual interviews followed by mixed focus groups including 72 participants: healthcare professionals, lawyers, tribunal members, service users (“clients”), family members, and advocates. Interview data were analyzed to identify recurring concerns and inform focus group discussion topics. Focus groups explored potential areas of alignment across participant groups, with particular attention to points of consensus. A lived-experience advisory panel informed study design.

Across participant groups, 6 main areas of agreement were visible. Participants identified the need for: (1) increased client involvement in treatment decisions, even within compulsory frameworks; (2) improved police involvement during CTO enforcement; (3) improved availability and quality of CTO-related data, enabling evaluation, accountability and attention to equity; (4) enhanced guidance and support for substitute decision-makers; (5) stronger oversight of medical decision-making, though preferred mechanisms varied; and (6) expanded community services—particularly housing, addiction treatment and case management—viewed as essential for CTOs to be able to have their intended benefit.

This study shows there is meaningful agreement on several areas requiring improvement in Ontario's CTO system. These points of convergence represent promising foundations for policy development, although translation into actionable reform will require further policy work.

Community treatment orders (CTOs) allow people with mental illness to be required to follow treatment while living in the community. They are used in Ontario and many other places. Many people involved in the system, including healthcare professionals, lawyers, service users, and family members, have expressed concerns about how CTOs work. However, discussions about improving the system do not always include service users and families. Also, there is often disagreement between groups involved in CTOs about how they should improve. This study aimed to identify areas where different groups agree about how the CTO system could be improved.

The research team conducted interviews and focus groups with 72 participants in Ontario, including healthcare professionals, lawyers, tribunal members, service users, family members, and advocates. Interviews identified key concerns about CTOs, and focus groups explored these issues further, with particular attention to areas of agreement. People with lived experience of being on CTOs also helped guide the study.

Participants agreed on several important areas for improvement. These included increasing service user involvement in treatment decisions, improving police involvement during CTO enforcement, and collecting better data to evaluate CTO use. Participants also agreed that substitute decision-makers need better guidance, and that medical decision-making should have stronger oversight. Finally, participants emphasised that CTOs cannot work effectively without adequate community services, especially housing, addiction treatment, and case management.

There is meaningful agreement across groups about how the CTO system could be improved. These shared priorities provide a strong foundation for policymakers seeking to improve compulsory community mental health treatment.

The gut microbiome has been proposed as a potential modifiable target to treat mental illness. This double-blind randomized control trial investigated fecal microbiota transplant (FMT) in bipolar disorder (BD) to assess efficacy, safety, and feasibility. The primary outcome evaluated the effectiveness of standard approved therapy for BD depression + FMT in individuals not responding to standard treatment, measured by change in the Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to week 24. Secondary outcomes included FMT's impact on anxiety, global function, side-effects, and safety. The feasibility of this novel intervention was also assessed. Microbial analysis utilized whole-genome shotgun metagenomic sequencing, comparing outcomes between allogenic (donor) and autologous (participants own) FMT.

A total of 35 participants (28 women and 7 men) with at least moderate depressive-phase BD (MADRS) were randomized to receive either allogenic FMT (n = 17) or autologous FMT (n = 18) via colonoscopy and were followed for 24 weeks.

MADRS scores significantly improved from baseline to the last visit in both treatment arms. There was no significant difference between allogenic FMT (16.74-point improvement) and autologous FMT (15.4-point improvement) regarding clinical efficacy (t = −0.47, p-value = .64, 95% confidence interval [CI] = −7.3–4.6). Microbiota analysis showed that allogenic FMT let to a bacterial profile similar to the healthy donor and increased bacterial diversity at the 6-month mark, whereas those receiving autologous FMT did not. The intervention was well tolerated with no significant adverse events. Recruitment, randomization, and retention metrics support feasibility of a larger trial.

Feasibility and tolerability data indicate further investigation into microbial manipulation in BD is warranted. The absence of efficacy differences between the two types of FMT, despite microbial change, highlights the importance of a true placebo in future studies, as well as the importance of understanding exactly what bacteria are linked to improvements. ClinicalTrials.gov, NCT0327922

This study was a proof-of-concept, double-blind randomized control trial (RCT) that investigated Fecal Microbiota Transplant (FMT) as a modifiable target to treat mental illness, specifically focusing on depression in bipolar disorder (BD). The trial assessed the efficacy, safety, and tolerability of combining FMT with approved BD depression therapy in individuals not responding to standard treatment. Participants (35 total: 28 women and 7 men) were 18 years or older and presented in the depressed phase of BD of at least moderate severity, as measured by the Montgomery-Åsberg Depression Rating Scale (MADRS). They received either FMT from a healthy donor (allogenic, n = 17) or their own stool (autologous, n = 18) via colonoscopy and were followed for 24 weeks. Secondary measures included assessing anxiety via the Stait-Trait Anxiety Index and global function via the World Health Organization Brief Quality of Life Scale.

Key Findings: Overall, participants showed significant improvement in depression scores, however, there was no significant difference in clinical improvement between the allogenic FMT (16.7-point improvement) and the autologous FMT (15.4-point improvement). Microbial analysis via metagenomic sequencing showed that participants receiving the allogenic FMT developed a bacterial profile similar to the healthy donor and showed increased bacterial diversity at the 6-month mark, while those receiving autologous FMT did not show these specific microbial changes. The intervention was very well tolerated; no significant adverse events noted, and the feasibility of a larger trial was supported.

Conclusion: The lack of significant clinical difference between the two types of FMT, despite actual microbial changes only occurring in the donor group, indicates a need to ensure the use of a true placebo in future studies. Further research is warranted to understand the impact of microbial manipulation in BD and to identify what bacteria are linked to clinical improvement. ClinicalTrials.gov, NCT03279224.

Major depressive disorder is a debilitating mental health issue that frequently emerges during childhood or adolescence. Although prior research has established the burden of depressive symptoms in young people, less is known about how depression affects quality of life (QoL), a multidimensional construct encompassing emotional, physical and social functioning. This systematic review aimed to systematically evaluate the association between depression and QoL in children and adolescents, with particular attention to domain-specific and informant effects.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase and PsycINFO were searched from inception to July 31, 2025, and reference lists of included studies were searched. Eligible studies included English-language, peer-reviewed, observational studies assessing depression and QoL using validated measures in children and adolescents (defined as samples with all participants <18 years or with a mean age <18). Studies focused on general well-being and samples with comorbidities were excluded. Risk of bias was assessed using the appropriate Joanna Briggs Institute Critical Appraisal Checklists. A structured narrative synthesis was conducted, grouping studies by comparison type (e.g., depressed vs. nondepressed groups, severity–QoL associations, domain-specific outcomes and informant differences).

Twenty-seven studies (N = 28,738) met inclusion criteria. Across clinical and community samples, depression was consistently associated with lower QoL, particularly within emotional domains. Several studies also highlighted discrepancies between child and parent QoL assessments.

Evidence was limited by heterogeneity in measurement tools, inconsistent adjustment for confounders, item overlap between constructs and a scarcity of longitudinal designs. Nonetheless, findings underscore the significant impact of depression on children's and adolescents’ lives beyond symptom severity alone. This systematic review highlights the importance of assessing QoL alongside depression symptoms to inform comprehensive, person-centred approaches to child and adolescent mental health care. Future research should prioritize longitudinal designs and the examination of mediators and moderators that shape the depression–QoL relationship.

Research indicates a significant overlap between transgender and gender-diverse (TGD) and autistic identities. This intersectional population has higher risks of mental health challenges and worse mental health outcomes than individuals with just one of the two identities. Limited research focuses on adults at this intersection and their care access needs. To better characterize this population in the Canadian context, this study examines the population referred to Canada's largest publicly funded adult gender-related care clinic and compares demographic and diagnostic characteristics between those with and without a pre-existing autism diagnosis.

The data come from the medical records of 1,843 adults referred to the Gender Identity Clinic (GIC) at the Centre for Addiction and Mental Health in Toronto, Canada, between January 2020 and March 2025. The prevalence of autism diagnosis prior to entering the clinic was calculated. Average age, sex-assigned-at-birth composition, prevalence of gender dysphoria diagnoses and of additional mental health and neurodevelopmental diagnoses were compared between autistic and non-autistic groups. Changes across time in the number of autistic individuals referred to the GIC were analyzed.

Approximately 6.3% of adults referred to GIC had a diagnosis of autism. The autistic and non-autistic groups had no difference in average age. The groups had no differences in sex-assigned-at-birth distribution. Autistic adults had greater rates of gender dysphoria. Autistic adults had higher rates of each category of mental health and neurodevelopmental diagnoses examined.

This study is a first step in developing a holistic understanding of the experiences of autistic TGD adults seeking clinical gender-related care in the Canadian context, providing a starting point to addressing needs and barriers to care for this population, as well as insight into the substantial mental health challenges experienced by this population.

Many transgender and gender-diverse (TGD) individuals are autistic. They are more likely to have mental health problems but have a harder time getting mental health care. We wanted to know how common it was for the people coming to get gender care services at a large gender related clinic to have an autism diagnosis, and how those with an autism diagnosis were the same or different than other people at the clinic. We collected data from the medical records of 1,843 adults who had been referred to the Gender Identity Clinic at a large hospital in Toronto, Canada between January 2020 and March 2025. We examined the number of adults in the population who had a recorded diagnosis of autism at the point of intake, and compared the autistic and non-autistic groups in terms of: average age, sex-assigned-at-birth makeup, the rates of participants with a diagnosis of gender dysphoria, and other mental health or neurodevelopmental diagnoses. We also looked at the rates of adults with an autism diagnosis accessing care at the clinic across time. The researchers found that about 6.3% of the sample had a diagnosis of autism upon referral to the clinic. The autistic and non-autistic groups had no differences in average age. The sex-assigned-at-birth makeup of the two groups was equal. The autistic group was more likely to have higher rates of gender dysphoria and of mental health diagnoses than the non-autistic group. This study highlights the mental health difficulties experienced by this population, urging researchers, clinicians, families, and self-advocates to work toward removing the barriers experienced by this population in accessing care.