The Canadian Journal of Psychiatry

In 2023/2024, there were 15 psychiatrists/100,000 Canadians with inequitable distribution across Canada and unprecedented demand for mental health and addiction services. Psychiatry human resource planning in Canada has not occurred for more than a decade. The objectives of this study were to understand the current state and future directions related to Psychiatry Human Resources in the Canadian mental health care system.

Using Delphi methods, we surveyed the 17 chairs of the academic departments of psychiatry in Canada and held focus groups. The Royal College and subspecialty programs were also engaged. Themes were extracted, summarized and refined. The refined themes were distributed via an online survey to all 17 chairs for final review and input, ensuring alignment and consensus across institutions.

Common themes focused on: the role of psychiatrists working in teams to provide care for complex mental disorders and addictions; need for innovative models of care including use of physician extenders, technology to reach the larger population of patients with mild to moderate disorders, working closely with primary care in collaborative care models. Due to the large proportion of Canadian psychiatrists being 35 years or more in practice (26%) and close to retirement, the chairs supported the need to expand the number of residency positions for psychiatry and continue strong recruitment efforts for international medical graduates. Although the majority of chairs supported shortening the general psychiatry residency program from 5 to 4 years, the Association of Chairs of Psychiatry of Canada (ACPC) could not reach a consensus on this issue. Pan-Canadian licensing for psychiatrists should be considered due to inequitable distribution of psychiatrists in Canada and advances in virtual care post-COVID-19 pandemic.

This study will contribute to the dialogue on psychiatry human resources planning in Canada.

Current pharmacological antidepressant treatments suffer from low remission rates and slow initiation of therapeutic effects. In addition, the development of new antidepressant treatments is confounded by the lack of consensus on efficient and valid neurophysiological targets. Temporal complexity is an alternative measure of dynamic brain activity that estimates brain signal variability at several timescales. It can be easily extracted from non-invasive brain recordings and provides new insights into pathophysiological mechanisms. We aim to assess the potential of brain temporal complexity as a novel neuromarker to predict the effectiveness of antidepressant treatments.

We measured longitudinal changes in temporal complexity of electroencephalography signals in patients undergoing 8 weeks of escitalopram treatment through a Canadian Biomarker Integration Network in Depression (CAN-BIND) trial.

As early as 2 weeks after the start of treatment, reduction of complexity in fine timescales was associated with improvement in depressive symptoms. After 8 weeks of treatment, the treatment-related effect shifted towards an increase in coarse timescale complexity, linked to symptom improvement.

These results suggest a relative shift away from local, segregated information processing, measured by complexity at fine timescales, in the short term, potentially in favour of a higher long-range communication across networks, as indicated by higher complexity measures at coarse timescales in the long term. Further research into the modulation of multiscale temporal complexity by antidepressant treatments could open new possibilities for faster-acting and more efficient treatments.

Cognitive impairment is a core feature of schizophrenia spectrum disorders. Our previous study on a first-episode psychosis cohort showed that symptoms related to impoverished/disorganized communication and motor impoverishment predicted verbal and working memory scores, respectively. This study aimed to explore those predictors in people across the range of illness chronicity.

We employed iterative Constrained Principal Component Analysis (iCPCA) to investigate the relationship between 15 cognitive measures from the MATRICS battery, including processing speed, attention, working, verbal and nonverbal memory, reasoning, and problem-solving, and 27 Positive and Negative Syndrome Scale (PANSS) items in 198 outpatients from two sites in Australia and one in Canada. The iCPCA method was used to determine symptoms that reliably predict specific combinations of cognitive measures while controlling Type I errors.

We found that a verbal memory and learning component was predicted by the PANSS item Lack of Spontaneity and Flow of Conversation, and a visual attention/working memory component was linked to the PANSS item Motor Retardation.

These accord with our previous findings in an early psychosis sample, that is, negative symptoms of diminished expression are key predictors of cognitive abilities in schizophrenia. Namely, communication and motor impoverishments predicted lower scores on tests of verbal memory, learning, visual attention, and working memory. These findings may inform personalized treatment approaches targeting cognitive deficits and negative symptoms in schizophrenia.

Guidelines for treatment-resistant schizophrenia (TRS) advocate for a trial of clozapine monotherapy before the consideration of antipsychotic augmentation. Commonly cited justifications for augmentation include inadequate response to clozapine monotherapy and the potential to lower the necessary clozapine dose or serum concentration, thereby reducing dose-dependent adverse effects. Nonetheless, the degree to which these outcomes are realized in routine clinical practice, particularly among individuals with concurrent disorders, remains uncertain. This study aimed to explore the extent to which clozapine monotherapy is utilized before the initiation of antipsychotic augmentation strategies, and to assess the effects of antipsychotic augmentation on clozapine serum concentrations and the incidence of related adverse effects.

We retrospectively analyzed clinical and drug monitoring data from 80 adults with TRS and substance use disorder (SUD) comorbidity at a provincial inpatient centre for concurrent disorders. Antipsychotic augmentation was quantified using Defined Daily Dose (DDD). Generalized and linear mixed models compared the impact of monotherapy vs. augmentation on clozapine serum levels and adverse effects, adjusting for covariates.

Most patients receiving antipsychotic augmentation (78%) did not have an adequate trial of clozapine monotherapy. Analysis revealed that clozapine with antipsychotic augmentation was modestly and negatively associated (B = –0.039; 95% CI = –0.078 - −0.001) with clozapine serum concentrations, particularly at higher DDD (≥2). Clozapine with antipsychotic augmentation was not associated with reduced incidence of dose-dependent adverse events (tachycardia, constipation, or overall anticholinergic medication use).

Findings from this study indicate that commonly cited rationales for combining clozapine with antipsychotic augmentation – namely, enhancing tolerability through clozapine dose reduction or mitigating inadequate response to monotherapy – are not consistently supported by real-world outcomes. These results underscore the necessity for clinical guidelines to incorporate context-sensitive recommendations that address the complexities inherent in managing individuals with TRS and comorbid SUDs, while integrating real-world considerations and the perspectives of those with lived experience.

The current supply and distribution of child psychiatrists in Ontario is not well understood, making it difficult to effectively plan mental healthcare services for children and adolescents. Therefore, we developed a data-driven definition of psychiatrists who focus on treating child and adolescents, and described their demographic characteristics, geographic distribution, and practice patterns across Ontario in 2023.

A cross-sectional study was employed using administrative data from ICES. All practicing Ontario-based psychiatrists, defined as those submitting at least one billing claim to the Ontario Health Insurance Plan were included. Psychiatrists from the years 2013–2023 were included to create the definition of child-focused psychiatrists. Child-focused psychiatrists were defined as those with ≥50% or more of their patients ≤18 years of age. Then, this definition was applied to psychiatrists in 2023 to compare and descriptively summarize data (e.g., age, sex, rurality of practice location, and practice patterns) between child- and adult-focused psychiatrists.

In 2023, there was a total of 259 child-focused psychiatrists and 2,099 adult-focused psychiatrists in Ontario. Child-focused psychiatrists were younger (mean age ± SD: 55.8 ± 9.3 vs. 60.1 ± 11.5, p < 0.001), more likely to be female (59.1% vs. 46.2%, p < 0.001), and less likely to work in rural regions than adult-focused psychiatrists. Both, on average, saw a similar number of patients overall (276.7 ± 265.9 vs. 329.3 ± 403.1, p = 0.115), but child-focused psychiatrists saw patients less frequently than adult-focused psychiatrists (3.0 ± 1.8 vs 6.5 ± 9.1, p<0.001). Child-focused psychiatrists were less likely to have small patient panels as well (p < 0.001).

Child-focused psychiatrists represent a small proportion of the psychiatric workforce in Ontario, with particularly limited availability in rural regions. Compared to adult-focused psychiatrists, they are less likely to maintain smaller practices and they see their patients less frequently.