Psychiatry

Treatment of ADHD that is accompanied by disruptive behaviour disorders should include adequate education of patients and their families, behavioural interventions, psychological treatments and educational accommodations first. If this approach is not sufficient, stimulant medication and a behavioural analysis to ensure appropriate support from the parent and classroom is indicated. The use of alpha 2 agonists (such as guanfacine or clonidine) and atomoxetine should be considered before using atypical antipsychotics (such as risperidone) in children with ADHD and comorbid disruptive behaviour disorders (oppositional defiant disorder, conduct disorder). Although risperidone may provide some short-term reduction in aggression and conduct problems in children, its negative metabolic side effects must be balanced against its potential benefits.

Preschool children with ADHD need to be assessed for other neurodevelopmental disorders and consideration given to environmental stressors such as neglect, abuse or exposure to domestic violence. Although there is some evidence supporting the use of stimulants among preschoolers with ADHD, treatment should instead start with adequate education and support of parents followed by advice on behavioural management and community placement, given the potential side effects of stimulants in younger ages.

Recent research confirms a dramatic increase in the use of atypical antipsychotics with subsequent side-effects including obesity, which is already a major health issue. These drugs carry significant risk of potential side-effects including weight gain and metabolic complications, even at low doses used to treat insomnia. In patients with dementia, they can also potentially cause serious side-effects of increased risk of cerebrovascular event and increased risk of death. It is prudent to pursue nonpharmacological measures first, such as behavioural modifications and ensuring good sleep hygiene (such as eliminating daytime napping and shutting off electronics an hour before bedtime). If these interventions are not successful and with clinician awareness of recent guidelines, medications may be suggested.

Antidepressant response rates are usually lower for mild or subsyndromal cases of depression, and higher for depression of a moderate to severe nature. For mild or subsyndromal depressive symptoms, regardless of age, a complete assessment, evaluation of suicide risk, ongoing support and monitoring, psychosocial interventions (e.g., exercise, light therapy, school accommodations for youth or interventions to address loneliness in elder patients), evidence-based psychotherapy approaches (e.g., cognitive behavioural therapy, interpersonal therapy or behavioural activation) and lifestyle modifications should be the first lines of treatment. Although there is evidence for efficacy of antidepressants for mild depression, on balance there are greater risks to the use of antidepressants compared to psychotherapy and lifestyle interventions. This may avoid the side-effects of medication and establish etiological factors important to future assessment and management. Antidepressants may be appropriate in cases of persistent mild depression, where there is a past history of more severe depression, or where other interventions have failed.

Signs and symptoms suggestive of intracranial pathology include headaches, nausea and vomiting, seizure-like activity, and later-age of onset of symptoms. Multiple studies have found that routine neuroimaging in first episode psychoses does not yield findings which alter clinical management in a meaningful way. The risks of radiation exposure and delay in treatment also argue against routine neuroimaging. Although a recent meta-analysis supported the use of MRI for all patients with first episode psychosis, the conclusion is controversial, did not review if clinical signs or symptoms of intracranial pathology were present or not, and based the conclusions on MRI abnormalities in 5.9 per cent of first episode psychosis patients, prompting further neuroimaging or referral to neurology for opinion, rather than changes in the management of the psychosis.

Benzodiazepines, while helpful for short-term relief of anxiety and insomnia, are associated with a variety of side-effects and long-term problems including cognitive and psychomotor impairment as well as abuse and dependence. Benzodiazepines are prescribed in clinical settings to treat patients presenting with symptoms such as agitation, anxiety or difficulty sleeping the achieve rapid relief while longer term treatment strategies are being initiated. A plan for tapering and discontinuing benzodiazepines should be completed and specified early on in treatment planning and should be discussed with the patient. If continuation of benzodiazepines is indicated longer term, beyond the acute phase of treatment, then evidence-based guidelines of the rationale should be consulted and reviewed with the patient, and regular monitoring initiated.

The concurrent management of psychiatric illness and alcohol use disorders requires evaluation of the role alcohol plays as a causative factor for depressive symptoms. Studies have found that response rates to antidepressants are higher when antidepressants are reserved for persistence of symptoms after a period of sobriety lasting from two to four weeks. Additionally, studies have demonstrated remission from depressive symptoms with sobriety in the absence of antidepressant treatment in a significant percentage of cases. Management of comorbid psychiatric illness and substance use disorders including alcohol dependence involves assessment and treatment delivered in a concurrent manner.

Persons with schizophrenia should receive an adequate trial of an antipsychotic at adequate dose in monotherapy, before switching to a trial of a different antipsychotic, also in monotherapy. One of the monotherapy antipsychotic treatment trials should use a long-acting injectable format to ensure non-adherence is not a reason for a lack of treatment response. If a person fails adequate trials at adequate doses of two different antipsychotics, a trial of clozapine thereafter is recommended. If they have a partial response to clozapine, but still have ongoing psychotic symptoms, there may be some evidence for an adjunctive second antipsychotic being prescribed (most data for aripiprazole) with clozapine. If they fail or decline clozapine, there is limited guidance as to what are next best strategies.

Prescription of high-dose antipsychotics (prescription above standard dosing ranges) can involve monotherapy with an antipsychotic, but more frequently is due to the use of a combination of two or more antipsychotics, as they will both primarily block dopamine type 2 receptors. There is little convincing evidence that prescription of antipsychotic doses above standard dosing has any therapeutic advantage in any clinical setting, but there is clear evidence for increased side-effect burden and need for safety monitoring. As such, prescription of high-dose antipsychotics is not recommended unless there is a clear rationale and taken on as a time-limited individual trial with a specific treatment target that includes a plan for regular clinical review and safety monitoring.

A high-dose antipsychotic treatment trial should only be continued if it shows clear evidence of benefit that outweighs any potential tolerability or safety concerns. In general, combination strategies of antipsychotics should only be used if cross-tapering from one monotherapy to another, for a partial response to clozapine, if the person fails clozapine, or if they decline a trial of clozapine and monotherapy is not an option due to medication intolerance.

People with dementia often exhibit challenging behavioural symptoms such as aggression and psychosis. In such instances, antipsychotic medicines may be necessary, but should be prescribed cautiously as they provide limited benefit and can cause serious harm, including premature death. Use of these drugs should be limited in dementia to cases where nonpharmacologic measures have failed, and where the symptoms either cause significant suffering, distress, and/or pose an imminent threat to the patient or others. A thorough assessment that includes identifying and addressing causes of behaviour change can make use of these medications unnecessary. Epidemiological studies suggest that typical (i.e., first generation) antipsychotics (i.e., haloperidol) are associated with at least the same risk of adverse events. This recommendation does not apply to the treatment of delirium or major mental illnesses such as mood disorders or schizophrenia.

Nonpharmacological interventions such as cognitive behavioural therapy and brief behavioural interventions have proven benefit in the management of insomnia in older adults.  Epidemiological studies have shown that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Prescribing or discontinuing sedative-hypnotics in hospital can have substantial impact on long-term use. These potential harms and others such as impaired cognition need to be recognized when considering treatment strategies for insomnia. Use of benzodiazepines should be limited to as short a period as possible, in cases where nonpharmacological therapies have failed, and the symptoms of sleep disturbance cause significant suffering or distress.

Driving is one of the activities with a high carbon footprint. Cars emit an average of 206 g of CO2 per kilometre. To put this in context a mature tree metabolizes about 20 kg of CO2 per year, the equivalent of driving less than 100km. Travel to and from health facilities by patients, visitors and staff accounted for 10 per cent of the UK NHS emissions. Travel is a significant contributor to health care emissions.

In a cross-sectional study of more than 10 million patients and 63 million virtual care visits, virtual care was associated with avoidance of 3.2 billion km of patient travel, 545 to 658 million kg of carbon dioxide emissions, and $569 to $733 million (Canadian [US $465-$599 million]) in expenses for gasoline, parking, or public transit.

There is an increasing volume of literature which shows that mental health care delivered virtually can be as effective as in-person care.

Canadian Psychiatric Association