The inter-relationship between depression, medication use and cognitive decline in older persons has potentially important clinical and public health implications, yet research findings on the nature of this relationship remain inconclusive. This thesis presents a systematic investigation into this topic in a sample of 281 medical inpatients aged 65 and over, who were followed for up to 12 months after admission. / In the first three chapters, the concept, population burden and measurement of depression and cognitive function in the elderly population are described. The relevant literature is reviewed, and the rationale and approaches of this thesis are presented. / In the fourth chapter (1st manuscript), the short-term temporal relationship between depression and cognitive functioning was explored using an interviewer-rated depression severity scale. Based on competing mixed effects models under alternative temporal assumptions, the severity of depression symptoms appeared to have a concurrent rather than prospective relationship with cognitive functioning. / In the fifth chapter (2nd manuscript), diagnostic criteria were used to define depression. After adjusting for covariates, both major and minor depression were significantly predictive of subsequent cognitive decline, and the strength of the association appeared to increase with the duration of "exposure". / In the sixth chapter (3rd manuscript), using a provincial prescription database, the effects of medication exposure on cognitive function were evaluated. Antidepressant use was not associated with cognitive decline in general, but interacted with depression diagnoses. In exploratory analyses, antidepressant use appeared to be associated with improved cognitive function over time in the minor depression group, independent of comorbid diseases, current depression symptoms and concomitant medications. Both major and minor depression were independently predictive of subsequent cognitive decline, especially in those not prescribed antidepressants. / In summary, this thesis demonstrates that, in this sample of older medical inpatients, both major and minor depression are independent risk factors for 12-month cognitive decline. The potentially beneficial effects of antidepressants for patients with minor depression should be investigated.

The cognitive regulation of negative emotions using a situational focused strategy require the activation of prefrontal and subcortical structures, in particular the dorsolateral prefrontal cortex (DLPFC) and the amygdala (Amy). These structures present structural and functional abnormalities in bipolar disorder, a psychiatric illness characterised by an abnormal mood regulation. This thesis presents the assessment of physiological responses to a paradigm designed to assess the functioning of the DLPC and the Amy. This paradigm tests the response to stimuli of different valence and assesses the down-regulation of negative emotions. We employed GSR and HR with the goals to determine whether changes occurring at the central nervous system can be recorded at a peripheral level. We also wanted to see if these variations differed between individuals either affected or non-affected by bipolar disorder. Finally, this study assesses the usefulness of the designed paradigm to be used in a future study using functional Magnetic Resonance Imaging. Results show that the recording of Heart Rate (HR) in non-affected individuals allows the detection of the exposure to negative stimuli and that the recording of the Galvanic Skin Response (GSR) is sensitive to detecting the exposure to negative stimuli and as well as the effects of the cognitive regulation of negative emotions. These effects are not observed in the group affected by bipolar disorder who seem to have an attenuated response to the exposure to stimuli of difference valence and to the effects of the cognitive regulation of negative emotions. / La régulation cognitive des émotions négatives avec une concentration sur la stratégie situationnelle demande l'utilisation de structures préfrontales et subcorticales, en particulier celles du cortex préfrontal dorsolateral et de l'amygdale. Ces structures présentent des anomalies structurelles et fonctionnelles dans les troubles bipolaires, maladie qui se caractérise par une anormale régulation de l'humeur. Cette thèse présente l'évaluation des réponses physiologiques à un paradigme désigné à évaluer le fonctionnalisme du cortex préfrontal dorsolateral et de l'amygdale. Ce paradigme évalue les réponses aux stimuli émotionnels visuels ainsi que la réponse à la régulation des émotions négatives. La conductance galvanique de la peau et le rythme cardiaque ont étés employés pour déterminer si les changements qui se présentent au niveau du system nerveux central peuvent être enregistrés au niveau périphérique. De plus, nous sommes intéressés à déterminer si ces changements varient entre les personnes atteintes et non atteintes de trouble bipolaire. Enfin, cette étude vise à étudier si le paradigme employé serait utile pour une étude à venir en imagerie cérébrale avec l'utilisation de résonance magnétique fonctionnelle. Les résultats de cette étude ont démontré que chez les individus non atteint de trouble bipolaire l'enregistrement du rythme cardiaque permet la détection à l'exposition aux stimuli négatifs. Les résultats ont aussi démontré que la conductance de la peau est sensible à détecter l'exposition aux stimuli négatifs ainsi que les effets de la régulation cognitive aux émotions négatives. Ces effets ne sont pas aperçue chez les sujets atteintes de trouble affective bipolaire, lesquels semblent avoir des réponses atténués à l'exposition aux stimuli de différents types émotionnels et à l'effet de la régulation cognitive des émotions négatives.

BACKGROUND Keeping pace with the rapidly evolving demands of infectious disease monitoring requires constant advances in surveillance methodology and infrastructure. A promising new method is syndromic surveillance, where health department staff, assisted by automated data acquisition and statistical alerts, monitor health indicators in near real-time. Several syndromic surveillance systems use diagnoses in administrative databases. However, physician claim diagnoses are not audited, and the effect of diagnostic coding variation on surveillance case definitions is not known. Furthermore, syndromic surveillance systems are limited by high false-positive (FP) rates. Almost no effort has been made to reduce FP rates by improving the positive predictive value (PPV) of surveilled data. OBJECTIVES 1) To evaluate the feasibility of identifying syndrome cases using diagnoses in physician claims. 2) To assess the accuracy of syndrome definitions based on diagnoses in physician claims. 3) To identify physician, patient, encounter and billing characteristics associated with the PPV of syndrome definitions. METHODS & RESULTS STUDY 1: We focused on a subset of diagnoses from a single syndrome (respiratory). We compared cases and non-cases identified from physician claims to medical charts. A convenience sample of 9 Montreal-area family physicians participated. 3,526 visits among 729 patients were abstracted from medical charts and linked to physician claims. The sensitivity and PPV of physician claims for identifying respiratory infections were 0.49, 95%CI (0.45, 0.53) and 0.93, 95%CI (0.91, 0.94). This pilot work demonstrated the feasibility of the proposed method and contributed to planning a full-scale validation of several syndrome definitions. STUDY 2: We focused on 5 syndromes: fever, gastrointestinal, neurological, rash, and respiratory. We selected a random sample of 3,600 physicians practicing in the province of Quebec in 2005-2007, then a stratified random sample of 10 visits per physician from their claims. We obtained chart diagnoses for all sampled visits through double-blinded chart reviews. Sensitivity, specificity, PPV, and negative predictive value (NPV) of syndrome definitions based on diagnoses in physician claims were estimated by comparison to chart review. 1,098 (30.5%) physicians completed the chart review and 10,529 visits were validated. The sensitivity of syndrome definitions ranged from 0.11, 95%CI (0.10, 0.13) for fever to 0.44, 95%CI (0.41, 0.47) for respiratory syndrome. The specificity and NPV were high for all syndromes. The PPV ranged from 0.59, 95%CI (0.55, 0.64) for fever to 0.85, 95%CI (0.83, 0.88) for respiratory syndrome. STUDY 3: We focused on the 4,330 syndrome cases identified from the claims of the 1,098 physicians who participated in study 2. We estimated the association between claim-chart agreement and physician, patient, encounter and billing characteristics using multivariate logistic regression. The likelihood of the medical chart agreeing with the physician claim about the presence of a syndrome was higher when the physician had billed many visits for the same syndrome recently (RR per 10 visits, 1.05; 95%CI, 1.01-1.08), had a lower workload (RR per 10 claims, 0.93; 95%CI, 0.90-0.97), and when the patient was younger (RR per 5 years, 0.96; 95%CI, 0.94-0.97) and less socially deprived (RR most vs least deprived, 0.76; 95%CI, 0.60-0.95). CONCLUSIONS This was the first population-based validation of syndromic surveillance case definitions based on diagnoses in physician claims. We found that the sensitivity of syndrome definitions was low, the PPV was moderate to high, and the specificity and NPV were high. We identified several physician, patient, encounter and billing characteristics associated with the PPV of syndrome definitions, many of which are readily accessible to public health departments and could be used to reduce the FP rate of syndromic surveillance systems. / CONTEXTE La surveillance des maladies infectieuses est un défi en constante évolution et un progrès continu au niveau des méthodes et des infrastructures est nécessaire pour répondre à la demande. Une nouvelle approche est la surveillance syndromique, où le personnel de santé publique, assisté de collecte automatisée de données et d'alertes statistiques, surveille des indicateurs de santé en temps quasi-réel. Plusieurs systèmes de surveillance syndromique s'appuient sur les diagnostics issus de bases de données administratives. Parce que ces codes de diagnostics ne font pas l'objet d'audits, l'effet de variations dans leur codage sur les définitions syndromiques demeure inconnu. OBJECTIFS 1) Évaluer la faisabilité d'identifier des syndromes à partir des diagnostics issus des services facturés par les médecins. 2) Évaluer l'exactitude de définitions syndromiques basées sur les diagnostics issus des services facturés par les médecins.3) Identifier les caractéristiques du médecin, du patient, de la rencontre médecin-patient et du mode de facturation associées au coefficient de prédiction positif (CPP) des définitions syndromiques. MÉTHODES & RÉSULTATS ÉTUDE 1: Cette étude a porté sur un seul syndrome (respiratoire). Nous avons comparés les cas positifs et négatifs identifiés à partir de la facturation, aux dossiers médicaux. Un échantillon de 9 médecins généralistes Montréalais a été utilisé. Les diagnostics de 3 526 visites effectuées par 729 patients ont été extraits des dossiers médicaux, et reliés à la facturation. La sensibilité et le CPP des diagnostics d'infection respiratoire issus de la facturation étaient 0.49 et 0.93. Cette étude de faisabilité a permis la planification d'une validation à grande-échelle de plusieurs définitions syndromiques. ÉTUDE 2: Cette étude a porté sur 5 syndromes: fièvre, gastro-intestinal, neurologique, cutané et respiratoire. Nous avons sélectionné aléatoirement 3600 médecins pratiquant au Québec en 2005-2007 et, parmi tous les services facturés, 10 visites par médecin. Pour chaque visite, le diagnostic du dossier médical a été obtenu grâce à une révision de dossier à double insu. La sensibilité, la spécificité, le CPP et le coefficient prédictif négatif (CPN) des définitions syndromiques basées sur les diagnostics issus de la facturation ont été estimés. 1098 (30.5%) médecins ont participé à l'étude et 10529 visites ont été validées. La sensibilité des définitions syndromiques variait de 0.11 pour la fièvre à 0.44 pour le syndrome respiratoire. La spécificité et le CPN étaient élevés pour tous les syndromes. Le CPP variait de 0.59 pour la fièvre à 0.85 pour le syndrome respiratoire. ÉTUDE 3: Nous avons restreint notre échantillon aux 4330 visites des 1098 médecins de l'étude 2 où le diagnostic de la facturation correspondait à l'un des syndromes. Nous avons utilisé une régression logistique multi-variée afin d'estimer l'association entre l'accord facturation-dossier et les caractéristiques du médecin, du patient, de la rencontre médecin-patient et du mode de facturation. La probabilité que le dossier médical confirme un syndrome présent selon la facturation était plus élevée lorsque le médecin avait facturé plusieurs visites pour le même syndrome récemment, avait une charge de travail moindre, et lorsque le patient était plus jeune et moins défavorisé socialement. CONCLUSIONS Cette étude a été la première validation à grande-échelle de définitions syndromiques basées sur les diagnostics issus des services facturés par les médecins. Nous avons découvert que la sensibilité de ces définitions est faible, le CPP varie de moyen à élevé, et la spécificité et le CPN sont élévés. Nous avons identifiés maintes caractéristiques du médecin, du patient, de la rencontre médecin-patient et du mode de facturation associées au CPP des définitions syndromiques, dont plusieurs sont accessibles aux agences de santé publique et pourraient être utilisées pour améliorer les systèmes de surveillance syndromique.

Background Several studies have shown that the Individual Placement and Support (IPS) model of supported employment is an effective approach to help many people with severe mental illness to find and maintain competitive employment. These studies include a randomized trial conducted in Montreal, Canada. Very few studies, however, have evaluated the cost-effectiveness of IPS compared to traditional services. Objective To evaluate the cost-effectiveness of IPS model compared to usual vocational services, using data from the Montreal trial. Methods A total of 149 unemployed adult with severe mental illness were randomly assigned to receive either IPS or usual vocational services and were followed for 12 months. Costs were estimated from the perspectives of the health and social care system, the government, and the society. Competitive employment hours and wages were taken as measures of effectiveness. A cost-effectiveness analysis was conducted, using the net benefit framework. A sensitivity analysis was carried out to take into account baseline differences of inpatient days between the two groups. Results IPS dominated usual services with significantly better competitive employment outcomes and less average costs, regardless of the economic perspective. IPS is likely to be more cost-effective than usual services even if the decision maker is only willing to pay a small amount of money per unit improvement in employment outcomes. If only clients without inpatient days during the year before the baseline are considered, IPS costs more than usual services but still with significantly better competitive employment outcomes: $155.73 per additional competitive employment hour and $20.12 per additional dollar of competitive employment earnings from the health and social care services perspective. Conclusions In this study, IPS proved cost-effective compared to usual services, although the baseline difference in inpatient days attenuates the strength of this finding. / IntroductionPlusieurs études ont démontré que le modèle de soutien à l'emploi « Individual Placement and Support » (IPS - Placement et soutien individuels) constitue une méthode efficace pour aider un grand nombre de personnes qui ont des troubles graves de santé mentale à obtenir et conserver un emploi régulier. Ces études incluent une étude expérimentale menée à Montréal, Canada. Très peu d'études, toutefois, ont évalué la coût-efficacité de IPS en comparaison avec des services traditionnels. Objectif Évaluer la coût-efficacité du modèle IPS en comparaison avec des services d'insertion socio-professionnelle habituels, en utilisant des données de l'étude montréalaise. Méthodes Au total, 149 adultes sans emploi et ayant des troubles mentaux graves furent répartis de façon aléatoire entre un programme IPS et des services habituels, et suivis pendant 12 mois. Les coûts furent estimés à partir des perspectives du système de santé et de services sociaux, du gouvernement et de la société. L'efficacité a été évaluée au moyen de deux variables: les heures en emploi régulier et les revenus de ces emplois. Une analyse coût-efficacité fut menée, en utilisant le cadre bénéfice net (net benefit framework). Une analyse de sensibilité fut effectuée pour tenir compte de la différence entre les deux groupes entre leurs jours d'hospitalisation au cours de l'année précédant leur entrée dans l'étude. Résultats IPS domine les services habituels avec de bien meilleurs résultats au niveau de l'emploi compétifi et des coûts moyens moindres, qu'importe la perspective économique. IPS semble plus coût-efficace que les services habituels même si le décideur n'est prêt qu'à payer un faible montant pour une amélioration dans les résultats au niveau de l'emploi. Si on ne retient que les clients qui n'avaient aucun jour d'hospitalisation pendant l'année précédant l'entrée dans l'étude, les sujets du groupe IPS coûtent nettement plus cher en moyenne que ceux des services habituels, mais toujours avec des résultats meilleurs au niveau de l'emploi compétitif. Du point de vue du systèeme de santé et services sociaux, les ratios coût-efficacité incrémentaux qui en résultent sont de 155,73 $ par heure d'emploi compétitif additionnelle et 20,12 $ par dollar additionnel de revenus compétitifs. Conclusions Dans cette étude, IPS s'est révélé coût-efficace en comparaison avec les services habituels, quoique la différences entre les groupes au niveau des jours d'hospitalisation à l'entrée atténue la force de cette conclusion.

No description available.

Self-esteem is an important construct in psychiatric disorders. We hypothesize that in patients with first onset of a psychotic disorder, self-esteem will be associated with outcome and it will, in turn, be influenced by early life experiences. Methods: The Self-Esteem Rating Scale, The Parental Bonding Instrument (PBI), the Measure of Parental Style (MOPS) and The Childhood Trauma Questionnaire (CTQ) were administered to individuals with first-episode psychosis. Symptoms and the GAF were assessed at entry to the program and at six months. Results: Self-esteem was positively correlated with the GAF, but not with remission status at six months. Self-esteem was negatively correlated with the PBI Overprotection, MOPS Overcontrol and Abuse subscales, in relation to mothers and also negatively with Emotional Neglect, Emotional Abuse and Sexual Abuse subscales of the CTQ. Conclusion: Self-esteem influences outcome in early psychosis and is in turn, influenced by early life experiences. This may have implications for designing special interventions to improve outcome. / L'estime de soi est un élément important dans le développement de troubles psychiatriques. Nous posons l'hypothèse que chez les patients présentant des signes avant-coureurs de trouble psychotique, l'estime de soi sera associée avec le pronostic et elle sera en retour influencée par les expériences en début de vie.Méthode: L'échelle de mesure de l'estime de soi (The Self-Esteem Rating Scale), la mesure sur l'attachement parental (PBI), l'instrument de mesure sur le style d'attachement (MOPS) et le questionnaire des traumatismes de l'enfance (CTQ) ont été administrés aux individus confrontés à un premier épisode psychotique. Les symptômes et le niveau de fonctionnement global (GAF) ont été évalués à l'entrée du programme et six mois plus tard.Résultats: L'estime de soi était corrélée positivement avec le GAF, mais elle n'était pas corrélée avec le statut de rémission à six mois. L'estime de soi était négativement corrélée avec la surprotection du PBI, les échelles de surcontrôle et d'abus du MOPS, en relation avec les mères. L'estime de soi était aussi négativement corrélée avec les échelles de négligence émotionnelle, d'abus émotionnel et sexuel du CTQ.Conclusion: L'estime de soi influence le pronostic de psychoses précoces et, en retour, elle est influencée par les premières expériences de vie. Ceci pourrait avoir des implications afin de développer des interventions spécialisées améliorant le pronostic.

This research has two objectives. First, mental health problems among refugee children were studied in terms of the intensity and the form of the symptomatology, and in terms of school performance. Second, the characteristics of the refugee process which influence the manifestation of these problems were identified as specific stressors stemming from the pre-migratory and post-migratory experiences of the refugees. / The research was conducted among 156 refugee children, born in Southeast Asia and Central America. The methodology was based on both quantitative and qualitative approaches. / Results indicate that the manifestation of emotional problems and the principal risk and protection factors vary greatly as a function of the ethnic origin of the subjects; this seems to be secondary to the interaction of specific cultural and contextual variables. / This heterogeneity of the refugee children population put into question the strategies put forward by the schools and the health services for the detection and prevention of mental health problems in these children.

The objectives of this research are to assess the impact of prenatal courses on the birthweight of newborns, and on two intermediate variables: cigarette consumption and maternal weight gain during pregnancy. / Ninety-eight per cent (98%) of primiparous women giving birth in one of four Montreal hospitals during the nine-month study period, completed a questionnaire during their postpartum stay in hospital. Medical data on mothers and newborns were extracted from the medical records. / Women who participated in prenatal courses were of higher socioeconomic status than nonparticipants. An analysis of covariance showed that prenatal courses did not affect: the mean birthweight of newborns, the proportion of women who gained less than 20 pounds (9.1 kilos) during pregnancy, and cigarette consumption during the last five months of pregnancy. The results were consistent regardless of the > of the prenatal course which was measured by it duration, content, and trimester of enrolment in the prenatal course. / Prenatal courses did not affect the birthweight of newborns or cigarette consumption during pregnancy in women at higher risk for have low birthweight babies. Although prenatal courses did reduce by half the proportion of these higher risk women who gained less than 20 pounds, the result is of little importance since birthweight was not affected. / From a community health perspective, prenatal courses are not appropriate interventions to increase the mean birthweight of newborns. The apparent effect of prenatal courses on the birthweight of newborns is eliminated after adjusting for confounding variables. It is important to adjust for confounding variables when evaluating prenatal courses. The analysis of co-variance is an appropriate analytic technique to perform this adjustment.

The objective of this research was to study the relationship between stillbirth and chemical exposure of pregnant workers. / A case control study was conducted among women working in three sectors: Health, Personal services and Agriculture, and Manufacturing industries. Two hundred and twenty-seven (227) stillbirths aged 20 weeks of gestation or more, were matched to two hundred and twenty-seven (227) livebirths, for mother's age, gravidity and socio-economic status. Chemicals were divided into ten (10) groups. Exposure was assessed by visits to the workplaces, telephone calls or extrapolations. Conditional logistic regression analyses were done. / Women working as hairdressers-beauticians$ sp+$ (O.R. 0,01 (0,00-0,34)) and those working in the garment industry* (O.R. 0,24 (0,08-0,77)) had significantly less stillbirths while women working in metal-electrical-chemical industries* (O.R. 5,11 (0,99-26,37)) had a significant excess of stillbirth. Exposure to pesticides/germicides, irrespective of the level or frequency$ sp+$ (O.R. 2,06 (1,15-3,68)), and occasional exposure to "miscellaneous" chemicals (other chemicals potentially fetotoxic)* (O.R. 12,07 (1,22-119,9)) showed a significant increased risk of stillbirth while exposure to a low level of metals$ sp+$ (O.R. 0,28(0,10-0,83)) showed a significantly lower risk of stillbirth. / Leatherworkers* (O.R. 2,59 (0,47-14,33)), women working in the textile industry$ sp+$ (O.R. 2,55 (0,42-15,41)), agricultural workers* (O.R. 3,88 (0,47-31,88)), women exposed to a moderate (2) level of metals$ sp+$ (O.R. 2,32 (0,59-9,10)) and those exposed to a high (3) level of solvents$ sp+$ (O.R. 2,49 (0,47-13,30)) had a non significant (P $>$ 0,05) increased risk of stillbirth. / The author proposes that ergonomic factors could be a confounder of the association between stillbirth and exposure to pesticides/germicides or metals. A study looking more closely at the association between stillbirth and ergonomic factors is therefore suggested. Because exposure of pregnant workers to elevated levels of chemicals is quite rare, further epidemiological studies should include more subjects. ftn$ sp+$: stillbirths aged 20 weeks of gestation or more. ftn*: stillbirths aged 28 weeks of gestation or more.

A study was conducted to determine the effects of interdisciplinary team care on acute hospitalized stroke patients. After obtaining baseline process and outcome information on 42 stroke victims who received traditional care in a general hospital, 130 stroke patients were stratified and randomly assigned to a Traditional or a Team care group. Assessments by independent evaluators, permitted comparisons between Team and Traditional groups with reference to patient survival, motor and functional abilities. Data obtained from charts and treatment logs allowed the care process across groups to be compared. Results demonstrated that Team and Traditional patients fared similarly in survival and motor performance but Team patients achieved significantly better functional outcomes. As well more Team patients received rehabilitation services and these were provided earlier in the hospital stay. Team input was considered to be a contributing factor in promoting superior functional performance among Team patients.