Integrated e-CBT and intravenous Ketamine for suicidality in treatment-resistant depression: A randomized, Midazolam-controlled clinical trial
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Year: 2021
‍Role: Co-investigator, site lead, e-CBT lead
‍Funding Agency: CIHR
‍Amount: $918,000 ($150,000 allocated to e-CBT lead)
Duration: 3 years

The high prevalence of mental health challenges and disorders in post-secondary and high school students demands accessible and efficacious care. Online psychotherapy and psychoeducation programs have shown promise in mitigating the risk and clinical symptoms of mental health disorders. The study will focus on students enrolled in post-secondary institutions within Kingston, Frontenac, Lennox, and Addington (KFL&A) and Durham Region. In the LOI phase, surveys and focus groups will be conducted with diverse student samples to identify common mental challenges and how to best address them. The findings will then inform the development of online psychoeducation and psychotherapy programs and increase city-wide mental health awareness initiatives.
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Year: 2022
‍Role: This was a team grant and Dr. Alavi is the PI
‍Funding Agency: CIHR
‍Amount: $25,000
Duration: 1 year

Toppling Monuments: Colonial Trauma, Justice, Heritage, and Restorative Healing
‍Year: 2021
‍Role: Collaborator
‍Funding Agency: New Frontiers in Research Fund Exploration
‍Amount: $200,000
‍Duration: 2 years

Delivering e-CBT to address mental health challenges in correctional officers and other public safe personnel
‍Year: 2020
‍Role: Principal Investigator
‍Funding Agency: CIHR Team Grant
‍Amount: $860,000
‍Duration: 3 years

Autonomic modulation training: A biological approach to building resilience and wellness capacity among police exposed to post-traumatic stress injuries
‍Year: 2020
‍Role: Co-investigator
‍Funding Agency: CIHR Team Grant
‍Amount: $990,000
‍Duration: 3years  

Developing and implementing an e-psychotherapy program to address mental health challenges in oncology and palliative care
‍Year: 2020
‍Role: Principal Investigator
‍Funding Agency: Queen’s University, Department of Psychiatry, Internal Grant
‍Amount: $17,000
‍Duration: 2 years

Ketamine infusions combined with e-CBT for treatment of post-traumatic stress disorder Year: 2020
‍Role: Co-principal investigator
‍Funding Agency: Queen’s University Department of Psychiatry, Internal Grant
‍Amount: $17,000
‍Duration: 2 years

Delivering e-CBT to patients with bipolar disorder and residual depressive symptoms  
‍Year: 2020
‍Role: Co-Principal Investigator
‍Funding Agency: Providence Care Hospital Research Innovation Grant
‍Amount: $58,300
‍Duration: 3 years

Online delivery of psychotherapy, tailored to patients' suffering from mental health problems due to COVID-19
‍Year: 2020
‍Role: Principal Investigator
‍Amount: $25,000
‍Duration: 6 months

Delivering online cognitive behavioural therapy (iCBT) to address mental health challenges in correctional officers and other public safe personnel
‍Year: 2019
‍Role: Principal Investigator
‍Amount: $30,000
‍Duration: 1 year

Autonomic Modulation Training: A Biological Approach to Building Resilience and Wellness Capacity Among Police Exposed to Post-Traumatic Stress Injuries
‍Year: 2019
‍Role: Co-Investigator
‍Amount: $30,000
‍Duration: 1 year

A merit-based scholarship through the Ontario Graduate Scholarship (OGS) Program for graduate students.

Canada’s premiere research internship program connecting OPTT with Queen's University. Interns transfer their skills from theory to real-world application, while the companies gain a competitive advantage by accessing high-quality research expertise. The project of focus is on using machine learning to allocate stratified care in an electronic cognitive behavioural therapy program for depression.

Usona Institute provides scholarships to qualified post-graduate students and licensed practitioners engaged in study or professional training within the field of psychedelic sciences.

This award provides special recognition and financial support to students who are pursuing a master’s degree in a health-related field in Canada. Candidates are expected to have an exceptionally high potential for future research achievement and productivity.

Awarded based on academic excellence and/or research achievement to funding-eligible master’s or PhD level students enrolled in Neuroscience Studies.

It is a Mitacs Elevate Postdoctoral Fellowship, from Feb 2020 to Feb 2022, and it is a joint program: Academic supervisor is Dr. Alavi and the partner organization is OPTT Inc.

Background: Over a third of patients with Post-Traumatic Stress Disorder (PTSD) do not respond to current interventions. Ketamine is one potential treatment avenue, although its effects are temporary. Administering ketamine alongside psychotherapy is one potential means of prolonging its effects, however, there are few studies investigating this treatment method to date, and none testing ketamine with internet-based, or, electronic Cognitive Behavioural Therapy (e-CBT). Objectives: The present study is an open label randomized controlled trial assessing the efficacy of a combined treatment of sub-anesthetic IV ketamine in conjunction with e-CBT to treat patients with PTSD. Methods: 20 participants with refractory PTSD recruited from a community clinic will be randomly assigned either to an experimental group (n=10) receiving a combination of ketamine and therapist-administered e-CBT over 14 weeks, or they will be assigned to a waitlist-control group (n=10) at the end of which they will receive the experimental treatment. Both groups will be assessed for symptoms of PTSD and comorbid disorders before treatment, at two midway points, and at the end of the experiment. Results: Symptoms of PTSD for participants in the experimental group are expected to improve significantly more than participants in the waitlist-control group (P=.05) with a large effect size (η2=.14). Conclusions: This would be the first experiment assessing the relationship between e-CBT and ketamine and their combined ability to treat refractory PTSD. If successful, this study will open online/asynchronous therapeutic options to patients with PTSD and will provide new insights into the functional role of glutamate in trauma-related disorders as well as in learning, memory, and fear-extinction.
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Citation:  Philipp-Muller AE, Reshetukha T, Vazquez G, Milev R, Armstrong D, Jagayat J, Alavi N. Combining Ketamine and Internet-Based Cognitive Behavioural Therapy for the Treatment of Post-Traumatic Stress Disorder: Protocol for a Randomized Control Trial. JMIR Res Protoc 2021;0(0). doi: 10.2196/30334

Background: The demand for mental health care, particularly for depression and anxiety, is three times greater in oncology and palliative care patients compared to the general population. This population faces unique barriers making them more susceptible to mental health challenges. Various forms of psychotherapy have been deemed effective in addressing mental health challenges in this population including supportive psychotherapy, cognitive behavioural therapy, problem-based therapy, and mindfulness. However, oncology and palliative care patient's access to traditional face-to-face psychotherapy resources is limited due to compromised immune systems making frequent visits to hospitals dangerous. Additionally, patients can face hospital fatigue from numerous appointments and investigations or may live in remote areas making commutes both physically and financially taxing. The online delivery of psychotherapy is a promising solution to address these accessibility barriers. Moreover, the online delivery of psychotherapy has been proven effective in addressing depression and anxiety in other populations and may be able to be transferred to oncology and palliative care patients. Objective: The study will investigate the feasibility and effectiveness of online delivery of psychotherapy for oncology and palliative care patients with comorbid depression or anxiety. It is hypothesized that this program will be a viable and efficacious treatment modality compared to treatment as usual in addressing depression and anxiety symptoms in this population. Methods: Participants (n = 60) with depression or anxiety will be recruited from oncology and palliative care settings in Kingston, Ontario, Canada. Participants will be randomly allocated to either receive 8 weeks of online psychotherapy plus treatment as usual (treatment arm), or treatment as usual exclusively (control arm). The online psychotherapy program will incorporate cognitive behavioural therapy, mindfulness, and problem-solving skills as well as homework assignments with personalized feedback from a therapist. All online programs will be delivered through a secure online platform specifically designed for the online delivery of psychotherapy. To evaluate treatment efficacy, all participants will complete standardized symptomology questionnaires at baseline, mid-point (week 4), and post-treatment. Results: The study received ethics approval in February 2021 and began recruitment in April 2021. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, there have been 11 (treatment n = 5; control n = 4; drop-out n = 2) participants recruited. Data collection is expected to conclude by December 2021, and data analysis is expected to be completed by January 2022. Linear regression (for continuous outcomes) will be conducted with interpretive qualitative methods. Conclusions: Findings from this study can be incorporated into clinical policy and help develop more accessible mental health treatment options for oncology and palliative care patients. The asynchronous and online delivery of psychotherapy is a more accessible, scalable, and financially feasible treatment that could have major implications on the health care system.

Background: Generalized anxiety disorder (GAD) is an extremely prevalent and debilitating mental health disorder. Currently, the gold standard treatment for GAD is cognitive behavioural therapy (CBT) and/or pharmacotherapy. The most common medications used to treat GAD are selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs). While CBT is a gold standard treatment for GAD, it is costly, time-consuming, and often inaccessible. Fortunately, the electronic delivery of CBT (e-CBT) has emerged as a promising solution to address these barriers. e-CBT has shown to offer comparable results to in-person CBT while improving accessibility for patients and time-efficiency for clinicians. Objective: The following project aims to investigate the treatment efficacy of e-CBT compared to, and in conjunction with pharmacotherapy for GAD. Methods: This study has been designed using a quasi-experimental design to allow patients the freedom to choose which treatment modality they would like to receive. Participants with a diagnosis of GAD will be enrolled in 1 of 3 possible treatment arms: e-CBT, medication, or combination. The e-CBT program will include a 12-week psychotherapy program delivered through the Online Psychotherapy Tool (OPTT), a secure, cloud-based, digital mental health platform. The treatment efficacy of e-CBT will be compared to the treatment efficacy of the medication arm and the combination arm. Conclusions: If e-CBT is shown to either be comparable to medication or that the effects of both treatments are augmented when used in tandem, these findings could have major implications on the mental health care system. e-CBT is a more accessible, and affordable treatment that could increase mental health care capacity by four-folds if proven viable.
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Citation:  Alavi N, Stephenson C, Yang M, Shirazi A, Shao Y, Kumar A, Yee CS, Miller S, Stefatos A, Gholamzadehmir M, Abbaspour M, Patel A, Patel C, Reshetukha T, Omrani M, Groll D. Determining the efficacy of online cognitive behavioural therapy for generalized anxiety disorder compared to pharmaceutical interventions: Research protocol. Journal of Medical Internet Research – Research Protocols. 2021. In-Press.

Background: Borderline personality disorder is a debilitating and prevalent mental health disorder, with often inaccessible treatment options. Electronically delivered dialectical behavioral therapy could be an efficacious and more accessible intervention. Objective: We aimed to evaluate the efficacy of electronic delivery of dialectical behavioral therapy in the treatment of individuals with symptoms of borderline personality disorder. Methods: Study participants diagnosed with borderline personality disorder were offered either an email-based or in-person group format dialectical behavioral therapy skill-building program. During each session, participants were provided with both the material and feedback regarding their previous week's homework. Electronically delivered dialectical behavioral therapy protocol and content were designed to mirror in-person content. Participants were assessed using the Self-Assessment Questionnaire(SAQ) and Difficulties in Emotion Regulation Scale (DERS). Results: There were significant increases in SAQ scores from pre- to post treatment in the electronic delivery group (F1,92=69.32, P<.001) and in-person group (F1,92=60.97, P<.001). There were no significant differences observed between the groups at pre- and post treatment for SAQ scores (F1,92=.05, P=.83).There were significant decreases in DERS scores observed between pre- and post treatment in the electronic delivery group (F1,91=30.15, P<.001) and the in-person group (F1,91=58.18, P<.001). There were no significant differences observed between the groups for DERS scores pre- and post treatment (F1,91=.24,P=.63). There was no significant difference in treatment efficacy observed between the 2 treatment arms (P<.001). Conclusions: Despite the proven efficacy of in-person dialectical behavioral therapy in the treatment of borderline personality disorder, there are barriers to receiving this treatment. With the prevalence of internet access continuing to rise globally, delivering dialectical behavioral therapy with email may provide a more accessible alternative to treatment for individuals with borderline personality disorder without sacrificing the quality of care.

Citation:  Alavi N, Stephenson C, Rivera M. Effectiveness of delivering dialectical behavioural therapy techniques by e-mail in patients with borderline personality disorder. Journal of Medical Internet Research – Mental Health. 2021;8(4):e27308

Background: Major Depressive Disorder (MDD) is a prevalent and debilitating mental health disorder. Among different therapeutic approaches (e.g., medication, psychotherapy), psychotherapy in the form of cognitive behavioural therapy (CBT) is considered the gold standard treatment for MDD. However, while efficacious, CBT is not readily accessible to many patients in need due to hurdles like stigma, long wait times, high cost, the large time commitment for health care providers, and cultural/geographic barriers. Online delivery of CBT (e-CBT) can effectively address many of these accessibility barriers. Objective: This study aims to investigate the efficacy and feasibility of implementing an e-CBT program compared to in-person treatment for MDD. It is hypothesized that the e-CBT program will offer comparable results to the in-person treatment program regarding symptom reduction and quality of life improvement. Methods: This non-randomized control trial intervention will provide e-CBT for MDD through the Online Psychotherapy Tool (OPTT), a secure, cloud-based, digital mental health platform. Participants (age: 18-65 years) will be offered 12 weekly sessions of an e-CBT program tailored to MDD to address their depressive symptoms. Participants (n = 55) will complete pre-designed modules and homework assignments while receiving personalized feedback and asynchronous interaction with a therapist through the platform. Using clinically validated symptomology questionnaires, the efficacy of the e-CBT program will be compared to a group (n = 55) receiving in-person CBT. Questionnaires will be completed at baseline, week 6, week 12, and at a 6-month follow-up. Focus groups will be conducted to investigate personal, cultural, and social factors impacting the accessibility and feasibility of implementing an online psychotherapy clinic from a patient and care provider perspective. Inclusion criteria include diagnosis of MDD, competence to consent to participate, ability to speak and read English, and consistent and reliable access to the internet. Exclusion criteria include active psychosis, acute mania, severe alcohol or substance use disorder, and/or active suicidal or homicidal ideation. Conclusions: The results from this study can provide valuable information used to develop more accessible and scalable mental health interventions with increased care capacity for MDD, without sacrificing the quality of care.
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Citation:  Alavi N, Stephenson C, Yang M, Kumar A, Shao Y, Miller S, Yee CS, Stefatos A, Gholamzadehmir M, Abbaspour Z, Jagayat J, Shirazi A., Omrani M, Patel A, Patel C, Groll D. Feasibility and efficacy of delivering cognitive behaviour therapy through online psychotherapy tool (OPTT) for depression: Protocol and methods. Journal of Medical Internet Research – Research Protocols. 2021. Accepted.

Background: Obsessive-compulsive disorder (OCD) is a debilitating and prevalent anxiety disorder. While the basal ganglia and frontal cortex are the most hypothesized brain regions involved, the exact pathophysiology is unknown. By observing the effects of proven treatments on brain activation levels, the cause of OCD can be better understood. Currently, the gold standard treatment for OCD is cognitive behavioural therapy (CBT) with exposure and response prevention (ERP). However, this is often temporally and geographically inaccessible, time-consuming, and costly. Fortunately, CBT can be effectively delivered using the internet (e-CBT) due to its structured nature thus addressing these barriers. Objective: This study will implement an e-CBT program for OCD and observe its effects on brain activation levels using functional magnetic resonance imaging (fMRI). It is hypothesized that brain activation levels in the basal ganglia and frontal cortex will decrease following treatment. Methods: Individuals with OCD will be offered a 16-week e-CBT program with ERP mirroring in-person CBT content that will be administered through a secure online platform. Efficacy of treatment will be evaluated using clinically validated symptomology questionnaires at baseline, week 8, and post-treatment (week 16). Using fMRI at baseline and post-treatment, brain activation levels will be assessed at resting state, and while exposed to anxiety-inducing images (i.e., dirty dishes if cleanliness is an obsession). The effects of treatment on brain activation levels and the correlation between symptom changes and activation levels will be analyzed. Results: The study received initial ethics approval in December 2020 and participant recruitment began in January 2021. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, there have been 5 participants recruited. Data collection is expected to conclude by January 2022, and data analysis is expected to be completed by February 2022. Conclusions: The findings from this study can further our understanding of the causation of OCD, helping to develop more effective treatments for this disorder.

Citation: Stephenson C, Malakouti N, Nashed JY, Salomons T, Cook DJ, Milev R, Alavi N. Using electronically delivered therapy and brain imaging to understand OCD pathophysiology: Protocol. JMIR – Research Protocols, 2021. doi: 10.2196/30726.

A lack of resources and cultural stigma associated with mental health treatment necessitate the development of innovative and economical individualized treatments. This study evaluated the efficacy of delivering computer-based cognitive behavioral therapy (e-CBT) presented through Microsoft PowerPoint and delivered via email in the treatment of generalized anxiety disorder (GAD) to Iranian patients, as a means of overcoming treatment barriers. Participants (N=80) of Iranian descent were recruited through announcements on psychology websites, Iranian organization websites, weblogs, and in flyers. Participants were randomly assigned to either an e-CBT or a control group. The e-CBT group received 12 weekly modules and homework assignments through email, presented using PowerPoint. The control group received no treatment (individuals in the control group were able to pursue another treatment, but would then be excluded from the study although they could continue with the program). All emails were sent by an attending or resident psychiatrist, who also provided feedback on weekly homework via email. The Beck Anxiety Inventory was used to measure levels of anxiety before study onset and changes in levels of anxiety upon completion of the program at 12 weeks, and at 6-month and 1-year follow-up in both groups. Beck Anxiety Inventory scores were significantly reduced in the group who received PowerPoint e-CBT modules delivered via email, compared with the control group, following 12 weeks of treatment, and the reductions were maintained at both follow-up points. Delivery of PowerPoint e-CBT modules via email was found to be a viable method for delivering CBT to individuals with GAD and a simple method for overcoming language, cultural, and travel barriers to accessing mental health resources. This simplified approach to the individualization and delivery of treatment modules has the potential to improve access to CBT as a treatment option throughout the world.

Citation: Alavi, Nazanin & Hirji, Alyssa. (2020). The Efficacy of PowerPoint-based CBT Delivered Through Email: Breaking the Barriers to Treatment for Generalized Anxiety Disorder. Journal of psychiatric practice. 26. 89-100. 10.1097/PRA.0000000000000455.

Background: The considerable rise of mental health challenges during the COVID-19 pandemic has had detrimental effects on the public health sector and economy. To meet the overwhelming and growing demand for mental health care, innovative approaches must be employed to significantly expand mental health care delivery capacity. Although it is not feasible to increase the number of mental health care providers or hours they work in the short term, improving their time efficiency may be a viable solution. Virtually and digitally delivering psychotherapy, which has been shown to be efficient and clinically effective, might be a good method for addressing this growing demand. Objective: This research protocol aims to evaluate the feasibility and efficacy of using an online, digital, asynchronous care model to treat mental health issues that are started or aggravated by stressors associated with the COVID-19 pandemic. Methods: This nonrandomized controlled trial intervention will be delivered through the OnlinePsychotherapy Tool, a secure, cloud-based, digital mental health platform.Participants will be offered a 9-week electronically delivered cognitive behavioral therapy program that is tailored to address mental health problems in the context of the COVID-19 pandemic. This program will involve weekly self-guided educational material that provides an overview of behavioral skills and weekly homework. Participants (N=80) will receive personalized feedback from and weekly interaction with a therapist throughout the course of the program. The efficacy of the program will be evaluated using clinically validated symptomology questionnaires, which are to be completed by participants at baseline, week 5, and posttreatment. Inclusion criteria includes the capacity to consent; a primary diagnosis of generalized anxiety disorder or major depressive disorder, with symptoms that started or worsened during theCOVID-19 pandemic; the ability to speak and read English; and consistent and reliable access to the internet. Exclusion criteria includes active psychosis, acute mania, severe alcohol or substance use disorder, and active suicidal or homicidal ideation. Conclusions: If proven feasible, this care delivery method could increase care capacity by up to fourfold. The findings from this study can potentially influence clinical practices and policies and increase accessibility to care during the COVID-19 pandemic, without sacrificing the quality of care.
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Citation:  Alavi N, Yang M, Stephenson C, Nikjoo N, Malakouti N, Layzell G, Jagayat J, Shirazi A, Groll D, Omrani M, O’Riordan A, Khalid-Khan S, Freire R, Brietzke E, Gomes FA, Milev R, Soares CN. Using the Online Psychotherapy Tool to address mental health problems in the context of the COVID-19 pandemic: Protocol for an electronically delivered cognitive behavioural therapy program. Journal of Medical Internet Research – Research Protocols. 2020;9(12).

Background: Limited help-seeking behaviours, among adolescents with mental health concerns and many barriers to accessing mental health services, make innovative approaches to administering mental health therapies crucial. Therefore, this study evaluated the efficacy of e-CBT given via PowerPoint slides to treat adolescents with anxiety and/or depression. Method: 15 adolescents referred to an outpatient adolescent psychiatry clinic to treat a primary DSM-IV diagnosis of anxiety and/or depression chose between 8 weeks of e-CBT (n=7) or 7 weeks of live CBT (n=8). The e-CBT modules were presented using PowerPoint delivered weekly through email by either a senior psychiatry resident or an attending physician. Within each session, participants in both groups had personalized feedback on their mandatory weekly homework assignment from the previous week's module. BYIs were completed before treatment and and after final treatment within both groups to assess changes in depression, anxiety, anger, disruption, and self-concept. Findings: Before treatment, BYI scores did not sig. differ between groups. After treatment, e-CBT participants reported sig. improved depression, anger, anxiety, and self-concept BYI scores while live CBT participants did not report any sig. changes. Only the Beck Anxiety Inventory sig. differed between groups after CBT. Conclusion: Despite the low sample size within this study, using email to deliver e-CBT PowerPoint slides and individualized homework feedback shows promise as an alternate method of CBT delivery that reduces barriers to receiving mental health treatment that occur internationally.

Citation: Alavi, Nazanin & Stefanoff, Matthew & Hirji, Alyssa & Khalid-Khan, Sarosh. (2018). Cognitive Behavioural Therapy through PowerPoint: Efficacy in an Adolescent Clinical Population with Depression and Anxiety. International Journal of Pediatrics. 2018. 1-5. 10.1155/2018/1396216.

Objective: To determine the efficacy of two interventions on suicide risk assessment within emergency departments (EDs) on improving the documentation of suicide risk factors by emergency medicine and psychiatric physicians during suicide risk assessment. Method: An educational intervention on suicide was provided to all emergency medicine and psychiatry physicians and was followed by the placement of a suicide risk assessment prompt within local EDs. The medical charts of all ED patients presenting with suicidal ideation or behaviours were reviewed immediately and six months after the interventions and compared to pre-intervention. Differences in the documentation of 40 biopsychosocial suicide risk factors between specialties and after the interventions were determined. Results: The documentation of 34/40 (p ≤ 0.008) and 33/40 (p ≤ 0.009) suicide risk factors was significantly improved by emergency medicine and psychiatry physicians, respectively, after the interventions and maintained six months later. Immediately and six months after the interventions, the documentation of 8/40 (p ≤ 0.041) and 14/40 (p ≤ 0.048) suicide risk factors, respectively, significantly differed between specialties. Conclusion: This suggests that providing a brief educational intervention on suicide to emergency medicine and psychiatry physicians followed by placing a prompt for important, yet commonly undocumented risk factors within the ED is a low-cost and effective intervention for improving documentation of suicide risk assessments within the ED.

Citation: Reshetukha, Taras & Alavi, Nazanin & Prost, Eric & Kirkpatrick, Ryan & Sajid, Saad & Patel, Charmy & Groll, Dianne. (2018). Improving suicide risk assessment in the emergency department through physician education and a suicide risk assessment prompt. General Hospital Psychiatry. 52. 10.1016/j.genhosppsych.2018.03.001.

Objective: Although risk assessment for suicide has been extensively studied, it is still an inexact process. The current study determined how busy emergency clinicians actually assessed and documented suicide risk, while also examining the differences between psychiatric and emergency medicine opinions on the importance of various suicide predictors. Method: Phase 1 of the study involved the administration of a survey on the relative importance of various suicide predictors for the specialties of psychiatry and emergency medicine. In phase 2 of the study, a chart review of psychiatric emergency room patients was conducted to determine the actual documentation rates of the suicide predictors. Results: Several predictors that were deemed to be important, including suicidal plan, intent for suicide, having means available for suicide, and practicing suicide (taking different steps leading up to suicide but not actually attempting suicide), had low documentation rates. Conclusions: Medical specialties have different opinions on the importance of various suicide predictors. Also, some predictors deemed important had low documentation rates. Educational interventions and simple assessment tools may help to increase documentation rates of several suicide predictors in busy clinical settings.


Citation: Alavi, Nazanin & Reshetukha, Taras & Prost, Eric & Antoniak, Kristen & Groll, Dianne. (2017). Assessing Suicide Risk: What is Commonly Missed in the Emergency Room?. Journal of Psychiatric Practice. 23. 82-91. 10.1097/PRA.0000000000000216.

Objective: Increasing numbers of adolescents are visiting emergency departments with suicidal ideation. This study examines the relationship between bullying and suicidal ideation in emergency department settings. Method: A chart review was conducted for all patients under 18 years of age presenting with a mental health complaint to the emergency departments at Kingston General or Hotel Dieu Hospitals in Kingston, Canada, between January 2011 and January 2015. Factors such as age, gender, history of abuse, history of bullying, type and time of bullying, and diagnoses were documented. Results: 77% of the adolescents had experienced bullying, while 68.9% had suicide ideation at presentation. While controlling for age, gender, grade, psychiatric diagnosis, and abuse, a history of bullying was the most significant predictor of suicidal ideation. Individuals in this study who reported cyber bullying were 11.5 times more likely to have suicidal ideation documented on presentation, while individuals reporting verbal bullying were 8.4 times more likely. Conclusions: The prevalence of bullying in adolescent patients presenting to emergency departments is high. The relationship found between suicidal ideation and bullying demonstrates that clinicians should ask questions about bullying as a risk factor for suicide ideation during the assessment of children and adolescents.

Citation: Alavi, Nazanin & Reshetukha, Taras & Prost, Eric & Antoniak, Kristen & Patel, Charmy & Sajid, Saad & Groll, Dianne. (2017). Relationship between Bullying and Suicidal Behaviour in Youth presenting to the Emergency Department. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent. 26. 70-77.

Introduction Suicidal behaviour remains the most common reason for presentation to the emergency rooms. In spite of identifiable risk factors, suicide remains essentially unpredictable by current tools and assessments. Moreover, some factors may not be included consistently in the suicidal risk assessments in the emergency room by either emergency medicine physicians or psychiatrists. Method Step 1 involved the administration of a survey on the importance of suicide predictors for assessment between psychiatry and emergency medicine specialties. In step 2 a chart review of psychiatric emergency room patients in Kingston, Canada was conducted to determine suicide predictor documentation rates. In step 3, based on the result of the first 2 steps a suicide risk assessment tool (Suicide RAP [Risk Assessment Prompt]) was developed and presented to both teams. A second patient chart review was conducted to determine the effectiveness of the educational intervention and suicide RAP in suicide risk assessment. Results Significant differences were found in the rating of importance and the documentation rates of suicide predictors between the two specialties. Several predictors deemed important, have low documentation rates. Thirty of the suicide predictors showed increased rates of documentation after the educational intervention and the presentation of the suicide RAP. Conclusion Though a surfeit of information regarding patient risk factors for suicide is available, clinicians and mental health professionals face difficulties in integrating and applying this information to individuals. Based on the result of this study suicide RAP and educational intervention could be helpful in improving the suicidal risk assessment.

Citation: Alavi, Nazanin & Reshetukha, Taras & Prost, Eric & Kristen, A. & Groll, Dianne. (2017). What is commonly missed in the suicidal risk assessments in the emergency room?. European Psychiatry. 41. S562. 10.1016/j.eurpsy.2017.01.815.

Introduction Psychotherapy is one of the most widely investigated and practiced forms of treatment used in the treatment of different mental health problems. However, there are some barriers in delivering this treatment, including long waiting lists, therapist shortage and lack of access to therapists in remote areas. Therefore, using alternative methods to overcome these barriers seems necessary. Method The division of psychiatry at Queen's university provides different psychotherapy groups for individuals suffering from different kinds of mental health problem. We gave the participants the opportunity to choose online psychotherapy through an online clinic or the live group sessions. All the patients were assessed by different questionnaires for evaluation of the efficacy of the treatment. The online clinic was designed to facilitate the communication between patients and clinicians and the material was delivered in PowerPoint format through the online platform. All user activities were logged for security purposes. Results Statistical analysis showed that this method of delivering psychotherapy significantly reduced patients’ symptoms and also decreased the number of people on the waiting list and increased the amount of compliance in patient's taking part in psychotherapy and number of people who were able to receive psychotherapy. Conclusion Despite the proven short and long-term efficacy of psychotherapy, there are some barriers in delivering this treatment. It is an unequivocal public health needs to overcome these barriers through alternative methods of therapy. With Internet use ever rising, developing an online clinic could be a new way in delivering different kinds of psychotherapy.

Citation: Omrani, M. & Alavi, Nazanin & Rivera, Margo & Khalid-Khan, Sarosh. (2017). Online clinic, a new method of delivering psychotherapy. European Psychiatry. 41. S148. 10.1016/j.eurpsy.2017.01.1997.

Introduction Involuntary hospitalization in those presumed to be mentally ill has been a common practice. Although some patients are hospitalized for aggression, two-thirds of the patients are hospitalized because of the threat they pose to themselves. Although these patients require risk assessment and evaluation for possible presence of mental illness, the question is how much these patients will benefit from involuntary admission and what the long-term outcome would be. Method All patients admitted involuntary to the psychiatric ward in Kingston, Canada, and psychiatrists involved in their care were interviewed to see whether they think the involuntary admission was helpful. All patients were asked to fill-out MacArthur AES to assess their satisfaction with hospitalization. Results Although psychiatrists frequently reported that the admission was justified, only 29 out of 81 patients reported being explained to why they had been admitted involuntarily. Also, there was a significant difference in AES scores between those who were and were not given an explanation for admission. In addition, psychiatrists more often reported that the involuntary admission worsened the therapeutic relationship which was significantly associated with involuntary admission that was not explained to patients. Discussion The results of our study shows that patients admitted involuntarily often feel disappointed with staff and mental health system. It could lead to feeling of hopelessness, frustration and low self-esteem. If explained, some patients who present with risk to self might accept voluntary admissions, that will improve therapeutic alliance with psychiatrists and increase satisfaction from hospitalization. Result of this study could improve the decision making process for involuntary admissions.


Citation: Reshetukha, Taras & Alavi, Nazanin & Prost, Eric & Groll, Dianne & Cardy, Robyn & Mofidi, Naser & Wang, P. & Patel, Charmy & Sajid, Saad. (2017). Outcomes of involuntary hospital admission. Satisfaction with treatment and the effect of involuntary admissions on patients. European Psychiatry. 41. S328-S329. 10.1016/j.eurpsy.2017.02.264.

Objective: The goal of this study was to evaluate the efficacy of weekly email in delivering online cognitive behavioral therapy (CBT) to treat mild to moderately depressed individuals. The effectiveness of the online CBT was measured following treatment and then again at a 6-month follow-up and was compared with outcomes in a waitlist control group. Methods: Participants were recruited through announcements on psychology Web sites, Iranian organization Web sites, and weblogs and flyers. Ninety-three individuals who met inclusion criteria, including a score >18 on the Beck Depression Inventory (BDI), participated in the study, with 47 randomly assigned to the CBT group and 46 to the control group. The CBT group received 10 to 12 sessions of online CBT conducted by a psychiatrist and a psychiatry resident. Following completion of the CBT, a second BDI was sent to participants. Another BDI was then sent to participants 6 months after the completion of treatment. Results: Email-based CBT significantly reduced BDI scores compared with results in a waitlist control group following 10 to 12 weeks of treatment and at 6-month follow-up. Conclusions: Email is a viable method for delivering CBT to individuals when face-to-face interaction is not possible. Limitations and future directions are discussed.

Citation: Alavi, Nazanin & HIRJI, ALYSSA & Sutton, Chloe & Naeem, Farooq. (2016). Online CBT Is Effective in Overcoming Cultural and Language Barriers in Patients With Depression. Journal of Psychiatric Practice. 22. 2-8. 10.1097/PRA.0000000000000119.

Introduction Suicidal behaviour is one of the most common reasons for presentation to the emergency rooms. Bullying is a universal public health concern that affects significant number of adolescents. Many children and adolescents are recurrently involved in school bullying. Research suggests that both bullies and victims are overrepresented amongst those seen by mental health professionals. Objectives Understand the the relationship between bullying and suicidal behaviour, prevalence of different kinds of bullying in patients with mental health problems and prevalence of cyber bullying and it's affect on the victim Aim Increase public awareness on importance of cyber bullying. We feel that many patients won't disclose that they had been or are being cyber bullied because the characteristics are unclear. Method Charts of all patients who visited emergency room from 2011 to 2013 with a mental health complaint were reviewed. Variables understudy were gender, history of bullying, type of bullying (verbal, physical, emotional), DSM-IV-TR diagnosis and outcome following the assessment. Results Our study shows significant association between bullying, and suicidal behaviours, although based on our study, this predictor was not commonly assessed . Conclusion Our study showed that there was a significant link between bullying and future suicidal behaviour which is not commonly assessed. It is important that physicians identify these risk factor while assessing suicidality. Involvement in current cyber bullying was found to be less frequent than other forms of bullying such as verbal and physical. However, significant links were observed between cyber bullying and suicidal behaviour.


Citation: Alavi, Nazanin & Reshetukha, Taras & Prost, Eric. (2015). Bullying Including Cyber Bullying Increases the Risk of Suicidal Behaviour. European Psychiatry. 30. 209. 10.1016/S0924-9338(15)30169-3.

Objective: To examine the prevalence of bullying victimization among adolescents referred for urgent psychiatric consultation, to study the association between bullying victimization and suicidality, and to examine the relation between different types of bullying and suicidality. Method: A retrospective chart review was conducted for all adolescents referred to a hospital-based urgent consultation clinic. Our study sample consisted of adolescents with a history of bullying victimization. The Research Ethics Board of Queen's University provided approval. Data analysis was conducted using SPSS (IBM SPSS Inc, Armonk, NY). Chi-square tests were used for sex, suicidal ideation, history of physical and sexual abuse, and time and type of bullying, and an independent sample t test was used for age. Results: The prevalence of bullying victimization was 48.5% (182 of 375). There was a significant association between being bullied and suicidal ideation (P = 0.01), and between sex and suicidal ideation (P ≤ 0.001). Victims of cyberbullying reported more suicidal ideation than those who experienced physical or verbal bullying (P = 0.04). Conclusions: Bullying victimization, especially cyberbullying, is associated with increased risk of suicidal ideation among adolescents referred for psychiatric risk assessment. The detailed history of the type and duration of bullying experienced by the victims should be considered when conducting a psychiatric risk assessment.


Citation: Alavi, Nazanin & Roberts, Nasreen & Sutton, Chloe & Axas, Nicholas & Repetti, Leanne. (2015). Bullying Victimization (Being Bullied) Among Adolescents Referred for Urgent Psychiatric Consultation: Prevalence and Association With Suicidality. Canadian Journal of Psychiatry. 60. 427-431. 10.1177/070674371506001003.

Introduction Depression is the most prevalent mental health condition with high morbidity and mortality. rTMS is an alternative treatment of acute depression validated in controlled trials. rTMS was approved by FDA for treatment of unipolar non-psychotic depression in patients who have failed one adequate antidepressant trial (Lisanby, 2009). Maintenance application of rTMS in depression remains under – researched. Objectives To investigate published evidence of maintenance rTMS in unipolar and bipolar depression. Methods Systematic review of maintenance rTMS studies in unipolar and bipolar depression was conducted. An electronic search was carried out including The Cochrane Library, MEDLINE (1988-2014), EMBASE (1974-2014), and Psych Lit (1980-2014). References of selected articles were searched manually. English-language case reports, case series, cohort studies and controlled trials were selected. Studies reporting maintenance rTMS equal or less then 3 month were excluded. Results 8 case reports, 5 case series, 1 retrospective cohort study and 4 prospective open-label studies were critically appraised. No RCTs were available. Most patients reported had prolonged treatment-resistant depression. Considerable heterogeneity in maintenance rTMS frequency and parameters was observed. All studies reported short-term prolongation of remission period or preservation of acute treatment gains. Few rTMS studies reported longer-term maintenance treatment. Conclusions rTMS appears to be a viable well-tolerated option for maintenance treatment of unipolar and bipolar depression either as monotherapy or as an adjunct to maintenance pharmacotherapy. Absence of consistent stimulation parameters makes it difficult to discuss rTMS relapse prevention effectiveness in systematic way. Large sample long-term sham control studies are needed.


Citation: Reshetukha, Taras & Alavi, Nazanin & Milev, Roumen. (2015). Maintenance Repetitive Transcranial Magnetic Stimulation (RTMS) in Relapse Prevention of Depression. European Psychiatry. 30. 836. 10.1016/S0924-9338(15)30652-0.

Citation: Khalid-Khan, Sarosh & Alavi, Nazanin & Odejayi, Gbolahan & Arachna, P. & Choi, E.. (2014). EPA-0917 - Multifamily psychoeducation groups: comparing email psychoeducation to live groups. European Psychiatry. 29. 1. 10.1016/S0924-9338(14)78242-2.

Abstract Objectives: a) To study the characteristics of children referred to day treatment for Pervasive Developmental Disorders (PDD). b) To study association between outcome and the variables understudy. Method: This was a retrospective chart review of all children and adolescents with PDD, who attended a hospital based Day treatment program. Demographic data and variables such as type of community classroom they came from, Length of Stay (LOS), full scale IQ scores, DSM-IV Diagnosis and type of placement at discharge were extracted. Descriptive statistic was used for categorical data and multinomial logistic regression was used for association between outcome and variables understudy. Results: There was an association between gender and outcome, females had better outcome than males. 2/3 of the patients with and without comorbidities had a significant reduction in behavioral symptoms allowing successful reintegration into community schools. Conclusions: A proportion of children with Autistic Spectrum Disorder (ASD) present with severe emotional and behavioral dysregulation which are unmanageable. These children have multiple comorbidities and require more intensive longitudinal assessment by a skilled multidisciplinary team and specific evidence -based interventions to enable them to return to community school. Intensive Day treatment in a therapeutic classroom by skilled multidisciplinary staff reduces the impairing behaviors and allows families and schools to better manage these children.


Citation: Alavi, Nazanin & Roberts, Nasreen & deGrace, Elizabeth. (2013). Outcome Study of Intensive Day treatment for Children with Pervasive Developmental Disorders.. Autism-Open Access.

Theoretical models attempting to explain why approximately twice as many women as men suffer from depression often involve the role of stressful life events. However, detailed empirical evidence regarding gender differences in rates of life events that precede onset of depression is lacking, due in part to the common use of checklist assessments of stress that have been shown to possess poor validity. The present study reports on a combined sample of 375 individuals drawn from 4 studies in which all participants were diagnosed with major depressive disorder and assessed with the Life Events and Difficulties Schedule (Bifulco et al., 1989), a state-of-the-art contextual interview and life stress rating system. Women reported significantly more severe and nonsevere, independent and dependent, and other-focused and subject-focused life events prior to onset of depression than did men. Further, these relations were significantly moderated by age, such that gender differences in rates of most types of events were found primarily in young adulthood. These results are discussed in term of their implications for understanding the etiological role of stressful life events in depression.

Citation: Harkness, Kate & Alavi, Nazanin & Monroe, Scott & Slavich, George & Gotlib, Ian & Bagby, R.. (2010). Gender Differences in Life Events Prior to Onset of Major Depressive Disorder: The Moderating Effect of Age. Journal of abnormal psychology. 119. 791-803. 10.1037/a0020629.