Projects

Principal Investigator: Dr. Ayal Schaffer

Bipolar disorder (BD) is a lifelong condition characterized by recurrent episodes of depression and (hypo) mania. Periods of chronic and recurring depressive episodes are more common and can be severely disabling. Effective treatments exist; however, a significant portion of bipolar depressed patients do not respond to or have difficulty tolerating many of these interventions and thus look beyond established treatments to achieve symptom relief.

Cannabidiol (CBD), a chemical from the cannabis sativa plant has shown to have some beneficial effects on mood symptoms in a few small studies which assessed its effects in other mental and physical health conditions, but no large studies have been conducted to assess the safety and efficacy in bipolar depression. Additionally, several clinical studies have shown CBD to be safe and tolerable.

The primary objective of this study is to assess the effectiveness, safety and tolerability of adding on cannabidiol in patients with bipolar depression (BD I or BD II) who have not responded to adequate trials with at least one first-line treatment for bipolar depression in comparison to those who will have an add-on placebo in addition to their usual mood stabilizer and/or atypical antipsychotic treatment. Placebo is an inactive substance that looks identical to the study medication but contains no therapeutic ingredient. This study is a randomized (like the flip of a coin), double-blind (you and the study team will not know which treatment arm you receive) study in which participants will receive either CBD or placebo added to their current treatment. Participants will have 5 clinical appointments and a phone appointment over a period of 10 weeks.

Principal Investigators: Dr. Ayal Schaffer & Dr. Mark Sinyor

Our group has a strong track record of studies conducted using data from the Office of the Chief Coroner of Ontario. Our goal is to identify individual-level factors implicated in suicide that could lead to actionable prevention strategies. Our ongoing research, which we call the Toronto Analysis of Suicide for Knowledge and Prevention (TASK-P) study, involves detailed data collection from what is now >5,000 suicide deaths in Toronto. To our knowledge, this is the largest chart review of suicide deaths ever conducted. Since 2014, we have published more than 30 scholarly articles from this data in journals including the CMAJ, British Journal of Psychiatry, and World Psychiatry that advance our knowledge of suicide and have led to public policy and prevention recommendations for many groups including people suffering from depression with cardiovascular disease, bipolar disorder, schizophrenia, as well as youth, older adults, and homeless people. This work is ongoing.

Principal Investigators: Dr. Rachel Mitchell, Dr. Mark Sinyor

In North America, the rate of suicide among youth aged 10 to 19 has been steadily rising for over a decade. In parallel, emergency department (ED) visits for self-harm (SH) have increased dramatically over the same time period. Risk of suicide is substantially elevated among youth who present to the ED with SH. Yet suicide is rare, even among high-risk groups, and the predictive value of aggregative scales and models is limited and impractical in clinical settings. Rapid risk stratification based on method of SH presentation in youth, and other objective factors such as age and sex, can readily complement the clinical assessment and guide decision-making in the ED.

SH by cutting or poisoning accounts for >90% of non-fatal SH presentations to the ED in youth. To date, no studies have differentiated the subsequent risk of suicide based on the method of first presentation SH by cutting vs. poisoning. Moreover, little is known about the longitudinal course of repeated non-fatal SH after the first presentation of SH, or how the trajectories relate to method of first presentation SH or to risk of suicide.

In this population-based cohort study, we leverage almost 20 years of linked administrative health data of Ontario youth (i.e. age 10-19) to compare the risk of suicide between individuals with a first presentation of self-harm to an ED by cutting vs. poisoning. Further, this study examines the ~1500 ED visits for non-fatal SH per year among youth in Ontario to determine whether cutting and poisoning are associated with differential longitudinal trajectories of repeated SH after first presentation. As part of our secondary aim, we are also building latent trajectories of repeated SH presentation to the ED. Findings from this study will guide the development of targeted tertiary suicide prevention strategies and enable resource-efficient allocation of services to youth most at risk.

Project Lead: Ms. Jasmine Amini

Suicide is a tragically common outcome of bipolar disorder (BD), with approximately 15-20% of diagnosed individuals dying by suicide. Compared to the general population, the annual risk of death by suicide is 10-30x higher in BD. Even amongst psychiatric populations, BD exhibits the highest risk of suicide and one of the highest death rates, second only to schizophrenia.

The suicide literature has consistently demonstrated differences in suicide rates by sex across the lifespan. Within high income countries, rates of male suicide are significantly higher than rates of female suicide, at all ages. Preliminary evidence of sex differences in suicide rates within the BD population suggests, however, that females are more at risk for suicide than males. Unlike non-BD populations, females with BD exhibit a suicide standardized mortality ratio that is higher compared to males. Notably, this sex difference in suicide standardized mortality ratio is not found in the general population, or within other mood disorders.

To date, few studies have explored sex-specific suicide risk factors within BD populations. Determining sex-specific clinical phenotypes of suicide risk in BD is essential to identifying those at an elevated risk for suicide. Further, by determining such differences, future research can investigate when, why, and how these sex differences appear within the context of BD suicide, as compared to other populations high-risk for suicide. This retrospective cohort study explores sex- and BD-specific correlates of suicide using data of all suicide deaths occurring within the city of Toronto between 1998 and 2020.

Principal Investigator: Dr. Mark Sinyor

Media plays a crucial role in both suicide contagion and prevention. Our lab has conducted some of the largest studies to date examining the impact of traditional print and online media as well as social media on suicide deaths. We have demonstrated that media reports about celebrity suicide, several specific suicide methods and reports that emphasized the inevitability of suicide are associated with increased subsequent suicides in Toronto whereas stories of hope and survival appear to have the opposite effect. Our group has organized Canada’s first public forums on suicide and the media including international experts. Our ongoing studies have more recently focused on overarching narratives of stories in the media and their association with subsequent suicides. We are also actively studying the impact of efforts to improve media reporting and suicide-related discourse in Canada and beyond.

AFP Study Principal Investigators: Dr. Rachel Mitchell, Dr. Mark Sinyor
Thematic Analysis: Gillian Grant-Allen, Joy Wang

By virtue of their developmental stage, adolescents are impressionable, prone to peer influence and social learning, and amongst the groups at highest risk for suicide contagion. Social media plays an important role in self-harm and suicide contagion as harmful content can be easily disseminated. Self-harm, (defined as intentional, non-fatal self-injury or self-poisoning, irrespective of degree of suicidal intent) is highly prevalent among youth (~15-20%)5, and especially influenced by social media. As self-harm is a robust predictor of death by suicide in youth, developing primary and tertiary suicide prevention strategies that maximize the benefits and minimize the harms of social media use is a public health priority. TikTok is the fastest growing social media app among teens. A video-based app that boasts over one billion members, 93% of TikTok users are aged 13 to 34. Mental health content is incredibly popular on the app. TikTok hosts a plethora of poorly constructed mental health content that has potential to cause harm, such as diagnostic misinformation and graphically triggering self-harm and suicide-related material. Although the platform explicitly bans the glorification of self-harm and suicide, users easily circumvent these guidelines.

Our team is conducting multiple projects that assess the scope of suicide and self-harm related content on TikTok, and its impact on the mental health of youth users. The first in this series, a thematic analysis of suicide and self-harm content on TikTok, surveyed popular suicide and self-harm related hashtags to determine the tone, valence, and subject matter of relevant videos. Preliminary results revealed a number of concerning trends, such as the use of euphemistic language to circumvent community guidelines and community identifiers.

In addition, we are also running a cross-sectional mixed-methods study directly exploring the connections between TikTok use and its impact on mental health. In the quantitative phase, youth seeking care from the departments of Family Practice and Psychiatry will complete a set of questionnaires evaluating TikTok use and mental health symptoms. In the qualitative phase, youth seeking acute psychiatric care will engage with one-on-one interviews discussing the impact of TikTok use on mental health.

Principal Investigator: Dr. Mark Sinyor
Project lead: Ms. Prudence Chan

The MyOwl project is a mental health research initiative focused on improving wellbeing in youth. Specifically, it is a 3-month teacher-delivered curriculum imparting cognitive behavioural therapy (CBT) skills to middle schoolers while reading Harry Potter and the Prisoner of Azkaban in English class. Detailed information of the curriculum, including its student and teacher manual can be found on: https://www.myowl.org/. The goal of the study is to:

• Determine whether the Harry Potter-based curriculum diminishes suicidality (ideation and attempts) in students who receive it
• Determine whether the Harry Potter-based curriculum decreases depression and anxiety symptoms and improves wellbeing longitudinally (immediately after the curriculum and at the beginning of the next school year)
• Determine the teacher and student satisfaction with the Harry Potter-based mental health curriculum

This intervention was first piloted in a rural Catholic school board in Eastern Ontario and was deemed feasible. A composite measure of suicidal ideation, attempts, and self-harm scores was reduced by nearly half. Another randomized control trial found significant improvement in suicidality, emotional regulation, self-concept, interpersonal difficulties, depression and anxiety in youth, particularly in girls following this intervention. Our group is currently trying to replicate these studies in larger samples globally to confirm these results. The study runs across Canadian provinces, with plans to expand internationally to Hong Kong, Australia, Israel and more. If you are a teacher, school principal or school board interested in participating in the myowl study, you can email us at myowl@sunnybrook.ca.

Principal Investigator: Dr. Mark Sinyor

Partnerships for life or Alianzas por la vida is an international initiative proposed by the International Association for Suicide Prevention (IASP) and the World Health Organization (WHO). This project specifically aims to analyse, assess, develop, and evaluate national suicide prevention strategies in regions that belong to the Americas. To achieve this, the project has the following as main goals, including those proposed by the IASP:

• To share experience in, and/or knowledge and learning about, suicide prevention strategies between countries within each region.

• To facilitate spaces that encourage equal participation of regions in the strengthening and/or construction of suicide prevention strategies and initiatives.

• To support the development of a strategic, cross-sectoral and evidence-informed approach to suicide prevention in countries within each region.

• To support collaboration, coordination and mutual support with respect to the development, implementation and evaluation of suicide prevention strategies between countries within each region and between regions.

• To promote learning and provide mentorship between countries with established suicide prevention strategies and countries which are at an earlier stage of suicide prevention strategy development.

• To raise global awareness about the importance and potential positive impact of a comprehensive, national strategic approach to suicide prevention.

The project looks to establish meaningful connections with professionals and organizations that work within the suicide prevention field. We have been able to establish connections with over 120 partners in more than 25 different countries and counting. Partners or Aliados will be invited to participate in different workshops, webinars, seminars, and informative sessions with the purpose of leverage international collaboration and support. There are no fees associated with the affiliation to this initiative and participation is voluntary. This project offers support in both English and Spanish. For more information regarding enrollment and additional questions, please connect with us through email:

• Dr. Mark Sinyor (Principal coordinator - English base contact): mark.sinyor@sunnybrook.ca
• Daniel Sanchez Morales (Project Coordinator - Spanish/English base contact): daniel.sanchezmorales@sri.utoronto.ca

Principal Investigators: Dr. Rosalie Steinberg and Dr. Ayal Schaffer

The time-period after discharge from psychiatric hospitalization is associated with an increased risk for suicide. Individuals may experience worsening of symptoms as they return to their stressors at home, as well as as adjusting to reduced contact with caring health care providers. Caring Contacts is a simple, cost-effective psychosocial intervention that can help to maintain levels of care post-discharge through sending brief communications of hope and support. Pilot data from the first Canadian RCT of Caring Contacts carried out at Sunnybrook in 2021 demonstrated that patients who received an automated Caring Contact email had an attenuated worsening of mood symptoms and suicidal ideation compared to a control group.

Building on our RCT, this 3-phase quality improvement project used an implementation science approach to adapt and improve Caring Contacts messages. In phase 1, community members and inpatients participated in focus groups to discuss how Caring Contacts messages could be improved. Updates were made to the content and tone of initial messages which previously emphasized crisis intervention and stabilization (e.g. addition of recovery and wellness focused resources with direct links to peer supports), appearance (e.g. colour-set, font, images), and logistics (e.g. timing within first 30 days, number of emails). Members of the Department of Psychiatry’s Patient Family Advisory Committee helped to guide the development of prototype messages in phase 2. Selected messages were then piloted in phase 3 among individuals who received the revised Caring Contact shortly after their discharge from the inpatient unit. Participants received Caring Contacts messages on days 2 and 7 post-discharge and completed mental health symptom measures at baseline (e.g. 1-3 days prior to discharge) and day 7 post-discharge. Although the phase 3 sample size was too small to detect statistical differences on mental health measures, feedback indicated that Caring Contacts messages were positively received by participants and helped increase hopefulness and willingness to engage in help-seeking behaviours if needed.

In both phases 1 and 3 of this study, feedback forms consistently demonstrated a desire for an increased level of personalization in Caring Contacts messages. The current Caring Contacts program is designed to send generic, automated messages in order to provide support to patients post-discharge without increasing burden on care staff to craft these messages. To address these concerns without increasing demands on clinical staff time, the Caring Contacts team is currently collaborating with an artificial intelligence (AI) research group based at Sunnybrook to assess the feasibility of using a natural language processing model (NLPM) to generate personalized Caring Contacts messages. This forthcoming study will employ an AI model to create sample personalized Caring Contacts messages. Community members will then be asked to assess and compare AI-generated messages to messages written by a clinician or clinical care team member. Results from this study will evaluate the feasibility of using an AI platform as well as the acceptability of using AI models to craft personalized Caring Contacts messages with the end goal of improving the Caring Contacts program and enhancing patient outcomes post-discharge.

Since the discovery of lithium as an effective treatment for mania in 1949, it has become an established first-line treatment with level 1 evidence for acute mania, bipolar depression and maintenance treatment in adults with bipolar disorder. This substantial body of work has also been the foundation for treatment recommendations for use of lithium in paediatric bipolar disorder (PBD) (age ≤18 years) due to comparatively limited data in this population. For bipolar depression in PBD, there are no controlled trials of lithium, and although a positive open trial is promising, the first-line treatment recommendations for lithium are based largely on expert clinical experience and extrapolation from the adult literature.

Patients with PBD may be on lithium for many decades. One of the most challenging and yet important decision points in the course of PBD is evaluating the risk- versus benefit- of long-term lithium use prior to initiation. There are numerous other clinical scenarios involving lithium for PBD, across all phases of illness, where there is limited to no evidence to inform similarly important decisions. Missed opportunities as well as preventable morbidity may persist due to lack of data on lithium in PBD.

This series of three studies seeks to summarize the literature and gather expert opinion on the use of lithium in PBD, with the ultimate goal of developing more stringent guidelines for its use in child and adolescent populations.

Principal Investigators: Dr. Rachel Mitchell, Dr. Simina Toma, Dr. Charlotte Moore-Hepburn

The promise of long-term use of lithium for PBD is diminished by the association with renal impact such as nephrogenic diabetes insipidus (20-40%) and less commonly, chronic interstitial nephritis (15-20%). Other side-effects such as thyroid abnormalities, gastrointestinal upset, acne, weight gain, tremor, and toxicity can occur at any point in treatment. These risks must be carefully considered as part of a risk-benefit discussion at every decision point for all patients initiating, continuing or discontinuing lithium. Lithium also has a narrow therapeutic window and requires careful monitoring for toxicity.

The incidence of adverse events associated with lithium use is relatively common, however prevalence estimates are crude and not PBD-specific. Understanding the relative prevalence of lithium-related adverse events among PBD populations is necessary to develop guidelines for lithium use with PBD patients. This study will survey pediatricians and pediatric subspecialists from across Canada on clinical experiences of lithium-related adverse events, with an emphasis on recording the types of adverse events observed and clinical outcomes.

Principal Investigators: Dr. Rachel Mitchell, Dr. Simina Toma

Since its establishment as a treatment agent for BD in 1949, a rich research literature has formed, exploring the physiological and pharmokinetic parameters for lithium use, as well as its safety and efficacy, among adult populations. Results from these studies have informed the creation of rigorous guidelines for the safe use of lithium in the treatment of bipolar disorder among adults.

In contrast, the literature supporting the use of lithium in PBD is much more limited. Given their age, there may be specific physiological or developmental considerations that should be accounted for in the formation of guidelines for lithium use in PBD. This narrative review aims to summarize studies documenting the pharmacodynamics of lithium use in children/adolescents, and considers these results in the context of renal and thyroid organ development. Further, this review will compare studies of lithium’s efficacy, pharmacokinetics, and dosing paradigms between adult and child/adolescent populations.

Principal Investigators: Dr. Rachel Mitchell, Dr. Simina Toma

The primary aim of this study is to use the Delphi Method to conduct a survey of international experts on the safe and effective use of lithium for the treatment of PBD in all phases of illness. Given the paediatric-specificity of the organs affected by lithium (eg. kidney, thyroid), the secondary aim is to seek guidance from paediatric subspecialists on the physiological parameters integral to the safe use of lithium for PBD, to supplement the Delphi Survey of PBD experts. Finally, the inclusion of youth with lived experience of PBD will provide patient insight on critical treatment decision-making.

Principal Investigators: Dr. Rachel Mitchell, Dr. Fiona Moloney

Sex differences in the global prevalence of NSSI in adolescents
Non-suicidal self-injury (NSSI) is a growing public health concern in youth. Rates of NSSI tend to be higher in female youth relative to male youth; however, it is of interest to observe whether this trend differs by geography. This meta-analysis examines sex differences in the global and regional prevalence of non-suicidal self-injury (NSSI) among adolescents, analyzing data across 17 countries and over 260,000 records.

Sex differences in the clinical correlates of NSSI in adolescents
Building on data from meta-analysis of NSSI prevalence among adolescents, this systematic review examines sex differences in the characteristics of NSSI, the clinical and social correlates of NSSI, and associations of NSSI with suicide. When possible, geographical variation on sex differences of NSSI-related correlates were considered.

Principal Investigator: Dr. Rosalie Steinberg

This clinical trial is part of the St. John’s Rehab Research Program. It focuses on using group therapy to improve coping and wellbeing in rehabilitation inpatients recovering from limb loss and major trauma. This project is also focused on designing wellness intervention to promote wellbeing and minimize burnout in frontline clinical staff during COVID-19. Dr. Steinberg won the Best AFP Podium Presentation “Implementing a Novel Wellness Program for Healthcare Workers during COVID19 Pandemic” at the 2022 Clinical Impact Through Innovation Expo at Sunnybrook Health Sciences Centre for this project.

Principal Investigators: Dr. Rosalie Steinberg, Dr. Janet Ellis

This study focused on designing a wellness intervention to promote wellbeing and minimize burnout in frontline clinical staff during COVID-19. Dr. Steinberg and her colleagues won the Best AFP Podium Presentation “Implementing a Novel Wellness Program for Healthcare Workers during COVID19 Pandemic” at the 2022 Clinical Impact Through Innovation Expo at Sunnybrook Health Sciences Centre.