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Back to Basics; Mood Disorders Margo Rioux PGY2 psychiatry With Thanks to Dr. Primeau, Dr. Petit and Dr. Gray for their slides April 8th, 2016 LMCC Objectives (1) Given a patient with depressed mood or hypomania/mania, the candidate will diagnose the cause, severity and complications, and will initiate an appropriate management plan. The candidate should also pay particular attention to assessment of (suicide) risk and the potential need for urgent care. LMCC Objectives (2) • List and interpret critical clinical findings, including ▫ results of an appropriate history, physical examination and assessment of the patient's mental state; ▫ Collateral information as appropriate ▫ a differential diagnosis based upon differentiation of clinical syndromes presenting with mood dysregulation; ▫ specific risk factors that warrant immediate intervention; • List and interpret appropriate investigations, ▫ including appropriate laboratory investigations (e.g., toxicology screen, thyroid stimulating hormone); • Construct an initial management plan including ▫ ▫ ▫ ▫ an assessment of safety (e.g., suicide risk, risk of harm to others); initiation of appropriate pharmacotherapy, if indicated; appropriate involvement of family and supportive resources; determination as to whether a referral for specialized care is required. LMCC Objectives (3) • • • • • • • Major depressive disorder Bipolar disorder (type I, type II) Persistent depressive disorder (dysthymia) Cyclothymic disorder Normal grief Substance-induced mood disorder Mood disorder secondary to a general medical condition • Adjustment disorder References • CANMAT Guidelines • Caplan et al. Mnemonics in a Mnutshell: 32 aids to psychiatric diagnosis • Stephan Stahl pharmacology • Kaplan & Sadock`s Synopsis • DSM-5 • Toronto Notes Mood Disorders made overly simple Important tips • Must cause clinically significant distress or impairment in function. • Always consider substances or general medical conditions your DDx. • Cognitive Behavioural Therapy is indicated for almost everything • Know the name and starting dose of at least one medication from each class ▫ Ei: Citalopram 10mg Lifetime prevalence • Major Depressive Disorder ▫ Women 10-25% ▫ Men 5-12% • Persistent depressive Disorder ▫ 6% • Bipolar disorder ▫ Type 1: 0.4 – 1.6% ▫ Type 2: 0.5% History Taking (1) • Mood disorders are usually episodic ▫ May lead to opposite state ▫ May lead to partial or full remission • Inquire about current episode and past episodes ▫ Confirms diagnosis ▫ Past Response to treatment ▫ Prognosis History Taking (2) • Substance Use and medication • Family History • ALWAYS ASK ABOUT SAFETY ISSUES ▫ Suicide ▫ Homicide ▫ Risk to physical health Mental Status Examination ▫ Psychomotor retardation, catatonic features ▫ Psychomotor agitation such as fidgeting, moving about, handwringing, nail biting, hair pulling, lip biting ▫ Speech (slow pressured) ▫ Affect Type (depressed euphoric) Lability Range (flat expansive) Reactivity ▫ Thought process (paucity of content flight of ideas) ▫ Thought content (worthlessness, hopelessness, grandiosity, psychotic features, suicidal or homicidal ideation) ▫ Cognition, distractibility ▫ Insight, judgment Physical Examination ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ Vital signs Weight Skin (look for previous suicide attempt) Stigmata of drug and/or alcohol use Thyroid gland Cardiopulmonary GI including liver Neurological exam (pupils) Laboratory Workup • CANMAT = when clinically indicated • Routine screening ▫ ▫ ▫ ▫ ▫ ▫ Complete blood count Thyroid function test Liver function test Electrolytes B12, folates Urinalysis, urine drug screen ▫ ▫ ▫ ▫ Neurological consultation CXR EKG CT-scan • Additional screening Common Medical Conditions Associated With Mood Disorders • Pulmonary disease (COPD, asthma) • Endocrine disorders (Hypo/hyperthyroidism, diabetes) • Cancer • Cardiovascular disease, especially MI • CNS (migraine, infection, tumour, stroke, head injury, hypoxia) • Neurological disorders(Epilepsy, Parkinson's, Huntington's, Multiple Sclerosis) • B12, folate deficiency • Chronic pain, back problems • Sleep apnea Drugs Commonly Associated With Mood Disorders • Antidepressant & somatic treatments for depression ▫ Manic “switch” ▫ FDA warning, increased suicidality in adolescents • • • • • • Psychostimulants Steroids, corticosteroids Isotretinoin (Accutane) Oral contraceptives, progesterone Interferon A Parkinson’s Disease agents (mostly psychotic symptoms) Specific Mood Disorders Major Depressive Disorder (1) • Mean age of onset = 30 years • 50% of all patients have an onset between the ages 20-50 • At least 1 Major Depressive Episode • Not better accounted by another disorder, medical condition or substance • No Manic, Hypomanic or Mixed episode Major Depressive Episode (2) • 5 or more for 2 weeks nearly every day: ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ Mood depressed* Sleep ↑↓ Interest ↓, libido ↓, social withdrawal* Guilt, hopelessness, worthlessness Energy ↓ Concentration ↓, indecisiveness Appetite↑↓, weight ↑↓, loss of taste for food Psychomotor ↑↓ Suicidal ideation, recurrent thoughts about death Major Depressive Episode (3) • Many patients with depression do not report feeling depressed, but will have loss of interest • Elderly patients often have new onset of somatic complaints but may deny feeling depressed • Patients can also present with panic attacks or obsessivecompulsive symptoms • Physical symptoms (sleep, appetite, energy level, psychomotor activity) are often referred to as “vegetative symptoms” ▫ New onset of these symptoms can be a good predictor to antidepressant response Major Depressive Disorder (4) • Etiology ▫ Genetics (65-75% monozygotic twins) ▫ Neurotransmitter dysfunction ▫ Psychosocial Low self-esteem Negative thinking Environmental ex: acute stressor Co-morbid psychiatric disorders ex: substance use Major Depressive Disorder (5) • Risk factors ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ ▫ Female > Male Age (20-50 years old) Rural > urban areas Positive family history Childhood experiences (loss of parent before age 11, abuse) Personality structure Recent stressors ex: loss of spouse, unemployed Postpartum Lack of support network Major Depressive Disorder (6) • Treatment ▫ ▫ ▫ ▫ Pharmacotherapy (ie SSRIs, SNRIs…) Electroconvulsive therapy Light therapy if seasonal component Psychotherapy Cognitive behavioral therapy Interpersonal therapy (grief, transitions, interpersonal conflicts or deficits) ▫ Social Vocational rehabilitation Social skills training Major Depressive Disorder (7) • Light to moderate ▫ Psychotherapy, medication depending on patient preference • Moderate to severe ▫ Medication with or without psychotherapy, electroconvulsive therapy (ECT) • Depression with psychotic features ▫ Combination of antidepressant and antipsychotic, gold standard is ECT Ottawa Depression Algorithm Major Depressive Disorder (8) • Treat until remission is complete • Duration of untreated illness affects future treatment response (untreated depression can last 6-12 months) • Maintain treatment to prevent relapse (at least 6-12 months for a first episode) ▫ 50% recurrence after 1 episode ▫ 75% after 2 episodes ▫ > 90% after 3 episodes Major Depressive Disorder (9) • Up to 15% of patients with Mood Disorders will die by suicide • Prognosis at 1 year ▫ 40% still meet criteria ▫ 20% have partial symptoms ▫ 40% have no mood disorder Particularities of Depression • • • • • • • • With Atypical Features With Melancholic Features With Catatonic Features With Anxious Distress With Psychotic Features With Seasonal Pattern With Postpartum Onset Grief & Bereavement With Atypical Features • Mood reactivity ▫ Mood brightens in response to actual or potential positive events • At least two of ▫ ↑ appetite (carbohydrate cravings), weight gain ▫ Hypersomnia ▫ Leaden paralysis (heavy, leaden feelings in arms or legs) ▫ Long-standing pattern of interpersonal rejection hypersensitivity With Melancholic Features • At least one of ▫ Anhedonia (inability to find pleasure in positive things) ▫ Lack of mood reactivity (mood does not improve with positive events) • At least three of ▫ Distinct quality of depression subjectively different from grief ▫ Depression regularly worse in the morning ▫ Early morning awakening (at least 2 hours) ▫ Marked psychomotor agitation or retardation ▫ Severe anorexia or weight loss ▫ Excessive or inappropriate guilt With Anxious Distress • At least two of ▫ ▫ ▫ ▫ ▫ Feeling keyed up or on tense Feeling unusually restless Difficulty concentrating because of worry Fear that something awful may happen Feeling that individual might lose contr0l With Catatonic Features • At least 3/12 ▫ Decreased motor activity ▫ Decreased engagement ▫ Stupor (No psychomotor response to the environment Catalepsy (Keeps the posture you place them in) Waxy Flexibility (slight even resistance to mvt) Posturing (spontaneous and active maintenance of posture against gravity) Mutism (No verbal response) Negativism (no response to external stimuli) Excessive or Peculiar motor activity Mannerism (odd circumstancial caricature of normal actions) Agitation Grimacing Stereotypy Echolalia Echopraxia With Psychotic Features • Psychosis may be present in 10-15% of patients with a Major Depressive Episode • Associated with worse prognosis • Increase risk of suicide and homicide • Treatment implications ▫ Antidepressant + antipsychotic ▫ Consider ECT With Seasonal Pattern • Regular temporal relationship between onset of Major Depressive Episode and a particular time of year, usually fall or winter • Full remission (or switch to mania) also occurs at a regular time of year, usually spring • In the last 2 years, 2 Major Depressive Episodes have occurred as above with no non-seasonal episode • More seasonal episodes than non seasonal episodes during lifetime of the patient. With Postpartum Onset • 10% of postpartum women • Etiology likely a combination of neuroendocrine alterations and psychosocial adjustments • Onset has to be during pregnancy or within 4 weeks after childbirth (DSM) • Distinguish from the “baby blues” (70%) ▫ During 10 days postpartum, transient, not impairing functioning • Severe ruminations or delusional thoughts about the infant is associated with significantly increased risk of harm to the infant ▫ Command hallucinations to kill the infant ▫ Delusional belief that the infant is possessed Adjustment Disorder (1) • Development of emotional or behavioural symptoms in response to an identifiable stressor (within 3 months) • Clinically significant ▫ Distress (Out of proportion) ▫ Impairment in function • Not meeting criteria for another M.I. • Less than 6 months after end of stressor Adjustment Disorder (2) • Specifier ▫ ▫ ▫ ▫ ▫ Depressed mood Anxiety Mixed anxiety and depressed mood Disturbance of conduct Mixed disturbance of conduct and emotion Grief & Bereavement (1) • Normal grief or bereavement reaction versus Major Depressive Episode • Complicated or pathological grief or bereavement (not in DSM-IV) Grief & Bereavement (2) • DSM-IV = Normal grief reaction can present with depressive symptoms as long as it is < 2 months • Red flags that point towards Depressive Disorder (HIP GOD) ▫ Hallucinations (Other than hearing the voice/seeing the deceased person) ▫ IADL/ADL impairement ▫ Psychomotor retardation ▫ Guilt: Unrelated to the loved ones death ▫ Overwhelming morbid preoccupation with worthlessness ▫ Death: Thought of death (other than wanting to have died with the person. Grief & Bereavement Grief Depression Comes in waves Continuous Preserved self esteem Self Loathing Unlikely to impair function Impairment in function Persistent Depressive Disorder (1) • Female > Male (2-3:1) • Depressed mood for at least 2 years, most days than not • Never without the symptoms for more than 2 months at one time • No Major Depressive Episode is present for the first 2 years • Treatment with psychotherapy ± antidepressants Persistent Depressive Disorder (2) • • • • Hopelessness Energy ↓ Self-esteem ↓ 2 years of depressed, for more days than not (1 year in kids, mood can be irritable) • Sleep ↑↓ • Appetite ↑↓ • Decision-making ↓, concentration ↓ Premenstrual Dysphoric Disorder • In the MAJORITY of menstrual Cycles ▫ 5 sx in week before menses and start to improve within a few days of onset; minimal or absent in week postmenses. ▫ Lability/irritability/depressed/anxiety ▫ Anhedonia/concentration/lethargy/ appetite/sleep/overwhelmed/physical symptoms ▫ Significant distress ▫ Prospective daily ratings Premenstrual Dysphoric Disorder • Lifestyle ▫ Exercise ▫ Decrease ETOH/caffeine ▫ Possible benefits from relaxation and stress reduction • Meds ▫ SSRI: similar or lower dose than MDD Intermittent vs continuous treatment Bipolar Disorder (1) • Bipolar I Disorder = at least 1 Manic or Mixed Episode ▫ Commonly have more Major Depressive Episodes but not required for diagnosis • Bipolar II Disorder = at least 1 Major Depressive Episode & 1 Hypomanic Episode No past Manic or Mixed Episode • Not better accounted by another disorder, a general medical condition, a substance or medication Bipolar Disorder (2) • • • • Male = Female (1:1) Age of onset teens to 20s Average age for first Manic Episode = 32 Family history of a major Mood Disorder in 6065% of patients with Bipolar Disorder • Untreated Manic Episode can last 3 months • Untreated Major Depressive Episode can last 613 months Bipolar Disorder (3) • Pharmacotherapy (Bipolar I) ▫ Acute Manic Episode Lithium, divalproex, olanzapine,risperidone, quetiapine, quetiapine XR, Asenapine, aripiprazole, ziprasidone Taper and discontinue antidepressants ▫ Acute Major Depressive Episode Lithium, lamotrigine, quetiapine, quetiapine XR Combo: Li + SSRI or divalproex or buproprion Divalproex + SSRI or Li or Buproprion Olanz + SSRI Do not use antidepressant as monotherapy ▫ Maintenance treatment Lithium, divalproex, olanzapine, quetiapine, risperidone LAI, aripiprazole (mainly for preventing mania, Lamotrigine (limited in preventing mania) With Rapid Cycling • Can be applied to Bipolar I and II • At least 4 mood episodes in previous 12 months (Major depressive, Manic, Hypomanic or Mixed episodes) • Episode demarcated by either switch to the opposite state or 2 months of partial or full remission between episodes • Rapid cycling diagnosis has treatment implications Cyclothymia • Numerous periods of hypomanic and depressive symptoms for at least 2 years • Never without symptoms for more than 2 months • No Major Depressive, Manic or Mixed episodes • No evidence of psychotic symptoms Back to Basics: Suicide LMCC Objectives Given a patient with suicidal behavior, the candidate will determine the degree of risk and institute appropriate management LMCC Objectives • List and interpret critical clinical findings, including ▫ potential contributing conditions identified through an appropriate history and physical examination; ▫ assessed and quantified risk for suicide, including imminent risk, recent stresses and life events; • List and interpret critical investigations, including ▫ illicit drug and alcohol screen, where appropriate; • Construct an effective initial management plan, including ▫ ensuring the safety of patient at imminent risk for self harm (e.g., urgent hospitalization), including continuous observation while arrangements are being made; ▫ assessing capacity to make decisions if patient demands to leave; ▫ initiating management of underlying problems if the risk for suicide is not imminent (e.g., depression, psycho-social stressor); ▫ maintaining confidentiality while recognizing the benefits of support networks; ▫ referring the patient for specialized care, if necessary. Epidemiology • 1 death every 40 seconds • 1 attempt every 3 seconds • In all countries, 1/3 leading cause of death among 15-34 year olds • 3 men: 1 Women Who Data 2000 Distribution of methods by sex Suicide by age group and sex Suicide as a percentage of all deaths by age group Percentage distribution of method used in suicide by age group Etiology • • • • • • Biochemical Factors Genetics and Family Variables Psychiatric diagnosis Personality Psychosocial Environmental Factors Chronic Medical Illness Etiology- Biochemical Factors • 5HT (serotonin) dysregulation ▫ association between aggression, impulsivity and 5HT dysregulation ▫ relative deficiency of 5HT has been found in CNS of suicide completers ▫ 5HIAA (metabolite of 5HT) is decreased in the CSF of depressed patients and even more decreased in suicide attempters and completers (especially violent suicides) Genetics • Roy and colleagues (1991) • Reviewed the world literature of case reports of twin suicides • Found a much higher concordance for suicide among monozygotic than dizygotic twins (11.3 percent vs. 1.8 percent) Etiology - Genetic and Family Variables • Family history of suicide is a significant risk factor for suicide ▫ ▫ ▫ ▫ identification with/imitation of family member family stress/contagion effect transmission of genetic factors for suicide transmission of genetic factors for psychiatric illness Psychiatric Illness and Suicide • 90% of suicide completers have a major psychiatric illness ▫ 50% to 80% are clinically depressed ▫ 25-50% are substance abusers • BUT it is a small percentage of patients with psychiatric illness who commit suicide • • • • Mood Disorder Schizophrenia Alcohol Dependence Borderline PD • • • • 2 – 8% commit suicide 4 – 5% 5 – 7% 5 – 10% Bostwick, JM. Pankratz VS. 2000; Hor, K, Taylor, M. 2010; Palmer BA, Pankratz VS, Bostwick JM. 2005; Inskip HM, Harris EC, Barraclough B, 1998 ; Oumaya M, Friedman S, Pham A, et al. 2008; Psychiatric Illness and Suicide • Psychiatric diagnosis in completers tends to vary with age • suicide completers <30 years old ▫ substance abuse disorders or antisocial PD ▫ Stressors: separation, rejection, unemployment, legal troubles • suicide completers >30 years old ▫ mood disorders and cognitive disorders ▫ Stressors: illness Personality Traits and Disorders • Important contributory risk factors • antisocial and borderline personality disorders are particularly associated with suicidal behaviour in adults • conduct disorder and borderline traits in adolescent suicides • add depression to any of these -- lethal combination • • • • Decreased social supports Bereavement Separation/divorce Humiliation ▫ interpersonal discord, job loss, impending disciplinary crisis, threat of incarceration • Retirement • Stressful life events Chronic Medical Illness • About 5% of suicide completers have serious physical illness • elevated suicide rates in patients with ▫ ▫ ▫ ▫ ▫ ▫ brain trauma, epilepsy MS, Huntington’s, Parkinson’s AIDS, cancer Cushings, Klinefelter’s syndrome, porphyria Peptic ulcer, cirrhosis (likely related to Etoh) Prostatectomy, hemodialysis • Elevated rates of suicide have been found in patients with diagnoses of ▫ Neurological disorders Seizures, MS, Huntington’s chorea, Brain injury ▫ Cancer ▫ Asthma, bronchitis ▫ CHF ▫ End stage renal disease Druss, B., Pincus, H. 2000; Jurrlink, DN, Herrmann N, Szalai JP, et al. 2004; Kurella, M, Kimmel PL, Young BS, et al. 2005 ;Carrico, A, Johnson, M, Morin, et al., 2007; Berger, D. 1995; ▫ HIV • The first week after a patient's discharge from a psychiatric hospital is of particularly high risk for a suicide (Hunt IM, Kapur N, Webb R, et al. 2009) ▫ 43% of suicides occurred within a month of discharge ▫ 47% of these patients died before their first followup appointment • 40% of those who die by suicide have made a previous attempt (Cavanagh J, Carson A. Sharpe M, et al. 2003) • Of those who make an attempt 7% go on to die by suicide 23% go on to make further attempts 70% make no further attempts (Owens D, Horrocks J, House A. 2002) In children and youth who make a suicide attempt ▫ 25 to 66% will make another attempt (Stewart SE, Manion IG, Davidson S, et al. 2001; Rosewater KM, Burr BH.1998) • Increases risk for suicide • Study of adolescent suicide completers ▫ Were twice as likely to have firearms in the home (Brent DA, Perper JA, Allman CJ, et al, 1991) • Overall, 50.7% of suicide completers use firearms (Karch DL, Dhalberg LL, Patel N, 2007) • Highlights importance of removing access to firearms in the homes of suicidal patients Attempters vs. Completers • Difficult to know exactly how many people attempt suicide ▫ don’t seek help, not reported • estimates are 8 to 10 attempters for each completer • up to 40% or more of attempters have personality disorders Suicide Attempters • • • • • • Female Younger Depression, Alcoholism, Personality D/O Impulsive Low lethality (overdose) High availability of help Suicide Completers • • • • • • • Male Older Depression, Alcoholism, Schizophrenia Careful planning High lethality (firearms) Low availability of help, socially isolated 30% have history of suicide attempts Suicide completers • Approximately 1 in 6 completers leave a suicide note • 50% of people who commit suicide have been seen by a primary care MD within one month prior to their deaths • with older suicide victims, this rises to 70% Risk Factors for Suicide-SADPERSONS scale • • • • • • • • • • Sex (Male) Age (very young or very old) Depression Previous attempt Ethanol abuse Rational thinking loss (psychosis) Social supports lacking Organized plan No spouse Sickness (chronic illness) SADPERSONS Scale • 1 point for each if present • 7-10 points then hospitalize or commit • 5-6 points strongly consider hospitalization, depending on confidence in follow up arrangement • 3-4 points then close follow up, consider hospitalization • 0-2 points send home with follow up Risk Factors • BUT people don’t kill themselves because statistics suggest they should • people kill themselves because of unbearable psychological pain • statistics are good for large populations, but not so good when applied to an individual • patients can have very few risk factors and still decide to kill themselves • Introducing the topic in a sensitive manner ▫ Sometimes when people are feeling down, it can be hard to get up and greet the day – do you ever feel this way? ▫ Do you ever feel like you don’t want to go on living? ▫ Have you ever had thoughts of wanting to end your life? ▫ Can you tell me about these thoughts? ▫ Have you ever thought of a plan to kill yourself? • Degree of hopelessness is more predictive of future suicidal behaviour than severe depression ▫ Do you have hope that things will get better? • Passive ▫ “I wish I could disappear” ▫ “I’d like to go to sleep and not wake up” ▫ “It would be okay with me if I were to be hit by a bus” • Active ▫ “I want to die” ▫ I am going to go and kill myself” • • • • • • Patient felt their attempt would kill them Low chance of being found following attempt Concrete suicidal plans, with access to means A wish to be reunited with a dead loved one Putting affairs in order “Things would be better for everyone if I were dead” • Reluctant to communicate and/or accept help • Lack of social support When to send suicidal patients to the Emergency Department • Acute suicidal ideation ▫ ▫ ▫ ▫ ▫ ▫ With plan and intent With poor social supports With lack of future orientation Use of scales from 1-10 Hopelessness Contracts • Safety Safety Safety • If at all unsure about patient’s ability to control his/her suicidal behaviour, then admit patient to hospital • Can admit voluntarily or involuntarily • Can order a sitter for 1:1 observation on the ward When to refer suicidal patients to a mental health professional • Patients not at imminent risk • Use of contracts • Always ensure patient knows they can use the ED if situation changes • Ensure close follow up or bridging until appointment • No evidence to support “contracting for safety” ▫ Having suicidal patient agree to no longer be suicidal • Safety planning makes much more sense ▫ Developed in collaboration with the patient ▫ List of things patient agrees to try when feeling suicidal • • • • • • Potential triggers for suicidal thinking Potential coping strategies Social supports Phone numbers for crisis lines Instructions on when to return to ED How to make environment safe (removing firearms) • Suicide is a major public health issue • BUT there is hope! ▫ < 1% of people who have had suicidal ideation go on to kill themselves ▫ suicidal ideation is transient for most people • SO, if we an detect the acutely suicidal patient and provide an alternative that delays the act, there is a reasonable chance the patient will change their mind Ethics and Legal Considerations Consent to Treatment (1) • MCC objectives: ▫ Patients who are depressed can meet the criteria for decision capacity, but their preferences are clouded by their mood disorder ▫ Overriding the wishes of a seemingly capable patient who is depressed is a serious matter and is one situation in which psychiatric involvement should be sought ▫ Decisions to limit care should be deferred if possible until depression has been adequately treated Consent to Treatment (2) • MCC objectives (continued): ▫ If time pressures dictate the need to make a prompt choice, the physician should seek surrogate involvement ▫ If the surrogate has previously discussed the patient's wishes at a time when he or she was not depressed, the surrogate will be able to explain whether the patient's choice is consistent with previously stated beliefs or has changed since the onset of depression Consent to Treatment (3) • Specific to the issue • Informed – no misrepresentation • Voluntary – no coercion or persuasion • Capable Consent to Treatment (4) • • • • Diagnosis and nature of treatment Purpose of proposed treatment Anticipated risks and benefits of treatment Alternative treatments and their risks and benefits • Prognosis, with and without treatment Duty to Warn & Protect • Criteria for involuntary admission ▫ Serious bodily harm to himself/herself ▫ Serious bodily harm to another person ▫ Serious physical impairment • Child in harm’s way Warn Children’s Aid Society (CAS) • Dangerous driving Warn Ministry of Transportation (MOT) [email protected]