The Canadian Depression Research and Intervention Network (CDRIN) Maritimes Registry
The Canadian Depression Research and Intervention Network (CDRIN) Maritimes Registry
While effective interventions for depression exist, their success rates are unsatisfactory
 and their provision is haphazard. The Canadian Depression Research and Intervention Network
 (CDRIN) Maritimes Depression Hub will improve the delivery of care and the quality of
 outcomes for youths, adults and seniors with depression across the Maritimes. The
 investigators will establish an integrated system of assessment, treatment, research and
 education related to depression with the active involvement of those with lived experience.
 The establishment of a patient registry is a key step that will facilitate evaluation and
 reform of current services, integration of patient choice and community resources into
 treatment programs, monitoring long-term outcomes, and development of more effective
 treatment approaches through research. The registry will facilitate research that will
 include validation of new diagnostic and outcome measurement tools, low-cost clinical trials
 and collaborative projects with national and international partners. Educational programs
 will involve training the next generation of researchers, those with lived experience,
 clinicians, and health system managers in critical appraisal and will facilitate their
 involvement in research. The registry, the proposed systematic measurement of outcomes and
 the broad dissemination of information and skills will improve the quality of research and of
 care as well as the experience of patients and their families.

 The need for a registry: It is increasingly recognized that major advances in the treatment
 of mental disorders will require large scale clinical research. Recently demonstrated ways of
 completing large-scale research with finite resources include the routine use of electronic
 health records (EHR), data linkage and randomized registry trial. Use of EHR is the most
 efficient way of rapidly obtaining large amounts of information. However, EHR cannot
 completely exclude confounding by indication and other unmeasured variables. Therefore, tests
 of treatment effects require experimental designs that cannot be replaced by routine health
 records data. The gold standard for testing the effects of treatment in an unbiased way is
 the randomized controlled trial (RCT), where measured and unmeasured confounders are balanced
 through the randomization process and any remaining confounding is due to chance alone. RCTs
 are valued as the highest level of evidence, but are costly and take significant time to be
 completed, partly because of the need to screen a large group of individuals to identify
 eligible participants.

 The most efficient unbiased test of interventions, new treatment modalities and novel ways of
 treatment delivery is a method that combines EHR use with the randomized controlled trial
 (RCT) methodology: the randomized registry trial (RRT). The RRT takes advantage of a registry
 of individuals with available information to identify a large number of individuals suitable
 for an RCT. The RRT approach is efficient especially if the same information (e.g. diagnosis
 and treatment history) is used repeatedly for different purposes. The same information can be
 used for clinical purposes, service improvement and multiple research projects. RRT will
 allow obtaining answers about the efficacy of new treatments and management strategies
 significantly faster and at a much lower cost than traditional RCTs. Therefore, the
 investigators propose to establish a registry that has the capacity to conduct RRTs. The
 proposed registry will be integrated with similar efforts across Canada. Jointly, this
 collaborative network of registries will facilitate fast and economical testing of new
 treatments, which is urgently needed to advance the therapeutic options for people with
 depression and related conditions.
Registry The CDRIN Maritimes registry will provide an integrated platform for clinical
 research and service evaluation. Participation in the registry will be offered to individuals
 seeking help for mental disorders across primary, secondary and tertiary care settings in
 Nova Scotia. In the spirit of participatory research, all participants in the registry will
 become members of the registry and will be kept informed of registry development, as well as
 educational and training opportunities. Those who have consented to be contacted regarding
 future research opportunities will be invited to actively participate in research.

 Number of participants The number of participants in the registry is not set in advance and
 will depend on funding and needs of service development and research studies that will use
 the registry. The registry will be scalable and the investigators expect to enrol between
 1000 and 30,000 participants. For the additional reliability study, numbers of participant
 have been determined based on a power calculation. A power calculation suggests that between
 313 and 400 individuals assessed twice are required to establish the reliability of
 diagnostic instruments with an acceptably small measurement error (confidence interval for
 reliability coefficient alpha of 0.15 or smaller for disorders present in 10% of participants
 or more). Therefore, the investigators propose to recruit 400 individuals for the reliability
 study.

 Inclusion and exclusion criteria The registry will be broadly inclusive with minimal
 exclusion criteria. Any individual who is seeking or receiving help for mental health related
 problems in Nova Scotia is eligible to become a member of the registry. Residents of Nova
 Scotia will be eligible to enter the Registry if they understand English or French and have a
 capacity to provide informed consent or if an appropriate substitute decision maker provides
 consent on their behalf. There are no exclusion criteria related to age, sex, or ethnicity.
 Whilst the recruitment will be targeted to include individuals suffering with depression and
 other types of mental illness, no specific diagnosis is required for participation in the
 registry. Recruitment is diagnosis-independent as the goal of the registry is to create an
 inclusive database of individuals seeking mental health care in the Maritimes. As such, no
 specific formal diagnosis is necessary. Many individuals will present at various primary,
 secondary, and tertiary health care settings who will not meet full diagnostic criteria for a
 mental health condition, but could still be sub threshold and meet diagnostic criteria at a
 later time. It is important to include these individuals in the registry to facilitate the
 clinical care of those seeking mental health care and also to facilitate research on various
 subsets of individuals seeking mental health care, with and without formal mental health
 diagnoses. Furthermore, restricting participation to people who only fulfill diagnostic
 criteria would not allow for testing of the reliability of the diagnosis or the boundaries
 between disorders and normality. Recruitment will be targeted toward individuals suffering
 from a potential diagnosis of Depression as it is one of the most common and burdensome
 mental health conditions in Canada. Participants will not be excluded from the registry if
 they are found to not meet diagnostic criteria following diagnostic interviews.

 Participant enrollment Potential participants will be approached at the point of
 registration, in waiting rooms and during clinical consultations in primary, secondary and
 tertiary care services that are likely to serve people suffering from depression and other
 types of mental illness. A clinician or researcher will offer participation in the registry.
 After explanation of the registry purpose and the need for reliability studies, participants
 will provide written informed consent for their information to be kept in a registry and used
 for research on the causation, classification and treatment of depression and other mental
 disorders.

 The participants will also be given the option to participate in instrument reliability
 studies that may include repeated completion of the same instruments.

 Assessments The registry will include a minimal set of core assessments (Tables 1 and 2) and
 a broader palette of optional instruments (Tables 3 and 4) for screening, diagnosis and
 current state (symptom profile, severity and functioning) assessment for youth (Table 1 and
 3) and adult (Tables 2 and 4) participants. The selection of assessment instruments beyond
 the minimal set will be determined in conjunction with participant, clinician and
 investigator preferences. It is not expected that any participant would complete all optional
 measures at any given time. Selection of instruments will take into account burden to
 participants, so that no single assessment takes more than 3 hours. Tables 1 and 2 list the
 minimal sets of instruments for youth and adult participants. Table 3 shows the broad palette
 of optional instruments for youth and table 4 shows the full palette of assessment
 instruments for adults. Screening and status assessment instruments will be administered
 repeatedly (typically once every 3-6 months, but more often if needed to assess an effect of
 recently initiated treatment or change in care delivery). Diagnostic instruments will
 typically be administered once (twice for participants in a reliability study), but may be
 repeated in after 1 to 5 years to assess changes in psychopathology profile and diagnoses.

 Screening instruments Strengths and Difficulties Questionnaire (SDQ) will be the core
 screening instrument for youth participants up to age 16. SDQ is a 25-item measure of
 psychopathology for children and adolescents with parent-report and self-report versions
 validated for ages 3-16 and 11-16 respectively. Simple and accessible language makes SDQ easy
 to complete. Balance of positive and negative items makes this measure highly acceptable. The
 total difficulties scale / emotional subscale is a highly sensitive screener for depression
 and anxiety disorders in youth. The questionnaire takes only 5 minutes to complete and
 detects depression and other disorders with an accuracy equal to or higher than longer
 instruments. An established cut-off value of 14 on the total difficulties scale of SDQ will
 be used to select participants who are likely to suffer from depression or related disorders.

 Patient Health Questionnaire (PHQ-9) will be the core screening instrument for adults and
 older adolescents (from age 17). PHQ-9 is a 9-item self-report questionnaire that has been
 extensively validated for use with adults and, more recently, adolescents. PHQ-9 is highly
 sensitive in screening for depression, with a score of 10 or higher suggestive of diagnosis.
 Thanks to its brevity and straightforward response format, PHQ-9 is easy and quick to
 complete, has been found to be acceptable and is widely used in primary and secondary care
 practice.

 Mood and Feelings Questionnaire (MFQ) will be an alternative screening measure for older
 children and adolescents that is more directly focussed on depression. MFQ has two versions:
 a long 33-item version and a short 13-item version. The investigators will use the short MFQ,
 which has been validated for 7- to 18-year old participants and has been found to be
 acceptable with a cut-off of 11 or more being highly sensitive in detecting a diagnosis of
 major depressive disorder.

 Screen for Child Anxiety Related Emotional Disorders (SCARED) and the Generalized Anxiety
 Disorder 7-item scale (GAD-7) will be used as optional screening measures for services and
 investigators interested in detecting anxiety disorders in addition to depression. SCARED
 self-report and parent-report versions have been validated for children and adolescents aged
 8-18, with a high-sensitivity threshold of 20 for detecting anxiety disorders. The
 self-report and parent-report versions have been found to be psychometrically equivalent.
 GAD-7 has been validated as a highly sensitive screen for generalized anxiety disorder in
 adults. GAD-7 is moderately specific for generalized anxiety and detects a range of anxiety
 disorders.

 Everyday Feelings Questionnaire (EFQ) will be optionally used to screen for depression and
 anxiety disorders among parents of child and adolescent participants. EFQ is a brief 10-item
 measure of current depressive and anxiety symptoms with a balance of positive and negative
 items making it highly acceptable, non- stigmatizing and suitable for a brief assessment of
 emotional wellbeing in the parents of children and adolescents presenting to health services.
 Availability of a spouse-report version facilitates obtaining information on both parents
 when only one parent is available for direct assessment. EFQ has excellent psychometric
 properties and strong convergent validity with established measures of depression and
 anxiety.

 Diagnostic instruments Kiddie Schedule for Affective Disorders and Schizophrenia - Present
 and Lifetime version, adapted for the Diagnostic and Statistical Manual of Mental Disorders
 (DSM)-5th Edition (K-SADS -5). K-SADS -5 is a semi-structured diagnostic interview to
 establish current and lifetime diagnoses of mental disorders in children and adolescents
 based on interviews with parent and with the young person. Previous versions of K-SADS have
 been validated for children and adolescents aged 7-18 and have been found to have high
 inter-rater reliability. K-SADS has recently been adapted to DSM-5 by Dr Joan Kaufman and
 colleagues at Yale University (as K-SADS-5) and is awaiting a test of reliability. Based on
 the K-SADS-5, the investigators will derive best estimate DSM-5 diagnoses established in
 consensus meetings involving experienced psychiatrists blind to the diagnoses of parents.
 Information provided by parents will be submitted for use in these meetings after being
 checked to be free of any indication of parental diagnosis. Our team has received training in
 using K-SADS by the team of John Nurnberger and will be receiving additional training on the
 DSM-5 adaptation with Dr Joan Kaufmann in September 2014.

 Structured Clinical Interview for DSM-5 (SCID-5) is a semi-structured diagnostic interview
 for adults designed to be administered by a clinically trained interviewer. While earlier
 versions of SCID have been shown to be highly acceptable and reliable, the recently developed
 SCID-5 is awaiting its test of reliability. SCID-5 provides exact wording of questions to ask
 for specific diagnostic symptoms but allows additional probing to establish the symptom
 presence and timing with adequate accuracy and make a judgment about its clinical
 significance. SCID-5 provides algorithmic rules that guide the interviewer through DSM-5
 diagnoses and allows skipping questions that will not make a difference to a diagnostic
 conclusion, given the information already provided. In October 2013 Dr. Michael First
 (Columbia University) trained the team of investigators at Dalhousie in using SCID-5. Based
 on our preliminary experience, a SCID-5 interview can last between 45 minutes and 3 hours,
 depending on the complexity of psychopathology, efficiency of the interviewer and
 communication skills of the interviewee. The interviewers will be clinically trained nurses,
 social workers, occupational therapists, psychologists or psychiatrists. They will initially
 receive a three-day training from Dr. First, the author of SCID-5 and a collaborator in this
 project. Following this, the investigators will conduct once monthly meetings to review
 recorded interviews, discuss intervening issues and maintain the quality of interview
 administration. The investigators expect most of the interviews (70%) to be carried out by
 research coordinators (nurses/social workers/occupational therapists) and a smaller
 proportion (30%) to be carried out by the investigators and clinicians (psychiatrists and
 clinical psychologists). The investigators will record the qualifications and experience
 level of each interviewer.

 Status assessment: symptom severity and functioning Current severity of depressive, anxiety
 and psychotic symptoms will be assessed with established and validated self-report and
 clinician-rated instruments. In children and adolescents, the primary measure of depression
 symptom severity will be the broadly used and extensively validated 16-item clinician-rated
 Children's Depression Rating Scale-Revised (CDRS-R). In addition, the self- and parent-rated
 versions of the widely used and validated 41-item Screen for Child Anxiety Disorders (SCARED)
 will be used to measure anxiety symptoms in children and adolescents.

 In adults, the current severity of depression symptoms will be measured primarily with the
 10-item clinician-rated Montgomery and Åsberg Depression Rating Scale (MADRS), an internally
 consistent scale that is highly sensitive to therapeutic change, and the self-report Quick
 Inventory of Depressive Symptomatology - Self-Rated (QIDS-SR), a widely used and extensively
 validated measure of depressive symptoms that closely matches DSM diagnostic criteria for
 depression. Optional and alternative measures of depressive symptom severity in adults will
 include the clinician-rated Hamilton Rating Scale for Depression (HAM-D) and Quick Inventory
 of Depressive Symptomatology - Clinician Rated (QIDS-C) and the self-report Beck Depression
 Inventory (BDI),60,54 , the PROMIS depression scale (http://www.nihpromis.org/) and the
 Clinically Useful Depression Outcome Scale (CUDOS). Anxiety in adults will be optionally
 measured with the self-report Beck Anxiety Inventory (BAI), Penn State Worry Questionnaire
 (PSWQ), Social Phobia Inventory (SPIN), Impact of Event Scale (IES), Clinically Useful
 Anxiety Outcome Scale (CUXOS) and Cognitive Behavioural Avoidance Scale (CBAS), the PROMIS
 anxiety scale (http://www.nihpromis.org/) and the Hospital Anxiety and Depression Scale
 (HADS).

 Manic symptoms will be optionally measured with the clinician-rated Young Mania Rating Scale
 (YMRS) and the self-report Altman Self-rated Mania Scale (ASMS). Psychotic symptoms will be
 optionally measured with the clinician-rated Positive and Negative Symptom Scale (PANSS).

 Severity of suicidal ideation and behaviour in children and adults will be measured with the
 paediatric and adult versions of the Columbia Suicide Severity Rating Scale (CSSRS).

 Status assessment: functioning The investigators will assess current level of functioning in
 children and youth with the widely used and validated Columbia Impairment Scale (CIS), parent
 and youth report. CIS is a 13-item questionnaire that provides a global measure of impairment
 with scored ranging from 0 to 52. Higher scores indicate a greater level of impairment. A
 score of 15 or higher is considered clinically significantly impaired. In adults, the
 investigators will assess current level of general, role- and social functioning in adults
 with the widely used and validated clinician-rated 2-item Role and Social Functioning Scales
 (RSFS), the self-report 5-item Work and the Social Adjustment Scales (WSAS) and the
 self-report 11-item Lam Employment Absence and Productivity Scale (LEAPS).

 New Measures New instruments have been developed to measure two domains of interest for which
 no adequate established measures were identified: positive mood-related functioning and
 acceptability of and preferences for pharmacological and psychological treatments.

 Engagement with Life Scale - self report (ELS-SR) is a self-report questionnaire developed
 based on qualitative material including interviews with individuals at different stages of
 recovery from depression and clinicians treating depression. It captures domains of
 functioning identified as related to mood and relevant to the quality of remission from
 depression. These domains include: enthusiasm, happiness, socializing, creativity,
 motivation, energy, interest, pleasure, decision-making, sense of purpose, self-confidence,
 resilience and hope. For example, individuals clinically recovered from depression often
 noted that before getting depressed they had been keen to try new things and associated this
 with being well, therefore, the measure includes items related to wanting to try new things
 to do and starting new activities. At present, this measure is at a developmental stage of a
 50-item bank. The investigators propose to collect responses from 400 participants to obtain
 psychometric data that will allow shortening the measure to optimize efficiency and avoid
 redundancy.

 Engagement with Life Scale - clinician rated (ELS-C). This is a 16-item clinician-rated scale
 covering the same domains as the self-report version (enthusiasm, happiness, socializing,
 creativity, motivation, energy, interest, pleasure, decision-making, sense of purpose,
 self-confidence, resilience and hope). It is administered as a semi-structured interview with
 obligatory and optional questions and then rated according to provided anchor points. The
 added value of the clinician-rated version is a degree of objectivity added by the
 clinician's judgement. Like the self-report version, this scale will undergo psychometric
 analysis and is likely to be refined and shortened based on the results.

 Treatment acceptability and preferences questionnaire (TAP-Q). Antidepressant medication and
 structured psychological therapy (such as cognitive behavioural therapy, CBT) are comparably
 effective for treating depression and related conditions. Many individuals have strong
 preferences for either pharmacological or psychological treatment, but there is no
 established way for measuring such preferences. Pre-existing attitudes are likely to
 influence outcomes of treatment trials comparing psychological and pharmacological
 treatments. Therefore, the investigators have designed a measure that starts by providing
 brief descriptions of typical first-line pharmacological and psychological treatment, then
 asks the individual about the acceptability of each treatment, about any barriers to
 acceptability, whether there is a preference for one treatment modality over the other and
 whether the participant would be willing to receive one or the other treatment by chance
 (randomly). The investigators have obtained pilot data from 60 participants, who have found
 the measure clear and easy to complete. The investigators propose using this measure with 400
 individuals with depression to carry out psychometric analysis and establish the rates of
 treatment preferences in Nova Scotia.

 Patient-centered outcomes While the clinician may be most concerned with the reduction of
 symptoms or achieving remission, each individual with depression may have her/his own goals
 and expectations from treatment: e.g. for one person a good outcome may be returning to a
 busy career, while for others it may be the ability to read a novel or enjoy time with grand
 children. A patient-centred outcome (PCO) recommended by individuals with lived experience of
 depression aims to measure achievement of such personalized treatment goals. PCO will be
 personalized in content (individual's most valued treatment goal) and standardized in scale
 (0-100% goal achievement). PCO will be developed collaboratively with each patient in a
 goal-setting session where the patient will name her/his most valued outcome and with the
 help of an interviewer will create specific anchors for what conditions should be fulfilled
 for the personally valued outcome to be 25%, 50%, 75% and 100% achieved.

 Physical health and side-effects of medication Unintended adverse reactions to medication are
 often a concern expressed by people living with mental illness. Therefore, the investigators
 will offer measurement of adverse reactions to medication ('side-effects') with several
 self-report scales including the Toronto Side Effects Scale (TSES), the Antidepressant
 Side-Effect Checklist (ASEC) and the Sex Effects Scale (SexFX). The three scales complement
 each other: TSES has the broadest range of symptoms, ASEC adds additional
 antidepressant-specific side effects and assesses the probability of association with an
 antidepressant, and SexFX assesses sexual side effects that are common but not well covered
 by the other scales. In addition, the database will allow recording routine health indicators
 including body weight, height, waist circumference, blood pressure, C-reactive protein (a
 measure of systemic inflammation and cardiovascular risk), triglycerides, cholesterol,
 glucose, insulin, and glycated haemoglobin (measures of glucose metabolism). These indicators
 will allow evaluating effects of medication on body weight, metabolic status and
 cardiovascular risk.

 Data linkage The registry will have the capacity to be linked with public health and
 population databases using health card numbers. For participants who provide consent for data
 linkage, this will allow accessing additional information on health service utilization,
 prescriptions and diagnoses with no additional assessment burden. In addition, this will
 allow obtaining prospective information on longevity and causes of death and information
 about participants who are lost to follow-up.

 Release of research data for clinical use To fulfill the mission of CDRIN to use research
 data for improvement of clinical care and following on suggestions from people with lived
 experience of depression, the registry participants will be able to choose that
 health-related information kept on them in the Registry be sent to their clinicians. This may
 provide additional information, save time, spare participants answering the same questions
 repeatedly, streamline clinical care and enhance evidence-based practice. Information will
 only be passed to clinicians on explicit (verbal or written) request of the participant. The
 information passed on to clinicians will take the form of a single sheet concisely
 summarizing the diagnostic and outcome information on the participant obtained so far as well
 as tips about possible treatments and community resources. Mental-health communication
 specialists (e.g. Healing Tree Communications) will review the form passed on to clinicians
 to maximise its usefulness and minimize the risk of passing on unhelpful or confusing
 information. External communication specialists will only provide guidance on the design and
 format of the generic feedback template. These communications specialists will not access any
 information on individual participants (identified or de-identified).

 Potential benefits Unlike most ongoing research projects, the CDRIN Maritimes Registry will
 become a resource for clinical care and the participants are likely to personally benefit
 from their participation in the project. Participants will be able to request that the
 information collected about them in the Registry be sent to clinicians they are going to see.
 Participants will also be sent information about existing community resources, such as peer
 support and vocational services.

 The study involving reliability of assessment instruments will not directly benefit the
 participants, but will ensure that instruments used to assess the diagnoses and severity of
 depression and related mental disorders are reliable and that different psychiatrists and
 other clinicians agree when making the diagnosis or measuring the severity of a disorder.
 More accurate measurement will improve the fit between individual's problems and prescribed
 treatment and will facilitate evidence-based practice. Training of health professionals in
 the use of reliable diagnostic and assessment instruments is known to improve the quality of
 clinical care. Routine systematic collection of outcome information will also facilitate the
 evaluation of specific treatment procedures, service changes and improvement initiatives.
 This will improve the quality of care for depression and other mental disorders in the medium
 to long term.

 Potential harms All proposed procedures are safe and carry very low-risk. The potential harms
 include the burden of repeated interviews, upsetting content of diagnostic interviews and
 inadvertent breaches of confidentiality.

 Burden of repeated interviews. The diagnostic interviews can be time-consuming, lasting
 typically 90-120 minutes. Repeating the same interview twice within a short time can be
 perceived as boring and it may put a strain on the participants' time resources. The
 investigators take the participants' time limitations seriously and the investigators take
 the following measures to limit the negative impact of interview burden. The investigators
 inform each participant in advance about the likely duration of interviews and emphasise that
 they are free to decide to participate or not in the interviews and that opting out of the
 repeated interview does not change their participation in the Registry. The investigators
 minimize the time required for interviews by efficient preparation and interviewer training.
 The investigators reimburse participants for their travel expenses and time spent with the
 repeated interviews.

 Upsetting interviews. The diagnostic interviews and assessment instruments inevitably ask
 questions that can be upsetting for some participants. These include questions about the
 symptoms experienced in the past, suicide attempts, hospital admissions and traumatic
 experiences. Evidence shows that asking such sensitive questions is not harmful and that
 participants prefer to discuss these personally important issues with sensitive professionals
 rather than avoiding them. The investigators will minimize the upsets and provide a
 containing environment with the following measures. All staff conducting the interviews will
 have clinical experience and be able to contain upsets in a sensitive and responsible way. At
 the beginning of each interview, it will be emphasised that participants can refuse to answer
 specific questions or can chose to discontinue the interview if they find it too upsetting.
 An on-call system involving the investigators will be in place to bring in a psychiatrist if
 a participant is judged to be too upset or if risk to self or others is judged to be acutely
 increased. Most investigators are licensed psychiatrists or clinical psychologists, can
 attend at short notice, provide crisis intervention and arrange a referral if appropriate.

 Breaches in confidentiality. In the course of this study participants will provide
 information that is highly sensitive since it concerns private experiences, information about
 mental health and personal information including contact details. The investigators will
 maintain the highest standards of confidentiality and minimize the potential harms from any
 breaches of confidentiality in the following ways. First, information that directly allows
 identification of subjects [names, addresses and similar] will be encoded using alphanumeric
 codes [the investigators will not use initials]. Collected information will be kept in a
 secured relational database in anonymized form with only the alphanumeric code identifying
 each participant. Personal information, contact details and their relationship to the
 alphanumeric code will be kept separate from the remainder of the data and secured with an
 even higher degree of security [kept in a password-protected file on a computer only
 accessible to the principal investigators and the study coordinators]. Even the anonymized
 data will only be accessible to study investigators and authorized staff of Dalhousie
 University, Capital District Health Authority and the Izaac Walton Killam (IWK) Health
 Centre, who are directly linked with the study and are familiar with principles of
 confidentiality and personal data protection. Information necessary for collaborative studies
 will only be made available to known researchers from academic institutions on signing a
 transfer agreement that includes binding statements on data confidentiality. All
 investigators will be required to keep study related data in encrypted/password-protected
 files on password-protected computers only, and take all precautions to prevent access by
 unauthorized individuals. No personally identifiable information will be made publicly
 available without separate REB approval and the participant's consent.

 Balance of benefits and harms With the above outlined measures to minimize foreseeable
 potential harms, the investigators believe that the minimal risk of harm to participants will
 be outweighed by the expected direct benefits to participants, benefits to society and the
 advancement of knowledge stemming from the proposed research.

 Future directions The investigators envisage that the Maritimes Depression Registry will
 become a long-term resource that will facilitate clinical research efforts and pioneer the
 iterative use of research information for improvement of clinical care and services. The
 assessment instruments with demonstrated reliability will become part of assessment for both
 research and clinical purposes. Specific instruments for assessing the positive aspects of
 mood and functioning and treatment preferences will fill in gaps in our assessment
 instruments. The registry will become a platform for large-scale low-cost clinical trials.
 The registry infrastructure will serve as a platform to develop and assess components to be
 incorporated in EHR systems that are expected to be implemented between 2019 and 2021.
Inclusion Criteria:

 -  male or female

 -  seeking or receiving help for mental health related problems in the maritime provinces
 of Canada

 -  able to provide informed consent or have an appropriate substitute decision maker that
 can provide consent on their behalf.

 -  English or French speaking

 Exclusion Criteria:

 -  There are no exclusion criteria related to age, sex, or ethnicity.

 -  Whilst the recruitment will be targeted to include individuals suffering with
 depression and other types of mental illness, no specific diagnosis is required for
 participation in the registry.

 -  unable to provide informed consent or does not have an appropriate substitute decision
 maker that can provide consent on their behalf

 -  does not speak English or French