Golden opportunity for intervention? Identifying vitamin D deficiency in patients with substance use disorders in hospital.

SETTING: Based at a busy city hospital, the alcohol care team is a drug and alcohol specialist service, taking referrals for a wide range of patients with substance use disorders (SUD). OBJECTIVES: Patients with SUD are at high risk of vitamin D deficiency; this relates to frequent fractures and proximal myopathy. The coronavirus pandemic brought vitamin D into focus. Local guidelines advise that patients at high risk of vitamin D deficiency are offered replacement. There were no local data on vitamin D deficiency prevalence or any mention of patients with SUD in local vitamin D guidelines. The main aim of this project was to offer vitamin D checks and replacement to all appropriate patients. RESULTS: We collected data on 207 patients, [pilot study (n=50) and two subsequent samples (n=95 and n=62)]. Our pilot study showed that no patients were offered vitamin D testing or replacement. We then offered vitamin D checks to 95 patients. Most had low vitamin D (30 patients were vitamin D deficient and 26 were vitamin D insufficient). We provided vitamin D replacement and follow-up advice. Quality improvement was demonstrated 6 months later. We collected data on a further 62 patients who were all on our current or recent caseload. Following exclusions, nearly half (48%) of patients had had a vitamin D check. Almost all of these (95%) had low vitamin D (60% being classified as deficient). CONCLUSIONS: Patients had not been offered vitamin D replacement despite often having multiple risk factors for vitamin D deficiency. Vitamin D checks (and subsequent replacement) rose in frequency since the outset of this project. Local guidelines should add SUD as a risk factor for vitamin D deficiency. Hospital admission provides a rich opportunity to offer this simple intervention to patients who are often poorly engaged with community services.

Risk factors for interpersonal violence: an umbrella review of meta-analyses.

BACKGROUND: Interpersonal violence is a leading cause of morbidity and mortality. The strength and population effect of modifiable risk factors for interpersonal violence, and the quality of the research evidence is not known.AimsWe aimed to examine the strength and population effect of modifiable risk factors for interpersonal violence, and the quality and reproducibility of the research evidence. METHOD: We conducted an umbrella review of systematic reviews and meta-analyses of risk factors for interpersonal violence. A systematic search was conducted to identify systematic reviews and meta-analyses in general population samples. Effect sizes were extracted, converted into odds ratios and synthesised, and population attributable risk fractions (PAF) were calculated. Quality analyses were performed, including of small study effects, adjustment for confounders and heterogeneity. Secondary analyses for aggression, intimate partner violence and homicide were conducted, and systematic reviews (without meta-analyses) were summarised. RESULTS: We identified 22 meta-analyses reporting on risk factors for interpersonal violence. Neuropsychiatric disorders were among the strongest in relative and absolute terms. The neuropsychiatric risk factor that had the largest effect at a population level were substance use disorders, with a PAF of 14.8% (95% CI 9.0-21.6%), and the most important historical factor was witnessing or being a victim of violence in childhood (PAF = 12.2%, 95% CI 6.5-17.4%). There was evidence of small study effects and large heterogeneity. CONCLUSIONS: National strategies for the prevention of interpersonal violence may need to review policies concerning the identification and treatment of modifiable risk factors.Declarations of interestJ.R.G. is an NIHR Senior Investigator. The views expressed within this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Effectiveness of a single day induction programme in changing medical students' attitudes towards the speciality of forensic psychiatry.

OBJECTIVES: We aimed to investigate the effectiveness of a day visit in changing attitudes towards a high-security forensic psychiatric hospital, with regard to the current recruitment difficulties in psychiatry. METHODS: Broadmoor Hospital, a UK high-security psychiatric hospital, runs day visits for medical students, led by doctors. At the beginning and the end of the day students wrote their responses to the question, 'What do you think of Broadmoor?' Attitudes and themes were identified, and their prevalence was analysed. RESULTS: The responses of 296 students were initially analysed; however, 19 responses had to be excluded because they were illegible or incomplete. Before the visit, 15 responses were rated as positive, 169 neutral and 93 negative. After the visit, 205 responses were positive, 69 neutral and three negative. The themes that changed markedly following the visit were those indicating a change to favourable attitude. CONCLUSIONS: A single day visit was shown to be effective in altering the attitudes of medical students towards forensic psychiatry within a high-security psychiatric hospital.

Prevention of Suicidal Behavior in Prisons.

BACKGROUND: Worldwide, prisoners are at high risk of suicide. Research on near-lethal suicide attempts can provide important insights into risk and protective factors, and inform suicide prevention initiatives in prison. AIMS: To synthesize findings of research on near-lethal attempts in prisons, and consider their implications for suicide prevention policies and practice, in the context of other research in custody and other settings. METHOD: We searched two bibliographic indexes for studies in any language on near-lethal and severe self-harm in prisoners, supplemented by targeted searches over the period 2000-2014. We extracted information on risk factors descriptively. Data were not meta-analyzed owing to heterogeneity of samples and methods. RESULTS: We identified eight studies reporting associations between prisoner near-lethal attempts and specific factors. The latter included historical, prison-related, and clinical factors, including psychiatric morbidity and comorbidity, trauma, social isolation, and bullying. These factors were also identified as important in prisoners' own accounts of what may have contributed to their attempts (presented in four studies). CONCLUSION: Factors associated with prisoners' severe suicide attempts include a range of potentially modifiable clinical, psychosocial, and environmental factors. We make recommendations to address these factors in order to improve detection, management, and prevention of suicide risk in prisoners.

Asenapine augmentation and treatment-resistant schizophrenia in the high-secure hospital setting.

INTRODUCTION: Asenapine is a novel, recently introduced antipsychotic drug. It has a unique receptor profile and it is licensed in the UK for the treatment of bipolar-affective disorder. However, there is some evidence for its effectiveness in schizophrenia and it is licensed for schizophrenia treatment in a number of countries. Significant numbers of patients within the high-secure hospital setting suffer from treatment-resistant schizophrenia. Many patients fail to respond to adequate antipsychotic trials, and require trials of augmentation with other medications. METHODS: We report on our experience of using asenapine for augmentation of other antipsychotic medications in two male patients with treatment-resistant schizophrenia and histories of interpersonal violence. The patients provided informed consent to participate in this case series. Data were collected from the patients' clinical records, incident reports and hospital medical centre records. These records were used to derive primary and secondary outcome measures. These included time spent in seclusion, verbal and physical aggression, numbers of incidents and metabolic parameters. Symptoms were rated pre- and postaugmentation using the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression rating scales. RESULTS: Both patients showed an improvement after the addition of asenapine. These improvements were characterized by a reduction in global PANSS scores, in the PANSS excitability component, a reduction in scores of violence, overall incidents and reduction in seclusion hours. CONCLUSIONS: We found asenapine to be an effective augmentation agent with other antipsychotics in both patients. Clinical improvement was noted within weeks. The case-series nature and small sample size limited our ability to draw firm conclusions from our data. However, retrospective analysis has allowed us to take a naturalistic approach that this augmentation strategy may be advantageous on an individual patient basis in a high-secure hospital setting.