The development of pathways for responding to patient complexity in a liaison psychiatry setting.

OBJECTIVES: The aims were to develop and operationalise a method of identifying patients at increased risk of adverse outcomes due to clinical and systems complexity within consultation-liaison psychiatry (CLP), and to formalise escalation processes for enhanced input with targeted clinical and organisational support. METHODS: The literature pertaining to methods for identifying and responding to complexity in general hospital settings was reviewed. An Escalation Tool operationalising the identification of complexity and response pathways was devised and tested. Feedback on the face validity and utility guided refinement. RESULTS: Two established tools that assess complexity, INTERMED and the Patient-Centred Accreditation method (PCAM) and a novel 'episode complexity' screening method, were identified and informed the development of a tool for identifying and responding to complexity, which was then piloted. The tool was deemed useful, notwithstanding variability in scoring. CONCLUSIONS: The Escalation Tool combined elements of existing measures to identify complexity in general hospital inpatients and guide pathways for action. It was well received and considered feasible for implementation, with local adaptation according to available resources.

Beck Depression Inventory as a screening tool for depression in chronic haemodialysis patients.

OBJECTIVES: To evaluate the psychometric properties of the Beck Depression Inventory (BDI) and Cognitive Depression Index (CDI) as a potential screening tool for major depression in haemodialysis (HD) patients. METHODS: Forty-five HD patients completed both the BDI/CDI and diagnostic interview. The interview was conducted by two experienced clinicians and was based on DSM-IV criteria. The sensitivity, specificity and positive (PPV) and negative (NPV) predictive values were then calculated. RESULTS: A diagnosis of depression was found in 6 of the 45 participants (13.3%). Optimal cut-offs were ≥18 for the BDI (sensitivity 1.0, specificity 0.90, PPV 0.60, NPV 1.0) and ≥11 for the CDI (sensitivity 1.0, specificity 0.92, PPV 0.67, NPV 1.0). CONCLUSIONS: Both the BDI and CDI were shown to be acceptable screening tools for depression in this population of chronic HD patients. The recommended cut-off scores for both scales are higher than those suggested for the general population and slightly higher than previously found in the chronic kidney disease literature, suggesting that altered thresholds are required when using these screening tools amongst HD patients.

A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression.

OBJECTIVE: Electroconvulsive therapy (ECT) is an effective depression treatment, but it has potential cognitive side effects. Ultrabrief pulse (UBP) right unilateral (RUL) ECT is an increasingly used treatment option that can potentially combine efficacy with lesser cognitive side effects. However, current trials are underpowered or have conflicting results. A systematic review and meta-analysis was conducted to evaluate the relative efficacy and cognitive effects of brief pulse (BP) and UBP RUL ECT. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CENTRAL, DARE, and the International Clinical Trials Registry Platform were searched with the search terms ECT, electroconvulsive therapy, electroconvulsive shock, electroconvulsive shock therapy, electrical stimulation, electroconvulsive combined with brief, ultra*, pulse, and trial in English, all fields including title, abstract, subject heading, and full text up to June 20, 2013, for studies comparing BP and UBP RUL ECT in depressed patients that reported formalized mood ratings for depression. STUDY SELECTION: Six studies met the inclusion criteria, comprising a total of 689 patients. DATA EXTRACTION: Efficacy, cognitive, response, and remission outcomes were extracted from each publication or obtained directly from authors. RESULTS: BP RUL ECT was significantly more efficacious in treating depression than UBP RUL ECT (standardized mean difference = 0.25; 95% CI, 0.08­0.41; P = .004) but showed significantly more cognitive side effects in all cognitive domains examined (global cognition, anterograde learning and recall, retrograde memory) (P < .01). The mean number of treatment sessions given was 8.7 for BP ECT and 9.6 for UBP ECT (P < .001). UBP had a lower remission rate (OR = 0.71; 95% CI, 0.51­0.99; P = .045), with a number needed to treat of 12.1. CONCLUSIONS: BP compared with UBP RUL ECT was slightly more efficacious in treating depression and required fewer treatment sessions, but led to greater cognitive side effects. The decision of whether to use BP or UBP RUL ECT should be made on an individual patient basis and should be based on a careful weighing of the relative priorities of efficacy versus minimization of cognitive impairment.

Depression and chronic kidney disease: A review for clinicians.

OBJECTIVE: To review the recent academic literature surrounding the prevalence, aetiopathology, associations and management of depression in chronic kidney disease (CKD), in order to provide a practical and up-to-date resource for clinicians. METHODS: We conducted electronic searches of the following databases: MEDLINE, EMBASE and PsycINFO. The main search terms were: depression, mood disorders, depressive disorder, mental illness, in combination with kidney disease, renal insufficiency, dialysis, kidney failure. Separate searches were conducted regarding antidepressant use in CKD. RESULTS: A number of recent, large and well-conducted studies have confirmed markedly raised rates of depression amongst those with CKD, with meta-analysis suggesting the prevalence of interview-defined depression to be approximately 20%. The interactions between depression and CKD are complex, bidirectional and multifactorial. Depression in CKD has been shown to be associated with multiple poor outcomes, including increased mortality and hospitalisation rates, as well as poorer treatment compliance and quality of life. Clinical evaluation of depression in patients with CKD can be challenging; however, once a diagnosis is made, a range of treatment modalities can be considered. CONCLUSIONS: Depression is common in CKD and is associated with a significant risk of adverse outcomes. Given the importance of this issue, there is now an urgent need for well-conducted randomised trials of interventions for depression in CKD in order to provide information on the safety and efficacy of treatments.

Parental care and control during childhood: associations with maternal perinatal mood disturbance and parenting stress.

This study examined the associations between perceived parental care and control in childhood and maternal anxiety, depression and parenting stress during the transition to parenthood. Eighty-eight women completed the Parental Bonding Instrument, self-report measures of anxiety and depression and a structured diagnostic interview (Mini-plus International Neuropsychiatric Interview) during the third trimester of pregnancy. The MINI-Plus and anxiety and depression measures were re-administered at 7 months postpartum. The Parenting Stress Index was also administered at this time. Significant associations were found between maternal 'affectionless control' and prenatal and postnatal symptom measures of anxiety and depression, p values <0.005. Compared to women who reported optimal parenting, women who recalled maternal 'affectionless control' were also six times more likely to be diagnosed with an anxiety disorder during pregnancy (OR = 6.1, 95% CI = 2.17-30.11) and seven times more likely to be diagnosed with postnatal major depression (OR = 6.8, 95% CI = 1.80-25.37). Paternal 'affectionless control' was associated with significantly higher scores on symptom measures of prenatal and postnatal anxiety, p values <0.005. This study suggests that assessing a woman's own parenting history is important in identifying and managing the risk of prenatal and postnatal affective disorders and parenting stress.