Neighbourhood characteristics and the incidence of first-episode psychosis and duration of untreated psychosis.

BACKGROUND: The incidence of psychotic disorders varies between geographical areas and it has been hypothesized that neighbourhood-level factors may influence this variation. It is also plausible that the duration of untreated psychosis (DUP) is associated with neighbourhood characteristics. The aims of this study were to determine whether the incidence of first-episode psychosis (FEP) and the DUP are associated with the level of social deprivation, fragmentation, social capital and population density. METHOD: All individuals with a FEP from a geographical defined catchment area over a 5-year period were included. Age-standardized incidence rates were calculated for each neighbourhood factor. RESULTS: A total of 292 cases of FEP were included in the study and 45% had a diagnosis of a schizophrenia-spectrum disorder. The age standardized incidence rate of FEP in the most deprived area was 72.4 [95% confidence interval (CI) 26.4-162.7] per 100 000 person-years compared with 21.5 (95% CI 17.6-26.0) per 100 000 person-years in the most affluent areas. This represents a 3.4-fold increase in FEP incidence in the most deprived areas. The incidence of FEP was also increased in neighbourhoods that were more socially fragmented [incidence rate ratio (IRR) = 2.40, 95% CI 1.05-5.51, p = 0.04] and there was a trend for the incidence to be increased in neighbourhoods with lower social capital (IRR = 1.43, 95% CI 0.99-2.06, p = 0.05). The median DUP was 4 months and was higher in more socially fragmented neighbourhoods. CONCLUSIONS: The incidence of psychotic disorders is related to neighbourhood factors and it may be useful to consider neighbourhood factors when allocating resources for early intervention services.

Characteristics of a later life population in a general adult community mental health service setting.

OBJECTIVES: Globally, increasing life expectancy has escalated demands on psychiatric services caring for a later life population. It is recognised that those with enduring mental illness may have specific needs with advancing age. In this study, we describe the characteristics of a population aged over 60 years attending a general adult community psychiatric service and compare demographic and clinical features across age and diagnostic categories. The study aims to gather preliminary information which may guide future local mental health service planning. METHODS: We conducted a cross-sectional observational study using retrospective chart review of all patients aged over 60 years attending four community mental health teams in North Dublin. Cohorts of attenders were stratified by age comparing 60-64 year age group with the population aged 65 years and over. Attenders were also stratified by diagnosis and regression analysis was used to determine predictors of psychotic disorder diagnosis. RESULTS: The study included 127 patients. There was a higher prevalence of psychotic disorders among those aged 65 years and over (n = 73), while those aged 60-64 years (n = 54) were more likely to have depression and non-affective, non-psychotic disorders. Among the population aged 65 years and over 78% (n = 57) were long-term psychiatric service attenders. CONCLUSIONS: The majority of the sample aged 65 years and over were long-term service attenders with a diagnosis of severe mental illness. Further research is warranted to determine optimal service delivery for later life psychiatric service attenders.

Socio-demographic and clinical characteristics of migrants to Ireland presenting with a first episode of psychosis.

OBJECTIVES: When presenting with a first episode of psychosis (FEP), migrants can have different demographic and clinical characteristics to the native-born population and this was examined in an Irish Early Intervention for Psychosis service. METHODS: All cases of treated FEP from three local mental health services within a defined catchment area were included. Psychotic disorder diagnoses were determined using the SCID and symptom and functioning domains were measured using validated and reliable measures. RESULTS: From a cohort of 612 people, 21.1% were first-generation migrants and there was no difference in the demographic characteristics, diagnoses, symptoms or functioning between migrants and those born in the Republic of Ireland, except that migrants from Africa presented with less insight. Of those admitted, 48.6% of admissions for migrants were involuntary compared to 37.7% for the native-born population (p = 0.09). CONCLUSIONS: First-generation migrants now make up a significant proportion of people presenting with a FEP to an Irish EI for psychosis service. Broadly the demographic and clinical characteristics of migrants and those born in the Republic of Ireland are similar, except for less insight in migrants from Africa and a trend for a higher proportion of involuntary admissions in the total migrant group.

Consultant psychiatrists' experience of the impact of the COVID-19 pandemic on mental health services.

OBJECTIVES: The novel coronavirus 2019 (COVID-19) has spread worldwide threatening human health. To reduce transmission, a 'lockdown' was introduced in Ireland between March and May 2020. The aim of this study is to capture the experiences of consultant psychiatrists during lockdown and their perception of it's impact on mental health services. METHODS: A questionnaire designed by the Royal College of Psychiatrists was adapted and circulated to consultant members of the College of Psychiatrists of Ireland following the easing of restrictions. The questionnaire assessed the perceived impact on referral rates, mental health act provision, availability of information technology (IT), consultant well-being and availability of personal protective equipment (PPE). Thematic analysis was employed to analyse free-text sections. RESULTS: Response rate was 32% (n = 197/623). Consultants reported an initial decrease/significant decrease in referrals in the first month of lockdown (68%, n = 95/140) followed by an increase/significant increase in the second month for both new (83%, n = 100/137) and previously attending patients (65%, n = 88/136). Social isolation and reduced face-to-face mental health supports were among the main reasons identified. The needs of children and older adults were highlighted. Most consultants (76%, n = 98/129) felt their working day was affected and their well-being reduced (52%, n = 61/119). The majority felt IT equipment availability was inadequate (67%, n = 88/132). Main themes identified from free-text sections were service management, relationship between patients and healthcare service and effects on consultants' lives. CONCLUSIONS: The COVID-19 pandemic has placed increased pressure on service provision and consultant wellness. This further supports the longstanding need to increase mental health service investment.

Illness characteristics and symptoms in an Irish early intervention for psychosis service.

OBJECTIVES: Study of illness characteristics and symptoms in a young population with psychosis can assist for understanding of their needs, and can inform service planning strategies. The aims of the current study were to describe illness characteristics and symptoms of a first episode psychosis (FEP) sample aged 25 years and under, and compare with a sample aged over 25 years. METHODS: Interviews were conducted for 437 individuals aged 16-65 years presenting with suspected psychosis between 2005 and 2012 in a defined catchment area (population of 390 000) using the Structured Clinical Interview for DSM IV to determine the presence of a psychosis diagnosis. Individuals with confirmed psychosis were assessed using standardised instruments to determine illness characteristics at first presentation. RESULTS: Among the 25 years, and under FEP sample, 23.9% had their first onset of symptoms (prodromal or psychotic) before 18 years of age. After controlling for confounders, the sample aged 25 years and under had a significantly shorter log transformed duration of untreated psychosis (p=0.002), more negative symptoms (p=0.045) and greater frequency of comorbid cannabis abuse diagnosis (p=0.027). CONCLUSIONS: Symptom onset in a youth FEP sample frequently occurs before age 18 years. Certain illness characteristics differed across the age categories, such as greater negative symptoms and cannabis abuse in the youth sample. Overall, the findings support the provision of adequate strategies for management of negative symptom deficits and substance abuse across all ages in FEP.

A randomised crossover trial of post-operative cognitive and psychomotor recovery from benzodiazepine sedation: effects of reversal with flumazenil over a prolonged recovery period.

OBJECTIVE: To study the post-operative cognitive and psychomotor recovery from midazolam conscious sedation, after reversal with the benzodiazepine antagonist flumazenil over a prolonged recovery period. DESIGN: A prospective, double-blind, randomised, crossover trial. SETTING: Out-patient Sedation Department, Newcastle Dental Hospital and School METHOD: Eighteen patients, ASA I or II, received midazolam on two separate occasions to undergo equivalent dental treatment. Following treatment patients were reversed with intravenous flumazenil or saline (placebo) at alternate appointments. Assessment of mood and cognitive function was undertaken using a highly sensitive and specific computerised battery of cognitive tests administered by telephone. Cognitive and psychomotor tests were administered prior to sedation and every hour for 6 hours post reversal. RESULTS: Results indicated no significant effect of flumazenil on simple reaction time and choice reaction time but did show a trend of reversing the effects of midazolam on numeric working memory and word recognition. CONCLUSION: The cognitive and psychomotor effects of the sedation were not fully reversed by flumazenil. Cognitive impairments were still present up to 6 hours post-reversal, despite patients appearing clinically more alert. This has important implications for treatment protocols and discharge instructions.

A prospective randomised controlled study of patient-controlled propofol sedation in phobic dental patients.

The safety and effectiveness of patient-controlled propofol sedation was prospectively assessed in 18 healthy, phobic dental patients. Using a randomised, crossover design each patient received two sessions of equivalent dental treatment under patient-controlled or clinician-controlled propofol sedation. The patient-controlled technique used 29.8% less drug (time-weighted dose) than the clinician-controlled method (p = 0.011). There was a high correlation between number of demands and number of doses actually infused during the patient-controlled technique (r = 0.99, p < 0. 001). Clinically, the level of sedation was lighter and the degree of operator satisfaction was higher with patient-controlled sedation. Blood pressure and arterial oxygen saturation showed minimal changes and remained within normal ranges during both techniques. Patient-controlled sedation produced a greater reduction in dental and general anxiety compared with clinician-controlled sedation, but the difference did not reach statistical significance. Three times the number of patients expressed a preference for the patient-controlled, compared with the clinician-controlled, technique. Patient-controlled sedation provides safe and acceptable intra-operative anxiolysis for phobic dental patients, but with reduced propofol dosage.

A randomised, controlled trial of cognitive and psychomotor recovery from midazolam sedation following reversal with oral flumazenil.

Flumazenil is traditionally administered intravenously to reverse the adverse effects of over sedation with benzodiazepines. The aim of this study was to test postoperative cognitive and psychomotor recovery from midazolam conscious sedation, following reversal with orally administered flumazenil. It was hypothesised that when administered by the oral route, flumazenil may enhance recovery over a prolonged period, thus increasing safety. Eighteen patients requiring intravenous midazolam sedation for dental treatment completed a randomised, double-blind, crossover trial. Following treatment the patients' sedation was reversed using either flumazenil or saline (as placebo), administered orally, on alternate appointments. Assessment of mood and cognitive function were undertaken using ClinPhone.cdr(R), a highly sensitive and specific computerised battery of cognitive tests administered by telephone prior to sedation and every hour for seven hours post reversal. Results indicate that within 20 min of administration, oral flumazenil is capable of partially reversing some cognitive and psychomotor impairments but the attentional and stimulus discrimination effects of midazolam sedation still remain.