COVID-19-related posttraumatic stress disorder in adults with lived experience of psychiatric disorder.

BACKGROUND: Prevalence estimates of COVID-19-related posttraumatic stress disorder (PTSD) have ranged from 1% to over 60% in the general population. Individuals with lived experience of a psychiatric disorder may be particularly vulnerable to COVID-19-related PTSD but this has received inadequate attention. METHODS: Participants were 1571 adults with lived experience of psychiatric disorder who took part in a longitudinal study of mental health during the COVID-19 pandemic. PTSD was assessed by the International Trauma Questionnaire (ITQ) anchored to the participant's most troubling COVID-19-related experiencevent. Factors hypothesised to be associated with traumatic stress symptoms were investigated by linear regression. RESULTS: 40.10% of participants perceived some aspect of the pandemic as traumatic. 5.28% reported an ICD-11 PTSD qualifying COVID-19 related traumatic exposure and 0.83% met criteria for probable ICD-11 COVID-19-related PTSD. Traumatic stress symptoms were associated with younger age, lower income, lower social support, and financial worries, and lived experience of PTSD/complex PTSD. Depression and anxiety measured in June 2020 predicted traumatic stress symptoms at follow-up approximately 20 weeks later in November 2020. CONCLUSIONS: We did not find evidence of widespread COVID-19-related PTSD among individuals with lived experience of a psychiatric disorder. There is a need for future research to derive valid prevalence estimates of COVID-19-related PTSD.

Contacts with primary and secondary healthcare prior to suicide: case-control whole-population-based study using person-level linked routine data in Wales, UK, 2000-2017.

BACKGROUND: Longitudinal studies of patterns of healthcare contacts in those who die by suicide to identify those at risk are scarce. AIMS: To examine type and timing of healthcare contacts in those who die by suicide. METHOD: A population-based electronic case-control study of all who died by suicide in Wales, 2001-2017, linking individuals' electronic healthcare records from general practices, emergency departments and hospitals. We used conditional logistic regression to calculate odds ratios, adjusted for deprivation. We performed a retrospective continuous longitudinal analysis comparing cases' and controls' contacts with health services. RESULTS: We matched 5130 cases with 25 650 controls (5 per case). A representative cohort of 1721 cases (8605 controls) were eligible for the fully linked analysis. In the week before their death, 31.4% of cases and 15.6% of controls contacted health services. The last point of contact was most commonly associated with mental health and most often occurred in general practices. In the month before their death, 16.6 and 13.0% of cases had an emergency department contact and a hospital admission respectively, compared with 5.5 and 4.2% of controls. At any week in the year before their death, cases were more likely to contact healthcare services than controls. Self-harm, mental health and substance misuse contacts were strongly linked with suicide risk, more so when they occurred in emergency departments or as emergency admissions. CONCLUSIONS: Help-seeking occurs in those at risk of suicide and escalates in the weeks before their death. There is an opportunity to identify and intervene through these contacts.

Means restriction for the prevention of suicide on roads.

BACKGROUND: Road traffic suicides are common. However, due to the difficulty in distinguishing between motor vehicle crash fatalities and actual suicides, no official figures exist for this method of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide on roads is not well established. We conducted a systematic review to assess the impact of restrictions on the availability of, or access to, means of suicide on roads. OBJECTIVES: To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide on roads. SEARCH METHODS: We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, and the Transport Research International Documentation (TRID) Database from the date of database inception to March 2020. We conducted searches of the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. We applied no date, language, or publication status restrictions to these searches. SELECTION CRITERIA: Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide on roads. DATA COLLECTION AND ANALYSIS: Two review authors screened abstracts and full-text publications against the inclusion criteria. Two review authors planned to independently extract data and assess risk of bias of included studies. However, we identified no studies eligible for inclusion. MAIN RESULTS: We identified no studies that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS: This systematic review highlights the paucity of research around road traffic suicides and the need for future robust studies that aim to investigate the effectiveness of interventions to prevent suicide on roads. Suicide ascertainment is a key issue; therefore, clear objective criteria are necessary in order to scale up and study this method more accurately. In the absence of any substantial evidence, we advocate for more awareness on road traffic suicides and its inclusion in future government suicide prevention policies. Further research exploring effective measures, particularly those that do not require driver compliance, are also needed.

Means restriction for the prevention of suicide by jumping.

BACKGROUND: Jumping from a height is an uncommon but lethal means of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide by jumping is not well established. OBJECTIVES: To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide by jumping. These include the use of physical barriers, fencing or safety nets at frequently-used jumping sites, or restriction of access to these sites, such as by way of road closures. SEARCH METHODS: We searched the Cochrane Library, Embase, MEDLINE, PsycINFO, and Web of Science to May 2019. We conducted additional searches of the international trial registries including the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, to identify relevant unpublished and ongoing studies. We searched the reference lists of all included studies and relevant systematic reviews to identify additional studies and contacted authors and subject experts for information on unpublished or ongoing studies. We applied no restrictions on date, language or publication status to the searches. Two review authors independently assessed all citations from the searches and identified relevant titles and abstracts. Our main outcomes of interest were suicide, attempted suicide or self-harm, and cost-effectiveness of interventions. SELECTION CRITERIA: Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-and-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide by jumping. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion and three review authors extracted study data. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary. We summarised the quality of the evidence included in this review using the GRADE approach. MAIN RESULTS: We included 14 studies in this review. Thirteen were before-and-after studies and one was a cost-effectiveness analysis. Three studies each took place in Switzerland and the USA, while two studies each were from the UK, Canada, New Zealand, and Australia respectively. The majority of studies (10/14) assessed jumping means restriction interventions delivered in isolation, half of which were at bridges. Due to the observational nature of included studies, none compared comparator interventions or control conditions. During the pre- and postintervention period among the 13 before-and-after studies, a total of 742.3 suicides (5.5 suicides per year) occurred during the pre-intervention period (134.5 study years), while 70.6 suicides (0.8 suicides per year) occurred during the postintervention period (92.4 study years) - a 91% reduction in suicides. A meta-analysis of all studies assessing jumping means restriction interventions (delivered in isolation or in combination with other interventions) showed a directionality of effect in favour of the interventions, as evidenced by a reduction in the number of suicides at intervention sites (12 studies; incidence rate ratio (IRR) = 0.09, 95% confidence interval (CI) 0.03 to 0.27; P < 0.001; I2 = 88.40%). Similar findings were demonstrated for studies assessing jumping means restriction interventions delivered in isolation (9 studies; IRR = 0.05, 95% CI 0.01 to 0.16; P < 0.001; I2 = 73.67%), studies assessing jumping means restriction interventions delivered in combination with other interventions (3 studies; IRR = 0.54, 95% CI 0.31 to 0.93; P = 0.03; I2 = 40.8%), studies assessing the effectiveness of physical barriers (7 studies; IRR = 0.07, 95% CI 0.02 to 0.24; P < 0.001; I2 = 84.07%), and studies assessing the effectiveness of safety nets (2 studies; IRR = 0.09, 95% CI 0.01 to 1.30; P = 0.07; I2 = 29.3%). Data on suicide attempts were limited and none of the studies used self-harm as an outcome. There was considerable heterogeneity between studies for the primary outcome (suicide) in the majority of the analyses except those relating to jumping means restriction delivered in combination with other interventions, and safety nets. Nevertheless, every study included in the forest plots showed the same directional effects in favour of jumping means restriction. Due to methodological limitations of the included studies, we rated the quality of the evidence from these studies as low. A cost-effectiveness analysis suggested that the construction of a physical barrier on a bridge would be a highly cost-effective project in the long term as a result of overall reduced suicide mortality. AUTHORS' CONCLUSIONS: The findings from this review suggest that jumping means restriction interventions are capable of reducing the frequency of suicides by jumping. However, due to methodological limitations of included studies, this finding is based on low-quality evidence. Therefore, further well-designed high-quality studies are required to further evaluate the effectiveness of these interventions, as well as other measures at jumping sites. In addition, further research is required to investigate the potential for suicide method substitution and displacement effects in populations exposed to interventions to prevent suicide by jumping.

Self-Harm, Suicidal Behaviours, and Cyberbullying in Children and Young People: Systematic Review.

BACKGROUND: Given the concerns about bullying via electronic communication in children and young people and its possible contribution to self-harm, we have reviewed the evidence for associations between cyberbullying involvement and self-harm or suicidal behaviors (such as suicidal ideation, suicide plans, and suicide attempts) in children and young people. OBJECTIVE: The aim of this study was to systematically review the current evidence examining the association between cyberbullying involvement as victim or perpetrator and self-harm and suicidal behaviors in children and young people (younger than 25 years), and where possible, to meta-analyze data on the associations. METHODS: An electronic literature search was conducted for all studies published between January 1, 1996, and February 3, 2017, across sources, including MEDLINE, Cochrane, and PsycINFO. Articles were included if the study examined any association between cyberbullying involvement and self-harm or suicidal behaviors and reported empirical data in a sample aged under 25 years. Quality of included papers was assessed and data were extracted. Meta-analyses of data were conducted. RESULTS: A total of 33 eligible articles from 26 independent studies were included, covering a population of 156,384 children and young people. A total of 25 articles (20 independent studies, n=115,056) identified associations (negative influences) between cybervictimization and self-harm or suicidal behaviors or between perpetrating cyberbullying and suicidal behaviors. Three additional studies, in which the cyberbullying, self-harm, or suicidal behaviors measures had been combined with other measures (such as traditional bullying and mental health problems), also showed negative influences (n=44,526). A total of 5 studies showed no significant associations (n=5646). Meta-analyses, producing odds ratios (ORs) as a summary measure of effect size (eg, ratio of the odds of cyber victims who have experienced SH vs nonvictims who have experienced SH), showed that, compared with nonvictims, those who have experienced cybervictimization were OR 2.35 (95% CI 1.65-3.34) times as likely to self-harm, OR 2.10 (95% CI 1.73-2.55) times as likely to exhibit suicidal behaviors, OR 2.57 (95% CI 1.69-3.90) times more likely to attempt suicide, and OR 2.15 (95% CI 1.70-2.71) times more likely to have suicidal thoughts. Cyberbullying perpetrators were OR 1.21 (95% CI 1.02-1.44) times more likely to exhibit suicidal behaviors and OR 1.23 (95% CI 1.10-1.37) times more likely to experience suicidal ideation than nonperpetrators. CONCLUSIONS: Victims of cyberbullying are at a greater risk than nonvictims of both self-harm and suicidal behaviors. To a lesser extent, perpetrators of cyberbullying are at risk of suicidal behaviors and suicidal ideation when compared with nonperpetrators. Policy makers and schools should prioritize the inclusion of cyberbullying involvement in programs to prevent traditional bullying. Type of cyberbullying involvement, frequency, and gender should be assessed in future studies.

Case-finding for common mental disorders of anxiety and depression in primary care: an external validation of routinely collected data.

BACKGROUND: The robustness of epidemiological research using routinely collected primary care electronic data to support policy and practice for common mental disorders (CMD) anxiety and depression would be greatly enhanced by appropriate validation of diagnostic codes and algorithms for data extraction. We aimed to create a robust research platform for CMD using population-based, routinely collected primary care electronic data. METHODS: We developed a set of Read code lists (diagnosis, symptoms, treatments) for the identification of anxiety and depression in the General Practice Database (GPD) within the Secure Anonymised Information Linkage Databank at Swansea University, and assessed 12 algorithms for Read codes to define cases according to various criteria. Annual incidence rates were calculated per 1000 person years at risk (PYAR) to assess recording practice for these CMD between January 1(st) 2000 and December 31(st) 2009. We anonymously linked the 2799 MHI-5 Caerphilly Health and Social Needs Survey (CHSNS) respondents aged 18 to 74 years to their routinely collected GP data in SAIL. We estimated the sensitivity, specificity and positive predictive value of the various algorithms using the MHI-5 as the gold standard. RESULTS: The incidence of combined depression/anxiety diagnoses remained stable over the ten-year period in a population of over 500,000 but symptoms increased from 6.5 to 20.7 per 1000 PYAR. A 'historical' GP diagnosis for depression/anxiety currently treated plus a current diagnosis (treated or untreated) resulted in a specificity of 0.96, sensitivity 0.29 and PPV 0.76. Adding current symptom codes improved sensitivity (0.32) with a marginal effect on specificity (0.95) and PPV (0.74). CONCLUSIONS: We have developed an algorithm with a high specificity and PPV of detecting cases of anxiety and depression from routine GP data that incorporates symptom codes to reflect GP coding behaviour. We have demonstrated that using diagnosis and current treatment alone to identify cases for depression and anxiety using routinely collected primary care data will miss a number of true cases given changes in GP recording behaviour. The Read code lists plus the developed algorithms will be applicable to other routinely collected primary care datasets, creating a platform for future e-cohort research into these conditions.

Contacts with primary and secondary healthcare before suicide by those under the care of mental health services: case-control, whole-population-based study using person-level linked routine data in Wales, UK during 2000-2015.

BACKGROUND: People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons. AIMS: To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services. METHOD: This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001-2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database - Cymru with primary and secondary healthcare records. We present results of conditional logistic regression. RESULTS: We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1-2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4-1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6-0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2-0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5-4.5) v. 2.6 (95% CI 2.1-3.1)). CONCLUSIONS: We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.

Preoperative clinical, demographic, and urodynamic measures associated with failure to demonstrate urodynamic stress incontinence in women enrolled in two randomized clinical trials of surgery for stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The unexpected absence of urodynamic stress incontinence (USI) in women planning surgery for stress urinary incontinence (SUI) is a challenge to surgeons. We examined the prevalence and clinical and demographic factors associated at baseline (preoperatively) with the unexpected absence of USI among study participants of two multicenter randomized clinical trials of surgery for treating SUI. METHODS: Women with SUI symptoms and positive stress tests on physical examination enrolled in two separate clinical trials-one comparing the autologous fascial sling with the Burch colposuspension [Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr), and the other comparing the retropubic mid-urethral sling with the transobturator midurethral sling [Trial of Mid-Urethral Slings (TOMUS)]-were evaluated for USI preoperatively. The association of clinical, demographic, and urodynamic parameters was examined in women without USI in univariate and multivariate analyses. RESULTS: Overall, 144 of 1,233 women (11.7 %) enrolled in the two studies showed no USI. These women had a significantly lower mean volume at maximum cystometric capacity than those with USI (347.5 vs. 395.8 in SISTEr, p = 0.012), (315.2 vs. 358.2 in TOMUS, p = 0.003) and a lower mean number of daily accidents reported on a 3-day diary (2.2 vs 2.7 in SISTEr, p = 0.030) (1.7 vs 2.7 in TOMUS, p < 0.001). Additionally, those without demonstrable USI were more likely to have Pelvic Organ Prolapse Quantification (POP-Q) stage III/IV (31.7 % vs 14.4 % in SISTEr, p = 0.002), (15.5 % vs 6.9 % in TOMUS, p = 0.025). SUI severity as recorded on the Urogenital Distress Inventory (UDI) correlated strongly with the presence of USI in both studies. CONCLUSIONS: We observed that about one of eight women planning surgery for SUI does not show USI. Stage 3/4 POP was strongly associated with the unexpected absence of USI. A diminished urodynamic bladder capacity among women who did not display USI may reflect an inability to reach the limits of capacity during urodynamics, at which these women normally leak.

Working hard to avoid: Fixed-ratio response effort and maladaptive avoidance in humans.

Maladaptive avoidance of safe stimuli is a defining feature of anxiety and related disorders. Avoidance may involve physical effort or the completion of a fixed series of responses to prevent occurrence of, or cues associated with, the aversive event. Understanding the role of response effort in the acquisition and extinction of avoidance may facilitate the development of new clinical treatments for maladaptive avoidance. Despite this, little is known about the impact of response effort on extinction-resistant avoidance in humans. Here, we describe findings from two laboratory-based treatment studies designed to investigate the impact of high and low response effort on the extinction (Experiment 1) and return (Experiment 2) of avoidance. Response effort was operationalised as completion of fixed-ratio (FR) reinforcement schedules for both danger and safety cues in a multi-cue avoidance paradigm with behavioural, self-report, and physiology measures. Completion of the FR response requirements cancelled upcoming shock presentations following danger cues and had no impact on the consequences that followed safety cues. Both experiments found persistence of high response-effort avoidance across danger and safety cues and sustained (Experiment 1) and reinstated (Experiment 2) levels of fear and threat expectancy. Skin conductance responses evoked by all cues were similar across experiments. The present findings and paradigm have implications for translational research on maladaptive anxious coping and treatment development.

Trends in socioeconomic inequalities in incidence of severe mental illness - A population-based linkage study using primary and secondary care routinely collected data between 2000 and 2017.

OBJECTIVE: In 2008, the UK entered a period of economic recession followed by sustained austerity measures. We investigate changes in inequalities by area deprivation and urbanicity in incidence of severe mental illness (SMI, including schizophrenia-related disorders and bipolar disorder) between 2000 and 2017. METHODS: We analysed 4.4 million individuals from primary and secondary care routinely collected datasets (2000-2017) in Wales and estimated the incidence of SMI by deprivation and urbanicity measured by the Welsh Index of Multiple Deprivation (WIMD) and urban/rural indicator respectively. Using linear modelling and joinpoint regression approaches, we examined time trends of the incidence and incidence rate ratios (IRR) of SMI by the WIMD and urban/rural indicator adjusted for available confounders. RESULTS: We observed a turning point of time trends of incidence of SMI at 2008/2009 where slope changes of time trends were significantly increasing. IRRs by deprivation/urbanicity remained stable or significantly decreased over the study period except for those with bipolar disorder sourced from secondary care settings, with increasing trend of IRRs (increase in IRR by deprivation after 2010: 1.6 % per year, 95 % CI: 1.0 %-2.2 %; increase in IRR by urbanicity 1.0 % per year, 95 % CI: 0.6 %-1.3 %). CONCLUSIONS: There was an association between recession/austerity and an increase in the incidence of SMI over time. There were variations in the effects of deprivation/urbanicity on incidence of SMI associated with short- and long-term socioeconomic change. These findings may support targeted interventions and social protection systems to reduce incidence of SMI.

Understanding Suicide Clusters Through Exploring Self-Harm Behaviors.

Background: There is little information about characteristics and long-term outcomes of individuals who self-harm during a suicide cluster. Aims: To compare characteristics of individuals who self-harmed during a suicide cluster in South Wales (∼10 deaths between December 2007 and March 2008) with others who self-harmed prior to the cluster and to evaluate 10-year self-harm and mortality outcomes. Method: Using records from the hospital serving the catchment area of the suicide cluster, enhanced by national routinely collected linked data, we created the following two groups: individuals who self-harmed (a) during the suicide cluster and (b) 1 year before. We compared individuals' characteristics and performed logistic regression to compute odds ratios of 10-year self-harm and mortality outcomes. Results: Individuals who self-harmed during the cluster were less likely to be hospitalized or have a mental health history than those who self-harmed prior to the cluster. No significant group differences were found for 10-year self-harm outcomes, but all-cause mortality was higher for males. Limitations: Sample size was small, and data were lacking on psychological and social proximity to individuals who died during the suicide cluster. Conclusion: Our findings highlight the importance of long-term healthcare follow-up of those who self-harm during a suicide cluster, particularly males.

Understanding suicide clusters through exploring self-harm: Semi-structured interviews with individuals presenting with near-fatal self-harm during a suicide cluster.

There was a highly publicised cluster of at least ten suicides in South Wales, United Kingdom, in 2007-2008. We carried out a qualitative descriptive study using cross-case thematic analysis to investigate the experiences and narratives of eight individuals who lived in the area where the cluster occurred and who survived an episode of near-fatal self-harm at the time of the cluster. Interviews were conducted from 01.01.2015 to 31.12.2015. All interviewees denied that the other deaths in the area had affected their own suicidal behaviour. However, in other sections of the interviews they spoke about the cluster contributing to difficulties they were experiencing at the time, including damage to social relationships, feelings of loss and being out of control. When asked about support, the interviewees emphasized the importance of counselling, which they would have found helpful but in most cases did not receive, even in the case of close contacts of individuals who had died. The findings suggest that effective prevention messaging must be subtle, since those affected may not be explicitly aware of or acknowledge the imitative aspects of their behaviour. This could be related to stigma attached to suicidal behaviour in a cluster context. Lessons for prevention include changing the message from asking if people 'have been affected by' the suicide deaths to emphasising the preventability of suicide, and directly reaching out to individuals rather than relying on people to come forward.

The effect of the COVID-19 pandemic on mental health in individuals with pre-existing mental illness.

BACKGROUND: There is evidence that the COVID-19 pandemic has negatively affected mental health, but most studies have been conducted in the general population. AIMS: To identify factors associated with mental health during the COVID-19 pandemic in individuals with pre-existing mental illness. METHOD: Participants (N = 2869, 78% women, ages 18-94 years) from a UK cohort (the National Centre for Mental Health) with a history of mental illness completed a cross-sectional online survey in June to August 2020. Mental health assessments were the GAD-7 (anxiety), PHQ-9 (depression) and WHO-5 (well-being) questionnaires, and a self-report question on whether their mental health had changed during the pandemic. Regressions examined associations between mental health outcomes and hypothesised risk factors. Secondary analyses examined associations between specific mental health diagnoses and mental health. RESULTS: A total of 60% of participants reported that mental health had worsened during the pandemic. Younger age, difficulty accessing mental health services, low income, income affected by COVID-19, worry about COVID-19, reduced sleep and increased alcohol/drug use were associated with increased depression and anxiety symptoms and reduced well-being. Feeling socially supported by friends/family/services was associated with better mental health and well-being. Participants with a history of anxiety, depression, post-traumatic stress disorder or eating disorder were more likely to report that mental health had worsened during the pandemic than individuals without a history of these diagnoses. CONCLUSIONS: We identified factors associated with worse mental health during the COVID-19 pandemic in individuals with pre-existing mental illness, in addition to specific groups potentially at elevated risk of poor mental health during the pandemic.

Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study.

OBJECTIVE: To describe surgical complications in 597 women over a 24-month period after randomization to retropubic or transobturator midurethral slings. STUDY DESIGN: During the Trial of Midurethral Slings study, the Data Safety Monitoring Board regularly reviewed summary reports of all adverse events using the Dindo Surgical Complication Scale. Logistic regression models were created to explore associations between clinicodemographic factors and surgical complications. RESULTS: A total of 383 adverse events were observed among 253 of the 597 women (42%). Seventy-five adverse events (20%) were classified as serious (serious adverse events); occurring in 70 women. Intraoperative bladder perforation (15 events) occurred exclusively in the retropubic group. Neurologic adverse events were more common in the transobturator group than in retropubic (32 events vs 20 events, respectively). Twenty-three (4%) women experienced mesh complications, including delayed presentations, in both groups. CONCLUSION: Adverse events vary by procedure, but are common after midurethral sling. Most events resolve without significant sequelae.

The Role of National Specialist Societies in Influencing Transformational Change in Low-Middle Income Countries - Reflections on the Model of Implementation for a National Endoscopy Training Programme in Bangladesh.

The British Society of Gastroenterology (BSG) and the Bangladesh Gastroenterology Society (BGS) have collaborated on an endoscopy training programme, which has grown up over the past decade from a small scheme borne out of the ideas of consultant gastroenterologists in Swansea, South Wales (United Kingdom) to improve gastroenterology services in Bangladesh to become a formalised training programme with broad reach. In this article, we document the socioeconomic and historical problems that beset Bangladesh, the current training needs of doctors and how the BSG-BGS collaboration has made inroads into changing outcomes both for gastroenterologists in Bangladesh, but also for the populations they serve.

The prescribed duration algorithm: utilising 'free text' from multiple primary care electronic systems.

PURPOSE: To develop and test an algorithm that translates total dose and daily regimen, inputted as 'free text' on a prescription, into numerical values to calculate the prescribed treatment duration. METHOD: The algorithm was developed using antibiotic prescriptions (n = 711,714) from multiple primary care computer systems. For validation, the prescribed treatment duration of an independent sample of antibiotic scripts was calculated in two ways: (a) computer algorithm, (b) manually reviewed by a researcher blinded to the results of (a). The outputs of the two methods were compared and the level of agreement assessed, using confidence intervals for differences in proportions. This was repeated on sample of antidepressant scripts to test generalisability of the algorithm. RESULTS: For the antibiotic prescriptions, the algorithm processed 98.5% with an accuracy of 99.8% and the manual review processed 98.5% with 98.9% accuracy. The differences between these proportions are 0.0% (95%CI of -0.9, 0.9%) and 1.0% (95%CI of -0.1, 2.3%), respectively. For the antidepressant prescriptions, the algorithm processed 91.5% with an accuracy of 96.6% compared to the manual review with 96.4% processed and 99.8% accuracy; difference between these proportions is 4.9% (95%CI of 2.0, 8.0%) and 3.2% (95%CI of 1.6, 5.3%), respectively. CONCLUSION: The algorithm proved to be applicable and efficient for assessing prescribed duration, with sensitivity and specificity values close to the manual review, but with the added advantage that the computer can process large volume of scripts rapidly and automatically.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: efficacy, quality of life and functional outcome.

OBJECTIVE: This international, non-randomised study evaluated maintained efficacy and safety of Risperidone Long-Acting Injectable (RLAI) compared to previous medications. To investigate the possible effect of differences in national health care systems across Europe, the UK subset efficacy, health-related quality of life (HRQoL) and functioning data are reported here. METHODS: Patients with schizophrenia or other psychotic disorders, symptomatically stable on antipsychotic medication, received intramuscular injections of RLAI 25 mg (to a maximum of 50 mg) every 2 weeks for 6 months. RESULTS: Of 182 UK patients recruited; 79% had schizophrenia (87% paranoid), 21% other psychotic disorders; 96% had been hospitalised at sometime. Improvement in mean Positive and Negative Syndrome Scale (PANSS) total score was significant at 1 month through to endpoint (p = 0.0001). There were significant improvements in PANSS subscales (p

Narrating uncertainties about treatment of mental health conditions.

BACKGROUND: Integration of patient views in mental health service planning is in its infancy despite service provision being clearly dominated by narratives from professional consultations and medical records. We wished to clarify perceptions of uncertainty about mental health conditions from a range of provider and user perspectives (patients, carers, parents, mental health service providers) and understand the role of narratives in mental health research. AIMS: (1) To explore the utility of qualitative research methods, particularly narrative content analysis in mental health research, and (2) identify aspects of uncertainty in mental health service users and providers. MATERIAL: Four hundred and six free text responses were considered as one element of an existing questionnaire about uncertainties about mental health treatments, collected from mental healthcare users and providers through charities, the Mental Health Research Network in Wales, health professionals and websites. Free text responses were analysed using narrative content analysis, an elaborate and rigorous research technique that involves groups of analysts working independently and together over extended group sessions. FINDINGS: Three main themes emerged across respondent groups: "medication and treatment options", "objectification and marginalisation of patient" and "integrity of service delivery". Within these, patients embraced the opportunity to write about their illness at length, whilst carers' and parents' main concerns were about how patients were dealing with their illnesses, the services they were getting and the side effects of treatments. Carers and patients' parents perceived themselves to be the 'go-between', carrying messages between patients and professionals, in order to enable services to function. Mental health service providers and professionals considered uncertainties surrounding medication and treatment from an 'evidence-base' perspective, concentrating on medication choices and the adoption of new approaches to care rather than patient need and expectation. Patients wanted to know what alternatives were available to the drug regimes they were on and felt their opinions were rarely listened to. As a consequence patients felt marginalised by the health systems there to support them and by society as a whole. CONCLUSIONS: Narrative content analysis can help distil large amounts of free text data and enable their successful interpretation. Listening to patients' voices should become an integral part of routine service evaluation and may help bring patient expectation more in line with service organisation and delivery towards an optimal delivery of care.