Detection of Neuroinflammation Induced by Typhoid Vaccine Using Quantitative Magnetization Transfer MR: A Randomized Crossover Study.

BACKGROUND: The role of neuroinflammation in psychiatric disorders is not well-elucidated. A noninvasive technique sensitive to low-level neuroinflammation may improve understanding of the pathophysiology of these conditions. PURPOSE: To test the ability of quantitative magnetization transfer (QMT) MR at 3 T for detection of low-level neuroinflammation induced by typhoid vaccine within a clinically reasonable scan time. STUDY TYPE: Randomized, crossover, placebo-controlled. SUBJECTS: Twenty healthy volunteers (10 males; median age 34 years). FIELD STRENGTH/SEQUENCE: Magnetization prepared rapid gradient-echo and MT-weighted 3D fast low-angle shot sequences at 3 T. ASSESSMENT: Participants were randomized to either vaccine or placebo first with imaging, then after a washout period received the converse with a second set of imaging. MT imaging, scan time, and blood-based inflammatory marker concentrations were assessed pre- and post-vaccine and placebo. Mood was assessed hourly using the Profile of Mood States questionnaire. QMT parameter maps, including the exchange rate from bound to free pool (kba) were generated using a two-pool model and then segmented into tissue type. STATISTICAL TESTS: Voxel-wise permutation-based analysis examined inflammatory-related alterations of QMT parameters. The threshold-free cluster enhancement method with family-wise error was used to correct voxel-wise results for multiple comparisons. Region of interest averages were fed into mixed models and Bonferroni corrected. Spearman correlations assessed the relationship between mood scores and QMT parameters. Results were considered significant if corrected P < 0.05. RESULTS: Scan time for the MT-weighted acquisition was approximately 11 minutes. Blood-based analysis showed higher IL-6 concentrations post-vaccine compared to post-placebo. Voxel-wise analysis found three clusters indicating an inflammatory-mediated increase in kba in cerebellar white matter. Cerebellar kba for white matter was negatively associated with vigor post-vaccine but not post-placebo. DATA CONCLUSION: This study suggested that QMT at 3 T may show some sensitivity to low-level neuroinflammation. Further studies are needed to assess the viability of QMT for use in inflammatory-based disorders. EVIDENCE LEVEL: 1 TECHNICAL EFFICACY: Stage 2.

Towards Personalised Mood Prediction and Explanation for Depression from Biophysical Data.

Digital health applications using Artificial Intelligence (AI) are a promising opportunity to address the widening gap between available resources and mental health needs globally. Increasingly, passively acquired data from wearables are augmented with carefully selected active data from depressed individuals to develop Machine Learning (ML) models of depression based on mood scores. However, most ML models are black box in nature, and hence the outputs are not explainable. Depression is also multimodal, and the reasons for depression may vary significantly between individuals. Explainable and personalised models will thus be beneficial to clinicians to determine the main features that lead to a decline in the mood state of a depressed individual, thus enabling suitable personalised therapy. This is currently lacking. Therefore, this study presents a methodology for developing personalised and accurate Deep Learning (DL)-based predictive mood models for depression, along with novel methods for identifying the key facets that lead to the exacerbation of depressive symptoms. We illustrate our approach by using an existing multimodal dataset containing longitudinal Ecological Momentary Assessments of depression, lifestyle data from wearables and neurocognitive assessments for 14 mild to moderately depressed participants over one month. We develop classification- and regression-based DL models to predict participants' current mood scores-a discrete score given to a participant based on the severity of their depressive symptoms. The models are trained inside eight different evolutionary-algorithm-based optimisation schemes that optimise the model parameters for a maximum predictive performance. A five-fold cross-validation scheme is used to verify the DL model's predictive performance against 10 classical ML-based models, with a model error as low as 6% for some participants. We use the best model from the optimisation process to extract indicators, using SHAP, ALE and Anchors from explainable AI literature to explain why certain predictions are made and how they affect mood. These feature insights can assist health professionals in incorporating personalised interventions into a depressed individual's treatment regimen.

From the chemical imbalance to the power imbalance: A psychiatry trainee's perspectives on service-user supervision.

OBJECTIVE: This paper describes perspectives and insights of a trainee's experience of service-user supervision. This includes the background to this novel approach, outlining its process and content, key themes arising, applications in practice, limitations of the approach, and future considerations. CONCLUSIONS: Service-user supervision promotes education and experiences at this important stage of professional development and can promote clinical, cultural, and systemic changes required to support the paradigm shift towards recovery-oriented and human rights-based practice.

Broadening the state of play - the second national survey of Consultation-Liaison Psychiatry services in New Zealand, 2021.

OBJECTIVE: The original national survey of Consultation-Liaison Psychiatry (CLP) services in New Zealand (NZ) that was undertaken in 2018 (CLPSNZ-1) established a baseline but was limited in scope. The aim of the current study was to conduct a more in-depth national survey. METHOD: A 44-question survey was emailed to clinicians at each of the 16 general hospitals in NZ with specialist adult CLP services in 2021. RESULTS: Responses were obtained from all 16 CLP services. These services were found to be under-resourced (with mean total full-time equivalents of 0.26 psychiatrists and 1.10 clinicians per 100 inpatient beds, respectively), operate with highly variable service models (with major variations in operating hours and coverage of age groups, the Emergency Department and outpatients) and provide a predominantly consultation service. CONCLUSION: While many of the findings from CLPSNZ-1 remain relevant, the current survey has extended our understanding of the circumstances, achievements and challenges of this psychiatric subspecialty in NZ.

A survey of the psychiatric care provided for medically ill older adults in general hospitals in New Zealand.

OBJECTIVE: The aim of this study was to conduct an in-depth survey of the psychiatric care provided for medically ill older adults in general hospitals in New Zealand (NZ). METHOD: As part of a larger survey of Consultation-Liaison Psychiatry (CLP) services for all ages in NZ (CLPSNZ-2), a 44-question survey was emailed to clinicians who were involved in providing psychiatric care for medically ill older adults at each of the 16 general hospitals with designated CLP services. RESULTS: Responses were obtained from 22 services at 16 hospitals - 14 CLP services and eight Psychiatry of Old Age (POA) in-reach services. These services were found to be under-resourced, operate with highly variable service models, and predominantly provide inpatient consultations. Services could be conceptualised as six prototypes with variations of POA in-reach to hospitals, scope of CLP cover and collaboration between services. CONCLUSION: The heterogeneity in the psychiatric care for medically ill older adults in NZ means that there is an urgent need to develop more consistent CLP service models that better serve the specialist needs of older adults, and establish the policies, resources and standards needed to support them.

Concurrent Disorders and Decision-Making in Electronic Gaming Machine Gamblers.

This study aimed to investigate the self-reported measures of concurrent disorders (stress, social anxiety, anxiety, depression and alcohol use) among electronic gaming machine (EGM) gamblers with varying levels of gambling severity and to examine its relationship to decision-making. This cross-sectional study in New Zealand involved an online survey that utilised validated questionnaires to assess self-reported measures of concurrent disorders and the Iowa gambling task (IGT) to analyse decision-making. The study comprised of active EGM gamblers (n = 153) who were divided into two groups: non-problem gambling (NPG, n = 71) and problem gambling (PG, n = 82) based on the cut-off point of the South Oaks Gambling Screen (SOGS). Multiple logistic regression models were performed to analyse co-occurring disorders separately and simultaneously, and a log-linear model was developed to define the associations between significant variables. The first model showed a strong correlation between gambling severity and measures for depression (p < 0.01), anxiety (p < 0.05), stress (p < 0.05) and alcohol use (p < 0.01), however only depression (p < 0.05) and alcohol use (p < 0.01) remained significant in the second model. Further, no association between social anxiety scores and problem gambling was found in this sample of EGM gamblers in both models. On the IGT, EGM gamblers in the PG group performed significantly worse. Further, the presence of poor decision-making was more pronounced with higher depression scores (p < 0.01) across both NPG and PG groups and higher alcohol use scores (p < 0.05) scores in the PG group. The presence of high levels of co-occurring disorders and its link to poor decision-making are important considerations in the treatment paradigm of EGM problem gamblers.

The perceptions of cancer health-care practitioners in New Zealand and the USA toward psychedelic-assisted therapy with cancer patients: A cross-sectional survey.

OBJECTIVES: A resurgence of research investigating the administration of psychedelic compounds alongside psychotherapy suggests that this treatment is a promising intervention for anxiety, depression, and existential distress in people with cancer. However, psychedelic treatment that induces a mind-altering experience potentially poses barriers to vulnerable cancer patients, and health-care practitioners may have concerns about referring their patients to trials investigating this approach. The aim of the current study was to investigate the perceptions of cancer health-care practitioners based in New Zealand and the USA related to psychedelic-assisted therapy. METHODS: This study utilized a cross-sectional survey of cancer health-care practitioners in New Zealand and the USA via convenience sampling to identify their perceptions about the concept of conducting psychedelic-assisted therapy with cancer patients. RESULTS: Participants perceived that (1) psychedelic-assisted therapy has the potential to provide benefit for cancer patients, (2) research in this area across a variety of domains is important, (3) work should consider spiritual and indigenous perspectives of health, and (4) there was willingness to refer patients to trials in this area, especially patients with advanced disease who were no longer going through curative treatment. Participants in the USA had greater awareness of psychedelics than the New Zealand sample; however, New Zealand participants more strongly believed that spiritual/indigenous factors should be considered in psychedelic-assisted therapy. SIGNIFICANCE OF RESULTS: Cancer health-care practitioners in our sample considered research investigating the potential for psychedelic-assisted therapies to be important and may be more open to studies that start in palliative and end-of-life contexts.

General practitioners and decision-making capacity assessment: the experiences and educational needs of New Zealand general practitioners.

BACKGROUND: Assessing decision-making capacity to health care is within the scope of practice for all doctors, yet the experience of GPs in this area is unknown. OBJECTIVE: To explore the experiences, perspectives, approaches and challenges for GPs in New Zealand when conducting decision-making capacity assessments. METHODS: Qualitative study design comprising individual in-depth semi-structured interviews conducted with a convenience sample of GPs. Interview transcripts were transcribed verbatim and analysed using a thematic analysis approach. RESULTS: Twelve participants were recruited. The following themes emerged: (i) GPs' roles and responsibilities in decision-making capacity assessments; (ii) GPs lack formal training, knowledge, and confidence in decision-making capacity assessments; (iii) the legal interface of decision-making capacity assessments; (iv) GPs' relationships with specialists and the resulting impact on their confidence in decision-making capacity assessments; and (v) opportunities to improve GPs' knowledge and confidence in decision-making capacity assessments. CONCLUSIONS: GPs take responsibility for decision-making capacity assessments; however, assessments can be complex. There is a need to develop specific curriculum and training resources for GPs to improve their clinical skills and legal knowledge in decision-making capacity assessments.

The state of play - the first national survey of consultation-liaison psychiatry services in New Zealand.

OBJECTIVE: The aim of this study was to conduct the first national survey of consultation-liaison psychiatry (CLP) services in New Zealand. METHOD: An online survey based on the Multidimensional Matrix for Consultation-Liaison Psychiatry (mMAX-LP) was circulated to a psychiatrist at each of 12 identified CLP services nationally during April-May 2018. Existing data for Middlemore Hospital (where the lead author is based) were added later for completion. RESULTS: Most CLP services in New Zealand are funded and managed by the mental health division, operate within office hours, and have psychologists and other allied health staff external to their service. However, there was significant heterogeneity amongst these services in terms of structure and function and in particular, the coverage of emergency departments and young/older patient groups. CONCLUSION: This first national survey has provided a snapshot of CLP services in New Zealand in 2018 and found striking heterogeneity. The survey has established a baseline for future local and international comparisons.

The multi-dimensional matrix for consultation-liaison psychiatry (mMAX-LP).

OBJECTIVE: Consultation-liaison psychiatry (CLP) services are particularly susceptible to heterogeneity, developing haphazardly in response to local interests and perceived need. This hampers the generalisability of comparisons between services in terms of service models, resource requirements and outcome data. The objective of this paper therefore is to chronicle the development of a method to meaningfully describe, map and compare different CLP services. METHOD: A review of the literature was followed by multiple site visits in both New Zealand and England, and an extended process of consultation and feedback. RESULTS: Sixteen dimensions common to CLP services were extracted to create a multi-dimensional matrix (mMAX-LP) which had three broad clusters (structure, coverage and relationship with physical health services). The model was applied and discussed with the previously visited hospitals over the succeeding five years. Additionally, the matrix was tested, and its utility demonstrated during the planned reconfiguration of CLP services at a large teaching hospital in South Auckland, New Zealand by tracking the evolution of CLP services. CONCLUSIONS: mMAX-LP shows promise as a useful model for profiling and comparing CLP services; mapping their evolution over time; and sign-posting future service development.

Nonepileptic seizures in individuals attending neurological services in New Zealand.

OBJECTIVES: This study examined the demographic, social, and clinical (neurological and psychiatric) characteristics of people with psychogenic nonepileptic seizures (PNES) presenting to tertiary neurological services at Auckland District Health Board, New Zealand. METHODS: Electronic notes and video-electroencephalography (video-EEG) data gathered from the telemetry unit based on synchronized acquisition (motor activity and brain electrophysiology) over a five-year period (2011 to 2015 inclusive) were retrospectively examined. Two groups were compared: people with PNES only or people with combined PNES and epileptic seizures (ES) (the group with PNES) and a control group with ES only, matched 1:1 by age and gender. RESULTS: Sixty-six people in the group with PNES were matched with an equivalent number of ES controls. As a cohort, there was high psychiatric and medical comorbidity in both groups, but overall, those with PNES experienced higher rates than their ES counterparts. An older age of onset, female gender, and history of abuse were more frequently seen in those with PNES. Compared with controls, people with PNES more commonly had daily seizures (rather than monthly) but presented less frequently to neurology services. A high proportion of people with PNES experienced historical traumas, ongoing stressors, and disability. Almost half of the people with PNES were on antiepileptic drugs (AEDs) and received limited psychiatric or psychological input. In contrast, people with ES were more likely to be on psychotropic medication. CONCLUSION: Both PNES and ES are associated with high levels of psychiatric and medical comorbidity. Additionally, PNES were found to be associated with iatrogenic harm and disability. Though people with PNES and ES often have a range of associated needs, there is, however, limited access to appropriate services. The needs of these populations should be better met through enhanced integration across psychiatry, neurology, and multidisciplinary services.

Do suicide characteristics differ by age in older people?

ABSTRACTBackground:Suicide rates increase with age in the population aged over 65 years. The aims of this study were to (i) report the characteristics of older people who died by suicide; and (ii) investigate whether these characteristics differ in three age bands: 65-74 years, 75-84 years, and 85+ years. METHODS: Using information from national coroner records, relevant socio-demographic and clinical factors in all suicides (age ≥ 65 years; n = 225) from July 2007 to December 2012 in New Zealand were analyzed and compared in the three age bands. RESULTS: We found the older the person, the more likely they are to be widowed but the less likely to have a past psychiatric admission or recent contact with psychiatric services in the month prior to suicide. However, most of the older people (61.7% of 65-74 years, 65.6% of 75-84 years, and 77.3% of 85+ years) had contact with their general practitioner within one month of suicide. Women were less likely to use violent methods than men in all three age bands but with increasing age, men were less likely to use violent methods. CONCLUSIONS: Suicide characteristics in older people differ by age. The oldest people who die by suicide are not necessarily under psychiatric services and may benefit from a primary care-based approach in which there is screening for depression and suicide risk.

Death wishes among older people assessed for home support and long-term aged residential care.

OBJECTIVE: Death wishes in older people are common and may progress to suicidal ideation and attempts. This study used routinely collected data from the interRAI Home Care assessment to examine the prevalence and clinical predictors of death wishes in older New Zealanders assessed for home support and long-term aged residential care. METHODS: Data were collected from 35 734 people aged over 65 during 2012-2014. Chi-squared analyses were used to determine significant relationships between the presence of death wishes and demographic factors, health and functional status, and emotional and psychosocial well-being. A three-step hierarchical logistic regression model was used to determine the predictive variables of death wishes, and odds ratios were calculated. RESULTS: Death wishes were present in 9.5% of the sample. The following factors were significantly associated with death wishes: physical health (poor self-reported health, recurrent falls, severe fatigue and inadequate pain control), psychological factors (depression, major stressors and anxiety), social factors (loneliness and decline in social activities) and impaired cognition. Depression (odds ratio = 2.54, 95% confidence interval = 2.29-2.81), loneliness (odds ratio = 2.40, 95% confidence interval = 2.20-2.63) and poor self-reported health (odds ratio = 2.34, 95% confidence interval = 1.78-3.07) had the greatest odds ratios in the full model. CONCLUSIONS: Clinically significant depression alone cannot fully account for the development of death wishes in the elderly, and several factors are independently associated with death wishes. This knowledge can help clinicians caring for older persons to identify people who are most at risk of developing death wishes. Copyright © 2016 John Wiley & Sons, Ltd.

Predictors for repeat self-harm and suicide among older people within 12 months of a self-harm presentation.

BACKGROUND: A past history of self-harm is a significant risk factor for suicide in older people. The aims of this study are to (i) characterize older people who present with self-harm to emergency departments (EDs); and (ii) determine the predictors for repeat self-harm and suicide. METHODS: Demographic and clinical data were retrospectively collected on older people (age 65+ years), who presented to seven EDs in New Zealand following an episode of self-harm between 1st July 2010 and 30th June 2013. In addition, 12-month follow-up information on repeat self-harm and suicide was collected. RESULTS: The sample included 339 older people (55.2% female) with an age range of 65-96 years (mean age = 75.0; SD = 7.6). Overdose (68.7%) was the most common method of self-harm. 76.4% of the self-harm cases were classified as suicide attempts. Perceived physical illness (47.8%) and family discord (34.5%) were the most common stressors. 12.7% of older people repeated self-harm and 2.1% died by suicide within 12 months. Older people who had a positive blood alcohol reading (OR = 3.87, 95% Cl = 1.35-11.12, p = 0.012) and were already with mental health services at the index self-harm (OR = 2.73, 95% Cl = 1.20-6.25, p = 0.047) were more likely to repeat self-harm/suicide within 12 months. CONCLUSION: Older people who self-harm are at very high risk of repeat self-harm and suicide. Screening and assessment for alcohol use disorders should be routinely performed following a self-harm presentation, along with providing structured psychological treatment as an adjunct to pharmacological treatment for depression and interventions to improve the person's resilience resources.

Understanding the Progression from Physical Illness to Suicidal Behavior: A Case Study Based on a Newly Developed Conceptual Model.

Suicide in older people is a significant public health issue given the aging population and increasing suicide rates with age in many parts of the world. Depression and physical illness are two factors consistently associated with suicidal behavior in older people; however, their inter-relationships are not well understood. We present here a case study based on a newly developed conceptual model illustrating the various medical, psychological, social and resilience factors involved in the progression of physical illness to suicidal behavior. This model provides a framework for clinicians to understand protective factors and address late-life suicide risk.

Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy.

OBJECTIVES: Psychogenic nonepileptic seizures (PNESs) are closely linked with psychological distress, but their etiology is not well-understood. We reviewed psychiatric comorbidity in PNESs and epileptic seizures (ESs) with an aim to assist understanding, diagnosis, and management of PNESs. METHODS: A search of Web of Science, MEDLINE (PubMed), PsycINFO, and Scopus identified 32 relevant studies on the prevalence of psychiatric comorbidity in PNESs. We used meta-analysis to compare psychiatric comorbidity between PNESs and ESs. RESULTS: Samples with PNESs had high rates of psychiatric comorbidity overall (53-100%), notably including posttraumatic stress disorder (PTSD), depression, and personality and anxiety disorders. Compared with ESs, samples with PNESs had more psychiatric comorbidity overall (RR: 1.30, 95% CI: 1.14-1.48, p<0.0001) with significantly elevated risks found for PTSD, personality disorder, and anxiety but not depression. CONCLUSIONS: Psychiatric disorders are more common in PNESs than ESs. Because of methodological limitations of available studies, causality cannot be established; prospective longitudinal designs are required.

Enhancing suicide risk assessment: a novel visual metaphor learning tool.

OBJECTIVE: Suicide risk assessment is variably taught and learnt by health professionals. The literature indicates that training programs of this fundamental competency need to be enhanced. To facilitate teaching and learning of this core clinical skill, we propose a novel visual metaphor in order to conceptualize suicide risk factors. The design of the proposed visual metaphor was informed by the Cognitive Load Theory to enhance deep learning of the various suicide risk factors. CONCLUSION: The visual metaphor depicting suicide risk factors can potentially improve memory and recall. It activates prior knowledge and is based on educational theory informed design principles.

Late-life homicide-suicide: a national case series in New Zealand.

Homicide-suicide is a rare event, but it has a significant impact on the family and community of the perpetrator and victim(s). The phenomenon of late-life homicide-suicide has not been previously studied in New Zealand, and there is only limited data in the international literature. The aim of this study is to systematically review coroners' records of late-life homicide-suicides in New Zealand. After ethics approval was granted, the Coronial Services of New Zealand was approached to provide records of all closed cases with a suicide verdict (age 65+) over a five-year period (July 2007-December 2012). Of the 225 suicides, 4 cases of homicide-suicide were identified (an estimated incidence of 0.12 per 100,000 per persons year). All four perpetrators were men; three had been farmers. Their ages ranged from 65 to 82. One case occurred in the context of an underlying psychiatric illness (psychotic depression in bipolar disorder). Firearms were used in three cases. Two cases were categorized as spousal/consortial subtype, one case as filicide-suicide, and one case as siblicide-suicide. The prospect of major social upheaval in the form of losing their homes was present in all four cases. The findings of this case series were consistent with the limited existing literature on homicide-suicide. Age-related biopsychosocial issues were highlighted in this case series of late-life homicide-suicide. Additionally, evaluating firearm licences in high-risk groups may represent a prevention strategy.

Medical examiner and coroner reports: uses and limitations in the epidemiology and prevention of late-life suicide.

OBJECTIVE: Late-life suicide is a growing public health concern in many parts of the world. Understanding the contributory factors to completed suicide is essential to inform the development of effective suicide risk assessment and management. The aim of this study is to synthesise the findings in studies that used coroner or medical examiner records to determine these contributory factors. METHODS: The databases of Scopus (from 1960), MEDLINE (from 1946) and PsychINFO (from 1806) were searched in August 2013, to identify studies that used coroner or medical examiner records for investigating the epidemiological, sociodemographic characteristics and clinical aspects of late-life suicide. RESULTS: In total, 25 studies were identified. There was a lack of standardisation of variables assessed between studies leading to incomplete datasets in some work. However, a diagnosis of depression was found in 33%, and depressive mood/symptoms in 47% of cases. About 55% had a physical health problem. Terminal illness was associated with a smaller proportion (7.1%) of the cases. Older people were more likely to have had contact with primary care rather than mental health services prior to suicide. CONCLUSIONS: Despite their limitations, coroner and medical examiner records provide an opportunity for examining suicide epidemiology. Targeting primary care providers where late-life depression and physical illness can be detected and treated is a potential strategy to address late-life suicide.