Demonstration of automated non-adherence and service disengagement risk monitoring with active follow-up for severe mental illness.

AIMS: Medication cessation and service disengagement often precedes relapse in people with severe mental illnesses but currently specialist mental health services only become involved after a relapse. Early detection of non-adherence is needed to enable intervention to avert relapse. This paper aims to demonstrate how digitally automated non-adherence risk monitoring from Medicare data with active follow-up can work and perform in practice in a real-world mental health service setting. METHODS: AI2 software is an automated risk monitoring tool to detect non-adherence using Medicare data. It was implemented prospectively in a cohort of 354 registered patients of a community mental health clinic between July 2019 and February 2020. Patients flagged as at risk by the software were reviewed by two clinicians. We describe the risks automatically flagged for non-adherence and the clinical responses. We examine differences in clinical and demographic factors in patients flagged at increased risk of non-adherence. RESULTS: In total, 46.7% (142/304) were flagged by the software as at risk of non-adherence, and 22% (31/142) received an intervention following clinician review of their case notes. Patients flagged by the software were older in age and had more prior mental health treatment episodes. More alerts were associated with patients who had been transferred from the mental health service to the care of their general practitioners, and those with more alerts were more likely to receive a follow-up intervention. CONCLUSION: Digitally automated monitoring for non-adherence risk is feasible and can be integrated into clinical workflows in community psychiatric and primary care settings. The technology may assist clinicians and services to detect non-adherence behaviour early, thereby triggering interventions that have the potential to reduce rates of mental health deterioration and acute illness relapse.

Determining the Influence of Psychiatric Comorbidity on Hospital Admissions in Cardiac Patients Through Multilevel Modelling of a Large Hospital Activity Data Set.

BACKGROUND: Increasingly, big data derived from administrative hospital records can be subject to analytics to provide clinical insights. The aim of this study was to determine the impact of psychiatric comorbidity on length of hospital stay and number of hospital admissions in cardiac patients utilising routinely collected hospitalisation records. METHODS: We routinely collected clinical and socio-demographic variables extracted from 37,580 cardiac patients, between 18 and 65 years old, admitted to South Australian hospitals between 2001/02 to 2010/11 financial years with cardiac diagnoses used to derive patient level and separation level variables used in the modelling. Multi-level models were constructed to analyse the impact of psychiatric comorbidity on both length of stay and the total number of hospitalisations, allowing for interactions between socioeconomic status and the burden of disease. Possible confounders for these models were, sex, age, indigenous status, country of birth, and rural status. RESULTS: For cardiac patients a mental health diagnosis was associated with an increase of 12.5% in the length of stay, and an increase in the number of stays by 20.0%. CONCLUSIONS: This study demonstrates the potential utility of routinely collected hospitalisation records to demonstrate the impact of psychiatric comorbidity on health service utilisation.

Health timeline: an insight-based study of a timeline visualization of clinical data.

BACKGROUND: The increasing complexity and volume of clinical data poses a challenge in the decision-making process. Data visualizations can assist in this process by speeding up the time required to analyze and understand clinical data. Even though empirical experiments show that visualizations facilitate clinical data understanding, a consistent method to assess their effectiveness is still missing. METHODS: The insight-based methodology determines the quality of insights a user acquires from the visualization. Insights receive a value from one to five points based on a domain-specific criteria. Five professional psychiatrists took part in the study using real de-identified clinical data spanning 4 years of medical history. RESULTS: A total of 50 assessments were transcribed and analyzed. Comparing a total of 558 insights using Health Timeline and 576 without, the mean value using the Timeline (1.7) was higher than without (1.26; p<0.01), similarly the cumulative value with the Timeline (11.87) was higher than without (10.96: p<0.01). The average time required to formulate the first insight with the Timeline was higher (13.16 s) than without (7 s; p<0.01). Seven insights achieved the highest possible value using Health Timeline while none were obtained without it. CONCLUSIONS: The Health Timeline effectively improved understanding of clinical data and helped participants recognize complex patterns from the data. By applying the insight-based methodology, the effectiveness of the Health Timeline was quantified, documented and demonstrated. As an outcome of this exercise, we propose the use of such methodologies to measure the effectiveness of visualizations that assist the clinical decision-making process.

Designing Online Interventions in Consideration of Young People's Concepts of Well-Being: Exploratory Qualitative Study.

BACKGROUND: A key challenge in developing online well-being interventions for young people is to ensure that they are based on theory and reflect adolescent concepts of well-being. OBJECTIVE: This exploratory qualitative study aimed to understand young people's concepts of well-being in Australia. METHODS: Data were collected via workshops at five sites across rural and metropolitan sites with 37 young people from 15 to 21 years of age, inclusive. Inductive, data-driven coding was then used to analyze transcripts and artifacts (ie, written or image data). RESULTS: Young adults' conceptions of well-being were diverse, personally contextualized, and shaped by ongoing individual experiences related to physical and mental health, along with ecological accounts acknowledging the role of family, community, and social factors. Key emerging themes were (1) positive emotions and enjoyable activities, (2) physical wellness, (3) relationships and social connectedness, (4) autonomy and control, (5) goals and purpose, (6) being engaged and challenged, and (7) self-esteem and confidence. Participants had no difficulty describing actions that led to positive well-being; however, they only considered their own well-being at times of stress. CONCLUSIONS: In this study, young people appeared to think mostly about their well-being at times of stress. The challenge for online interventions is to encourage young people to monitor well-being prior to it becoming compromised. A more proactive focus that links the overall concept of well-being to everyday, concrete actions and activities young people engage in, and that encourages the creation of routine good habits, may lead to better outcomes from online well-being interventions.

Correlation between symptoms and functioning in psychiatric patients and temporal patterns of medication refills derived from pharmacy prescription claims.

OBJECTIVES:: Pharmacy dispensing claims data provide longitudinal records of prescriptions and refill events. Previous studies in psychiatric patients have utilised these data to derive indicators of medication adherence based on information regarding the amount of medication supplied and its dosage. An alternative approach was developed in which the regularity of medication refill events was analysed as a potential indicator of psychiatric patient symptoms and functioning. METHODS:: A method to quantify the regularity of medication refills was developed and subsequently used to investigate how the resulting regularity index (RI), derived from retrospective prescription refill records, correlated with symptomatic and functional assessments of 89 psychiatric patients after adjusting for covariates. RESULTS:: A two-step hierarchical regression model indicated that variances explained by prior hospitalisation and the RI were significant for patient scores on the Kessler 10 Psychological Distress Scale (K10), standard beta value 0.22, p < 0.05, for the SF-12 MC, standard beta value -0.31, p < 0.01, and the Work and Social Adjustment Scale (WSAS), standard beta value 0.31, p < 0.01. CONCLUSIONS:: This method to quantify the regularity of medication refills using prescription supply date alone may provide valuable information about patients' symptoms and functioning.

Efficacy of a Web-Based Guided Recommendation Service for a Curated List of Readily Available Mental Health and Well-Being Mobile Apps for Young People: Randomized Controlled Trial.

BACKGROUND: Mental disorders are highly prevalent for the people who are aged between 16 and 25 years and can permanently disrupt the development of these individuals. Easily available mobile health (mHealth) apps for mobile phones have great potential for the prevention and early intervention of mental disorders in young adults, but interventions are required that can help individuals to both identify high-quality mobile apps and use them to change health and lifestyle behavior. OBJECTIVES: The study aimed to assess the efficacy of a Web-based self-guided app recommendation service ("The Toolbox") in improving the well-being of young Australians aged between 16 and 25 years. The intervention was developed in collaboration with young adults and consists of a curated list of 46 readily available health and well-being apps, assessed and rated by professionals and young people. Participants are guided by an interactive quiz and subsequently receive recommendations for particular apps to download and use based on their personal goals. METHODS: The study was a waitlist, parallel-arm, randomized controlled trial. Our primary outcome measure was change in well-being as measured by the Mental Health Continuum-Short Form (MHC-SF). We also employed ecological momentary assessments (EMAs) to track mood, energy, rest, and sleep. Participants were recruited from the general Australian population, via several Web-based and community strategies. The study was conducted through a Web-based platform consisting of a landing Web page and capabilities to administer study measures at different time points. Web-based measurements were self-assessed at baseline and 4 weeks, and EMAs were collected repeatedly at regular weekly intervals or ad hoc when participants interacted with the study platform. Primary outcomes were analyzed using linear mixed-models and intention-to-treat (ITT) analysis. RESULTS: A total of 387 participants completed baseline scores and were randomized into the trial. Results demonstrated no significant effect of "The Toolbox" intervention on participant well-being at 4 weeks compared with the control group (P=.66). There were also no significant differences between the intervention and control groups at 4 weeks on any of the subscales of the MHC-SF (psychological: P=.95, social: P=.42, emotional: P=.95). Repeat engagement with the study platform resulted in a significant difference in mood, energy, rest, and sleep trajectories between intervention and control groups as measured by EMAs (P<.01). CONCLUSIONS: This was the first study to assess the effectiveness of a Web-based well-being intervention in a sample of young adults. The design of the intervention utilized expert rating of existing apps and end-user codesign approaches resulting in an app recommendation service. Our finding suggests that recommended readily available mental health and well-being apps may not lead to improvements in the well-being of a nonclinical sample of young people, but might halt a decline in mood, energy, rest, and sleep. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000710628; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366145 (Archived by WebCite at http://www.webcitation.org/ 6pWDsnKme).

Characteristics of patients seen by visiting psychiatrists through Medicare in a rural community mental health service with an established telemedicine service.

OBJECTIVE: We aimed to determine characteristics of patients receiving Medicare-funded face-to-face consultations by psychiatrists in a rural service with an established telemedicine service. METHODS: For this study, 55 case-managed patients from four rural community mental health teams in South Australia provided information through questionnaires regarding psychological symptoms, quality of life, body mass index (BMI) and gave access to their Medicare data. RESULTS: In a logistic regression, it was found that being younger was more likely associated with a Medicare psychiatric consultation ( p<0.05). Participants with at least one recorded visit to a Medicare psychiatrist consultation also tended to have lower levels of psychological distress at the end of the 4-year period, have a higher BMI, and more general practitioner consultations. CONCLUSION: The study provides clinicians and policy makers with preliminary information on the subtle differences in clinical profile of patients seen by Medicare-funded psychiatrists within an established state-managed telepsychiatry service.

There is No Association Between the Omega-3 Index and Depressive Symptoms in Patients With Heart Disease Who Are Low Fish Consumers.

BACKGROUND: Long chain Omega-3 polyunsaturated fatty acids (LCn3PUFAs) may improve cardiovascular health and depression. This study investigated the relationships between erythrocyte membrane LCn3PUFA status, depression and angina symptoms in patients with heart disease. METHODS: We recruited 91 patients (65 males and 26 females, mean age 59.2±10.3 years) with heart disease and depressive symptoms (Center for Epidemiological Studies Depression Scale, CES-D ≥ 16) and low fish/fish oil intakes. The Omega-3 Index (EPA+DHA) of erythrocyte membranes (as a percentage of total fatty acids) was assessed by gas chromatography. Depression status was measured by both self-report and clinician-report scales; CES-D and the Hamilton depression scale (HAM-D). Angina symptoms were measured using the Seattle Angina Questionnaire and the Canadian Cardiovascular Society Classification for Angina Pectoris. RESULTS: The mean Omega-3 Index was 4.8±1.0% (±SD). Depression scores measured by CES-D and HAM-D were 29.2±8.8 (moderate to severe) and 11.0±5.7 (mild) (arbitrary units) respectively reflecting a different perception of depressive symptoms between patients and clinicians. Angina status was inversely associated with depression scores (r>-0.26, P<0.03). There were no significant relationships between individual LCn3PUFA or the Omega-3 Index and either the depression scores or the angina symptoms. CONCLUSION: Worse angina status was associated with worse depression, but the Omega-3 Index was not associated with symptoms of depression or angina in patients with heart disease.

The promise and the reality: a mental health workforce perspective on technology-enhanced youth mental health service delivery.

BACKGROUND: Digital technologies show promise for reversing poor engagement of youth (16-24 years) with mental health services. In particular, mobile and internet based applications with communication capabilities can augment face-to-face mental health service provision. The literature in this field, however, fails to adequately capture the perspectives of the youth mental health workforce regarding utility and acceptability of technology for this purpose. METHODS: This paper describes results of in-depth qualitative data drawn from various stakeholders involved in provision of youth mental health services in one Australian rural region. Data were obtained using focus groups and semi-structured interviews with regional youth mental health clinicians, youth workers and support/management staff (n = 4 focus groups; n = 8 interviews) and analysed via inductive thematic analysis. RESULTS: Results question the acceptability of technology to engage clients within youth mental health services. Six main themes were identified: young people in a digital age, personal connection, power and vulnerability, professional identity, individual factors and organisational legitimacy. CONCLUSIONS: These findings deepen the understanding of risks and challenges faced when adopting new technologies in mental healthcare. Recommendations for technology design and implementation in mental health services are made.

Paid and Unpaid Online Recruitment for Health Interventions in Young Adults.

PURPOSE: There is a growing need to identify new and innovative approaches to recruit representative samples of young adults in health intervention research. The current study used a data set of screening information from an online well-being intervention trial of young adults, to investigate cost-effectiveness of different recruitment strategies and whether the clinical and demographic characteristics of participants differed depending on paid or unpaid online recruitment sources. METHODS: Data were collected from 334 18- to 25-year-old Australians. The study was advertised through a variety of paid and unpaid online recruitment channels (e.g., Google, Facebook, Twitter, YouTube, recruitment agency), with response rates to different recruitment channels tracked using unique Web links. Well-being of participants was measured using the Mental Health Continuum Short Form. Analyses consisted of independent t tests and χ2 tests. RESULTS: Overall, unpaid recruitment channels had a considerably higher yield than paid recruitment channels. Of paid recruitment channels, a recruitment agency and paid Facebook advertisements attracted the largest number of individuals. This study also found differences between paid and unpaid online recruitment channels with regard to the well-being and mood of participants. CONCLUSIONS: Although the success of online recruitment channels is likely subject to a complex interplay between the number of exposures, the targeted sample, the wording, and placement of the advertisement, as well as study characteristics, our study demonstrated that unpaid recruitment channels are more effective than paid channels and that paid and unpaid channels may result in samples with different characteristics.

Service providers' experiences of using a telehealth network 12 months after digitisation of a large Australian rural mental health service.

BACKGROUND: Despite evidence of benefits of telehealth networks in increasing access to, or providing, previously unavailable mental health services, care providers still prefer traditional approaches. For psychiatric assessment, digital technology can offer improvements over analog systems for the technical and, subsequently, the social quality of provider-client interaction. This is in turn expected to support greater provider uptake and enhanced patient benefits. OBJECTIVE: Within the framework of Innovation Diffusion Theory, to study service providers' experiences of an existing regional telehealth network for mental health care practice twelve months after digitisation in order to identify the benefits of digital telehealth over an analog system for mental health care purposes in rural Australia. METHODS: Qualitative interviews and focus groups were conducted with over 40 service providers from June to September 2013 in South Australia, ranging from the metropolitan central operations to health providers located up to 600km away in rural and remote areas of the same state. Participants included rural mental health teams, directors of nursing at rural hospitals, metropolitan-based psychiatrists and registrars, the metropolitan-based mental health team dedicated to rural provider support, rural GPs, administrative staff, and the executive group of the state rural health department. Fieldwork was conducted 12 months after the analog system was digitised. The interview and focus group data were analysed using thematic analysis, focusing on three key areas of innovation diffusion theory: relative advantage, technical complexity and technical compatibility. RESULTS: Five themes with 11 sub-themes were identified: (1) "Existing Uses", with three sub-themes: current mental health use, use by GPs, and use for staff support; (2) "Relative Advantage", with four sub-themes: improved technical quality, improved clinical practice, time and cost benefits for providers, and improved patient care; (3) "Technical Complexity"; (4) "Technical Compatibility" with two sub-themes: technical-clinical and technical-administrative; and (5) "Broader Organisational Culture", with two sub-themes: organizational policy support and 'digital telehealth' culture. CONCLUSIONS: The digitised telehealth network was generally well received by providers and adopted into clinical practice. Compared with the previous analog system, staff found advantages in better visual and audio quality, more technical stability with less "drop-out", less time delay to conversations and less confusion for clients. Despite these advantages, providers identified a range of challenges to starting or continuing use and they recommended improvements to increase uptake among mental health service providers and other providers (including GPs), and to clinical uses other than mental health. To further increase uptake and impact of telehealth-mediated mental health care in rural and remote areas, even with a high quality digital system, future research must design innovative care models, consider time and cost incentives for providers to use telehealth, and must focus not only on technical training but also how to best integrate technology with clinical practice and must develop an organization-wide digital telehealth culture.

Geography of primary mental health care through the Better Access initiative in South Australia 2006-2010.

OBJECTIVE: To examine how the rates of the use of particular face-to-face primary mental health care services changed in the first 4 years (2006-2010) of the Better Access initiative in both urban and rural regions of South Australia. DESIGN: Time-series analysis of the number of psychology session, psychiatry assessment and general practitioner care plan services recorded in Medicare Australia data. SETTING: South Australia. Pre-existing data set of South Australian residents who accessed Medicare between 2006 and 2010 MAIN OBJECTIVE MEASURE: Number of services per 100 000 population (service rate). RESULTS: Psychology session service rates increased in all regions, but continued to follow a 'location gradient', being higher in areas closer to Adelaide and lower in areas more distant from Adelaide. Psychiatry assessment service rates increased in Adelaide but did not change in other regions. Rates in remote areas were subject to substantial variation over time. General practitioner care plan service rates increased in Adelaide and in the Riverland, but declined in the Murray Mallee region. CONCLUSIONS: Overall, service rates increased in Adelaide and nearby regions, but the results for rural and remote regions were mixed. Possible explanations for the geographical variability include population characteristics (such as socio-economic status), methods of service delivery (visiting practitioners, telepsych), the relative proportion of total health services provided by general practitioners versus other practitioners, or real variations in the need for primary mental health services.

Changes in monthly unemployment rates may predict changes in the number of psychiatric presentations to emergency services in South Australia.

BACKGROUND: To determine the extent to which variations in monthly Mental Health Emergency Department (MHED) presentations in South Australian Public Hospitals are associated with the Australian Bureau of Statistics (ABS) monthly unemployment rates. METHODS: Times series modelling of relationships between monthly MHED presentations to South Australian Public Hospitals derived from the Integrated South Australian Activity Collection (ISAAC) data base and the ABS monthly unemployment rates in South Australia between January 2004-June 2011. RESULTS: Time series modelling using monthly unemployment rates from ABS as a predictor variable explains 69% of the variation in monthly MHED presentations across public hospitals in South Australia. Thirty-two percent of the variation in current month's male MHED presentations can be predicted by using the 2 months' prior male unemployment rate. Over 63% of the variation in monthly female MHED presentations can be predicted by either male or female prior monthly unemployment rates. CONCLUSIONS: The findings of this study highlight that even with the relatively favourable economic conditions, small shifts in monthly unemployment rates can predict variations in monthly MHED presentations, particularly for women. Monthly ABS unemployment rates may be a useful metric for predicting demand for emergency mental health services.

Development of an online well-being intervention for young people: an evaluation protocol.

BACKGROUND: Research has shown that improving well-being using positive mental health interventions can be useful for predicting and preventing mental illness. Implementing online interventions may be an effective way to reach young people, given their familiarity with technology. OBJECTIVE: This study will assess the effectiveness of a website called the "Online Wellbeing Centre (OWC)," designed for the support and improvement of mental health and well-being in young Australians aged between 16 and 25 years. As the active component of the study, the OWC will introduce a self-guided app recommendation service called "The Toolbox: The best apps for your brain and body" developed by ReachOut.com. The Toolbox is a responsive website that serves as a personalized, ongoing recommendation service for technology-based tools and apps to improve well-being. It allows users to personalize their experience according to their individual needs. METHODS: This study will be a two-arm, randomized controlled trial following a wait-list control design. The primary outcome will be changes in psychological well-being measured by the Mental Health Continuum Short Form. The secondary outcomes will be drawn from a subsample of participants and will include depression scores measured by the Center for Epidemiologic Studies Depression Scale, and quality of life measured by the Assessment of Quality of Life-four dimensions (AQOL-4D) index. Cost-effectiveness analysis will be conducted based on a primary outcome of cost per unique visit to the OWC. Utility-based outcomes will also be incorporated into the analysis allowing a secondary outcome to be cost per quality-adjusted life year gained (based on the AQOL-4D values). Resource use associated with both the intervention and control groups will be collected using a customized questionnaire. Online- and community-based recruitment strategies will be implemented, and the effectiveness of each approach will be analyzed. Participants will be recruited from the general Australian population and randomized online. The trial will last for 4 weeks. RESULTS: Small but clinically significant increases in well-being symptoms are expected to be detected in the intervention group compared with the control group. CONCLUSIONS: If this intervention proves to be effective, it will have an impact on the future design and implementation of online-based well-being interventions as a valid and cost-effective way to support mental health clinical treatment. Findings regarding recruitment effectiveness will also contribute to developing better ways to engage this population in research. CLINICALTRIAL: This study is registered in the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000710628.

Participatory Research as One Piece of the Puzzle: A Systematic Review of Consumer Involvement in Design of Technology-Based Youth Mental Health and Well-Being Interventions.

BACKGROUND: Despite the potential of technology-based mental health interventions for young people, limited uptake and/or adherence is a significant challenge. It is thought that involving young people in the development and delivery of services designed for them leads to better engagement. Further research is required to understand the role of participatory approaches in design of technology-based mental health and well-being interventions for youth. OBJECTIVE: To investigate consumer involvement processes and associated outcomes from studies using participatory methods in development of technology-based mental health and well-being interventions for youth. METHODS: Fifteen electronic databases, using both resource-specific subject headings and text words, were searched describing 2 broad concepts-participatory research and mental health/illness. Grey literature was accessed via Google Advanced search, and relevant conference Web sites and reference lists were also searched. A first screening of titles/abstracts eliminated irrelevant citations and documents. The remaining citations were screened by a second reviewer. Full text articles were double screened. All projects employing participatory research processes in development and/or design of (ICT/digital) technology-based youth mental health and well-being interventions were included. No date restrictions were applied; English language only. Data on consumer involvement, research and design process, and outcomes were extracted via framework analysis. RESULTS: A total of 6210 studies were reviewed, 38 full articles retrieved, and 17 included in this study. It was found that consumer participation was predominantly consultative and consumerist in nature and involved design specification and intervention development, and usability/pilot testing. Sustainable participation was difficult to achieve. Projects reported clear dichotomies around designer/researcher and consumer assumptions of effective and acceptable interventions. It was not possible to determine the impact of participatory research on intervention effectiveness due to lack of outcome data. Planning for or having pre-existing implementation sites assisted implementation. The review also revealed a lack of theory-based design and process evaluation. CONCLUSIONS: Consumer consultations helped shape intervention design. However, with little evidence of outcomes and a lack of implementation following piloting, the value of participatory research remains unclear.

An eHealth Intervention for Patients in Rural Areas: Preliminary Findings From a Pilot Feasibility Study.

BACKGROUND: eHealth facilitation of chronic disease management has potential to increase engagement and effectiveness and extend access to care in rural areas. OBJECTIVE: The objective of this study was to demonstrate the feasibility and acceptability of an eHealth system for the management of chronic conditions in a rural setting. METHODS: We developed an online management program which incorporated content from the Flinders Chronic Condition Management Program (Flinders Program) and used an existing software platform (goACT), which is accessible by patients and health care workers using either Web-enabled mobile phone or Internet, enabling communication between patients and clinicians. We analyzed the impact of this eHealth system using qualitative and simple quantitative methods. RESULTS: The eHealth system was piloted with 8 recently hospitalized patients from rural areas, average age 63 (SD 9) years, each with an average of 5 chronic conditions and high level of psychological distress with an average K10 score of 32.20 (SD 5.81). Study participants interacted with the eHealth system. The average number of logins to the eHealth system by the study participants was 26.4 (SD 23.5) over 29 weeks. The login activity was higher early in the week. CONCLUSIONS: The pilot demonstrated the feasibility of implementing and delivering a chronic disease management program using a Web-based patient-clinician application. A qualitative analysis revealed burden of illness and low levels of information technology literacy as barriers to patient engagement.

Prevalence of depression in patients with chest pain and non-obstructive coronary artery disease.

Many studies have demonstrated the prevalence of depression in patients with coronary artery disease (CAD), but few have examined this relation in those with chest pain who do not have obstructive CAD on angiography. The aim of this study was to compare the prevalence of depression amongst patients with chest pain in the presence or absence of obstructive CAD and a healthy control group without chest pain. This prospectively designed, observational cohort study used 2 independent data sets: (1) The Queen Elizabeth Hospital Coronary Angiogram Database (n = 1,144), consisting of 819 patients with obstructive CAD and 325 patients with nonobstructive CAD (NoCAD), all of whom had chest pain and (2) the North West Adelaide Health Study (NWAHS; n = 3,168), a population-based biomedical cohort, from which patients with chest pain were excluded. The presence of depression was determined by a previously validated method using the Short Form 36. The prevalence of depression differed among the 3 groups, with 63% in those with NoCAD, 53% in those with CAD, and only 24% in the healthy NWAHS cohort. Analysis of the angiography cohort revealed age, gender, antidepressant medication, previous myocardial infarction, previous airway disease, Short Form 36 physical summary score, Seattle Angina Questionnaire physical limitation score, and NoCAD on angiography to be independent predictors of depression. In conclusion, these findings highlight the importance of screening for depression in patients with NoCAD.

Depression and 5-year mortality in patients with acute myocardial infarction: analysis of the IDACC database.

OBJECTIVE: Symptoms of depression are highly prevalent and persistent following myocardial infarction (MI). Whether depression is a risk factor for long-term mortality following MI remains controversial. The present study aimed to determine whether depression during hospitalisation for acute MI (AMI) predicted 5-year all-cause or cardiac mortality. METHOD: This study utilised the Identifying Depression as a Comorbid Condition (IDACC) database of 337 hospitalised patients with AMI. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression scale (CES-D). Data were linked to a government administrative death registry to determine 5-year mortality. Survival data were analysed using Cox's proportional hazards model. RESULTS: The mean age during AMI hospitalisation was 59 years ± 12, 74% of patients were men and depression (CES-D ≥ 16) was present in 132 patients (39.3%). The 5-year all-cause mortality rate was 10.4% (35 deaths) and the cardiac mortality rate was 6.5% (22 deaths). When depression was defined as a dichotomous variable, moderate to severe depression (defined by CES-D ≥ 27) at the time of AMI was associated with all-cause mortality (hazard ratio 2.54, 95% confidence interval 1.03 to 6.28; p = 0.04) but not cardiac mortality. However, when depression was defined by three categories (no depression CES-D < 16, mild depression CES-D 16-26, moderate to severe depression CES-D ≥ 27), it was not found to predict mortality. In addition, perceived social support was a predictor of all-cause and cardiac mortality in AMI patients. CONCLUSIONS: Our results indicate that the relationship between mortality and depression severity is not linear and that the association only becomes evident when the severity reaches a threshold level of CES-D ≥ 27, consistent with major depression. Low power may have influenced the finding of a lack of association between depression and cardiac mortality.

Impact of a psychiatric unit's daily discharge rates on emergency department flow.

OBJECTIVE: To investigate relationships between time spent in the emergency department (ED) in patients requiring admission to the psychiatric ward, the day of the week of presentation and the daily number of discharges from the psychiatric ward. METHOD: Retrospective analysis of patient flow as a function of day of week, time of day (a.m., p.m.), number of patients requiring admission and number of ward discharges over a one-year period, for all mental health related presentations to the ED of the Queen Elizabeth Hospital in Adelaide, South Australia, before their admission to the psychiatric inpatient facility. RESULTS: The time spent by patients in the ED waiting for admission to the psychiatric ward was significantly greater on weekends. There were significantly fewer discharges from the psychiatric ward during weekends compared with weekdays. The average time spent by patients in the ED requiring admission to the psychiatric ward for those days when there were vacant beds was 17.9 hours (SD=14.5). More people presented to the ED with a psychiatric diagnosis in the afternoons. There was a significant inverse correlation between the time spent by patients in the ED requiring admission to the psychiatric ward per day and the number of discharges from the psychiatric ward per day. CONCLUSION: These findings demonstrate that patient flow is significantly slower on weekends because of fewer discharges from the ward, leading to longer times spent in the ED before ward transfer. Waiting times in the ED were very substantially greater than the proposed 4-hour target even when vacant beds were available, raising considerable doubt about that target being realistic for psychiatric patients.