Community-based models of care for adolescent and adult depression, suicidal behavior, anxiety, trauma, and substance use in Africa: a scoping review.

Background: Community-based care (CBC), where care is delivered outside of the traditional health facility setting, has been proposed to narrow the mental health (MH) and substance use (SU) treatment gap in Africa. Objective: This scoping review aims to comprehensively summarize CBC models addressing adolescent and adult MH (depression, anxiety, trauma, suicidal behavior) and (non-tobacco) SU problems in Africa. Methods: We searched PsycINFO, Embase, Scopus, CINAHL, and Medline Ovid. Studies and protocols were included if they reported on CBC intervention's effects on MH or SU symptoms/ diagnoses, acceptability, feasibility, or patient engagement in care, regardless of whether the intervention itself was designed specifically for MH or SU. Results: Among 11,477 screened publications, 217 were eligible. Of the unique intervention studies (n = 206), CBC models were classified into the following approaches (non-mutually exclusive): psychotherapeutic (n = 144), social (n = 81), lifestyle/physical health (n = 55), economic (n = 26), and psychopharmacological (n = 2). While quantitative results suggest possible efficacy of CBC models, description of CBC location was often poor. Fewer interventions addressed suicidal behavior (n = 12), the needs of adolescents (n = 49), or used traditional healers or religious figures as providers (n = 3). Conclusion: Many CBC models have been tested on MH and SU in Africa and should be critically appraised and meta-analyzed in subsequent reviews, where possible.

The effectiveness of brief non-pharmacological interventions in emergency departments and psychiatric inpatient units for people in crisis: A systematic review and narrative synthesis.

OBJECTIVE: Heterogeneous brief non-pharmacological interventions and guidelines exist to treat the burgeoning presentations to both emergency department and inpatient settings, for those in a crisis of mental ill-health. We systematically reviewed the literature to create a taxonomy of these brief non-pharmacological interventions, and review their evaluation methods and effectiveness. METHOD: We conducted a systematic review across Cochrane, CINAHL, DARE, Embase, MEDLINE, PsycINFO databases. Studies meeting quality criteria, using Joanna Briggs Institute tools, were eligible. Interventions were categorised, and outcomes synthesised. RESULTS: Thirty-nine studies were included: 8 randomised controlled trials, 17 quasi-experimental, 11 qualitative studies, and 3 file audits. Taxonomy produced six coherent intervention types: Skills-focussed, Environment-focussed, Special Observation, Psychoeducation, Multicomponent Group and Multicomponent Individual. Despite this, a broad and inconsistent range of outcome measures reflected different outcome priorities and prevented systematic comparison of different types of intervention or meta-analysis. Few brief non-pharmacological interventions had consistent evidential support: sensory modulation rooms consistently improved distress in inpatient settings. Short admissions may reduce suicide attempts and readmission, if accompanied by psychotherapy. Suicide-specific interventions in emergency departments may improve depressive symptoms, but not suicide attempt rates. There was evidence that brief non-pharmacological interventions did not reduce incidence of self-harm on inpatient wards. We found no evidence for frequently used interventions such as no-suicide contracting, special observation or inpatient self-harm interventions. CONCLUSION: Categorising brief non-pharmacological interventions is feasible, but an evidence base for many is severely limited if not missing. Even when there is evidence, the inconsistency in outcomes often precludes clinicians from making inferences, although some interventions show promise.

Community-based models of care for management of type 2 diabetes mellitus among non-pregnant adults in sub-Saharan Africa: A scoping review.

INTRODUCTION: The prevalence of type 2 diabetes mellitus (T2DM) and associated morbidity and mortality are increasing in sub-Saharan Africa (SSA). To facilitate access to quality care and improve treatment outcomes, there is a need for innovative community care models and optimized use of non-physician healthcare workers bringing diagnosis and care closer to patients' homes. AIM: We aimed to describe with a scoping review different models of community-based care for non-pregnant adults with T2DM in SSA, and to synthesize the outcomes in terms of engagement in care, blood sugar control, acceptability, and end-organ damage. We further aimed to critically appraise the different models of care and compare community-based to facility-based care if data were available. METHODS: We searched Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus, supplemented with backward and forward citation searches. We included cohort studies, randomized trials and case-control studies that reported on non-pregnant individuals diagnosed with T2DM in SSA, who received a substantial part of care in the community. Only studies which reported at least one of our outcomes of interest were included. A narrative analysis was done, and comparisons made between community-based and facility-based models, where within-study comparison was reported. RESULTS: We retrieved 5,335 unique studies, four of which met our inclusion criteria. Most studies were excluded because interventions were facility-based; community care interventions described in the studies were only add-on features of a primarily facility-based care; and studies did not report outcomes of interest. The included studies reported on a total of 383 individuals with T2DM. Three different community care models were identified. 1) A community-initiated model where diagnosis, treatment and monitoring occurred primarily in the community. This model reported a higher linkage and engagement in care at 9 months compared to the corresponding facility model, but only slight reductions of average blood glucose levels at six months compared to baseline. 2) A facility-originated community model where after treatment initiation, a substantial part of follow-up was offered at community level. Two studies reported such a model of care, both had as core component home-delivery of medication. Acceptability of this approach was high. But neither study found improved T2DM control when compared to facility care 3) An eHealth model with high acceptability scores for both patients and care providers, and an absolute 1.76% reduction in average HbA1c levels at two months compared to baseline. There were no reported outcomes on end-organ damage. All four studies were rated as being at high risk for bias. CONCLUSION: Evidence on models of care for persons with T2DM in SSA where a substantial part of care is shifted to the community is scant. Whereas available literature indicates high acceptability of community-based care, we found no conclusive data on their effectiveness in controlling blood sugar and preventing complications. Evidence from larger scale studies, ideally randomized trials with clinically relevant endpoints is needed before roll-out of community-based T2DM care can be recommended in SSA.

Meta-analysis of clinical risk factors for suicide among people presenting to emergency departments and general hospitals with suicidal thoughts and behaviours.

BACKGROUND: Suicidal thoughts and behaviours (STB) are a common reason for presentation to emergency departments and general hospitals. A meta-analysis of the strength of clinical risk factors for subsequent suicide might aid understanding of suicidal behaviour and help suicide prevention. METHODS: We conducted a meta-analysis of cohort and controlled studies on clinical risk factors and later suicide among people presenting to emergency departments and general hospitals with STB. Data were extracted from papers meeting inclusion criteria, published in Medline, PsycINFO, and Embase between 1 January 1960 and 10 October 2022 using papers located with the search terms ((suicide*).m_titl AND (emergency* OR accident and emergency OR casualty OR general hospital OR toxicology service).mp) or were indexed in PubMed and had titles located with the search terms (suicide* OR self-harm OR self-harm OR self-injury OR self-injury OR self-poisoning OR self-poisoning OR overdose OR para-suicide OR parasuicide [title/abstract]) AND (Emergency department OR emergency room OR Casualty OR general hospital OR toxicology OR accident and emergency [all fields]). Data about the association between clinical risk factors and suicide extracted from three or more studies were included in a random-effects meta-analysis of the odds of later death by suicide. The study was registered in PROSPERO and conducted according to MOOSE and PRISMA guidelines. RESULTS: Seventy-five studies reported on 741,624 people, of which 19,649 died by suicide (2.65%). Male sex (odds ratio (OR) = 1.99) and age (OR = 2.01) were the most consistently reported risk factors. The strongest associations with subsequent death by suicide related to violent self-harm methods at the hospital presentation, including: unspecified violent method (OR = 4.97), any violent method (OR = 4.57) and the specific violent methods of drowning (OR = 4.32), hanging (OR = 4.26), and use of firearms (OR = 10.08). Patients categorised as higher risk using suicide prediction scales or any other method that combined risk factors had moderately increased odds of suicide (OR = 2.58). Younger age, Black and Hispanic ethnicity, overdose, a diagnosis of adjustment disorder, and the absence of any psychiatric diagnosis were protective against suicide. CONCLUSIONS: Most risk factors for suicide among people who have presented with STB are not strongly associated with later suicide. The strongest risk factors relate to self-harm methods. In the absence of clear indicators of future suicide, all people presenting with suicidality warrant a thorough assessment of their needs, and further research is needed before we can meaningfully categorise people with STB according to suicide risk.

The NSW Emergency Psychiatry Network.

Emergency Psychiatry is evolving. In an environment that lacks a clear evidence base, and where a constellation of factors is driving up Emergency Department presentation rates and lengths of stay, several stakeholders are working towards and clamouring for change. With the goal of collaborating with such parties, we believe Emergency Psychiatrists should position themselves to establish and advocate for best-practice change in culture, research, clinical care and training, and funding in the provision of mental health crisis care. To this end, we have formed the NSW Emergency Psychiatry Network, a group of Emergency Psychiatrists with a broad experience in a range of settings, from tertiary metropolitan emergency facilities with access to subspecialty psychiatric services, to rural and remote emergency settings with sporadic in-reach from local mental health services and telehealth. We unanimously recognise the need to upskill both Emergency Department and Mental Health clinicians in crisis care, and the need for committed, evidence-based Mental Health resourcing within Emergency Departments.

Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: a literature scoping review and framework for designing chronic services.

BACKGROUND: Arterial hypertension (aHT) is the leading cardiovascular disease (CVD) risk factor in sub-Saharan Africa; it remains, however, underdiagnosed, and undertreated. Community-based care services could potentially expand access to aHT diagnosis and treatment in underserved communities. In this scoping review, we catalogued, described, and appraised community-based care models for aHT in sub-Saharan Africa, considering their acceptability, engagement in care and clinical outcomes. Additionally, we developed a framework to design and describe service delivery models for long-term aHT care. METHODS: We searched relevant references in Embase Elsevier, MEDLINE Ovid, CINAHL EBSCOhost and Scopus. Included studies described models where substantial care occurred outside a formal health facility and reported on acceptability, blood pressure (BP) control, engagement in care, or end-organ damage. We summarized the interventions' characteristics, effectiveness, and evaluated the quality of included studies. Considering the common integrating elements of aHT care services, we conceptualized a general framework to guide the design of service models for aHT. RESULTS: We identified 18,695 records, screened 4,954 and included twelve studies. Four types of aHT care models were identified: services provided at community pharmacies, out-of-facility, household services, and aHT treatment groups. Two studies reported on acceptability, eleven on BP control, ten on engagement in care and one on end-organ damage. Most studies reported significant reductions in BP values and improved access to comprehensive CVDs services through task-sharing. Major reported shortcomings included high attrition rates and their nature as parallel, non-integrated models of care. The overall quality of the studies was low, with high risk of bias, and most of the studies did not include comparisons with routine facility-based care. CONCLUSIONS: The overall quality of available evidence on community-based aHT care is low. Published models of care are very heterogeneous and available evidence is insufficient to recommend or refute further scale up in sub-Sahara Africa. We propose that future projects and studies implementing and assessing community-based models for aHT care are designed and described according to six building blocks: providers, target groups, components, location, time of service delivery, and their use of information systems.

Algorithm for the use of the Guardianship Act, the Mental Health Act and the Public Health Act in emergency departments in New South Wales.

OBJECTIVE: To address frequently asked questions regarding the use of the Guardianship Act, the Mental Health Act and the Public Health Act within New South Wales EDs and present an algorithm to guide the use of this legislation. METHODS: An ED-specific algorithm was developed for the use of the three pieces of legislation. Then an emergency psychiatrist and an emergency physician reviewed the algorithm with ED staff to understand its usefulness and where further detail was required. Frequently asked questions were collated. RESULTS: Frequently asked questions are addressed with reference to the algorithm. CONCLUSION: This paper offers an algorithm that can be easily followed for use in EDs across New South Wales.

Months of May: Mental health presentations and the impact of a psychiatric emergency care centre on an inner-city emergency department.

OBJECTIVES: The impact of psychiatric emergency care centres (PECCs) on ED mental health (MH) presentations has not been presented. We aim to compare demographics, diagnosis and admission frequency of patients presenting to an inner-city ED with MH complaints, before and for several years after the opening of a PECC. METHODS: We collected ED patient data for the first 200 'mental health' presentations during the month of May in 2005-2007, and 2015-2017. Data included demographics, diagnosis, post-ED disposition, length of stay in ED, use of the Mental Health Act, and the presence of expressed suicidality and psychotic disorders. RESULTS: The days to reach 200 MH presentations decreased from 43 days in 2005 to 17 days in 2017. The mean length of ED stay approximately halved with PECC's introduction, with 20% of patients being admitted to PECC. Prior to PECC, 75% of suicidal patients were discharged from ED; after the opening of PECC, 84% of patients expressing suicidality were admitted to PECC; and 73% of patients admitted with psychotic symptoms went to the acute psychiatric ward. CONCLUSIONS: Between 2005 and 2017, MH presentations to ED became significantly more frequent. The opening of PECC reduced length of stay in ED and provided an admission trajectory for patients expressing suicidality, while retaining the pathway to the acute psychiatric ward for those patients presenting with psychosis.

Community-based models of care for management of type 2 diabetes mellitus among non-pregnant adults in sub-Saharan Africa: a scoping review protocol.

Background: The burden of type 2 diabetes mellitus (T2DM) is increasing in low- and middle-income countries, including sub-Sahara Africa (SSA). However, awareness of and access to T2DM diagnosis and care remain low in SSA, leading to delayed treatment, early morbidity, and mortality. Particularly in rural settings with long distances to health care facilities, community-based care models may contribute to increased timely diagnosis and care. This scoping review aims to summarize and categorize existing models of community-based care for T2DM among non-pregnant adults in SSA, and to synthesize the evidence on acceptance, clinical outcomes, and engagement in care. Method and analysis: This review will follow the framework suggested by Arskey and O'Malley, which has been further refined by Levac et al. and the Joanna Briggs Institute. Electronic searches will be performed in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus, supplemented with backward and forward citation searches. We will include cohort studies, randomized trials and case-control studies that report cases of non-pregnant individuals diagnosed with T2DM in SSA who receive a substantial part of care in the community. Our outcomes of interest will be model acceptability, blood sugar control, end organ damage, and patient engagement in care. A narrative analysis will be conducted, and comparisons made between community-based and facility-based models, where within-study comparison is reported. Conclusion: Care for T2DM has become a global health priority. Community-based care may be an important add-on approach especially in populations with poor access to health care facilities. This review will inform policy makers and program implementers on different community-based models for care of T2DM in SSA, and critically appraise their acceptability and clinical outcomes. It will further identify evidence gaps and future research priorities in community-based T2DM care.

ECT and lithium in old age depression - cause or treatment of rapid cycling?

OBJECTIVE: This article presents the case of an elderly woman experiencing a depressive phase of Bipolar Affective Disorder 1 (BPAD1), who required electroconvulsive therapy (ECT), prior to which her lithium was ceased, and who developed ultra-ultra-rapid cycling (UURC) and ultra-rapid cycling (URC). This resolved with the recommencement of lithium and continuation of ECT. METHOD: Case report and review of the relevant literature. RESULTS: The patient's mood stabilized with recommencement of lithium and continuation of ECT. CONCLUSIONS: Ceasing lithium prior to ECT may carry a risk of URC or UURC in BPAD1.

A comparative assessment of interface pressures generated by four surgical theatre heel pressure ulcer prophylactics.

Current heel protection devices used in the operating room do not comply with the consensus document of the European and National (North American) Pressure Ulcer Advisory Panels. A complying prototype has been tested. Prospective cohort study comparing interface pressures. While using the prototype device, the heel interface pressure is significantly [mean 0·0 mmHg, standard deviation (SD) 0·0] less than the viscose elastic gel (VEG) mat (mean 174·8 mmHg, SD 64·5), the Action(®) heel block (mean 182·3 mmHg, SD 70·8) and the theatre table (mean 193·2 mmHg, SD 57·1). At the Achilles tendon, the prototype device (mean 16·2 mmHg, SD 19·0) is significantly superior to the Oasis (mean 183·7 mmHg, SD 67·4) and Action(®) heel blocks (mean 112·3 mmHg, SD 64·7). At the lateral malleolus, the prototype device (mean 0·0, SD 0·0) is better than the Action(®) (mean 24·3 mmHg, SD 53·4) and Oasis heel blocks (mean 20·9 mmHg, SD 49·2). At the calf, the prototype (mean 53·7 mmHg, SD 23·0) imposed more pressure than all other devices tested but was not statistically significant compared with the theatre table or the VEG mat. It is possible to design a device that protects the heel, lateral malleolus and Achilles tendon without causing hyperextension of the knee and consequent popliteal vein compression, thereby complying with the above guidelines.

Increasing heel skin perfusion by elevation.

OBJECTIVE: To determine the efficacy of elevation in the primary prevention and treatment of pressure ulcers by studying the blood flow in tissue at risk of ulceration. DESIGN: A prospective study was used to compare different preventative devices with an elevating prosthesis. SETTING: : Wollongong Hospital Wollongong, New South Wales, Australia. PARTICIPANTS: Normal subjects and subjects with vasculopathy were tested with their heel resting on a hospital bed, medical-grade lamb's wool, or a viscoelastic gel overlay, with or without the test prosthesis. Skin perfusion was measured throughout using a laser Doppler monitor. INTERVENTION: A device designed to elevate the heel off the bed and distribute the weight of the leg and foot on the calf. MAIN OUTCOME MEASURE: Heel capillary blood perfusion. MAIN RESULTS: Perfusion in the heel was significantly greater when elevated than when using the other devices tested. The differences in mean red blood cell flux were significant, with P < .0001 for bed-normals, ie, subjects with no peripheral vascular disease on an alpha Xcell mattress overlay as the control with flux increasing from 7.6 to 163.1 arbitrary units (AU); P < .005 bed-vasculopathy, ie, subjects with peripheral vascular disease on an alpha Xcell mattress overlay as the control with flux increasing from 31.6 to 224.7 AU; P < .0001 viscoelastic overlay subjects where the viscoelastic overlay was the control with flux increasing from 26.6 to 291.4 AU; and P < .01 lamb's wool subjects where the lamb's wool was the control with flux increasing from 27.7 AU to 169.2 AU. CONCLUSION: In this study, when the heels were elevated, tissue perfusion to that area was substantially increased. When the heel was transferred to the elevating splint, the heel capillary bed underwent reactive hyperemia, indicating the alleviation of tissue hypoxia. Elevation is therefore an important technique in pressure ulcer prevention and treatment and should be incorporated into health care practice.