Modelling admission lengths within psychiatric intensive care units.

OBJECTIVES: To examine whether discharge destination is a useful predictor variable for the length of admission within psychiatric intensive care units (PICUs). METHODS: A clinician-led process separated PICU admissions by discharge destination into three types and suggested other possible variables associated with length of stay. Subsequently, a retrospective study gathered proposed predictor variable data from a total of 368 admissions from four PICUs. Bayesian models were developed and analysed. RESULTS: Clinical patient-type grouping by discharge destination displayed better intraclass correlation (0.37) than any other predictor variable (next highest was the specific PICU to which a patient was admitted (0.0585)). Patients who were transferred to further secure care had the longest PICU admission length. The best model included both patient type (discharge destination) and unit as well as an interaction between those variables. DISCUSSION: Patient typing based on clinical pathways shows better predictive ability of admission length than clinical diagnosis or a specific tool that was developed to identify patient needs. Modelling admission lengths in a Bayesian fashion could be expanded and be useful within service planning and monitoring for groups of patients. CONCLUSION: Variables previously proposed to be associated with patient need did not predict PICU admission length. Of the proposed predictor variables, grouping patients by discharge destination contributed the most to length of stay in four different PICUs.

Cancer and severe mental illness in low- and middle-income countries: The challenges and outlook for the future.

OBJECTIVE: Patients with severe mental illness (SMI) face health inequalities that lead to under treatment of diseases such as cancer and result in increased mortality. There is literature addressing this issue for SMI patients in high-income countries but few for those in low- and middle-income countries. This review aims to draw attention to the health inequalities and the compounding factors faced by SMI patients in low- and middle-income countries. The relevance of integration of psycho-oncology in the care of SMI patients with cancer is integral to reduce disparities and address varied contributory factors. METHODS: The literature review was conducted by searching through two databases which includes PubMed and Google Scholar. We searched for articles using keyword search terms: severe mental illness, SMI, schizophrenia, bipolar disorder, cancer, low- middle-income countries, low- and middle-income countries, psycho-oncology, HPV vaccine, cancer incidence, cancer mortality, cancer control, cancer screening, cancer treatment and palliative care. RESULTS: A total of 80 research articles were included in our literature review. We found that there was an increased requirement for adapting to the changing disease landscape in low- and middle-income countries. An improvement on aspects such as vaccination, screening and prevention is necessary, and also efforts to change social stance towards SMI is crucial. CONCLUSION: There is an increase incidence of cancer in low- and middle-income countries, and the number of patients with SMI in low- and middle-income countries is also rising. This is due to social, psychological, economical and healthcare factors. Low- and middle-income countries must consider improving these aspects in order to adapt to the changing landscape.

Possible pharmacogenetic factors in clozapine treatment failure: a case report.

There is still much to learn about the predictors of therapeutic response in psychiatry, but progress is gradually being made and precision psychiatry is an exciting and emerging subspeciality in this field. This is critically important in the treatment of refractory psychotic disorders, where clozapine is the only evidence-based treatment but only about half the patients experience an adequate response. In this case report, we explore the possible biological mechanisms underlying treatment failure and discuss possible ways of improving clinical outcomes. Further work is required to fully understand why some patients fail to respond to the most effective treatment in refractory schizophrenia. Therapeutic drug monitoring together with early pharmacogenetic testing may offer a path for some patients with refractory psychotic symptoms unresponsive to clozapine treatment.

Magna Carta for individuals living with mental illness.

There is considerable evidence to suggest that individuals with mental illness as well as their carers and families are discriminated against across a number of domains. It is also well recognized that people with mental illness are likely to die younger than their counterparts who do not have mental illness. We propose that a Magna Carta is urgently needed to protect the rights of people with mental illness and help reduce discrimination. In this paper a background and rationale for this is offered alongside suggestions for reducing discrimination. The simple message is this; progress in health, economic, environmental and global development will not be made without improvements in mental health. The reasons are equally straightforward as mental illnesses cause more disability than any other health condition and bring enormous pain and suffering to individuals, their families and communities. These impacts lead to early death, damage to the economy and restrain individual progress. Every country needs to take urgent responsibility for defending the rights of individuals with mental illness.

Wellbeing and burnout in medical students in India; a large scale survey.

Medical students in India completed an anonymous online questionnaire regarding mental health and wellbeing, including Oldenburg burnout ratings, CAGE questionnaires, and general health questionnaire (GHQ12). Out of 597 student responses, over 80% were characterised as experiencing burnout. This study highlights the need to further examine this issue, including possible causes and solutions.

Antidepressants for the treatment of depression in neurological disorders: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Despite the high prevalence of depression in people with neurological disorders, no previous study has sought to summarise existing evidence on the use of antidepressants in this population. A systematic review and meta-analysis was undertaken to determine whether antidepressants are more effective than placebo in the treatment of depression in neurological disorders, and whether any benefit is associated with improvement in function. METHODS: Embase, Pubmed, Psycinfo and Cochrane trial registers were searched for randomised controlled trials (RCTs) comparing the efficacy of antidepressant and placebo in the treatment of depression in adults with a neurological disorder. FINDINGS: 20 RCTs were included in the review, including patients with Parkinson's disease, multiple sclerosis, brain injury, epilepsy and stroke. Outcomes were analysed at four time points: 4-5 weeks, 6-8 weeks, 9-18 weeks and >18 weeks. The primary outcome was response to treatment at 6-8 weeks. The evidence favoured the use of antidepressants over placebo at all time points although pooled results were not statistically significant at all time points. At 6-8 weeks, antidepressant treatment was associated with a greater than twofold odds of remission (OR 2.23; 95% CI 1.54 to 3.23; number needed to treat=7). Fewer data were available for quality of life, and functional and cognitive outcomes, and there was little evidence of improvement with antidepressant treatment. INTERPRETATION: Antidepressants are effective for the treatment of depression in patients with neurological disorders but the evidence for the efficacy of antidepressants in improving quality of life, and functional and cognitive outcomes is inconclusive.

Antidepressants for the treatment of depression in palliative care: systematic review and meta-analysis.

Depression can exacerbate symptoms associated with life-threatening illness and increase disability and distress. In palliative care, depression occurs in a context of multiple symptoms, which complicates detection and treatment. While systematic reviews of antidepressants have been conducted in specific life-threatening diseases, no previous study has synthesized the evidence in palliative care. The objective of this study was to determine the efficacy of antidepressants for the treatment of depression in palliative care. MEDLINE, EMBASE, PSYCINFO and Cochrane trials registers were systematically searched to identify randomized controlled trials comparing antidepressants and placebo for the treatment of depression in palliative care. The primary outcome was efficacy assessed at three time-points. Twenty-five studies were included in the review. At each time-point antidepressants were more efficacious than placebo: 4-5 weeks odds ratio (OR) 1.93 (1.15-3.42) p = 0.001; 6-8 weeks OR 2.25 (1.38-3.67) p = 0.001; 9-18 weeks OR 2.71 (1.50-4.91) p = 0.001. This review provides evidence that antidepressants are effective in treating depression in palliative care. Their superiority over placebo is apparent within 4-5 weeks and increases with continued use. It is probable that the effect sizes yielded in this review overestimate the efficacy of antidepressants due to biases such as selective reporting and publication. Nevertheless, the magnitude and consistency of the effect suggests genuine benefit.

Antidepressants for depression in physically ill people.

BACKGROUND: There is an increased risk of depression in people with a physical illness. Depression is associated with reduced treatment adherence, poor prognosis, increased disability and higher mortality in many physical illnesses. Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients. This review updates Gill's Cochrane review (2000), which found that antidepressants were effective for depression in physical illness. Since Gill there have been a number of larger trials assessing the efficacy of antidepressants in this context. OBJECTIVES: To determine the efficacy of antidepressants in the treatment of depression in patients with a physical illness. SEARCH STRATEGY: Electronic searches of the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) trial registers were conducted together with supplementary searches of The Cochrane Central Register of Controlled Trials (CENTRAL) and the standard bibliographic databases, MEDLINE, EMBASE and PsycINFO. Reference lists of included studies were scanned and trials registers were searched to identify additional unpublished data. Last searches were run in December 2009. SELECTION CRITERIA: Randomised controlled trials comparing the efficacy of antidepressants and placebo in the treatment of depression in adults with a physical illness. Depression included diagnoses of Major Depression, Adjustment Disorder and Dysthymia based on standardised criteria. DATA COLLECTION AND ANALYSIS: The primary outcome was efficacy 6-8 weeks after randomisation. Data were also extracted at three additional time-points (4-5 weeks, 9-18 weeks, >18 weeks). Acceptability and tolerability were assessed by comparing the number of drop-outs and adverse events. Odds ratios with 95% confidence intervals were calculated for dichotomous data (response to treatment). Standardised mean differences with 95% CI were calculated for continuous data (mean depression score). Data were pooled using a random effects model. MAIN RESULTS: Fifty-one studies including 3603 participants were included in the review. Forty-four studies including 3372 participants contributed data towards the efficacy analyses. Pooled efficacy data for the primary outcome provided an OR of 2.33, CI 1.80-3.00, p<0.00001 (25 studies, 1674 patients) favouring antidepressants. Antidepressants were also more efficacious than placebo at the other time-points. At 6-8 weeks, fewer patients receiving placebo dropped out compared to patients treated with an antidepressant. Dry mouth and sexual dysfunction were more common in patients treated with an antidepressant. AUTHORS' CONCLUSIONS: This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.