Social contacts, friends and satisfaction with friendships in patients with psychotic, mood and neurotic disorders 1 year after hospitalisation: data from five European countries.

BACKGROUND: People with severe mental illness often struggle with social relationships, but differences among diagnostic groups are unclear. We assessed and compared objective and subjective social relationship indicators among patients with psychotic, mood and neurotic disorders one year after hospitalisation in five European countries (Belgium, Germany, Italy, Poland and United Kingdom). METHODS: The number of social contacts, including family members and friends during the previous week (Social Network Schedule), and satisfaction with the number and quality of friendships (Manchester Short Assessment of Quality of Life Quality) were assessed by face-to-face interview. Linear regression models were used to analyse associations with diagnostic groups. RESULTS: Participants (n = 2155) reported on average 2.79 ± 2.37 social contacts overall in the previous week, among whom, a mean of 1.65 ± 1.83 (59.2 ± 38.7%) were friends. Satisfaction with friendships was moderate (mean 4.62, SD 1.77). In the univariable model, patients with psychotic disorders reported having less social contact with friends than those with either mood (p < 0.05) or neurotic disorders (p < 0.001), but this difference disappeared when adjusting for socioeconomic and clinical variables (ß = - 0.106, 95% CI - 0.273 to 0.061, p = 0.215). Satisfaction with friendships was similar across diagnostic groups in both univariable (ß = - 0.066, 95% CI - 0.222 to 0.090, p = 0.408) and multivariable models (ß = 0.067, 95% CI - 0.096 to 0.229, p = 0.421). The two indicators showed a weak correlation in the total sample (total social contacts, rs = 0.266; p < 0.001; friends, rs = 0.326, p < 0.001). CONCLUSION: While objective and subjective social relationship indicators appear to be weakly correlated concepts, there is no variation in either indicator across diagnostic groups when confounders are taken into account among patients with severe mental illness. Interventions specifically targeting social relationships are needed, but they do not necessitate diagnosis-specific adaptations.

Oral antipsychotic prescribing and association with neighbourhood-level socioeconomic status: analysis of time trend of routine primary care data in England, 2011-2016.

BACKGROUND: Increasing rates of antipsychotic prescribing have been reported previously, particularly for second-generation antipsychotics (SGAs), which are generally better tolerated than the older first-generation antipsychotics (FGAs). Prescribers, however, may exert bias, favouring prescriptions of novel drugs for patients of higher socioeconomic status (SES). We aimed to examine time trends in: (1) prescriptions of oral FGAs vs. SGAs and (2) associations between antipsychotic prescriptions and neighbourhood-level SES in England between 2011 and 2016. METHODS: We used publicly available data for prescriptions made in primary care and linked general practices' postcodes with the Index of Multiple Deprivation (IMD) as a measure for neighbourhood-level SES. Absolute numbers of antipsychotic prescriptions were calculated. Linear regression analysis was used to examine the association of SGA vs. FGA prescription pattern with time and with SES. RESULTS: A total of 27,486,000 oral antipsychotics were prescribed during the study period, mostly SGAs (n = 21,700,000; 78.9%). There was a significant increase in the ratio of SGA/FGA prescriptions over time (ß = 0.376, 95% CI 0.277-0.464, P < 0.001). Individual FGAs were increasingly prescribed in areas of lower SES and the converse for SGAs except amisulpride. During the study period, a significantly larger proportion of total SGA prescriptions relative to total FGAs were made in areas of higher SES (ß = 0.182, 95% CI 0.117-0.249, P < 0.001). CONCLUSION: Prescriptions of antipsychotics continue to rise overall, with SGAs taking preference especially in areas of higher SES. The pattern of antipsychotic prescription favouring people in areas of lower social deprivation carries implications on inequalities even among sub-groups of people with mental disorders.

Physical health behaviours and health locus of control in people with schizophrenia-spectrum disorder and bipolar disorder: a cross-sectional comparative study with people with non-psychotic mental illness.

BACKGROUND: People with mental illness experience high levels of morbidity and mortality from physical disease compared to the general population. Our primary aim was to compare how people with severe mental illness (SMI; i.e. schizophrenia-spectrum disorders and bipolar disorder) and non-psychotic mental illness perceive their: (i) global physical health, (ii) barriers to improving physical health, (iii) physical health with respect to important aspects of life and (iv) motivation to change modifiable high-risk behaviours associated with coronary heart disease. A secondary aim was to determine health locus of control in these two groups of participants. METHODS: People with SMI and non-psychotic mental illness were recruited from an out-patient adult mental health service in London. Cross-sectional comparison between the two groups was conducted by means of a self-completed questionnaire. RESULTS: A total of 146 people participated in the study, 52 with SMI and 94 with non-psychotic mental illness. There was no statistical difference between the two groups with respect to the perception of global physical health. However, physical health was considered to be a less important priority in life by people with SMI (OR 0.5, 95% CI 0.2-0.9, p = 0.029). There was no difference between the two groups in their desire to change high risk behaviours. People with SMI are more likely to have a health locus of control determined by powerful others (p < 0.001) and chance (p = 0.006). CONCLUSIONS: People with SMI appear to give less priority to their physical health needs. Health promotion for people with SMI should aim to raise awareness of modifiable high-risk lifestyle factors. Findings related to locus of control may provide a theoretical focus for clinical intervention in order to promote a much needed behavioural change in this marginalised group of people.

Recent physical conditions and health service utilization in people with common mental disorders and severe mental illness in England: Comparative cross-sectional data from a nationally representative sample.

BACKGROUND: Policies addressing the physical health of people with mental disorders have historically focused on those with severe mental illness (SMI), giving less prominence to the more prevalent common mental disorders (CMDs). Little is known about the comparative physical health outcomes of these patient groups. We aimed to first compare the: (a) number of past-year chronic physical conditions and (b) recent physical health service utilization between CMDs vs. SMI, and secondly compare these outcomes between people with CMDs vs. people without mental disorders. METHODS: We analyzed cross-sectional data from the third Adult Psychiatric Morbidity Survey, a representative sample of the English population. We determined the presence of physical conditions and health service utilization by self-report and performed logistic regression models to examine associations of these outcomes between participant groups. RESULTS: Past-year physical conditions were reported by the majority of participants (CMDs, n = 815, 62.1%; SMI = 27, 63.1%) with no variation in the adjusted odds of at least one physical condition between diagnoses (odds ratio [OR] = 0.96, 95% confidence intervals [CI] 0.42-1.98, p = 0.784). People with CMDs were significantly more likely to be recently hospitalized relative to with those with SMI (OR = 6.33, 95% CI 5.50-9.01, p < 0.05). Having a CMD was associated with significantly higher odds of past-year physical conditions and recent health service utilization (all p < 0.001) compared with the general population. CONCLUSIONS: People with CMDs experience excess physical health morbidities in a similar pattern to those found among people with SMI, while their somatic hospitalization rates are even more elevated. Findings highlight the importance of recalibrating existing public health strategies to bring equity to the physical health needs of this patient group.

Mortality risk from long-term treatment with antipsychotic polypharmacy vs monotherapy among adults with serious mental illness: A systematic review and meta-analysis of observational studies.

BACKGROUND: Long-term use of more than one concurrent antipsychotic [antipsychotic polypharmacy (APP)] is widely believed to contribute to excess mortality in people with serious mental illness (SMI) compared to those taking only one antipsychotic (monotherapy). However, no conclusive evidence is available. METHODS: We conducted a systematic search in 6 major electronic databases from inception until December 2019, identifying observational studies examining the association between mortality and exposure to long-term APP vs monotherapy. Studies were eligible if they adopted a follow-up design and antipsychotic exposure was >3 months among adults with SMI. We determined the pooled mortality risk using random-effects meta-analyses. The review was registered in PROSPERO (CRD42019148044). RESULTS: A total of 12 studies fulfilled all eligibility criteria reporting quantitative data for 834, 534 person years. No difference was found in the association between all-cause mortality and APP vs monotherapy use, in both crude (rate ratio = 0.94, 95% CI 0.81-1.10, p = 0.446; I2 = 83.2%, p < 0.001; 10 studies) and adjusted models (adjusted HR = 0.98, 95% CI 0.80-1.19, p = 0.802; I2 = 58.3%, p < 0.05; 5 studies). Meta-regression did not identify any moderators influencing all-cause mortality risk. For natural causes of death, risk estimates followed the same pattern: (i) crude rate ratio = 0.88, 95% CI 0.67-1.14, p = 0.324; I2 = 77.7%, p = 0.01 (5 studies); (ii) adjusted HR = 1.04, 95% CI 0.90-1.99, p = 0.590; I2 = 0.0%, p = 0.744 (5 studies). CONCLUSION: Mortality risk of APP use in people with SMI appears to be comparable to that of monotherapy use, although work to date remains heterogeneous, precluding firm conclusions from made. Complex real-world clinical scenarios may be contributing to this lack of variation between these two types of antipsychotic use.

Association of First- vs. Second-Generation Antipsychotics with Lipid Abnormalities in Individuals with Severe Mental Illness: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: Individuals with severe mental illness experience increased morbidity and mortality as a result of metabolic problems that may partly be related to the adverse effects of antipsychotics. Compared with first-generation antipsychotics, second-generation antipsychotics collectively are considered to have stronger associations with lipid abnormalities, but evidence for this specific claim has not been systematically reviewed. The objective of this review was to evaluate the risk of dyslipidaemia with second-generation versus first-generation antipsychotics amongst individuals with severe mental illness. METHODS: Major electronic databases were searched until November 2018. Studies were eligible if they were cross-sectional, cohort, case-control or interventional, where any individual second-generation antipsychotic was directly compared with first-generation antipsychotics in individuals with severe mental illness, and where lipid metabolism was a primary or secondary outcome. The evidence was reviewed and appraised according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: In total, 18 studies were eligible. The reported associations between second-generation antipsychotics vs. first-generation antipsychotics with dyslipidaemia were inconsistent, with high variability between studies and only a full qualitative synthesis was feasible. We had sufficient data, however, to undertake limited meta-analyses for clozapine, olanzapine and risperidone, all showing mildly elevated associations with dyslipidaemia "caseness" (clozapine, odds ratio 1.26, 95% confidence interval 1.16-1.38; olanzapine, odds ratio 1.29, 95% confidence interval 0.89-1.87; risperidone, odds ratio 1.05, 95% confidence interval 0.80-1.37) compared with first-generation antipsychotics, but heterogeneity was high (all I2 > 50%, p < 0.05). Clozapine was also associated with increased triglycerides (standardised mean difference = 0.51, 95% confidence interval 0.21-0.81, I2 = 5.74%), but not with cholesterol. Compared with haloperidol, neither olanzapine nor risperidone was associated with statistically significant increases in cholesterol or triglycerides. CONCLUSIONS: There was considerable variation in study design and methodologies. Determining the comparative risk of second-generation vs. first-generation antipsychotics as a group of antipsychotics for lipid dysregulation may be of limited clinical utility, as drugs from either group have the potential to cause such adversity to varying degrees. It is therefore more valuable to consider the metabolic risks of specific antipsychotics rather than focusing on collective metabolic effects belonging to either antipsychotic group.

Accuracy of prescribing documentation by UK junior doctors undertaking psychiatry placements: a multi-centre observational study.

OBJECTIVES: Medical records are critical to patient care, but often contain incomplete information. In UK hospitals, record-keeping is traditionally undertaken by junior doctors, who are increasingly completing early-career placements in psychiatry, but negative attitudes towards psychiatry may affect their performance. Little is known about the accuracy of medical records in psychiatry in general. This study aimed to evaluate the accuracy of Electronic Medical Records (EMRs) pertinent to clinical decision-making ("rationale") for prescribing completed by junior doctors during a psychiatry placement, focusing on the differences between psychotropic vs. non-psychotropic drugs and the temporal association during their placement. RESULTS: EMRs of 276 participants yielding 780 ward round entries were analysed, 100% of which were completed by Foundation Year or General Practice specialty training junior doctors rather than more senior clinicians. Compared with non-psychotropic drugs, documentation of prescribing rationale for psychotropic drugs was less likely (OR = 0.24, 95% CI 0.16-0.36, p < 0.001). The rate of rationale documentation significantly declined over time especially for psychotropic drugs (p < 0.001). Prescribing documentation of non-psychotropic drugs for people with mental illness is paradoxically more accurate than that of psychotropic drugs. Early-career junior doctors are therefore increasingly shaping EMRs of people receiving psychiatric care.

[Methylphenidate augmentation of fluvoxamine for treatment-resistant depression: a case report and review literature]. / Tedaviye Dirençli Depresyonda Metilfenidat Ile Güçlendirme: Bir Olgu Bildirimi ve Literatürün Gözden Geçirmesi.

Methylphenidate and other psychostimulants have received substantial attention for the management of depression in patients with medical co-morbidities as well as for the symptomatic palliation of various neuropsychiatric disorders. Despite having been of little use in the first-line treatment of depressive disorders, some evidence does suggest that they may be of potential benefit as an antidepressant augmentation strategy in patients who fail to respond to stand-alone antidepressant regimens. However, such claims appear to be based entirely on case reports and to date, no appropriate placebo-controlled studies have been carried out on healthy young subjects. We report a case of a woman with refractory depression who successfully responded to methylphenidate augmentation of fluvoxamine. Her clinical picture was dominated by significant biological symptoms, which included apathy, anergia, increased appetite, and somnolence, with marked secondary functional impairment. Several antidepressant treatment modalities were attempted, including electroconvulsive therapy, with little improvement in her symptomatology. Augmentation of fluvoxamine with methylphenidate ultimately brought about a rapid and sustained complete remission of her depression. We will highlight how methylphenidate and other psychostimulants, when used with caution and an appreciation of their potential risk for abuse, may prove to be remarkably effective agents for antidepressant augmentation, including that of partially-effective or ineffective selective serotonin re-uptake inhibitors. Evidence for such use of methylphenidate unfortunately remains largely empirical and adequate placebo-controlled studies are therefore required to support or refute this claim.

Behavioural and psychological symptoms of dementia in primary care: a survey of general practitioners in Ireland.

Background Management of neuropsychiatric symptoms is a challenging task in primary care. Aims To assess self-reported confidence and knowledge of general practitioners (GPs) regarding the identification and management of behavioural and psychological symptoms of dementia (BPSD).Methods A self-designed two-page paper questionnaire was sent to a random sample of 160 GPs practising in north Dublin. They were asked to evaluate their confidence and knowledge on several aspects of diagnosis and management of BPSD.Results Completed questionnaires were returned from 109 GPs (response rate = 68%), of which 106 were usable. In general, GPs were somewhat critical of their self-reported skills in diagnosing (76.4%) and managing (77.4%) BPSD, as well as in discriminating BPSD from other behavioural disturbances (71.7%). Many of them (67.9%) also encountered difficulty accessing specialist services. There was no correlation between demographic characteristics of GPs or patient caseload with respect to their responses to questionnaire items. Although many GPs (92.5%) highly valued the important role of non-pharmacological interventions in BPSD, none of them reported recommending these in their daily practice.Conclusions Despite the fact that GPs have a wealth of knowledge about BPSD, they are largely critical of their knowledge and management skills of these symptoms. Efforts should be focused on supporting GPs by means of educational interventions that consider all aspects of dementia, but additionally highlight the more challenging neuropsychiatric components of the illness. Health services need to be structured in a way that promotes collaboration between GPs and mental health professionals for a seamless delivery of care.

Quality of end-of-life care for dementia patients during acute hospital admission: a retrospective study in Ireland.

OBJECTIVES: To examine the quality of end-of-life care received by patients with and without dementia on acute medical wards during their final hospitalization. METHODS: A retrospective clinical case note review of patients aged over 65 who had died on acute medical wards within a 6-month period in a general hospital in Dublin was conducted. Seventy-five multidisciplinary clinical notes were available for scrutiny in order to identify cognitive status, measure the frequency of invasive procedures undertaken and examine the quality of palliative care as benchmarked with the Liverpool Care Pathway for the Dying Patient (LCP) program. Comparison between patients with and without dementia was made. RESULTS: Eighteen (24.0%) subjects had dementia, 32 (42.7%) subjects were described as "cognitively intact" and 25 subjects did not have reference to cognitive status. Of the 50 patients with known cognitive status, 27 (54.0%) had had a Mini Mental State Examination (MMSE) conducted (10 dementia vs. 17 nondementia). Patients were equally subjected to invasive interventions regardless of their cognitive status. However, dementia patients were significantly less likely to be referred to palliative care interventions (P=.007), to be prescribed palliative drugs (P=.017) and to have carers involved in decision making (P=.006). CONCLUSION: Individuals with dementia may be receiving different end-of-life care from those without. The effective delivery of robust multidisciplinary frameworks for the palliation of symptoms of hospitalized dementia patients remains an important clinical goal.

Common mental health disorders in children and adolescents in primary care: A survey of knowledge, skills and attitudes among general practitioners in a newly developed European country

Background and Objectives: General Practitioners (GPs) are generally the first point of contact for children and adolescents with mental health problems. This study investigates the confidence, beliefs, and knowledge of GPs regarding common mental health problems in youngsters. Methods: A self-designed questionnaire was distributed to nearly all registered GPs in a middle-income European country in order to address the aims of the study. Results: Response rate was 58%. Many GPs reported relatively low confidence on a number of issues, including diagnosis (70.0%), initiating management (86.6%), assessing the child-caregiver relationship (72.0%) and the ability to distinguish between normal and pathological behavioural problems (75.1%). However, GPs showed greater inclination to conduct follow-up care after assessment by specialist services (53.5%). Few GPs considered psychosocial interventions to play a role in the treatment of anxiety disorders (18.5%), hyperkinetic disorders (24.2%), depression (22.9%) and disruptive behaviour disorders (18.5%) and this largely came from younger GPs (p < 0.001). Conclusions: Confidence of GPs in the management of youngsters with mental health problems is generally low. They may require significant back-up from specialist services in the form of both training and clinical collaboration (AU)