Management of total anomalous pulmonary venous connections has been extensively studied to further improve outcomes. Our institution previously reported factors associated with mortality, recurrent obstruction, and reintervention. The study purpose was to revisit the cohort of patients and evaluate factors associated with reintervention, and mortality in early and late follow-up.

A retrospective review at our institution identified 81 patients undergoing total anomalous pulmonary venous connection repair from January 2002 to January 2018. Demographic and operative variables were evaluated. Anastomotic reintervention (interventional or surgical) and/or mortality were primary endpoints.

Eighty-one patients met the study criteria. Follow-up ranged from 0 to 6,291 days (17.2 years), a mean of 1263 days (3.5 years). Surgical mortality was 16.1% and reintervention rates were 19.8%. In re-interventions performed, 80% occurred within 1.2 years, while 94% of mortalities were within 4.1 months. Increasing cardiopulmonary bypass times (p = 0.0001) and the presence of obstruction at the time of surgery (p = 0.025) were predictors of mortality, while intracardiac total anomalous pulmonary venous connection type (p = 0.033) was protective. Risk of reintervention was higher with increasing cardiopulmonary bypass times (p = 0.015), single ventricle anatomy (p = 0.02), and a post-repair gradient >2 mmHg on transesophageal echocardiogram (p = 0.009).

Evaluation of a larger cohort with longer follow-up demonstrated the relationship of anatomic complexity and symptoms at presentation to increased mortality risk after total anomalous pulmonary venous connection repair. The presence of a single ventricle or a post-operative confluence gradient >2 mmHg were risk factors for reintervention. These findings support those found in our initial study.

Cyberchondria involves excessive and uncontrollable online searching of information about a perceived illness. This behavior can cause or maintain distress.

Little is known about cyberchondria during the COVID-19 pandemic or how cyberchondria in one individual may cause distress in their significant other if they are self-isolating together; our study sought to fill these gaps.

We conducted a Qualtrics Panel survey with 760 cohabitating Canadian couples; in June 2020, participants retrospectively reported on their cyberchondria behavior, general anxiety, and COVID-19 fears during the month of April 2020, while adhering to stay-at-home advisories. Two separate actor-partner interdependence models (APIMs) used cyberchondria excessiveness and compulsion to predict generalized anxiety and COVID-19 danger/contamination fears in the actor and partner.

Both cyberchondria excessiveness and compulsion were associated with higher general anxiety and higher COVID-19 danger/contamination fears in the individual (actor effects). Partner cyberchondria compulsion was associated with higher general anxiety in the individual whereas partner cyberchondria excessiveness was associated with higher COVID-19 danger/contamination fears in the individual (partner effects).

Findings suggest that excessive and uncontrollable searching of information about COVID-19 on the internet during lockdown may contribute to distress in both the individual engaging in the cyberchondria behavior, and in their romantic partner. Moreover, different aspects of cyberchondria in the partner (compulsion vs. excessiveness) appears to contribute to general vs. COVID-19-specific anxiety/fears in the partner, respectively. Future research should examine mechanisms underlying the observed partner effects (e.g., co-rumination, social contagion) and reasons for the differential partner effects of cyberchondria components.

Remote consultation technology has been rapidly adopted due to the COVID-19 pandemic. However, some healthcare settings have faced barriers in implementation. We present a study to investigate changes in rates of remote consultation during the pandemic using a large electronic health record (EHR) dataset.

The Clinical Record Interactive Search tool (CRIS) was used to examine de-identified EHR data of people receiving mental healthcare in South London, UK. Data from around 37,500 patients were analysed for each week from 7th January 2019 and 20th September 2020 using linear regression and locally estimated scatterplot smoothing (LOESS) to investigate changes in the number of clinical contacts (in-person, remote or non-attended) with mental healthcare professionals and prescribing of antipsychotics and mood stabilisers. The data are presented in an interactive dashboard: http://rpatel.co.uk/TelepsychiatryDashboard.

The frequency of in-person contacts was substantially reduced following the onset of the pandemic (β coefficient: -5829.6 contacts, 95% CI -6919.5 to -4739.6, p<0.001), while the frequency of remote contacts increased significantly (β coefficient: 3338.5 contacts, 95% CI 3074.4 to 3602.7, p<0.001). Rates of remote consultation were lower in older adults than in working age adults, children and adolescents. Despite the increase in remote contact, antipsychotic and mood stabiliser prescribing remained at similar levels.

The COVID-19 pandemic has been associated with a marked increase in remote consultation, particularly among younger patients. However, there was no evidence that this has led to changes in prescribing. Further work is needed to support older patients in accessing remote mental healthcare.

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: RS has received funding from Janssen, GSK and Takeda outside the submitted work. RP has received funding from Janssen, Induction Healthcare and H

The ‘sick-quitter’ hypothesis states that mental disorders associated with alcohol abstinence are accounted for by people who stop consuming alcohol because of poor health.

We investigated the association between alcohol abstinence and symptoms of common mental disorder and personality disorder, distinguishing between lifelong abstinence and abstinence following previous consumption.

Analyses were based on the British National Survey of Psychiatric Morbidity 2000, which sampled 8580 residents aged 16 to 74 years. Heavy consumers of alcohol were excluded, using the Alcohol Use Disorders Identification Test Questionnaire. Symptoms of common mental disorder (depression/anxiety) were identified by the Clinical Interview Schedule. The screening questionnaire of the Structured Clinical Interview for Axis II Personality Disorders was used to identify potential personality disorder. Self-reported alcohol abstinence was divided into lifelong abstinence and previous consumption. Previous consumers were asked why they had stopped. Covariates included socioeconomic status, social activity and general health status.

After adjustment, alcohol abstinence was associated with both common mental disorder symptoms and any personality disorder, but only for previous consumers (respective odds ratios 1.70 (1.23-2.34) and 1.45 (1.09-1.94)). Associations were non-specific, being apparent for most individual mental disorder symptoms and personality disorder categories. More detailed analysis indicated that associations were limited to previous consumers who reported ceasing alcohol consumption for health reasons.

The results were consistent with the ‘sick-quitter’ hypothesis and should be taken into account when interpreting associations between moderate alcohol consumption and beneficial health outcomes.

Autism Spectrum Disorders (ASDs) affect 1% of children and are associated with lifelong psychosocial impairments. The majority of children with ASD will experience co-occurring psychiatric disorders. In the UK, antipsychotics remain unlicensed for use in ASDs, however 10% of children with ASD receive antipsychotic treatment; the co-occurring disorders being targeted by these medications remains unclear.

To examine rates of antipsychotic medication use and identify associated co-occurring disorders among children with ASD receiving psychiatric care.

The sample consisted of 2844 children aged 2 to 17 with a NHS clinician recorded ICD-10 diagnoses for ASD between 2008–2013. Clinical variables extracted from their anonymised electronic patient records included disorder severity, medication use, co-occurring ICD-10 diagnoses, family characteristics, demographics and antipsychotic use.

Of the 2844 children (79% male), the majority (57%) had co-occurring psychiatric diagnoses. 313 (11%) received antipsychotic medication. The proportion of children aged 13 to 17 years and 6 to 12 years prescribed antipsychotics was 19% and 7% respectively. After controlling for socio-demographic factors, disorder severity, specialist treatment, inpatient duration, risk of self harm, violence to others, self injurious behaviour, maltreatment history, parental mental illness, caregiver anxiety, and neighbourhood deprivation, multivariate regression analysis revealed only hyperactivity disorders (O.R 1.94, 95%C.I. 1.32–2.86), psychotic disorders (O.R 5.12 95% C.I. 2.6–10.1), mood disorders (O.R 2.02, 95%C.I. 1.04–3.92) and intellectual disability (O.R 2.89 95% C.I. 1.89–4.71) were associated with anti-psychotic use.

The prescription of antipsychotic medications in this UK ASD clinical sample is strongly associated with specific co-occurring psychiatric disorders and intellectual disability.

Higher all-cause mortality and shorter life expectancies for people with severe mental illness (SMI, including schizophrenia, schizoaffective disorder, and bipolar disorder) have been frequently reported. Cancer contributes a substantial proportion of mortality (20 to 30%) as the second or third leading cause of death among people with SMI. Outcomes of cancer incidence studies in SMI were considerably heterogeneous, varying by cancer types and mental disorders.

To compare the incidence of overall and each type of cancer between people with SMI in southeast London and general population in UK.

Using the anonymised linkage between a regional monopoly secondary mental health service provider covering four southeast London boroughs and a population-based cancer register, we carried out the comparisons of cancer incidences between people with SMI and general population by age- and gender-standardisation in 2011.

Among SMI subjects with cancer (N=105), the most common cancer types were lung and colorectal cancer followed by breast cancer for women and prostate cancer for men in this area. Standardised incidence ratios (SIRs) for all cancers in SMI were 1.19 (95% CI: 0.97-1.44) overall, 2.43 (95% CI: 1.98-2.94) in men (n=61), and 0.98 (95% CI: 0.71-1.31) in women (n=44). Based on relatively small case numbers, raised SIRs were found for lung cancer in men (SIR=7.57, 95% CI: 3.04-15.6) and women (SIR=7.61, 95% CI: 2.79-16.6), and in women for colorectal (SIR=7.85, 95%CI: 2.55-18.32) and breast cancer (SIR=7.86, 95% CI: 4.58-12.59).

Specific pattern of elevated risks of cancer incidence were found for people with SMI.

The symptoms of bipolar disorder are sometimes misrecognised for unipolar depression and inappropriately treated with antidepressants. This may be associated with increased risk of developing mania. However, the extent to which this depends on what type of antidepressant is prescribed remains unclear.

To investigate the association between different classes of antidepressants and subsequent onset of mania/bipolar disorder in a real-world clinical setting.

Data on prior antidepressant therapy were extracted from 21,012 adults with unipolar depression receiving care from the South London and Maudsley NHS Foundation Trust (SLaM). multivariable Cox regression analysis (with age and gender as covariates) was used to investigate the association of antidepressant therapy with risk of developing mania/bipolar disorder.

In total, 91,110 person-years of follow-up data were analysed (mean follow-up: 4.3 years). The overall incidence rate of mania/bipolar disorder was 10.9 per 1000 person-years. The peak incidence of mania/bipolar disorder was seen in patients aged between 26 and 35 years (12.3 per 1000 person-years). The most frequently prescribed antidepressants were SSRIs (35.5%), mirtazapine (9.4%), venlafaxine (5.6%) and TCAs (4.7%). Prior antidepressant treatment was associated with an increased incidence of mania/bipolar disorder ranging from 13.1 to 19.1 per 1000 person-years. Multivariable analysis indicated a significant association with SSRIs (hazard ratio 1.34, 95% CI 1.18–1.52) and venlafaxine (1.35, 1.07–1.70).

In people with unipolar depression, antidepressant treatment is associated with an increased risk of subsequent mania/bipolar disorder. These findings highlight the importance of considering risk factors for mania when treating people with depression.

The authors have not supplied their declaration of competing interest.

Mood instability is an important problem but has received relatively little research attention. Natural language processing (NLP) is a novel method, which can used to automatically extract clinical data from electronic health records (EHRs).

To extract mood instability data from EHRs and investigate its impact on people with mental health disorders.

Data on mood instability were extracted using NLP from 27,704 adults receiving care from the South London and Maudsley NHS Foundation Trust (SLaM) for affective, personality or psychotic disorders. These data were used to investigate the association of mood instability with different mental disorders and with hospitalisation and treatment outcomes.

Mood instability was documented in 12.1% of people included in the study. It was most frequently documented in people with bipolar disorder (22.6%), but was also common in personality disorder (17.8%) and schizophrenia (15.5%). It was associated with a greater number of days spent in hospital (B coefficient 18.5, 95% CI 12.1–24.8), greater frequency of hospitalisation (incidence rate ratio 1.95, 1.75–2.17), and an increased likelihood of prescription of antipsychotics (2.03, 1.75–2.35).

Using NLP, it was possible to identify mood instability in a large number of people, which would otherwise not have been possible by manually reading clinical records. Mood instability occurs in a wide range of mental disorders. It is generally associated with poor clinical outcomes. These findings suggest that clinicians should screen for mood instability across all common mental health disorders. The data also highlight the utility of NLP for clinical research.

The authors have not supplied their declaration of competing interest.

There are often substantial delays before diagnosis and initiation of treatment in people bipolar disorder. Increased delays are a source of considerable morbidity among affected individuals.

To investigate the factors associated with delays to diagnosis and treatment in people with bipolar disorder.

Retrospective cohort study using electronic health record data from the South London and Maudsley NHS Foundation Trust (SLaM) from 1364 adults diagnosed with bipolar disorder. The following predictor variables were analysed in a multivariable Cox regression analysis on diagnostic delay and treatment delay from first presentation to SLaM: age, gender, ethnicity, compulsory admission to hospital under the UK Mental Health Act, marital status and other diagnoses prior to bipolar disorder.

The median diagnostic delay was 62 days (interquartile range: 17–243) and median treatment delay was 31 days (4–122). Compulsory hospital admission was associated with a significant reduction in both diagnostic delay (hazard ratio 2.58, 95% CI 2.18–3.06) and treatment delay (4.40, 3.63–5.62). Prior diagnoses of other psychiatric disorders were associated with increased diagnostic delay, particularly alcohol (0.48, 0.33–0.41) and substance misuse disorders (0.44, 0.31–0.61). Prior diagnosis of schizophrenia and psychotic depression were associated with reduced treatment delay.

Some individuals experience a significant delay in diagnosis and treatment of bipolar disorder, particularly those with alcohol/substance misuse disorders. These findings highlight a need to better identify the symptoms of bipolar disorder and offer appropriate treatment sooner in order to facilitate improved clinical outcomes. This may include the development of specialist early intervention services.

The authors have not supplied their declaration of competing interest.

Public health monitoring is commonly undertaken in social media but has never been combined with data analysis from electronic health records. This study aimed to investigate the relationship between the emergence of novel psychoactive substances (NPS) in social media and their appearance in a large mental health database.

Insufficient numbers of mentions of other NPS in case records meant that the study focused on mephedrone. Data were extracted on the number of mephedrone (i) references in the clinical record at the South London and Maudsley NHS Trust, London, UK, (ii) mentions in Twitter, (iii) related searches in Google and (iv) visits in Wikipedia. The characteristics of current mephedrone users in the clinical record were also established.

Increased activity related to mephedrone searches in Google and visits in Wikipedia preceded a peak in mephedrone-related references in the clinical record followed by a spike in the other 3 data sources in early 2010, when mephedrone was assigned a ‘class B’ status. Features of current mephedrone users widely matched those from community studies.

Combined analysis of information from social media and data from mental health records may assist public health and clinical surveillance for certain substance-related events of interest. There exists potential for early warning systems for health-care practitioners.

To evaluate long-term efficacy of deutetrabenazine in patients with tardive dyskinesia (TD) by examining response rates from baseline in Abnormal Involuntary Movement Scale (AIMS) scores. Preliminary results of the responder analysis are reported in this analysis.

In the 12-week ARM-TD and AIM-TD studies, the odds of response to deutetrabenazine treatment were higher than the odds of response to placebo at all response levels, and there were low rates of overall adverse events and discontinuations associated with deutetrabenazine.

Patients with TD who completed ARM-TD or AIM-TD were included in this open-label, single-arm extension study, in which all patients restarted/started deutetrabenazine 12mg/day, titrating up to a maximum total daily dose of 48mg/day based on dyskinesia control and tolerability. The study comprised a 6-week titration and a long-term maintenance phase. The cumulative proportion of AIMS responders from baseline was assessed. Response was defined as a percent improvement from baseline for each patient from 10% to 90% in 10% increments. AlMS score was assessed by local site ratings for this analysis.

343 patients enrolled in the extension study (111 patients received placebo in the parent study and 232 patients received deutetrabenazine). At Week 54 (n=145; total daily dose [mean±standard error]: 38.1±0.9mg), 63% of patients receiving deutetrabenazine achieved ≥30% response, 48% of patients achieved ≥50% response, and 26% achieved ≥70% response. At Week 80 (n=66; total daily dose: 38.6±1.1mg), 76% of patients achieved ≥30% response, 59% of patients achieved ≥50% response, and 36% achieved ≥70% response. Treatment was generally well tolerated.

Patients who received long-term treatment with deutetrabenazine achieved response rates higher than those observed in positive short-term studies, indicating clinically meaningful long-term treatment benefit.

Presented at: American Academy of Neurology Annual Meeting; April 21–27, 2018, Los Angeles, California, USA.

Funding Acknowledgements: This study was supported by Teva Pharmaceuticals, Petach Tikva, Israel.

To evaluate the long-term safety and tolerability of deutetrabenazine in patients with tardive dyskinesia (TD) at 2years.

In the 12-week ARM-TD and AIM-TD studies, deutetrabenazine showed clinically significant improvements in Abnormal Involuntary Movement Scale scores compared with placebo, and there were low rates of overall adverse events (AEs) and discontinuations associated with deutetrabenazine.

Patients who completed ARM-TD or AIM-TD were included in this open-label, single-arm extension study, in which all patients restarted/started deutetrabenazine 12mg/day, titrating up to a maximum total daily dose of 48mg/day based on dyskinesia control and tolerability. The study comprised a 6-week titration period and a long-term maintenance phase. Safety measures included incidence of AEs, serious AEs (SAEs), and AEs leading to withdrawal, dose reduction, or dose suspension. Exposure-adjusted incidence rates (EAIRs; incidence/patient-years) were used to compare AE frequencies for long-term treatment with those for short-term treatment (ARM-TD and AIM-TD). This analysis reports results up to 2 years (Week106).

343 patients were enrolled (111 patients received placebo in the parent study and 232 received deutetrabenazine). There were 331.4 patient-years of exposure in this analysis. Through Week 106, EAIRs of AEs were comparable to or lower than those observed with short-term deutetrabenazine and placebo, including AEs of interest (akathisia/restlessness [long-term EAIR: 0.02; short-term EAIR range: 0–0.25], anxiety [0.09; 0.13–0.21], depression [0.09; 0.04–0.13], diarrhea [0.06; 0.06–0.34], parkinsonism [0.01; 0–0.08], somnolence/sedation [0.09; 0.06–0.81], and suicidality [0.02; 0–0.13]). The frequency of SAEs (EAIR 0.15) was similar to those observed with short-term placebo (0.33) and deutetrabenazine (range 0.06–0.33) treatment. AEs leading to withdrawal (0.08), dose reduction (0.17), and dose suspension (0.06) were uncommon.

These results confirm the safety outcomes seen in the ARM-TD and AIM-TD parent studies, demonstrating that deutetrabenazine is well tolerated for long-term use in TD patients.

Presented at: American Academy of Neurology Annual Meeting; April 21–27, 2018, Los Angeles, California,USA

Funding Acknowledgements: Funding: This study was supported by Teva Pharmaceuticals, Petach Tikva, Israel