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Physical health checks in primary care for people with severe mental illness ((SMI) defined as schizophrenia, bipolar disorders and non-organic psychosis) aim to reduce health inequalities. Patients who decline or are deemed unsuitable for screening are removed from the denominator used to calculate incentivisation, termed exception reporting.
Aims
To describe the prevalence of, and patient characteristics associated with, exception reporting in patients with SMI.
Method
We identified adult patients with SMI from the UK Clinical Practice Research Datalink (CPRD), registered with a general practice between 2004 and 2018. We calculated the annual prevalence of exception reporting and investigated patient characteristics associated with exception reporting, using logistic regression.
Results
Of 193 850 patients with SMI, 27.7% were exception reported from physical health checks at least once. Exception reporting owing to non-response or declining screening increased over the study period. Patients of Asian or Black ethnicity (Asian: odds ratio 0.72, 95% CI 0.65–0.80; Black: odds ratio 0.86, 95% CI 0.76–0.97; compared with White) and women (odds ratio 0.90, 95% CI 0.88–0.92) had a reduced odds of being exception reported, whereas patients diagnosed with ‘other psychoses’ (odds ratio 1.19, 95% CI 1.15–1.23; compared with bipolar disorder) had increased odds. Younger patients and those diagnosed with schizophrenia were more likely to be exception reported owing to informed dissent.
Conclusions
Exception reporting was common in people with SMI. Interventions are required to improve accessibility and uptake of physical health checks to improve physical health in people with SMI.
Late-life affective disorders (LLADs) are common and are projected to increase by 2050. There have been several studies linking late-life depression to an increased risk of dementia, but it is unclear if bipolar affective disorder or anxiety disorders pose a similar risk.
Aims
We aimed to compare the risk of LLADs progressing to all-cause dementia, and the demographic and clinical variables mediating the risk.
Methods
We used the South London and Maudsley National Health Service Foundation Trust Clinical Records Interactive Search system to identify patients aged 60 years or older with a diagnosis of any affective disorder. Cox proportional hazard models were used to determine differences in dementia risk between late-life anxiety disorders versus late-life depression, and late-life bipolar disorder versus late-life depression. Demographic and clinical characteristics associated with the risk of dementia were investigated.
Results
Some 5695 patients were identified and included in the final analysis. Of these, 388 had a diagnosis of bipolar affective disorder, 1365 had a diagnosis of an anxiety disorder and 3942 had a diagnosis of a depressive disorder. Bipolar affective disorder was associated with a lower hazard of developing dementia compared to depression (adjusted model including demographics and baseline cognition, hazard ratio: 0.60; 95% CI: 0.41–0.87). Anxiety disorders had a similar hazard of developing dementia (adjusted hazard ratio: 1.05; 95% CI: 0.90–1.22). A prior history of a depressive disorder reduced the risk of late-life depression progressing to dementia – suggesting the new onset of a depressive disorder in later life is associated with higher risk – but a prior history of anxiety disorders or bipolar affective disorder did not alter risk.
Conclusions
LLADs have a differential risk of developing all-cause dementia, with demographic- and illness-related factors influencing the risk. Further prospective cohort studies are needed to explore the link between LLADs and dementia development, and mediators of the lower risk of dementia associated with late-life bipolar disorder compared to late-life depression.
The new American Law Institute Medical Malpractice Restatement posits a novel rule in § 6(b) that would authorize the use of medical-practice guidelines as a standard of care for medical-malpractice litigation. However, it would only be a “safe harbor” shield; guidelines could not be similarly used by plaintiffs as a sword. For defendants, the rule would transform what heretofore has been indisputably hearsay evidence into prima facie proof that would serve as a substitute for expert testimony, and which would be sufficient to defeat a malpractice claim. Plaintiffs wishing to use practice guidelines would be relegated to the “learned treatise” exception of the hearsay rule.
Practice guidelines are not however the panacea that the Restatement envisions. In the present-day proliferation of guidelines, there are many objectivity and credibility issues, resulting in severe criticism of the guideline promulgation process within the profession. Many guidelines offer inconsistent and conflicting recommendations, contain inherent conflicts of interest and mixed purposes, and some are even blatant attempts to tilt the playing field in favor of defendants.
There is no jurisdictional support for this rule. No case has ever held that practice guidelines constitute a standard of care or that they can be introduced as substantive proof or that their use is different depending on whether they are offered by a defendant or a plaintiff. Nor is there any sound reason or public policy that would support the rule or to believe any guideline is more authoritative than expert testimony, which can be tested in the crucible of the courtroom. The guidelines rule also suffers from practical problems and still requires expert testimony for support. The rule would also violate fundamental principles of equal justice and fairness by compromising the right to cross-examination and by allowing the medical profession to set its own variable standards of care. It is more akin to tort reform that a common law rule of evidence. For those reasons, courts should not accept the invitation to adopt § 6(b).
In the context of climate change, the impacts of extreme weather events are increasingly recognised as a significant threat to mental health in the UK. As clinicians and researchers with an interest in mental health, we have a collective responsibility to help understand and mitigate these impacts. To achieve this, however, it is vital to have an appreciation of the relevant policy and regulatory frameworks. In this feature article, a collaboration amongst mental health and policy experts, we provide an overview of the integration of mental health within current climate policies and regulations in the UK, including gaps and opportunities. We argue that current policy and regulatory frameworks are lacking in coverage, ambition, detail and implementation, as increases in weather extremes and their negative impacts on mental health outpace action. For example, across current national and local climate policies, there is almost no reference to the impacts of extreme weather events on mental health. Whilst alarming, this provides scope for future research to fill evidence gaps and inform policy and regulatory change. We call for mental health and policy experts to work together to improve our understanding of underlying mechanisms and develop practical interventions, helping to bring mental health within climate policy and regulatory frameworks.
People simultaneously entangled in multiple state systems are often subject to contradictory legal mandates that can foster distrust and incentivize system avoidance. This study focuses on those indebted to both the child support system and the criminal legal system, a situation we describe as dual debt. We ask whether and how the imposition of legal debts with punitive surveillance and collections mechanisms fosters alienation in the form of legal cynicism and estrangement, which we refer to jointly as legal anomie. Drawing from interview data in Minnesota, we find that legal anomie and system avoidance are mutually reinforcing processes, as debts in these systems triggered consequences that pushed people out of the formal labor market and heightened their distrust of legal institutions. The case of dual debt demonstrates how alienating and contradictory policy systems can foster both legal anomie and system avoidance, particularly in the context of economic and social precarity.
People with schizophrenia-spectrum and bipolar disorders (severe mental illnesses; ‘SMI’) experience excess mortality. Our aim was to explore longer-term trends in mortality, including the COVID-19 pandemic period, with a focus on additional vulnerabilities (psychiatric comorbidities and race/ ethnicity) in SMI.
Methods
Retrospective cohort study using electronic health records from secondary mental healthcare, covering a UK region of 1.3 million people. Mortality trends spanning fourteen years, including the COVID-19 pandemic, were assessed in adults with clinician-ascribed ICD-10 diagnoses for schizophrenia-spectrum and bipolar disorders.
Results
The sample comprised 22 361 people with SMI with median follow-up of 10.6 years. Standardized mortality ratios were more than double the population average pre-pandemic, increasing further during the pandemic, particularly in those with SMI and psychiatric comorbidities. Mortality risk increased steadily among people with SMI and comorbid depression, dementia, substance use disorders and anxiety over 13-years, increasing further during the pandemic. COVID-19 mortality was elevated in people with SMI and comorbid depression (sub-Hazard Ratio: 1.48 [95% CI 1.03–2.13]), dementia (sHR:1.96, 1.26–3.04) and learning disabilities (sHR:2.30, 1.30–4.06), compared to people with only SMI. COVID-19 mortality risk was similar for minority ethnic groups and White British people with SMI. Elevated all-cause mortality was evident in Black Caribbean (adjusted Rate Ratio: 1.40, 1.11–1.77) and Black African people with SMI (aRR: 1.59, 1.07–2.37) during the pandemic relative to earlier years.
Conclusions
Mortality has increased over time in people with SMI. The pandemic exacerbated pre-existing trends. Actionable solutions are needed which address wider social determinants and address disease silos.
Severe mental illness (SMI), which includes schizophrenia, schizoaffective disorder and bipolar disorder, has profound health impacts, even in the elderly.
Aims
To evaluate relative risk of hospital admission and length of hospital stay for physical illness in elders with SMI.
Method
To construct a population-based retrospective cohort observed from April 2007 to March 2016, data from a case registry with full but de-identified electronic health records were retrieved for patients of the South London and Maudsley NHS Foundation Trust, the single secondary mental healthcare service provider in south-east London. We compared participants with SMI aged >60 years old with the general population of the same age and residing in the same areas through data linkage by age-, sex- and fiscal-year-standardised admission ratios (SARs) for primary diagnoses at hospital discharge. Furthermore, we compared the duration of hospital stay with an age-, sex- and cause-of-admission-matched random group by linear regression for major causes of admission.
Results
In total, records for 4175 older people with SMI were obtained, relating to 10 342 admission episodes, showing an overall SAR for all physical illnesses of 5.15 (95% CI: 5.05, 5.25). Among the top causes of admission, SARs ranged from 3.87 for circulatory system disorders (ICD-10 codes: I00–I99) to 6.99 for genitourinary system or urinary conditions (N00–N39). Specifically, the diagnostic group of ‘symptoms, signs and findings, not elsewhere classified’ (R00–R99) had an elevated SAR of 6.56 (95% CI: 6.22, 6.90). Elders with SMI also had significantly longer hospital stays than their counterparts in the general population, especially for digestive system illnesses (K00–K93), after adjusting for confounding.
Conclusions
Poorer overall physical health and specific patterns were identified in elders with SMI.
To assess the psychosocial functioning concerning obsessive-compulsive symptoms (OCS) and/or obsessive-compulsive disorder (OCD) comorbidity in people with schizophrenia, schizoaffective disorder, or bipolar disorder diagnosed in a large case register database in Southeast London. Data were retrieved from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) register using Clinical Record Interactive Search (CRIS) system, a platform allowing research on full but de-identified electronic health records for secondary and tertiary mental healthcare services. Information of schizophrenia, schizoaffective disorder, bipolar disorder diagnosis and OCS/OCD status was ascertained from structural or free-text fields through natural language processing (NLP) algorithms based on artificial intelligence techniques during the observation window of January 2007 to December 2016. Associations between comorbid OCS/OCD and recorded Health of the Nation Outcome Scales (HoNOS) for problems with activities of daily living (ADLs), living conditions, occupational and recreational activities, and relationships were estimated by logistic regression with socio-demographic confounders controlled. Of 15,412 subjects diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder, 2,358 (15.3%) experienced OCS without OCD, and 2,586 (16.8%) had OCD recorded. The presence of OCS/OCD was associated with more problems with relationships (adj.OR = 1.34, 95% CI: 1.25–1.44), ADLs (adj.OR = 1.31, 95%CI: 1.22–1.41), and living conditions (adj.OR = 1.31, 95% CI: 1.22–1.41). Sensitivity analysis revealed similar outcomes. Comorbid OCS/OCD was associated with poorer psychosocial functioning in people with schizophrenia, schizoaffective disorder, or bipolar disorder. This finding highlights the importance of identification and treatment of comorbid OCS among this vulnerable patient group.
Very late-onset psychosis (VLOP) is associated with higher rates of dementia but the proportion who develop dementia with Lewy bodies (DLB) is unknown. We aimed to identify individuals with VLOP who develop dementia and DLB and characterize the risk factors for progression.
Methods
Anonymized data were retrieved from electronic records for individuals with VLOP. Patients developing dementia after psychosis were identified, in addition to those with >2 core features of DLB at the time of dementia or DLB identified by a natural language processing application (NLP-DLB). Demographic factors, Health of the National Outcome Scale (HoNOS) and symptoms at index psychosis were explored as predictors of progression to dementia.
Results
In 1425 patients with VLOP over 4.29 years (mean) follow up, 197 (13.8%) received a subsequent diagnosis of dementia. Of these, 24.4% (n = 48) had >2 core features of DLB and 6% (n = 12) had NLP-DLB. In cox proportional hazard models, older age and cognitive impairment at the time of psychosis were associated with increased risk of incident dementia. Visual hallucinations and 2+ core features of DLB at index psychosis were associated with increased risk of dementia with 2+ symptoms of DLB but not all-cause dementia. Two or more core features of DLB at index psychosis were associated with 81% specificity and 67% sensitivity for incident NLP-DLB.
Conclusions
In patients with VLOP who develop dementia, core features of DLB are common. Visual hallucinations or two core features of DLB in VLOP should prompt clinicians to consider DLB and support further investigation.
Depression is an independent risk factor for cardiovascular disease (CVD), but it is unknown if successful depression treatment reduces CVD risk.
Methods
Using eIMPACT trial data, we examined the effect of modernized collaborative care for depression on indicators of CVD risk. A total of 216 primary care patients with depression and elevated CVD risk were randomized to 12 months of the eIMPACT intervention (internet cognitive-behavioral therapy [CBT], telephonic CBT, and select antidepressant medications) or usual primary care. CVD-relevant health behaviors (self-reported CVD prevention medication adherence, sedentary behavior, and sleep quality) and traditional CVD risk factors (blood pressure and lipid fractions) were assessed over 12 months. Incident CVD events were tracked over four years using a statewide health information exchange.
Results
The intervention group exhibited greater improvement in depressive symptoms (p < 0.01) and sleep quality (p < 0.01) than the usual care group, but there was no intervention effect on systolic blood pressure (p = 0.36), low-density lipoprotein cholesterol (p = 0.38), high-density lipoprotein cholesterol (p = 0.79), triglycerides (p = 0.76), CVD prevention medication adherence (p = 0.64), or sedentary behavior (p = 0.57). There was an intervention effect on diastolic blood pressure that favored the usual care group (p = 0.02). The likelihood of an incident CVD event did not differ between the intervention (13/107, 12.1%) and usual care (9/109, 8.3%) groups (p = 0.39).
Conclusions
Successful depression treatment alone is not sufficient to lower the heightened CVD risk of people with depression. Alternative approaches are needed.
There is a lack of data on mental health service utilisation and outcomes for people with experience of forced migration living in the UK. Details about migration experiences documented in free-text fields in electronic health records might be harnessed using novel data science methods; however, there are potential limitations and ethical concerns.
Lithofacies and biostratigraphical analysis has enabled the establishment of a stratigraphic event framework for Ludfordian and Pridoli strata in south Wales and the Welsh Borderland. In SW Wales, the Golden Grove Axis acted as a structural hinge separating the shallow marine storm-influenced Cae’r mynach Seaway from a pediment surface above which Ludfordian colluvium (Abercyfor Formation) was deposited. The Axis seeded four NW-derived river-influenced delta progrades of Leintwardinian to early Pridoli age (Tilestones Formation). A NE-sourced early Pridoli wave-influenced delta deposited the Downton Castle Sandstone Formation (DCSF), coeval to the youngest Tilestones prograde, with a lateral interface existing between Mynydd Epynt and the Clun Forest area. Except for the Malverns area, the DCSF is no longer recognized south of the Neath Disturbance. Early Pridoli forced regression promoted widespread subaerial exposure north of the Neath Disturbance, with incision into tracts close to the Welsh Borderland Fault System. The basinward-shift in facies belts resulted in marine erosion and deposition of a phosphatic ravinement pebble lag. The wave-influenced Clifford’s Mesne Sandstone Formation delta subsequently seeded on the Gorsley Axis with tidally influenced Rushall Formation accumulating in a back-barrier setting. The Pwll-Mawr Formation records the easterly advance of coeval coastal deposits on the western side of the remnant Cae’r mynach Seaway. Behind migrating delta coastlines, green muds accumulated on coastal plains (Temeside Mudstone Formation) with better drained red dryland alluvium (Moor Cliffs Formation) charting expansion of Old Red Sandstone lithofacies. Mid-Pridoli incision preserves the Pont ar Llechau Formation estuarine valley fill.
Following the onset of the COVID-19 pandemic, healthcare trusts began to implement remote working arrangements, with little knowledge of their impact on staff well-being.
Aims
To investigate how remote working of healthcare workers during the pandemic may have been associated with stress, productivity and work satisfaction at that time, and associations between loneliness, workplace isolation, perceived social support and well-being.
Method
A questionnaire was developed to explore remote working and productivity, stress and work satisfaction during time spent working remotely. Associations between current loneliness, workplace isolation and well-being, and the influence of perceived social support, were explored with perceived social support as a potential moderator.
Results
A total of 520 participants responded to the study, of whom 112 were men (21.5%) and 406 were women (78.1%), with an age range of 21–77 years (mean 40.0, s.d. = 12.1). Very few (3.1%) worked remotely before the COVID-19 pandemic, and this had increased significantly (96.9%). Those who worked ≥31 h a week remotely reported higher stress and lower workplace satisfaction at that time, compared with office work, yet also felt more productive. Current loneliness, workplace isolation and perceived social support were cross-sectionally associated with lower current well-being.
Conclusions
Those who worked more hours a week remotely during the pandemic reported increased stress, which may be related to the lack of resources in place to support this change in work.
Phase three trials of the monoclonal antibodies lecanemab and donanemab, which target brain amyloid, have reported statistically significant differences in clinical end-points in early Alzheimer's disease. These drugs are already in use in some countries and are going through the regulatory approval process for use in the UK. Concerns have been raised about the ability of healthcare systems, including those in the UK, to deliver these treatments, considering the resources required for their administration and monitoring.
Aims
To estimate the scale of real-world demand for monoclonal antibodies for Alzheimer's disease in the UK.
Method
We used anonymised patient record databases from two National Health Service trusts for the year 2019 to collect clinical, demographic, cognitive and neuroimaging data for these cohorts. Eligibility for treatment was assessed using the inclusion criteria from the clinical trials of donanemab and lecanemab, with consideration given to diagnosis, cognitive performance, cerebrovascular disease and willingness to receive treatment.
Results
We examined the records of 82 386 people referred to services covering around 2.2 million people. After applying the trial criteria, we estimate that a maximum of 906 people per year would start treatment with monoclonal antibodies in the two services, equating to 30 200 people if extrapolated nationally.
Conclusions
Monoclonal antibody treatments for Alzheimer's disease are likely to present a significant challenge for healthcare services to deliver in terms of the neuroimaging and treatment delivery. The data provided here allows health services to understand the potential demand and plan accordingly.
People with tuberculosis (TB) are susceptible to mental distress. Mental distress can be driven by biological and socio-economic factors including poverty. These factors can persist beyond TB treatment completion yet there is minimal evidence about the mental health of TB survivors. A cross-sectional TB prevalence survey of adults was conducted in an urban community in Zambia. Survey participants were administered the five-item Self Reporting Questionnaire (SRQ-5) mental health screening tool to measure mental distress. Associations between primary exposure (history of TB) and other co-variates with mental distress were investigated using logistic regression. Of 3,393 study participants, 120 were TB survivors (3.5%). The overall prevalence of mental distress (SRQ-5 ≥ 4) in the whole study population was 16.9% (95% CI 15.6%–18.1%). Previous TB history was not associated with mental distress (OR 1.20, 95% CI 0.75–1.92, p-value 1.66). Mental distress was associated with being female (OR 1.23 95% CI 1.00–1.51), older age (OR 1.71 95% CI 1.09–2.68) and alcohol abuse (OR 1.81 95% CI 1.19–2.76). Our findings show no association between a previous TB history and mental distress. However, approximately one in six people in the study population screened positive for mental distress.
The association of COVID-19 with death in people with severe mental illness (SMI), and associations with multimorbidity and ethnicity, are unclear.
Aims
To determine all-cause mortality in people with SMI following COVID-19 infection, and assess whether excess mortality is affected by multimorbidity or ethnicity.
Method
This was a retrospective cohort study using primary care data from the Clinical Practice Research Database, from February 2020 to April 2021. Cox proportional hazards regression was used to estimate the effect of SMI on all-cause mortality during the first two waves of the COVID-19 pandemic.
Results
Among 7146 people with SMI (56% female), there was a higher prevalence of multimorbidity compared with the non-SMI control group (n = 653 024, 55% female). Following COVID-19 infection, the SMI group experienced a greater risk of death compared with controls (adjusted hazard ratio (aHR) 1.53, 95% CI 1.39–1.68). Black Caribbean/Black African people were more likely to die from COVID-19 compared with White people (aHR = 1.22, 95% CI 1.12–1.34), with similar associations in the SMI group and non-SMI group (P for interaction = 0.73). Following infection with COVID-19, for every additional multimorbidity condition, the aHR for death was 1.06 (95% CI 1.01–1.10) in the SMI stratum and 1.16 (95% CI 1.15–1.17) in the non-SMI stratum (P for interaction = 0.001).
Conclusions
Following COVID-19 infection, patients with SMI were at an elevated risk of death, further magnified by multimorbidity. Black Caribbean/Black African people had a higher risk of death from COVID-19 than White people, and this inequity was similar for the SMI group and the control group.
Adverse effects are a common concern when prescribing and reviewing medication, particularly in vulnerable adults such as older people and those with intellectual disability. This paper describes the development of an app giving information on side-effects, called Medichec, and provides a description of the processes involved in its development and how drugs were rated for each side-effect. Medications with central anticholinergic action, dizziness, drowsiness, hyponatraemia, QTc prolongation, bleeding and constipation were identified using the British National Formulary (BNF) and frequency of occurrence of these effects was determined using the BNF, product information and electronic searches, including PubMed.
Results
Medications were rated using a traffic light system according to how commonly the adverse effect was known to occur or the severity of the effect.
Clinical implications
Medichec can facilitate access to side-effects information for multiple medications, aid clinical decision-making, optimise treatment and improve patient safety in vulnerable adults.
People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.
Previous evidence on antidepressant medication and cardiovascular disease (CVD) among patients with posttraumatic stress disorder (PTSD) has been inconclusive. We estimated the association between antidepressant medication and CVD by applying a marginal structural model.
Methods
We analyzed medical utilization records of 27 170 people with PTSD without prior major cardiovascular events in the Korean National Health Insurance Database (NHID). PTSD and CVD were defined in accordance with the recorded ICD-10 diagnostic codes. We acquired information on antidepressant use from the NHID and categorized them by medication type. A composite major adverse cardiovascular events (MACE) outcome was defined as coronary artery disease with revascularization, ischaemic stroke, and/or haemorrhagic stroke. We used inverse probability of treatment weighting to estimate the parameters of a marginal structural discrete-time survival analysis regression model, comparing the resulting estimates to those derived from traditional time-fixed and time-varying Cox proportional hazards regression. We calculated cumulative daily defined doses to test for a dose–response relationship.
Results
People exposed to antidepressants showed a higher hazard of MACE [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.18–1.53]. The estimated effects were strongest for selective serotonin reuptake inhibitors (HR 1.24, 95% CI 1.08–1.44) and TCAs (HR 1.33, 95% CI 1.13–1.56). Exposure to serotonin-norepinephrine reuptake inhibitors did not appear to increase the risk of MACE. People exposed to higher doses of antidepressants showed higher risk of MACE.
Conclusions
In a national cohort of people with PTSD, exposure to antidepressant medications increased the risk of MACE in a dose–response fashion.