Andrea L. Gordon

The development of a screening method for abnormal illness behaviour

Abstract The 62-item Illness Behaviour Questionnaire (IBQ) was administered to 100 Pain Clinic patients and 78 General Practice patients in Seattle, Washington; and to 100 Pain Clinic patients and 155 General Practice patients in Adelaide, South Australia. A discriminant function which included scores on Scale 2 (disease conviction), Scale 3 (somatic focusing), Scale 6 (denial) and Scale 7 (irritability) was derived from the scores of the Seattle populations. When this function was applied to the Adelaide populations, the IBQ was found to have a sensitivity of 97%, specificity of 73.55% and hits-positive rate of 0.70. It appears, therefore, that the IBQ may be successfully utilized as a screening instrument in General Practice populations to identify patients manifesting abnormal illness behaviour.

A magic pill? A qualitative analysis of patients' views on the role of antidepressant therapy in inflammatory bowel disease (IBD)

BackgroundStudies with healthy volunteers have demonstrated that antidepressants can improve immunoregulatory activity and thus they may have a potential to positively impact the disease course in inflammatory bowel disease (IBD), a chronic and incurable condition. However, patients’ views on the role of antidepressants in the management of their IBD are unknown. Thus, this study aimed to explore patients’ experiences and opinions regarding the effect of antidepressants on IBD course before possibly undertaking future treatment trials with antidepressants.MethodsSemi-structured in-depth interviews with open-ended questions were conducted with a randomly selected sample of IBD patients recruited at the Australian public hospital IBD clinic and currently receiving antidepressants. A qualitative content analysis was undertaken to summarise patients’ responses. A Visual Analogue Scale was used to provide a quantitative assessment of patients’ experiences with antidepressants.ResultsOverall, 15 IBD sufferers currently on antidepressants (nine females, six males) were interviewed. All 15 reported a positive response to antidepressants reporting they improved their quality of life, with minimal side-effects. Five patients (33.3%) felt the antidepressant had specifically improved their IBD course. Three patients noted how they believed the reduction in feelings of stress mediated the positive influence of the antidepressant on IBD course. Ten patients (66.7%) felt the antidepressants had not specifically influenced their IBD. Nine patients (60.0%) had a generally positive attitude towards antidepressants, four patients (26.7%) were ambivalent, and two patients (13.3%) held a negative view towards antidepressants. Twelve patients (80.0%) stated that they would be willing to participate in clinical trials.ConclusionsAntidepressants seem to be well tolerated by IBD patients. One third of patients reported an observable improvement of their IBD under the influence of this treatment. The positive attitude towards antidepressants in these participants may make the conduct of clinical trials to further assess for any specific role on IBD course feasible. However, due to a small sample size, a qualitative nature of this study and in light of the results of studies on other populations indicating reluctance to taking antidepressants at least in some patients, these results should be interpreted with caution until confirmed in quantitative studies.

Audit of Domperidone Use as a Galactogogue at an Australian Tertiary Teaching Hospital

Background: Domperidone is often used to promote lactation among women who have difficulty breastfeeding. Objective: To examine prescribing and dispensing practices of domperidone at the Women’s and Children’s Hospital (WCH), Adelaide. Methods: A retrospective audit of domperidone dispensing among women with singleton pregnancies who delivered at the WCH between January 2000 and July 2010 was undertaken. Women dispensed domperidone were identified using WCH pharmacy dispensing records. Maternal and infant clinical data were obtained from the WCH Perinatal Statistics Collection. An audit of paper-based medical records was undertaken for a random sample of 261 mother-child pairs to collect prescribing and additional clinical data. Results: From 2000 to 2010, 1605 women were dispensed domperidone. There was a steady increase in the percentage of women dispensed domperidone, from < 0.5% in 2000 to > 5% of total WCH pregnancies in 2010. Among women dispensed domperidone, the percentage of women who received > 1 dispensing remained consistent (20%) over time, as did the median number of days (12) from delivery to first dispensing. Multiparous women were more likely to receive domperidone within 3 days following delivery compared to primiparous women (8% vs 4%; P < .01). Most women (80%) received directions to take domperidone according to a standard tapering dosing regimen over 12 days. Notably, 60% of women had no documentation of being assessed by a lactation consultant. Conclusion: From 2000 to 2010, there was a considerable increase in domperidone dispensing. With a lack of clinical evidence to guide use, current practice appears to be based on anecdotal evidence.

The role of antidepressants in the management of inflammatory bowel disease (IBD): a short report on a clinical case-note audit.

OBJECTIVE This study sought to determine the frequency of use and types of antidepressants used in IBD patients and to collect data with respect to any effect of antidepressants on the course of IBD in a usual care setting. METHOD A case-note audit was conducted at an IBD Service in a public tertiary hospital. Included patients were those diagnosed with IBD by a gastroenterologist; and have had contact with the IBD Service in the last 6months. Descriptive statistics were used to summarise the data. RESULTS Overall, 313 patients were eligible and 287 had complete data. Overall, 51 (17.8%) patients were currently taking antidepressants and 71 (24.7%) previously received antidepressants. Eighty-three (28.9%) patients had used an antidepressant at some time. In terms of disease activity while on antidepressants, the majority of patients had inactive disease but presented with what were thought by their clinicians to be functional symptoms. CONCLUSION Antidepressants are commonly prescribed in IBD patients. In our cohort, they appear to be mostly used for functional symptoms. The current data do not allow us to judge whether they improve IBD disease activity. Targeted studies are needed to answer this question and to improve practice and patient outcomes.

(R)‐ and (S)‐methadone and buprenorphine concentration ratios in maternal and umbilical cord plasma following chronic maintenance dosing in pregnancy

AIMS The aim of this study was to compare the transfer of buprenorphine and methadone between maternal and cord blood in women under chronic dosing conditions and to determine if differences exist in the transfer of the two methadone enantiomers. METHODS Maternal and cord blood samples were collected at delivery from women maintained on methadone (35, 25-140 mg day⁻¹) (median; range) or buprenorphine (6.00, 2-20 mg day⁻¹) during pregnancy. Plasma concentration ratios are presented as an indicator of foetal exposure relative to the mother. RESULTS Methadone was quantified in all samples, with cord : maternal plasma methadone concentration ratios (n= 15 mother-infant pairs) being significantly higher (P < 0.0001; mean difference (MD) 0.07; 95% confidence interval (CI) 0.048, 0.092) for the active (R)-methadone enantiomer (0.41; 0.19, 0.56) (median; range) compared with (S)-methadone (0.36; 0.15, 0.53). (R)- : (S)-methadone concentration ratios were also significantly higher (P < 0.0001; MD 0.24 95% CI 0.300, 0.180) for cord (1.40; 0.95, 1.67) compared with maternal plasma (1.16; 0.81, 1.38). Half the infant buprenorphine samples were below the assay lower limit of quantification (LLOQ) (0.125 ng ml⁻¹). The latter was four-fold lower than the LLOQ for methadone (0.50 ng ml⁻¹). The cord : maternal plasma buprenorphine concentration ratio (n= 9 mother-infant pairs) was 0.35; 0.14, 0.47 and for norbuprenorphine 0.49; 0.24, 0.91. CONCLUSIONS The transfer of the individual methadone enantiomers to the foetal circulation is stereoselective. Infants born to buprenorphine maintained women are not exposed to a greater proportion of the maternal dose compared with methadone and may be exposed to relatively less of the maternal dose compared with infants born to women maintained on methadone during pregnancy.

Fluoxetine for Maintenance of Remission and to Improve Quality of Life in Patients with Crohn’s Disease: a Pilot Randomized Placebo-Controlled Trial

Abstract Background and Aims: Previous studies have shown that antidepressants reduce inflammation in animal models of colitis. The present trial aimed to examine whether fluoxetine added to standard therapy for Crohn’s disease [CD] maintained remission, improved quality of life [QoL] and/or mental health in people with CD as compared to placebo. Methods: A parallel randomized double-blind placebo controlled trial was conducted. Participants with clinically established CD, with quiescent or only mild disease, were randomly assigned to receive either fluoxetine 20 mg daily or placebo, and followed for 12 months. Participants provided blood and stool samples and completed mental health and QoL questionnaires. Immune functions were assessed by stimulated cytokine secretion [CD3/CD28 stimulation] and flow cytometry for cell type. Linear mixed-effects models were used to compare groups. Results: Of the 26 participants, 14 were randomized to receive fluoxetine and 12 to placebo. Overall, 14 [54%] participants were male. The mean age was 37.4 [SD=13.2] years. Fluoxetine had no effect on inflammatory bowel disease activity measured using either the Crohn’s Disease Activity Index [F(3, 27.5)=0.064, p=0.978] or faecal calprotectin [F(3, 32.5)=1.08, p=0.371], but did have modest effects on immune function. There was no effect of fluoxetine on physical, psychological, social or environmental QoL, anxiety or depressive symptoms as compared to placebo [all p>0.05]. Conclusions: In this small pilot clinical trial, fluoxetine was not superior to placebo in maintaining remission or improving QoL. [ID: ACTRN12612001067864.]

Ineffective morphine treatment regimen for the control of Neonatal Abstinence Syndrome in buprenorphine- and methadone-exposed infants

This study aimed to determine if morphine is effective in ameliorating Neonatal Abstinence Syndrome (NAS) symptoms to non-opioid-exposed control levels in methadone- and buprenorphine-exposed infants. A prospective, non-randomized comparison study with flexible dosing was undertaken in a large teaching maternity hospital in Australia. Twenty-five infants in the groups of buprenorphine-, methadone- and control non-opioid-exposed infants were compared (total n = 75 infants). Oral morphine sulphate (1 mg/ml) was administered every 4 h to opioid agonist-exposed infants. Modified Finnegan Withdrawal Scale (MFWS) scores determined dosing: score of 8-10: 0.5 mg/kg/day, 11-13: 0.7 mg/kg/day and 14+: 0.9 mg/kg/day. Withdrawal score, amount of morphine administered and length of hospital stay, were used to assess NAS over a 4-week follow-up period. No controls achieved a score higher than 7 on the MFWS. There was no significant difference in the percentage of infants requiring treatment between methadone (60%) and buprenorphine (48%) infants. For treated infants, significantly (P < 0.01) more morphine was administered to methadone (40.07 ± 3.95 mg) compared with buprenorphine infants (22.77 ± 4.29 mg) to attempt to control NAS. Following treatment initiation, significantly more (P < 0.01) methadone (87%) compared with buprenorphine infants (42%) continued to exceed scoring thresholds for morphine treatment requirement, and non-opioid-exposed control infant scores. For treated infants, there was no significant difference in length of hospital stay between methadone and buprenorphine infants. Morphine treatment was not entirely effective in ameliorating NAS to non-opioid-exposed control symptom levels in methadone or buprenorphine infants. The regimen may be less effective in methadone compared with buprenorphine infants.

People with schizophrenia and depression have a low omega-3 index

Cardiovascular disease (CVD) is higher in people with mental illness and is associated with a 30 year higher mortality rate in this population. Erythrocyte docosahexaenoic acid (DHA) plus eicosapentaenoic acid (EPA) (omega-3 index)≤4% is a marker for increased mortality risk from CVD while >8% is protective. Omega-3 polyunsaturated fatty acids are also important for brain function and may ameliorate symptoms of mental illness. We investigated the erythrocyte omega-3 index in people with mental illness. One hundred and thirty adults aged 18-65 years (32.6% male) with schizophrenia (n=14) and depression (n=116) provided blood samples and completed physiological assessments and questionnaires. Both populations had risk factors for metabolic syndrome and CVD. The average omega-3 index was 3.95% (SD=1.06), compared to an estimated 5% in the Australian population. These data indicate an unfavourable omega-3 profile in people with mental illness that could contribute to higher CVD risk.

Patterns of symptom reporting during pregnancy comparing opioid maintained and control women.

Objective:To characterize the range of symptoms experienced by pregnant methadone-maintained (MM) and buprenorphine-maintained (BM) women to determine whether these differ from those experienced by a control group of nonopioid exposed pregnant women. Opioid-maintained (OM) patients report high rates of symptoms related to direct opioid effects and withdrawal. Pregnancy is associated with a range of symptoms, some overlapping with opioid effects and withdrawal. Methods:Prospective, nonrandomized, open-label comparison study undertaken in a large teaching maternity hospital in South Australia. Pregnant BM (n = 25), MM (n = 25) and nonopioid exposed controls (n = 25) were recruited and matched for age, parity, gravidity, alcohol consumption, and smoking status. Symptom report patterns, maternal withdrawal, and additional substance use were assessed. Results:MM women reported 10 and BM women reported 2 symptoms throughout pregnancy at rates greater than controls. Methadone-maintained women reported significantly (P < 0.05) more symptoms than BM women compared to controls throughout pregnancy. Methadone-maintained women reported 8 and BM women reported 3 symptoms in the third trimester at rates greater than controls. Methadone-maintained women reported greater opioid withdrawal than controls; this did not occur in BM women. Additional substance use was comparable between BM and MM women but greater than controls. Conclusions:Patterns of symptom reports may have clinical implications for maternal and fetal health during pregnancy for OM women including optimization of opioid dosing regimens, education regarding maternal nutritional intake and preventing postnatal depression, thereby ensuring maternal health and fetal development during pregnancy and enhancing mother-infant bonding and healthy child development postnatally.

Antidepressants for depression during pregnancy

The objectives are as follows: To assess the safety of antidepressant use, compared with placebo or psychological therapy, for the treatment of pre-existing and ante-natal depression during pregnancy. To assess the effectiveness of antidepressant use, compared with placebo or psychological therapy, for the treatment of pre-existing and ante-natal depression during pregnancy.