Brian Kidd

Factors associated with mortality in Scottish patients receiving methadone in primary care: retrospective cohort study

Objective To assess predictors of mortality in a population of people prescribed methadone. Design Retrospective cohort study. Setting Geographically defined population in Tayside, Scotland. Participants 2378 people prescribed and dispensed liquid methadone between January 1993 and February 2004. Main outcome measures All cause mortality (primary outcome) and drug dependent cause specific mortality (secondary outcome) by means of Cox proportional hazards models during 12 years of follow-up. Results Overall, 181 (8%) people died. Overuse of methadone (adjusted hazard ratio 1.67, 95% confidence interval 1.05 to 2.67), history of psychiatric admission (2.47, 1.67 to 3.66), and increasing comorbidity measured as Charlson index ≥3 (1.20, 1.15 to 1.26) were all associated with an increase in all cause mortality. Longer duration of use (adjusted hazard ratio 0.95, 0.94 to 0.96), history of having urine tested (0.33, 0.22 to 0.49), and increasing time since last filled prescription were protective in relation to all cause mortality. Drug dependence was identified as the principal cause of death in 60 (33%) people. History of psychiatric admission was significantly associated with drug dependent death (adjusted hazard ratio 2.41, 1.25 to 4.64), as was history of prescription of benzodiazepines (4.35, 1.32 to 14.30). Conclusions Important elements of care in provision of methadone maintenance treatment are likely to influence, or be a marker for, a person’s risk of death.

Substance misuse of gabapentin.

Neuropathic pain affects up to 8% of the population,1 causing significant distress and morbidity. Good evidence-based treatment is available,2 so early diagnosis is important. Recent publicity and guidelines, and increasing prevalences of age-related causes of neuropathic pain (including postherpetic neuralgia and diabetic neuropathy), have led to increasing rates of diagnosis and treatment in primary care. Gabapentin is one of the recommended mainstays of evidence-based treatment.3nnUnfortunately, our clinical experience suggests that gabapentin is now prevalent as a drug of abuse. The drug’s effects vary with the user, dosage, …

Screening for psychiatric distress and low self-esteem in patients presenting for excimer laser surgery for myopia

BACKGROUNDnPatients presenting for photorefractive keratectomy (PRK) may have unusual psychological profiles. Certain psychological variables may impact treatment outcome, making early identification crucial. We report a controlled questionnaire study of psychiatric anxiety/distress and self-esteem in myopic patients who presented for excimer laser treatment.nnnMETHODSnNinety consecutive myopic individuals (patients) who presented for excimer laser PRK and 50 consecutive myopic individuals who presented to an optometrist for contact lens fitting (controls) were assessed using two self-completion questionnaires-the GHQ30 and Hudson Index of Self-Esteem ISE. The questionnaires were distributed during assessment for treatment.nnnRESULTSnPRK patients had a 90% response rate for both questionnaires and control patients, 98% for GHQ30 and 100% for Hudson ISE. PRK patients were significantly older (p = 0.000003), had a greater myopic spherical equivalent refraction (p = 0.012) and had better spectacle-corrected visual acuity (p = 0.0096). No significant differences were demonstrated with regard to anxiety/distress in terms of absolute scores (p = 0.07), or the proportion of patients being positive or negative (p = 0.10). Similarly, self-esteem was not significantly different between the two groups (absolute scores p = 0.69; positive/negative p = 0.29). The high response rate shows that the GHQ30 and Hudson ISE are easy to use and well tolerated by myopes in a busy clinic setting. The fact that the patients were older, with a greater refractive error, may partly reflect the onset of contact lens intolerance.nnnCONCLUSIONnThe psychological findings suggest that PRK patients cannot be considered more distressed or anxious than other myopic individuals. There is no evidence that their decision to undergo surgery is driven by abnormally low self-esteem.

Assessing the Adherence to Guidelines of Media Reporting of Suicide Using a Novel Instrument—the “Risk of Imitative Suicide Scale” (RISc)

Media guidelines for reporting of suicide are considered important in suicide prevention because of the risk of imitative suicide. There are currently no established tools for the quantification of quality of reporting. We sought to develop and validate a quality assessment instrument-the Risk of Imitative Suicide Scale (RISc). The RISc appears capable of discriminating reliably between adherent and nonadherent articles. Our data suggest that adherence to guidelines is inconsistent, and there are major differences between web-based and print media. The RISc could be used to evaluate effectiveness and consistency of media engagement with suicide prevention strategies.

Differences between injectors and non-injectors, and a high prevalence of benzodiazepines among drug related deaths in Scotland 2003

Drug related deaths (DRDs) have been increasing in Scotland over at least the past decade. This study aimed to describe the characteristics (gender, age, ICD10 cause of death), toxicology and circumstances of all Scotlands DRDs in 2003 to help inform a national overdose prevention strategy. Coronial files for 300/317 (95%) DRDs registered with the General Register Office for Scotland (GROS) in 2003 were examined retrospectively (in 2004). Characteristics: 241/300 (80%) were male. Mean age at death was 32.8 years (SE 0.63, range 16–82). Route of administration was injecting for 137/268 (51%) who were classifiable. Classified injectors were more likely to be male (91%: 124/137) and younger (mean age of 32 years) than those whose death was by a non-injecting route (male: 87/131 (66%) and mean age of 35 years). Twenty-five to forty-four year olds made up 108/137 DRDs by injecting (79%), but only 62/131 (47%) by non-injecting routes. Cases of intentional self-poisoning (injectors 1; non-injecting 34) and undetermined intent (injectors 14; non-injecting 26) were infrequent among injectors. Of those who died by the injecting route, 108/137 were known intravenous drug users, but so too were 29/131 DRDs by non-injecting routes. Toxicology: overall 38/300 cases of DRD (13%) were negative for opioid drugs–only 2/137 DRDs by injecting (1%) were negative for opioids compared with 33/131 (25%) by non-injecting route. Methadone was present for 15/137 DRDs by injecting route (11%) and for 57/131 DRDs by non-injecting routes (44%, p < 0.001). Presence of dihydrocodeine, and anti-depressants was about three times and six times respectively, more likely in DRDs by non-injecting routes. Irrespective of route, two-thirds of DRDs tested positive for benzodiazepines (202/300 DRDs). Circumstances: time between overdose and death was within the hour for 61/137 DRDs (45%) by injecting, but rarely by non-injecting routes (3%: 4/131). Three out of four DRDs occurred in a house or flat: 98/137 DRDs (72%) by the injecting route and 101/131 (77%) by non-injecting routes. Interpretation: A relatively high proportion of cases died by non-injecting routes. National mortality databases should separate out cases of injecting-related DRD from non-injecting cases, and public health strategies to reduce DRDs should distinguish between these groups. Widespread availability in Scotland of prescribed and illicit benzodiazepines needs attention.

Recording of clinical information in a Scotland-wide drug deaths study

The aim of this study was to analyse the nature and extent of data extracted from case files of deceased individuals in contact with services 6 months prior to drug deaths in Scotland during 2003. A cross-sectional descriptive analysis of 317 case notes of 237 individuals who had drug-related deaths was undertaken, using a data linkage process. All contacts made with services in the 6 months prior to death were identified. Information on clinical and social circumstances obtained from social care, specialist drug treatment, mental health, non-statutory services, the Scottish Prison Service and Criminal Records Office was collated. More than 70% (n = 237) were seen 6 months prior to their drug death. Sociodemographic details were reported much more frequently than medical problems, for example, ethnicity (49%), living accommodation (66%), education and income (52%) and dependent children (73%). Medical and psychiatric history was recorded in only 12%, blood-borne viral status in 17% and life events in 26%. This paucity of information was a feature of treatment plans and progress recorded. The 237 drug deaths were not a population unknown to services. Highly relevant data were missing. Improved training to promote in-depth recording and effective monitoring may result in better understanding and reduction of drug deaths.

Persistent post-traumatic stress disorder.

EDITOR,—Brigitta Bende and Robin M Philpott report on a patient with post-traumatic symptoms 50 years after the precipitating events who improved after appropriate treatment.1 The NHS could do a great deal to treat post-traumatic symptoms in its own workers and so ensure that as few as possible develop similar syndromes.nnOne study found that up to 61% of clinical staff who report assaults by patients experience symptoms of post-traumatic stress disorder, and 10% meet the criteria for …

Assaults and threats on psychiatrists

Sir: Recent papers on psychiatrists safety raise important issues. Davies reaffirms the view that psychiatrists are vulnerable to violence ( Psychiatric Bulletin , March 2001, 25 , 89-91). Osborn and Tang demonstrate the ineffectiveness of audit in ensuring that interview rooms are safe (