Claire Dibben

Does maternal body mass index during pregnancy influence risk of schizophrenia in the adult offspring

Maternal obesity in pregnancy has been linked with several adverse outcomes in offspring including schizophrenia. The rising prevalence of obesity may contribute to an increase in the number of schizophrenia cases in the near future; therefore, it warrants further exploration. We reviewed current evidence regarding maternal body mass index (BMI) in pregnancy and risk of schizophrenia in adult offspring.

Mental health tribunals: an issue for clinical governance

Purpose – The purpose of this article is to examine reasons given by Mental Health Review Tribunals for discharging patients from detention and the effect the length of detainment had on the immediate outcome of discharged patients and to examine the effect on outcome from quality of reports and sources of evidence presented to the MHRTs.Design/methodology/approach – All documentation pertaining to MHRTs heard in the Cambridge area over a 12‐month period were reviewed.Findings – A quarter of tribunals heard were discharged, as they did not fulfil the legal criteria for detention. RMO non‐attendance was significant in this group. Unfavourable short‐term outcomes suggest that half of these discharges were premature. Improved aftercare compliance was associated with longer duration on a Section of the Mental Health Act prior to MHRT discharge.Research limitations/implications – This study reflects practice in the service (with a relatively small number of in‐patient sections) and may not be generalisable to ...

Evaluating care pathways for community psychiatry in England: a qualitative study

Abstract Objectives  In view of forthcoming ‘payment by results’ (PbR) for mental health, increasing number of National Health Service (NHS) Trusts are reorganizing their community services for working age adults to create care pathways. However, research base for the care pathways model in mental health is limited. Our NHS Foundation Trust was one of the first to introduce care pathways for community psychiatry in the UK. We have carried out a qualitative study to evaluate how this model works out in practice, including its impact on quality of patient care, mental health professionals and primary care. Methods  We interviewed doctors, multidisciplinary staff and Trusts managers (19 in total). Transcripts of recorded interviews were coded and analysed thematically using a grounded theory approach. Results  Overall, despite teething problems, working in pathways was generally seen as a positive change. It led to more focused interventions being offered, and practitioners being held to account over clear standards of care. It is more cost‐effective and allows for active case management and clear clinical leadership. It is recovery focused and encourages social inclusion. The arbitrary time frame, strict criteria and thresholds for different teams can create issues. Improved communication, flexible and patient‐centred approach, staff supervision, and increasing support to primary care were felt to be central to this model working efficiently and effectively. Conclusions  Introduction of care pathways is an important step towards effective implementation of PbR for mental health. Our study would inform future research into care pathways, facilitate organizational learning and help to improve effectiveness of services.Objectives  In view of forthcoming ‘payment by results’ (PbR) for mental health, increasing number of National Health Service (NHS) Trusts are reorganizing their community services for working age adults to create care pathways. However, research base for the care pathways model in mental health is limited. Our NHS Foundation Trust was one of the first to introduce care pathways for community psychiatry in the UK. We have carried out a qualitative study to evaluate how this model works out in practice, including its impact on quality of patient care, mental health professionals and primary care. Methods  We interviewed doctors, multidisciplinary staff and Trusts managers (19 in total). Transcripts of recorded interviews were coded and analysed thematically using a grounded theory approach. Results  Overall, despite teething problems, working in pathways was generally seen as a positive change. It led to more focused interventions being offered, and practitioners being held to account over clear standards of care. It is more cost-effective and allows for active case management and clear clinical leadership. It is recovery focused and encourages social inclusion. The arbitrary time frame, strict criteria and thresholds for different teams can create issues. Improved communication, flexible and patient-centred approach, staff supervision, and increasing support to primary care were felt to be central to this model working efficiently and effectively. Conclusions  Introduction of care pathways is an important step towards effective implementation of PbR for mental health. Our study would inform future research into care pathways, facilitate organizational learning and help to improve effectiveness of services.

First-generation antipsychotics: not gone but forgotten.

Aims and method To identify training needs of the next generation of psychiatrists and barriers in prescribing first-generation antipsychotics (FGAs). We have surveyed psychiatry trainees in East Anglia with regard to their training experience, knowledge and attitudes to the use of oral FGAs as regular medication. Results Two-thirds of trainees were aware that first- and second-generation antipsychotics (SGAs) have similar efficacy, and a similar proportion perceived the older drugs to have more or ‘stronger’ side-effects. Lack of training experience was noted as the second leading concern for prescribing FGAs. A quarter of trainees received no training exposure to the older drugs and two-thirds had never initiated these drugs themselves. Although nearly 90% of trainees felt confident about initiating an oral SGA as a regular medication, only about 40% felt confident with FGAs (P<0.001). Clinical implications The survey highlights worrying gaps in training. FGAs can be used effectively, minimising side-effects, by careful dose titration, avoiding antipsychotic polypharmacy, high-dose, and high-potency drugs, thus ensuring they are not lost to future generations of psychiatrists.

Protocol for the insight study: a randomised controlled trial of single-dose tocilizumab in patients with depression and low-grade inflammation.

Introduction Observational studies indicate a potentially causal role for interleukin 6 (IL-6), a proinflammatory cytokine, in pathogenesis of depression, but interventional studies based on patients with depression have not been conducted. Tocilizumab, anti-inflammatory drug, is a humanised monoclonal antibody that inhibits IL-6 signalling and is licensed in the UK for treatment of rheumatoid arthritis. The main objectives of this study are to test whether IL-6 contributes to the pathogenesis of depression and to examine potential mechanisms by which IL-6 affects mood and cognition. A secondary objective is to compare depressed participants with and without evidence of low-grade systemic inflammation. Methods and analysis This is a proof-of-concept, randomised, parallel-group, double-blind, placebo-controlled clinical trial. Approximately 50 participants with International Classification of Diseases 10th revision (ICD-10) diagnosis of depression who have evidence of low-grade inflammation, defined as serum high-sensitivity C reactive protein (hs-CRP) level ≥3 mg/L, will receive either a single intravenous infusion of tocilizumab or normal saline. Blood samples, behavioural and cognitive measures will be collected at baseline and after infusion around day 7, 14 and 28. The primary outcome is somatic symptoms score around day 14 postinfusion. In addition, approximately, 50 depressed participants without low-grade inflammation (serum hs-CRP level <3 mg/L) will complete the same baseline assessments as the randomised cohort. Ethics and dissemination The study has been approved by the South Central—Oxford B Research Ethics Committee (REC) (Reference: 18/SC/0118). Study findings will be published in peer-review journals. Findings will be also disseminated by conference/departmental presentations and by social and traditional media. Trial registration number ISRCTN16942542; Pre-results.

Prenatal maternal influenza and schizophrenia in offspring: What does this tell us about fetal programming of chronic disease?

Accumulating evidence suggests that chronic diseases, physical as well as neuropsychiatric, may have their origins in early life. Alterations in fetal development have been reported to be associated with an increased risk of subsequent cardiovas- cular and metabolic disorders. This has been formulated as the fetal or developmental programming hypothesis. Schizophrenia is a severe and chronic neuropsychiatric illness of teenage and adult life. Birth cohort studies have reported low birth weight, delays in attaining motor milestones, and deficits in premorbid cognitive and social functioning as factors associated with, and possible risk factors for future schizophrenia. These provide empirical support for the currently widely accepted neurodevelopmental hypothesis of schizophrenia, where abnormalities in early brain development contribute to the evolution of the disorder. Inter- ference with brain development from infections in early life is in line with a neurodevelopmental view of schizophrenia. Prenatal maternal infections such as influenza have been linked with increased risk of both childhood sub-clinical psychotic symptoms and adult schizophrenia. Prenatal maternal infections can increase fetal exposure to excessive maternal glucocorticoids. This can reprogram the hypothalamic-pituitary-adrenal axis leading to increased risk of several chronic diseases including schizophrenia. In this review we focus on epidemiological and preclinical studies concerning prenatal maternal influenza and risk of both childhood psychotic symptoms and later development of schizophrenia in the offspring. We discuss these findings in light of the fetal programming hypothesis, which points towards common links, in early life, between chronic diseases, physical (such as hypertension and type-two diabetes) and neuropsychiatric (such as schizophrenia).

Hearing voices: are we getting the message?

In a large study of adults with bipolar disorder, Upthegrove and colleagues report associations between childhood sexual abuse and lifetime occurrence of mood congruent auditory and visual hallucinations; however, no associations are seen for delusions or diagnoses of psychotic disorders.[1][1] The

Lithium monitoring: should tracking prescriptions be implemented to improve outcome?

Purpose – This study seeks to compare rates of blood lithium monitoring with rates of lithium prescription collection in order to evaluate whether identifying patients with low frequency of monitoring could alert clinicians to poor prescription collection. It examines whether routine monitoring of lithium prescription pick‐up would be likely to reduce admissions to hospital, as a way of identifying those who were poorly adherent with treatment. It also ascertains the frequency of lithium toxicity and its outcomes.Design/methodology/approach – The frequency of monitoring of lithium was assessed through laboratory results of 773 patients. A sub‐sample of 119 patients on lithium was found through general practice records and the rates of medication collection determined. Admission data were examined to assess whether this was related to a failure in blood monitoring or prescription collection.Findings – A total of 87 per cent of the GP group had lithium levels measured at least twice a year and 84 per cent c...