Dan Siskind

Patterns of antipsychotic medication use in Australia 2002–2007

Objective: Atypical antipsychotic medications that are primarily used to treat schizophrenia and bipolar disorder cost the Pharmaceutical Benefits Scheme (PBS) AUD

Anxiolytic, hypnotic and sedative medication use in Australia

334.4m in 2007. There are indications that they have also been used outside the approved indications to treat behavioural disturbances in the elderly. The aim of the present study was therefore to examine (i) trends in prescribing of subsidized atypical antipsychotic drugs in the Australian population from 2002 to 2007; and (ii) gender and age differences in the utilization of these drugs. Methods: Government (Medicare Australia) data on numbers of prescriptions, quantity and doses for atypical and typical antipsychotics from 2002 to 2007 were analysed. Defined daily dose per 1000 population per day were estimated for age and sex groups using Australian Bureau of Statistics population data. Results: The proportion of prescribed antipsychotics that were atypical increased from 61% in 2002 to 77% in 2007. In male subjects, olanzapine was most often prescribed between the ages of 25 and 55 years. In female subjects, in contrast, the highest rates of prescribing were in those ≥75 years. Lower doses of these drugs were prescribed in older adults. Conclusions: Atypical antipsychotic drugs were most commonly used to treat schizophrenia in younger men and behavioural disturbances in older women with dementia. They appear to have been used outside of the approved indication for schizophrenia and bipolar disorder with significant financial costs to the PBS. Research into the reasons for their extensive use in elderly women is needed to inform more rational prescribing of these medicines.

Deep brain stimulation for obsessive–compulsive disorder: a systematic review and meta-analysis

New sedative drugs have been marketed in Australia in the last few years. We examined the trends in the prescribing of subsidised anxiolytic, hypnotic and sedative (AHS) medication use in the Australian population from 2002 to 2007.

A systematic review and meta-analysis of the association between poor oral health and severe mental illness

BACKGROUND Deep brain stimulation (DBS) is increasingly being applied to psychiatric conditions such as obsessive-compulsive disorder (OCD), major depression and anorexia nervosa. Double-blind, randomized controlled trials (RCTs) of active versus sham treatment have been limited to small numbers. We therefore undertook a systematic review and meta-analysis of the effectiveness of DBS in psychiatric conditions to maximize study power. METHOD We conducted a systematic literature search for double-blind, RCTs of active versus sham treatment using Pubmed/Medline and EMBASE up to April 2013. Where possible, we combined results from studies in a meta-analysis. We assessed differences in final values between the active and sham treatments for parallel-group studies and compared changes from baseline score for cross-over designs. RESULTS Inclusion criteria were met by five studies, all of which were of OCD. Forty-four subjects provided data for the meta-analysis. The main outcome was a reduction in obsessive symptoms as measured by the Yale-Brown Obsessive Compulsive Scale (YBOCS). Patients on active, as opposed to sham, treatment had a significantly lower mean score [mean difference (MD) -8.93, 95% confidence interval (CI) -13.35 to -5.76, p < 0.001], representing partial remission. However, one-third of patients experienced significant adverse effects (n = 16). There were no differences between the two groups in terms of other outcomes. CONCLUSIONS DBS may show promise for treatment-resistant OCD but there are insufficient randomized controlled data for other psychiatric conditions. DBS remains an experimental treatment in adults for severe, medically refractory conditions until further data are available.

ECT efficacy and treatment course: a systematic review and meta-analysis of twice vs thrice weekly schedules.

Background Psychiatric patients have increased comorbid physical illness. There is less information, however, on dental disease, especially tooth decay, despite life-style risk factors or psychotropic-induced dry mouth in this population. Importantly, poor oral health can predispose people to chronic physical disease leading to avoidable admissions to hospital for medical causes. Methods Using MEDLINE, PsycInfo, EMBASE, and article bibliographies, we undertook a systematic search for studies from the last 25 years regarding the oral health of people with severe mental illness (SMI). Results were compared with the general population. The two outcomes were total tooth loss (edentulism) and dental decay measured through the following standardized measures: the mean number of decayed, missing, and filled teeth or surfaces. Results We identified 25 studies that had sufficient data for a random-effects meta-analysis. These covered 5076 psychiatric patients and 39,545 controls, the latter from either the same study or community surveys. People with SMI had 2.8 the odds of having lost all their teeth compared with the general community (95% confidence interval [CI] = 1.7–4.6). They also had significantly higher decayed, missing, and filled teeth (mean difference = 5.0, 95% CI = 2.5–7.4) and surfaces scores (mean difference = 14.6, 95% CI = 4.1–25.1). Conclusion The increased focus on the physical health of people with SMI should encompass oral health. Possible interventions could include oral health assessment conducted using standard checklists that can be completed by non–dental personnel, help with oral hygiene, management of iatrogenic dry mouth, and early dental referral.

Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults.

BACKGROUND Electroconvulsive therapy (ECT) guidelines, across various regulatory bodies, lack consensus as to the optimal frequency of treatment for individual patients. Some authors postulate that twice weekly ECT may have a similar efficacy to thrice weekly, and may have a lower risk of adverse cognitive outcomes. We did a systematic review and a meta-analysis to assess the strength of associations between ECT frequency and depression scores, duration of treatment, number of ECTs, and remission rates. METHODS We searched on Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (to December 2009), and searched reports to identify comparative studies of frequency of ECT. We did both random-effects (RE) and quality effect (QE) meta-analyses to determine the risk of various outcomes associated with lesser frequency as compared to the thrice weekly frequency. RESULTS We analysed 8 datasets (7 articles), including 214 subjects. Twice-weekly frequency of ECT was associated with a similar change in depression score (QE model SMD -0.11 [-0.55-0.33] and RE model SMD -0.17 [-0.77-0.43]) as compared to thrice weekly ECT. The number of real ECTs trended towards fewer in the twice weekly group. There was a statistically significant longer duration of treatment with a twice weekly protocol (QE model 6.48 days [4.99-7.97] and RE model 4.78 days [0.74-8.82]). There was a statistically significant greater efficacy for thrice weekly ECT compared to once weekly ECT (QE model SMD 1.25 [-0.62-1.9] and RE model SMD 1.31 [0.6-2.02]). CONCLUSIONS Twice weekly ECT is associated with similar efficacy to thrice weekly ECT, may require fewer treatments and may be associated with longer treatment duration when compared to thrice weekly. These epidemiological observations support the routine use of twice weekly ECT in acute courses, though choice of frequency should take into account individual patient factors. These observations have implications for resource utilisation e.g. costs of duration of admission vs cost of provision of ECT, as well as issues of access to inpatient beds and anaesthetist time.

A systematic review and meta-regression of the prevalence and incidence of perinatal depression.

Objectives: To describe the frequency, type and quality of mental health treatment among Australian adults with past‐year affective and/or anxiety disorders.

Australian national trends in stimulant dispensing: 2002-2009.

BACKGROUND Major Depressive Disorder (MDD) is a leading cause of the disease burden for women of childbearing age, but the burden of MDD attributable to perinatal depression is not yet known. There has been little effort to date to systematically review available literature and produce global estimates of prevalence and incidence of perinatal depression. Enhanced understanding will help to guide resource allocation for screening and treatment. METHODS A systematic literature review using the databases PsycINFO and PubMed returned 140 usable prevalence estimates from 96 studies. A random-effects meta-regression was performed to determine sources of heterogeneity in prevalence estimates between studies and to guide a subsequent random-effects meta-analysis. RESULTS The meta-regression explained 31.1% of the variance in prevalence reported between studies. Adjusting for the effects of all other variables in the model, prevalence derived using symptom scales was significantly higher than prevalence derived using diagnostic instruments (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.3-2.0). Additionally, prevalence was significantly higher in women from low and middle income countries compared to women from high income countries (OR 1.8, 95% CI 1.4-2.2). The overall pooled prevalence was 11.9% of women during the perinatal period (95% CI 11.4-12.5). There were insufficient data to calculate pooled incidence. LIMITATIONS Studies in low income countries were especially scarce in this review, demonstrating a need for more epidemiological research in those regions. CONCLUSIONS Perinatal depression appears to impose a higher burden on women in low- and middle-income countries. This review contributes significantly to the epidemiological literature on the disorder.

Personalised support delivered by support workers for people with severe and persistent mental illness: A systematic review of patient outcomes

Objective: Internationally there has been an increase in the prescriptions of stimulant medication. The aim of this study was to examine longitudinal national trends of stimulant dispensing in Australia between 2002 and 2009. Method: Government databases were retrospectively reviewed for all dispensed stimulant prescriptions between 2002 and 2009. Prescriptions were converted to defined daily dose (DDD)/1000 population/day using census data. Utilization of dexamphetamine and methylphenidate were analysed by source (subsidized or non-subsidized), prescriber (general practitioner, psychiatrist or other specialists), gender and age of patient. Results: Between 2002 and 2009, dispensing of stimulants in Australia increased 87% from 2.93 to 5.47 DDD/1000 population/day. Dexamphetamine remained the most commonly dispensed stimulant, with rates of dispensing falling 13% from 2.02 to 1.75 DDD/1000 population/day. Dispensed prescriptions of methylphenidate increased 300% from 0.45 in 2002 to 1.81 DDD/1000 population/day in 2009, attributable to the availability of long-acting preparations. Dispensing of stimulants to males was four-fold greater than to females. There was substantial dispensing of dexamphetamine to those older than 25 years. Conclusions: Stimulant dispensing in Australia increased between 2002 and 2009 as a result of increased dispensing of long-acting preparations of methylphenidate. Further research is required to determine if the increase in stimulant dispensing in Australia is clinically appropriate.

International trends in clozapine use: a study in 17 countries

AIMS Personalised support services assist patients with severe and persistent mental illness (SPMI) to live with functional deficits by providing living skills, emotional support, community access and advocacy. This paper aims to systematically review the evidence for personalised support. METHODS Systematic searches of Medline, PsycINFO and Google Scholar (inception to March 2011) identified studies investigating patient outcomes for personalised support services. The quality of the selected studies was assessed. The strength of evidence for the three categories of patient outcomes (illness acuity, personal functioning and patient satisfaction) was graded. RESULTS Fifteen studies met inclusion criteria with most rated as having moderate or weak study designs. The selected studies evaluated programs for outpatients with SPMI. There was moderate strength of evidence for reducing illness acuity and improving patient satisfaction with services, and weak strength of evidence for improving personal functioning in studies published to date. Most programs delivered multiple service types, and no clear pattern of service types leading to specific patient outcomes could be discerned. CONCLUSIONS Although evidence published to date for personalised support is of variable quality, it suggests that services may be effective. More research on the effects of personalised support subtypes on patient outcomes is required.