David B Menkes

Antidepressants and Violence: Problems at the Interface of Medicine and Law

David Healy and colleagues review several sources of data which suggest an association in a small number of cases between antidepressant treatment and aggression and violence.

Soft Targets: Nurses and the Pharmaceutical Industry

The nursing literature has yet to pay much attention to the expansive reach of the pharmaceutical industry into the nursing profession.

Evidence-based medicine in practice

Evidence‐based medicine (EBM) has emerged as a dominant paradigm in healthcare, strongly influencing clinical decision‐making, access to and funding for interventions. However, EBM has a number of limitations, which appear to have been under‐represented in the literature. We explore the development and shortcomings of EBM, and consider a complementary role for practice‐based evidence in guiding clinical decision‐making. EBM is a valuable and important part of the medical landscape. However, a range of significant limitations makes over‐reliance on this paradigm problematic. Appropriate recognition of practice‐based evidence helps to bridge the gap between evidence and clinical practices.

Nurses' reported influence on the prescription and use of medication

AIM To identify the activities senior nurses report undertaking that may influence the prescription and use of medicines. BACKGROUND While much attention has focused on the role of nurse prescribing, little is known about the extent to which non-prescribing nurses influence medication decision making. The pharmaceutical industry recognizes this influence in its marketing strategies, and courts nurses by provision of promotional material and sponsorship of nursing professional development. METHODS We undertook parallel web- and paper-based surveys of 100 senior registered nurses employed by government-funded health boards in two distinct New Zealand regions. FINDINGS Only 2/96 (2%) of nurses had prescribing rights, yet 74/94 (79%) reported recommending treatments to the prescribing doctor, 74/95 (79%) stated they provided advice to patients about over-the-counter medications and 71/92 (77%) participated in the development of guidelines or policies that include the use of medications. All nurses in this sample reported influencing the prescription of medicines in one way or another. DISCUSSION From actually writing prescriptions to providing feedback on treatment outcomes, there are many opportunities for nurses to influence the decision making of medical and other prescribers, which open nurses to exploitation from commercial forces. Policy and education regarding prescriber relationships with the pharmaceutical industry should also recognize the role of non-prescribing nurses.

Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy

OBJECTIVES Psychogenic nonepileptic seizures (PNESs) are closely linked with psychological distress, but their etiology is not well-understood. We reviewed psychiatric comorbidity in PNESs and epileptic seizures (ESs) with an aim to assist understanding, diagnosis, and management of PNESs. METHODS A search of Web of Science, MEDLINE (PubMed), PsycINFO, and Scopus identified 32 relevant studies on the prevalence of psychiatric comorbidity in PNESs. We used meta-analysis to compare psychiatric comorbidity between PNESs and ESs. RESULTS Samples with PNESs had high rates of psychiatric comorbidity overall (53-100%), notably including posttraumatic stress disorder (PTSD), depression, and personality and anxiety disorders. Compared with ESs, samples with PNESs had more psychiatric comorbidity overall (RR: 1.30, 95% CI: 1.14-1.48, p<0.0001) with significantly elevated risks found for PTSD, personality disorder, and anxiety but not depression. CONCLUSIONS Psychiatric disorders are more common in PNESs than ESs. Because of methodological limitations of available studies, causality cannot be established; prospective longitudinal designs are required.

Releasing psychiatry from the constraints of categorical diagnosis.

Objective: The aim of this study was to make a case for freeing psychiatry from the limits of categorical diagnosis. Conclusions: From Pinel through to Kraepelin, Bleuler, DSM-IV and ICD-10, clinical and research activities in psychiatry have all depended upon categorical classification. Recent decades have seen increasing argument in favour of dimensional measurement, description and prediction, in part because invalidities in categorical classification are becoming impossible to deny. Some suggestions for developing useful dimensional approaches are made.

Classification in psychiatry: Does it deliver in schizophrenia and depression?

BackgroundIn the context of ongoing work to develop the next iteration of psychiatric classification systems, we briefly review the performance of current systems against their own stated objectives, for two major diagnostic groupings.DiscussionIn the major groupings of schizophrenia and depression, experience over the last 50 years has highlighted particular inadequacies in the utility and validity of available classifications.SummaryAdvances in psychiatric knowledge and practice notwithstanding, present classification systems would be enhanced by the incorporation of dimensional components. Minor tinkering with current systems will reflect only a missed opportunity. Improving classification will facilitate quality improvement of mental health systems.

Antipsychotic prescribing and its correlates in New Zealand

Objectives: Antipsychotics are the cornerstone of schizophrenia management. There is substantial literature on their efficacy and optimal use. Doubts remain, however, regarding the translation of this knowledge into day-to-day practice. This study aimed to investigate antipsychotic prescribing in three New Zealand regions and its relationship to clinical guidelines and patient characteristics. Methods: We studied 451 patients discharged from inpatient units with a diagnosis of schizophrenia or a related disorder (International Classification of Disease, version 10) between July 2009 and December 2011. Available information included patient demography, legal status, prescribed medications, duration of index admission and prescriber’s country of postgraduate training and years of postgraduate experience. Results: There was a high rate (33.7%) of multiple antipsychotic prescription, and lower than expected clozapine use (20%); Maori were prescribed clozapine more frequently than non-Maori (24% vs. 13%, respectively). Compulsory treatment was associated with more use of injectable medication and increased length of stay in hospital. Clinician characteristics did not significantly influence prescribing. Conclusions: Observed prescribing practice aligned with existing guidelines except for antipsychotic polypharmacy and clozapine under-utilisation.

Substance use disorders in New Zealand adults with severe mental illness: descriptive study of an acute inpatient population

Objective: To elucidate patterns of substance misuse, across diagnoses and demographic variables, in patients with severe mental illness. Method: We studied 141 adults admitted to an acute psychiatric unit in Hamilton, New Zealand. Semi-structured interviews, including the Alcohol Use Disorders Identification Test (AUDIT) and Cannabis Use Disorders Identification Test – Revised (CUDIT-R), were used to assess substance use. Results: Seventy-six participants were of European origin (56%), 59 were Maori (42%). Tobacco smoking was noted in 81% overall, with a higher frequency (93%) among Maori. A majority of patients had alcohol use disorder, with greater prevalence in bipolar and schizoaffective disorder compared to schizophrenia. By contrast, cannabis use disorder was strikingly associated with schizophrenia. Younger patients and Maori were disproportionately affected by both alcohol and cannabis use. Conclusions: Substance misuse in New Zealand patients with severe mental illness is common, particularly among younger patients and Maori, and differentially distributed across diagnoses.

Patients' appraisal of psychiatric trainee interview skills.

ObjectiveThe aim of this pilot project was to explore the extent to which judgments made by psychiatrist examiners accord with those of patients in postgraduate clinical examinations, so as to inform further consideration of the role of patients in such assessments.MethodSenior psychiatrist examiners (N=8) and patients (N=30) rated 16 aspects of trainee psychiatrist interviewing style and performance during 30 observed clinical interviews (OCIs) conducted in the format of official examinations.ResultsSignificant differences were apparent in the judgments of examiners and patients regarding 7 of 16 rated aspects of trainee performance. Differences were evident largely in domains in which patients could be expected to be “expert,” reflecting their subjective experience of the interviewer. By contrast, there was little difference in the judgments of patients and examiners on the more technical criteria.ConclusionThese preliminary findings provide some challenge to the assumption that psychiatrists are the best judges of the “technical” skills and knowledge required by the profession. They support previous findings, with simulated patients, of the discrepancy between patient and examiner judgments of the more subjective elements of the examination. Psychiatric patients could contribute to clinical examinations as co-examiners, rather than merely constituting the substrate for the examination.