Hannah Myles

Meta-Analysis of Longitudinal Cohort Studies of Suicide Risk Assessment among Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over Time.

Objective It is widely assumed that the clinical care of psychiatric patients can be guided by estimates of suicide risk and by using patient characteristics to define a group of high-risk patients. However, the statistical strength and reliability of suicide risk categorization is unknown. Our objective was to investigate the odds of suicide in high-risk compared to lower-risk categories and the suicide rates in high-risk and lower-risk groups. Method We located longitudinal cohort studies where psychiatric patients or people who had made suicide attempts were stratified into high-risk and lower-risk groups for suicide with suicide mortality as the outcome by searching for peer reviewed publications indexed in PubMed or PsychINFO. Electronic searches were supplemented by hand searching of included studies and relevant review articles. Two authors independently extracted data regarding effect size, study population and study design from 53 samples of risk-assessed patients reported in 37 studies. Results The pooled odds of suicide among high-risk patients compared to lower-risk patients calculated by random effects meta-analysis was of 4.84 (95% Confidence Interval (CI) 3.79–6.20). Between-study heterogeneity was very high (I2 = 93.3). There was no evidence that more recent studies had greater statistical strength than older studies. Over an average follow up period of 63 months the proportion of suicides among the high-risk patients was 5.5% and was 0.9% among lower-risk patients. The meta-analytically derived sensitivity and specificity of a high-risk categorization were 56% and 79% respectively. There was evidence of publication bias in favour of studies that inflated the pooled odds of suicide in high-risk patients. Conclusions The strength of suicide risk categorizations based on the presence of multiple risk factors does not greatly exceed the association between individual suicide risk factors and suicide. A statistically strong and reliable method to usefully distinguish patients with a high-risk of suicide remains elusive.

Cannabis use in first episode psychosis: Meta-analysis of prevalence, and the time course of initiation and continued use:

Objectives: Cannabis use is prevalent among people with first episode psychosis and the epidemiology of its use in early psychosis is unclear. We performed a meta-analysis of observational studies to determine; (1) the interval between age at initiation of cannabis use and age at onset of first episode psychosis, (2) the prevalence of cannabis use at time of first episode psychosis, and (3) the odds of continuing cannabis following treatment for first episode psychosis. Data sources: Search of electronic databases MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL for English-language papers using search terms (psychosis OR schizophrenia) AND (cannabis OR marijuana) IN (title OR keyword OR abstract), current to October 2014. Study selection: Studies were included if they reported on prevalence of current cannabis use in first episode psychosis cohorts. A total of 37 samples were included for meta-analysis. Data extraction: Rates of cannabis use in each sample were extracted to determine prevalence estimates. The age at initiation of regular cannabis and age at onset of psychosis were used to determine the length of cannabis use preceding psychosis. Prevalence estimates at first episode psychosis and various time points of follow-up following first episode psychosis were analysed to determine odds ratio of continuing cannabis use. Data synthesis was performed using random-effects meta-analyses. Results: The pooled estimate for the interval between initiation of regular cannabis use and age at onset of psychosis was 6.3 years (10 samples, standardised mean difference = 1.56, 95% confidence interval = [1.40, 1.72]). The estimated prevalence of cannabis use at first episode psychosis was 33.7% (35 samples, 95% confidence interval = [31%, 39%]). Odds of continued cannabis use between 6 months and 10 years following first episode psychosis was 0.56 (19 samples, 95% confidence interval = [0.40, 0.79]).

Known unknowns and unknown unknowns in suicide risk assessment: evidence from meta-analyses of aleatory and epistemic uncertainty

Suicide risk assessment aims to reduce uncertainty in order to focus treatment and supervision on those who are judged to be more likely to die by suicide. In this article we consider recent meta-analytic research that highlights the difference between uncertainty about suicide due to chance factors (aleatory uncertainty) and uncertainty that results from lack of knowledge (epistemic uncertainty). We conclude that much of the uncertainty about suicide is aleatory rather than epistemic, and discuss the implications for clinicians.

Obstructive sleep apnea and schizophrenia: A systematic review to inform clinical practice.

BACKGROUND Risk factors for obstructive sleep apnea (OSA) are common in people with schizophrenia. Identification and treatment of OSA may improve physical health in this population; however there are no guidelines to inform screening and management. OBJECTIVES Systematic review to determine, in people with schizophrenia and related disorders: the prevalence of OSA; the prevalence of OSA compared to general population controls; the physical and psychiatric correlates of OSA, associations between antipsychotic medications and OSA; the impact of treatment of OSA on psychiatric and physical health; and the diagnostic validity of OSA screening tools. DATA SOURCES Medline, EMBASE, ISI Web of Science and PsycINFO electronic databases. Cohort, case-control and cross-sectional studies and RCTs reporting on prevalence of OSA in subjects with schizophrenia and related disorders were reviewed. RESULTS The prevalence of OSA varied between 1.6% and 52%. The prevalence of OSA was similar between people with schizophrenia and population controls in two studies. Diagnosis of OSA was associated with larger neck circumference, BMI>25, male sex and age>50years. There were no data on physical or psychiatric outcomes following treatment of OSA. The diagnostic utility of OSA screening tools had not been investigated. CONCLUSION OSA may be prevalent and potentially under-recognized in people with schizophrenia. Further research is required to determine utility of OSA screening tools, the relationships between antipsychotic medications and OSA and any benefits of treating OSA. We propose a strategy for the identification of OSA in people with schizophrenia and related disorders.

Australia’s economic transition, unemployment, suicide and mental health needs:

Objective: There have been substantial changes in workforce and employment patterns in Australia over the past 50 years as a result of economic globalisation. This has resulted in substantial reduction in employment in the manufacturing industry often with large-scale job losses in concentrated sectors and communities. Large-scale job loss events receive significant community attention. To what extent these mass unemployment events contribute to increased psychological distress, mental illness and suicide in affected individuals warrants further consideration. Methods: Here we undertake a narrative review of published job loss literature. We discuss the impact that large-scale job loss events in the manufacturing sector may have on population mental health, with particular reference to contemporary trends in the Australian economy. We also provide a commentary on the expected outcomes of future job loss events in this context and the implications for Australian public mental health care services. Results and conclusion: Job loss due to plant closure results in a doubling of psychological distress that peaks 9 months following the unemployment event. The link between job loss and increased rates of mental illness and suicide is less clear. The threat of impending job loss and the social context in which job loss occurs has a significant bearing on psychological outcomes. The implications for Australian public mental health services are discussed.

Risk Factors for Obstructive Sleep Apnea Are Prevalent in People with Psychosis and Correlate with Impaired Social Functioning and Poor Physical Health

Background Obstructive sleep apnea (OSA) in the general community is associated with obesity, smoking, alcohol, and sedative medication use and contributes to depressed mood, daytime sedation, and sudden cardiovascular deaths. Poor cardiovascular health, impaired social functioning, and negative and cognitive symptoms are also among the common clinical features of psychotic disorders. People with psychosis have higher rates of sleep disturbance; however, OSA has not been extensively investigated in this population. Aims This study aimed to determine the prevalence of OSA and general sleep disruption symptoms in a representative Australian sample of people with psychosis. We investigated the prevalence of potential risk factors for OSA, including obesity, psychotropic medications, and substance abuse in this population. Finally, we evaluated associations between symptoms of OSA, symptoms of general sleep disruption, and various clinical features in people with psychosis. Methods Participants took part in the Second National Australian Survey of Psychosis, a population-based survey of Australians with a psychotic disorder aged 18–64 years. Symptoms associated with OSA (snoring and breathing pauses during sleep) in the past year were assessed using questions from the University of Maryland Medical Centre Questionnaire and symptoms associated with general sleep disruption in the past week using the Assessment of Quality of Life Questionnaire. Data collected included psychiatric diagnosis and symptoms, education, employment, medications, smoking status, physical activity, drug and alcohol use, and cognitive function. Physical health measures included body mass index, waist circumference, blood pressure, fasting blood glucose, and lipids. Results Snoring was reported by 41.9%; 7% stating they frequently stopped breathing (pauses) during sleep. Univariate logistic regressions show OSA symptoms (pauses and snoring) were associated with older age, female gender, lower levels of social participation or employment, cardiovascular risk factors, sedentary lifestyle, and poorer quality of life, while symptoms of general sleep disruption were more likely in people with depressive symptoms. Conclusion Australians with psychosis have high levels of sleep disturbance, including OSA. OSA symptoms were associated with cardiovascular disease risk factors, reduced social participation and employment, and poorer quality of life. Whether correction of OSA can improve these factors in people with psychosis remains to be determined.

How long will we sleep on obstructive sleep apnoea in schizophrenia

Australian & New Zealand Journal of Psychiatry, 51(1) usual’ results in ‘outcomes as usual’). A challenge for clinicians, researchers and policy makers is to establish and evaluate programmes that benefit those with persistent illness over the long term. For any lifestyle intervention to be truly meaningful, benefits need to be sustainable. Furthermore, lifestyle interventions alone are unlikely to benefit most individuals. Given the complex interaction between physical health and mental health, addressing the social determinants of health such as unemployment, unstable housing, stigma and social exclusion which challenge this patient population is likely to be necessary in order to make a meaningful difference. Changing the lives of people with psychotic disorders will require a societal and cultural shift supported by robust research evidence, and political leadership with appropriately financed research and service provision. Only then will solutions start to bridge the gaps in morbidity and mortality. The increased recognition of the physical comorbidities in the CPGs represents an essential step towards achieving health equity in our patients, and highlights our collective professional responsibility in achieving this goal.

Meta-analysis examining the epidemiology of clozapine-associated neutropenia

Clozapine is associated with life‐threatening neutropenia. There are no previous meta‐analyses of the epidemiology of clozapine‐associated neutropenia.

Developing a metformin prescribing tool for use in adults with mental illness to reduce medication-related weight gain and cardiovascular risk:

Objectives: There is considerable evidence that metformin reduces weight gain associated with antipsychotic medication. The aim of this study was to develop an easy-to-use metformin prescribing tool in order to enable clinicians to prescribe metformin safely and confidently. Methods: The authors undertook a survey of clinicians and reviewed the published literature and existing guidelines concerning the use of metformin to reduce weight gain in adults with mental illness. Results: A metformin prescribing tool was devised based on the literature, national cardiovascular and diabetes guidelines and Australian metformin prescribing recommendations. The metformin prescribing tool guides clinicians through the considerations required for appropriate selection of the target patient population and safe prescription of metformin. Conclusions: A novel, easy-to-use, one-page reference has been developed for busy clinicians that can be laminated and displayed in consulting rooms and psychiatric inpatient units to address weight gain and obesity associated with antipsychotic medications in people with mental illness.

F165. OBSTRUCTIVE SLEEP APNOEA IS COMMON IN SCHIZOPHRENIA AND RESPONDS WELL TO TREATMENT – A NOVEL AND PRACTICAL MEANS TO IMPROVE COGNITION AND METABOLIC HEALTH?

Abstract Background Obstructive sleep apnoea (OSA) is characterised by repeated collapse of the upper airway during sleep, causing hypoxia, frequent arousals and disruption to sleep architecture. OSA is more likely in people who are obese, smoke tobacco, and use alcohol and sedating medications – all these factors are more common in schizophrenia. OSA is likely to be underdiagnosed in schizophrenia as symptoms such as non-restorative sleep, depression and daytime somnolence may be attributed to chronic mental illness. OSA in the normal population is associated with cognitive deficits and poor cardiovascular health, both of which are common in schizophrenia, so comorbid OSA in schizophrenia may be exacerbating these problems. Treatment of OSA with continuous positive airway pressure (CPAP) reduces daytime sleepiness, and improves quality of life, cognitive function, and cardiovascular risk factors. There are no published studies of CPAP treatment of OSA in schizophrenia, so it is not known whether these benefits also occur in the patient population. Methods Previous research into OSA in schizophrenia has utilised subjective screening instruments and there are no large studies using polysomnography (PSG), the gold standard method to diagnose OSA. We undertook home sleep studies using polysomnography in 30 people with schizophrenia, treated with clozapine. Participants cooperated well and all studies were of good quality. We treated 6 participants with severe OSA with CPAP. Treatment adherence was good with mean CPAP usage of of 7.7 hours/night. Results We found that 14/30 (40%) of our participants with schizophrenia had OSA and 8/30 (27%) had severe OSA; twice the prevalence of severe OSA in the general population. After six months CPAP treatment there was significant improvement in cognition, especially verbal memory, working memory and motor skills. Average weight loss was 7.2kg (SD 9k) with a 12mmHg (SD 18) reduction in systolic blood pressure. Normal sleep architecture was restored: on average the percentage of the night spent in restorative slow wave sleep increased from 4.8% to 31.6%, and the percentage in REM sleep from an average of 4.1% to 31.4%. The mean percentage of the night spent in a hypoxic state with oxygen saturation less than 90% reduced from an average of 27.6% to 2%. Discussion Improved awareness of the high prevalence of OSA in schizophrenia and access to diagnostic screening by home PSG should ensure this important comorbid condition is not missed. CPAP treatment for OSA in people with schizophrenia is feasible and has the potential to improve both cognition and cardiovascular health, resulting in better functioning and reduced cardiovascular morbidity.