Maria Calem

Increased Prevalence of Insomnia and Changes in Hypnotics Use in England over 15 Years: Analysis of the 1993, 2000, and 2007 National Psychiatric Morbidity Surveys

STUDY OBJECTIVES To investigate changes over 15 years in the prevalence of insomnia and its association with demographic characteristics and hypnotic medication use. DESIGN Analysis of 3 cross-sectional national mental health surveys carried out in 1993, 2000, and 2007, which used comparable sampling methods and identical insomnia assessments. SETTING Adults living in private households in England. PATIENTS OR PARTICIPANTS 20,503 people aged 16-64 years. MEASUREMENTS AND RESULTS Insomnia was defined according to 4 different criteria, using relevant questions from the revised Clinical Interview Schedule. Modest increases in insomnia prevalence were found over the survey periods (any symptoms increasing from 35.0% in 1993 to 38.6% in 2007; insomnia diagnosis from 3.1% to 5.8%, respectively). In all 3 surveys, similar strengths of association in relation to all criteria were found, with female gender, increased age, lower educational attainment, depression, unemployment, economic inactivity, and widowed, divorced, or separated status. Prevalence of hypnotic use was double in 2000 (0.8%) compared to 1993 (0.4%); from limited information on selected medications, there was no such increase between 2000 and 2007. The reasons reported for any sleep disturbance over the last month were generally similar across surveys, the most marked change being illness/discomfort increasing as an explanation from 14.3% to 17.4% to 19.0%. CONCLUSIONS In the English general population, insomnia (by any definition) showed a modest but steady increase in prevalence over a 15-year period. Strengths of associations with demographic factors and self-reported reasons for sleep disturbance remained reasonably stable over this period.

Criminal offending and distinguishing features of offenders among persons experiencing a first episode of psychosis

Aims: Persons with severe mental illness (SMI) are at increased risk of criminal offending, particularly violent offending, as compared with the general population. Most offenders with SMI acquire convictions prior to contact with mental health services. This study examined offending among 301 individuals experiencing their first episode of psychosis.

Current prevalence of dementia, depression and behavioural problems in the older adult care home sector: the South East London Care Home Survey

BACKGROUND a large and increasing number of older people in the UK are living in care homes. Dementia is a frequent reason underlying admission and determining care needs, but prevalence data are becoming increasingly outdated and reliant on brief screening instruments. OBJECTIVE to describe the prevalence and severity of dementia, depression, behavioural problems and relevant medication use in a representative sample of residential and nursing care home residents. DESIGN/SETTING a survey conducted in 15 randomly selected South East London care homes. Consensus clinical dementia diagnoses were made from multi-source information, and the Clinical Dementia Rating (CDR) Scale applied. Depression was ascertained using the Cornell Depression in Dementia Scale and psychological/behavioural problems using the Neuropsychiatric Inventory (NPI). PARTICIPANTS three hundred and one residents with a mean (SD) age of 83.5 (9.8) and 65.8% female were included. RESULTS dementia (CDR 1-3) prevalence was 75.1% overall, 55.8% in residential homes, 91.0% in residential elderly mentally infirm care and 77.0% in nursing homes. Depression prevalences were 26.5, 22.0 and 29.6%, respectively, and mean (95% CI) NPI severity scores 3.99 (3.47-4.50), 6.34 (5.29-7.39) and 6.10 (5.50-6.70) with 87.3% of the sample exhibiting at least one NPI symptom. Antidepressants were prescribed in 25.6, 25.0 and 41.3%, respectively, and antipsychotics in 7.0, 34.1 and 19.1%. CONCLUSION dementia is substantially more common in care homes than recorded diagnoses would suggest, but studies using brief screening instruments may overestimate prevalence. High prevalences of depressive and/or behavioural symptoms and psychotropic use suggest significant unmet need.

Towards a Standard Psychometric Diagnostic Interview for Subjects at Ultra High Risk of Psychosis: CAARMS versus SIPS

Background. Several psychometric instruments are available for the diagnostic interview of subjects at ultra high risk (UHR) of psychosis. Their diagnostic comparability is unknown. Methods. All referrals to the OASIS (London) or CAMEO (Cambridgeshire) UHR services from May 13 to Dec 14 were interviewed for a UHR state using both the CAARMS 12/2006 and the SIPS 5.0. Percent overall agreement, kappa, the McNemar-Bowker χ 2 test, equipercentile methods, and residual analyses were used to investigate diagnostic outcomes and symptoms severity or frequency. A conversion algorithm (CONVERT) was validated in an independent UHR sample from the Seoul Youth Clinic (Seoul). Results. There was overall substantial CAARMS-versus-SIPS agreement in the identification of UHR subjects (n = 212, percent overall agreement = 86%; kappa = 0.781, 95% CI from 0.684 to 0.878; McNemar-Bowker test = 0.069), with the exception of the brief limited intermittent psychotic symptoms (BLIPS) subgroup. Equipercentile-linking table linked symptoms severity and frequency across the CAARMS and SIPS. The conversion algorithm was validated in 93 UHR subjects, showing excellent diagnostic accuracy (CAARMS to SIPS: ROC area 0.929; SIPS to CAARMS: ROC area 0.903). Conclusions. This study provides initial comparability data between CAARMS and SIPS and will inform ongoing multicentre studies and clinical guidelines for the UHR psychometric diagnostic interview.

Psychological processes underlying the association between childhood trauma and psychosis in daily life: an experience sampling study

Background Evidence has accumulated that implicates childhood trauma in the aetiology of psychosis, but our understanding of the putative psychological processes and mechanisms through which childhood trauma impacts on individuals and contributes to the development of psychosis remains limited. We aimed to investigate whether stress sensitivity and threat anticipation underlie the association between childhood abuse and psychosis. Method We used the Experience Sampling Method to measure stress, threat anticipation, negative affect, and psychotic experiences in 50 first-episode psychosis (FEP) patients, 44 At-Risk Mental State (ARMS) participants, and 52 controls. Childhood abuse was assessed using the Childhood Trauma Questionnaire. Results Associations of minor socio-environmental stress in daily life with negative affect and psychotic experiences were modified by sexual abuse and group (all pFWE < 0.05). While there was strong evidence that these associations were greater in FEP exposed to high levels of sexual abuse, and some evidence of greater associations in ARMS exposed to high levels of sexual abuse, controls exposed to high levels of sexual abuse were more resilient and reported less intense negative emotional reactions to socio-environmental stress. A similar pattern was evident for threat anticipation. Conclusions Elevated sensitivity and lack of resilience to socio-environmental stress and enhanced threat anticipation in daily life may be important psychological processes underlying the association between childhood sexual abuse and psychosis.

Modeling the Interplay Between Psychological Processes and Adverse, Stressful Contexts and Experiences in Pathways to Psychosis: An Experience Sampling Study

Several integrated models of psychosis have implicated adverse, stressful contexts and experiences, and affective and cognitive processes in the onset of psychosis. In these models, the effects of stress are posited to contribute to the development of psychotic experiences via pathways through affective disturbance, cognitive biases, and anomalous experiences. However, attempts to systematically test comprehensive models of these pathways remain sparse. Using the Experience Sampling Method in 51 individuals with first-episode psychosis (FEP), 46 individuals with an at-risk mental state (ARMS) for psychosis, and 53 controls, we investigated how stress, enhanced threat anticipation, and experiences of aberrant salience combine to increase the intensity of psychotic experiences. We fitted multilevel moderated mediation models to investigate indirect effects across these groups. We found that the effects of stress on psychotic experiences were mediated via pathways through affective disturbance in all 3 groups. The effect of stress on psychotic experiences was mediated by threat anticipation in FEP individuals and controls but not in ARMS individuals. There was only weak evidence of mediation via aberrant salience. However, aberrant salience retained a substantial direct effect on psychotic experiences, independently of stress, in all 3 groups. Our findings provide novel insights on the role of affective disturbance and threat anticipation in pathways through which stress impacts on the formation of psychotic experiences across different stages of early psychosis in daily life.

Meta-analysis of associations between childhood adversity and hippocampus and amygdala volume in non-clinical and general population samples

Background Studies of psychiatric populations have reported associations between childhood adversity and volumes of stress-related brain structures. This meta-analysis investigated these associations in non-clinical samples and therefore independent of the effects of severe mental health difficulties and their treatment. Methods The MEDLINE database was searched for magnetic resonance imaging studies measuring brain structure in adults with and without childhood adversity. Fifteen eligible papers (1781 participants) reporting hippocampal volumes and/or amygdala volumes were pooled using a random effects meta-analysis. Results Those with childhood adversity had lower hippocampus volumes (hedges g = − 0.15, p = 0.010). Controlling for gender, this difference became less evident (hedges g = − 0.12, p = 0.124). This association differed depending on whether studies included participants with some psychopathology, though this may be due to differences in the type of adversity these studies examined. There was no strong evidence of any differences in amygdala volume. Discussion Childhood adversity may have only a modest impact on stress-related brain structures in those without significant mental health difficulties.

Have we forgotten about dementia in care homes? The importance of maintaining survey research in this sector

Dementia is one of the leading causes of disability in later life with substantial societal impact in terms of economic costs [1, 2], many of which arise because of the need for institutional care later in the disorder. A recent report estimated that of the 820,000 people with dementia in the UK, over 30% were living in long-term care institutions with the cost of caring for these individuals amounting to £9 billion per year to the UK economy. However, funding for research into dementia has been substantially less than that for other common chronic disorders [3]. The lack of research funding is also reflected in the fact that only 1.4% of chronic disorder research papers published between 2002 and 2007 were devoted to dementia in contrast to 23.5% on cancer and 17.6% on cardiovascular disease [2]. The intention of the new UK government to prioritise the support of dementia research is therefore to be welcomed. However, even within this field, there has been a lack of investigation into the aspects of dementia care of most economic importance, namely the provision of institutional care and the impact of dementia in these settings. Specifically, a review of publications within the past 10 years, summarised below, has led us to conclude that basic research into dementia impact in UK elderly care homes is becoming increasingly outdated, despite rapidly changing social and political developments regarding the use of and funding for long-term care. There are numerous methodological complexities involved in conducting research with care home residents. First, there is the complexity of care home sampling, given the blurring of service provision (e.g. between ‘residential’ and ‘nursing’ homes). A close working relationship with care homes is key, but presents substantial challenges. One cited reason for a lack of research has been the increase in private sector provision since the 1980s, so that control over access lies with a large number of autonomous owners or managers resulting in random selection of homes being quickly rendered unrepresentative due to refusals [4]. Increased media and political attention to quality of care issues may increase reluctance of care homes to participate in research. Moreover, there are substantial time constraints to staff participation (e. g. to provide informant accounts of behavioural symptoms) in the context of high workload and low staff:resident ratios. Further challenges are also posed in the recruitment of residents who lack capacity to provide informed consent and in identifying an appropriate person to provide consultee consent if there is no relative in close contact. However, failing to include these people risks excluding arguably the most vulnerable members of society [5]. The care home sector in the UK is an environment which has been rapidly changing in terms of organisational structures, relationships between health and social services contributing to referrals and care provision available, all against a background of demographic ageing. Because of this, evidence from conventional cross-sectional surveys cannot be assumed to remain up to date and there is a pressing need for continued research, despite the challenges described above. In order to evaluate this issue, we carried out a systematic review of articles reporting dementia prevalence in any UK care home setting over the last 10 years and, for each article, sought to ascertain the period over which data had been collected. We searched PsycINFO, PubMed, Google Scholar and other relevant data sources using ‘care home’, ‘dementia’ and other related terms as keywords. Furthermore, we manually searched for references within journals. Of 19 reports where dementia prevalence could be ascertained from findings (data available on request), we found only four where the period surveyed was explicitly later than 2000. Of these, Aldred et al. [6] surveyed clinical records from 331 residents in 65 care homes in Leeds in 2002–03 and found a prevalence of 44% for documented dementia and 75% for cognitive impairment from recorded MMSE scores. Hancock et al. [7] carried out a survey of care homes in London, Manchester and North Wales and, from MMSE scores, reported prevalences of 6, 27 and 48% for mild, moderate and severe dementia, respectively. Bowman et al. [8] surveyed 244 BUPA care homes in 2003 using staff questionnaires on residents and reported recorded dementia diagnoses for 31% of residential and 38% of nursing home residents, with respective prevalences of staff-reported confusion/forgetfulness of 60 and 65%. Most recently, Fossey et al. [9] conducted a cluster randomised trial across 12 Elderly Mentally Infirm nursing homes. At baseline, they reported prevalences of 19, 23 and 58% for non/questionable/mild, moderate and severe dementia, respectively. However, eligible sites were those where a minimum of 25% of residents with dementia were taking neuroleptic drugs. In summary, despite the clinical, social and economic importance of the care home sector, 10 years into the 21st century, there has been a paucity of research. Furthermore, forecasts of future dementia prevalence and the associated

Increased Resting Hippocampal and Basal Ganglia Perfusion in People at Ultra High Risk for Psychosis: Replication in a Second Cohort

We recently reported that resting hippocampal, basal ganglia and midbrain perfusion is elevated in people at ultra high risk (UHR) for psychosis. The present study sought to replicate our previous finding in an independent UHR cohort, and examined the relationship between resting perfusion in these regions, psychosis and depression symptoms, and traumatic experiences in childhood. Pseudo-Continuous Arterial Spin Labelling (p-CASL) imaging was used to measure resting cerebral blood flow (rCBF) in 77 UHR for psychosis individuals and 25 healthy volunteers in a case-control design. UHR participants were recruited from clinical early detection services at 3 sites in the South of England. Symptoms levels were assessed using the Comprehensive Assessment of At Risk Mental States (CAARMS), the Hamilton Depression Scale (HAM-D), and childhood trauma was assessed retrospectively using the Childhood Trauma Questionnaire (CTQ). Right hippocampal and basal ganglia rCBF were significantly increased in UHR subjects compared to controls, partially replicating our previous finding in an independent cohort. In UHR participants, positive symptoms were positively correlated with rCBF in the right pallidum. CTQ scores were positively correlated with rCBF values in the bilateral hippocampus and negatively associated with rCBF in the left prefrontal cortex. Elevated resting hippocampal and basal ganglia activity appears to be a consistent finding in individuals at high risk for psychosis, consistent with data from preclinical models of the disorder. The association with childhood trauma suggests that its influence on the risk of psychosis may be mediated through an effect on hippocampal function.