Rachel Churchill

Youth-friendly primary-care services: how are we doing and what more needs to be done?

For developmental as well as epidemiological reasons, young people need youth-friendly models of primary care. Over the past two decades, much has been written about barriers faced by young people in accessing health care. Worldwide, initiatives are emerging that attempt to remove these barriers and help reach young people with the health services they need. In this paper, we present key models of youth-friendly health provision and review the evidence for the effect of such models on young peoples health. Unfortunately, little evidence is available, since many of these initiatives have not been appropriately assessed. Appropriate controlled assessments of the effect of youth-friendly health-service models on young peoples health outcomes should be the focus of future research agendas. Enough is known to recommend that a priority for the future is to ensure that each country, state, and locality has a policy and support to encourage provision of innovative and well assessed youth-friendly services.

Anterior cingulate volumes in schizophrenia: A systematic review and a meta-analysis of MRI studies

OBJECTIVES Several MRI studies have investigated the anterior cingulate in schizophrenia, as this is a key region for emotional processing and higher executive performances. A systematic review of structural MRI studies and a meta-analysis were conducted to explore whether anterior cingulate volumes are abnormal in patients with schizophrenia. METHOD A systematic search strategy was used to identify eligible MRI studies. Thereafter, a meta-analysis was carried out by using a random effect model. Also, a meta-regression analysis was used to assess the influence of age, gender and slice thickness on effect sizes. RESULTS The meta-analysis was performed on seven studies. These results showed that the anterior cingulate volumes were significantly reduced in patients compared to healthy controls. Significant heterogeneity between these studies was observed. The meta-regression demonstrated that the effect size was significantly related only to slice thickness. CONCLUSIONS Our work confirmed the presence of abnormally reduced anterior cingulate volumes in schizophrenia. However, several methodological issues limited the interpretation of these findings. Among these were different MR acquisition parameters and the small size of the sample, which was mostly composed of chronic patients. Future MRI studies should be planned to better understand the functional expression of anterior cingulate structural abnormalities.

Trends in the use of the Mental Health Act: England, 1984-96

The Mental Health Act 1983 provides legislation to ensure a consistent and comprehensive approach to the compulsory admission of psychiatric patients in England and Wales. Since the introduction of the act, the provision of service has changed: hospitals have closed and the care in the community programme has been introduced. Despite the reduction in the number of psychiatric beds available Department of Health data show a rise in the absolute number of compulsory admissions.1 We aimed to determine the proportion of all psychiatric admissions that these compulsory “formal” admissions represent. The Department of Health collects data from health authorities on compulsory psychiatric admissions, and these data were used to determine the proportion of all psychiatric admissions that were compulsory. Between 1984 and 1986 these data were presented for each calendar year. Since 1987 they have been presented for each financial year. Data were available from the Mental Health Enquiry from 1984 …

Dysfunctional attitudes and the common mental disorders in primary care

BACKGROUND Dysfunctional attitudes may predispose to episodes of depression, although the evidence for this is poor. Most previous studies have been cross-sectional, or have followed up clinical samples. The aim of the study was to test the hypothesis that dysfunctional attitudes are associated with the onset and repeat prevalence of episodes of the common mental disorders among primary care attenders. METHODS A 12-month prospective cohort study of 305 consecutive primary care attenders at a health centre in south London. RESULTS Linear associations were found between (high) score on the Dysfunctional Attitude Scale (DAS) and both the onset and repeat prevalence of episodes of the common mental disorders over 12 months (unadjusted OR for episode onset 1.05, 95% CI 1.01-1.09) (P = 0.009). The association with episode onset, but not with repeat prevalence, remained statistically significant after adjusting for CIS-R score at baseline (OR 1.05, 95% CI 1.00-1.09) (P = 0.03). LIMITATIONS This study was based in a single general practice, and had limited power to detect statistically significant interactions between DAS score and socio-economic adversity. CONCLUSIONS Dysfunctional attitudes may be a risk factor for the onset (but not the outcome) of episodes of moderately severe, typically comorbid, anxiety and depression found in primary care settings.

Can pill placebo augment cognitive-behavior therapy for panic disorder?

BackgroundIn a number of drug and psychotherapy comparative trials, psychotherapy-placebo combination has been assumed to represent psychotherapy. Whether psychotherapy plus pill placebo is the same as psychotherapy alone is an empirical question which however has to date never been examined systematically.MethodsWe conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) that directly compared cognitive-behavior therapy (CBT) alone against CBT plus pill placebo in the treatment of panic disorder.ResultsExtensive literature search was able to identify three relevant RCTs. At the end of the acute phase treatment, patients who received CBT plus placebo had 26% (95%CI: 2 to 55%) increased chances of responding than those who received CBT alone. At follow-up the difference was no longer statistically significant (22%, 95%CI: -10% to 64%).ConclusionThe act of taking a pill placebo may enhance the placebo effect already contained in the effective psychotherapeutic intervention during the acute phase treatment. Theoretically this is an argument against the recently claimed null hypothesis of placebo effect in general and clinically it may point to some further room for enhancing the psychotherapeutic approach for panic disorder.

Efficacy, tolerability and side-effect profile of fluvoxamine for major depression: meta-analysis.

Abstract Fluvoxamine, one of the oldest selective serotonin reuptaking inhibitors, is commonly prescribed to patients with major depression. Several studies have reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are outdated, have not been systematic and/or suffered from several methodological weaknesses. We conducted a systematic review to synthesize the best available evidence on the efficacy of fluvoxamine for adult patients suffering from major depression in comparison with other active antidepressive agents. Relevant randomized controlled trials were identified through a comprehensive search. The primary outcome was a relative risk of response, and the secondary outcome was a relative risk of remission. Tolerability and side-effect profile were also examined. Fifty-three trials were included. There were no large differences between fluvoxamine and any other antidepressants in terms of efficacy and tolerability. There is evidence of differing side effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclics. Clinicians should focus on practically or clinically relevant differences including those in side-effect profiles.

Strategies for the prevention of psychiatric disorder in primary care in south London.

STUDY OBJECTIVE: To compare the potential impact of high risk and population based approaches to the prevention of psychiatric disorder, using a representative sample of general practice attenders as the target population. DESIGN: This was a prospective cohort study. SETTING: A health centre in south London. PARTICIPANTS: Three hundred and seven consecutive attenders aged 16-65, recruited at randomly selected general practice surgeries. MAIN RESULTS: A linear association was found between the number of different types of socioeconomic adversity reported at recruitment (T1) and the prevalence of psychiatric disorder one year later (T2). The population attributable fraction (PAF) for socioeconomic adversity at T1 was 37.4%. In theory, social interventions for high risk individuals at T1 would reduce the prevalence of psychiatric disorder at T2 by 9% at most, compared with a reduction of 18% if just one item of socioeconomic adversity were eliminated among those with any socioeconomic risk factors. CONCLUSIONS: Social interventions targeted at individuals at highest risk of the most common mental disorders are likely to be extremely limited in their capacity to reduce the prevalence of these conditions. A population based risk reduction strategy, modified according to individual risk, represents a potentially feasible and effective alternative.

Capacity, consent and electroconvulsive therapy: A qualitative and cross-sectional study

Background: Mental capacity based mental health legislation has been proposed, but its potential impact on practice has not been described. Aims: To describe the extent to which mental capacity based law might change prescriptions of electroconvulsive therapy (ECT) in England and Wales. Method: A qualitative study using focus groups and semi-structured interviews of psychiatrists, was followed by a cross sectional study of 186 consultant psychiatrists. Results: Psychiatrists were divided in their management of detained but apparently competent patients refusing ECT. From the cross sectional survey, 15.9% reported having prescribed ECT in such patients, but some expressed views that the treatment was not acceptable under these circumstances. Conclusions: Mental capacity based legislation could limit the use of compulsory treatment to some individuals refusing treatment. However, it might equally lead to psychiatrists redefining their operational definitions of mental capacity. Declaration of interest: This study was funded by the Department of Health.