Simon Chu

Effects of orally administered lavender essential oil on responses to anxiety‐provoking film clips

Lavender odour is commonly used to alleviate mild anxiety. Double blind studies are difficult to conduct with odours, and there are few reliable investigations of lavenders efficacy.

Eliminating Context-Dependent Forgetting: Changing Contexts can be as Effective as Reinstating Them

Standard context-dependent memory studies have shown that when information is encoded in a certain environmental context (EC), recall performance is weakened when retrieval occurs in a different, rather than the same, EC. Here, we show that this contextdependent forgetting can be eliminated using mental imagery at encoding. In two studies, participants used mental visualization of the retrieval EC during the encoding process. The results of the first study highlighted the importance of context familiarity. When familiarity was controlled in the second study, users of the mental visualization technique who encoded and retrieved in different EGs showed no context-dependent forgetting as compared with participants who encoded and retrieved in the same EC. These findings suggest that information can become linked with mental images of EGs such that the physical instantiation of an imagined EC can function as effectively as physical EC reinstatement and eliminate context-dependent forgetting.

An evaluation of subjective experiences, effects and overall satisfaction with clozapine treatment in a UK forensic service

Objectives: Patients prescribed clozapine were surveyed to assess (a) the effects, both positive and adverse, and overall satisfaction with clozapine in comparison to previously prescribed antipsychotics and (b) the relative significance of effects experienced, both positive and adverse, in terms of impact on subjective well-being. Methods: A total of 56 male patients prescribed clozapine at a forensic psychiatric hospital were surveyed using a 27-item questionnaire. All patients had been prescribed clozapine for a minimum of 3 months. Respondents were asked to rate effects and satisfaction with clozapine treatment in comparison with previously prescribed antipsychotic medication on a five-point scale. Respondents were also asked to rate effects experienced with clozapine treatment in terms of impact on subjective well-being on a five-point scale. Results: A total of 89% of respondents reported greater satisfaction with clozapine than with previously prescribed antipsychotic medication. A majority of patients reported positive effects in terms of an improvement in their quality of life (68%) and social abilities (52%) with clozapine in comparison with previously prescribed antipsychotics. Nocturnal hypersalivation (84%) and weight gain (57%) were the most common adverse effects. Hedonic responses were assessed for each effect in order to determine the associated subjective experiences. The most positive hedonic responses were for quality of life, mood and alertness. In terms of adverse impact on subjective well-being, nocturnal hypersalivation ranked highest. Conclusions: Patients in a UK forensic sample are largely satisfied with clozapine treatment. The subjective effects of clozapine treatment should be taken into account by clinicians when assessing response. This may provide an opportunity to highlight the positive changes and prioritize management of the most undesirable adverse effects, which is likely to promote compliance and improve longer term treatment outcomes.

Sleep and its association with aggression among prisoners: Quantity or quality?

OBJECTIVE The current paper aims to examine the association between self-reported sleep quality and quantity and how these relate to aggression motivation and hostile cognition in a male prisoner sample. The cognitive component of sleep, namely perception, is consequently a variable of particular interest and one neglected by previous research. METHODS Two independent studies are presented. The first comprised 95 adult male prisoners who completed a sleep quality index along with measures of implicit and explicit aggression. The second study extended this to consider aggression motivation and hostile attribution biases using a sample of 141 young male adult prisoners. RESULTS In study one, sleep quantity and indicators of sleep quality were found not to associate with aggression whereas the perception of poor sleep did; those perceiving poor sleep quality were more likely than those perceiving good sleep to report they had perpetrated aggression in the previous week and to report higher levels of implicit aggression. Study two found that while increased indicators of poor sleep quality were associated with lower prosocial attribution tendencies and higher levels of reactive and proactive aggression, sleep quantity was not associated. The perception of poor quality sleep was important; those perceiving poor sleep were more likely to report higher levels of reactive and proactive aggression than those reporting good sleep. CONCLUSIONS Collectively the studies highlight the importance of accounting for the perception of sleep quality as an important cognitive component in understanding the association between sleep and aggression.

The impact of an intensive inpatient violent offender treatment programme on intermediary treatment targets, violence risk and aggressive behaviour in a sample of mentally disordered offenders

Abstract This study examined the impact of an intensive inpatient violent offender treatment programme, Life Minus Violence-Enhanced (LMV-E), on intermediary treatment targets, risk for violence, and aggressive behaviour during treatment in a sample of male mentally disordered offenders. Using quasi-experimental design, offenders who completed LMV-E and a comparison group showed reduced problems with impulsivity and anger regulation and improvements in social problem solving. Aggregate risk for future violence lessened in both treatment and comparison groups, although by a significantly greater degree for the comparison group. The aggressive behaviour of both groups reduced. Completion of the LMV-E conferred additional improvements in some facets of social problem solving and anger regulation. Neither group showed improvements in empathic responses, coping skills or problematic interpersonal style. Overall, these results suggest anger regulation, impulsivity and social problem solving are most amenable to change, that reductions in certain facets of these dynamic risk factors transpires with nonspecific psychiatric inpatient treatment, but that the LMV-E, a cognitive behavioural violence specific psychological treatment, confers greater change in some facets of social problem solving and anger regulation.

The impact of a night confinement policy on patients in a UK high secure inpatient mental health service

Purpose – From 2012, all high-secure forensic mental health services in England began operating a policy of confining patients to their locked bedrooms overnight to increase service efficiency and reduce costs. The purpose of this paper is to assess the views of staff and patients concerning the policy and examine the specific impact of the policy on patients. Design/methodology/approach – Measures of patients’ sleep hygiene, patients’ behaviour, ward atmosphere, engagement with therapy and adverse incidents were taken both before and after the night confinement (NC) policy was implemented. Both patients and staff also expressed their views of the impact of the NC policy. Findings – Results provide converging evidence that the impact of the NC policy on patients is negligible. There were no consistent negative effects of confining patients overnight. Rather, patients and staff were broadly positive about the impact that the practice had on patients. Practical implications – Confining patients to locked bedrooms overnight does not exert any consistent influence, positive or negative, on patients’ sleep hygiene, behaviour or engagement with therapy, and patients expressed a broadly positive view of the practice of NC. Thus, a NC policy may have a contribution to make to the provision an effective high-secure mental health service. Originality/value – The study provides convincing evidence that secure inpatient mental health services that are considering the adoption of a NC policy may do so without fear of a negative impact on patients.

A natural study of the efficacy of replacement medications for the treatment of clozapine-induced hypersalivation

Clozapine-induced hypersalivation is a stigmatizing and debilitating side effect of clozapine treatment that may threaten adherence to treatment [Taylor et al. 2009]. Hyoscine hydrobromide is the most popular treatment for hypersalivation, but has a poor evidence base [Syed et al. 2008]. During autumn 2013, a shortage of hyoscine tablets in the UK (due to production problems) required patients who had been prescribed hyoscine to change to a replacement medication. This provided an opportunity to assess the subjective relative efficacy of hyoscine hydrobromide compared with alternative medications in the treatment of clozapine-induced hypersalivation. We undertook a service evaluation and surveyed patients prescribed clozapine at Ashworth Hospital (Mersey Care NHS Trust) who had been prescribed hyoscine hydrobromide for hypersalivation. Participants were prescribed alternative medication for clozapine-induced hypersalivation by September 2013 and we conducted our survey in November 2013. Of the 42 consenting participants, 15 were prescribed pirenzepine, 13 were prescribed atropine, and 6 were prescribed a small number other replacement medications (procyclidine, orphenedrine, hyoscine patches) which, owing to small sample sizes, were excluded from our analysis. Eight patients previously prescribed hyoscine were prescribed no replacement medication. In each case, we asked patients to rate on a 7 point scale (1 = much worse, 4 = no change, 7 = much better) their current experience of nocturnal salivation, daytime salivation and a number of other side effects (vision problems, dizziness) compared with when previously prescribed hyoscine. Mean ratings of subjective relative efficacy in comparison with hyoscine for each of the three medication groups (pirenzepine, atropine, no replacement) are shown in Table 1. Subjective ratings showed that nocturnal salivation improved for both the pirenzepine group and the atropine group, but all patients in the no replacement group reported unchanged scores in night salivation. A one-way analysis of variance (ANOVA) showed this to be statistically significant [F(2,35) = 34.36, p < 0.001], with post hoc Tukey tests suggesting that ratings in the pirenzepine and atropine groups were both higher than in the no replacement group. Similarly, ANOVA confirmed that changes in daytime salivation for the pirenzepine group and the atropine group were significantly different to the no replacement group which again reported no change [F(2,35) = 23.4, p < 0.001]. This is unlikely to be a general reporting bias in the pirenzepine and atropine groups because the three groups did not differ in their ratings of changes in vision problems [F(2,35) = 0.99, p = 0.38] and dizziness [F(2,35) = 0.0, p = 1.0]. Table 1. Mean rated changes in side effects according to replacement medication groups. Participants who ceased taking hyoscine and with no replacement medication reported no change in hypersalivation. By comparison, participants who replaced hyoscine with pirenzepine or atropine consistently reported an improvement in salivation (day and night). It should be noted that our service evaluation survey did not implement any randomization to groups and that the data are in the form of retrospective report, both of which limit the interpretation of the outcome. Nevertheless, whilst hyoscine hydrobromide is the treatment of choice for clozapine-induced hypersalivation, a Cochrane Review has indicated that the evidence base is weak [Syed et al. 2008]. There is a broad range of treatment alternatives but these appear equally unsupported in the literature. Thus, clinicians are forced to make pragmatic prescribing judgements in the absence of reliable evidence. Our small-scale survey suggests that hyoscine may not be an effective treatment for hypersalivation and there is a clear need for more convincing evidence of the efficacy of treatments to confidently inform clinical practice. Indeed, a feasibility study funded by the UK National Institute for Health Research (NIHR) to investigate glycopyrrolate and hyoscine in the treatment of clozapine-induced hypersalivation is currently being conducted by our clinical team.

The prevalence of constant supportive observations in high, medium and low secure services

Aims and method We explored the prevalence and use of constant supportive observations (CSO) in high, medium and low secure in-patient services in a single National Health Service (NHS) mental health trust. From clinical records, we extracted data on the length of time of CSO, the reason for the initiation of CSO and associated adverse incidents for all individuals who were placed on CSO between July 2013 and June 2014. Results A small number of individuals accounted for a disproportionately large proportion of CSO hours in each setting. Adverse incident rates were higher on CSO than when not on CSO. There was considerable variation between different settings in terms of CSO use and the reasons for commencing CSO. Clinical implications The study describes the prevalence and nature of CSO in secure forensic mental health services and the associated organisational costs. The marked variation in CSO use between settings suggests that mental health services continue to face challenges in balancing risk management with minimising restrictive interventions. Declaration of interest A.B. and J.L.I. are both directly employed by the NHS trust in which the study was conducted.

Glycopyrrolate in comparison to hyoscine hydrobromide and placebo in the treatment of hypersalivation induced by clozapine (GOTHIC1): study protocol for a randomised controlled feasibility study

BackgroundClozapine is the only medication licensed for the treatment of resistant schizophrenia in the UK. Although efficacious, a common and unpopular side effect of clozapine treatment is clozapine-induced hypersalivation (CIH), which can contribute to non-adherence. The standard treatment for CIH in the UK is hyoscine hydrobromide but this may aggravate cognitive deficits in patients with schizophrenia while glycopyrrolate may be an effective alternative with a more tolerable side effect profile. There is currently no convincing evidence for hyoscine, or any other medication, as an effective treatment for CIH.Methods/designThis is a multicentre randomised, double-blind, placebo-controlled feasibility study of glycopyrronium bromide (glycopyrrolate) and hyoscine hydrobromide (hyoscine) in patients with clozapine-induced hypersalivation. We aim to recruit 42 patients who have been prescribed clozapine and are experiencing hypersalivation, and randomise them to one of three study arms (either hyoscine, glycopyrrolate or placebo). The primary outcome measures will be the participant recruitment and attrition rates, and the secondary outcome will be the metrics of the daytime hypersalivation measure. After a 1-week washout period (discontinuing CIH medication, if any), there will be a 4-week treatment period where participants will be titrated up to the maximum tolerated dose of hyoscine, glycopyrrolate or placebo. Measurements of daytime salivation, nocturnal salivation, cognition and side effects will be taken during home visits in week 2 and week 5. Information on salivation and side effects will also be taken through telephone calls in week 3 and week 4. To gather information on the experience of study participants, exit interviews will also be requested with all participants who drop out of the study and a sample of participants who complete the study.DiscussionThere is currently no convincing evidence for hyoscine, or any other medication, as an effective treatment for CIH. There is promising evidence that glycopyrrolate may be more successful in the treatment of CIH causing fewer cognitive side effects. We propose to conduct a randomised placebo-controlled feasibility study of glycopyrrolate and hyoscine in the treatment of clozapine-induced hypersalivation to inform the design of a future efficacy trial.Trial registrationClinicaltrials.gov NCT02613494, 23 November 2015.

Predicting hospital aggression in secure psychiatric care.

Background Risk assessment instruments have become a preferred means for predicting future aggression, claiming to predict long-term aggression risk. Aims To investigate the predictive value over 12 months and 4 years of two commonly applied instruments (Historical, Clinical and Risk Management - 20 (HCR-20) and Violence Risk Appraisal Guide (VRAG)). Method Participants were adult male psychiatric patients detained in a high secure hospital. All had a diagnosis of personality disorder. The focus was on aggression in hospital. Results The actuarial risk assessment (VRAG) was generally performing better than the structured risk assessment (HCR-20), although neither approach performed particularly well overall. Any value in their predictive potential appeared focused on the longer time period under study (4 years) and was specific to certain types of aggression. Conclusions The value of these instruments for assessing aggression in hospital among patients with personality disorder in a high secure psychiatric setting is considered. Declaration of interest J.L.I., C.A.M. and J.K. are employed by the trust where the data were collected. Copyright and usage