Stephen Macfarlane

Psychological Factors Among Elderly Women With Suicidal Intentions or Attempts to Suicide: A Controlled Comparison

The aim of this study was to measure a range of psychological factors identified as important in the literature (resilience, psychological distress, feelings of hopelessness, personal and interpersonal control) among community-dwelling elderly women (N = 31) who had suicidal intentions or attempted suicide. The target group was matched to a control group on age within 5 years. The target group reported lower resilience, personal and interpersonal control but higher psychological distress and feelings of hopelessness compared to the control group. Women who had suicidal ideation or attempts in the last 12 months reported higher personal and interpersonal control. This suggests that although suicide among older women is strongly linked to psychological factors, it warrants further investigation.

A Phase IIa Randomized Control Trial of VEL015 (Sodium Selenate) in Mild- Moderate Alzheimer's Disease

BACKGROUND There is increasing interest in targeting hyperphosphorylated tau (h-tau) as a disease modifying approach for Alzheimers disease (AD). Sodium selenate directly stimulates the activity of PP2A, the main enzyme responsible for h-tau dephosphorylation in the brain. OBJECTIVE This study assessed the safety and tolerability of 24-week treatment with VEL015 (sodium selenate) in AD. Investigating the effects of VEL015 on cognitive, CSF, and neuroimaging biomarkers of AD were secondary, exploratory objectives. Data were used to identify biomarkers showing most promise for use in subsequent efficacy trials. METHODS A 24-week, multicenter, Phase IIa, double-blinded randomized controlled trial. Forty patients aged ≥55 y with mild-moderate AD (MMSE 14-26) were randomized to supranutritional (VEL015 10 mg tds [n = 20]) and control (VEL015 320μg tds [n = 10] or placebo [n = 10]) groups. Patients were regularly monitored for safety, adverse events (AEs), and protocol compliance. Exploratory biomarkers included cognitive tests, neuroimaging (diffusion MR), and CSF (p-tau, t-tau, and Aβ1-42). RESULTS Thirty-six (90%; [supranutritional n = 18, control/placebo n = 18]) patients completed the trial. There were no differences in the incidence of specific AEs between groups. Only one secondary biomarker, diffusion MR measures, showed group differences, with less deterioration in the supranutritional group (p < 0.05). CONCLUSION Treatment with VEL015 at doses up to 30 mg per day for 24 weeks was safe and well-tolerated in patients with AD. Diffusion MR measures appear to be the most sensitive biomarkers to assess disease progression over 24 weeks.

Getting started in research: research questions, supervisors and literature reviews

Objectives: Research can seem daunting, especially for trainees and early career researchers. This paper focuses on how to formulate and begin a research project such as the RANZCP Scholarly Project. Methods: We outline an approach to framing a research question, developing theses and hypotheses, choosing a supervisor and conducting a literature review. Conclusions: Through systematic planning early career researchers and other clinicians can plan and conduct research suitable for the Scholarly Project or other research activity.

Systemic approach to behavioural and psychological symptoms of dementia in residential aged care facilities

Australian & New Zealand Journal of Psychiatry, 48(2) The perspective ‘Rethinking psychotropics in nursing homes’ (Hilmer and Gnjidic, 2013) raises justifiable concern regarding the potential overuse of psychotropic medication in Australian residential aged care facilities (RACFs), which we argue is actually a downstream effect of systemic problems in the provision of mental health care in the RACF environment (Snowdon, 2010) and thus requires broader scale interventions. The psychiatric morbidity of RACF residents is alarming: an international systematic review found that dementia had a prevalence of 58%, with 78% of those with dementia exhibiting behavioural and psychological symptoms (BPSD). In addition, major depression had a prevalence of 10% and depressive symptoms were evident in 28% (Seitz et al., 2010). There is no room for therapeutic nihilism (Macfarlane et al., 2012) in the presence of burgeoning evidence of the efficacy of non-pharmacological interventions (CohenMansfield et al., 2012; Conn and Seitz, 2010; Kolanowski et al., 2011; Leone et al., 2013; O’Connor et al., 2009), as well as evidence for the judicious usage of antidepressants (Seitz et al., 2011), antipsychotics (Ballard et al., 2006) and cognition-enhancing agents in at least some residents with BPSD (Conn and Seitz, 2010). Routine discontinuation of antipsychotics (Devanand et al., 2012) and antidepressants (Bergh et al., 2012) in people with dementia may have adverse outcomes, with recurrence of the disorders and increased distress. As experienced geriatric psychiatrists, we argue that a comprehensive systemic approach is required to care for and support people with BPSD and other types of mental illness in RACFs. This approach should encompass structured assessment of problem behaviours and symptoms, targeted psychological and pharmacological interventions, appropriate levels of properly remunerated staff who have undergone dementia-specific education and training, and physical design components to produce a prosthetic environment. Hilmer and Gnjidic (2013) asserted that ‘... we tend to use [psychotropic medications] too often, for too long, at doses that are too high, in dangerous combinations ...’ (p.77). They cited findings from a series of studies in 44 nursing homes in Sydney (Snowdon et al., 2011). This series of studies found that between 1993 and 2009 the use of regularly administered antipsychotics rose from 27% to 28%; regular hypnotics dropped from 26% to 11%; regular anxiolytics dropped from 8.6% to 4.7%; regular antidepressants rose from 15.6% to 25.6%; and the overall psychotropic use (all classes combined) dropped from 58.9% to 47.5%. From these findings it is clear that lumping all psychotropic medications into a single category obscures the complexities of usage of these drugs (Snowdon et al., 2011). Despite this caveat, we agree that critical review of medications for the treatment of BPSD for persons residing in RACFs is important and that changes to treatment regimens, including starting and stopping medication, warrant careful consideration; especially since a recent Australian study showed that medications for RACF residents were infrequently reviewed (O’Connor et al., 2010). We have argued elsewhere (Macfarlane et al., 2012) that the limited evidence of efficacy of antidepressants in people with dementia is likely to arise from the rather limited volume and sophistication of the available evidence, whilst acknowledging that depressive symptoms and disorders may be difficult to ascertain, monitor and treat in this population. A Cochrane Systematic Review noted there were few trials of treatment of BPSD with antidepressants, but concluded that two selective serotonin Systemic approach to behavioural and psychological symptoms of dementia in residential aged care facilities

Limited antidepressant efficacy in depression in dementia, in the context of limited evidence ...

Australian & New Zealand Journal of Psychiatry, 46(7) We comment on the contribution of Banerjee et al. (2011) to the limited literature concerning antidepressant efficacy in elderly populations with dementia. Together with a Cochrane review (Bains et al., 2002) and a 2011 systematic review of studies that enrolled 330 patients (Nelson and Devanand, 2011), it appears the evidence base for antidepressant efficacy in these groups is equivocal. The potential importance of the Banerjee study lies in the influence exerted by its size, with 326 patients enrolled, making this the largest single study to examine the question of antidepressant efficacy in this group of patients. However, as we and others have argued (Brodaty, 2011), the study has significant limitations impacting on its findings. We believe evidence of limited antidepressant efficacy, in the context of limited evidence itself, prompts consideration of how clinicians should approach treatment of depression in those suffering from dementia – as well as having potential health policy implications.

The Clinical and Service Outcomes of Unilateral and Bilateral ECT Electrode Placements in Australian Aged Psychiatry Services

Objective The aim of the study was to determine whether depressed aged inpatients treated with brief pulse unilateral electroconvulsive therapy (ECT) differed from those treated with bilateral (bitemporal or bifrontal) ECT with respect to numbers of treatments, length of hospital admission, changes in scores on depression and cognitive scales, and serious adverse effects. Methods An audit of routinely collected data regarding 221 acute ECT courses in 7 public aged psychiatry services in Victoria, Australia. Results Patients given unilateral, bifrontal, and bitemporal treatments were similar with respect to personal, clinical, and treatment characteristics. Most treatments were administered in line with local clinical guidelines and were rated as effective. Psychiatrists preferred unilateral ECT in the first instance with stimulus dosing based on patients’ seizure thresholds. Approximately a quarter of unilateral courses were switched later to bitemporal placement, most probably because of insufficient progress. Bilateral treatments were associated with a larger number of treatments, less improvement in scores on mood and cognitive scales, and more refusals to continue treatment than unilateral-only ECT. Discussion Brief pulse unilateral ECT proved more effective than bitemporal and bifrontal ECT for most aged patients, especially when coupled with stimulus dosing based on seizure threshold.

A guide to clinical research supervision for psychiatrists: a mentoring approach.

Objectives: To provide a guide for clinically-based psychiatrist supervisors of research projects for early career researchers. Methods: This paper will describe a mentoring framework for supervision, for psychiatrist clinical research supervisors and early career researchers. Results: The domains discussed include, across various aspects of a study: the role of the supervisor, project management, and where and when to seek advice. Conclusions: Supervision of clinical research can be a professionally rewarding experience for psychiatrists, as well as early career researcher supervisees.

Getting started in research: systematic reviews and meta-analyses

Objectives: Systematic reviews are one of the major building blocks of evidence-based medicine. This overview is an introduction to conducting systematic reviews and meta-analyses. Conclusions: Systematic reviews and meta-analyses of randomised controlled trials (RCTs) represent the most robust form of design in the hierarchy of research evidence. In addition, primary data do not have to be collected by the researcher him/herself, and there is no need for approval from an ethics committee. Systematic reviews and meta-analyses are not as daunting as they may appear to be, provided the scope is sufficiently narrow and an appropriate supervisor available.

Getting started in research: Designing and preparing to conduct a research study

Objective: To discuss common pitfalls and useful tips in designing a quantitative research study, the importance and process of ethical approval, and consideration of funding. Conclusions: Through careful planning, based on formulation of a research question, early career researchers can design and conduct quantitative research projects within the framework of the Scholarly Project or in their own independent projects.

Quality indicators of psychotropic prescribing to people with dementia in aged psychiatry inpatient units

ABSTRACT Objectives: To develop indicators of safe psychotropic prescribing practices for people with dementia and to test them in a convenience sample of six aged mental health services in Victoria, Australia. Method: The clinical records of 115 acute inpatients were checked by four trained auditors against indicators derived from three Australian health care quality and safety standards or guidelines. Indicators addressed psychotropic medication history taking; the prescribing of regular and ‘as needed’ psychotropics; the documentation of psychotropic adverse reactions, and discharge medication plans. Results: The most problematic areas concerned the gathering of information about patients’ psychotropic prescribing histories at the point of entry to the ward and, later, the handing over on discharge of information concerning newly prescribed treatments and the reasons for ceasing medications, including adverse reactions. There were wide variations between services. Conclusion: The indicators, while drawn from current Australian guidelines, were entirely consistent with current prescribing frameworks and provide useful measures of prescribing practice for use in benchmarking and other quality improvement activities.