Steve Kisely

The prescribing of psychotropic drugs by primary care physicians: an international collaborative study.

Psychotropic drugs play a major role in primary care management of mental disorders. This study expands the existing data on prescribing practices using data from a 15-center, primary care epidemiologic survey. Questions to be addressed include the following: Which clinical and nonclinical factors are related to the prescribing of psychotropic drugs by primary care physicians? How do prescribing patterns vary across primary care centers? At each center, primary care patients were screened using the General Health Questionnaire, and a stratified random sample completed a standardized diagnostic assessment. For each patient completing the diagnostic assessment, the treating primary care physician provided data on clinical diagnosis and medications prescribed. Study results indicated that 11.5% of all practice attenders, 51.7% of cases who received a diagnosis of mental disorders by a physician, and 27.6% of cases who received a diagnosis using the Composite International Diagnostic Interview were treated with psychotropic medication because of their psychologic problems. Anxiolytics, hypnotics, and antidepressants each accounted for approximately 20% of all prescriptions. Prescription rates increased with the prominence of psychologic complaints, severity of mental disorder, severity of social disability, female gender, age older than 40 years, lower education, unemployment, and marital separation. Rates and type of drugs also varied among specific mental disorders; 19.3% of patients with brief recurrent depression but 55.0% with agoraphobia got any psychotropic drug. Antidepressant drugs were prescribed in 7.7% of anxiety disorders compared with 31.9% of depressive disorders. There were large differences between international centers. When comparing client-type centers with clinic-type centers, overall prescription rates were similar (51.2 vs. 52.9%), but significant differences were observed with respect to psychotropic polypharmacy (12.6% client, 6.3% clinic), tranquilizer medication (24.2 client, 32.9% clinic), and antidepressant medication (17.3 client, 8.9% clinic). Psychotropic drugs have an important role in the treatment of mental disorders by general practitioners. Prescription is associated with a number of clinical but also nonclinical factors that must be recognized when guidelines for international use are to be published. Recognition of mental disorders and selection of specific drug classes are important areas in which medical practice needs improvement.

A comparison between somatic symptoms with and without clear organic cause: results of an international study

BACKGROUND The aim of this study was to determine differences between patients attending primary-care clinics with somatic symptoms for which no organic cause can be found, and those with a clear organic basis for their complaints. METHODS Physical and psychiatric morbidity was measured in 5447 subjects presenting for primary care in 14 countries. Subjects were recruited using a two-stage design from 26,969 consecutive attenders and 25,916 (96.5%) subjects were successfully screened using the General Health Questionnaire (GHQ-12). The response rate for the second-stage assessment was 63% and consisted of the Composite International Diagnostic Instrument adapted for use in primary care (CIDI-PHC), the 28-item GHQ, the Groningen Social Disability Schedule (GSDS) and GP ratings to assess physical psychiatric and social status. Patients who reached the threshold for the number of somatic symptoms (five or more symptoms) were then divided into two groups on the basis of whether their somatic symptoms were medically explained or not. RESULTS The presence of somatic symptoms, irrespective of aetiology, was associated with increased social and psychiatric morbidity. In the case of non-medically explained symptoms there was a clear linear relationship while with medically explained symptoms psychiatric morbidity rose sharply in the presence of more than 11 symptoms. Patients who had five or more non-medically explained symptoms were significantly younger, had greater psychiatric morbidity, were at greater risk of harmful use of alcohol and reported greater social disability than those with a medical explanation for their somatic symptoms. Patients who had an excess of somatic symptoms in both categories had especially high rates of social and psychiatric morbidity. CONCLUSIONS These results show a strong association between somatic symptoms irrespective of aetiology and psychiatric morbidity across disparate cultures.

Assessing the outcome of compulsory psychiatric treatment in the community: epidemiological study in Western Australia

Abstract Objective: To examine whether community treatment orders for psychiatric patients reduce subsequent use of health services in comparison with control patients not placed on an order. Design: Epidemiological study with a before and after, two stage design of matching and multivariate analysis, controlling for sociodemographic variables, clinical features, and psychiatric history. Setting: All community based and inpatient psychiatric services in Western Australia, covering a population of 1.7 million people. Participants: 228 subjects placed on a community treatment order, matched with an equal number of controls to give a total of 456 patients. Main outcome measures: Inpatient admissions, bed days, and outpatient contacts one year after subjects were placed on a community treatment order or the index date of matched controls. Results: Both subjects and their matched controls had reduced inpatient admissions and bed days in hospital. Subjects had significantly more outpatient contacts. Multivariate analysis indicated that being placed on a community treatment order was associated with increased outpatient contacts in the subsequent year compared with the control group. Otherwise, orders did not affect subsequent use of health services. Other factors associated with increased use of health services were age and inpatient admissions, bed days, and outpatient contacts before the order or index date. No covariates were shown to be associated with changes in within pair differences in inpatient admissions or bed days. Conclusions: The introduction of compulsory treatment in the community does not lead to reduced use of health services. What is already known on this topic Various forms of compulsory treatment in the community have been suggested as being effective in reducing use of services by patients with mental health disorders Studies have often lacked epidemiological sampling frames and control for possible confounding factors What this study adds Patients placed on community treatment orders and those not on such orders had reduced hospital admissions and bed days one year later Placement of an order did not predict subsequent use of services Community treatment orders may not be an effective alternative to assertive community treatment programmes

Systematic review and meta-analysis of distraction and hypnosis for needle-related pain and distress in children and adolescents.

OBJECTIVE To systematically review the evidence (and quality) for distraction and hypnosis for needle-related pain and distress in children and adolescents. To explore the effects of distraction characteristics (e.g., adult involvement, type of distracter), child age, and study risk of bias on treatment efficacy.  METHODS 26 distraction and 7 hypnosis trials were included and self-report, observer-report, and behavioral pain intensity and distress examined. Distraction studies were coded for 4 intervention characteristics, and all studies coded for child age and study risk of bias.  RESULTS Findings showed strong support for distraction and hypnosis for reducing pain and distress from needle procedures. The quality of available evidence was low, however. Characteristics of distraction interventions, child age, and study risk of bias showed some influence on treatment efficacy. CONCLUSIONS Distraction and hypnosis are efficacious in reducing needle-related pain and distress in children. The quality of trials in this area needs to be improved.

Protective associations of importance of religion and frequency of service attendance with depression risk, suicidal behaviours and substance use in adolescents in Nova Scotia, Canada

PURPOSE We examined relationships of measures of personal importance of religion and frequency of attendance at religious services with risk of depression and risk behaviours in high school students in Cape Breton, Canada. We examined the impact of confounding and explanatory factors on these relationships. METHODS Data were drawn from self-report surveys of adolescents aged 15-19 (N=1615) at three high schools in May, 2006. We used logistic regression to assess associations of religious importance and religious service attendance with risk of depression, suicidal behaviour, binge drinking and frequent marijuana use, controlling in multivariate models for sociodemographic factors, family structure and social capital. RESULTS Among females, higher personal importance of religion was associated with decreased odds of depression, suicidal ideation, drinking and marijuana use, while more religious attendance was protective for substance use behaviours and suicidal ideation. In males, both measures of religiosity were associated with decreased substance use. In multivariate models, religious importance had weak protective effects for depression and suicidal thinking in females, which were respectively modified by social trust and substance use. Attendance was protective for suicidal thinking in females, and was modified by depression. These associations were not seen in males. Attendance was consistently associated with less substance use in females, while importance was not. Importance was consistently protective for marijuana use and attendance was protective for binge drinking in males. LIMITATIONS This was a cross-sectional self-report survey and causality cannot be inferred. CONCLUSION Protective associations of measures of religiosity are seen in Canadian adolescents, as they are elsewhere.

Reducing all-cause mortality among patients with psychiatric disorders: a population-based study

Background: Among patients with psychiatric disorders, there are 10 times as many preventable deaths from physical disorders as there are from suicide. We investigated whether compulsory community treatment, such as community treatment orders, could reduce all-cause mortality among patients with psychiatric disorders. Methods: We conducted a population-based survival analysis of an inception cohort using record linking. The study period extended from November 1997 to December 2008. The cohort included patients from all community-based and inpatient psychiatric services in Western Australia (state population 1.8 million). We used a 2-stage design of matching and Cox regression to adjust for demographic characteristics, previous use of health services, diagnosis and length of psychiatric history. We collected data on successive cohorts for each year for which community treatment orders were used to measure changes in numbers of patients, their characteristics and outcomes. Our primary outcome was 2-year all-cause mortality. Our secondary outcomes were 1-and 3-year all-cause mortality. Results: The study population included 2958 patients with community treatment orders (cases) and 2958 matched controls (i.e., patients with psychiatric disorders who had not received a community treatment order). The average age for cases and controls was 36.7 years, and 63.7% (3771) of participants were men. Schizophrenia and other nonaffective psychoses were the most common diagnoses (73.4%) among participants. A total of 492 patients (8.3%) died during the study. Cox regression showed that, compared with controls, patients with community treatment orders had significantly lower all-cause mortality at 1, 2 and 3 years, with an adjusted hazard ratio of 0.62 (95% confidence interval 0.45–0.86) at 2 years. The greatest effect was on death from physical illnesses such as cancer, cardiovascular disease or diseases of the central nervous system. This association disappeared when we adjusted for increased outpatient and community contacts with psychiatric services. Interpretation: Community treatment orders might reduce mortality among patients with psychiatric disorders. This may be partly explained by increased contact with health services in the community. However, the effects of uncontrolled confounders cannot be excluded.

Deep brain stimulation for obsessive–compulsive disorder: a systematic review and meta-analysis

BACKGROUND Deep brain stimulation (DBS) is increasingly being applied to psychiatric conditions such as obsessive-compulsive disorder (OCD), major depression and anorexia nervosa. Double-blind, randomized controlled trials (RCTs) of active versus sham treatment have been limited to small numbers. We therefore undertook a systematic review and meta-analysis of the effectiveness of DBS in psychiatric conditions to maximize study power. METHOD We conducted a systematic literature search for double-blind, RCTs of active versus sham treatment using Pubmed/Medline and EMBASE up to April 2013. Where possible, we combined results from studies in a meta-analysis. We assessed differences in final values between the active and sham treatments for parallel-group studies and compared changes from baseline score for cross-over designs. RESULTS Inclusion criteria were met by five studies, all of which were of OCD. Forty-four subjects provided data for the meta-analysis. The main outcome was a reduction in obsessive symptoms as measured by the Yale-Brown Obsessive Compulsive Scale (YBOCS). Patients on active, as opposed to sham, treatment had a significantly lower mean score [mean difference (MD) -8.93, 95% confidence interval (CI) -13.35 to -5.76, p < 0.001], representing partial remission. However, one-third of patients experienced significant adverse effects (n = 16). There were no differences between the two groups in terms of other outcomes. CONCLUSIONS DBS may show promise for treatment-resistant OCD but there are insufficient randomized controlled data for other psychiatric conditions. DBS remains an experimental treatment in adults for severe, medically refractory conditions until further data are available.

A systematic review and meta-analysis of the association between poor oral health and severe mental illness

Background Psychiatric patients have increased comorbid physical illness. There is less information, however, on dental disease, especially tooth decay, despite life-style risk factors or psychotropic-induced dry mouth in this population. Importantly, poor oral health can predispose people to chronic physical disease leading to avoidable admissions to hospital for medical causes. Methods Using MEDLINE, PsycInfo, EMBASE, and article bibliographies, we undertook a systematic search for studies from the last 25 years regarding the oral health of people with severe mental illness (SMI). Results were compared with the general population. The two outcomes were total tooth loss (edentulism) and dental decay measured through the following standardized measures: the mean number of decayed, missing, and filled teeth or surfaces. Results We identified 25 studies that had sufficient data for a random-effects meta-analysis. These covered 5076 psychiatric patients and 39,545 controls, the latter from either the same study or community surveys. People with SMI had 2.8 the odds of having lost all their teeth compared with the general community (95% confidence interval [CI] = 1.7–4.6). They also had significantly higher decayed, missing, and filled teeth (mean difference = 5.0, 95% CI = 2.5–7.4) and surfaces scores (mean difference = 14.6, 95% CI = 4.1–25.1). Conclusion The increased focus on the physical health of people with SMI should encompass oral health. Possible interventions could include oral health assessment conducted using standard checklists that can be completed by non–dental personnel, help with oral hygiene, management of iatrogenic dry mouth, and early dental referral.

Protective Associations of School Connectedness with Risk of Depression in Nova Scotia Adolescents

Objective: To determine whether school connectedness demonstrated an independent protective association with risk of depression in students in grades 10 to 12 attending a high school in a rural community in southwestern Nova Scotia. Methods: Students at a high school in rural Nova Scotia participated in a self-completion survey in May 2009. Students were asked about a wide range of health-related factors to determine their needs for health services and promotion. Examining girls and boys separately, we used logistic regression to examine associations of an established measure of school connectedness with risk of depression as measured by the 12-item Center for Epidemiologic Studies Depression (CES-D) Scale, while including numerous potential confounding variables in our models. Results: The response rate was 95.2% among registered students present in class during the survey. Four hundred eight students (216 girls and 192 boys) completed both the CES-D12 and the School Connectedness Scale. Higher school connectedness was independently protective of risk of depression in girls (OR 0.85; 95% CI 0.78 to 0.93, P < 0.01) and in boys (OR 0.81; 95% CI 0.71 to 0.91, P < 0.01). Conclusions: Among adolescents in rural Nova Scotia, higher school connectedness has protective associations with risk of depression in both girls and boys, independent of a wide range of factors known to be associated with depression in adolescents. School may be a key place for helping adolescents to develop positive mental health.

Suicidal behaviours in adolescents in Nova Scotia, Canada: protective associations with measures of social capital.

PurposeFew studies of adolescent suicidality have examined its associations with social capital. We explored associations of measures of individual level social capital with self-reported suicide ideation and suicide attempt in adolescents in Cape Breton, Nova Scotia, Canada, controlling for other factors known to be associated with adolescent suicidality.MethodsWe surveyed 1,597 grade 10–12 students at three high schools in 2006 using self-completion questionnaires. Both sexes were combined for analysis. Outcome measures were suicidal ideation and attempt in the previous year. Measures of social capital included perceptions of trustworthiness and helpfulness of others at school, frequency of religious attendance and participation in extracurricular activities. Logistic regressions were carried out to determine associations of social capital with suicidality while controlling for other factors.ResultsPerceived trustworthiness and helpfulness were protective for suicidal ideation and suicide attempt in the previous year. In adjusted analyses, there were interactions of gender and social capital—females reporting more social capital were more protected from suicide attempt relative to males with similar levels of social capital.ConclusionsThis study provides initial evidence of protective associations of individual level social capital with adolescent suicidality. Our findings suggest that among adolescents low social capital as measured by perceptions of trust and helpfulness of others at school may be a warning sign for suicidality, particularly for females. It may be helpful to inquire of young people how they perceive the trustworthiness and helpfulness of their school environment as a measure of how supportive that environment might be to them when they are facing challenges to their mental health.