Stuart Lee

Piloting the effective therapeutic dose of adjunctive selective estrogen receptor modulator treatment in postmenopausal women with schizophrenia.

Estrogen treatment may enhance the recovery of schizophrenia in women. However, adverse effects on uterine and breast tissue and other physical side effects may limit the long-term therapeutic use of estrogen. Raloxifene hydrochloride is a selective estrogen receptor modulator that acts as an estrogen antagonist in breast tissue and may have agonistic actions in the brain, potentially offering mental health benefits with few estrogenic side effects. To provide an indication of the potential therapeutic dose for raloxifene hydrochloride in postmenopausal women with schizophrenia, this study pools data from an ongoing randomized controlled trial of adjunctive 120 mg/day oral raloxifene hydrochloride (n=13) versus oral placebo (n=13), with data from a previous pilot study administering 60 mg/day raloxifene hydrochloride (n=9). Analysis of variance found significant interaction effects for total (p=.01) and general (p=.02) Positive and Negative Syndrome Scale (PANSS) symptomatology. Participants randomized to receive 120 mg/day raloxifene hydrochloride experienced a significantly more rapid recovery of total and general psychotic symptoms compared to both 60 mg/day raloxifene hydrochloride and placebo. The demonstrated benefit of adjunctive treatment with 120 mg/day raloxifene hydrochloride offers support for the potential role of this selective estrogen receptor modulator in treating postmenopausal women with schizophrenia.

Estrogens and men with schizophrenia: Is there a case for adjunctive therapy?

Adjunctive use of estrogen therapy has been shown to be effective in enhancing the treatment of schizophrenia in women. In men, consideration of estrogen therapy has been impacted by concerns of feminising side effects, however, clinical trials of the use of estrogen in treating prostate cancer, bone density loss and even aggression and psychosis in dementia or traumatic brain injury, show this to be a safe and effective therapy. The current 14-day randomised placebo-controlled trial in 53 men with schizophrenia was conducted to evaluate the efficacy of 2 mg oral estradiol valerate as an adjunct to atypical antipsychotic treatment. Results demonstrated for estradiol participants a more rapid reduction in general psychopathology that occurred in the context of greater increases in serum estrogen levels and reductions in FSH and testosterone levels. Approximately 28% of estradiol participants did not achieve an increase (at least a 50% from baseline) in serum estrogen suggesting that further research is needed to refine the type, dose and administration route for estrogen therapy in men. Findings do, however, suggest further exploration of a therapeutic role for adjunctive estradiol treatment in men with schizophrenia is warranted.

Sensory assessment and therapy to help reduce seclusion use with service users needing psychiatric intensive care

Background : In acute psychiatry, seclusion has traditionally been used to manage people at risk of harming themselves or others. However, being secluded can be traumatising and cause harm to service users and staff. In North America, sensory modulation strategies and a focus on early identification of aggression warning signs and tailored responses have significantly improved care and reduced seclusion use. Methods : A six-month pilot of the use of sensory modulation strategies and a brief sensory and risk assessment tool (Safety Tool) was implemented on a 30-bed acute psychiatric unit. Indicators of the impact on seclusion use were audited from service users’ files with feedback collected from clinical staff. Results : Safety Tools for 43 psychiatric intensive care service users were audited. They required significantly longer hospitalisation (mean=39.4 days) than was the average for the unit (mean=19.0 days). Whereas 65% had been previously secluded, only 26% were secluded after completing a Safety Tool. Most staff had completed or read a Safety Tool with 76% saying it should become part of standard care. Conclusion : Findings support the significant role that sensory assessment and engagement can play in improving service user care in acute psychiatry.

Predictors of health status and health-related quality of life 12 months after severe burn

INTRODUCTION Sustaining a moderate to severe burn injury is associated with the potential for substantial impairments to long-term physical and psychosocial health, including health related quality of life (HRQoL). The objective of this study was to identify clinical and patient characteristics which predict HRQoL 12-months after injury. METHODS A total of 125 patients were recruited over the study period, although only 99 were included in the final analysis representing all those who completed both the pre-burn and 12-months after burn injury Short Form 36 Medical Outcomes Survey (SF-36v2). These patients also completed the Burn Specific Health Scale-Brief (BSHS-B). Patient demographics and burn injury characteristics and treatment factors were collected to identify which factors predict 12-month health status outcomes. Multiple linear regression analyses were conducted to identify important predictors of outcomes. The SF36v2 models were adjusted for pre-injury measurements. RESULTS Older age (regression coefficient -0.26, 95% confidence interval (95% CI) -0.38, -0.13), female gender (-8.08, 95% CI -12.8, -3.34) and increased percentage of full-thickness burns per body surface area (-0.51; 95% CI -0.88, -0.13) were important predictors of poorer physical health status at 12 months. Older age (-0.15, 95% CI -0.26, -0.04) and increased percentage of full-thickness burns per body surface area (-0.36, 95% CI -0.69, -0.03) were important predictors of poorer mental health status at 12 months. Older age (-0.38; 95%CI -0.66, -0.11) and female gender (-12.17; 95% CI -22.76, -1.57) were important predictors of poorer BSHS-B total score at 12 months after injury. CONCLUSIONS Given the complexity of burn care rehabilitation, physical and psychosocial screening and assessment within the first weeks after a burn injury along with adequate monitoring after discharge should be undertaken in burn injured patients. In this context, patients of specific demographics, such as female patients and older patients, and patients with a higher percentage of full thickness surface area burns are of greater risk for poorer physical and psychological outcomes and may benefit from additional monitoring and rehabilitation.

What is needed to deliver collaborative care to address comorbidity more effectively for adults with a severe mental illness

Objective: Innovative models of care for people with a severe mental illness have been developed across Australia to more effectively address comorbidity and disability by enhancing the collaboration between clinical and non-clinical services. In particular, this review paper focuses on collaboration that has occurred to address comorbidities affecting the following domains: homelessness; substance addiction; physical ill-health; unemployment; and forensic issues. Method: The identification of relevant collaborative care models was facilitated by carrying out a review of the published peer-reviewed literature and policy or other published reports available on the Internet. Contact was also made with representatives of the mental health branches of each Australian state and territory health department to assist in identifying examples of innovative collaborative care models established within their jurisdiction. Results: A number of nationally implemented and local examples of collaborative care models were identified that have successfully delivered enhanced integration of care between clinical and non-clinical services. Several key principles for effective collaboration were also identified. Governmental and organisational promotion of and incentives for cross-sector collaboration is needed along with education for staff about comorbidity and the capacity of cross-sector agencies to work in collaboration to support shared clients. Enhanced communication has been achieved through mechanisms such as the co-location of staff from different agencies to enhance sharing of expertise and interagency continuity of care, shared treatment plans and client records, and shared case review meetings. Promoting a ‘housing first approach’ with cross-sector services collaborating to stabilise housing as the basis for sustained clinical engagement has also been successful. Conclusions: Cross-sector collaboration is achievable and can result in significant benefits for mental health consumers and staff of collaborating services. Expanding the availability of collaborative care across Australia is therefore a priority for achieving a more holistic, socially inclusive, and effective mental health care system.

What factors determine whether a woman becomes depressed during the perimenopause

Perimenopause has long been associated with psychological distress, both anecdotally and clinically. Research has identified this time as a period of increased risk for both first-episode depression and for depression reoccurrence. However, we know that the majority of women do not experience these difficulties during perimenopause. This review examines the current research literature looking at the factors associated with depression during perimenopause, with a view to identifying those factors which are protective and those factors which predict increased risk. From the literature, it is evident that some women have a hormonal vulnerability to mood disorders. However, this does not account for the phenomenon of perimenopausal depression in and of itself. Rather, there appears to be a complex interplay between hormonal vulnerability, the psychosocial resources one has (coping skills and social support), their overall well-being (exercise and other lifestyle factors) and the demands on their coping resources (stressful life events). The complexity of the relationship between perimenopause and depression means that there is a need to look beyond either as a sole explanation of mood during midlife. Education is required for both general practitioners and for women regarding the individual risks of psychological distress during perimenopause, as well as the knowledge of the life factors which we know to be protective.

Challenges Relating to the Interface Between Crisis Mental Health Clinicians and Police When Engaging with People with a Mental Illness

Symptoms of mental illness can increase the risk of disturbed behaviour. Joint intervention between police and mental health services is therefore sometimes needed to manage crisis events safely, and to divert people with a mental illness from further criminal justice system contact. This study explored how crisis mental health clinicians and police officers experience the service interface to identify perceived challenges tocollaboration and possible solutions. This was explored through circulation of a developed questionnaire to staff of the Crisis Assessment Team of Alfred Psychiatry and police officers from three Melbourne police stations. In addition to identifying the high frequency of contact between interfacing services, a number of challenges to effective interface were identified. These included: inefficient communication before or following a joint event; difficulty accessing support from the interfacing service and delays in handing over care in hospital emergency departments; and staff occasionally not respecting the professional abilities of staff from interfacing services.

Mental health care on the streets: An integrated approach

Background: Mental illness can be both a cause of and a reaction to being homeless. When homelessness co-exists with mental illness, the provision of care for very vulnerable people is significantly complicated. Our initiative built on a model of assertive outreach and embedded mental health staff into the daily operations of Hanover Welfare Services and Sacred Heart Mission welfare services in inner Melbourne. The initiatives aim was to facilitate closer collaboration between mental health and welfare services and develop staff capacity to better identify and support people living homeless with a mental illness. Method: The project involved studying the impact of our assertive outreach model on consumer and service outcomes. Demographic, clinical and service usage details for consumers engaged by the initiative were recorded. Changes to the rate of admission of people from both welfare services to The Alfred Inpatient Psychiatry Unit and requests for support from The Alfred Crisis Assessment and Treatment Service were also recorded. Results: People engaged by this initiative had high levels of previous emergency medical or psychiatric service usage, but relatively low levels of current community mental health engagement. There were also high levels (almost 52%) of comorbid substance misuse. The initiative was, however, able to engage more people in ongoing community mental health care, which particularly when provided in collaboration between mental health and welfare staff, achieved improvements in accommodation stability. The initiative also resulted in improved identification and prevention of mental illness crises through supporting a more rapid onsite mental health response. Conclusions: Embedding mental health staff into the daily operations of two welfare services in inner Melbourne improved inter-service collaboration and the identification and care for people living homeless with a mental illness.

A prospective study of the relationship between sense of coherence, depression, anxiety, and quality of life of haematopoietic stem cell transplant patients over time

The primary aim of this study was to examine the impact of patient sense of coherence (SOC) on anxiety and depressive symptoms, and quality of life (QoL) dimensions in the acute phase of haematopoietic stem cell transplantation (HSCT). A secondary aim was to determine if SOC measured pre‐transplant was predictive of psychological distress and QoL post‐transplantation, after controlling for physical wellbeing.

Factors Associated with Depression During the Perimenopausal Transition

BACKGROUND This paper examines the factors associated with depressive symptoms during the perimenopausal transition, to increase the understanding about the etiology of perimenopausal depression. METHOD Seventy-six peri- and early postmenopausal women with or without current depressive symptoms were recruited (mean, 49.5 years; standard deviation, 4.3). Participants completed a series of questionnaires relating to depression (Beck Depression Inventory-II), perimenopausal symptoms (Greene Climacteric Scale), social support, life events, history of mood disorders, exercise regime, and questions regarding lifestyle and well-being. FINDINGS Univariate relationships between predictors and depression scores were assessed. All significant variables at this level (history of depression, history of premenstrual syndrome, recent negative life events, aerobic exercise, social support, and somatic symptoms) were then analyzed via multiple regression. The presence of recent negative life events, a history of depression, and severity of somatic symptoms of perimenopause were all found to predict unique variance in depression scores. There was also a trend toward a protective role of aerobic exercise. CONCLUSIONS This study confirmed the role of negative life events, previous depression history, and somatic complaints in the development of depressive symptoms during perimenopause. Further exploration of this relationship is warranted.