Vivek Furtado

Evidence Base for Using Atypical Antipsychotics for Psychosis in Adolescents

Atypical antipsychotic medications have been the first line of treatment for adolescents with psychosis in the past couple of decades. Till the late 90s, there were very few randomized controlled trials (RCTs) on the treatment of adolescents with psychosis, although a fifth of schizophrenia starts during adolescence. Most of the treatment guidelines for adolescents with psychosis were derived from data on adults. In the past 10 years, there has been increasing number of studies on adolescents with psychosis. The current paper summarizes the findings of trials on adolescents with psychosis in 4 groups: (a) atypical antipsychotic medications vs placebo, (b) atypical antipsychotic medication vs typical antipsychotic medications, (c) one atypical antipsychotic medication vs another atypical antipsychotic medication, and (d) Low dose vs standard dose of atypical antipsychotic medication. We included 13 RCTs, with a total of 1112 participants. Although our review suggest that atypical antipsychotic medications are as effective as typical antipsychotic medications as regards clinical efficacy, atypical antipsychotic medications have a preferred side effect profile and lesser drop-out rate from trials. Obviously, this is extremely important as treatment adherence is key to successful remission of psychotic symptoms and also in some case prevent relapse of illness. Treatment with olanzapine, risperidone, and clozapine is often associated with weight gain. Aripiprazole is not associated with increased prolactin or with dyslipidemia. Adolescents may respond better to standard-dose as opposed to lower dose risperidone, but for aripiprazole and ziprasidone, lower doses may be equally effective. Future trial should be longer term and have uniform ways of reporting side effects.

An oral health intervention for people with serious mental illness (Three Shires Early Intervention Dental Trial): study protocol for a randomised controlled trial

BackgroundOral health is an important part of general physical health and is essential for self-esteem, self-confidence and overall quality of life. There is a well-established link between mental illness and poor oral health. Oral health problems are not generally well recognized by mental health professionals and many patients experience barriers to treatment.Methods/DesignThis is the protocol for a pragmatic cluster randomised trial that has been designed to fit within standard care. Dental awareness training for care co-ordinators plus a dental checklist for service users in addition to standard care will be compared with standard care alone for people with mental illness. The checklist consists of questions about service users’ current oral health routine and condition. Ten Early Intervention in Psychosis (EIP) teams in Nottinghamshire, Derbyshire and Lincolnshire will be cluster randomised (five to intervention and five to standard care) in blocks accounting for location and size of caseload. The oral health of the service users will be monitored for one year after randomisation.Trial registrationCurrent Controlled Trials ISRCTN63382258.

Non-pharmacological interventions for reducing aggression and violence in serious mental illness: A systematic review and narrative synthesis

BACKGROUND For people with mental illness that are violent, a range of interventions have been adopted with the aim of reducing violence outcomes. Many of these interventions have been borrowed from other (offender) populations and their evidence base in a Serious Mental Illness (SMI) population is uncertain. AIMS To aggregate the evidence base for non-pharmacological interventions in reducing violence amongst adults with SMI and PD (Personality Disorder), and to assess the efficacy of these interventions. We chose to focus on distinct interventions rather than on holistic service models where any element responsible for therapeutic change would be difficult to isolate. METHODS We performed a systematic review and narrative synthesis of non-pharmacological interventions intended to reduce violence in a SMI population and in patients with a primary diagnosis of PD. Five online databases were searched alongside a manual search of seven relevant journals, and expert opinion was sourced. Eligibility of all returned articles was independently assessed by two authors, and quality of studies was appraised via the Cochrane Collaboration Tool for Assessing Risk of Bias. RESULTS We included 23 studies of diverse psychological and practical interventions, with a range of experimental and quasi-experimental study designs that included 7 Randomised Controlled Trials (RCTs). The majority were studies of Mentally Disordered Offenders. The stronger evidence existed for patients with a SMI diagnosis receiving Cognitive Behavioural Therapy or modified Reasoning & Rehabilitation (R&R). For patients with a primary diagnosis of PD, a modified version of R&R appeared tolerable and Enhanced Thinking Skills showed some promise in improving attitudes over the short-term, but studies of Dialectical Behaviour Therapy in this population were compromised by high risk of experimental bias. Little evidence could be found for non-pharmacological, non-psychological interventions. CONCLUSIONS The evidence for non-pharmacological interventions for reducing violence in this population is not conclusive. Long-term outcomes are lacking and good quality RCTs are required to develop a stronger evidence base.

Terrorism, Radicalisation, Extremism, Authoritarianism and Fundamentalism: A Systematic Review of the Quality and Psychometric Properties of Assessments

Background Currently, terrorism and suicide bombing are global psychosocial processes that attracts a growing number of psychological and psychiatric contributions to enhance practical counter-terrorism measures. The present study is a systematic review that explores the methodological quality reporting and the psychometric soundness of the instruments developed to identify risk factors of terrorism, extremism, radicalisation, authoritarianism and fundamentalism. Method A systematic search strategy was established to identify instruments and studies developed to screen individuals at risk of committing extremist or terrorist offences using 20 different databases across the fields of law, medicine, psychology, sociology and politics. Information extracted was consolidated into two different tables and a 26-item checklist, reporting respectively background information, the psychometric properties of each tool, and the methodological quality markers of these tools. 37 articles met our criteria, which included a total of 4 instruments to be used operationally by professionals, 17 tools developed as research measures, and 9 inventories that have not been generated from a study. Results Just over half of the methodological quality markers required for a transparent methodological description of the instruments were reported. The amount of reported psychological properties was even fewer, with only a third of them available across the different studies. The category presenting the least satisfactory results was that containing the 4 instruments to be used operationally by professionals, which can be explained by the fact that half of them refrained from publishing the major part of their findings and relevant guidelines. Conclusions A great number of flaws have been identified through this systematic review. The authors encourage future researchers to be more thorough, comprehensive and transparent in their methodology. They also recommend the creation of a multi-disciplinary joint working group in order to best tackle this growing contemporary problem.

EPA-0119 – Characteristics and needs of long stay patients in high and medium secure forensic psychiatric care - implications for service organisation

Introduction Forensic-psychiatric services are costly and very restrictive for patients. Clinical experience and the limited research available indicate that some patients stay for too long in these settings. A proportion of patients may, however, require long-term, potentially life-long, secure forensic-psychiatric care but their needs may not be met by existing service provision designed for faster throughput. Here we report the initial findings of a three year study on long-stay patients in forensic care conducted in England. Objectives The overall objective of this project is to improve the quality and cost-efficiency of the care and management of patients who stay for prolonged periods in secure forensic-psychiatric settings. Aims 1. Estimate the number of long-stay patients in secure settings in England (length of stay over 5 years in medium secure care or 10 years in high secure care) 2. Describe their characteristics, needs, care pathways and reasons for prolonged stay 3. Identify patients’ perceptions of their treatment pathways, long-term needs, service provisions and quality of life 4. Develop recommendations following the exploration of international models for this patient group Methods This project uses a mixed-methods approach including analysis of administrative data, case file reviews, patient interviews, interviews with clinicians and commissioners and a Delphi survey. Results Initial findings indicate that up to 25% of the forensic population fulfill criteria for long-stay, a much greater number than originally estimated. Conclusions The high number of long-stay patients in high and medium secure services calls for specific service provision for this patient group, which we will explore further.

Characteristics and Needs of Long-Stay Forensic Psychiatric Inpatients: A Rapid Review of the Literature

ABSTRACT This rapid review summarizes currently available information on the definition, prevalence, characteristics, and needs of long-stay patients within forensic psychiatric settings. Sixty nine documents from 14 countries were identified. Reports on what constitutes “long-stay” and on the characteristics of long-stay patients were inconsistent. Factors most frequently associated with longer stay were seriousness of index offence, history of psychiatric treatment, cognitive deficit, severity of illness, diagnosis of schizophrenia or psychotic disorder, history of violence, and history of substance misuse. Although some countries are developing specific long-stay services, there is presently no consensus on what might constitute “best practice” in such settings.

How effective are interventions to improve social outcomes among offenders with personality disorder: a systematic review

BackgroundOffenders with personality disorder are supported by health, criminal justice, social care and third sector services. These services are tasked with reducing risk, improving health and improving social outcomes. Research has been conducted into interventions that reduce risk or improve health. However, interventions to improve social outcomes are less clearly defined.MethodsTo review the effectiveness of interventions to improve social outcomes we conducted a systematic review using Cochrane methodology, expanded to include non-randomised trials. Anticipated high heterogeneity of the studies informed narrative synthesis.ResultsEleven studies met inclusion criteria. Five contained extractable data. No high-quality studies were identified. Outcomes measured clustered around employment and social functioning. Interventions vary and their mechanisms for influencing social outcomes are poorly operationalised. Although change was observed in employment rates, there was no evidence for the effectiveness of these interventions.ConclusionsThere is a lack of evidence for effective interventions that improve social outcomes. Further research is recommended to reach consensus on the outcomes of importance, identify the factors that influence these and design theoretically-informed and evidence-based interventions.

P-657 - Long-term forensic psychiatric care in the united kingdom: an epidemiological study

Introduction In the UK forensic psychiatric care is provided in 3 different levels of security and patients are expected to progress through this system till rehabilitated. Some patients spend more time than average in secure settings. This group has hitherto been largely neglected within research priorities. Objectives To identify number and characteristics of patients who are “long-stayers” in secure hospitals in the United Kingdom and compare it to other hospitals internationally. Aims To identify number of patients in secure forensic settings based on various hypothetical cut-offs (time spent in hospital). To identify patient characteristics. To compare patient characteristics with those internationally. Methods Data was collected from 3 high-secure hospitals in the UK along with one medium secure unit with regards to sex, age, date of admission, directorate category and LoS. Descriptive statistics were used to analyse data. Data obtained from 2 units internationally were compared with results from the UK. Results Results suggest that mean age of 40 years. The average LoS in high secure hospitals was about 70 months. Around 15% of patients have spent more than 10 years in high secure settings. Average LoS in medium secure was 14 months whilst more than 20% stayed longer than 24 months. Conclusions A large proportion of patients spend more than 10 years in high secure hospitals and more than 2 years in medium secure in the United Kingdom. This informs future research in order to identify various patient and system characteristics that prevent them from moving on.

Monitoring oral health of people in Early Intervention for Psychosis (EIP) teams: The extended Three Shires randomised trial

BACKGROUND The British Society for Disability and Oral Health guidelines made recommendations for oral health care for people with mental health problems, including providing oral health advice, support, promotion and education. The effectiveness of interventions based on these guidelines on oral health-related outcomes in mental health service users is untested. OBJECTIVE To acquire basic data on the oral health of people with or at risk of serious mental illness. To determine the effects of an oral health checklist in routine clinical practice. DESIGN Clinician and service user-designed cluster randomised trial. SETTINGS AND PARTICIPANTS The trial compared a simple form for monitoring oral health care with standard care (no form) for outcomes relevant to service use and dental health behaviour for people with suspected psychosis in Mid and North England. Thirty-five teams were divided into two groups and recruited across 2012-3 with one year follow up. RESULTS 18 intervention teams returned 882 baseline intervention forms and 274 outcome sheets one year later (31%). Control teams (n=17) returned 366 baseline forms. For the proportion for which data were available at one year we found no significant differences for any outcomes between those allocated to the initial monitoring checklist and people in the control group (Registered with dentist (p=0.44), routine check-up within last year (p=0.18), owning a toothbrush (p=0.99), cleaning teeth twice a day (p=0.68), requiring urgent dental treatment (p=0.11). CONCLUSION This trial provides no clear evidence that Care Co-ordinators (largely nursing staff) using an oral health checklist improves oral health behaviour or oral health state in those thought to be at risk of psychosis or with early psychosis.

Characteristics and pathways of long-stay patients in high and medium secure settings in England ; a secondary publication from a large mixed-methods study

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood. Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England. Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings. Results: 22% of patients in high security and 18% in medium security met the definition for “long-stay,” with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample. Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group.