Determining the future role of clinical practice guidelines: The experience of Australia and New Zealand

There has been recent discussion in Australia and New Zealand concerning the utility of Clinical Practice Guidelines (CPGs) and the role of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in their development. The College Board therefore established a Steering Group (SG) to oversee an exploration of options and produce recommendations about contemporary approaches to the development of high-quality evidence-based clinical practice guidance for psychiatry. This paper outlines the SG's conclusions and recommendations, as well as the underlying methods and reasoning. In particular, we discuss best practice and recent developments in the synthesis of research evidence. Account has been taken of the opportunities offered by digital technologies, the proliferation of clinical evidence and awareness of the gains to be made by increased inclusion of lived-experience perspectives. It is recommended that the broader concept of best practice resources (BPRs) as now emphasised in so many fields of service is the most appropriate starting point for the College's role in this area especially as the expertise of the College and its fellows lends itself to the development of a range of BPRs. In conclusion, contemporary guidance needs to be tailored to the requirements of the practitioners seeking it, to articulate the real-world needs and experiences of patients, and to be delivered in a contemporary format that is responsive to rapidly emerging evidence. The experience in Australia and New Zealand may have implications elsewhere for the development of CPGs and BPRs more broadly.

Emergency department presentations for deliberate self-harm and suicidal ideation in 25-39 years olds following agency-notified child maltreatment: results from the Childhood Adversity and Lifetime Morbidity (CALM) study

AIMS

To compare prospective reports of child maltreatment (CM) with emergency department (ED) presentations for deliberate self-harm (DSH) and suicidal ideation in individuals aged between 25 and 39 years old.

METHODS

Linked records between the Mater-University of Queensland Study of Pregnancy birth cohort and Queensland administrative health data were used, which included notifications to child protection agencies for CM. ED presentations for individuals aged between 25 and 39 years of age for suicidal ideation, suicidal behaviour or poisoning by paracetamol or psychotropic medications where the intention was unclear were examined using logistic regression analyses.

RESULTS

A total of 609 (10.1%) individuals were the subject of one or more CM notifications for neglect or physical, sexual or emotional abuse before the age of 15 years. Of these, 250 (4.1%) presented at least once to ED for DSH and/or suicidal ideation between 25 and 39 years of age. In adjusted analysis, any notification of CM was associated with significantly increased odds of presenting to ED for these reasons (aOR = 2.80; 95% CI = 2.04-3.84). In sensitivity analyses, any notification of CM increased the odds of the combined outcome of DSH and suicidal ideation by 275% (aOR = 2.75; 95% CI = 1.96-4.06) and increased the odds of DSH alone by 269% (aOR = 2.69; 95% CI = 1.65-4.41).

CONCLUSIONS

All CM types (including emotional abuse and neglect) were associated with ED presentations for DSH and suicidal ideation in individuals between 25 and 39 years of age. These findings have important implications for the prevention of DSH, suicidal ideation and other health outcomes. They also underscore the importance of trauma-informed care in ED for all individuals presenting with DSH and suicidal ideation.

Self-reported child maltreatment and cardiometabolic risk in 30-year-old adults

BACKGROUND

Childhood maltreatment (CM) is associated with both dietary fat intake and obesity in later life. There is less information on associations with metabolic risk factors and specific types of CM such as physical, sexual and emotional abuse, as well as neglect.

AIMS

To assess the association between five types of self-reported CM and a range of obesity and metabolic indicators in a subsample of a birth cohort.

METHODS

This was a study of 1689 adults born in a major metropolitan maternity hospital in Australia and followed up 30 years later. Body mass index, bioimpedance and fasting lipid levels/insulin resistance were measured. Details on self-reported CM were collected using the Child Trauma Questionnaire. We adjusted for birth weight, parental income and relationship at participants' birth, as well as maternal age and alcohol or tobacco use. We also adjusted for participants' smoking, depression, educational level, marital and employment status at follow up.

RESULTS

One-fifth reported maltreatment (n = 362), most commonly emotional neglect (n = 175), followed by emotional abuse (n = 128), physical neglect (n = 123), sexual (n = 121) and physical abuse (n = 116). On adjusted analyses, there were significant associations for CM, particularly neglect or emotional abuse, and one or more of the following outcomes: obesity, the total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio and HDL levels. Results for other outcomes were more equivocal.

CONCLUSIONS

Of child maltreatment types, emotional abuse and neglect show the strongest associations with obesity and several cardiometabolic risk factors, therefore highlighting the public health importance of early intervention to reduce childhood adversity.

Optimising plasma clozapine levels to improve treatment response: an individual patient data meta-analysis and receiver operating characteristic curve analysis

BACKGROUND

Although clozapine is the most efficacious medication for treatment-refractory schizophrenia, not all patients will have an adequate response. Optimising clozapine dose using therapeutic drug monitoring could therefore maximise response.

AIMS

Using individual patient data, we undertook a receiver operating characteristic (ROC) curve analysis to determine an optimal therapeutic range for clozapine levels to guide clinical practice.

METHOD

We conducted a systematic review of PubMed, PsycINFO and Embase for studies that provided individual participant level data on clozapine levels and response. These data were analysed using ROC curves to determine the prediction performance of plasma clozapine levels for treatment response.

RESULTS

We included data on 294 individual participants from nine studies. ROC analysis yielded an area under the curve of 0.612. The clozapine level at the point of optimal diagnostic benefit was 372 ng/mL; at this level, the response sensitivity was 57.3%, and specificity 65.7%. The interquartile range for treatment response was 223-558 ng/mL. There was no improvement in ROC performance with mixed models including patient gender, age or length of trial. Clozapine dose and clozapine concentration to dose ratio did not provide significantly meaningful prediction of response to clozapine.

CONCLUSIONS

Clozapine dose should be optimised based on clozapine therapeutic levels. We found that a range between 250 and 550 ng/mL could be recommended, while noting that a level of >350 ng/mL is the most optimal for response. Although some patients may not respond without clozapine levels >550 ng/mL, the benefits should be weighed against the increased risk of adverse drug reactions.

Australian older persons mental health inpatient and ambulatory services in 2015-2020 - A descriptive analysis and commentary

OBJECTIVE

To provide a commentary on Australian state/territory older persons mental health service (OPMHS) expenditure, inpatient and outpatient services and key performance indicators (KPIs).

METHOD

Descriptive analysis of data from the Australian Institute of Health and Welfare (AIHW), the Australian Bureau of Statistics and the World Health Organisation.

RESULTS

Between 2015-16 and 2019-20, annual expenditure on OPMHS in Australia increased by an average of only 2.3%, compared to 2.9% for all population groups, despite an increase in the number of over 65 year olds. Per capita recurrent expenditure on OPMHS decreased by an average of 1% annually. Australia's total mental health beds increased, whereas OPMHS beds decreased, mainly due to a reduction in non-acute beds. Outcomes for OPMHS admissions were similar to other age groups, except for a longer length of stay and reduced readmission rate. Older Australians accessed ambulatory mental health care at a lower rate and had a lower rate of improvement after a completed episode.

CONCLUSIONS

OPMHS expenditure has not increased at commensurate levels compared to other populations. The mental health of people aged over 65 appears to be a neglected policy priority in Australia. The Royal Commission into Aged Care Quality and Safety may herald service and expenditure changes.

Mental Disorders and Oral Diseases: Future Research Directions

The poor physical health (including oral health) of people with mental disorders is a global problem. The burden of oral diseases among this group is substantial given their high prevalence and ability to increase the personal, social, and economic impacts of mental disorders. This article summarizes causes of mental disorders and oral diseases, critically reviews current evidence on interventions to reduce the burden of oral diseases in people with mental disorders, and suggests future research directions. The relationship between mental disorders and oral diseases is complex due to the shared social determinants and bidirectional interaction mechanisms that involve interconnected social, psychological, behavioral, and biological processes. Research has, to date, failed to produce effective and scalable interventions to tackle the burden of oral diseases among people with mental disorders. Transformative research and actions informed by a dynamic involvement of biological, behavioral, and social sciences are needed to understand and tackle the complex relationship between mental disorders and oral diseases, as well as inform the design of complex interventions. Examples of future research on complex public health, health service, and social care interventions are provided. The design and testing of these interventions should be carried out in real-world settings, underpinned by the principles of coproduction and systems thinking, and conducted by a transdisciplinary team. We propose this starts with setting research priorities and developing complex intervention theory, which we report to support future research to improve oral health and hence physical and mental health in this disadvantaged group.

Translating research into action: The design and development of an Indigenous specific suicide intervention skills training program (I-ASIST)

Note: We respectfully refer to Aboriginal and Torres Strait Islander people as Indigenous in this study.

OBJECTIVE

To design and develop an Indigenous specific suicide intervention skills program that focuses on education and intervention training as an effective suicide prevention strategy.

METHOD

Using a co-designed wrap-around framework, we developed a program in collaboration with >90 communities, stakeholders and service providers across Australia to understand knowledge, awareness and sense of connectedness between at-risk groups and health services or support groups.

RESULTS

The I-ASIST training provides participants with the necessary skills and knowledge to apply a suicide intervention model. The framework behind the intervention model provides caregivers the awareness to recognise when someone may be at risk of suicide. It then gives them the skills to connect with a person at risk of suicide and to understand and clarify that risk, steps to keep that person safe for a specific period and then provide them with the resources or links required for further help. The program enables the development of knowledge through interactive strategies through cultural recognition and empowerment of participants. Based on a social-enterprise model, I-ASIST has been translated into a certified program supported by LivingWorks Australia.

CONCLUSION

Based on a strengths-based and self-determination model of co-design, this grass roots innovative framework creates suicide safer communities.

Mindfulness based cognitive therapy for youth with inflammatory bowel disease and depression - Findings from a pilot randomised controlled trial

BACKGROUND

Mindfulness-based cognitive therapy (MBCT) is a promising adjunctive treatment for adolescents and young adults (AYAs) with Inflammatory Bowel Disease (IBD) and comorbid depression.

OBJECTIVES

This pilot randomised controlled trial (RCT) aimed to evaluate feasibility and efficacy of an adapted MBCT program for AYA, aged 16-29, with IBD.

METHODS

Sixty-four AYAs were randomly allocated to MBCT (n = 33) or treatment as usual (TAU) (n = 31). Primary outcome measure was the depression score on Depression, Anxiety and Stress Scale. Secondary outcomes included anxiety, stress, IBD-related quality of life, coping, mindfulness, post-traumatic growth, medication adherence, IBD activity, inflammatory markers, microbiome characteristics and brain functional connectivity.

RESULTS

Study recruitment rate was 75%, retention rate 70%, and session attendance 92%. Intention to treat analyses revealed that, compared to TAU group, MBCT group had significantly lower depression (∆ = -6.0; 95%CI = -10.8 to -1.2; P = 0.015) and stress (∆ = -5.1; 95%CI = -10.1 to -0.0; P = 0.049), higher active coping (∆ = 1.0;95%CI = 0.1-1.9; P = 0.022), and total mindfulness scores (∆ = 10.9;95%CI = 1.1-20.8; P = 0.030) at 8 weeks (post-therapy), and improved coping by positive reframing (∆ = 1.1;95%CI = 0.0-2.2; P = 0.043) and planning (∆ = 0.9;95%CI = 0.0-1.9; P = 0.045), mindful awareness (∆ = 5.2.;95%CI = 2.0-8.5; P = 0.002) and total mindfulness scores (∆ = 10.8.;95%CI = 0.4-21.1; P = 0.042) at 20 weeks. On per protocol analysis, MBCT group had significantly lower depression (∆ = -6.3; 95%CI = -11.4 to -1.2; P = 0.015), stress (∆ = -6.0; 95%CI = -11.2 to -0.5; P = 0.032), increased active coping (∆ = 0.9;95%CI = 0-1.7; P = 0.05) at 8 weeks, and mindful awareness (∆ = 5.4; 95%CI = 2.1-8.6; P = 0.001) at 20 weeks.

CONCLUSION

In AYAs with IBD, MBCT is feasible and beneficial in improving depression, stress, mindfulness and adaptive coping. It holds promise as an important component of integrated IBD care. Trial registration number ACTRN12617000876392, U1111-1197-7370; Pre-results.

A state-wide study of dental comorbidities in psychiatric disorders resulting in avoidable emergency department presentations

BACKGROUND

Attendances at emergency departments (EDs) for dental conditions are unnecessary and come at a significant cost to health services.

METHODS

A population-based record-linkage analysis of a retrospective cohort over 2 years across state-based facilities in Queensland. This was to determine if people with mental illness were more likely than the general population to attend EDs for a range of non-traumatic or avoidable dental conditions.

RESULTS

There were 1 381 428 individuals in the linked database, of whom 177 157 (13%) had a psychiatric history and 22 046 (1.5%) had one or more avoidable dental presentations. These were toothache (n = 9619), dental abscesses (n = 8449), caries (n = 1826), stomatitis (n = 1213) and gum disease (n = 939). After adjusting for confounders, psychiatric patients were significantly more likely to present with toothache, dental abscesses and caries but not stomatitis or gum disease. Depending on the dental outcome, other risk factors were male sex, lower income, rurality and Indigenous status.

CONCLUSIONS

Given these findings, possible interventions should include an increased emphasis on assessing oral health in mental health or primary care, especially in non-metropolitan areas, as well as early dental referral. Service planning for this population should including easier navigation of dental services, availability outside normal office hours and free outreach dental clinics.

Placing rehabilitation at the core of assertive community treatment

OBJECTIVES

Assertive community treatment (ACT) teams are increasingly being adapted to suit the needs of consumers who have never experienced long-term institutional care yet struggle to retain community tenure and quality of life due to residual functional disabilities associated with severe mental illness. Support needs can be provided by the growing disability support sector but recovery-orientated rehabilitation services delivered by specialist rehabilitation clinicians are also required. The Mobile Intensive Rehabilitation Team (MIRT) within the Metro South Addiction and Mental Health Service has adapted the ACT model to deliver assertive outreach that aims to work collaboratively with the person and their chosen supports to improve their function and their sense of self-efficacy in illness self-management. We described the characteristics of the consumers referred to MIRT over a 20-month time period, and reported on on their discharge location.

CONCLUSION

After two years with MIRT, half the participants were discharged out of case-management. Being on clozapine was a barrier to discharge from case-management despite functional improvement. Psychiatric hospitalisations predicted longer duration working with MIRT.

Evaluation of the proposed anti-N-methyl-d-aspartate receptor encephalitis clinical diagnostic criteria in psychiatric patients

OBJECTIVE

The gold standard for diagnosing anti-NMDAR encephalitis is demonstration of the antibody in CSF. Clinical diagnostic criteria have been proposed for when this is not available in a timely manner which is evaluated, in this study, for a psychiatric population.

METHODS

This study retrospectively assessed the proposed criteria in patients presenting to psychiatric services for the first time with known anti-NMDAR antibody status. Antibody-positive cases were derived from the literature (conception to December 2019) and a state-wide (Queensland, Australia) cohort. Antibody-negative cases were derived from a service-wide (Metro South, Queensland, Australia) cohort of psychiatric cases which underwent antibody testing for routine organic screening. Sensitivity and specificity were calculated at 1 week following admission and the point of discharge.

RESULTS

The proposed criteria were applied to 641 cases (500 antibody-positive and 141 antibody-negative), demonstrating a sensitivity which increased from around 19% after 1 week to 49% by the point of discharge. Specificity was 100% at both time points. The mean average time to become positive using the proposed criteria was 19.5 days compared to 34.9 days for return of antibody testing.

CONCLUSIONS

High specificity of the proposed criteria, seen in this study, suggests that cases which are positive can be considered for expedited commencement of treatment. However, if clinical suspicion is high despite criteria being negative, it is essential to test CSF for anti-NMDAR antibody.

Metabolic measures 12 months after a randomised controlled trial of treatment of clozapine associated obesity and diabetes with exenatide (CODEX)

Clozapine is associated with obesity and type 2 diabetes. Glucagon-like-peptide-1 (GLP-1) receptor agonists such as exenatide can counter clozapine-associated GLP-1 dysregulation. Our 24-week randomized, controlled, open-label, pilot trial of once-weekly extended-release subcutaneous exenatide or usual care (CODEX) (n = 28), found exenatide was associated with significantly greater weight loss. We examined whether this effect was maintained at 12-months post-intervention. We followed up CODEX trial participants at 12-months post trial endpoint, collecting information on weight, BMI, waist circumference, blood pressure, fasting glucose, HbA1c, and use of metformin. The primary outcome of interest was change in weight from trial baseline to 12-months post endpoint and trial endpoint to 12-months post endpoint compared between former exenatide and usual care participants. Only HbA1c differed between baseline and 12-months post endpoint between the exenatide and control groups. From endpoint to 12-month follow up there were significantly greater increases among the former exenatide versus former usual care participants for weight, BMI, HbA1c and proportion with >5% weight gain. Stratifying results by whether participants used metformin post trial did not alter proportion with >5% weight gain. Although there were no significant differences in weight and BMI between baseline and 12-month post endpoint, there were significant increases in weight and BMI in the 12 months post endpoint for the former exenatide group. This was irrespective of metformin use and is in keeping with studies of other GLP-1RA agents. Further studies on GLP-1RAs use beyond 24 weeks for people with clozapine associated weight gain are needed.

Meta-analysis examining the epidemiology of clozapine-associated neutropenia

BACKGROUND

Clozapine is associated with life-threatening neutropenia. There are no previous meta-analyses of the epidemiology of clozapine-associated neutropenia.

OBJECTIVES

To determine the cumulative incidence of mild, moderate and severe neutropenia, incidence of death related to severe neutropenia, case fatality rate of neutropenia and the longitudinal incidence of neutropenia following exposure to clozapine.

DATA SOURCES

A systematic search of Medline, EMBASE and PsycINFO using search terms [clozapine OR clopine OR zaponex OR clozaril] AND [neutropenia OR agranulocytosis].

METHODS

Random effects meta-analysis to determine event rates and longitudinal incidence of events per 100 person-years of exposure.

RESULTS

A total of 108 studies were included. The incidence of clozapine-associated neutropenia was 3.8% (95% CI: 2.7-5.2%) and severe neutropenia 0.9% (95% CI: 0.7-1.1%). The incidence of death related to neutropenia following prescription of clozapine was 0.013% (95% CI: 0.01-0.017%). The case fatality rate of severe neutropenia was 2.1% (95% CI: 1.6-2.8%). The peak incidence of severe neutropenia occurred at one month of exposure and declined to negligible levels after one year of treatment.

CONCLUSION

Severe neutropenia associated with clozapine is a rare event and occurs early with a substantial decline in risk after one year of exposure. Death from clozapine-associated neutropenia is extremely rare. Implications for haematological monitoring are discussed.

Routine measurement of mental health service outcomes: Health of the Nation Outcome Scales in Nova Scotia

Aims and Method

Although the Health of the Nation Outcome Scales (HoNOS) were designed for routine clinical use, completion rates in clinical settings rarely exceed 60%. We evaluated two initiatives to increase completion rates: timely feedback to clinicians, useful at individual, team and service levels, and improved supporting materials (tabulated glossaries for all versions covering the life-span).

Results

Clinicians in South Shore Health district provided ratings on all outpatient referrals over 12 months as part of routine care. Data were captured using the Nova Scotia routine administrative data system. Completion rates rose from 61% to 86% (n=1190). Clinicians' ratings of the instrument's ease of use were significantly improved.

Clinical Implications

Use of a tabulated glossary and enhanced feedback of clinically useful information improved clinician support for the routine measurement of health outcomes with HoNOS.

Oral health impacts of medications used to treat mental illness

BACKGROUND

Many psychotropic medications affect oral health. This review identified oral side effects for antidepressant, antipsychotic, anticonvulsant, antianxiety and sedative drugs that are recommended in Australia for the management of common mental illnesses and provides recommendations to manage these side-effects.

METHODS

The Australian Therapeutic Guidelines and the Australian Medicines Handbook were searched for medications used to treat common mental health conditions. For each medication, the generic name, class, and drug company reported side-effects were extracted from the online Monthly Index of Medical Specialties (eMIMs) and UpToDate databases. Meyler's Side Effect of Drugs Encyclopaedia was used to identify additional oral adverse reactions to these medications.

RESULTS

Fifty-seven drugs were identified: 23 antidepressants, 22 antipsychotics or mood stabilisers, and 12 anxiolytic or sedative medications. Xerostomia (91%) the most commonly reported side effect among all classes of medications of the 28 identified symptoms. Other commonly reported adverse effects included dysguesia (65%) for antidepressants, and tardive dyskinesia (94%) or increased salivation (78%) for antipsychotic medications.

CONCLUSIONS

While xerostomia has often been reported as a common adverse effect of psychotropic drugs, this review has identified additional side effects including dysguesia from antidepressants and tardive dyskinesia and increased salivation from antipsychotics. Clinicians should consider oral consequences of psychotropic medication in addition to other side-effects when prescribing. For antidepressants, this would mean choosing duloxetine, agomelatine and any of the serotonin re-uptake inhibitors except sertraline. In the case of antipsychotics and mood stabilisers, atypical agents have less oral side effects than older alternatives.

The impact of clozapine on hospital use: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to perform a systematic review and meta-analysis of studies reporting the impact of clozapine on hospital use in people with a psychotic illness.

METHOD

PubMed, EMBASE, PsycINFO and the Cochrane Schizophrenia Group Trials Register were systematically searched from inception to 12 October 2016. We included all trials and observational studies, except case reports.

RESULTS

Thirty-seven studies were included. Clozapine significantly reduced the proportion of people hospitalised compared to control medicines (RR = 0.74; 95% CI: 0.69-0.80, P < 0.001, 22 studies, n = 44 718). There were significantly fewer bed days after clozapine treatment compared to before clozapine treatment in both controlled (MD = -34.41 days; 95% CI: -68.22 to -0.60 days, P = 0.046, n = 162) and uncontrolled studies (MD = -52.86 days; 95% CI: -79.86 days to -25.86 days, P < 0.001, n = 2917). Clozapine and control medicines had a similar time to rehospitalisation (-19.90 days; 95% CI: -62.42 to 22.63 days, P = 0.36).

CONCLUSION

Clozapine treatment reduced the number of people hospitalised and the number of bed days after treatment compared with before treatment. Clozapine has the potential to reduce acute hospital use among people with treatment refractory schizophrenia.

A Surveillance System to Monitor Excess Mortality of People With Mental Illness in Canada

OBJECTIVE

Outcome measures are rarely available for surveillance and system performance monitoring for mental disorders and addictions. Our study aims to demonstrate the feasibility and face validity of routinely measuring the mortality gap in the Canadian context at the provincial and regional levels using the methods and data available to the Canadian Chronic Disease Surveillance System (CCDSS) of the Public Health Agency of Canada.

METHODS

We used longitudinal data from the Quebec Integrated Chronic Disease Surveillance System, which also provides aggregated data to the CCDSS. This includes data from the health insurance registry physician claims and the hospital discharge abstract for all mental disorder diagnoses (International Classification of Diseases [ICD]-9 290-319 or ICD-10 F00-F99). Patients were defined as having had received a mental disorder diagnosis at least once during the year. Life expectancy was measured using Chiang's method for abridged life tables, complemented by the Hsieh method for adjustment of the last age interval.

RESULTS

We found a lower life expectancy among psychiatric patients of 8 years for men and 5 years for women. For patients with schizophrenia, life expectancy was lowered by 12 years for men and 8 years for women. Cardiovascular disease and cancer were the most common causes of premature death. Findings were consistent across time and regions of the province. Lower estimates of the mortality gap, compared with literature, could be explained by the inclusion of primary care patients and methods.

CONCLUSIONS

Our study demonstrates the feasibility of using administrative data to measure the impact of current and future mental health plans in Canada provided the techniques can be replicated in other Canadian provinces.

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.

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.

Effectiveness of quadrivalent human papillomavirus vaccine for the prevention of cervical abnormalities: case-control study nested within a population based screening programme in Australia

OBJECTIVE

To measure the effectiveness of the quadrivalent human papillomavirus (HPV) vaccine against cervical abnormalities four years after implementation of a nationally funded vaccination programme in Queensland, Australia.

DESIGN

Case-control analysis of linked administrative health datasets.

SETTING

Queensland, Australia.

PARTICIPANTS

Women eligible for free vaccination (aged 12-26 years in 2007) and attending for their first cervical smear test between April 2007 and March 2011. High grade cases were women with histologically confirmed high grade cervical abnormalities (n = 1062) and "other cases" were women with any other abnormality at cytology or histology (n = 10,887). Controls were women with normal cytology (n = 96,404).

MAIN OUTCOME MEASURES

Exposure odds ratio (ratio of odds of antecedent vaccination (one, two, or three vaccine doses compared with no doses) among cases compared with controls), vaccine effectiveness ((1-adjusted odds ratio) × 100), and number needed to vaccinate to prevent one cervical abnormality at first screening round. We stratified by four age groups adjusted for follow-up time, year of birth, and measures of socioeconomic status and remoteness. The primary analysis concerned women whose first ever smear test defined their status as a case or a control.

RESULTS

The adjusted odds ratio for exposure to three doses of HPV vaccine compared with no vaccine was 0.54 (95% confidence interval 0.43 to 0.67) for high grade cases and 0.66 (0.62 to 0.70) for other cases compared with controls with normal cytology, equating to vaccine effectiveness of 46% and 34%, respectively. The adjusted numbers needed to vaccinate were 125 (95% confidence interval 97 to 174) and 22 (19 to 25), respectively. The adjusted exposure odds ratios for two vaccine doses were 0.79 (95% confidence interval 0.64 to 0.98) for high grade cases and 0.79 (0.74 to 0.85) for other cases, equating to vaccine effectiveness of 21%.

CONCLUSION

The quadrivalent HPV vaccine conferred statistically significant protection against cervical abnormalities in young women who had not started screening before the implementation of the vaccination programme in Queensland, Australia.

The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: retrospective analysis of population based registers

OBJECTIVE

To examine the mortality experience of psychiatric patients in Western Australia compared with the general population.

DESIGN

Population based study.

SETTING

Western Australia, 1985-2005.

PARTICIPANTS

Psychiatric patients (292,585) registered with mental health services in Western Australia.

MAIN OUTCOME MEASURES

Trends in life expectancy for psychiatric patients compared with the Western Australian population and causes of excess mortality, including physical health conditions and unnatural causes of death.

RESULTS

When using active prevalence of disorder (contact with services in previous five years), the life expectancy gap increased from 13.5 to 15.9 years for males and from 10.4 to 12.0 years for females between 1985 and 2005. Additionally, 77.7% of excess deaths were attributed to physical health conditions, including cardiovascular disease (29.9%) and cancer (13.5%). Suicide was the cause of 13.9% of excess deaths.

CONCLUSIONS

Despite knowledge about excess mortality in people with mental illness, the gap in their life expectancy compared with the general population has widened since 1985. With most excess deaths being due to physical health conditions, public efforts should be directed towards improving physical health to reduce mortality in people with mental illness, in addition to ongoing efforts to prevent suicide.