Excess cancer mortality in psychiatric patients

OBJECTIVES

There are conflicting data on cancer incidence and mortality in psychiatric patients, although most studies suggest that while cancer mortality is higher, incidence is no different from that in the general population. Different methodologies and outcomes may account for some of the conflicting results. We investigated the association between mental illness and cancer incidence, first admission rates, and mortality in Nova Scotia using a standard methodology.

METHOD

A population-based record-linkage study of 247,344 patients in contact with primary care or specialist mental health services during 1995 to 2001 was used. Records were linked with cancer registrations and death records.

RESULTS

Cancer mortality was 72% higher in males (95%CI, 63% to 82%) and 59% higher in females (95%CI, 49% to 69%) among patients in contact with mental health services. This was reflected in similarly elevated first admission rates. However, there was weaker and less consistent evidence for increased incidence. For several cancer sites, incidence rate ratios were lower than might be expected given the mortality and first admission rate ratios, and no higher than that of the general population. These were melanoma, prostate, bladder, and colorectal cancers in males.

CONCLUSION

People with mental illness in Nova Scotia have increased mortality from cancer, which cannot always be explained by increased incidence. Possible explanations for further study include delays in detection or initial presentation leading to more advanced staging at diagnosis, and difficulties in communication or access to health care.

A systematic review of randomized controlled trials examining psychological interventions for needle-related procedural pain and distress in children and adolescents: an abbreviated cochrane review

OBJECTIVE

To report the results of a systematic review of randomized controlled trials (RCTs) of psychological interventions for children and adolescents undergoing needle-related procedures.

METHODS

A variety of cognitive-behavioral psychological interventions for managing procedural pain and distress in children and adolescents between 2 and 19 years of age were examined. Outcome measures included pain and distress as assessed by self-report, observer report, behavioral/observational measures, and physiological correlates.

RESULTS

Twenty-eight trials met the criteria for inclusion in the review and provided the data necessary for pooling the results. Together, the trials included 1,039 participants in treatment conditions and 951 in control conditions. The largest effect sizes for treatment improvement over control conditions were found for distraction, combined cognitive-behavioral interventions, and hypnosis, with promising but limited evidence for several other psychological interventions.

CONCLUSIONS

Recommendations for conducting future RCTs are provided, and particular attention to the quality of trial design and reporting is highlighted.

Use of smoking cessation therapies in individuals with psychiatric illness : an update for prescribers

Individuals with mental illness are particularly disadvantaged by their use of tobacco, spending as much as 40% of their income on cigarettes. They also have increased mortality from cardiovascular and respiratory disorders. The most effective interventions to help psychiatric patients stop smoking are similar to those that are effective in the general population. These include psychological treatments, nicotine replacement therapy (NRT), bupropion and nortriptyline, at least in the short term. Most studies agree that these gains can be achieved in the absence of significant adverse effects in terms of psychological morbidity. Effects diminish over time, but these findings also apply to the general population. The best long-term results have come from extended prescription and psychological interventions, and apply equally to patients with and without a history of psychiatric disorder, such as major depression. In spite of this, clinicians are not fully exploiting opportunities to help psychiatric patients stop smoking. It is not possible to plan a programme to help individuals stop smoking in mental health settings unless factors such as demographics, diagnosis and concurrent medication are taken into account.

Taking consultation-liaison psychiatry into primary care

Up to 50% of patients seen in primary care have mental health problems, the severity and duration of their problems often being similar to those of individuals seen in the specialized sector. This article describes the reasons, advantages, and challenges of collaborative or shared care between primary and mental health teams, which are similar to those of consultation-liaison psychiatry. In both settings, clinicians deal with the complex interrelationships between medical and psychiatric disorders. Although initial models emphasized collaboration between family physicians, psychiatrists, and nurses, collaborative care has expanded to involve patients, psychologists, social workers, occupational therapists, pharmacists, and other providers. Several factors are associated with favorable patient outcomes. These include delivery of interventions in primary care settings by providers who have met face-to-face and/or have pre-existing clinical relationships. In the case of depression, good outcomes are particularly associated with approaches that combined collaborative care with treatment guidelines and systematic follow-up, especially for those with more severe illness. Family physicians with access to collaborative care also report greater knowledge, skills, and comfort in managing psychiatric disorders, even after controlling for possible confounders such as demographics and interest in psychiatry. Perceived medico-legal barriers to collaborative care can be addressed by adequate personal professional liability protection on the part of each practitioner, and ensuring that other health care professionals with whom they work collaboratively are similarly covered.

Migration and mental health in Canada: can government policy help?

Canada admits more than 220 000 immigrants every year and this is reflected in the statistic that 18% of the population was born abroad (Beiser, 2005). However, government policy emphasises the admission of healthy immigrants rather than their subsequent health. Immigrants do not show a consistently elevated rate of psychiatric illness, and morbidity is related to an interaction between predisposition and socio-environmental factors, rather than immigrationper se. These factors include forced migration and circumstances after arrival, such as poverty, limited recognition of qualifications, discrimination and isolation from the immigrant's own community. For instance, in Canada more than 30% of immigrant families live below the official poverty line in the first 10 years of settlement (Beiser, 2005).

Migration and mental health in Canada: can government policy help?

Canada admits more than 220 000 immigrants every year and this is reflected in the statistic that 18% of the population was born abroad (Beiser, 2005). However, government policy emphasises the admission of healthy immigrants rather than their subsequent health. Immigrants do not show a consistently elevated rate of psychiatric illness, and morbidity is related to an interaction between predisposition and socio-environmental factors, rather than immigration per se. These factors include forced migration and circumstances after arrival, such as poverty, limited recognition of qualifications, discrimination and isolation from the immigrant's own community. For instance, in Canada more than 30% of immigrant families live below the official poverty line in the first 10 years of settlement (Beiser, 2005).

Does compulsory or supervised community treatment reduce 'revolving door' care? Legislation is inconsistent with recent evidence

Supervised community treatment to address 'revolving door' care is part of the new Mental Health Act in England and Wales. Two recent epidemiological studies in Australia (n>118 000), as well as a systematic review of all previous literature using appropriately matched or randomised controls (n=1108), suggest that it is unlikely to help.

Are the Health of the Nation Outcome Scales a valid and practical instrument to measure outcomes in North America? A three-site evaluation across Nova Scotia

We tested the usability, sensitivity and validity of the Health of the Nation Outcome Scales (HoNOS) in routine clinical practice in North America. Three pilot sites provided ratings on all inpatient and outpatient referrals over 4 months using versions covering children and adolescents (HoNOSCA), working-age adults and the over-65s. Data were entered using the routine administrative data system. Sixty-one percent of eligible patients had at least one HoNOS rating (n = 485). Following the initial rating, subsequent completion rates reached 80%. Ratings were sensitive to time and setting, with significantly higher scores in inpatients than outpatients. Individual diagnoses had different patterns of scores, further supporting validity.

Inequitable access for mentally ill patients to some medically necessary procedures

BACKGROUND

Although universal health care aims for equity in service delivery, socioeconomic status still affects death rates from ischemic heart disease and stroke as well as access to revascularization procedures. We investigated whether psychiatric status is associated with a similar pattern of increased mortality but reduced access to procedures. We measured the associations between mental illness, death, hospital admissions and specialized or revascularization procedures for circulatory disease (including ischemic heart disease and stroke) for all patients in contact with psychiatric services and primary care across Nova Scotia.

METHODS

We carried out a population-based record-linkage analysis of related data from 1995 through 2001 using an inception cohort to calculate rate ratios compared with the general public for each outcome (n = 215,889). Data came from Nova Scotia's Mental Health Outpatient Information System, physician billings, hospital discharge abstracts and vital statistics. We estimated patients' income levels from the median incomes of their residential neighbourhoods, as determined in Canada's 1996 census.

RESULTS

The rate ratio for death of psychiatric patients was significantly increased (1.34), even after adjusting for potential confounders, including income and comorbidity (95% confidence interval [CI] 1.29-1.40), which was reflected in the adjusted rate ratio for first admissions (1.70, 95% CI 1.67-1.72). Their chances of receiving a procedure, however, did not match this increased risk. In some cases, psychiatric patients were significantly less likely to undergo specialized or revascularization procedures, especially those who had ever been psychiatric inpatients. In the latter case, adjusted rate ratios for cardiac catheterization, percutaneous transluminal coronary angioplasty and coronary artery bypass grafts were 0.41, 0.22 and 0.34, respectively, in spite of psychiatric inpatients' increased risk of death.

CONCLUSIONS

Psychiatric status affects survival with and access to some procedures for circulatory disease, even in a universal health care system that is free at the point of delivery. Understanding how these disparities come about and how to reduce them should be a priority for future research.

Randomized and non-randomized evidence for the effect of compulsory community and involuntary out-patient treatment on health service use: systematic review and meta-analysis

BACKGROUND

There is limited randomized controlled trial (RCT) evidence for compulsory community treatment. Other study methods may clarify their effectiveness. We reviewed RCT and non-RCT evidence for the effect of compulsory community treatment on hospital admissions, bed-days, compliance and out-patient contacts.

METHOD

A systematic review of RCTs, controlled before-and-after (CBA) studies, and interrupted time series (ITS) analyses. Meta-analysis of RCTs.

RESULTS

Eight papers covering five studies (two RCTs and three CBAs) met inclusion criteria (total n=1108). There was no statistical difference in 12-month admission rates between subjects on involuntary out-patient treatment and controls. Survival analyses of time to admission were equivocal. All five studies reported decreases in the number of bed-days following involuntary out-patient treatment but this only reached statistical significance in one situation; patients receiving the intervention were less likely to have admissions of over 100 days. There was no difference in treatment adherence between the intervention and control groups in either RCT or two of the CBA studies. However, the third CBA study reported a statistically significant increase of nearly five visits in the mean number of overall contacts in the involuntary out-patient treatment group.

CONCLUSIONS

The evidence for involuntary out-patient treatment in reducing either admissions or bed-days is very limited. It therefore cannot be seen as a less restrictive alternative to admission. Other effects are uncertain. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.

Can epidemiological studies assist in the evaluation of community treatment orders? - The experience of Western Australia and Nova Scotia

Epidemiological studies using administrative databases have several advantages over other methodologies in studying the effectiveness of compulsory community treatment such as community treatment orders (CTOs). We compared patients placed on CTOs in Western Australia with controls drawn from both within the jurisdiction and from another without this measure (Nova Scotia). Although in different countries, the mental health services in both jurisdictions share common characteristics. Notably, we were able to control for forensic history in our comparison within Western Australia. We analysed predictors of admission and number of bed-days using multiple, logistic or Cox regression as appropriate. Of the 274 subjects placed on a CTO, we were able to find controls for up to 96% (n=265). CTO placement was not associated with reduced admissions or mean bed-days, although there was a threshold effect with a reduced risk of inpatient stays exceeding 100 days. Outpatient contacts were significantly greater for the CTO group. However, we do not know whether the intensity of treatment, or its compulsory nature, effected outcome.

Short-term psychodynamic psychotherapies for common mental disorders

BACKGROUND

Over the past 40 years, short-term psychodynamic psychotherapies (STPP) for a broad range of psychological and somatic disorders have been developed and studied. Four published meta-analyses of STPP, using different methods and samples, have found conflicting results.

OBJECTIVES

This review evaluated the efficacy of STPP relative to minimal treatment and non-treatment controls for adults with common mental disorders.

SEARCH STRATEGY

We searched CCDANCTR-Studies and CCDANCTR-References on 25/4/2005, CENTRAL, MEDLINE, CINAHL, EMBASE, PsycINFO, DARE and Biological Abstracts were also searched. We contacted triallists and checked references from papers retrieved.

SELECTION CRITERIA

All randomised controlled trials (RCT) of adults with common mental disorders, in which a brief psychodynamic therapy lasting less than 40 hours in total, and provided in individual format, were included.

DATA COLLECTION AND ANALYSIS

Three reviewers working in pairs evaluated studies. Studies were selected only if pairs of reviewers agreed they met inclusion criteria. A third reviewer was consulted if two reviewers could not reach consensus. Data were collected and entered into Review Manager. Study quality was assessed and scored by pairs of raters. Publication bias was assessed using a funnel plot. Sensitivity analyses were also conducted.

MAIN RESULTS

23 studies of 1431 randomised patients with common mental disorders were included. These studies evaluated STPP for general, somatic, anxiety, and depressive symptom reduction, as well as social adjustment. Outcomes for most categories of disorder suggested significantly greater improvement in the treatment versus the control groups, which were generally maintained in medium and long term follow-up. However, only a small number of studies contributed data for each category of disorder, there was significant heterogeneity between studies, and results were not always maintained in sensitivity analyses.

AUTHORS' CONCLUSIONS

STPP shows promise, with modest to moderate, often sustained gains for a variety of patients. However, given the limited data and heterogeneity between studies, these findings should be interpreted with caution. Furthermore, variability in treatment delivery and treatment quality may limit the reliability of estimates of effect for STPP. Larger studies of higher quality and with specific diagnoses are warranted.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

Needle-related procedures are a common source of pain and distress for children. Several psychological (cognitive-behavioral) interventions to help manage or reduce pain and distress are available; however, a previous comprehensive systematic review of the efficacy of these interventions has not been conducted.

OBJECTIVES

To assess the efficacy of cognitive-behavioral psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4, 2005), MEDLINE (1966 to 2005), PsycINFO (1887 to 2005), EMBASE (1974 to 2005), the Cumulative Index to Nursing and Allied Health Literature (1982 to 2005), Web of Science (1980 to 2005), and Dissertation-Abstracts International (1980 to 2005). We also searched citation lists and contacted researchers via various electronic list-servers and via email requests.

SELECTION CRITERIA

Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only randomized controlled trials (RCTs) with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. Included studies were coded for quality using the Oxford Quality Scale devised by Jadad and colleagues. Standardized mean differences with 95% confidence intervals were computed for all analyses using RevMan 4.0 software.

MAIN RESULTS

Twenty eight trials with 1951 participants were included. Together, these studies included 1039 participants in treatment conditions and 951 in control conditions. The most commonly studied needle-procedures were immunizations and injections. The largest effect sizes for treatment improvement over control conditions exist for distraction (on self-reported pain, SMD -0.24 (95% CI -0.45 to -0.04), combined cognitive-behavioral interventions--reduced other-reported distress (SMD -0.88, 95% CI -1.65 to -0.12; and behavioral measures of distress (SMD -0.67, 95% CI -0.95 to -0.38) with hypnosis being the most promising--self-reported pain (SMD -1.47, 95% CI -2.67 to -0.27), with promising but limited evidence for the efficacy of numerous other psychological interventions, such as information/preparation, nurse coaching plus distraction, parent positioning plus distraction, and distraction plus suggestion.

AUTHORS' CONCLUSIONS

Overall, there is preliminary evidence that a variety of cognitive-behavioral interventions can be used with children and adolescents to successfully manage or reduce pain and distress associated with needle-related procedures. However, many of the included studies received lower quality scores because they failed to describe the randomization procedure and participant withdrawals or drop-outs from the study. Further RCTs need to be conducted, particularly for the many interventions for which we could not locate any trials.

Collaboration between primary care and psychiatric services: does it help family physicians?

OBJECTIVE

To compare family physicians' reports of their experiences managing patients with psychiatric disorders in settings with and without access to collaborative mental health services.

DESIGN

Survey using a questionnaire adapted from a similar study in Australia. Family physicians were asked about their knowledge, skills, and degree of comfort in managing the following psychiatric disorders derived from the primary care version of the 10th edition of the International Classification of Diseases: psychosis, depression, anxiety, childhood disorders, and stress-related disorders. We also compared the 2 groups of physicians regarding their satisfaction with mental health services in general.

SETTING

The Capital District Health Authority (CDHA) in Nova Scotia.

PARTICIPANTS

All family physicians practising in the CDHA.

MAIN OUTCOME MEASURES

Self-reported knowledge, skills, and degree of comfort in managing psychiatric problems; satisfaction with mental health services, adjusted for family physicians' demographics; and stated interest in mental health.

RESULTS

We received 101 responses (37 from physicians with access to collaborative care and 64 from physicians without access) from 7 communities in the CDHA. Family physicians who had access to collaborative care reported significantly greater knowledge in the areas of psychosis, alcohol or substance use, and childhood behavioural problems; and better skills in managing psychosis, alcohol or substance use, childhood depression or anxiety, childhood behavioural disorders, and relationship problems. Their comfort levels in managing relationship problems and childhood behavioural disorders were also significantly higher. Family physicians with access to collaborative care were significantly more satisfied with mental health services, over and above shared care. All these differences remained significant after controlling for sex, level of interest in mental health, and years in practice.

CONCLUSION

Family physicians with access to collaborative care reported greater knowledge, better skills, and more comfort in managing psychiatric disorders and greater satisfaction with mental health services. Further work is needed to establish why this is so and to determine any effect on patient outcomes, such as symptoms, quality of life, and psychosocial functioning.

Duration of untreated symptoms in common mental disorders: association with outcomes: International study

Studies have assessed the association between a longer duration of untreated symptoms and outcome for psychoses in specialist care. We investigated the effect of longer duration on the outcome of common psychiatric disorders in primary care, where most patients are treated. Patients presenting to primary care for new episodes in 10 countries were recruited into a prospective cohort study. Information on duration of untreated symptoms and psychosocial status was collected for 351 individuals using standardised instruments and this was repeated 1 year later. At 1-year follow-up, longer duration was associated with worse psychiatric outcome even after controlling for potential confounders.

An international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome

OBJECTIVE

Cross-sectional studies show an association between somatic symptoms and psychiatric morbidity in primary care. However, medically explained and unexplained symptoms have been considered separately as distinct and unrelated. In addition, data on outcome in primary care are equivocal. We compare the effect of both constructs (medically explained and unexplained symptoms) on psychiatric morbidity and disability (social and physical) at 1 year follow-up.

METHOD

Of 5447 patients presenting for primary care in 14 countries, 3201 participants were followed up (72% compliance). We measured physical, psychiatric, and social status using standardised instruments.

RESULTS

Patients with five or more somatic symptoms had increased psychosocial morbidity and physical disability at follow-up, even after controlling for confounders such as sociodemographics and recognition or treatment by general practitioners. There was little difference in outcome between medically explained and unexplained symptoms.

CONCLUSIONS

Somatic symptoms-irrespective of aetiology-are associated with adverse psychosocial and functional outcome in diverse cultures.

Mortality in individuals who have had psychiatric treatment: population-based study in Nova Scotia

BACKGROUND

Most studies of mortality in psychiatric patients have investigated in-patients rather than those attending out-patient clinics or primary care, where most receive treatment.

AIMS

To evaluate the mortality risk in mental illness for patients in contact with psychiatric services or primary care (n=221 048) across Nova Scotia (population 936 025).

METHOD

A population-based record-linkage analysis was made of the period 1995-2000, using an inception cohort to calculate mortality rate ratios.

RESULTS

The mortality rate was 1.74, with increased ratios for all major causes of death. Male mortality was almost double that of females after controlling for demographic factors, treatment setting and place of residence. Patients of lower income, in specialist psychiatric settings, and with dementia or psychoses were also at greater risk. However, in absolute numbers, 72% of deaths occurred in patients who had only seen their general practitioner.

CONCLUSIONS

Mortality risk is increased in all psychiatric patients, not just those who have received in-patient treatment.

A comparison of health service use in two jurisdictions with and without compulsory community treatment

BACKGROUND

This study examines whether community treatment orders (CTOs) reduce psychiatric admission rates or bed-days for patients from Western Australia compared to control patients from a jurisdiction without this legislation (Nova Scotia).

METHOD

A population-based record linkage analysis of an inception cohort using a two-stage design of matching and multivariate analyses to control for sociodemographics, clinical features and psychiatric history. All discharges from in-patient psychiatric services in Western Australia and Nova Scotia were included covering a population of 2.6 million people. Patients on CTOs in the first year of implementation in Western Australia were compared with controls from Nova Scotia matched on date of discharge from in-patient care, demographics, diagnosis and past in-patient psychiatric history. We analysed time to admission using Cox regression analyses and number of bed-days using logistic regression.

RESULTS

We matched 196 CTO cases with an equal number of controls. On survival analyses, CTO cases had a significantly greater readmission rate. Co-morbid personality disorder and previous psychiatric history were also associated with readmission. However, on logistic regression, patients on CTOs spent less time in hospital in the following year, with reduced in-patient stays of over 100 days.

CONCLUSIONS

Although compulsory community treatment does not reduce hospital admission rates, increased surveillance of patients on CTOs may lead to earlier intervention such as admission, so reducing length of hospital stay. However, we do not know if it is the intensity of treatment, or its compulsory nature, that effects outcome.

Compulsory community and involuntary outpatient treatment for people with severe mental disorders

BACKGROUND

There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation.

OBJECTIVES

To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness.

SEARCH STRATEGY

We undertook searches of the Cochrane Schizophrenia Group Register to 2003 and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study.

SELECTION CRITERIA

All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness.

DATA COLLECTION AND ANALYSIS

We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H).

MAIN RESULTS

We identified two randomised clinical trials (total n=416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence to indicate that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n=416, RR readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2), social functioning (2 RCTs, n=416, RR outcome 'arrested at least once by 11-12 months' 0.97 CI 0.62 to 1.52), mental state, quality of life (2 RCTs, n=416, RR homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n=416, RR perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n=264, RR 0.5 CI 0.31 to 0.8, NNT 6 CI 6 to 6.5). In terms of numbers needed to treat, it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest.

AUTHORS' CONCLUSIONS

Based on current evidence, community treatment orders may not be an effective alternative to standard care. It appears that compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. There is currently no evidence of cost effectiveness. People receiving compulsory community treatment were, however, less likely to be victim of violent or non-violent crime. It is, nevertheless, difficult to conceive of another group in society that would be subject to measures that curtail the freedom of 85 people to avoid one admission to hospital or of 238 to avoid one arrest. We urgently require further, good quality randomised controlled studies to consolidate findings and establish whether it is the intensity of treatment in compulsory community treatment or its compulsory nature that affects outcome. Evaluation of a wide range of outcomes should be included if this type of legislation is introduced.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trails have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2002, Issue 3), MEDLINE (1966 to 2002), CINAHL (1982 to 2002) EMBASE (1980 to 2002), PSYCH Info (1887 to 2002), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to 2002). We also searched citation lists and approached authors.

SELECTION CRITERIA

RCTs with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Eight studies involving 403 randomised participants were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.58 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; the standardized mean difference = 0.85 (95% CI 0.38 to 1.31). However, there was high heterogeneity for this test. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult.

AUTHORS' CONCLUSIONS

Review suggested a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

An international study of the effect of physical ill health on psychiatric recovery in primary care

OBJECTIVE

The aim of this study was to determine the association between physical morbidity and recovery from psychiatric illness in primary care.

METHODS

A total of 1252 psychiatric cases were recruited using a 2-stage design from 5447 subjects presenting for primary care in 14 countries. Cases were assessed at the time of screening and 1 year subsequently. Information on physical, psychiatric, and social status was obtained using the Composite International Diagnostic Instrument adapted for use in primary care (CIDI-PHC) and the Groningen Social Disability Schedule (GSDS). Assessments of psychiatric morbidity were also obtained from the patients' family practitioners.

RESULTS

Medically explained somatic symptoms were strongly related to psychiatric outcome 1 year later. Whereas just over one half of patients (614 of 1078) with 4 or less medically explained symptoms had recovered from a psychiatric disorder, the percentage recovery fell to 38% (67 of 174) in those with 5 or more medically explained symptoms. Patients with 5 or more medically explained symptoms had a 70% increase in risk of remaining a psychiatric case 1 year later after controlling for demographics, country, initial severity of psychiatric disorder, medically unexplained somatic symptoms, and social disability.

CONCLUSION

Physical ill health is independently associated with psychologic outcome 1 year after a patient has been seen. The needs of these patients should receive greater attention.

BARRIERS TO MANAGING MENTAL HEALTH IN WESTERN AUSTRALIA

OBJECTIVE

To explore the views of community-care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed.

DESIGN

Qualitative content analysis of semi-structured interviews.

SETTING

Community and mental health services in Esperance.

SUBJECTS

One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n = 38).

MAIN OUTCOME MEASURES

The views of community-care and mental health workers on barriers to the management of mental health, and how these could be addressed.

RESULTS

Barriers included confusion about the role of mental health services, limited after-hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi-agency shared care with clinical streams for adults, those aged > 65 and children.

CONCLUSION

This study revealed a number of barriers that are being addressed through a memorandum of understanding between services.

WHAT IS ALREADY KNOWN

Initiatives to foster collaboration between rural mental health services and general practitioners have not included other providers of primary care. We wished to explore the views of community-care and mental health workers on barriers to the management of mental health problems in rural Western Australia and how these could be addressed.

WHAT THIS STUDY ADDS

We identified a number of barriers to collaboration between mental health and community-based services, including poor communication, difficulties with referral and cultural differences between services. Of all these themes, the most significant was the lack of communication at individual, case management and organisational levels.

A survey of the quality of web based information on the treatment of schizophrenia and Attention Deficit Hyperactivity Disorder

OBJECTIVE

To systematically assess the quality, accountability and readability of Internet information on the treatment of schizophrenia and Attention Deficit Hyperactivity Disorder (ADHD), using a standardized pro forma.

METHOD

We analysed the 20 most highly ranked pages on the treatment of ADHD and schizophrenia, identified by five common Internet search engines.

RESULTS

There was little overlap in the sites identified by different search engines. In the case of schizophrenia, one site was identified three times and another eight sites twice; while for ADHD four sites were identified twice. Accountability (Silberg score), presentation and readability, as assessed by the Flesch-Kincaid Grade Level score, were poor. Mean Silberg, presentation and Flesch-Kincaid Grade Level scores were 3.2 (range 0-9) out of 9, 1.9 (range 0-4) out of 4, and 11.5 (range 6.5-12.25), respectively. There was no statistical difference in scores between the two diagnoses. Depending on the recommendation, agreement with evidence-based practice for schizophrenia ranged from only 2 to 55% (mean = 2.8 (range 0-9) out of 12), while that for ADHD was from 14 to 54% (mean = 1.6 (range 0-6) out of 6). Only 50% of the sites advised readers to clarify information with an appropriate health professional. Interrater reliability in pro forma scores for schizophrenia and ADHD was high (r = 0.96 and 0.95, respectively, p < 0.0001). Sites in the top 10% of scores were significantly more likely to be owned by an organization or have an editorial board than those in the bottom 10%.

CONCLUSIONS

The Internet contains misleading information on both schizophrenia and ADHD. The methodology used in this paper could be adapted for other psychiatric conditions.

Staff perceptions of care for deliberate self-harm patients in rural Western Australia: a qualitative study

Suicide has been a major community concern in Esperance, a geographically isolated port on the south coast of Western Australia. This study explores the views of regional health staff on barriers to the effective management of deliberate self-harm (DSH) and ways in which those barriers could be addressed. Semi-structured interviews were tape-recorded, transcribed and subjected to qualitative content analysis. Interviewees included 77% of general practitioners (n = 7), 18% of nurses (n = 13) and 55% of mental health professionals (n = 5). The most important barrier was a lack of structure to treating DSH, resulting in deficiencies and inconsistencies in its management. Suggestions to improve the management of DSH included better communication between services, support for nurses in raising the issue of suicide, use of a simple risk assessment tool, the development of a nurse liaison position, and a multidisciplinary planning group. The higher rates of DSH and completed suicide in rural and remote regions compared with metropolitan areas make secondary prevention particularly important.

The Esperance primary prevention of suicide project

BACKGROUND

Suicide has been a major community concern in Esperance, a geographically isolated port on the south coast of Western Australia.

AIMS

To evaluate the effect of three evidence-based initiatives for the primary prevention of suicide: (i) providing suicide awareness sessions for staff members in health, education and social services; (ii) limiting the sale of over the counter analgesics (aspirin and paracetamol) to packets containing less than the minimum lethal dose; and (iii) implementing Commonwealth media guidelines in the reporting of suicides by media.

METHODS

Changes in knowledge, awareness, attitudes, comfort and use, before and after each intervention were assessed using standardized instruments and pro forma derived from previous work, such as the Youth Suicide Prevention Training Manual and Suicide Intervention Beliefs Scale. Percentage changes in the number of retail outlets selling over the counter analgesics to less than potentially lethal quantities (less than 8 g of paracetamol or aspirin) were also measured. Media representatives were interviewed to gain their perceptions of Commonwealth Guidelines for the reporting of suicide, and encouraged to consult the project team before reporting suicide related issues.

RESULTS

The baseline survey illustrated that mental health staff and general practitioners were more aware of suicide issues, risk factors for suicide and awareness of professional and ethical responses than staff from other services, and were more willing to raise the issue with a person at risk. Thirty-three subjects participated in suicide awareness training of whom 21 (66%) returned questionnaires. There were significant increases in awareness of suicide-related issues and risk factors, as well as reported levels of knowledge of professional and ethical responses and comfort, competence and confidence levels when assisting a person at risk. Only three media representatives were aware of the Commonwealth Health Department Guidelines for reporting suicide and only one believed that the guidelines influenced their reporting. The local newspapers subsequently contacted the researchers to check that their reporting met the guidelines. As regards access to analgesics, one out of seven retailers agreed to implement the strategy (pending agreement from other retailers), another claimed increased awareness of the danger of analgesics, and three maintained that they would attempt to monitor excessive amounts sold to one individual.

CONCLUSIONS

Local initiatives can improve the awareness and knowledge of staff in the assessment of suicide risk, as well as of local media. These need to be complemented by initiatives at State or Commonwealth level to produce change in statewide media, or sales of over the counter analgesics.

Increased collaboration between primary care and psychiatric services. A survey of general practitioners' views and referrals

AIM

To evaluate a primary care partnership between the Rockingham-Kwinana Mental Health Service and Division of General Practice including a memorandum of understanding to streamline referrals, a consultation-liaison service, and a Balint group.

METHOD

A questionnaire was sent to all 74 general practitioners in the Division. Standardised interviews compared GPs using the service with those who did not. We compared content of GP referrals before and after implementation with referrals of a control area (Armadale).

RESULTS

Thirty-four GPs (45%) returned questionnaires and 46 (62%) participated in interviews; 26 (80%) found the duty officer useful as a point of first consultation-liaison contact; 19 (60%) used referral forms. Most (80%) were aware of the consultation-liaison service and half had either used it or the Balint group. Referral content changed significantly compared to Armadale.

DISCUSSION

This study had weaknesses: it relied on self report and retrospective information on GP work practices, knowledge and interests, and nonblinded assessments of referral letters. Primary care partnerships may improve GPs' self reported skills in managing psychiatric disorder and referral behaviour.

Health issues of asylum seekers and refugees

This paper is written on behalf of the West Australian Branch of the Australasian Faculty of Public Health Medicine. As public health physicians, we feel it is important that public health professionals should contribute constructively to address the needs of a socially deprived, marginalised group with high rates of physical and psychiatric morbidity. Depending on the definition, there are between 18 and 48 million asylum seekers and refugees in the world. Most seek protection in neighbouring countries, largely in Africa and Asia, rather than coming to North America, Europe and Australasia. Contrary to popular belief, numbers of successful applications to Australia's humanitarian program have actually fallen. This article attempts to correct misperceptions and misapprehensions about the effect of asylum seekers on the public health. Public health professionals should lobby for changes to Govemment policy that at present leave asylum seekers vulnerable to a cycle of poverty, ill-health and limited access to health services.

Factors associated with dysmorphic concern and psychiatric morbidity in plastic surgery outpatients

OBJECTIVES

To compare new referrals to a plastic surgery clinic for cosmetic (non-medically explained) reasons with a control group of equal size with medically explained symptoms.

METHOD

Patients attending for cosmetic (non-medically explained) reasons were compared with the controls using the general health questionnaire (GHQ), and dysmorphic concern questionnaire (DCQ). Patients were divided into high and low DCQ scores on the basis of their median scores.

RESULTS

Ninety subjects were approached of whom 84 (93%) participated giving 42 patients each in the cosmetic (non-medically explained) and control groups. Forty-four per cent were referred for mammoplasty (n = 37) and 8% for rhinoplasty (n = 7). The other 40 cases (48%) were for other procedures including excision, abdominoplasty and blepharoplasty. Thirty-two per cent of the sample were GHQ cases (n = 27). Patients presenting for cosmetic (non-medically explained) reasons were 13 times more likely to be female (95% CI = 4.3-41), nine times more likely to have high DCQ scores (95% CI = 3.3-24), six times more likely to be GHQ cases (95% CI = 2.1-17), and seven times more likely to present for mammoplasty. The same factors were associated with high DCQ scores. Patients with high DCQ scores were 32 times as likely to be GHQ cases (95% CI = 6.8-151). On multivariate analysis, dysmorphic concern emerged as the only independent predictor of GHQ caseness rather than sex, surgical diagnosis or procedure (adjusted OR = 32.0, 95 % CI = 6.5-156). Similarly, only GHQ caseness and presentation for cosmetic (non-medically explained) surgery independently predicted DCQ score.

CONCLUSIONS

Patients presenting for cosmetic (non-medically explained) surgery have high rates of dysmorphic concern and psychiatric morbidity

Pathways and outcomes of psychiatric care: does it depend on who you are, or what you've got?

OBJECTIVES

To investigate predictors of outcome and cost for patients treated by Mental Health Services in the south metropolitan area of Perth using logistic regression to control for potential confounding factors.

METHOD

Data were collected over a 3-month period on 2691 subjects (47% male, 53% female) as part of the Mental Health Classification and Services Cost Project.

RESULTS

The average age of subjects was 44.3 years. Nearly 80% of care occurred in community settings and virtually all inpatient care was for acute emergencies. The most common diagnosis was schizophrenia (33%) followed by mood disorders (30%). Within the study period, 88% of patients had only one episode of care (n = 2361) and a further 8% two (n = 223). Patients with schizophrenia were one-third as likely to be discharged from care (95% CI = 0.2-0.4) and 30% as likely to have longer episodes of care (95% CI = 1.1-1.6). Patients with personality, substance or adjustment disorders spent less time in treatment, and those with personality or substance disorders were more likely to be discharged from psychiatric care. A past history of inpatient care was associated with a worse outcome in terms of length of care, or not being successfully discharged. Severity of illness as determined by involuntary treatment or elevated Health of the Nation Outcome Scales and Life Skills Profile (LSP) scores was associated with increased costs. Greater disability on the LSP was also associated with increased length of care. Sociodemographic factors were as least as important as diagnosis in predicting the cost and outcome of treatment.

CONCLUSIONS

Demographic factors may better predict increased health service use than diagnostic casemix. Since sociodemographic variables contribute as much to outcome as diagnosis, comparing results between units is likely to be misleading unless adjusted for these factors.

Why are patients prescribed psychotropic drugs by general practitioners? Results of an international study

BACKGROUND

There has been growing interest in factors that might influence the prescription of psychotropic drugs in general practice.

METHOD

This was a multi-centre study using a two-phase stratified sampling strategy in primary care facilities from 14 different countries to determine factors associated with the prescription of psychotropic drugs.

RESULTS

A total of 1763 consecutive GP attenders aged between 16 and 65 years of age were recruited. Although antidepressants were used more for depressive disorders and anxiolytics for patients with anxiety, the differential diagnosis was otherwise not an important factor in prescribing behaviour. Antidepressants and anxiolytics were prescribed twice as frequently in client centred clinics following a 'personal physician model' as opposed to non-client centred settings, where care was less personalized. The reverse was true of hypnotics (adjusted odds ratio of 0.5). General practitioners with a positive view of their undergraduate psychiatric training and who had had further postgraduate experience in the speciality were significantly less likely to prescribe medication, and if they did they were more likely to use antidepressants. Older patients were significantly more likely to be prescribed psychotropic medication. Several other patient factors emerged when individual classes of medication were considered; these included the loss of a spouse and the absence of physical ill health in the case of antidepressants, and female sex, fewer years of schooling and unemployment in the case of anxiolytics.

CONCLUSIONS

Social, health care and GP factors are at least as important as clinical features in the prescription and choice of psychotropic medication.

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.

More alike than different. Comparing the mental health needs of London and other inner city areas

BACKGROUND

In the absence of epidemiological data, mental health services planners often rely on routinely available sources to estimate needs including comparative and deprivation weighted approaches.

METHODS

This paper reviews available methods using the King's Fund review of mental health services in London as an example. Alternative sources of data to those chosen by the King's Fund report are also reviewed.

RESULTS

Results can vary depending on the comparative populations and methods used. The King's Fund report concluded that London's needs were uniquely high in relation to the rest of the country including other inner city areas, but the use of differing comparison populations in different areas of the document made it difficult to assess whether levels of need were actually higher. Often, London was compared with the national average rather than with inner cities elsewhere in the United Kingdom. There were also shortcomings in the report's assumptions underlying the estimation of services required for London. Alternative sources of data suggest that the needs of cities such as Birmingham, Manchester, Liverpool, Leeds and Newcastle are at least as great as those of London.

CONCLUSIONS

This paper illustrates how the use of different techniques on routinely available data can lead to differing conclusions, and offers guidelines to help analyse reports that rely on such methods. Rather than discussing the relative merits of different inner city areas, issues of equity should be addressed by the use of an agreed set of data to ensure that like is compared with like.