Antidepressants for the treatment of depression in people with schizophrenia: a systematic review

BACKGROUND

Depression is common in people with schizophrenia and is associated with substantial morbidity and an increased risk of suicide. Our aim was to review systematically all the randomized controlled trials that have investigated the clinical effectiveness of antidepressant medication in the treatment of depression in people who also suffer with schizophrenia.

METHOD

Electronic searches of ClinPsych, the Cochrane Library, the Cochrane Schizophrenia Group's Register of Trials, EMBASE and Medline were completed. Reference lists from identified articles were hand searched.

RESULTS

Eleven small studies were identified and all randomized fewer than 30 subjects to each group. We could only perform analyses on a subset of the trials. For five trials (aggregate N = 209) the proportion improved in the antidepressant group was 26% (95% CI 10% to 42%) higher than in the placebo group. In six studies (aggregate N = 267) the standardized mean difference on the Hamilton Rating Scale for Depression at the end of the trial was -0.27 (95 % CI -0.7 to 0.2). There was no evidence that antidepressant treatment given during the stable phase of illness led to a deterioration of psychotic symptoms in the included trials.

CONCLUSIONS

The literature reviewed was, overall, of poor quality and only a small number of trials could contribute towards the meta-analysis. The results provide weak evidence for the effectiveness of antidepressants in those with schizophrenia and depression and could be explained by publication bias. We need further research to determine the best approach towards treating depression in people with schizophrenia.

Australian Longitudinal Study of Ageing: prospective evaluation of anthropometric indices in terms of four year mortality in community-living older adults

The Australian Longitudinal Study of Ageing (ALSA) aims to identify factors that contribute to & predict the health & social well-being of older Australians. Analyses were performed to determine the predictive value of anthropometric measurements in older Australians for four-year mortality. Weight, height, skinfolds (triceps, abdominal, supra-spinale, sub-scapular, medial calf, and front thigh) & girth (arm, waist, hip, calf) measurements were performed on a randomly selected community-living sample of 772 men & 624 women aged>70 years. Waist: Hip, % weight loss, corrected-arm-muscle area (CAMA) & BMI were calculated. These measures were categorised into quartiles & also according to commonly adopted definitions of nutritional status. Cox regression analysis was undertaken to assess the predictive value of the independent anthropometric variables for four-year mortality, adjusting for potential confounders (age, gender, marital status, smoking, alcohol status, self-rated health, basic activities of daily living & co-morbidity). Risk of four-year mortality increased with weight loss >10% over two years (HR=2.53, CI=1.37-4.67) & CAMA <21.4cm2(M) & <21.6cm2(F) (HR=1.93, CI=1.03-3.60) independent of confounding variables. These results confirm that selected anthropometric indices (weight loss, CAMA) independently increase the risk of four-year mortality & highlights their potential use in the nutrition screening and assessment of community-living older adults.

Repeatability of standardized tests of functional impairment and well-being in older people in a rehabilitation setting

PURPOSE

The aim of this study was to establish the repeatability of standardized tests of vision (Snellen chart testing), hearing (whispered voice test), communication (Frenchay aphasia screening test), loneliness (UCLA loneliness scale), morale (Philadelphia geriatric centre morale scale), and a multidimensional instrument (EASY-care) when used in a rehabilitation setting.

METHOD

The tests were administered by a research nurse to 50 older subjects attending a day rehabilitation unit, with repeat administration one or two weeks later by a nurse on the unit. Kappa statistics were used for level of agreement for categorized data and interclass correlation coefficient were used for data based on scores.

RESULTS

Moderate repeatability for Snellen chart testing. whispered voice test; good to excellent for the FAST, UCLA loneliness scale and Philadelphia geriatric centre morale scale. Moderate to very good repeatability for all EASY-care items except communication, feeding, use of telephone and cognitive impairment, which had poor spread of data.

CONCLUSIONS

Poor repeatability for commonly used tests of vision and hearing is worrying, whereas the positive results for the other tests will increase confidence in using them more in routine practice.

Antidepressants for people with both schizophrenia and depression

BACKGROUND

Depressive symptoms, often of substantial severity, are found in 50% of newly diagnosed suffers of schizophrenia and 33% of people with chronic schizophrenia who have relapsed. Depression is associated with dysphoria, disability, reduction of motivation to accomplish tasks and the activities of daily living, an increased duration of illness and more frequent relapses.

OBJECTIVES

To determine the clinical effects of antidepressant medication for the treatment of depression in people who also suffer with schizophrenia.

SEARCH STRATEGY

We undertook electronic searches of the Cochrane Schizophrenia Group's Register (October 2000), ClinPsych (1988-2000), The Cochrane Library (Issue 3, 2000), EMBASE (1980-2000) and MEDLINE (1966-2000). This was supplemented by citation searching, personal contact with authors and pharmaceutical companies.

SELECTION CRITERIA

All randomised clinical trials that compared antidepressant medication with placebo for people with schizophrenia or schizoaffective disorder who were also suffering from depression.

DATA COLLECTION AND ANALYSIS

Data were independently selected and extracted. For homogeneous dichotomous data the fixed effects risk difference (RD), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences. Statistical tests for heterogeneity were also undertaken.

MAIN RESULTS

Eleven studies met the inclusion criteria. All were small, and randomised fewer than 30 people to each group. Most included people after the most acute phase of psychosis and investigated a wide range of antidepressants. The quality of reporting varied a great deal. For the outcome of 'no important clinical response' antidepressants were significantly better than placebo (n=209, 5 RCTs, summary risk difference fixed effects -0.26, 95% CI -0.39 to -0.13, NNT 4 95% CI 3 to 8). The depression score at the end of the trial, as assessed by the Hamilton Rating Scale (HAM-D), seemed to suggest that using antidepressants was beneficial, but this was only statistically significant when a fixed effects model was used (n=261, 6 RCTs, WMD fixed effects -2.2 95% CI -3.8 to -0.6; WMD random effects -2.1 95% CI -5.04 to 0.84). There was no evidence that antidepressant treatment led to a deterioration of psychotic symptoms in the included trials. Heterogeneous data on 'any adverse effect' are equivocal (n=110, 2 RCTs, RD fixed 0.11 CI -0.03 to 0.25, Chi square 7.5, df=1, p=0.0062). In one small study extrapyramidal adverse effects were reported less often by those allocated to antidepressant (n=52, 1 RCT, RD fixed -0.28 CI -0.5 to -0.04). Only about 10% of people left these studies by 12 weeks. There was no apparent difference between those allocated placebo and those given an antidepressant (n=426, 10 RCTs, RD fixed 0.04 CI -0.02 to 0.1).

REVIEWER'S CONCLUSIONS

Overall, the literature was of poor quality, and only a small number of trials made useful contributions. Though our results provide some evidence to indicate that antidepressants may be beneficial for people with depression and schizophrenia, the results, at best, are likely to overestimate the treatment effect, and, at worst, could merely reflect selective reporting of statistically significant results and publication bias. At present, there is no convincing evidence to support or refute the use of antidepressants in treating depression in people with schizophrenia. We need further well-designed, conducted and reported research to determine the best approach towards treating depression in people with schizophrenia.

ASE-1: an autoantigen in systemic lupus erythematosus

ASE-1 is a 55 kDa nucleolar autoantigen. We show that autoantibodies to this antigen occur at a higher frequency in the sera of patients with SLE than in other systemic rheumatic diseases and that the specificity of ASE-1 as a serum marker of SLE increases as the number of epitopes recognized by the sera increases. Autoantibodies to ASE-1 were temporally associated with autoantibodies to HsEg5 but were not found in conjunction with other known serum markers of SLE. The frequency of antibodies to ASE-1 epitopes in a SLE cohort was approximately the same as anti-dsDNA. However, anti-dsDNA is associated with renal involvement, whereas ASE-1 reactivity shows an association with a history of serositis. We conclude that ASE-1 is correlated with serositis and that ASE-1 should be added to a list of autoantigens that are considered important serological features of SLE.

Accessing residential care from an acute hospital: can we be more efficient?

Hospitalized patients who require admission to residential care are often thought to make prolonged and inappropriate use of hospital resources. There are no Australian data on the factors that contribute to length of hospital stay for such patients. The aim of this study was to determine the timing of critical steps in discharge planning for hospitalized patients who need residential care. We prospectively audited 100 consecutive referrals to an Aged Care Assessment Team (ACAT) from one acute hospital in South Australia. Case notes were examined to determine the timings of critical events in discharge planning. We found 47% of patients were discharged to a nursing home, 16% to a hostel, 11% died, 10% returned home and 16% went to another facility. The average length of hospital stay was 27.2 days, and an average of 8.4 days elapsed before a decision to seek residential care was first recorded. A further 4.5 days elapsed before ACAT referral, 4.6 days before ACAT approval and 9.7 days before a residential care bed became available. We conclude that people admitted to our hospital from the community and who subsequently need residential care, spend 36% of their stay awaiting a residential care bed. Most of their hospital stay has elapsed before residential care is considered necessary and referral and approval processes have been activated. Strategies to reduce length of stay should perhaps focus on the earlier recognition of the need for residential care and accelerated referral and assessment processes. Earlier involvement by social work and occupational therapy should be considered.

Hip fracture treatments--what happens to patients from residential care?

Hip fractures are a growing problem and new models of care have been called for. However, patients from residential care are rarely considered in these discussions. Hip fracture is a common serious problem for older people in residential care with profound effects on subsequent mobility and quality-of-life. There are no Australian data documenting differences in hospital treatments offered to patients from the community and residential care to inform discussions. In a prospective audit we describe the treatment and 4 month outcomes of patients with fractured hips who were admitted to Flinders Medical Centre in South Australia from the community and residential care between August 1998 and June 1999. Information was collected on prefracture health, types of surgical and rehabilitation treatments and dependency. Of the 215 older adults who were admitted during this time, 183 agreed to participate (119 from community and 64 from residential care). Surgical management of the fracture was not affected by admission accommodation. Those from residential care had short hospital stays, less rehabilitation and access to physiotherapy. Although 61% of those from residential care were classified as independently mobile prefracture, by 4 months this had declined to 32% of survivors. Strategies to improve outcomes in those from residential care include: early identification of those walking independently prefracture with assessment by rehabilitation teams. Inclusion of liaison with community therapists in the clinical pathway and in selected cases use of 'rehabilitation at home' services to provide physiotherapy services should be considered.

Use of in-patient hospital beds by people living in residential care

BACKGROUND

There is concern that people living in residential care in Australia make significant and often inappropriate use of acute in-patient hospital services. To date, no factual information has been collected in Australia and its absence may allow myths and negative stereotypes to proliferate.

OBJECTIVE

To determine how and why people living in residential care in Australia use in-patient hospital beds. To determine the outcome of hospitalisation and functional status at 3 months following discharge.

METHODS

Prospective study of 184 consecutive admissions to hospital following Emergency Department (ED) attendance involving people aged over 65 years and living in residential care in southern Adelaide, South Australia. Information was obtained from the facilities' transfer letters, and where these were inadequate or absent, telephone interviews were held with residential care staff.

RESULTS

153 people accounted for the 184 admissions. They had a mean age of 84 years and 69% were female. 61% came from hostels and 35% from nursing homes. They had a wide range of clinical problems and twice as many were admitted to medical than to surgical units. Their mean length of hospital stay was 7.9 days, 2.3 days higher than for non-same-day patients and was higher for hostel than for nursing home residents. All but two admissions were considered unavoidable though the provision of specialised care within residential care could have prevented a further 19 (10%) admissions. 96% of admissions resulted in survival to leave hospital and in 74%, people returned directly to their place of origin. At 3 months follow-up, a further 20% of the group had died while 5% were in hospital. In all, 14% of the original group were in a different long-term care facility while 56% were living at their former residence.

CONCLUSIONS

People living in residential care are often hospitalised because of acute illness. In the vast majority of cases hospitalisation is both appropriate and unavoidable. Most did not require prolonged hospitalisation and were discharged alive, usually to their original residence. However, within 3 months many had died or had functionally declined. Strategies that prevent health breakdown in the residential care setting need to be developed and trialed.

Profile of people referred to an emergency department from residential care

BACKGROUND

Elderly people in residential care are among the most infirm in society and are at high risk of developing acute medical problems. There are no Australian data on the use of acute hospital emergency services by this group.

AIM

To determine patterns of use of a major public hospital's Emergency Department (ED) by elderly people living in residential care, their presenting problems and the outcome of attendance.

METHODS

Prospective study of 300 consecutive referrals to a teaching hospital's ED involving people aged over 65 years and living in residential care in southern Adelaide, South Australia. Case records were examined and residential care staff were interviewed by telephone when information required clarification. This occurred in 25% of referrals.

RESULTS

The 300 referrals were seen over a three month period and accounted for 2.43% of the 12,371 ED attendances during this period. During this time, at least 4.9% of people in residential care in the region were referred to the ED. The referrals involved 239 residents, 196 (82%) who were referred once only, 32 (13%) twice and 11 (5%) three or more times. Residents had a mean age of 84 years and 70% were female. A broad range of acute medical problems precipitated referral and 61% of people referred were immediately hospitalised. There was no general practitioner (GP) involvement in the management of the presenting illness in 58% of all referrals and in 45% of those where symptoms had been present for over three days.

CONCLUSIONS

People living in residential care are frequently referred to an ED service, often bypassing their GP in the process. They present with a wide range of acute medical problems for which most are hospitalised. Strategies that anticipate, prevent and manage health breakdown in residential care and so minimise the need for ED referral should be trialed.

Identification and cloning of a novel phosphatase expressed at high levels in differentiating growth plate chondrocytes

Growth plate chondrocytes progress through a proliferative phase before acquiring a terminally-differentiated phenotype. In this study we used Percoll density gradients to separate chick growth plate chondrocytes into populations of different maturational phenotype. By applying agarose gel differential display to these populations we cloned a cDNA encoding a novel 268 amino acid protein (3X11A). 3X11A contains two peptide motifs that are conserved in a recently identified superfamily of phosphotransferases. It is likely that 3X11A is a phosphatase, but its substrate specificity remains uncertain. 3X11A expression is upregulated 5-fold during chondrocyte terminal differentiation and its expression is approximately 100-fold higher in hypertrophic chondrocytes than in non-chondrogenic tissues. This suggests that 3X11A participates in a biochemical pathway that is particularly active in differentiating chondrocytes.

Use of patient restraints in four Australian teaching hospitals

To examine the patterns of use of patient restraints in Australian hospitals and the level of adherence to accepted guidelines, we undertook a point-prevalence study in four teaching hospitals in three different States. This involved ward inspections and review of case notes. Overall, 51 (12.5%) of the 408 people audited were being restrained with a variety of physical and chemical agents. The rate of restraint use varied from 8.5% to 18.5% between hospitals. Although the overall prevalence of restraint use increased with age, the hospital with the oldest patients used restraints least. At all hospitals, there was scant documentation in the case notes concerning the use of restraints. The prevalence of restraint use varies widely in different hospitals. As this is not explained by the patient profile, it probably reflects different philosophies of care. Documentation of the use of restraints needs to be improved in all the centres studied.

Private Sector Criteria and the Radical Change in Provision of Social Housing in England

The 1988 Housing Act signalled substantial changes in the provision of social housing in England. The act places housing associations at the centre of social housing provision. Moreover, their role as the main providers of social housing depends, in line with government intentions, on the greater use of private finance, as the proportion of public sector funds declines. The introduction of what amounts to a new regime for social housing provision in England has effectively changed the agenda of provision from one informed by public sector thinking to one established around private sector criteria. Housing associations have thus had to readjust quickly to an environment in which they are now exposed to a variety of interrelated risks. In order to manage such risks, associations have had to reorganise internally and to reevaluate their priorities. Against this background, this paper is aimed, first, at reporting on how a selection of case-study associations active across the main regions of England have faced up to the challenges that the new environment presents, and, second, at presenting the views of a selection of private sector financial institutions about their perceptions of social housing as an investment medium, the types of risk they view as characteristic of this sector, and their response to the efforts made by associations to manage the risks of social housing provision. The paper is concluded by setting out the likely shape that social housing provision will take in the immediate future.

Management and motivational factors in the control of noise induced hearing loss (NIHL)

This paper describes a study investigating attitudes to noise as an occupational hazard. The objectives of the study were to understand the individual and organizational factors which affect attitudes towards noise induced hearing loss (NIHL) and to relate these to the standards of hearing conservation achieved in industry as demonstrated by compliance with the Noise at Work Regulations. The study comprised a survey of 48 organizations across Britain, and a more detailed examination of 10 of these as case studies. Methods used included desk research, audits of hearing conservation programmes, questionnaires and interviews. Whilst there is widespread acceptance that industrial noise is a hazard, it is one that is frequently taken for granted, and measures to deal with it are often inadequate. Most organizations place the onus on the workforce to protect their own hearing through the use of personal hearing protectors. Workers reactions to noise tended however to be passive and much of the time neither managers nor the workforce are concious of the noise hazard. This is the case even where some managers are committed to good industrial housekeeping and accident prevention. As effective hearing conservation programme requires three management attributes: leadership from senior management, the ability of middle management (particularly in production and engineering) to put hearing conservation measures into practice, and specialist technical knowledge of noise and of the legislation. The study points to the need for more education and motivation of senior managers as the priority in improving standards of hearing conservation and noise control.

The subjective effects of low-dose propofol. A double-blind study to evaluate dimensions of sedation and consciousness with low-dose propofol

In this study the subjective effects (sedation and mood) of subanaesthetic doses of propofol were examined in 28 healthy male volunteers. A computer model was used to predict the infusion profiles necessary to obtain steady state propofol plasma concentrations of 0.3 microgram.ml-1, 0.6 microgram.ml-1, 0.9 microgram.ml-1. Objective measures of sedation from saccadic eye movement and choice reaction time gave significant dose responses at each level but a battery of psychometric tests failed to show dose-related subjective responses. Of particular note in the subjective data is the lack of a difference between groups or even of a consistent trend within the data. This suggests that a low concentration of propofol in plasma does not induce euphoria or a sense of well-being. The anecdotal evidence available for mood changes with propofol therefore remains unsubstantiated.

Zopiclone as a preoperative night hypnotic: a double-blind comparison with temazepam and placebo

We have examined the hypnotic effects of zopiclone 7.5 mg and temazepam 20 mg compared with placebo in a double-blind, randomized, clinical study of 60 patients on the night before operation. Evaluation was both subjective (visual analogue scales and a sleep questionnaire), to measure the quality of sleep, and objective (critical flicker fusion, object recall and paired associates tasks), to measure residual impairment. We found that zopiclone was an effective single-dose hypnotic with similar residual effects to the benzodiazepine and it may therefore provide a suitable alternative to benzodiazepines.

Differential diagnosis of personality disorders by the seven-factor model of temperament and character

We used multiaxial structured interviews and questionnaires to evaluate the ability of self-reports on seven personality dimensions to predict independent interview diagnoses of DSM-III-R personality disorders. We studied 136 consecutive adult psychiatric inpatients, excluding those with psychosis, organic mental disorders, and severe agitation. Sixty-six patients had interview diagnoses of DSM-III-R personality disorders. Most also had mood disorders. We confirmed the hypotheses that self-reports of low self-directedness and cooperativeness strongly predicted the number of personality symptoms in all interview categories, whereas the other factors distinguished among subtypes as predicted. Self-directedness and cooperativeness also predicted the presence of any personality disorder by differentiating patients varying in risk from 11% to 94%. Patients in clusters A, B, and C were differentiated by low reward dependence, high novelty seeking, and high harm avoidance, respectively. We conclude that low self-directedness and cooperativeness are core features of all personality disorders and are validly measured by the seven-factor Temperament and Character Inventory, but not the five-factor Neuroticism-Extraversion-Openness inventory. Each DSM-III-R personality disorder category is associated with a unique profile of scores in the seven-factor model, providing an efficient guide to differential diagnosis and treatment.

Interaction of H2-receptor antagonists and benzodiazepine sedation. A double-blind placebo-controlled investigation of the effects of cimetidine and ranitidine on recovery after intravenous midazolam

H2-receptor antagonists differentially inhibit cytochrome P450 and this may affect the rate at which benzodiazepines are metabolised. However, it is not known whether this delayed clearance results in prolonged psychomotor impairment. In a randomised double-blind trial 28 healthy volunteers received two single doses of midazolam (0.07 mg.kg-1) at an interval of one week during which they took cimetidine 400 mg, ranitidine 150 mg or placebo, each twice daily. Recovery from the benzodiazepine was monitored on each occasion over a 12 h period using a battery of psychometric tests. There was wide individual variation in performance; however, an overall measure of impairment indicated a significant difference at 2.5 h (p < 0.05), the cimetidine group having a high impairment score. This decrement appeared to be in cognitive and psychomotor functions and was not reflected in the subjective assessment.

The meaning of quality of life for bone marrow transplant survivors. Part 2. Improving quality of life for bone marrow transplant survivors

Surviving bone marrow transplant (BMT) represents a major victory against malignant disease but also creates challenges of survivorship for patients and the professionals who care for them. Part 2 of this report presents the findings of a qualitative study (N = 119) related to improving quality of life (QOL) for BMT survivors. Results are shared based on BMT survivors' perceptions of (a) what makes QOL better, (b) what makes QOL worse, and (c) what doctors or nurses could do to enhance QOL. The findings of the study have been useful in constructing a quantitative instrument to measure QOL in BMT and in understanding the conceptual basis of QOL for the BMT population. Nursing interventions can improve the QOL for the BMT patient across all phases of the transplant process and long-term issues related to survival.

The meaning of quality of life for bone marrow transplant survivors. Part 1. The impact of bone marrow transplant on quality of life

Quality of life (QOL) is an important concept in cancer nursing and has particular significance for bone marrow transplant (BMT). BMT survivors are faced with the demands of acute transplant symptoms as well as chronic illness demands posttransplant. The purpose of this study was to explore the concept of QOL for BMT survivors and to gain understanding of nursing interventions that may improve QOL in this population. The conceptual framework for this study was derived from the model of QOL developed by Ferrell, Grant, and Padilla (1989) that depicts the QOL domains of physical well-being, psychological well-being, social concerns, and spiritual well-being. This qualitative study consisted of a one-time interview of 119 BMT survivors using six open-ended questions. The items were based on previous research of the authors and content validity was established by a panel of BMT experts. Content analysis was performed on verbatim written responses to six questions regarding BMT and QOL. Part one of this two-part report provides analysis based on the questions regarding the meaning of QOL to BMT survivors and the impact of BMT on QOL.

Cell proliferation and enzyme activities associated with the development of avian tibial dyschondroplasia: an in situ biochemical study

Avian tibial dyschondroplasia is a disorder of endochondral ossification which results in the accumulation of noncalcified, avascular cartilage. We have investigated the changes in cell proliferation and enzyme activities within specific cell types in the growth plate of chickens with differing severity of the disease using in situ biochemical techniques that allow the quantification of enzyme activity in unfixed undecalcified sections of tissue. Lactate dehydrogenase activity in the prehypertrophic zone and tartrate-resistant acid phosphatase activity in osteoclasts/chondroclasts were not affected by the severity of the disease. Glucose 6-phosphate dehydrogenase activity in both the proliferating and prehypertrophic zones of the growth plate was reduced in chicks with both moderate and severe lesions. Cell proliferation within the proliferating chondrocytes was slightly reduced in the severely affected birds. Alkaline phosphatase activity in the prehypertrophic chondrocytes was markedly elevated in chicks with moderate and severe lesions. These results rule out an increased rate of chondrocyte proliferation as a possible mechanism for the development of tibial dyschondroplasia. The aetiology of the disease therefore appears to be related to the control of chondrocyte differentiation, mineralization, and vascularization by local and/or systemic growth factors.