Premature Mortality Among Patients Recently Discharged From Their First Inpatient Psychiatric Treatment

IMPORTANCE

Nationwide cohorts provide sufficient statistical power for examining premature, cause-specific mortality in patients recently discharged from inpatient psychiatric services.

OBJECTIVE

To investigate premature mortality in a nationwide cohort of patients recently discharged from inpatient psychiatric treatment at ages 15 to 44 years.

DESIGN, SETTING, AND PARTICIPANTS

This single-cohort design included all persons born in Denmark (N = 1 683 385) between January 1, 1967, and December 31, 1996. Exactly 48 599 of these Danish residents were discharged from an inpatient psychiatric unit or ward on or after their 15th birthday, which took place during this study's observation period from January 1, 1982, through December 31, 2011. This group of patients was followed up beginning on their 15th birthday until their death, emigration, or December 31, 2011, whichever came first. Individuals discharged from inpatient psychiatric care at least once before their 15th birthday (n = 5882) were excluded from the study. All data were obtained from the Danish Civil Registration System, Psychiatric Central Research Register, and Register of Causes of Death. Data analysis took place between February 1, 2016, and December 10, 2016.

MAIN OUTCOMES AND MEASURES

Incidence rates and incidence rate ratios (IRRs) for all-cause mortality and for an array of unnatural and natural causes of death among patients recently discharged from an inpatient psychiatric unit vs persons not admitted to a psychiatric facility. Primary analysis considered risk within the year of first discharge.

RESULTS

Of the 48 599 discharged patients who were included in the study, 25 006 (51.4%) were female, 35 660 (73.4%) were aged 15 to 29 years, and 33 995 (70.0%) had a length of stay of 30 days or less. Compared with persons not admitted, patients discharged had an elevated risk for all-cause mortality within 1 year (IRR, 16.2; 95% CI, 14.5-18.0). The relative risk for unnatural death (IRR, 25.0; 95% CI, 22.0-28.4) was much higher than for natural death (IRR, 8.6; 95% CI, 7.0-10.7). The highest IRR found was for suicide at 66.9 (95% CI, 56.4-79.4), followed by alcohol-related death at 42.0 (95% CI, 26.6-66.1). Among the psychiatric diagnostic categories assessed, psychoactive substance abuse conferred the highest risk for all-cause mortality (IRR, 24.8; 95% CI, 21.0-29.4). Across the array of cause-specific outcomes examined, risk of premature death during the first year after discharge was markedly higher than the risk of death beyond the first year of discharge.

CONCLUSIONS AND RELEVANCE

Clinicians may help protect patients after discharge by serving as a liaison between primary and secondary health services to ensure they are receiving holistic care. Early intervention programs for drug and alcohol misuse could substantially decrease the greatly elevated mortality risk among these patients.

Thrombotic and bleeding outcomes following perioperative interruption of direct oral anticoagulants in patients with venous thromboembolic disease

Essentials Studies evaluating the procedural interruption of direct oral anticoagulants (DOACs) are lacking. We conducted a study of the interruption of DOACs for prior venous thromboembolic disease (VTE). The post-operative risks of recurrent VTE and major bleeding are low in this patient population. A scheme based on half-life and procedure-related bleeding appears safe and efficacious.

SUMMARY

Background Direct oral anticoagulants (DOACs) are increasingly being used in the setting of venous thromboembolic disease (VTE). There is little evidence to guide the peri-procedural interruption of DOACs in this patient population. A number of studies have evaluated the perioperative interruption of DOACs based on half-life of the anticoagulant and the underlying procedural bleeding risk in patient with atrial fibrillation, but it remains unclear whether these findings can be extended to patients with VTE. Objective Evaluate thrombotic and bleeding outcomes following the perioperative interruption of direct oral anticoagulation in patients with prior VTE. Methods We conducted a retrospective analysis of consecutive patients on a DOAC for prior VTE requiring temporary interruption of anticoagulation for an invasive procedure. The primary efficacy outcome was the 30-day symptomatic VTE rate, and the primary safety outcome was the 30-day major bleeding rate. Secondary outcomes included overall mortality and the rate of clinically relevant non-major bleeding. Results A total of 190 patients were included in the analysis. The 30-day VTE rate was 1.05% (95% CI, 0.29-3.8%) and the 30-day major bleeding rate was 0.53% (95% CI, 0.09-2.93%). There were no deaths during the 30-day follow-up period. The rate of clinically relevant non-major bleeding was 3.16% (95%CI , 1.46-6.72%). Conclusions The perioperative interruption of DOACs in the setting of VTE, using a strategy that considers the half-life of the DOAC and the underlying procedural bleeding risk, appears to be both safe and effective.

Treatment Barriers and Support for Male Ex-Armed Forces Personnel in Prison: Professional and Service User Perspectives

Ex-armed forces personnel represent a potentially vulnerable group within the prison population. To provide support to this group, we need to understand their needs and help-seeking behavior. A focus group with professionals and semi-structured interviews with service users explored perspectives of the treatment barriers faced by this group and their support needs. Data were analyzed using constant comparison methods, and four primary themes were identified. The findings suggest ex-armed forces personnel consider prison an opportunity to access support but find it difficult to ask for help. Staff having an awareness of military issues was thought to encourage help-seeking, but the variability of provision across prison establishments was considered a barrier. Resettlement was a prominent concern, and access to support when preparing for, and after, release was felt by all participants to be important. Implications for the provision of support in prison are discussed along with recommendations for practice.

iCanADAPT Early protocol: randomised controlled trial (RCT) of clinician supervised transdiagnostic internet-delivered cognitive behaviour therapy (iCBT) for depression and/or anxiety in early stage cancer survivors -vs- treatment as usual

BACKGROUND

This RCT with two parallel arms will evaluate the efficacy of an internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for the treatment of clinical depression and/or anxiety in early stage cancer survivors.

METHODS/DESIGN

Early stage cancer survivors will be recruited via the research arm of a not-for-profit clinical research unit and randomised to an intervention (iCBT) group or a 'treatment as usual' (TAU) control group. The minimum sample size for each group is 45 people (assuming effect size > 0.6, power of 80%, and alpha at .05), but 10% more will be recruited to account for attrition. A solitary or cumulative diagnosis(es) of Major Depressive Episode (current), Generalised Anxiety Disorder, Illness Anxiety Disorder, Panic Disorder, Agoraphobia, and/or Adjustment disorder will be determined using modules from the Anxiety Disorders Interview Schedule for DSM-5. Depression and anxiety levels with be measured via the total score of the Hospital Anxiety and Depression scale (HADS-T), the primary outcome measure. Secondary measures will include the Kessler 10 to measure general distress, the Fear of Cancer Recurrence Inventory (FCRI) to measure the specific fear of cancer recurrence and the Functional Assessment of Cancer Therapy, General Version 4 (FACT-G) for self-report of physical, social, emotional and functional well-being. iCBT participants will complete the measures before lessons 1 and 5, at post-treatment and at 3-month follow-up. The TAU group will complete similar measures at weeks 1, 8 and 16 of the waiting period. Program efficacy will be determined using intent-to-treat mixed models. Maintenance of gains will be assessed at 3-month follow-up. Mediation analyses using PROCESS will be used to examine the association between change in depressive and anxious symptoms over time and changes in FCRI and FACT-G QOL in separate analysis.

DISCUSSION

This is the first RCT looking at iCBT specifically for clinical depression and/or anxiety in a cancer population. Findings will help to direct the role of iCBT in streamlined psycho-social care pathways.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12616000231448, registered 19th February 2016 ( www.anzctr.org.au ). This trial protocol is in compliance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.

Critical time Intervention for Severely mentally ill Prisoners (CrISP): a randomised controlled trial

Background

The transition from prison to community is difficult for prisoners with mental illness. Critical time intervention (CTI) is designed to provide intensive support to meet health, social care and resettlement needs through close working between client and key worker pre, and up to 6 weeks post, release.

Objectives

To establish whether or not CTI is effective in (1) improving engagement of discharged male prisoners who have mental illness with community mental health teams (CMHTs) and (2) providing practical support with housing, finance and re-establishing social networks.

Trial design

A multicentre, parallel-group randomised controlled trial, with follow-up at 6 weeks and at 6 and 12 months. A subset of prisoners and case managers participated in a complementary qualitative study.

Setting

Eight English prisons.

Participants

One hundred and fifty adult male prisoners, convicted or remanded, cared for by mental health in-reach teams and diagnosed with severe mental illness, with a discharge date within 6 months of the point of recruitment.

Intervention

Participants were randomised to either the intervention or the control (treatment as usual). The intervention group was assigned a case manager who assessed mental and physical health before and following release, made appropriate links to health, housing and financial services and supported the re-establishment of family/peer contact.

Outcome

The primary outcome measure was engagement with a CMHT 6 weeks post discharge. Secondary outcomes included contact with mental health services at 6 and 12 months. A health economic evaluation was undertaken using service contact at the follow-up time points. We were unable to assess the intervention’s effect on reoffending and longer-term health-care use because of study delays.

Results

One hundred and fifty prisoners were recruited: 72 were randomised to the intervention and 78 were randomised to the control. Engagement with teams at 6 weeks was 53% for the intervention group compared with 27% for the control group [95% confidence interval (CI) 0.13% to 0.78%;p = 0.012]. At 6 months’ follow-up, intervention participants showed continued increase in engagement with teams compared with control participants (95% CI 0.12% to 0.89%;p = 0.029); there were no significant differences at 12 months. Increased engagement resulted in higher levels of service use and costs for the intervention than for the control. Qualitative data showed the intervention group reporting better continuity of care and improved access to services.

Conclusion

The intervention significantly improved contact with services at 6 weeks, although at a higher cost than the control. This is important as, in the days and weeks following release, recently released individuals are at a particularly high risk of suicide and drug overdose. Further research is required to establish how teams can better maintain contact with clients when the intervention ends.

Future work

Further studies are indicated for groups with different needs, for example women, young prisoners and those in police custody, and at other transition points, for example following arrest and short-term custody, and at points of transition between different mental health services.

Trial registration

Current Controlled Trials ISRCTN98067793.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.

Traumatic pulmonary pseudocyst: An underreported entity

BACKGROUND

Traumatic pulmonary pseudocysts (TPP) are underreported cavitary lesions of the pulmonary parenchyma that can develop following blunt chest trauma. Although the occurrence of traumatic pulmonary pseudocyst is rare, this condition should be considered in the differential diagnosis of any cavitary lesion. Awareness of this injury and its clinical significance is important for successful management in order to avoid medical errors in the course of treatment.

METHODS

A literature search was conducted through Medline using the key phrases "traumatic pulmonary pseudocyst" and "traumatic pneumatocele." Relevant articles, especially those with focus on diagnosis and management of traumatic pneumatocele in adults, were selected. Due to the scarcity of literature and lack of Level I evidence on this subject, studies published in any year were considered.

RESULTS

A search of "traumatic pulmonary pseudocyst" and "traumatic pneumatocele" yielded 114 studies. Most of these were excluded based on inclusion and exclusion criteria. Thirty-five articles were reviewed. The majority of these were individual case studies; only eight articles were considered large case studies (greater than eight patients).

CONCLUSION

Traumatic pulmonary pseudocysts are lesions that occur secondary to blunt chest trauma. Diagnosis is based on a history of trauma and appearance of a cystic lesion on CT. Accurate diagnosis of traumatic pulmonary pseudocyst is imperative to achieve successful outcomes. Failure to do so may lead to unnecessary procedures and complications.

Cryptic splicing events in the iron transporter ABCB7 and other key target genes in SF3B1-mutant myelodysplastic syndromes

The splicing factor SF3B1 is the most frequently mutated gene in myelodysplastic syndromes (MDS), and is strongly associated with the presence of ring sideroblasts (RS). We have performed a systematic analysis of cryptic splicing abnormalities from RNA sequencing data on hematopoietic stem cells (HSCs) of SF3B1-mutant MDS cases with RS. Aberrant splicing events in many downstream target genes were identified and cryptic 3' splice site usage was a frequent event in SF3B1-mutant MDS. The iron transporter ABCB7 is a well-recognized candidate gene showing marked downregulation in MDS with RS. Our analysis unveiled aberrant ABCB7 splicing, due to usage of an alternative 3' splice site in MDS patient samples, giving rise to a premature termination codon in the ABCB7 mRNA. Treatment of cultured SF3B1-mutant MDS erythroblasts and a CRISPR/Cas9-generated SF3B1-mutant cell line with the nonsense-mediated decay (NMD) inhibitor cycloheximide showed that the aberrantly spliced ABCB7 transcript is targeted by NMD. We describe cryptic splicing events in the HSCs of SF3B1-mutant MDS, and our data support a model in which NMD-induced downregulation of the iron exporter ABCB7 mRNA transcript resulting from aberrant splicing caused by mutant SF3B1 underlies the increased mitochondrial iron accumulation found in MDS patients with RS.

Suicide risk linked with clinical consultation frequency, psychiatric diagnoses and psychotropic medication prescribing in a national study of primary-care patients

BACKGROUND

Little is known about the precursors of suicide risk among primary-care patients. This study aimed to examine suicide risk in relation to patterns of clinical consultation, psychotropic drug prescribing, and psychiatric diagnoses.

METHOD

Nested case-control study in the Clinical Practice Research Datalink (CPRD), England. Patients aged ⩾16 years who died by suicide during 2002-2011 (N = 2384) were matched on gender, age and practice with up to 20 living control patients (N = 46 899).

RESULTS

Risk was raised among non-consulting patients, and increased sharply with rising number of consultations in the preceding year [⩾12 consultations v. 1: unadjusted odds ratio (OR) 6.0, 95% confidence interval (CI) 4.9-7.3]. Markedly elevated risk was also associated with the prescribing of multiple psychotropic medication types (⩾5 types v. 0: OR 62.6, CI 44.3-88.4) and with having several psychiatric diagnoses (⩾4 diagnoses v. 0: OR 31.1, CI 19.3-50.1). Risk was also raised among patients living in more socially deprived localities. The confounding effect of multiple psychotropic drug types largely accounted for the rising risk gradient observed with increasing consultation frequency.

CONCLUSIONS

A greater proportion of patients with several psychiatric diagnoses, those prescribed multiple psychotropic medication types, and those who consult at very high frequency might be considered for referral to mental health services by their general practitioners. Non-consulters are also at increased risk, which suggests that conventional models of primary care may not be effective in meeting the needs of all people in the community experiencing major psychosocial difficulties.

Improving risk management for violence in mental health services: a multimethods approach

Background

Mental health professionals increasingly carry out risk assessments to prevent future violence by their patients. However, there are problems with accuracy and these assessments do not always translate into successful risk management.

Objectives

Our aim was to improve the accuracy of assessment and identify risk factors that are causal to be targeted by clinicians to ensure good risk management. Our objectives were to investigate key risks at the population level, construct new static and dynamic instruments, test validity and construct new models of risk management using Bayesian networks.

Methods and results

We utilised existing data sets from two national and commissioned a survey to identify risk factors at the population level. We confirmed that certain mental health factors previously thought to convey risk were important in future assessments and excluded others from subsequent parts of the study. Using a first-episode psychosis cohort, we constructed a risk assessment instrument for men and women and showed important sex differences in pathways to violence. We included a 1-year follow-up of patients discharged from medium secure services and validated a previously developed risk assessment guide, the Medium Security Recidivism Assessment Guide (MSRAG). We found that it is essential to combine ratings from static instruments such as the MSRAG with dynamic risk factors. Static levels of risk have important modifying effects on dynamic risk factors for their effects on violence and we further demonstrated this using a sample of released prisoners to construct risk assessment instruments for violence, robbery, drugs and acquisitive convictions. We constructed a preliminary instrument including dynamic risk measures and validated this in a second large data set of released prisoners. Finally, we incorporated findings from the follow-up of psychiatric patients discharged from medium secure services and two samples of released prisoners to construct Bayesian models to guide clinicians in risk management.

Conclusions

Risk factors for violence identified at the population level, including paranoid delusions and anxiety disorder, should be integrated in risk assessments together with established high-risk psychiatric morbidity such as substance misuse and antisocial personality disorder. The incorporation of dynamic factors resulted in improved accuracy, especially when combined in assessments using actuarial measures to obtain levels of risk using static factors. It is important to continue developing dynamic risk and protective measures with the aim of identifying factors that are causally related to violence. Only causal factors should be targeted in violence prevention interventions. Bayesian networks show considerable promise in developing software for clinicians to identify targets for intervention in the field. The Bayesian models developed in this programme are at the prototypical stage and require further programmer development into applications for use on tablets. These should be further tested in the field and then compared with structured professional judgement in a randomised controlled trial in terms of their effectiveness in preventing future violence.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Mental health services, suicide and 7-day working

BACKGROUND

Patients admitted to hospital at the weekend appear to be at increased risk of death compared with those admitted at other times. However, a 'weekend effect' has rarely been explored in mental health and there may also be other times of year when patients are vulnerable.

AIMS

To investigate the timing of suicide in high-risk mental health patients.

METHOD

We compared the incidence of suicide at the weekend v. during the week, and also in August (the month of junior doctor changeover) v. other months in in-patients, patients within 3 months of discharge and patients under the care of crisis resolution home treatment (CRHT) teams (2001-2013).

RESULTS

The incidence of suicide was lower at the weekends for each group (incidence rate ratio (IRR) = 0.88 (95% CI 0.79-0.99) for in-patients, IRR = 0.85 (95% CI 0.78-0.92) for post-discharge patients, IRR = 0.87 (95% CI 0.78-0.97) for CRHT patients). Patients who died by suicide were also less likely to have been admitted at weekends than during the week (IRR = 0.52 (95% CI 0.45-0.60)). The incidence of suicide in August was not significantly different from other months.

CONCLUSIONS

We found evidence of a weekend effect for suicide risk among high-risk mental health patients, but with a 12-15% lower incidence at weekends. Our study does not support the claim that safety is compromised at weekends, at least in mental health services.