Is there a gap between recommended and 'real world' practice in the management of depression in young people? A medical file audit of practice

A collaborative realist review of remote measurement technologies for depression in young people

Digital mental health is becoming increasingly common. This includes use of smartphones and wearables to collect data in real time during day-to-day life (remote measurement technologies, RMT). Such data could capture changes relevant to depression for use in objective screening, symptom management and relapse prevention. This approach may be particularly accessible to young people of today as the smartphone generation. However, there is limited research on how such a complex intervention would work in the real world. We conducted a collaborative realist review of RMT for depression in young people. Here we describe how, why, for whom and in what contexts RMT appear to work or not work for depression in young people and make recommendations for future research and practice. Ethical, data protection and methodological issues need to be resolved and standardized; without this, RMT may be currently best used for self-monitoring and feedback to the healthcare professional where possible, to increase emotional self-awareness, enhance the therapeutic relationship and monitor the effectiveness of other interventions.

The implementation of a FIP guidance for COVID-19: insights from a nationwide survey

Background

The International Pharmaceutical Federation (FIP) has established an interim guidance of coronavirus disease 2019 (COVID-19) for pharmacists worldwide. The aim of this study was to identify the implementation of FIP guidance in China and provide applicable strategies for further actions.

Methods

A nationwide cross-sectional survey on Chinese pharmacists was distributed electronically through groups of WeChat between 9 December 2020 and 18 December 2020. The 29-item questionnaire for the survey was designed based on the FIP guidance and knowledge, attitudes, and practices (KAP) framework.

Results

A total of 237 responses from 237 pharmacists (69.20% females) were received. Most pharmacists (81.86%) participated in work related to COVID-19. Respondents referred to other guidelines or consensus more than they did to FIP guidance. Most participants were qualified for the knowledge-based questions regarding COVID-19 (67.51%), had positive attitudes towards pharmacists’ roles and actions (61.18%), and were qualified in the practices of prevention measures, infection risk monitoring, and pharmacists’ advice (50.63%). Several factors were revealed as having impact on pharmacists’ KAP, such as the relevance of participating in work related to COVID-19, work entailments, and information source.

Conclusions

The FIP guidance has a certain degree of dissemination and implementation in China, which can be improved through effective actions directed towards impact factors.

Antidepressant Prescribing and Suicide/Self-Harm by Young Australians: Regulatory Warnings, Contradictory Advice, and Long-Term Trends

In 2004, the US Food and Drug Administration (FDA) controversially issued a black box warning that antidepressants were associated with an increased risk of suicidal thoughts and behaviours in people aged under 18 years. In 2007, the warning was expanded to include young adults aged under 25 years. In 2005, the Australian Therapeutic Goods Administration responded to the FDA warning by requiring Product and Consumer Information leaflets to be updated to reflect the risk. However, there was considerable debate, and at times emotive backlash, in academic journals and the international media. Prominent US and Australian mental health organisations and psychiatrists challenged the FDA warning. They argued that, on balance, antidepressant use was likely to reduce the risk of suicide. Several ecological studies were cited misleadingly as evidence that decreasing antidepressant use increases suicide risk. From 2008 to 2018, Australian per-capita child, adolescent and young adult antidepressant dispensing (0-27 years of age) and suicide (0-24 years) rates have increased approximately 66% and 49%, respectively. In addition, there was a 98% increase in intentional poisonings among 5 to 19 year-olds in New South Wales and Victoria between 2006 and 2016, with substantial overlap between the most commonly dispensed psychotropics and the drugs most commonly used in self-poisoning. These results do not support claims that increased antidepressant use reduces youth suicide risk. They are more consistent with the FDA warning and the hypothesis that antidepressant use increases the risk of suicide and self-harm by young people. Causal relationships cannot be established with certainty until there is a vast improvement in post-marketing surveillance. However, there is clear evidence that more young Australians are taking antidepressants, and more young Australians are killing themselves and self-harming, often by intentionally overdosing on the very substances that are supposed to help them.

Youth Codesign of a Mobile Phone App to Facilitate Self-Monitoring and Management of Mood Symptoms in Young People With Major Depression, Suicidal Ideation, and Self-Harm

BACKGROUND

Effective treatment of depression in young people is critical, given its prevalence, impacts, and link to suicide. Clinical practice guidelines point to the need for regular monitoring of depression symptom severity and the emergence of suicidal ideation to track treatment progress and guide intervention delivery. Yet, this is seldom integrated in clinical practice.

OBJECTIVE

The objective of this study was to address the gap between guidelines about monitoring and real-world practice by codesigning an app with young people that allows for self-monitoring of mood and communication of this monitoring with a clinician.

METHODS

We engaged young people aged 18 to 25 years who had experienced depression, suicidal ideation including those who self-harm, as well as clinicians in a codesign process. We used a human-centered codesign design studio methodology where young people designed the features of the app first individually and then as a group. This resulted in a minimal viable product design, represented through low-fidelity hand-drawn wireframes. Clinicians were engaged throughout the process via focus groups.

RESULTS

The app incorporated a mood monitoring feature with innovative design aspects that allowed customization, and was named a "well-being tracker" in response to the need for a positive approach to this function. Brief personalized interventions designed to support young people in the intervals between face-to-face appointments were embedded in the app and were immediately available via pop-ups generated by a back-end algorithm within the well-being tracker. Issues regarding the safe incorporation of alerts generated by the app into face-to-face clinical services were raised by clinicians (ie, responding in a timely manner) and will need to be addressed during the full implementation of the app into clinical services.

CONCLUSIONS

The potential to improve outcomes for young people via technology-based enhancement to interventions is enormous. Enhancing communication between young people and their clinicians about symptoms and treatment progress and increasing access to timely and evidence-based interventions are desirable outcomes. To achieve positive outcomes for young people using technology- (app) based interventions, it is critical to understand and incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians.

A comparison of recommendations and received treatment for mood and anxiety disorders in a representative national sample

BACKGROUND

The exact nature of treatment and management recommendations made, and received, for mood and anxiety disorders in a community population is unclear. In addition, there is limited evidence on the impact of recommendations on actual receipt of treatment or implementation of management strategies. We aim to describe the frequency with which specific recommendations were made and implemented; and thus assess the size of any gap between the recommendation and implementation of treatments and management strategies.

METHODS

We used the Survey 'Living with a Chronic Condition in Canada - Mood and Anxiety Disorders (SLCDC-MA), a unique crossectional survey of a large (N = 3358) and representative sample of Canadians with a diagnosed mood or anxiety disorder, which was conducted by Statistics Canada. The survey collected information on recommendations for medication, counselling, exercise, reduction of alcohol consumption, smoking cessation and reduction of street drug use. We also estimate the frequency that recommendations are made and followed, as well the impact of the prior on the latter. We consulted people with lived experience of the disorders to help interpret our results.

RESULTS

The results generally showed that most people would receive recommendations, almost all for antidepressant medications (94.6%), with lower proportions for the other treatment and management strategies (e.g. 62.1 and 66% for counselling and exercise). Most recommendations were implemented and had an impact on behaviour. The exception to this was smoking reduction/cessation, which was often not recommended or followed through. Other than with medication, at least 20% of the population, for each recommendation, would not have their recommendation implemented. A substantive group also exists who access treatments, and employ various management strategies, without a recommendation.

CONCLUSIONS

The results indicate that there is a gap between recommendations made and the implementation of treatments. However, its size varies substantially across treatments.

Temporal trends in antidepressant prescribing to children in UK primary care, 2000-2015

BACKGROUND

The prevalence of antidepressant prescribing in children and adolescents increased steadily in the United States and parts of Europe between 2005 and 2012 despite regulatory safety warnings. Little is known about the characteristics of those being prescribed antidepressants for the first time.

METHODS

A longitudinal study of antidepressant prescribing in 3-17 year olds was carried out using data from the UK Clinical Practice Research Datalink (CPRD) between 2000 and 2015. Changes in the incidence of first ever antidepressant prescriptions and the characteristics of those being prescribed them was examined.

RESULTS

Incidence of first ever prescriptions nearly doubled between 2006 and 2015 rising from 1.60 (95%CI: 1.51, 1.69) to 3.12 (3.00, 3.25) per 1000 person years. Only 21% of the 1721 patients with incident prescriptions in 2015 could be linked to a depression diagnosis, with an additional 22% of prescriptions linked to alternative indications. The incidence of prescriptions linked to a depression diagnosis increased between 2012 and 2015, with an adjusted incidence rate ratio of 1.46 (1.26, 1.70). Antidepressant prescribing for depression and other indications has been increasing most rapidly in 15 to 17 year old females.

LIMITATIONS

Diagnoses are not directly linked to prescriptions in CPRD, so linkage must be inferred by temporal proximity.

CONCLUSIONS

Antidepressant prescribing in children increased between 2006 and 2015. This is, at least in part, due to a rise in alternative uses of antidepressants, including the treatment of anxiety, chronic pain and migraines.

Development of a Mobile Phone App to Support Self-Monitoring of Emotional Well-Being: A Mental Health Digital Innovation

BACKGROUND

Emotional well-being is a primary component of mental health and well-being. Monitoring changes in emotional state daily over extended periods is, however, difficult using traditional methodologies. Providing mental health support is also challenging when approximately only 1 in 2 people with mental health issues seek professional help. Mobile phone technology offers a sustainable means of enhancing self-management of emotional well-being.

OBJECTIVE

This paper aims to describe the development of a mobile phone tool designed to monitor emotional changes in a natural everyday context and in real time.

METHODS

This evidence-informed mobile phone app monitors emotional mental health and well-being, and it provides links to mental health organization websites and resources. The app obtains data via self-report psychological questionnaires, experience sampling methodology (ESM), and automated behavioral data collection.

RESULTS

Feedback from 11 individuals (age range 16-52 years; 4 males, 7 females), who tested the app over 30 days, confirmed via survey and focus group methods that the app was functional and usable.

CONCLUSIONS

Recommendations for future researchers and developers of mental health apps to be used for research are also presented. The methodology described in this paper offers a powerful tool for a range of potential mental health research studies and provides a valuable standard against which development of future mental health apps should be considered.

Comprehensive Online Self-Monitoring to Support Clinicians Manage Risk of Suicide in Youth Depression

BACKGROUND

Routine monitoring of depression symptoms and suicide risk is essential for appropriate treatment planning and risk management, but not well implemented by clinicians. We developed a brief online monitoring tool to address this issue.

AIMS

To investigate whether the online tool can feasibly improve monitoring; whether it is acceptable and useful for young people and their clinicians; and to determine whether a shorter tool could be implemented.

METHOD

In a naturalistic longitudinal cohort study, 101 young people with depression completed the online tool on a tablet, prior to their consultation. Their results were immediately available to their clinician. Clients and clinicians answered questionnaires about acceptability and usefulness.

RESULTS

The tool was feasible to implement. Young people and clinicians found the tool acceptable and useful for understanding symptoms and risk. A brief three-item suicidal ideation screening measure correlated well with a validated measure of suicidal ideation.

CONCLUSION

The online tool facilitates the quick exchange of key information about suicide risk, allowing clinicians to immediately address this. This level of responsiveness is likely to improve treatment outcomes. The brief version allows full integration into clinical practice to support clinicians managing those at risk of suicide.

The multidisciplinary depression guideline for children and adolescents: an implementation study

It is important that depressed patients receive adequate and safe care as described in clinical guidelines. The aim of this study was to evaluate the implementation of the Dutch depression guideline for children and adolescents, and to identify factors that were associated with the uptake of the guideline recommendations. The study took place in specialised child and adolescent mental healthcare. An implementation project was initiated to enhance the implementation of the guideline. An evaluation study was performed alongside the implementation project, using structured registration forms and interviews with healthcare professionals. Six multidisciplinary teams participated in the implementation study. The records of 655 patients were analysed. After 1 year, 72% of all eligible patients had been screened for depression and 38% were diagnosed with the use of a diagnostic instrument. The severity of the depression was assessed in 77% of the patients during the diagnostic process, and 41% of the patients received the recommended intervention based on the depression severity. Of the patients that received antidepressants, 25% received weekly checks for suicidal thoughts in the first 6 weeks. Monitoring of the patients' response was recorded in 32% of the patients. A wide range of factors were perceived to influence the uptake of guideline recommendations, e.g. the availability of capable professionals, available time, electronic tools and reminders, and the professionals' skills and attitudes. With the involvement of the teams, recommendations were provided for nationwide implementation of the guideline. In conclusion, a systematic implementation programme using stepped care principles for the allocation of depression interventions seems successful, but there remains room for further improvement.

Development and pilot testing of an online monitoring tool of depression symptoms and side effects for young people being treated for depression

AIM

To develop and examine the feasibility of an online monitoring tool of depressive symptoms, suicidality and side effects.

METHODS

The online tool was developed based on guideline recommendations, and employed already validated and widely used measures. Quantitative data about its use, and qualitative information on its functionality and usefulness were collected from surveys, a focus group and individual interviews.

RESULTS

Fifteen young people completed the tool between 1 and 12 times, and reported it was easy to use. Clinicians suggested it was too long and could be completed in the waiting room to lessen impact on session time. Overall, clients and clinicians who used the tool found it useful.

CONCLUSIONS

Results show that an online monitoring tool is potentially useful as a systematic means for monitoring symptoms, but further research is needed including how to embed the tool within clinical practice.

Attenuated psychosis syndrome: don't jump the gun

Attenuated psychosis syndrome (APS) was introduced in DSM-5 as a condition for further study. A number of concerns have been raised regarding APS, including its validity as a clinical entity, issues relating to stigma, the potential that it is an unnecessary diagnosis of what might be a self-limiting phase of attenuated psychotic symptoms, and treatment implications of the diagnosis. The current paper presents a number of conceptual and practical issues that should be addressed in deciding whether APS should be accepted as an official diagnosis in subsequent editions of DSM. These include the problem of transferring the established validity of 'at-risk' criteria to APS given some non-trivial differences between the criteria sets, the relationship between attenuated psychotic symptoms and other presenting non-psychotic disorders, the difficulties of operationalising the subthreshold or 'attenuated' concept in standard clinical practice, and the likelihood of the diagnosis leading to overprescription of antipsychotic medication for this group of patients.

Particular difficulties faced by GPs with young adults who will attempt suicide: a cross-sectional study

Background

Suicide is a major public health problem in young people. General Practitioners (GPs) play a central role in suicide prevention. However data about how physicians deal with suicidal youths are lacking. This study aims to compare young adult suicide attempters (from 18 to 39 years old) with older adults in a primary care setting.

Methods

A cross-sectional study was carried. All suicide attempts (N=270) reported to the French Sentinel surveillance System from 2009 to 2011 were considered. We conducted comparison of data on the last GP’s consultation and GPs’ management in the last three months between young adults and older adults.

Results

In comparison with older adults, young adults consulted their GP less frequently in the month preceding the suicidal attempt (40.9 vs. 64.6%, p=.01). During the last consultation prior to the suicidal attempt, they expressed suicidal ideas less frequently (11.3 vs. 21.9%, p=.03). In the year preceding the suicidal attempt, GPs identified depression significantly less often (42.0 vs. 63.4%, p=.001). In the preceding three months, GPs realized significantly less interventions: less psychological support (37.5 vs. 53.0%, p=.02), prescribed less antidepressants (28.6 vs. 54.8%, p<.0001) or psychotropic drugs (39.1 vs. 52.9%, p=.03) and made fewer attempts to refer to a mental health specialist (33.3 vs. 45.5%, p=.05).

Conclusion

With young adults who subsequently attempt suicide, GPs face particular difficulties compared to older adults, as a significant proportion of young adults were not seen in the previous six months, as GPs identified less depressions in the preceding year and were less active in managing in the preceding three months. Medical training and continuing medical education should include better instruction on challenges relative to addressing suicide risk in this particular population.