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Reilly S, Hobson-Merrett C, Gibbons B, Jones B, Richards D, Plappert H, Gibson J, Green M, Gask L, Huxley PJ, Druss BG, Planner CL. Collaborative care approaches for people with severe mental illness. Cochrane Database Syst Rev 2024; 5:CD009531. [PMID: 38712709 PMCID: PMC11075124 DOI: 10.1002/14651858.cd009531.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies. OBJECTIVES To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community. SEARCH METHODS We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021. SELECTION CRITERIA Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up. DATA COLLECTION AND ANALYSIS Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro. MAIN RESULTS Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years. AUTHORS' CONCLUSIONS This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.
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Affiliation(s)
- Siobhan Reilly
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Charley Hobson-Merrett
- Primary Care Plymouth, University of Plymouth, Plymouth, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Plymouth, UK
| | | | - Ben Jones
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Debra Richards
- Primary Care Plymouth, University of Plymouth, Plymouth, UK
| | - Humera Plappert
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | | | - Maria Green
- Pennine Health Care NHS Foundation Trust, Bury, UK
| | - Linda Gask
- Health Sciences Research Group, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Peter J Huxley
- Centre for Mental Health and Society, School of Health Sciences, Bangor University, Bangor, UK
| | - Benjamin G Druss
- Department of Health Policy and Management, Emory University, Atlanta, USA
| | - Claire L Planner
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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Ho JL, Roberts J, Payne GH, Holzum DN, Wilkoff H, Tran T, Cobb CD, Moore TD, Lee KC. Systematic literature review of the impact of psychiatric pharmacists. Ment Health Clin 2024; 14:33-67. [PMID: 38312443 PMCID: PMC10836561 DOI: 10.9740/mhc.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/01/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Pharmacists focusing on psychotropic medication management and practicing across a wide variety of healthcare settings have significantly improved patient-level outcomes. The Systematic Literature Review Committee of the American Association of Psychiatric Pharmacists was tasked with compiling a comprehensive database of primary literature highlighting the impact of psychiatric pharmacists on patient-level outcomes. Methods A systematic search of literature published from January 1, 1961, to December 31, 2022, was conducted using PubMed and search terms based on a prior American Association of Psychiatric Pharmacists literature review. Publications describing patient-level outcome results associated with pharmacist provision of care in psychiatric/neurologic settings and/or in relation to psychotropic medications were included. The search excluded articles for which there was no pharmacist intervention, no psychiatric disorder treatment, no clinical outcomes, no original research, no access to full text, and/or no English-language version. Results A total of 4270 articles were reviewed via PubMed, with 4072 articles excluded based on title, abstract, and/or full text in the initial pass and 208 articles selected for inclusion. A secondary full-text review excluded 11 additional articles, and 5 excluded articles were ultimately included based on a secondary review, for a final total of 202 articles meeting the inclusion criteria. A comprehensive database of these articles was compiled, including details on their study designs and outcomes. Discussion The articles included in the final database had a wide range of heterogeneity. While the overall impact of psychiatric pharmacists was positive, the study variability highlights the need for future publications to have more consistent, standardized outcomes with stronger study designs.
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Affiliation(s)
- Jessica L Ho
- Clinical Pharmacist, St. Peter Regional Treatment Center, St. Peter, Minnesota
- Director of Strategic Initiatives, American Association of Psychiatric Pharmacists, Lincoln, Nebraska
- Pain Management/Substance Use Disorder Clinical Pharmacy Practitioner, VISN 20 Clinical Resource Hub, Boise, Idaho
- Clinical Pharmacy Specialist- Behavioral Health, Adventist HealthCare Shady Grove Medical Center, Rockville, Maryland
- Medical Science Liaison, Medical Affairs, Braeuburn, Plymouth Meeting, Pennsylvania; Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois
- Founder and Consultant, Capita Consulting, Billings, Montana
- National Program Manager, Clinical Pharmacy, Clinical Practice Integration and Model Advancement Pharmacy Benefits Management (PBM), Colorado
- Professor of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California
| | - Jenna Roberts
- Clinical Pharmacist, St. Peter Regional Treatment Center, St. Peter, Minnesota
| | - Gregory H Payne
- Director of Strategic Initiatives, American Association of Psychiatric Pharmacists, Lincoln, Nebraska
| | - Dorothy N Holzum
- Pain Management/Substance Use Disorder Clinical Pharmacy Practitioner, VISN 20 Clinical Resource Hub, Boise, Idaho
| | - Hannah Wilkoff
- Clinical Pharmacy Specialist- Behavioral Health, Adventist HealthCare Shady Grove Medical Center, Rockville, Maryland
| | - Tran Tran
- Medical Science Liaison, Medical Affairs, Braeuburn, Plymouth Meeting, Pennsylvania; Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois
| | - Carla D Cobb
- Founder and Consultant, Capita Consulting, Billings, Montana
| | - Tera D Moore
- National Program Manager, Clinical Pharmacy, Clinical Practice Integration and Model Advancement Pharmacy Benefits Management (PBM), Colorado
| | - Kelly C Lee
- Professor of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California
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Taylor-Rowan M, Alharthi AA, Noel-Storr AH, Myint PK, Stewart C, McCleery J, Quinn TJ. Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment. Cochrane Database Syst Rev 2023; 12:CD015405. [PMID: 38063254 PMCID: PMC10704558 DOI: 10.1002/14651858.cd015405.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Anticholinergics are medications that block the action of acetylcholine in the central or peripheral nervous system. Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden. A high anticholinergic burden may cause cognitive impairment in people who are otherwise cognitively healthy, or cause further cognitive decline in people with pre-existing cognitive problems. Reducing anticholinergic burden through deprescribing interventions may help to prevent onset of cognitive impairment or slow the rate of cognitive decline. OBJECTIVES Primary objective • To assess the efficacy and safety of anticholinergic medication reduction interventions for improving cognitive outcomes in cognitively healthy older adults and older adults with pre-existing cognitive issues. Secondary Objectives • To compare the effectiveness of different types of reduction interventions (e.g. pharmacist-led versus general practitioner-led, educational versus audit and feedback) for reducing overall anticholinergic burden. • To establish optimal duration of anticholinergic reduction interventions, sustainability, and lessons learnt for upscaling • To compare results according to differing anticholinergic scales used in medication reduction intervention trials • To assess the efficacy of anticholinergic medication reduction interventions for improving other clinical outcomes, including mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, and neurobehavioral outcomes. SEARCH METHODS We searched CENTRAL on 22 December 2022, and we searched MEDLINE, Embase, and three other databases from inception to 1 November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions that aimed to reduce anticholinergic burden in older people and that investigated cognitive outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed the risk of bias of included studies. The data were not suitable for meta-analysis, so we summarised them narratively. We used GRADE methods to rate our confidence in the review results. MAIN RESULTS We included three trials with a total of 299 participants. All three trials were conducted in a cognitively mixed population (some cognitively healthy participants, some participants with dementia). Outcomes were assessed after one to three months. One trial reported significantly improved performance on the Digit Symbol Substitution Test (DSST) in the intervention group (treatment difference 0.70, 95% confidence interval (CI) 0.11 to 1.30), although there was no difference between the groups in the proportion of participants with reduced anticholinergic burden. Two trials successfully reduced anticholinergic burden in the intervention group. Of these, one reported no significant difference between the intervention versus control in terms of their effect on cognitive performance measured by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) immediate recall (mean between-group difference 0.54, 95% CI -0.91 to 2.05), CERAD delayed recall (mean between-group difference -0.23, 95% CI-0.85 to 0.38), CERAD recognition (mean between-group difference 0.77, 95% CI -0.39 to 1.94), and Mini-Mental State Examination (mean between-group difference 0.39, 95% CI -0.96 to 1.75). The other trial reported a significant correlation between anticholinergic burden and a test of working memory after the intervention (which suggested reducing the burden improved performance), but reported no effect on multiple other cognitive measures. In GRADE terms, the results were of very low certainty. There were no reported between-group differences for any other clinical outcome we investigated. It was not possible to investigate differences according to type of reduction intervention or type of anticholinergic scale, to measure the sustainability of interventions, or to establish lessons learnt for upscaling. No trials investigated safety outcomes. AUTHORS' CONCLUSIONS There is insufficient evidence to reach any conclusions on the effects of anticholinergic burden reduction interventions on cognitive outcomes in older adults with or without prior cognitive impairment. The evidence from RCTs was of very low certainty so cannot support or refute the hypothesis that actively reducing or stopping prescription of medications with anticholinergic properties can improve cognitive outcomes in older people. There is no evidence from RCTs that anticholinergic burden reduction interventions improve other clinical outcomes such as mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, or neurobehavioral outcomes. Larger RCTs investigating long-term outcomes are needed. Future RCTs should also investigate potential benefits of anticholinergic reduction interventions in cognitively healthy populations and cognitively impaired populations separately.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ahmed A Alharthi
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Clinical Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | | | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Belkacem A, Lavigne KM, Makowski C, Chakravarty M, Joober R, Malla A, Shah J, Lepage M. Effects of Anticholinergic Burden on Verbal Memory Performance in First-Episode Psychosis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2023; 68:894-903. [PMID: 37254533 PMCID: PMC10657580 DOI: 10.1177/07067437231179161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Antipsychotics are widely used to treat first-episode psychosis but may have an anticholinergic burden, that is, a cumulative effect of medications that block the cholinergic system. Studies suggest that a high anticholinergic burden negatively affects memory in psychosis, where cognitive deficits, particularly those in verbal memory, are a core feature of the disease. The present study sought to replicate this in a large cohort of well-characterized first-episode psychosis patients. We expected that patients in the highest anticholinergic burden group would exhibit the poorest verbal memory compared to those with low anticholinergic burden and healthy controls at baseline (3 months following admission). We further hypothesized that over time, at month 12, patients' verbal memory performance would improve but would remain inferior to controls. METHODS Patients (n = 311; low anticholinergic burden [n = 241] and high anticholinergic burden [n = 70], defined by a Drug Burden Index cut-off of 1) and healthy controls (n = 128) completed a clinical and neurocognitive battery including parts of the Wechsler Memory Scale at months 3 and 12. RESULTS Cross-sectionally, using an analysis of variance, patients in the highest anticholinergic burden group had the poorest performance in verbal memory when compared to the other groups at month 3, F(2,430) = 52.33, P < 0.001. Longitudinally, using a Generalized Estimating Equation model, the verbal memory performance of all groups improved over time. However, patients' performance overall remained poorer than the controls. CONCLUSION These findings highlight the importance of considering the anticholinergic burden when prescribing medications in the early stages of the disease.
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Affiliation(s)
- Agnès Belkacem
- Douglas Research Centre, McGill University, Montreal, Canada
| | - Katie M. Lavigne
- Douglas Research Centre, McGill University, Montreal, Canada
- Montreal Neurological Institute-Hospital, McGill University, Montreal, Canada
| | - Carolina Makowski
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
| | | | - Ridha Joober
- Douglas Research Centre, McGill University, Montreal, Canada
| | - Ashok Malla
- Douglas Research Centre, McGill University, Montreal, Canada
| | - Jai Shah
- Douglas Research Centre, McGill University, Montreal, Canada
| | - Martin Lepage
- Douglas Research Centre, McGill University, Montreal, Canada
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Ashkanani FZ, Rathbone AP, Lindsey L. The role of pharmacists in deprescribing benzodiazepines: A scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100328. [PMID: 37743854 PMCID: PMC10511800 DOI: 10.1016/j.rcsop.2023.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/14/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023] Open
Abstract
Background Polypharmacy can increase the risk of adverse drug events, hospitalisation, and unnecessary healthcare costs. Evidence indicates that discontinuing certain medications, such as benzodiazepines, can improve health outcomes, by resolving adverse drug effects. This scoping review aims to explore the pharmacists' role in deprescribing benzodiazepines. Method A scoping review has been conducted to distinguish and map the literature, discover research gaps, and focus on targeted areas for future studies and research. A systematic search strategy was conducted to identify relevant studies from PubMed, Medline, and EMBASE databases. The eligibility criteria involved studies that focused on the role of pharmacists in benzodiazepine deprescribing, quantitative and qualitative studies conducted in humans, full-text articles published in English. Results Twenty studies were identified, revealing three themes: 1) pharmacists' involvement in benzodiazepine deprescribing, 2) the impact of their involvement, and 3) obstacles impeding the process. Pharmacists involved in deprescribing procedures, mainly through completing medication reviews, collaborative work with other healthcare providers, and education. Pharmacists' involvement in benzodiazepine deprescribing intervention led to better health and economic outcomes. Withdrawal symptoms after medication discontinuation, dependence on medication, and lack of time and guidelines were identified in the literature as barriers to deprescribing. Conclusion Pharmacists' involvement in deprescribing benzodiazepines is crucial for optimizing medication therapy. This scoping review examines the pharmacists' role in benzodiazepine deprescribing. The findings contribute to enhancing healthcare outcomes and guiding future research in this area.
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Affiliation(s)
- Fatemah Zakariya Ashkanani
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Adam Pattison Rathbone
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Laura Lindsey
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
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Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
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Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
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Ng R, El-Den S, Stewart V, Collins JC, Roennfeldt H, McMillan SS, Wheeler AJ, O'Reilly CL. Pharmacist-led interventions for people living with severe and persistent mental illness: A systematic review. Aust N Z J Psychiatry 2022; 56:1080-1103. [PMID: 34560826 DOI: 10.1177/00048674211048410] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE People living with severe and persistent mental illness experience poorer physical health, often due to medication and preventable lifestyle factors, and exacerbated by barriers to accessing healthcare services. Pharmacists are well-positioned to improve the physical and mental health of this population. However, little is known about pharmacists' current practices when providing services to this population nor the impact of pharmacist-led interventions on consumer health outcomes. We undertook a systematic review to identify, describe and assess the effectiveness of pharmacist-led interventions for supporting people living with severe and persistent mental illness and the impact on consumer outcomes. METHODS MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts and ProQuest Dissertations and Theses were searched between January 1990 and April 2020. Full-text studies exploring pharmacist-led interventions in any setting for people living with severe and persistent mental illness were included. A risk of bias assessment was conducted. RESULTS A total of 37 studies were included. More than half of the pharmacist interventions were multifaceted. The most common components of pharmacist-led interventions included education and/or patient counselling, providing recommendations to healthcare professionals and conducting medication reviews. Multifaceted interventions demonstrated improvements in clinical outcomes, whereas single interventions focused mostly on consumer-reported outcomes. The methodological quality of included studies was moderate-to-high risk of bias and there was considerable heterogeneity in the study design, interventions described, and outcomes reported. CONCLUSION There is evidence that pharmacist-led interventions improve consumer-reported and clinical outcomes for people living with severe and persistent mental illness. Pharmacists are capable and have a role in supporting people living with severe and persistent mental illness, either individually or as interprofessional collaborators with other healthcare professionals. Future research should attempt to better understand which particular intervention components have the greatest impact and also evaluate the implementation and long-term sustainability of such interventions.
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Affiliation(s)
- Ricki Ng
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Sarira El-Den
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Victoria Stewart
- School of Health Sciences and Social Work, Griffith University, Brisbane, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Jack C Collins
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Helena Roennfeldt
- Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia.,Centre for Psychiatric Nursing, The University of Melbourne, Melbourne, VIC, Australia
| | - Sara S McMillan
- Health Systems Menzies Health Institute Queensland, School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD, Australia
| | - Amanda J Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia.,Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Claire L O'Reilly
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
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Laurin A, Bonjour M, Galvao F, Dubien Berbey C, Sauvaget A, Bulteau S. The anticholinergic burden is not associated with cognitive impairments in patients treated by electroconvulsive therapy for treatment-resistant depression. J Psychiatr Res 2022; 150:87-95. [PMID: 35366599 DOI: 10.1016/j.jpsychires.2022.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/03/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is the most effective non-pharmacological treatment for treatment-resistant depression (TRD) but can expose to transient cognitive impairments. Understanding factors underlying these cognitive side effects is important. This study investigated the impact of anticholinergic treatments on cognitive performances after ECT courses for TRD in naturalistic condition. METHODS Impact of anticholinergic burden (Anticholinergic Impregnation Scale, AIS) on cognitive changes (Montreal Cognitive Assessment, MoCA) adjusted on depression level (Montgomery and Asberg Depression Scale, MADRS) was investigated in 42 patients who received an ECT course between 2017 and 2020 for unipolar or bipolar TRD. Collection of daily treatments given during ECT was carried out via the computerized traceability of treatments validated by nurses. RESULTS Among the 31 treatments identified with an anticholinergic score, which represent only 38% of total treatments, the three most frequently given treatments were Lorazepam (47%), Venlafaxine (36%) and Cyamemazine (26%). Delayed recall was the most frequently impaired cognitive function after ECT courses. Using logistic regression, we found no association between the anticholinergic burden and the decrease in cognitive scores after ECT courses, adjusted on MADRS score evolution (p > 0.1). Conversely, improvement in MADRS scores were correlated with improvement in attention MoCA subscores. LIMITATIONS This is a retrospective monocentric study with a moderate sample size using anticholinergic scales to calculate the anticholinergic burden without plasma dosage. CONCLUSION Anticholinergic treatments did not seem to explain ECT-related cognitive impairments. This warrants further large prospective investigations including different measures of anticholinergic burden.
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Affiliation(s)
- Andrew Laurin
- CHU de Nantes, F-44000, Nantes, France; Laboratoire 'Mouvement, Interactions, Performance' (MIP), EA 4334, Nantes Université, F-44000, Nantes, France.
| | - Maxime Bonjour
- Hospices Civils de Lyon, F-69000, Lyon, France; Université Claude Bernard Lyon 1, F-69000, Lyon, France
| | - Filipe Galvao
- Centre Hospitalier Le Vinatier, F-69678, Bron, France
| | | | - Anne Sauvaget
- CHU de Nantes, F-44000, Nantes, France; Laboratoire 'Mouvement, Interactions, Performance' (MIP), EA 4334, Nantes Université, F-44000, Nantes, France
| | - Samuel Bulteau
- CHU de Nantes, F-44000, Nantes, France; INSERM U1246 SPHERE 'methodS in Patient-centered outcomes and Health ResEarch', Nantes Université, F-44000, Nantes, France
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Ramos H, Moreno L, Pérez-Tur J, Cháfer-Pericás C, García-Lluch G, Pardo J. CRIDECO Anticholinergic Load Scale: An Updated Anticholinergic Burden Scale. Comparison with the ACB Scale in Spanish Individuals with Subjective Memory Complaints. J Pers Med 2022; 12:jpm12020207. [PMID: 35207695 PMCID: PMC8876932 DOI: 10.3390/jpm12020207] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Abstract
The increase in life expectancy has also been accompanied by an increase in the use of medication to treat chronic diseases. Polypharmacy is associated with medication-related problems such as the increase in the anticholinergic burden. Older people are more susceptible to anticholinergic effects on the central nervous system and this, in turn, may be related to cognitive impairment. In this paper, we develop an updated anticholinergic burden scale, the CRIDECO Anticholinergic Load Scale (CALS) via a systematic review of the literature and compare it with the currently most used Anticholinergic Burden Scale (ACB). Our new scale includes 217 different drugs with anticholinergic properties, 129 more than the ACB. Given the effect that anticholinergic medications have on cognitive performance, we then used both scales to investigate the relationship between anticholinergic burden and cognitive impairment in adult Spanish subjects with subjective memory complaint. In our population, we observed an association between cognitive impairment and the anticholinergic burden when measured by the new CALS, but not when the ACB was applied. The use of a more comprehensive and upgraded scale will allow better discrimination of the risk associated with the use of anticholinergic medications on cognitive impairment. CALS can help raise awareness among clinicians of the problems associated with the use of medications, or combinations of them, with large anticholinergic effect, and promote a better personalized pharmacological approach for each patient.
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Affiliation(s)
- Hernán Ramos
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Department of Pharmacy, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Lucrecia Moreno
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Department of Pharmacy, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Jordi Pérez-Tur
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Institut de Biomedicina de València-CSIC, CIBERNED, Unitat Mixta de Neurologia i Genetica, IIS La Fe, 46010 Valencia, Spain
| | - Consuelo Cháfer-Pericás
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Alzheimer Disease Research Group, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Gemma García-Lluch
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Alzheimer Disease Research Group, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Juan Pardo
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Embedded Systems and Artificial Intelligence Group, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
- Correspondence:
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10
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Bužančić I, Kummer I, Držaić M, Ortner Hadžiabdić M. Community-based pharmacists' role in deprescribing: A systematic review. Br J Clin Pharmacol 2021; 88:452-463. [PMID: 34155673 DOI: 10.1111/bcp.14947] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/15/2021] [Accepted: 05/30/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS Community-based pharmacists are an important stakeholder in providing continuing care for chronic multi-morbid patients, and their role is steadily expanding. The aim of this study is to examine the literature exploring community-based pharmacist-initiated and/or -led deprescribing and to evaluate the impact on the success of deprescribing and clinical outcomes. METHODS Library and clinical trials databases were searched from inception to March 2020. Studies were included if they explored deprescribing in adults, by community-based pharmacists and were available in English. Two reviewers extracted data independently using a pre-agreed data extraction template. Meta-analysis was not performed due to heterogeneity of study designs, types of intervention and outcomes. RESULTS A total of 24 studies were included in the review. Results were grouped based on intervention method into four categories: educational interventions; interventions involving medication review, consultation or therapy management; pre-defined pharmacist-led deprescribing interventions; and pharmacist-led collaborative interventions. All types of interventions resulted in greater discontinuation of medications in comparison to usual care. Educational interventions reported financial benefits as well. Medication review by community-based pharmacist can lead to successful deprescribing of high-risk medication, but do not affect the risk or rate of falls, rate of hospitalisations, mortality or quality of life. Pharmacist-led medication review, in patients with mental illness, resulting in deprescribing improves anticholinergic side effects, memory and quality of life. Pre-defined pharmacist-led deprescribing did not reduce healthcare resource consumptions but can contribute to financial savings. Short follow-up periods prevent evaluation of long-term sustainability of deprescribing interventions. CONCLUSION This systematic review suggests community-based pharmacists can lead deprescribing interventions and that they are valuable partners in deprescribing collaborations, providing necessary monitoring throughout tapering and post-follow-up to ensure the success of an intervention.
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Affiliation(s)
- Iva Bužančić
- City Pharmacies Zagreb, Zagreb, Croatia.,Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Ingrid Kummer
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Prague, Czech Republic
| | - Margita Držaić
- City Pharmacies Zagreb, Zagreb, Croatia.,Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
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11
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Noel J, Viswanathan SA, Kuruvilla A. Nature and Correlates of Executive Dysfunction in Schizophrenia: An Exploratory Study. Indian J Psychol Med 2021; 43:16-23. [PMID: 34349302 PMCID: PMC8295581 DOI: 10.1177/0253717620929494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Executive function (EF) impairment has been demonstrated in patients with schizophrenia. This study attempted to examine the clinical and demographic correlates associated with the different components of EF in these patients using a comprehensive battery of neuropsychological tests. MATERIALS AND METHODS Consecutive inpatients with schizophrenia in remission were recruited. The following instruments were administered: (a) Positive and Negative Syndrome Scale (PANSS), (b)World Health Organization Disability Assessment Schedule 2.0, (c) Tower of London, (d) Stroop Test, (e) Controlled Oral Word Association Test, (f) Animal Names Test, and (g) Verbal N-Back Test. Sociodemographic and clinical details were also recorded. Data was analyzed using standard bivariate and multivariate statistics. RESULTS A total of 50 patients were recruited. The mean age of the population was 30 years (standard deviation [SD]: 7.74). The majority were male, literate, single, from a rural background, from a middle socioeconomic background, and unemployed. The mean dose of antipsychotic medication was 618.57 mg (SD: 282.08) of chlorpromazine equivalents per day. Impairment was found in the different sub-components of EF. On multivariate analysis, factors significantly associated with executive dysfunction were lower education, unemployment, lower income, positive PANSS score, higher antipsychotic dose, and history of treatment with electroconvulsive therapy. CONCLUSION EFs encompass a wide range of cognitive processes that influence an individual's ability to adapt and function in the society. These are often impaired in patients with schizophrenia. Clinicians need to be aware of these deficits and factors associated with them, to plan appropriate and effective remedial measures.
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Affiliation(s)
- Joseph Noel
- Dept. of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Anju Kuruvilla
- Dept. of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
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12
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Werremeyer A, Bostwick J, Cobb C, Moore TD, Park SH, Price C, McKee J. Impact of pharmacists on outcomes for patients with psychiatric or neurologic disorders. Ment Health Clin 2020; 10:358-380. [PMID: 33224694 PMCID: PMC7653731 DOI: 10.9740/mhc.2020.11.358] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Psychiatric and neurologic illnesses are highly prevalent and are often suboptimally treated. A 2015 review highlighted the value of psychiatric pharmacists in improving medication-related outcomes. There is a need to describe areas of expansion and strengthened evidence regarding pharmacist practice and patient care impact in psychiatric and neurologic settings since 2015. METHODS A systematic search of literature published from January 2014 to June 2019 was conducted. Publications describing patient-level outcome results associated with pharmacist provision of care in a psychiatric/neurologic setting and/or in relation to central nervous system (CNS) medications were included. RESULTS A total of 64 publications were included. There was significant heterogeneity of published study methods and data, prohibiting meta-analysis. Pharmacists practicing across a wide variety of health care settings with focus on CNS medication management significantly improved patient-level outcomes, such as medication adherence, disease control, and avoidance of hospitalization. The most common practice approach associated with significant improvement in patient-level outcomes was incorporation of psychiatric pharmacist input into the interprofessional health care team. DISCUSSION Pharmacists who focus on psychiatric and neurologic disease improve outcomes for patients with these conditions. This is important in the current health care environment as most patients with psychiatric or neurologic conditions continue to have unmet needs. Additional studies designed to measure pharmacists' impact on patient-level outcomes are encouraged to strengthen these findings.
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Affiliation(s)
- Amy Werremeyer
- Associate Professor, School of Pharmacy, North Dakota State University, Fargo, North Dakota,
| | - Jolene Bostwick
- Clinical Professor and Associate Chair, University of Michigan College of Pharmacy, Ann Arbor, Michigan
| | - Carla Cobb
- Owner and Consultant, Capita Consulting, Billings, Montana
| | - Tera D Moore
- National Pharmacy Benefits Management Program Manager, Clinical Practice Integration and Model Advancement, Clinical Pharmacy Practice Office, Pharmacy Benefits Management Services, US Department of Veterans Affairs, Washington, DC
| | - Susie H Park
- Associate Professor, School of Pharmacy, University of Southern California, Los Angeles, California
| | - Cristofer Price
- Clinical Pharmacy Program Manager - Mental Health, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Jerry McKee
- CEO and Lead Consultant, Psychopharm Solutions LLC, Morganton, North Carolina
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13
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Nathisuwan S, Pattharachayakul S, Subongkot S, Doungngern T, Jones SM, Engle JP, Lau A, Katz MD, Moreton JE, Ryan M. U.S.‐Thai Consortium for the development of pharmacy education in Thailand: History, progress, and impact. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | | | - Suphat Subongkot
- Faculty of Pharmaceutical Sciences Khon Kaen University Khon Kaen Thailand
| | - Thitima Doungngern
- Faculty of Pharmaceutical Sciences Prince of Songkla University Songkla Thailand
| | - Sirada M. Jones
- School of Pharmacy University of Wisconsin Madison Wisconsin USA
| | - Janet P. Engle
- Office of the Executive Director Accreditation Council for Pharmacy Education (ACPE) Chicago Illinois USA
| | - Alan Lau
- College of Pharmacy University of Illinois at Chicago Chicago Illinois USA
| | - Michael D. Katz
- College of Pharmacy University of Arizona Tucson Arizona USA
| | | | - Melody Ryan
- College of Pharmacy University of Kentucky Lexington Kentucky USA
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Biperiden Selectively Impairs Verbal Episodic Memory in a Dose- and Time-Dependent Manner in Healthy Subjects. J Clin Psychopharmacol 2020; 40:30-37. [PMID: 31834098 DOI: 10.1097/jcp.0000000000001157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE/BACKGROUND Biperiden is a muscarinic antagonist that produces memory impairments without impairing attention or motor functions in healthy subjects. It has been suggested that a biperiden-induced memory deficit could model age- and dementia-related memory impairments. The goal of the current study was to determine the dose- and time-dependent effects of biperiden on cognition in healthy volunteers. METHODS/PROCEDURES Twenty-one healthy volunteers participated in a placebo-controlled, 3-way, crossover study. After a baseline test, cognitive performance was tested at 3 time points after a single dose of biperiden 2 or 4 mg, or placebo. Episodic memory was measured using a 15-word verbal learning task (VLT). Furthermore, n-back tasks, a sustained attention to response task and a reaction time task were used, as well as subjective alertness and a side effects questionnaire. In addition, blood serum values and physiological measures were taken. FINDINGS/RESULTS Biperiden decreased the number of words recalled in immediate and delayed recall of the VLT 90 minutes after drug intake. A dose-dependent impairment was found for the delayed recall, whereas the immediate recall was equally impaired by the 2 doses. Biperiden did not affect the performance on the VLT 4 hours after administration. Performance in the n-back task and the sustained attention to response task were not affected by biperiden at any time point. Both doses were well tolerated as reported side effects were mild at Tmax and were minimal at the other time points. IMPLICATIONS/CONCLUSIONS Biperiden exerts effects on episodic memory without negatively affecting other cognitive performance and behavioral measures that were assessed in this study. The data provide further evidence that biperiden has selective effects on cognition, even after a high dose.
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López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci 2019; 13:1309. [PMID: 31866817 PMCID: PMC6908498 DOI: 10.3389/fnins.2019.01309] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/22/2019] [Indexed: 12/31/2022] Open
Abstract
Drugs with anticholinergic action are widely prescribed in the elderly population due to their potential clinical benefits. However, these benefits are limited by adverse effects which may be serious in particular circumstances. This review presents different aspects of the use of anticholinergics in old age with a focus in psychogeriatric patients. We critically review published data on benefits and disadvantages of anticholinergics, which are often controversial. Prevalence, pathophysiology and measurement methods of the anticholinergic action of drugs are discussed. We also present the most important drawbacks resulting from its use, including effects on cognition in healthy and cognitively impaired people, in aged schizophrenia patients, emergence of delirium and psychiatric symptoms, influence in functionality, hospitalization, institutionalization and mortality, and the potential benefits and limitations of their discontinuation. Finally, we suggest practical recommendations for the safe use of anticholinergics in clinical conditions affecting elderly patients, such as dementia, schizophrenia and acute hallucinatory episodes, depression, anxiety, Parkinson's disease, cardiovascular conditions and urinary incontinence.
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Affiliation(s)
- Jorge López-Álvarez
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Julia Sevilla-Llewellyn-Jones
- Instituto de Psiquiatría y Salud Mental, Hospital Clínico San Carlos, Madrid, Spain.,Instituto de Investigación (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Luis Agüera-Ortiz
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, Ministry of Science and Innovation, Madrid, Spain.,Departamento de Medicina Legal, Psiquiatría y Patología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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