What works for whom, how and why in mental health education for undergraduate health profession students? A realist synthesis protocol

INTRODUCTION

It has been shown that mental health education can support positive attitudes of health profession students towards people with mental health challenges, which supports them to provide optimal healthcare to this group. There are many different approaches to designing and delivering mental health education to health profession students. Each has their own advantages and disadvantages, and often mental health education programmes incorporate a multimodal approach in order to reap the benefits of a variety of teaching and learning approaches. The aim of this study is to understand the current landscape of teaching and learning approaches to mental health education for undergraduate health profession students. We will examine the features of successful outcomes for health profession students for:Learning environment.Knowledge development and retention.Confidence.

MOTIVATION

Preparedness for professional practice.

METHODS

For this, a realist synthesis has been chosen in order to review the literature. Realist synthesis lends itself to the review of complex interventions such as mental health education for undergraduate health profession curricula because it seeks to uncover the range of different mechanisms and context configurations that produce different outcomes. Health profession education and education practice, in general, is complex. A patient and public involvement (PPI) group is involved throughout this study and includes undergraduate health profession students, and members of the St John of Gods Hospital Consumers and Carers Council who are involved at every stage of the research. This study will engage with a stakeholder group who will support the refining of the programme theory.

ETHICS AND DISSEMINATION

Ethical approval has been sought and approved by Royal College of Surgeons, Ireland Ethical Committee (REC number: 212622783). We will aim to write up and publish the full synthesis as a journal article. We will also discuss ways of dissemination outside of academia with our PPI group.

Pharmacist-led medicines optimisation service in an inpatient mental health setting

Medicines optimisation ensures that people get the best possible outcomes from their medicines. As those with severe mental illness (SMI) are frequently prescribed psychotropic medicines with potentially significant side-effects, poor adherence to treatment and physical morbidity are common. This results in suboptimal symptom control, physical health problems and negative health outcomes. The specialist mental health pharmacist (SMHP) is best placed to provide leadership for medicines optimisation in the inpatient mental health setting. By adopting a patient-centred approach to providing information, improving adherence, screening, initiating and maintaining medicines, and supporting self-advocacy, the SMHP can ensure the patients' experience of taking medicines is optimised. As there is currently limited understanding of what a baseline clinical pharmacy service in a mental health setting looks like, we aim to outline a framework for pharmacist-led medicines optimisation for those with SMI. This framework is suitable to be scaled and adapted to other settings.

Cognitive decrements in 1991 Gulf War veterans: associations with Gulf War illness and neurotoxicant exposures in the Boston Biorepository, Recruitment, and Integrative Network (BBRAIN) cohorts

BACKGROUND

During deployment, veterans of the 1991 Gulf War (GW) were exposed to multiple war-related toxicants. Roughly a third of these veterans continue to exhibit neurotoxicant induced symptoms of Gulf War Illness (GWI), a multi-faceted condition that includes fatigue, pain and cognitive decrements. When studied empirically, both deployed veterans with exposures and those who meet the criteria for GWI are more likely to show deficits in the area of neuropsychological functioning. Although studies have shown cognitive impairments in small sample sizes, it is necessary to revisit these findings with larger samples and newer cohorts to see if other areas of deficit emerge with more power to detect such differences. A group of researchers and clinicians with expertise in the area of GWI have identified common data elements (CDE) for use in research samples to compare data sets. At the same time, a subgroup of researchers created a new repository to share these cognitive data and biospecimens within the GWI research community.

METHODS

The present study aimed to compare cognitive measures of attention, executive functioning, and verbal memory in a large sample of GWI cases and healthy GW veteran controls using neuropsychological tests recommended in the CDEs. We additionally subdivided samples based on the specific neurotoxicant exposures related to cognitive deficits and compared exposed versus non-exposed veterans regardless of case criteria status. The total sample utilized cognitive testing outcomes from the newly collated Boston, Biorepository, Recruitment, and Integrative Network (BBRAIN) for GWI.

RESULTS

Participants included 411 GW veterans, 312 GWI (cases) and 99 healthy veterans (controls). Veterans with GWI showed significantly poorer attention, executive functioning, learning, and short-and-long term verbal memory than those without GWI. Further, GW veterans with exposures to acetylcholinesterase inhibiting pesticides and nerve gas agents, had worse performance on executive function tasks. Veterans with exposure to oil well fires had worse performance on verbal memory and those with pyridostigmine bromide anti-nerve gas pill exposures had better verbal memory and worse performance on an attention task compared to unexposed veterans.

CONCLUSIONS

This study replicates prior results regarding the utility of the currently recommended CDEs in determining impairments in cognitive functioning in veterans with GWI in a new widely-available repository cohort and provides further evidence of cognitive decrements in GW veterans related to war-related neurotoxicant exposures.

Pharmacy student attitudes to mental illness and the provision of mental health care: a repeated cross-sectional survey

BACKGROUND

Attitudes to mental illness are an important factor in the willingness of professionals to engage in mental health care.

AIM

The aim of this study was to understand attitudes of undergraduate pharmacy students in Ireland to severe mental illness and the provision of medicines optimisation services as well as the variation in these attitudes throughout the undergraduate course.

METHOD

A survey instrument was compiled using existing published research and validated questionnaires. The survey was distributed to students in their first, third and Master of Pharmacy years annually between 2014 and 2019. Although designed as a longitudinal study, following the matching process there were a limited number of students who completed more than one survey and therefore data were treated as independent samples.

RESULTS

The overall average response rate was 25% per survey (n = 191 participants) Notwithstanding generally positive attitudes, a sizeable proportion of students felt people with severe depression and schizophrenia were hard to talk to (n = 48, 25.3%; n = 54, 29.2%) Less than half of MPharm students expressed confidence and competence in caring for people with more severe mental illnesses such as bipolar disorder and schizophrenia and 29% (n = 60) of students would feel awkward asking someone about their antipsychotic medication. Almost two thirds (n = 120, 63.8%) expressed an interest in a career in mental health.

CONCLUSION

Irish pharmacy students have generally positive attitudes towards people with severe mental illness and provision of medicines optimisation services. There is an opportunity to improve pharmacy graduates perceived competence and confidence to provide mental health services.

Cardiometabolic risk in people under 40 years with severe mental illness: reading between the guidelines

People with severe mental illness (SMI) have a shorter life expectancy than the rest of the population. Multimorbidity and poorer physical health contribute to this health inequality. Cardiometabolic multimorbidity confers a significant mortality risk in this population. Multimorbidity is not restricted to older people and people with SMI present with multimorbidity earlier in life. Despite this, most screening, prevention and treatment strategies target older people. People under 40 years with SMI are underserved by current guidelines for cardiovascular risk assessment and reduction. Research is needed to develop and implement interventions to reduce cardiometabolic risk in this population.

Priorities for future research on reducing and stopping psychiatric medicines using a James Lind Alliance priority setting partnership: The PROTECT study protocol

Background: There is a growing number of service users looking to discontinue use of psychiatric medicines. Tapering is the recommended approach for reducing and/or discontinuing the use of psychiatric medicines. This involves gradually reducing the dose over time to minimise the potential for withdrawal symptoms. However, many uncertainties exist regarding the process of reducing and stopping psychiatric medicines. This study will use a James Lind Alliance Priority Setting Partnership to determine the Top 10 unanswered questions and uncertainties about reducing and stopping psychiatric medicines. Methods : The Priority Setting Partnership will be conducted using the James Lind Alliance methodology. It will involve seven stages: (i) creating an international Steering Group of representatives from key stakeholder groups that will include people with lived experience of taking and/or stopping psychiatric medicines, family members, carers/supporters and healthcare professionals, and identifying potential partners to support key activities (e.g. dissemination); (ii) gathering uncertainties about reducing and stopping psychiatric medicines from key stakeholders using an online survey; (iii) data processing and summarising the survey responses; (iv) checking the summary questions against existing evidence and verifying uncertainties; (v) shortlisting the questions using a second online survey; (vi) determining the Top 10 research questions through an online prioritisation workshop; (vii) disseminating results. Conclusions : This study will use a Priority Setting Partnership to generate a Top 10 list of research questions and uncertainties about reducing and stopping psychiatric medicines. This list will help to guide future research and deliver responsive and strategic allocation of research resources, with a view to ultimately improving the future health and well-being of individuals who are taking psychiatric medicines.

The development and validation of a medicines optimisation tool to protect the physical health of people with severe mental illness (OPTIMISE)

BACKGROUND

The life expectancy of people with severe mental illness (SMI) is shorter than those without SMI, with multimorbidity and poorer physical health contributing to health inequality. Screening tools could potentially assist the optimisation of medicines to protect the physical health of people with SMI. The aim of our research was to design and validate a medicines optimisation tool (OPTIMISE) to help clinicians to optimise physical health in people with SMI.

METHODS

A review of existing published guidelines, PubMed and Medline was carried out. Literature was examined for medicines optimisation recommendations and also for reference to the management of physical illness in people with mental illness. Potential indicators were grouped according to physiological system. A multidisciplinary team with expertise in mental health and the development of screening tools agreed that 83 indicators should be included in the first draft of OPTIMISE. The Delphi consensus technique was used to develop and validate the contents. A 17-member multidisciplinary panel of experts from the UK and Ireland completed 2 rounds of Delphi consensus, rating their level of agreement to 83 prescribing indicators using a 5-point Likert scale. Indicators were accepted for inclusion in the OPTIMISE tool after achieving a median score of 1 or 2, where 1 indicated strongly agree and 2 indicated agree, and 75^th centile value of ≤ 2. Interrater reliability was assessed among 4 clinicians across 20 datasets and the chance corrected level of agreement (kappa) was calculated. The kappa statistic was interpreted as poor if 0.2 or less, fair if 0.21-0.4, moderate if 0.41-0.6, substantial if 0.61-0.8, and good if 0.81-1.0.

RESULTS

Consensus was achieved after 2 rounds of Delphi for 62 prescribing indicators where 53 indicators were accepted after round 1 and a further 9 indicators were accepted after round 2. Interrater reliability of OPTIMISE between physicians and pharmacists indicated a substantial level of agreement with a kappa statistic of 0.75.

CONCLUSIONS

OPTIMISE is a 62 indicator medicines optimisation tool designed to assist decision making in those treating adults with SMI. It was developed using a Delphi consensus methodology and interrater reliability is substantial. OPTIMISE has the potential to improve medicines optimisation by ensuring preventative medicines are considered when clinically indicated. Further research involving the implementation of OPTIMISE is required to demonstrate its true benefit.

TRIAL REGISTRATION

This article does not report the results of a health care intervention on human participants.

Metformin in the management of antipsychotic-induced weight gain in adults with psychosis: development of the first evidence-based guideline using GRADE methodology

BACKGROUND

Adjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin's place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.

OBJECTIVE

To produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.

METHODS

A list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be 'adopted or adapted' from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008-2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

FINDINGS

We confirmed that no published guideline-of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.

CONCLUSION

All 11 recommendations and 7 supporting good practice developed here were formulated de novo.

CLINICAL IMPLICATIONS

These recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.

Boston biorepository, recruitment and integrative network (BBRAIN): A resource for the Gulf War Illness scientific community

AIMS

Gulf War Illness (GWI), a chronic debilitating disorder characterized by fatigue, joint pain, cognitive, gastrointestinal, respiratory, and skin problems, is currently diagnosed by self-reported symptoms. The Boston Biorepository, Recruitment, and Integrative Network (BBRAIN) is the collaborative effort of expert Gulf War Illness (GWI) researchers who are creating objective diagnostic and pathobiological markers and recommend common data elements for GWI research.

MAIN METHODS

BBRAIN is recruiting 300 GWI cases and 200 GW veteran controls for the prospective study. Key data and biological samples from prior GWI studies are being merged and combined into retrospective datasets. They will be made available for data mining by the BBRAIN network and the GWI research community. Prospective questionnaire data include general health and chronic symptoms, demographics, measures of pain, fatigue, medical conditions, deployment and exposure histories. Available repository biospecimens include blood, plasma, serum, saliva, stool, urine, human induced pluripotent stem cells and cerebrospinal fluid.

KEY FINDINGS

To date, multiple datasets have been merged and combined from 15 participating study sites. These data and samples have been collated and an online request form for repository requests as well as recommended common data elements have been created. Data and biospecimen sample requests are reviewed by the BBRAIN steering committee members for approval as they are received.

SIGNIFICANCE

The BBRAIN repository network serves as a much needed resource for GWI researchers to utilize for identification and validation of objective diagnostic and pathobiological markers of the illness.

Impact of left heart disease risk factors on risk stratification and treatment response in pulmonary arterial hypertension

Background

Contemporary registries have documented a change in the epidemiology of PAH patients displaying increasing co-morbidities associated with left heart disease (LHD). These patients are often excluded from randomized clinical trials. It is unclear whether the presence of LHD comorbidities may adversely impact the accuracy of risk stratification and response to PAH therapy.

Method

Data was extracted from the Pulmonary Hypertension Society of Australia and New Zealand registry for incident patients with a diagnosis with idiopathic/heritable/toxin-induced (I/H/D)-PAH and connective tissue disease (CTD) associated PAH from 2011 - 2020. Patients without available medication and follow up data were excluded. We used the AMBITION trial exclusion criteria to define the subpopulation with LHD risk factors and haemodynamic phenotype (PAH-rLHD).

Results

489 patients (I/H/D-PAH=251, CTD-PAH=238) were included in our analysis, with 103 (21.0%) fulfilling the definition of PAH-rLHD (34 had ≥3 risk factors for left heart disease (rLHD-hypertension, diabetes, obesity or ischaemic heart disease) and 76 had borderline haemodynamics (mean capillary wedge pressure 13–15 with pulmonary vascular resistance <500 dynes sec/cm5) including 7 who met both criteria). Compared to classical PAH, patients with PAH-rLHD were older at diagnosis (66±13 vs 58±19, p<0.001), had lower pulmonary vascular resistance (PVR: 393±266 vs 708±391, p=0.031) but worse exercise capacity (6MWD: 286±130m vs 327±136m, p=0.005). PAH-rLHD were more likely to be started on initial monotherapy, compared with “classical” PAH (73% vs 56%, p=0.002). In the monotherapy groups, endothelin receptor antagonists (ERA) were used in 73% PAH-rLHD, compared with 66% in classical PAH group. Both groups exhibited similar response to both mono- and combination therapy with commensurate improvements in WHO functional class (mean change 0.3±0.6 vs 0.3±0.8, p=0.443) and 6-minute walk distance (mean change 44±82 vs 48±101, p=0.723). There was no difference in survival between classical PAH and PAH-rLHD (log rank, p=0.29). The REVEAL 2.0 risk score effectively discriminated risk in both populations at baseline and first follow up (classical PAH: baseline C statistic 0.750, follow up 0.774 and PAH-rLHD: baseline C statistic 0.756, follow up 0.791).

Conclusion

Despite lower PVR at diagnosis, PAH-rLHD patients and “classical” PAH demonstrate similar response to first-line therapy with similar long term survival. The REVEAL 2.0 risk score can be effectively applied to the subpopulation of PAH-rLHD in real life clinical practice.

Funding Acknowledgement

Type of funding sources: None.

UK and Ireland survey of MPharm student and staff experiences of mental health curricula, with a focus on Mental Health First Aid

Background

One in four people experience a mental health problem every year and improving mental health care is an international priority. In the course of their work, pharmacists frequently encounter people with mental health problems. The experience of mental health teaching, including Mental Health First Aid (MHFA) training, in undergraduate pharmacy (MPharm) students in the UK and Ireland is not well documented. Students’ viewpoints, contextualised with curricular overviews provided by staff, were analysed to understand their experience.

Methods

An anonymous, online questionnaire was distributed to MPharm students and staff in the UK and Ireland. Students were asked closed questions regarding their course and exposure to MHFA, which were analysed using descriptive statistics. Open questions were included to enable explanations and these data were used to contextualise the quantitative findings. One member of staff from each university was invited to answer a modified staff version of the questionnaire, to provide a curriculum overview and staff perspective.

Results

232 students and 13 staff, from 22 universities, responded. Three-quarters of students did not agree with the statement that ‘mental health was embedded throughout the MPharm’. Most students (80.6%) stated that they were taught neuropharmacology whilst 44.8% stated that their course included communicating with people about their mental health. One-third (33.2%) of students stated that their degree ‘adequately prepared them to help people with their mental health’. Twenty-six students (11.6%) had completed MHFA training of which 89% would endorse inclusion of this within the MPharm. Of those who had not completed the training, 81% expressed a desire to do so. Those who completed MHFA training self-reported greater preparedness than those who did not, but student numbers were small.

Conclusions

Mental health teaching for pharmacy undergraduates is more focussed on theoretical aspects rather than applied skills. MHFA was viewed by students as one way to enhance skill application. The association of the increased self-reported preparedness of those who completed MHFA could be confounded by a positive environmental cultural. MPharm programmes need sufficient focus on real-world skills such as communication and crisis response, to complement the fundamental science.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-021-00364-1.

P–118 A sperm selection technique to mitigate paternal contributions to embryo aneuploidy

Study question

Can microfluidic sperm selection (MFSS) select male gametes without sperm chromatin fragmentation (SCF) and double-stranded DNA breaks (dsDNA) in order to generate euploid conceptuses?

Summary answer

Couples treated by ICSI with MFSS had significantly improved embryo ploidy rates and pregnancy outcomes, demonstrating the efficacy of this novel selection method.

What is known already

SCF has been linked to infertility, specifically to embryo developmental and implantation failure. This damage can be both single-stranded (ssDNA) or double-stranded (dsDNA). Recent studies have shown that dsDNA in particular causes chromosomal aberrations and contributes to embryo aneuploidy, which leads to implantation failure.

Study design, size, duration

Consenting couples treated at our center by intracytoplasmic sperm injection (ICSI) with spermatozoa selected by MFSS were included. The majority of these couples had a medical history significant for elevated SCF, recurrent implantation failure, and embryo aneuploidy. ICSI clinical outcome, as well as preimplantation genetic testing for aneuploidy (PGT-A) and frozen embryo transfer (FET), was recorded and compared to the couples’ historical treatments following sperm selection by density gradient centrifugation (DGC).

Participants/materials, setting, methods

From 2016 to 2020, 51 consenting men had their ejaculates screened for SCF levels by terminal deoxynucleotidyl dUTP transferase nick-end labeling (TUNEL) using a commercially available kit. At least 500 spermatozoa were assessed per patient, with a normal threshold of ≤ 15%.

To screen for dsDNA, neutral Comet using a modified in-house protocol was also performed in a pilot study. At least 200 spermatozoa were assessed per patient, with a normal threshold of ≤ 3%.

Main results and the role of chance

A total of 51 men (average age, 41.0±8 years) had mean sperm concentrations of 39.0±33x106/mL, 38.4±12% motility, and 2.1±1% normal morphology. Following DGC and MFSS, the concentrations were 4.7±8 and 4.3±8x106/mL and the motility was 64.0±33 and 98.0±3%, respectively (P < 0.0001). The average SCF decreased from 20.1±18% in the ejaculate to 16±3% following DGC, but was 2.9±4% after MFSS. The dsDNA fell from 3.4±3% in raw specimens to 2.9±1% after DGC, and to only 0.5±0.7% following MFSS (P < 0.0001).

These men underwent ICSI with their female partners (average age, 37.3±4 years), with sperm selected by DGC; they achieved a fertilization rate of 56.4% (337/597) with 26.0% euploid embryos (36/139). FET cycles from these embryos yielded an implantation rate of 8.3% (2/24) and a clinical pregnancy rate (CPR) of 15.4% (2/13), but both miscarried.

These couples then underwent ICSI with MFSS, with a fertilization rate of 78.0% (588/754; P < 0.0001) and 50.0% (172/344; P < 0.0001) euploid embryos after PGT-A. A total of 37 embryos have been replaced, with an implantation rate of 67.6% (25/37; P < 0.0001) and a CPR of 73.5% (25/34; P < 0.001), with an ongoing/delivery rate of 70.6% (24/34; P < 0.0001).

Limitations, reasons for caution

While the oocyte contribution cannot be discounted, MFSS was able to yield spermatozoa that had the highest motility and ability to produce euploid embryos following ICSI.

Wider implications of the findings: The genome and epigenome of the spermatozoon, and their contribution to reproductive outcomes, are being vigorously explored and scrutinized. Alternative approaches to gamete selection, such as MFSS, in couples with elevated SCF and dsDNA provide the best chances for future pregnancies by mitigating embryo aneuploidy.

Trial registration number

Not applicable

Clozapine prescribing during follow-up of a first-episode psychosis cohort

Introduction

Of those with schizophrenia, one third develop treatment-resistant illness. Nearly 60% of these benefit from clozapine- the only antipsychotic medication licensed in this group.

Objectives

As treatment-resistant illness developed in the follow-up of a first-episode psychosis (FEP) cohort, clozapine was prescribed. This study retrospectively compared the clozapine prescribing patterns, within this cohort, to National Institute for Health and Care Excellence (NICE) guidelines. In addition, impact on hospitalisation, physical health monitoring and augmentation strategies employed following clozapine initiation were examined. Factors delaying initiation of clozapine treatment or contributing to its discontinuation were also explored.

Methods

The study included 339 individuals resident within an Irish community mental health team catchment area, referred with FEP from 1 January 2005 to 31 August 2016. Data were extracted from electronic medical records.

Results

Within the cohort, clozapine was prescribed to 32 individuals (9.4%). The mean number of adequate trials of antipsychotic prior to starting clozapine was 2.74 (SD 1.13; range 1–5). The mean time to clozapine trial was 2.1 years (SD 1.95; range 0.17–6.25). Following initiation of clozapine, mean hospital admissions per year fell from 2.3 to 0.3 (p=0.00). Mean inpatient days pre- and post-clozapine also decreased (147 vs. 53; p=0.00). In all, 18 patients ceased use of clozapine, 5 temporarily and 13 permanently.

Conclusions

Patients are being prescribed clozapine earlier than previously demonstrated. However, delayed treatment remains common, and many patients discontinue clozapine. Further research is necessary to describe and address factors which contribute to its discontinuation.

Disclosure

No significant relationships.

Mental health curricula and Mental Health First Aid in the MPharm

Introduction

Improving mental health care is an international priority, and one that is championed by the Royal Pharmaceutical Society. (1) In the course of their work, pharmacists frequently encounter people with mental health problems. The extent to which mental health is taught on the undergraduate pharmacy degree in the UK and Ireland, and the inclusion of Mental Health First Aid (MHFA) training, has not be described recently.

Aim

We aimed to determine how mental health teaching is embedded into the MPharm and students’ perception of their own preparedness to help people with their mental health. We explored if and how MHFA training is included, and students’ experience of, or desire to complete this.

Methods

We conducted an anonymous, online questionnaire of UK and Ireland MPharm students, distributed via networks and social media. Students were asked a series of closed questions about mental health teaching in the MPharm, and exposure to MHFA. We analysed answers using descriptive statistics. We included some open-ended questions to enable students to expand on their answers. We used this qualitative data to contextualize findings. We invited one member of staff from each university to answer a modified staff version of the questionnaire, in order to provide a curriculum overview and staff perspective on MHFA provision.

Results

232 students and 13 staff responded, from 22 universities in total. Eighty percent of student participants were female and 70% were in the third or final year of study. Three-quarters of students felt that mental health was not embedded throughout the MPharm. Eighty-percent of students stated that they were taught about neuropharmacology and 44.8% stated that their course included communicating with people about their mental health. One third of students felt that their degree adequately prepared them to help people with their mental health. Twenty-six students (11.6%) had completed MHFA training of which 89% would endorse inclusion of this within the MPharm. Of those who had not completed the training, 81% expressed a desire to do so. Those who completed MHFA training self-reported more preparedness than those who did not, but student numbers were small.

Conclusion

Mental health teaching remains focused on theoretical aspects, such as pharmacology, with less emphasis on practical skills, such as communication skills that might support interactions about mental health. MHFA was viewed by students as one way to enhance this. Of the small number of students who had completed MHFA, they displayed an increased self-reported preparedness. This could, however, be linked to the environmental culture of the programme rather than the training per se. MPharm programmes need sufficient focus on skills including communication and crisis response that may be required by pharmacists, alongside the fundamental scientific knowledge relating to mental health.

References

1. Royal Pharmaceutical Society. No health without mental health: How can pharmacy support people with mental health problems? London: RPS; 2018.

Prescribing pattern of antipsychotic medication for first-episode psychosis: a retrospective cohort study

OBJECTIVE

Guidelines for antipsychotic use in first-episode psychosis (FEP) recommend that medication be chosen initially on the basis of side effect profile with doses at the lower end of the range. Our objective was to describe the pattern of antipsychotic use in FEP over a period of 21 years in the context of changing clinical guidelines and the development of specialist early intervention in psychosis (EIP) services.

SETTING

A community-based mental health service in South County Dublin (population 187 000) and a large private hospital.

PARTICIPANTS

Participants included 465 patients with FEP (146 from an epidemiological study (1995-1999) and 319 from a specialist EIP service (2005-2016)). Treatment with antipsychotic medication did not exceed 30 days at study entry.

OUTCOME MEASURES

This is a descriptive study of prescribing practices in the context of service development and changing guidelines.

RESULTS

First-generation antipsychotics were prescribed for 65% of the early cohort compared with 4.3% of the EIP cohort. Olanzapine was initially prescribed for 79.7% of EIP patients. Initial doses of medication were frequently low (≤50% British National Formulary (BNF) maximum) in both cohorts (71% and 78.6%). The demographic and clinical factors investigated did not influence the initial choice of antipsychotic medication significantly. Univariate logistic regression analysis suggested inpatient treatment setting was associated with a higher initial dose (>50% BNF maximum) of antipsychotic medication. Increasing dose requirements over the first month of engagement with an EIP service was associated with poorer global functioning at baseline, greater positive symptoms at baseline and the inpatient treatment setting. However, these associations were not seen in the multivariable model.

CONCLUSIONS

Second-generation antipsychotic prescribing predominates, but guidelines are often overlooked when choosing olanzapine notwithstanding lower initial dosages. EIP services should include proactive support for optimising medicines in line with evidence-based guidelines.

Clozapine use - has practice changed?

BACKGROUND

One-third of individuals with schizophrenia have treatment-resistant illness. Of these, up to 60% will respond to clozapine treatment.

AIMS

This study retrospectively examined clozapine prescribing patterns against National Institute for Health and Care Excellence (NICE) guidelines as treatment-resistant illness emerged in a first-episode psychosis cohort.

METHODS

A total of 339 individuals with a first-episode psychosis were included in the study. Clozapine prescribing patterns were compared against the NICE guidelines and the impact of clozapine use on one index of service utilisation (hospitalisation) was assessed.

RESULTS

A total of 32 individuals (9.4%) from the cohort were prescribed clozapine. The mean time to clozapine trial was 2.1 years (SD 1.95; range 0.17-6.25). The mean number of adequate trials of antipsychotic prior to starting clozapine was 2.74 (SD 1.13; range 1-5). Following clozapine initiation, mean hospital admissions per year reduced from 2.3 to 0.3 (p=0.00). Mean hospital days pre- and post-clozapine also reduced (147 vs. 53; p=0.00). In total, 18 patients discontinued clozapine use during follow-up - 5 temporarily and 13 permanently.

CONCLUSIONS

Patients are being prescribed clozapine earlier than previously demonstrated, though delays are still evident, and many patients discontinue treatment. More work needs to be undertaken to understand and address factors which lead to its discontinuation.

Check the effects: systematic assessment of antipsychotic side-effects in an inpatient cohort

BACKGROUND

Antipsychotics are associated with a range of side-effects that can influence patients' subjective well-being negatively resulting in poor adherence. In order to limit the negative consequences of side-effects, they should be regularly systematically assessed. The aim of this study was to systematically assess antipsychotic side-effects in an inpatient cohort using validated rating scales.

METHODS

Eligible individuals prescribed an antipsychotic for at least 2 weeks were invited to have their side-effects assessed systematically.

RESULTS

A total of 208 individuals were assessed systematically for antipsychotic side-effects; 71.5% (n = 138) stated that they had not reported side-effects to their clinician prior to the assessment. The most commonly reported side-effects were daytime drowsiness (75%), dry mouth (58.2%) and weight gain (50.0%), while the most distressing side-effects reported were erectile dysfunction (35.0%), sexual dysfunction (26.3%) and amenorrhoea (26.3%). There was no evidence of an association between side-effect severity/number of side-effects reported/distress caused by those taking high dose/combination antipsychotics versus standard dose monotherapy.

CONCLUSION

Side-effects must be regularly and systematically assessed using a validated rating scale. As distress caused by side-effects plays a major role in non-adherence, assessment should examine distress and data on distressing side-effects should be available to those choosing an antipsychotic. Given the lack of correlation between high dose/combination antipsychotics and side-effects, treatment should be tailored to the individual based on response/tolerance and dose reduction/avoidance of polypharmacy should not be recommended to minimise side-effects.

Patients and Caregivers Helping to Shape the Undergraduate Pharmacy Mental Health Curriculum

Objective. To develop a model system for involving patients and caregivers in curriculum development of mental health education in an undergraduate pharmacy program. Methods. Purposive recruitment was used to convene a focus group of nine people with experience in using mental health services from either the patient or caregiver perspective. Group members were asked about their experience with using pharmacy services and their suggestions for enhancement of the undergraduate curriculum. Thematic analysis was conducted independently by two researchers. Results. Patients and caregivers believed that pharmacists could contribute to the care of people who experience mental health conditions by supporting shared decision making, providing information, actively managing side effects of psychotropic medication, and conducting regular medication review. Subjects suggested that the pharmacy undergraduate curriculum should introduce mental health from the beginning, include self-care for students, integrate mental and physical health education, and enhance students' communication skills. The curriculum should include broader issues relevant to mental health beyond the use of medication, such as stigma, the recovery approach, and interprofessional cooperation. These changes could support graduates in engaging proactively with people experiencing mental health difficulties. Conclusion. Involving patients and caregivers in the design of an undergraduate pharmacy curriculum in mental health resulted in a more person-centered and student-centered approach to mental health education at our university. Ultimately, the changes made to the undergraduate curriculum will improve the ability of pharmacy graduates to better meet the needs of patients.

Optimising prescribing for patients with severe mental illness: the need for criteria

The life expectancy of people with severe mental illness (SMI) is considerably shorter than those without SMI. Multimorbidity and poorer physical health outcomes contribute significantly to this health inequality. Psychotropic medicines, including antipsychotics, antidepressants, mood stabilisers and anxiolytic medicines, are the mainstay of treatment for SMI, and overall improve life expectancy and quality of life. Optimising medicines is required to ensure adequate control of symptoms while avoiding complications and negative physical health outcomes. Screening tools would offer an opportunity to assist clinicians in decision making and optimising medicines for people with SMI, who are particularly vulnerable to medication-related problems and poorer physical health.

Pharmacy Students' Reflections on an Experiential Learning Visit to a Psychiatric Hospital

Objective. To create a brief, experiential educational intervention for undergraduate pharmacy students aimed at developing appropriate attitudes, knowledge, and skills for the delivery of recovery-focused pharmacy services to people with mental illness, and to elicit student perceptions of the value and impact of the intervention. Methods. A brief intervention was developed in which a cohort of 44 fourth-year pharmacy students attended a psychiatric teaching hospital in groups of 10 to12. The intervention was integrated into the therapeutics module, and was based on Fink's taxonomy of learning. Delivery of the intervention included input from a multidisciplinary team of mental health professionals and the use of active-learning strategies to give students an insight into the holistic approach to care and the patient journey. Students participated in an exercise in reflective practice following the visit. Content analysis was performed on the reflective writings of consenting students to identify themes and insights gained. Results. Thirty-eight of the 44 students gave their consent for their reflective writings to be analyzed for the purpose of this research. Students expressed some apprehension before their visit to the hospital, but later gained an appreciation of the patient experience of care in the psychiatric setting. Students also described having a greater appreciation of the role of the pharmacist in caring for psychiatric patients as well as an insight into the role of other health care professionals and interventions supporting recovery. Conclusion. A brief experiential intervention helped students integrate their learning and appreciate the value of their expertise in supporting those experiencing mental illness.

A treatment algorithm for couples with unexplained infertility based on sperm chromatin assessment

OBJECTIVE

To design a reproductive treatment algorithm based on the sperm DNA fragmentation (SDF) for couples with unexplained infertility following a poor intrauterine insemination (IUI) outcome.

DESIGN

Couples that failed IUI with no apparent reproductive issue in both partners were allocated to diverse reproductive treatments on the basis of SDF.

SETTING

Reproductive medical center in an academic setting.

PATIENT(S)

Over 4 years, couples with an unexpected poor IUI outcome and no apparent female or male partner reproductive issues were recruited.

INTERVENTION(S)

IUI, IVF, and ICSI were performed in the standard fashion following sperm SDF assays.

MAIN OUTCOMES MEASURE(S)

Fertilization rate, implantation rate, pregnancy characteristics, and delivery rates.

RESULT(S)

A total of 354 couples with unexplained infertility and normal semen parameters underwent 1133 IUI cycles. Clinical pregnancy rate (CPR) with IUI at our center in an age-matched cohort is 23.9% while the study cohort had 1.8%. Following SDF assessment, couples with failed IUI attempts but normal SDF (SCSA 9.8 ± 4.6%; TUNEL 11.8 ± 6.2%) underwent IVF with a CPR of 12.7%; those with abnormal SDF underwent ICSI with ejaculated spermatozoa, resulting in a CPR of 18.7%. This group included couples with normal SDF that had failed IVF. Couples with abnormal SDF that failed ICSI with ejaculated spermatozoa achieved a CPR of 31.0% with surgically retrieved spermatozoa.

CONCLUSION(S)

Couples with unexplained infertility that present with unexpectedly poor IUI outcomes can be funneled into a treatment algorithm guided by the integrity of the sperm genome for higher chances of pregnancy using an alternate method of insemination.

Pharmacological guidelines for schizophrenia: a systematic review and comparison of recommendations for the first episode

OBJECTIVES

Clinical practice guidelines (CPGs) support the translation of research evidence into clinical practice. Key health questions in CPGs ensure that recommendations will be applicable to the clinical context in which the guideline is used. The objectives of this study were to identify CPGs for the pharmacological treatment of first-episode schizophrenia; assess the quality of these guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument; and compare recommendations in relation to the key health questions that are relevant to the pharmacological treatment of first-episode schizophrenia.

METHODS

A multidisciplinary group identified key health questions that are relevant to the pharmacological treatment of first-episode schizophrenia. The MEDLINE and EMBASE databases, websites of professional organisations and international guideline repositories, were searched for CPGs that met the inclusion criteria. The AGREE II instrument was applied by three raters and data were extracted from the guidelines in relation to the key health questions.

RESULTS

In total, 3299 records were screened. 10 guidelines met the inclusion criteria. 3 guidelines scored well across all domains. Recommendations varied in specificity. Side effect concerns, rather than comparative efficacy benefits, were a key consideration in antipsychotic choice. Antipsychotic medication is recommended for maintenance of remission following a first episode of schizophrenia but there is a paucity of evidence to guide duration of treatment. Clozapine is universally regarded as the medication of choice for treatment resistance. There is less evidence to guide care for those who do not respond to clozapine.

CONCLUSIONS

An individual's experience of using antipsychotic medication for the initial treatment of first-episode schizophrenia may have implications for future engagement, adherence and outcome. While guidelines of good quality exist to assist in medicines optimisation, the evidence base required to answer key health questions relevant to the pharmacological treatment of first-episode schizophrenia is limited.

Glasgow Antipsychotic Side-effects Scale for Clozapine - Development and validation of a clozapine-specific side-effects scale

OBJECTIVE

The authors developed and validated a clozapine-specific side-effects scale capable of eliciting the subjectively unpleasant side-effects of clozapine.

METHODS

Questions from the original Glasgow Antipsychotic Side-effects Scale (GASS) were compared to a list of the most commonly reported clozapine side-effects and those with a significant subjective burden were included in the GASS for Clozapine (GASS-C). The original authors of the GASS and a group of mental health professionals from the UK and Ireland were enlisted to comment on the questions in the GASS-C based on their clinical experience. 110 clozapine outpatients from two sites completed the GASS-C, the original GASS and a repeat GASS-C. Statistical analyses were performed using SPSS for Windows version 19.

RESULTS

The GASS-C was shown to have construct validity, in that Spearman's correlation coefficient was 0.816 (p<0.001) with the original GASS, whilst Cohen's kappa coefficient was >0.77 (p<0.001) for one question and >0.81 (p<0.001) for remaining relevant questions. GASS-C was also shown to have strong test-retest reliability, in that Cronbach's alpha coefficient was >0.907 (p<0.001), whilst Cohen's kappa coefficient was >0.81 (p<0.001) for 12 questions and >0.61 (p<0.001) for the remaining four questions.

CONCLUSION

The GASS-C is a valid and reliable clinical tool to enable a systematic assessment of the subjectively unpleasant side-effects of clozapine. Future research should focus on how the scale can be utilised as a clinical tool to improve real-world outcomes such as adherence to clozapine therapy and quality of life.

Multi-centre variability of ISCEV standard ERGs in two normal adults

BACKGROUND

The reproducibility of an individual's full-field ERG between centres has not previously been investigated.

METHODS

ERGs were recorded using both silver thread and skin electrodes from the same two normal adult subjects at 15 UK centres using routine, local protocols and a highly standardised, 'ISCEV-specified' protocol matching the values specified in the ISCEV standard; where the ISCEV standard allows options, a single value was chosen.

RESULTS

Inter-ocular differences were small, and amplitudes were smaller for skin than silver thread electrodes. No centre produced outlying data points, and ERGs across all 15 centres were remarkably similar. Amplitude variability was less for local protocols (using LED flashes) than for the ISCEV-specified protocol using xenon flashes (22 vs. 24 %, p = 0.01), but peak time variability was less for the ISCEV-specified protocol (6.1 vs. 7.4 %, p = 0.001). Only the DA 0.01 ERG correlated with photometric variability. The bifidity of the DA 3 a-wave doubled its peak time variability compared with the DA 10 a-wave.

CONCLUSIONS

Inter-centre amplitude variability was typically within clinically significant thresholds, suggesting that inter-centre variability with suitable standardisation may not add more to total variability than inter-subject variability. Variability improvements gained by the tighter specifications of the ISCEV-specified protocol were possibly more than lost due to imprecisions of xenon flashtubes. Peak time variability was far lower than amplitude variability, corresponding with acceptable variability of biochemical assays. These results represent a vindication of the existence of an ERG standard and suggest that further standardisation would lend itself to greater reproducibility of ERGs worldwide.

Investigation of the first outbreak of OXA-48-producing Klebsiella pneumoniae in Ireland

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) strains are encountered with increasing frequency in Europe. In November 2010 the European Centre for Disease Control (ECDC) graded Ireland as only having sporadic occurrence of CPE.

AIM

To describe the epidemiological and molecular typing analysis of the first outbreak of OXA-48-producing Klebsiella pneumoniae in an Irish tertiary care referral centre.

METHODS

Sixteen OXA-48-producing K. pneumoniae isolates were detected, from both clinical and screening specimens, and analysed by pulsed-field gel electrophoresis and by multi-locus sequence typing.

FINDINGS

Typing analysis revealed that two outbreak strains were circulating in the hospital, one among surgical patients and one among medical patients. The 'medical strain' ST13 had already been identified as an internationally disseminated clone, whereas the 'surgical strain' ST221 had not previously been reported as an OXA-48-carrying strain.

CONCLUSION

Although the outbreak on surgical wards was successfully controlled by implementing strict infection control measures, intermittent detection of individual patients carrying the 'medical strain' of OXA-48 K. pneumoniae has persisted since then. The experience from this outbreak suggests that OXA-48 K. pneumoniae is endemic at low level in the healthcare setting in the Dublin region.

The safety and efficacy of dexmedetomidine for postoperative sedation in the cardiac surgery intensive care unit

INTRODUCTION

The α2-adrenoceptor agonist dexmedetomidine is an effective postoperative sedative without clear advantages over midazolam or propofol. We hypothesized that routine use of dexmedetomidine allows early extubation in cardiac surgery patients. Secondary outcomes included the use of narcotic and non-narcotic analgesics during the first 48 hours, early postoperative functional status, and the incidence of bradycardia or hypotension.

METHODS

We retrospectively analyzed patients admitted to a cardiothoracic intensive care unit after cardiac surgery. Patient charts and the Society of Thoracic Surgery National database were reviewed. Patients who received no sedation were compared to those who received dexmedetomidine.

RESULTS

Ninety-nine patients (52 receiving no sedation and 47 receiving dexmedetomidine) were included in this study. The median time to extubation was 3.9 (2.8-5.4) hours in the control group versus 4.7 (3.45-6.52) hours in the dexmedetomidine (P=.16). The incidence of bradycardia, hypotension, the ability to ambulate, and Glascow Coma Scores = 15 on postoperative day 0 did not differ significantly. Acetaminophen was used more frequently in the first 48 hours postoperatively in dexmedetomidine patients (P=.02) and a trend toward higher opioid (P=.09) and ketorolac use (P=.30) over the first 48 hours was noted.

CONCLUSIONS

The use of dexmedetomidine did not allow earlier extubation or less use of analgesics when compared to no sedation. Bradycardia and hypotension were not a problem with the use of dexmedetomidine.

IVI epoprostenol as salvage therapy in pulmonary arterial hypertension: an Australian perspective

BACKGROUND

IVI epoprostenol is the only therapy for pulmonary arterial hypertension (PAH) with a randomized controlled trial demonstrating improved survival, when used as first-line monotherapy. In Australia it is used as salvage therapy for those failing treatment with other targeted therapies or presenting in World Health Organization functional class (FC) IV.

AIMS

Report experience with IVI epoprostenol, administered as salvage therapy for the treatment of adults with PAH in a single Australian PAH centre.

METHODS

Retrospective case series of all patients commenced on IVI epoprostenol for PAH, between 2002 and 2010. Review of case notes with collection of data at baseline and after treatment, including FC, 6-min walk test (6MWT), right ventricular systolic pressure (RVSP) on echocardiogram, patient survival and treatment complications. Change in indices was assessed using the Wilcoxon Sign Rank Test and is expressed as median (inter-quartile range).

RESULTS

A total of 23 patients was included. Treatment was generally well tolerated with few major complications. At the end of the study period, nine patients were successfully bridged to transplant, five had a sustained response to IVI epoprostenol, six had an incomplete response but were clinically stabilized, two died awaiting transplant and one died who was not a candidate for transplantation. Overall, when measured at best level post initiation of IVI epoprostenol, there were significant improvements in FC -1 [0 to -1] (P < 0.0001), 6MWT (m) +117 [70-264] (P= 0.002) and RVSP (mmHg) -7.0 [4.0 to -45] (P= 0.03).

CONCLUSION

Findings support efficacy of epoprostenol as salvage therapy for patients with PAH.

Integrating the implementation of the European Union Water Framework Directive and Floods Directive in Ireland

Water Framework Directive (WFD) statutory authorities and stakeholders in Ireland are now challenged with the issue of how the proposed programmes of measures in the newly required River Basin Management Plans - designed to protect and restore good ecology by reverting as closely as possible back to natural conditions - are to be implemented in a way that concurrently complies with other existing and emerging intersecting European Union legislation, such as the Floods Directive (FD). The WFD is driven largely by ecological considerations, whereas the FD and other legislation are more geared towards protecting physical property and mitigating public safety risks. Thus many of the same waterbodies, especially heavily modified waterbodies, arguably have somewhat competing policy objectives put upon them. This paper explores the means by which Ireland might best achieve the highest degrees of cost effectiveness, economic efficiency and institutional durability in pursuing the common and overarching objective of the WFD and FD - to ensure Irish waterways are put to their highest valued uses.

Lung transplantation in pulmonary fibrosis: challenging early outcomes counterbalanced by surprisingly good outcomes beyond 15 years

Interstitial lung disease (ILD) has been reported to have a poor outcome following lung transplantation due to difficulties getting ill recipients to transplantation and challenging early postoperative outcomes. To assess long-term outcomes for this cohort, we performed a retrospective 18-year chart review of all ILD lung transplant recipients. ILD single (SLT) and bilateral sequential lung transplantations (BSLT) were compared with all other lung transplant patients and International Society for Heart and Lung Transplantation (ISHLT) Registry data over the same time period. Of 585 lung transplantations, 90 (15%) were ILD (53 SLT, 37 BSLT); 67 (74%) were idiopathic pulmonary fibrosis (IPF), 9 (10%) were sarcoidosis, 9 (10%) were lymphangioleiomyomatosis, and 5 (6%) had other indications. Mean age was 52 years (range, 34-69 years). Actuarial survival at 1, 5, 10, 15, and 18 years compared favorably to all other lung transplantations performed (77% vs 83%, 51% vs 50%, 42% vs 26%, 28% vs 17%, and 28% vs 8%, respectively). IPF actuarial survival at 1, 5, and 10 years appeared superior to ISHLT Registry data (76% vs 72%, 50% vs 44%, and 34% vs 20%, respectively). There was equivocal survival between SLT and BSLT at 1, 5, and 10 years (78% vs 68%, 49% vs 50%, and 29% vs 50%, respectively). Our ILD figures compared favorably to lung transplantation for other diseases and international standards, while survival from SLT was as successful as BSLT both in the short and the longer term. Consideration should be given to utilizing SLT to maximize the allocation of donor lungs and to decrease waiting list mortality associated with IPF.