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Tanham M, Chen R, Warren N, Heussler H, Scott JG. The effectiveness and tolerability of pharmacotherapy for psychosis in 22q11.2 Deletion Syndrome: A systematic review. Aust N Z J Psychiatry 2024; 58:393-403. [PMID: 38383990 DOI: 10.1177/00048674241233118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE The 22q11.2 Deletion Syndrome (22q11.2DS) is the most common microdeletion in humans with over 180 phenotypic expressions. Approximately 30-40% of affected individuals will develop psychosis and 25% meet the criteria for schizophrenia. Despite this, pharmacotherapy for managing psychosis in 22q11.2DS is poorly understood and 22q11.2DS psychosis is frequently labelled as treatment resistant. The objectives of this paper are to evaluate the effectiveness and tolerability of pharmacotherapy for 22q11.2DS psychosis and evaluate the evidence for treatment resistance. METHOD A systematic search was performed using CINAHL, The Cochrane Library (Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials and Cochrane Clinical Answers), EMBASE, PsycINFO, PubMed, Scopus and Web of Science Core Collection from inception to December 2022. It yielded 39 case reports, 6 case series and 1 retrospective study which met the inclusion criteria. RESULTS Based on the current literature, individuals with 22q11.2DS psychosis experience a greater rate of medical co-morbidities such as cardiac arrhythmias, seizures and movement disorders, which complicate pharmacotherapy. Poor tolerability rather than poor clinical response motivates the switching of antipsychotics, which may explain the labelling of treatment resistance in the literature. CONCLUSION There are insufficient data to recommend a single antipsychotic for 22q11.2DS psychosis. Nonetheless, with proactive management of co-morbidities, antipsychotic medication in 22q11.2DS psychosis is an effective treatment commonly resulting in improvement in quality of life.
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Affiliation(s)
- Maya Tanham
- Child and Youth Mental Health Service, Children's Health Queensland, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Renee Chen
- Child and Youth Mental Health Service, Children's Health Queensland, Brisbane, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addictions and Mental Health Service, Woolloongabba, QLD, Australia
| | - Helen Heussler
- Child Development Program, Children's Health Queensland, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - James G Scott
- Child and Youth Mental Health Service, Children's Health Queensland, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
- Child and Youth Mental Health, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
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Warren N, McKeon G, Scott JG. Replacing universal anti-neuronal antibody screening with clinical assessment and testing of high probability cases in psychotic disorders. Aust N Z J Psychiatry 2024:48674241249575. [PMID: 38679857 DOI: 10.1177/00048674241249575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Affiliation(s)
- Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health, Brisbane, QLD, Australia
| | - Gemma McKeon
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, QLD, Australia
- West Moreton Health Psychology, The Park Centre for Mental Health, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - James G Scott
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Child and Youth Mental Health Service, Children's Health Queensland, Brisbane, QLD, Australia
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Bull C, Trott M, Najman JM, Arnautovska U, Siskind D, Warren N, Kisely S. Associations between child maltreatment and hospital admissions for alcohol and other substance use-related disorders up to 40 years of age: Results from the Childhood Adversity and Lifetime Morbidity study. Addiction 2024. [PMID: 38634806 DOI: 10.1111/add.16479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Evidence on the associations between child maltreatment (CM), alcohol use disorders (AUDs) and other substance use disorders (SUDs) comes largely from retrospective studies. These rely on self-reported data, which may be impacted by recall bias. Using prospective CM reports to statutory agencies, we measured associations between CM notifications and inpatient admissions for AUDs and SUDs up to 40 years of age. DESIGN, SETTING AND PARTICIPANTS Observational study linking administrative health data from Queensland, Australia to prospective birth cohort data comprising both agency-reported and substantiated notifications of CM. MEASUREMENTS Outcomes were inpatient admissions for AUDs and SUDs based on ICD-10-Australian modification (AM)-coded primary diagnoses. Unadjusted and adjusted logistic regression analyses were undertaken. FINDINGS Ten per cent (n = 609) of the cohort had a history of agency-reported or substantiated CM notifications before age 15. These individuals had higher adjusted odds of being admitted for AUDs and SUDs. For AUDs, the adjusted odds of inpatient admission were 2.86 [95% confidence interval (CI) = 1.73-4.74] greater where there was any previous agency-reported CM and 3.38 (95% CI = 1.94-5.89) greater where there was any previous substantiated CM. For SUDs, the adjusted odds of inpatient admission were 3.34 (95% CI = 2.42-4.61) greater where there was any previous agency-reported CM and 2.98 (95% CI = 2.04-4.36) greater where there was any previous substantiated CM. CONCLUSIONS People with a history of child maltreatment appear to have significantly higher odds of inpatient admissions for alcohol use disorders and other substance use disorders up to 40 years of age compared to people with no history of child maltreatment.
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Affiliation(s)
- Claudia Bull
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- The ALIVE National Centre for Mental Health Research Translation, The University of Queensland, Woolloongabba, QLD, Australia
- Queensland Centre for Mental Health Research, The University of Queensland, Woolloongabba, QLD, Australia
| | - Mike Trott
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- Queensland Centre for Mental Health Research, The University of Queensland, Woolloongabba, QLD, Australia
| | - Jake Moses Najman
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- School of Social Sciences, The University of Queensland, St Lucia, QLD, Australia
| | - Urska Arnautovska
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- Queensland Centre for Mental Health Research, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Dan Siskind
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- Queensland Centre for Mental Health Research, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Nicola Warren
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Steve Kisely
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia
- The ALIVE National Centre for Mental Health Research Translation, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
- Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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Halstead S, Cao C, Høgnason Mohr G, Ebdrup BH, Pillinger T, McCutcheon RA, Firth J, Siskind D, Warren N. Prevalence of multimorbidity in people with and without severe mental illness: a systematic review and meta-analysis. Lancet Psychiatry 2024:S2215-0366(24)00091-9. [PMID: 38642560 DOI: 10.1016/s2215-0366(24)00091-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND People with severe mental illness, such as schizophrenia-spectrum disorder and bipolar disorder, face poorer health outcomes from multiple chronic illnesses. Physical multimorbidity, the coexistence of two or more chronic physical conditions, and psychiatric multimorbidity, the coexistence of three or more psychiatric disorders, are both emerging concepts useful in conceptualising disease burden. However, the prevalence of physical and psychiatric multimorbidity in this cohort is unknown. This study aimed to estimate the absolute prevalence of both physical and psychiatric multimorbidity in people with severe mental illness, and also compare the odds of physical multimorbidity prevalence against people without severe mental illness. METHODS We searched CINAHL, EMBASE, PubMed, and PsycINFO from inception until Feb 15, 2024, for observational studies that measured multimorbidity prevalence. To be included, studies had to have an observational study design, be conducted in an adult population (mean age ≥18 years) diagnosed with either schizophrenia-spectrum disorder or bipolar disorder, and include a measurement of occurrence of either physical multimorbidity (≥2 physical health conditions) or psychiatric multimorbidity (≥3 psychiatric conditions total, including the severe mental illness). From control studies, a random-effects meta-analysis compared odds of physical multimorbidity between people with and without severe mental illness. Absolute prevalence of physical and psychiatric multimorbidity in people with severe mental illness was also calculated. Sensitivity and meta-regression analyses tested an array of demographic, diagnostic, and methodological variables. FINDINGS From 11 144 citations we included 82 observational studies featuring 1 623 773 individuals with severe mental illness (specifically schizophrenia-spectrum disorder or bipolar disorder), of which 21 studies featured 13 235 882 control individuals without severe mental illness (descriptive data for the entire pooled cohorts were not available for numbers of males and females, age, and ethnicity). This study did not feature involvement of people with lived experience. The odds ratio (OR) of physical multimorbidity between people with and without severe mental illness was 2·40 (95% CI 1·57-3·65, k=11, p=0·0009). This ratio was higher in younger severe mental illness populations (mean age ≤40 years, OR 3·99, 95% CI 1·43-11·10) compared with older populations (mean age >40 years, OR 1·55, 95% CI 0·96-2·51; subgroup differences p=0·0013). For absolute prevalence, 25% of those with severe mental illness have physical multimorbidity (95% CI 0·19-0·32, k=29) and 14% have psychiatric multimorbidity (95% CI 0·08-0·23, k=21). INTERPRETATION This is the first meta-analysis to estimate physical alongside psychiatric multimorbidity prevalence, showing that these are common in people with schizophrenia-spectrum disorder and bipolar disorder. The greater burden of physical multimorbidity in people with severe mental illness compared with those without is higher for younger cohorts, reflecting a need for earlier intervention. Our findings speak to the utility of multimorbidity for characterising the disease burden associated with severe mental illness, and the importance of facilitating integrated physical and mental health care. FUNDING None.
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Affiliation(s)
- Sean Halstead
- The University of Queensland, Medical School, Brisbane, QLD, Australia; Metro South Addiction and Mental Health, Brisbane, QLD, Australia.
| | - Chester Cao
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Grímur Høgnason Mohr
- Center for Neuropsychiatric Schizophrenia Research, Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Bjørn H Ebdrup
- Center for Neuropsychiatric Schizophrenia Research, Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Toby Pillinger
- South London & Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
| | - Robert A McCutcheon
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK; Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Joseph Firth
- Division of Psychology and Mental Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Dan Siskind
- The University of Queensland, Medical School, Brisbane, QLD, Australia; Metro South Addiction and Mental Health, Brisbane, QLD, Australia
| | - Nicola Warren
- The University of Queensland, Medical School, Brisbane, QLD, Australia; Metro South Addiction and Mental Health, Brisbane, QLD, Australia
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Kisely S, Bull C, Trott M, Arnautovska U, Siskind D, Warren N, Najman JM. Emergency department presentations for deliberate self-harm and suicidal ideation in 25-39 year olds following agency-notified child maltreatment: results from the Childhood Adversity and Lifetime Morbidity (CALM) study - CORRIGENDUM. Epidemiol Psychiatr Sci 2024; 33:e23. [PMID: 38604777 PMCID: PMC11022252 DOI: 10.1017/s204579602400026x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
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Campana M, Yakimov V, Moussiopoulou J, Maurus I, Löhrs L, Raabe F, Jäger I, Mortazavi M, Benros ME, Jeppesen R, Meyer Zu Hörste G, Heming M, Giné-Servén E, Labad J, Boix E, Lennox B, Yeeles K, Steiner J, Meyer-Lotz G, Dobrowolny H, Malchow B, Hansen N, Falkai P, Siafis S, Leucht S, Halstead S, Warren N, Siskind D, Strube W, Hasan A, Wagner E. Association of symptom severity and cerebrospinal fluid alterations in recent onset psychosis in schizophrenia-spectrum disorders - An individual patient data meta-analysis. Brain Behav Immun 2024; 119:353-362. [PMID: 38608742 DOI: 10.1016/j.bbi.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/03/2024] [Accepted: 04/09/2024] [Indexed: 04/14/2024] Open
Abstract
Neuroinflammation and blood-cerebrospinal fluid barrier (BCB) disruption could be key elements in schizophrenia-spectrum disorderś(SSDs) etiology and symptom modulation. We present the largest two-stage individual patient data (IPD) meta-analysis, investigating the association of BCB disruption and cerebrospinal fluid (CSF) alterations with symptom severity in first-episode psychosis (FEP) and recent onset psychotic disorder (ROP) individuals, with a focus on sex-related differences. Data was collected from PubMed and EMBASE databases. FEP, ROP and high-risk syndromes for psychosis IPD were included if routine basic CSF-diagnostics were reported. Risk of bias of the included studies was evaluated. Random-effects meta-analyses and mixed-effects linear regression models were employed to assess the impact of BCB alterations on symptom severity. Published (6 studies) and unpublished IPD from n = 531 individuals was included in the analyses. CSF was altered in 38.8 % of individuals. No significant differences in symptom severity were found between individuals with and without CSF alterations (SMD = -0.17, 95 %CI -0.55-0.22, p = 0.341). However, males with elevated CSF/serum albumin ratios or any CSF alteration had significantly higher positive symptom scores than those without alterations (SMD = 0.34, 95 %CI 0.05-0.64, p = 0.037 and SMD = 0.29, 95 %CI 0.17-0.41p = 0.005, respectively). Mixed-effects and simple regression models showed no association (p > 0.1) between CSF parameters and symptomatic outcomes. No interaction between sex and CSF parameters was found (p > 0.1). BCB disruption appears highly prevalent in early psychosis and could be involved in positive symptomś severity in males, indicating potential difficult-to-treat states. This work highlights the need for considering BCB breakdownand sex-related differences in SSDs clinical trials and treatment strategies.
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Affiliation(s)
- Mattia Campana
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany.
| | - Vladislav Yakimov
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany
| | - Joanna Moussiopoulou
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany
| | - Isabel Maurus
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany
| | - Lisa Löhrs
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany
| | - Florian Raabe
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany; Max Planck Institute of Psychiatry, Munich, Germany
| | - Iris Jäger
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany
| | - Matin Mortazavi
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
| | - Michael E Benros
- Copenhagen Research Centre for Biological and Precision Psychiatry. Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rose Jeppesen
- Copenhagen Research Centre for Biological and Precision Psychiatry. Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gerd Meyer Zu Hörste
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Eloi Giné-Servén
- Department of Psychiatry, Hospital Universitario de Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Javier Labad
- Department of Mental Health, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain; Translational Neuroscience Research Unit I3PT-INc-UAB, Institut de Innovació i Investigació Parc Taulí (I3PT), Institut de Neurociències, Universitat Autònoma de Barcelona, Spain
| | - Ester Boix
- Department of Mental Health, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Spain
| | - Belinda Lennox
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, UK
| | - Ksenija Yeeles
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, UK
| | - Johann Steiner
- Department of Psychiatry, Magdeburg University Hospital, Magdeburg, Germany
| | | | - Henrik Dobrowolny
- Department of Psychiatry, Magdeburg University Hospital, Magdeburg, Germany
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany; Max Planck Institute of Psychiatry, Munich, Germany; DZPG (German Center for Mental Health), partner site München/Augsburg, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University Munich, Munich, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University Munich, Munich, Germany
| | - Sean Halstead
- Department of Psychiatry, School of Medicine, University of Queensland, Brisbane, Australia
| | - Nicola Warren
- Department of Psychiatry, School of Medicine, University of Queensland, Brisbane, Australia
| | - Dan Siskind
- Department of Psychiatry, School of Medicine, University of Queensland, Brisbane, Australia
| | - Wolfgang Strube
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany; DZPG (German Center for Mental Health), partner site München/Augsburg, Germany
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstraße 7, D-80336 Munich, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany; Evidence-based Psychiatry and Psychotherapy, Faculty of Medicine, University of Augsburg, Augsburg, Germany
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Kisely S, Arnautovska U, Siskind D, Warren N, Najman JM. Admissions for psychosis following agency-notified child maltreatment at 40-year-follow-up: Results from the Childhood Adversity and Lifetime Morbidity (CALM) cohort. Schizophr Res 2024; 267:247-253. [PMID: 38581827 DOI: 10.1016/j.schres.2024.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/08/2024]
Abstract
There is substantial evidence of an association between self-reported child maltreatment (CM) and subsequent psychosis in retrospective data. Such findings may be affected by recall bias. Prospective studies of notifications to statutory agencies address recall bias but are less common and subject to attrition bias. These studies may therefore be underpowered to detect significant associations for some CM types such as sexual abuse. This study therefore linked administrative health data to a large birth cohort that included notifications to child protection agencies. We assessed psychiatric outcomes of CM as measured by inpatient admissions for non-affective psychoses (ICD10 codes F20-F29) to both public and private hospitals in Brisbane, Australia. Follow-up was up to 40 years old. There were 6087 cohort participants whose data could be linked to the administrative health data. Of these, 10.1 % had been the subject of a CM notification. Seventy-two participants (1.2 %) had been admitted for non-affective psychosis by 40-year follow-up. On adjusted analysis, all notified and substantiated types of CM were associated with admissions for non-affective psychosis. This included neglect, physical, sexual or emotional abuse, as well as notifications for multiple CM types. For instance, there was a 2.72-fold increase in admissions following any agency notification (95 % CI = 1.53-4.85). All maltreatment types therefore show a significant association with subsequent admissions for psychosis up to the age of 40. Screening for CM in individuals who present with psychosis is, therefore, indicated, as well as greater awareness that survivors of CM may be at higher risk of developing psychotic symptoms.
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Affiliation(s)
- Steve Kisely
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba 4102, Queensland, Australia; Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Canada; Metro South Addiction and Mental Health Service, Brisbane, Australia.
| | - Urska Arnautovska
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba 4102, Queensland, Australia; Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba 4102, Queensland, Australia; Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Nicola Warren
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba 4102, Queensland, Australia; Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Jake Moses Najman
- School of Public Health, The University of Queensland, Public Health Building, Herston 4006, Queensland, Australia; School of Social Sciences, The University of Queensland, St Lucia 4072, Queensland, Australia
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Halstead S, Sartorius N, Every-Palmer S, Siddiqi N, de Girolamo G, Siskind D, Warren N. Physical multimorbidity and mental illness: A global challenge. Aust N Z J Psychiatry 2024; 58:293-296. [PMID: 38517131 DOI: 10.1177/00048674241235587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Affiliation(s)
- Sean Halstead
- Medical School, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health, Queensland Health, Brisbane, QLD, Australia
- Section on Multimorbidity, World Psychiatric Association, Geneva, Switzerland
| | - Norman Sartorius
- Section on Multimorbidity, World Psychiatric Association, Geneva, Switzerland
- Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
| | - Susanna Every-Palmer
- Section on Multimorbidity, World Psychiatric Association, Geneva, Switzerland
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Najma Siddiqi
- Section on Multimorbidity, World Psychiatric Association, Geneva, Switzerland
- Department of Health Sciences, University of York, Hull York Medical School, York, UK
- Bradford District Care NHS, Foundation Trust, Bradford, UK
| | - Giovanni de Girolamo
- Section on Multimorbidity, World Psychiatric Association, Geneva, Switzerland
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Dan Siskind
- Medical School, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health, Queensland Health, Brisbane, QLD, Australia
- Section on Multimorbidity, World Psychiatric Association, Geneva, Switzerland
| | - Nicola Warren
- Medical School, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health, Queensland Health, Brisbane, QLD, Australia
- Section on Multimorbidity, World Psychiatric Association, Geneva, Switzerland
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Warren N, O'Gorman C, Horgan I, Weeratunga M, Halstead S, Moussiopoulou J, Campana M, Yakimov V, Wagner E, Siskind D. Inflammatory cerebrospinal fluid markers in schizophrenia spectrum disorders: A systematic review and meta-analysis of 69 studies with 5710 participants. Schizophr Res 2024; 266:24-31. [PMID: 38364730 DOI: 10.1016/j.schres.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 12/03/2023] [Accepted: 02/10/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND There is increasing evidence of immune dysregulation and neuroinflammation occurring in schizophrenia. The aim of this study is to combine studies on routine CSF parameters, as well as cytokines and inflammatory proteins, in individuals with schizophrenia spectrum disorders. METHODS CSF parameters were summated and inverse variance meta-analyses using a random effects model were performed comparing mean difference or odds ratios. Between study heterogeneity was assessed using the I2 statistic. Quality assessment and sensitivity analyses were performed. RESULTS There were 69 studies of 5710 participants, including 3180 individuals with schizophrenia spectrum disorders. Averaged CSF parameters were within normal limits, however, between 3.1 % and 23.5 % of individual cases with schizophrenia spectrum disorders had an abnormal CSF result: Protein (abnormal in 23.5 % cases), albumin (in 18.5 %), presence of oligoclonal bands (in 9.3 %), white blood cell count (in 3.6 %), and IgG levels (3.1 %). Meta-analysis of 55 studies with non-psychiatric controls demonstrated a significant increase in CSF total protein (MD: 3.50, CI: 0.12-6.87), albumin ratio (MD: 0.55, CI: 0.02-0.09), white cell count (MD: 0.25, CI: 0.05-0.46), IL-6 (SMD: 0.53, CI: 0.29 to 0.77) and IL-8 (SMD: 0.56, CI: 0.11 to 1.01). Sensitivity analysis did not alter findings. CONCLUSION Abnormal CSF parameters, cytokines and inflammatory proteins were found in a significant proportion of individuals with schizophrenia spectrum disorders. This may indicate alterations to blood brain barrier function and permeability, CSF flow dynamics or neuroinflammation. Further research is needed to explore these potential mechanisms.
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Affiliation(s)
- Nicola Warren
- The University of Queensland, Faculty of Medicine, Brisbane, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia.
| | - Cullen O'Gorman
- The University of Queensland, Faculty of Medicine, Brisbane, Australia; Department of Neurology, Metro South Health, Brisbane, Australia
| | | | | | - Sean Halstead
- The University of Queensland, Faculty of Medicine, Brisbane, Australia
| | - Joanna Moussiopoulou
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Mattia Campana
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Vladislav Yakimov
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; International Max Planck Research School for Translational Psychiatry (IMPRS-TP), Munich, Germany
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Dan Siskind
- The University of Queensland, Faculty of Medicine, Brisbane, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
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Kisely S, Bull C, Trott M, Arnautovska U, Siskind D, Warren N, Najman JM. Emergency department presentations for deliberate self-harm and suicidal ideation in 25-39 years olds following agency-notified child maltreatment: results from the Childhood Adversity and Lifetime Morbidity (CALM) study. Epidemiol Psychiatr Sci 2024; 33:e18. [PMID: 38532726 PMCID: PMC11022258 DOI: 10.1017/s2045796024000192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/28/2024] Open
Abstract
AIMS To compare prospective reports of child maltreatment (CM) with emergency department (ED) presentations for deliberate self-harm (DSH) and suicidal ideation in individuals aged between 25 and 39 years old. METHODS Linked records between the Mater-University of Queensland Study of Pregnancy birth cohort and Queensland administrative health data were used, which included notifications to child protection agencies for CM. ED presentations for individuals aged between 25 and 39 years of age for suicidal ideation, suicidal behaviour or poisoning by paracetamol or psychotropic medications where the intention was unclear were examined using logistic regression analyses. RESULTS A total of 609 (10.1%) individuals were the subject of one or more CM notifications for neglect or physical, sexual or emotional abuse before the age of 15 years. Of these, 250 (4.1%) presented at least once to ED for DSH and/or suicidal ideation between 25 and 39 years of age. In adjusted analysis, any notification of CM was associated with significantly increased odds of presenting to ED for these reasons (aOR = 2.80; 95% CI = 2.04-3.84). In sensitivity analyses, any notification of CM increased the odds of the combined outcome of DSH and suicidal ideation by 275% (aOR = 2.75; 95% CI = 1.96-4.06) and increased the odds of DSH alone by 269% (aOR = 2.69; 95% CI = 1.65-4.41). CONCLUSIONS All CM types (including emotional abuse and neglect) were associated with ED presentations for DSH and suicidal ideation in individuals between 25 and 39 years of age. These findings have important implications for the prevention of DSH, suicidal ideation and other health outcomes. They also underscore the importance of trauma-informed care in ED for all individuals presenting with DSH and suicidal ideation.
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Affiliation(s)
- S. Kisely
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba, QLD, Australia
- Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - C. Bull
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - M. Trott
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - U. Arnautovska
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - D. Siskind
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - N. Warren
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Woolloongabba, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - J. Moses Najman
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- School of Social Sciences, The University of Queensland, St Lucia, QLD, Australia
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11
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Northwood K, Eggleston K, Every-Palmer S, Galbally M, Warren N, Berk M, Gill N, Siskind D, Suetani S. Research Letter: The state of academic psychiatry in Aotearoa New Zealand and Australia: Data from a survey of the Royal Australian and New Zealand College of Psychiatrists membership. Aust N Z J Psychiatry 2024:48674241240592. [PMID: 38516914 DOI: 10.1177/00048674241240592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Affiliation(s)
- Korinne Northwood
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- Addiction and Mental Health Services, Metro South Health, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Katherine Eggleston
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
- Specialist Mental Health Services, Te Whatu Ora Waitaha, Christchurch, New Zealand
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
- Mental Health, Addiction and Intellectual Disability Service, 3DHB, Wellington, New Zealand
| | - Megan Galbally
- School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
- Health Futures Institute, Murdoch University, Perth, WA, Australia
| | - Nicola Warren
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- Addiction and Mental Health Services, Metro South Health, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Michael Berk
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
- IMPACT Strategic Research Centre, Barwon Health, Deakin University, Geelong, VIC, Australia
- Orygen Youth Health Research Centre, Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Neeraj Gill
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
- Health Research Institute, University of Canberra, Canberra, ACT, Australia
- Mental Health and Specialist Services, Gold Coast Health, Gold Coast, QLD, Australia
| | - Dan Siskind
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- Addiction and Mental Health Services, Metro South Health, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Shuichi Suetani
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
- Institute for Urban Indigenous Health, Windsor, QLD, Australia
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Gandar C, Scott JG, Warren N. Glucose-6-phosphate dehydrogenase deficiency and psychotic disorders: A systematic review. World J Biol Psychiatry 2024; 25:151-159. [PMID: 38044502 DOI: 10.1080/15622975.2023.2290563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVES Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD) is the most common enzymopathy globally. Early studies suggested an association with severe psychotic illness; however, changes to laboratory testing and diagnostic classification renders the association unclear. This study aims to explore the interaction between G6PD deficiency and psychotic symptoms, in particular to identify specific patterns of presentation or impact on outcomes. METHODS Pubmed, Embase, and PsycInfo databases were searched from inception to May 2023. Descriptive statistics and narrative review of were used to synthesise data on demographics, mental and physical health diagnoses, investigations, treatment, and outcomes. RESULTS No clear link was found in published data (eight case reports, case series of n = 29) with a high rate (63%) of haemolytic crisis at the time of psychiatric presentation suggested delirium as an alternative diagnosis. Four case control studies found no significant difference in the prevalence of G6PD deficiency. However, catatonic presentation was reported in 40% of the case series and a higher prevalence of G6PD deficiency in catatonic schizophrenia was noted in case control studies. CONCLUSIONS Based on the information available there was no clear association between G6PD deficiency and psychotic illness or treatment resistance, although paucity of studies and risk of bias limit strong conclusions.
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Affiliation(s)
- Christopher Gandar
- Child and Youth Mental Health Service, Children's Health Queensland, Brisbane, Australia
| | - James G Scott
- Child and Youth Mental Health Service, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
| | - Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health, Brisbane, Australia
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13
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Northwood K, Myles N, Clark SR, Every-Palmer S, Myles H, Kisely S, Warren N, Siskind D. Evaluating the epidemiology of clozapine-associated neutropenia among people on clozapine across Australia and Aotearoa New Zealand: a retrospective cohort study. Lancet Psychiatry 2024; 11:27-35. [PMID: 38040009 DOI: 10.1016/s2215-0366(23)00343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Clozapine is associated with the risk of serious neutropenia. However, this risk might decrease over time, meaning that indefinite absolute neutrophil count (ANC) monitoring could be unnecessary. We aimed to determine the epidemiology and timing of clozapine-associated neutropenia outcomes, to investigate variables that might contribute to the odds of neutropenia, and to determine risk of competing neutropenic events during clozapine treatment. METHODS We performed a retrospective analysis of the Australian and New Zealand Viatris Pharmacovigilance system (one of two monitoring databases for these two countries) between June 6, 1990, and Oct 25, 2022. Patients were excluded from analysis if they commenced clozapine before 1990, did not have a haematology test within 2 weeks of commencement date, or had no follow-up. We measured minor neutropenia (ANC 1·0-1·5 × 109 per L) and serious neutropenia (ANC <1·0 × 109 per L) leading to cessation of clozapine within 6 weeks of the neutropenic event. We determined the rates of minor and serious neutropenia and calculated odds ratios (ORs) for the likelihood of neutropenia leading to cessation. For serious neutropenia leading to cessation, we used time-to-event to calculate rolling weekly averages and to perform competing risk analysis of outcomes using Cox proportional hazards models and a Fine-Gray subdistribution hazards regression model. For the subset of data where information on previous clozapine use was available, we did an analysis for participants who did and did not have previous clozapine exposure. FINDINGS We included 26 630 people, with 2·6 million ANC values. Within the total cohort, 17 585 people (66%) were male, 9025 (33·9%) female, and 20 (0·1%) other gender, and the mean age was 36·1 years (SD 13·7). We did not have data on race or ethnicity. Of the 26 630 people taking clozapine, 1146 (4·3%) had minor neutropenia, 313 (1·2%) had serious neutropenia leading to cessation, and 223 (0·8%) had serious neutropenia unrelated to clozapine without cessation. In people with no previous exposure to clozapine (n=15 973), the cumulative incidence of serious neutropenia leading to cessation was 0·9% at 18 weeks and 1·4% at 2 years; the weekly incidence rate for serious neutropenia leading to cessation peaked at 9 weeks (0·128%) and fell to a rolling average weekly incidence of 0·001% by 2 years. For minor neutropenia, the cumulative incidence was 1·7% at 18 weeks and 3·5% at 2 years; the weekly incidence rate peaked at 9 weeks (0·218%) and fell to a stable rolling average of 0·01%. The median time to a serious neutropenic event leading to cessation was 17 weeks (IQR 9·96-102). Previous clozapine exposure reduced the risk of serious neutropenia leading to cessation (OR 0·19, 95% CI 0·12-0·31; p <0·0001). INTERPRETATION Most serious neutropenia leading to clozapine cessation occurs within 18 weeks of treatment and becomes negligible after 2 years. Weekly haematological monitoring after the first 18 weeks could be safely reduced to once every 4 weeks and ceased after 2 years unless clinically indicated. Clozapine retrial after interruption with 2 cumulative years of unremarkable testing might not require further haematological monitoring. A serious neutropenia ANC threshold of ≤1·0 × 109 per L could be used in more jurisdictions. FUNDING None.
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Affiliation(s)
- Korinne Northwood
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Nicholas Myles
- Discipline of Psychiatry, Adelaide University, Adelaide, SA, Australia
| | - Scott R Clark
- Discipline of Psychiatry, Adelaide University, Adelaide, SA, Australia
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Hannah Myles
- Northern Adelaide Health Network, Adelaide, SA, Australia
| | - Steve Kisely
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia.
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14
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Halstead S, Siskind D, Warren N. Making meaning of multimorbidity and severe mental illness: A viewpoint. Aust N Z J Psychiatry 2024; 58:12-20. [PMID: 37655619 PMCID: PMC10756013 DOI: 10.1177/00048674231195560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
People living with severe mental illness, such as schizophrenia and bipolar affective disorder, frequently experience poorer physical health compared to those without mental illness. This issue has hitherto been approached through the disease-centred construct of comorbidity, where subsequent conditions are viewed as secondary to an 'index condition'. In contrast, this Viewpoint sets out to explain why multimorbidity, a patient-centred concept that instead refers to the coexistence of multiple chronic illnesses, is a more versatile and robust framework for tackling the issue of poor physical health in people with severe mental illness. In establishing this argument, this Viewpoint has sought to address three key areas. First, this article will discuss the epidemiology of both physical and psychiatric multimorbidity, with respect to how they manifest at greater frequency and at younger ages in people with severe mental illness. Second, the profound consequences of this multimorbidity burden will be explored, with respect to the 'three D's' of death (premature mortality), disability (functional impacts) and deficit (health-economic impacts). Finally, the utility of multimorbidity as a framework will be illustrated through a proposal for a three-dimensional multimorbidity construct composed of (1) quantity, (2) severity and (3) duration of an individual's chronic illnesses. Consequently, this Viewpoint aims to capture why it is necessary for modern psychiatry to grasp the concept of multimorbidity to facilitate holistic healthcare for people living with severe mental illness.
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Affiliation(s)
- Sean Halstead
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Logan Hospital, Metro South Health, Meadowbrook, QLD, Australia
| | - Dan Siskind
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Nicola Warren
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
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15
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Ramachandra A, Thomas EHX, Vincent AJ, Hickey M, Warren N, Kulkarni J, Forrest LE, Bojadzieva J, Campbell A, Gurvich C. Subjective cognitive changes following premenopausal risk-reducing bilateral salpingo-oophorectomy. Climacteric 2023; 26:625-631. [PMID: 37751773 DOI: 10.1080/13697137.2023.2256659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVE Women at high risk of ovarian cancer are commonly advised to undergo risk-reducing bilateral salpingo-oophorectomy (BSO) prior to natural menopause. Cognitive symptoms during natural menopause transition are frequently reported; however, very few studies have examined cognitive changes following surgical menopause. To address this gap, we explored the cognitive experiences of women within 24 months post BSO. METHODS This observational cross-sectional sub-study is part of a larger project, the Early Menopause and Cognition Study (EM-COG). We investigated perceived cognitive experiences in Australian women (n = 16) who underwent risk-reducing BSO using qualitative interviews. Thematic analysis was undertaken to identify key themes. RESULTS Fifteen out of 16 participants (93.75%) reported changes to cognition within 24 months post BSO. The key cognitive symptoms reported were brain fog, memory and retrieval difficulties, slower processing speed as well as attention difficulties. Five participants (31.3%) experienced negative mood symptoms post BSO. CONCLUSION Findings from this study suggest that women experience subjective cognitive changes within 24 months post BSO. This period could be a vulnerable time for women's cognitive health. While these findings need to be confirmed by a large prospective study, our research indicates that psychoeducation and awareness will be helpful in managing cognitive symptoms after surgical menopause.
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Affiliation(s)
- A Ramachandra
- HER Centre Australia, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - E H X Thomas
- HER Centre Australia, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - A J Vincent
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Clayton, VIC, Australia
| | - M Hickey
- Women's Gynaecology Research Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - N Warren
- School of Social Sciences, Monash University, Melbourne, VIC, Australia
| | - J Kulkarni
- HER Centre Australia, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - L E Forrest
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - J Bojadzieva
- Clinical Genetics Unit, Austin Health, Melbourne, VIC, Australia
| | - A Campbell
- Clinical Genetics Unit, Austin Health, Melbourne, VIC, Australia
| | - C Gurvich
- HER Centre Australia, Central Clinical School, Monash University, Melbourne, VIC, Australia
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Northwood K, Warren N. A guide to support trainee's success in the psychotherapy written case submission. Australas Psychiatry 2023; 31:730-733. [PMID: 37621187 PMCID: PMC10725622 DOI: 10.1177/10398562231196684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Many trainees find the Psychotherapy Written Case (PWC) requirement of the Royal Australian and New Zealand College of Psychiatrists training program challenging. The skills developed and assessed through this experience are critical to the competencies expected of a psychiatrist. However, the process of psychodynamic psychotherapy is often dramatically different from the expectations associated with early clinical placements in acute psychiatric settings. To support trainees in achieving success in the PWC, a guide to the written report was developed based on a review of existing resources and various stakeholder perspectives. CONCLUSIONS The submission should reflect a training case rather than an idealised or fictionalised story attempting to demonstrate the therapist's competence. The PWC submission must meet the requirements of a general psychiatric report and provide a considered reflection on the experience of the novice therapist.
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Affiliation(s)
- Korinne Northwood
- Metro South Addiction and Mental Health Service, Woolloongabba, AU-QLD, Australia; and
- Faculty of Medicine, The University of Queensland, Herston, AU-QLD, Australia
| | - Nicola Warren
- Nicola Warren, Metro South Addiction and Mental Health Service, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, AU-QLD 4152, Australia.
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Warren N, Leske S, Arnautovska U, Northwood K, Kisely S, Siskind D. Prevalence of frailty in severe mental illness: findings from the UK Biobank. BJPsych Open 2023; 9:e185. [PMID: 37821357 PMCID: PMC10594184 DOI: 10.1192/bjo.2023.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/28/2023] [Accepted: 09/10/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Severe mental illness (SMI) is associated with significant morbidity. Frailty combines biological ageing, comorbidity and psychosocial factors and can predict adverse health outcomes. Emerging evidence indicates that frailty is higher in individuals with SMI than in the general population, although studies have been limited by sample size. AIMS To describe the prevalence of frailty in people with SMI in a large cohort using three different frailty measures and examine the impact of demographic and sociodemographic variables. METHOD The UK Biobank survey data, which included individuals aged 37-73 years from England, Scotland and Wales from 2006 to 2010, with linked in-patient hospital episodes, were utilised. The prevalence of frailty in individuals with and without SMI was assessed through three frailty measures: frailty index, physical frailty phenotype (PFP) and Hospital Frailty Risk Score (HFRS). Stratified analysis and dichotomous logistic regression were conducted. RESULTS A frailty index could be calculated for 99.5% of the 502 412 UK Biobank participants and demonstrated greater prevalence of frailty in women and an increase with age. The prevalence of frailty for those with SMI was 3.19% (95% CI 3.0-3.4), 4.2% (95% CI 3.8-4.7) and 18% (95% CI 15-23) using the frailty index, PFP and HFRS respectively. The prevalence ratio was between 3 and 18 times higher than in those without SMI. CONCLUSIONS As a measure, frailty captures the known increase in morbidity associated with SMI and may potentially allow for earlier identification of those who will benefit from targeted interventions.
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Affiliation(s)
- Nicola Warren
- Faculty of Medicine, The University of Queensland, Brisbane, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
| | - Stuart Leske
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Urska Arnautovska
- Faculty of Medicine, The University of Queensland, Brisbane, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
| | - Korinne Northwood
- Faculty of Medicine, The University of Queensland, Brisbane, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
| | - Steve Kisely
- Faculty of Medicine, The University of Queensland, Brisbane, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
| | - Dan Siskind
- Faculty of Medicine, The University of Queensland, Brisbane, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
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Kaazan P, Seow W, Tan Z, Logan H, Philpott H, Huynh D, Warren N, McIvor C, Holtmann G, Clark SR, Tse E. Deliberate foreign body ingestion in patients with underlying mental illness: A retrospective multicentre study. Australas Psychiatry 2023; 31:619-624. [PMID: 37473424 PMCID: PMC10566206 DOI: 10.1177/10398562231189431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Deliberate foreign body ingestion (DFBI) is characterised by recurrent presentations among patients with mental health conditions, intellectual disabilities and in prisoners. We aimed to profile the characteristics and evaluate the care of such patients in this study. METHODS Adult patients with an endoscopic record of attempted foreign body retrieval between January 2013 and September 2020 were identified at three Australian hospitals. Those with a documented mental health diagnosis were included and their standard medical records reviewed. Presentation history, demographics, comorbidities and endoscopic findings were recorded and described. RESULTS A total of 166 admissions were accounted for by 35 patients, 2/3 of which had borderline personality disorder (BPD). Repetitive presentations occurred in more than half of the cohort. There was an increased trend of hospital admissions throughout the years. At least half of the cohort had a documented mental health review during their admission. An average of 3.3 (2.9) foreign bodies were ingested per single episode. Endoscopic intervention was performed in 76.5% of incidents. The combined Length of stay for all patients was 680 days. CONCLUSION Deliberate foreign body ingestion in mental health patients is a common, recurring and challenging problem that is increasing in frequency and requires collaborative research to further guide holistic management.
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Affiliation(s)
- P Kaazan
- Department of Gastroenterology and Hepatology, The Princess Alexandra Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia; and
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - W Seow
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia; and
- Department of Gastroenterology and Hepatology, The Royal Adelaide Hospital, Adelaide, Australia
| | - Z Tan
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - H Logan
- Department of Gastroenterology and Hepatology, The Princess Alexandra Hospital, Brisbane, Australia; and
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - H Philpott
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - D Huynh
- Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Woodville South, Australia
| | - N Warren
- Faculty of Medicine, The University of Queensland, Brisbane, Australia; and
- Addiction and mental health services, Brisbane, Metro South health
| | - C McIvor
- Department of Gastroenterology and Hepatology, Logan Hospital, Logan, Australia
| | - G Holtmann
- Department of Gastroenterology and Hepatology, The Princess Alexandra Hospital, Brisbane, Australia; and
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - S R Clark
- Faculty of Health and Medical Sciences, University of Adelaide, Brisbane, Australia; and
- Discipline of Psychiatry, Central Adelaide Local Health Network
| | - E Tse
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia; and
- Department of Gastroenterology and Hepatology, The Royal Adelaide Hospital, Adelaide, Australia
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Arnautovska U, Vitangcol K, Kesby JP, Warren N, Rossell SL, Neill E, Harris A, Galletly C, Castle D, Siskind D. Verbal and visual learning ability in patients with treatment-resistant schizophrenia: A 1-year follow-up study. Schizophr Res Cogn 2023; 33:100283. [PMID: 37006704 PMCID: PMC10063404 DOI: 10.1016/j.scog.2023.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Objective In the general population, repeated cognitive testing produces learning effects with potential for improved test performance. It is currently unclear whether the same effect of repeated cognitive testing on cognition pertains to people living with schizophrenia, a condition often associated with significant cognitive impairments. This study aims to evaluate learning ability in people with schizophrenia and-considering the evidence that antipsychotic medication can additionally impair cognitive performance-explore the potential impact of anticholinergic burden on verbal and visual learning. Method The study included 86 patients with schizophrenia, treated with clozapine, who had persisting negative symptoms. They were assessed at baseline, weeks 8, 24 and 52 using Positive and Negative Syndrome Scale, Hopkins Verbal Learning Test-Revised (HVLT-R) and Brief Visuospatial Memory Test-R (BVMT-R). Results There were no significant improvements in verbal or visual learning across all measurements. Neither the clozapine/norclozapine ratio nor anticholinergic cognitive burden significantly predicted participants' total learning. Premorbid IQ was significantly associated with verbal learning on the HVLT-R. Conclusions These findings advance our understanding of cognitive performance in people with schizophrenia and demonstrate limited learning performance in individuals with treatment-refractory schizophrenia.
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Affiliation(s)
- Urska Arnautovska
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4102, Australia
- Metro South Addictions and Mental Health Service, Woolloongabba, QLD 4102, Australia
- Corresponding authors at: PAH Southside Clinical Unit, Faculty of Medicine, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD 4102, Australia.
| | - Kathryn Vitangcol
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4102, Australia
| | - James P. Kesby
- Queensland Centre for Mental Health Research, Wacol, QLD 4076, Australia
- Queensland Brain Institute, The University of Queensland, St Lucia, QLD 4067, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4102, Australia
- Metro South Addictions and Mental Health Service, Woolloongabba, QLD 4102, Australia
| | - Susan L. Rossell
- Centre for Mental Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, VIC 5062, Australia
- Department of Psychiatry, St Vincent's Hospital Melbourne, Fitzroy, VIC 3065, Australia
| | - Erica Neill
- Centre for Mental Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, VIC 5062, Australia
| | - Anthony Harris
- Specialty of Psychiatry, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Cherrie Galletly
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, SA 5005, Australia
- Northern Adelaide Local Health Network, Adelaide, SA 5005, Australia
| | - David Castle
- Department of Psychiatry, St Vincent's Hospital Melbourne, Fitzroy, VIC 3065, Australia
- Centre for Complex Intervention, Centre for Addiction and Mental Health, Toronto 2283, Canada
- Department of Psychiatry, The University of Toronto, Toronto 2283, Canada
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4102, Australia
- Metro South Addictions and Mental Health Service, Woolloongabba, QLD 4102, Australia
- Corresponding authors at: PAH Southside Clinical Unit, Faculty of Medicine, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD 4102, Australia.
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Warren N, Freier K, Siskind D, O'Gorman C, Blum S, Gillis D, Scott JG. Anti-glutamic acid decarboxylase antibody screening in first-episode psychosis. Aust N Z J Psychiatry 2023; 57:603-612. [PMID: 35362325 DOI: 10.1177/00048674221089560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The Royal Australian and New Zealand College of Psychiatrists recommends screening for a range of antibodies in first-episode psychosis, including anti-glutamic acid decarboxylase antibodies. Glutamic acid decarboxylase antibody-associated encephalitis occurs with high antibody titres and may cause cognitive dysfunction, seizures and psychiatric symptoms. However, glutamic acid decarboxylase antibodies are more frequently found in lower titre in association with other autoimmune disorders (such as diabetes mellitus type 1) and in healthy individuals. The utility of testing unselected populations of consumers with psychosis is unclear. The psychiatric manifestations of this disorder are also poorly described. METHODS First, systematic review of cohort and case-control studies that tested for IgG glutamic acid decarboxylase antibodies in psychiatric populations was conducted. Random-effects meta-analysis of odds ratio for antibody positivity in cases with psychosis and controls assessed prevalence. Second, literature review of all published cases and case series of glutamic acid decarboxylase antibody-associated limbic encephalitis was assessed for frequency and description of psychotic symptoms. RESULTS There were 17 studies, in which 2754 individuals with psychotic disorders were tested for glutamic acid decarboxylase IgG antibodies. Thirty-one consumers with psychosis (0.7%) had positive glutamic acid decarboxylase antibodies compared to 24 controls (1.0%), all at low titre and not fulfilling diagnostic criteria for autoimmune encephalitis. Meta-analysis found no significant difference in rates of glutamic acid decarboxylase antibody positivity (odds ratio = 1.8, 95% confidence interval: [0.90, 3.63]). Literature review found 321 cases of glutamic acid decarboxylase antibody-associated limbic encephalitis, with psychosis in 15 (4.3%) cases. Clinical screening would have identified all cases that presented to psychiatric services. CONCLUSION Glutamic acid decarboxylase antibodies were uncommon in consumers with psychosis, with no significant difference in prevalence from controls and no cases of encephalitis identified. In cases with established glutamic acid decarboxylase antibody-associated limbic encephalitis, psychotic symptoms were uncommon and identifiable by clinical assessment. Targeted antibody testing guidelines should be further considered.
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Affiliation(s)
- Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Karen Freier
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Dan Siskind
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - Stefan Blum
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, The Princess Alexandra Hospital, Brisbane, QLD, Australia
- Mater Centre for Clinical Neurosciences, Mater Hospital, Brisbane, QLD, Australia
| | - David Gillis
- Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - James G Scott
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Metro North Mental Health Service, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
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Halstead S, Siskind D, Amft M, Wagner E, Yakimov V, Shih-Jung Liu Z, Walder K, Warren N. Alteration patterns of peripheral concentrations of cytokines and associated inflammatory proteins in acute and chronic stages of schizophrenia: a systematic review and network meta-analysis. Lancet Psychiatry 2023; 10:260-271. [PMID: 36863384 DOI: 10.1016/s2215-0366(23)00025-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/11/2022] [Accepted: 01/06/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Immune system dysfunction is considered to play an aetiological role in schizophrenia spectrum disorders, with substantial alterations in the concentrations of specific peripheral inflammatory proteins, such as cytokines. However, there are inconsistencies in the literature over which inflammatory proteins are altered throughout the course of illness. Through conducting a systematic review and network meta-analysis, this study aimed to investigate the patterns of alteration that peripheral inflammatory proteins undergo in both acute and chronic stages of schizophrenia spectrum disorders, relative to a healthy control population. METHODS In this systematic review and meta-analysis, we searched PubMed, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to March 31, 2022, for published studies reporting peripheral inflammatory protein concentrations in cases of people with schizophrenia-spectrum disorders and healthy controls. Inclusion criteria were: (1) observational or experimental design; (2) a population consisting of adults diagnosed with schizophrenia-spectrum disorders with a specified indicator of acute or chronic stage of illness; (3) a comparable healthy control population without mental illness; (4) a study outcome measuring the peripheral protein concentration of a cytokine, associated inflammatory marker, or C-reactive protein. We excluded studies that did not measure cytokine proteins or associated biomarkers in blood. Mean and SDs of inflammatory marker concentrations were extracted directly from full-text publshed articles; articles that did not report data as results or supplementary results were excluded (ie, authors were not contacted) and grey literature and unpublished studies were not sought. Pairwise and network meta-analyses were done to measure the standardised mean difference in peripheral protein concentrations between three groups: individuals with acute schizophrenia-spectrum disorder, individuals with chronic schizophrenia-spectrum disorder, and healthy controls. This protocol was registered on PROSPERO, CRD42022320305. FINDINGS Of 13 617 records identified in the database searches, 4492 duplicates were removed, 9125 were screened for eligibility, 8560 were excluded after title and abstract screening, and three were excluded due to limited access to the full-text article. 324 full-text articles were then excluded due to inappropriate outcomes, mixed or undefined schizophrenia cohorts, or duplicate study populations, five were removed due to concerns over data integrity, and 215 studies were included in the meta-analysis. 24 921 participants were included, with 13 952 adult cases of schizophrenia-spectrum disorder and 10 969 adult healthy controls (descriptive data for the entire cohort were not available for age, numbers of males and females, and ethnicity). Concentration of interleukin (IL)-1β, IL-1 receptor antagonist (IL-1RA), soluble interleukin-2 receptor (sIL-2R), IL-6, IL-8, IL-10, tumour necrosis factor (TNF)-α, and C-reactive protein were consistently elevated in both individuals with acute schizophrenia-spectrum disorder and chronic schizophrenia-spectrum disorder, relative to healthy controls. IL-2 and interferon (IFN)-γ were significantly elevated in acute schizophrenia-spectrum disorder, while IL-4, IL-12, and IFN-γ were significantly decreased in chronic schizophrenia-spectrum disorder. Sensitivity and meta-regression analyses revealed that study quality and a majority of the evaluated methodological, demographic, and diagnostic factors had no significant impact on the observed results for most of the inflammatory markers. Specific exceptions to this included: methodological factors of assay source (for IL-2 and IL-8), assay validity (for IL-1β), and study quality (for transforming growth factor-β1); demographic factors of age (for IFN-γ, IL-4, and IL-12), sex (for IFN-γ and IL-12), smoking (for IL-4), and BMI (for IL-4); and diagnostic factors including diagnostic composition of schizophrenia-spectrum cohort (for IL-1β IL-2, IL-6, and TNF-α), antipsychotic-free cases (for IL-4 and IL-1RA), illness duration (for IL-4), symptom severity (for IL-4), and subgroup composition (for IL-4). INTERPRETATION Results suggest that people with schizophrenia-spectrum disorders have a baseline level of inflammatory protein alteration throughout the illness, as reflected by consistently elevated pro-inflammatory proteins, hypothesised here as trait markers (eg, IL-6), while those with acute psychotic illness might have superimposed immune activity with increased concentrations of hypothesised state markers (eg, IFN-γ). Further research is required to determine whether these peripheral alterations are reflected within the central nervous system. This research facilitates an entry point in understanding how clinically relevant inflammatory biomarkers might one day be useful to the diagnosis and prognostication of schizophrenia-spectrum disorders. FUNDING None.
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Affiliation(s)
- Sean Halstead
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia; Medical School, The University of Queensland, Brisbane, QLD, Australia
| | - Dan Siskind
- Medical School, The University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health, Brisbane, QLD, Australia
| | - Michaela Amft
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität München, Munich, Munich, Germany
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität München, Munich, Munich, Germany
| | - Vladislav Yakimov
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-Universität München, Munich, Munich, Germany
| | - Zoe Shih-Jung Liu
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Ken Walder
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Nicola Warren
- Medical School, The University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health, Brisbane, QLD, Australia.
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Northwood K, Pearson E, Arnautovska U, Kisely S, Pawar M, Sharma M, Vitangcol K, Wagner E, Warren N, Siskind D. Optimising plasma clozapine levels to improve treatment response: an individual patient data meta-analysis and receiver operating characteristic curve analysis. Br J Psychiatry 2023; 222:241-245. [PMID: 36994656 DOI: 10.1192/bjp.2023.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND Although clozapine is the most efficacious medication for treatment-refractory schizophrenia, not all patients will have an adequate response. Optimising clozapine dose using therapeutic drug monitoring could therefore maximise response. AIMS Using individual patient data, we undertook a receiver operating characteristic (ROC) curve analysis to determine an optimal therapeutic range for clozapine levels to guide clinical practice. METHOD We conducted a systematic review of PubMed, PsycINFO and Embase for studies that provided individual participant level data on clozapine levels and response. These data were analysed using ROC curves to determine the prediction performance of plasma clozapine levels for treatment response. RESULTS We included data on 294 individual participants from nine studies. ROC analysis yielded an area under the curve of 0.612. The clozapine level at the point of optimal diagnostic benefit was 372 ng/mL; at this level, the response sensitivity was 57.3%, and specificity 65.7%. The interquartile range for treatment response was 223-558 ng/mL. There was no improvement in ROC performance with mixed models including patient gender, age or length of trial. Clozapine dose and clozapine concentration to dose ratio did not provide significantly meaningful prediction of response to clozapine. CONCLUSIONS Clozapine dose should be optimised based on clozapine therapeutic levels. We found that a range between 250 and 550 ng/mL could be recommended, while noting that a level of >350 ng/mL is the most optimal for response. Although some patients may not respond without clozapine levels >550 ng/mL, the benefits should be weighed against the increased risk of adverse drug reactions.
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Affiliation(s)
- Korinne Northwood
- Metro South Addiction and Mental Health Service, Metro South Health, Australia and Faculty of Medicine, University of Queensland, Australia
| | - E Pearson
- College of Medicine and Public Health, Flinders University, Australia
| | - U Arnautovska
- Metro South Addiction and Mental Health Service, Metro South Health, Australia and Faculty of Medicine, University of Queensland, Australia
| | - S Kisely
- Metro South Addiction and Mental Health Service, Metro South Health, Australia and Faculty of Medicine, University of Queensland, Australia
| | - M Pawar
- Metro South Addiction and Mental Health Service, Metro South Health, Australia
| | - M Sharma
- Department of Mental Health, Monash Health, Australia
| | - K Vitangcol
- Faculty of Medicine, University of Queensland, Australia
| | - E Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - N Warren
- Metro South Addiction and Mental Health Service, Metro South Health, Australia and Faculty of Medicine, University of Queensland, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, Metro South Health, Australia and Faculty of Medicine, University of Queensland, Australia
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Kisely S, Leske S, Arnautovska U, Siskind D, Warren N, Northwood K, Suetani S, Najman JM. A 40-year study of child maltreatment over the early life course predicting psychiatric morbidity, using linked birth cohort and administrative health data: protocol for the Childhood Adversity and Lifetime Morbidity (CALM) study. BJPsych Open 2023; 9:e50. [PMID: 36880844 PMCID: PMC10044170 DOI: 10.1192/bjo.2023.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Child maltreatment is a major public health issue worldwide. Retrospective studies show a strong association between self-reported child maltreatment and poor mental and physical health problems. Prospective studies that use reports to statutory agencies are less common, and comparisons of self- and agency-reported abuse in the same cohort even rarer. AIMS This project will link state-wide administrative health data with prospective birth cohort data (N = 7223) from Brisbane in Queensland, Australia (including notifications to child protection agencies), to compare psychiatric outcomes in adulthood of agency- and self-reported child maltreatment while minimising attrition bias. METHOD We will compare people with all forms of self- and agency-reported child maltreatment to the rest of the cohort, adjusting for confounding in logistic, Cox or multiple regression models based on whether outcomes are categorical or continuous. Outcomes will be hospital admissions, emergency department presentations or community/out-patient contacts for ICD-10 psychiatric diagnoses, suicidal ideation and self-harm as recorded in the relevant administrative databases. CONCLUSIONS This study will track the life course outcomes of adults after having experienced child maltreatment, and so provide an evidence-based understanding of the long-term health and behavioural consequences of child maltreatment. It will also consider health outcomes that are particularly relevant for adolescents and young adults, especially in relation to prospective notifications to statutory agencies. Additionally, it will identify the overlap and differences in outcome for two different sources of child maltreatment identification in the same cohort.
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Affiliation(s)
- Steve Kisely
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Australia; Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Canada; and Addiction and Mental Health Services, Metro South Addiction and Mental Health Service, Australia
| | - Stuart Leske
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Australia
| | - Urska Arnautovska
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Australia; and Addiction and Mental Health Services, Metro South Addiction and Mental Health Service, Australia
| | - Dan Siskind
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Australia; and Addiction and Mental Health Services, Metro South Addiction and Mental Health Service, Australia
| | - Nicola Warren
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Australia; and Addiction and Mental Health Services, Metro South Addiction and Mental Health Service, Australia
| | - Korinne Northwood
- Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The University of Queensland, Australia; and Addiction and Mental Health Services, Metro South Addiction and Mental Health Service, Australia
| | | | - Jake Moses Najman
- School of Public Health, The University of Queensland, Australia; and School of Social Sciences, The University of Queensland, Australia
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Arnautovska U, Siskind D, Pearson E, Baker A, Reid N, Kwan WWL, Wang N, Gordon E, Hubbard R, Warren N. Comprehensive Geriatric Assessment for younger outpatients with severe mental illness: protocol for a feasibility study. BMJ Open 2023; 13:e069518. [PMID: 36810179 PMCID: PMC10439344 DOI: 10.1136/bmjopen-2022-069518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Individuals with severe mental illness are at risk of becoming prematurely frail. There is a critical unmet need for an intervention that reduces the risk of frailty and minimises the associated negative outcomes in this population. This study aims to provide novel evidence on the feasibility, acceptability and preliminary effectiveness of Comprehensive Geriatric Assessment (CGA) to improve health outcomes among people with co-occurring frailty and severe mental illness. METHODS AND ANALYSIS Twenty-five participants with frailty and severe mental illness, aged 18-64 years, will be recruited from Metro South Addiction and Mental Health Service outpatient clinics and provided with the CGA. Primary outcome measures will include the feasibility and acceptability of the CGA embedded in routine healthcare. Other variables of interest will include frailty status, quality of life, polypharmacy, and a range of mental and physical health factors. ETHICS AND DISSEMINATION All procedures involving human subjects/patients were approved by Metro South Human Research Ethics Committee (HREC/2022/QMS/82272). Study findings will be disseminated through peer-reviewed publications and conference presentations.
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Affiliation(s)
- Urska Arnautovska
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Woolloongabba, Queensland, Australia
| | - Dan Siskind
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Woolloongabba, Queensland, Australia
| | - Ella Pearson
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Andrea Baker
- Queensland Centre for Mental Health Research, Wacol, Queensland, Australia
| | - Natasha Reid
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Winona Wing Ling Kwan
- Metro South Addiction and Mental Health Service, Woolloongabba, Queensland, Australia
| | - Nancy Wang
- Metro South Addiction and Mental Health Service, Woolloongabba, Queensland, Australia
| | - Emily Gordon
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Ruth Hubbard
- Faculty of Medicine, Centre for Health Services Research, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Nicola Warren
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Woolloongabba, Queensland, Australia
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Abstract
OBJECTIVE This paper highlights the importance of psychiatric formulation and provides guidance to those learning the art of formulation. To achieve this, we explore the guidance on formulation that has been previously published in Australasian Psychiatry, identify the key components of psychiatric formulation, and outline an approach to comprehensive formulation in routine clinical practice. CONCLUSION Formulation is the foundation of good psychiatric practice but presents a considerable challenge to the novice practitioner. Understanding the ingredients of formulation and a method for meaningfully putting these together will guide deliberate practice to learn the art of psychiatric formulation.
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Affiliation(s)
- Stephen Parker
- The Prince Charles Hospital, Metro North Addiction and Mental Health Service, Chermside, QLD, Australia; School of Medicine and Dentistry, Griffith University, Nathan, QLD, Australia; and 420004The University of Queensland, Brisbane, QLD, Australia
| | - Kitty Nhieu
- Metro South Addiction and Mental Health, Brisbane, QLD, Australia
| | - Nicola Warren
- 420004The University of Queensland, Brisbane, QLD, Australia; and Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
| | - Frances Dark
- 420004The University of Queensland, Brisbane, QLD, Australia; and Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
| | - Jimsie Cutbush
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
| | - Shuichi Suetani
- School of Medicine and Dentistry, Griffith University, Nathan, QLD, Australia; 420004The University of Queensland, Brisbane, QLD, Australia; 90131Queensland Centre for Mental Health Research, Wacol, QLD, Australia; and Institute for Urban Indigenous Health, Windsor, QLD, Australia
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Lupke K, Warren N, Teodorczuk A, Steele S, Kolur U, Wand A, Robinson G, Parker S. A systematic review of modified electroconvulsive therapy (ECT) to treat delirium. Acta Psychiatr Scand 2022; 147:403-419. [PMID: 35996219 DOI: 10.1111/acps.13492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/30/2022] [Accepted: 08/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Delirium is costly for patients, carers, and healthcare systems. In addition, non-pharmacological and pharmacological management of delirium is challenging. Electroconvulsive therapy (ECT) has been proposed and used as an anecdotal treatment of delirium in clinical practice. However, the efficacy and safety of this approach are not well understood. OBJECTIVE To synthesise and review the evidence relating to the safety and efficacy of ECT as a treatment for delirium. METHODS A systematic review was completed according to PRISMA guidelines using the PubMed, CINAHL, Cochrane Library, and PsycINFO databases. Studies were eligible for inclusion if modified ECT was used to treat delirium symptoms. ECT for delirium in people with neuroleptic malignant syndrome, catatonia, or confusional states associated with acute primary psychiatric conditions were excluded. All included records were first ranked using the hierarchy of evidence-based medicine; quality was then assessed using the Joanna Briggs critical appraisal checklists. Pooled data across the cases identified were analysed using descriptive statistics. RESULTS Of 1226 records screened, 10 studies met inclusion criteria: six case reports, three case series, and one quasi-experimental study. The literature base was of mixed quality. A single quasi-experimental study was assessed to be of 'fair' quality, the remainder of the case series and case reports were rated as 'poor' to 'fair' quality. A total of only 40 individual people with delirium who were treated with ECT were identified. In 33/40 cases, the aetiology of delirium was substance withdrawal. The number of ECT treatments administered ranged from 1 to 13. ECT was reported to positively contribute towards treatment of delirium in all cases, although objective measures of improvement were reported in only 6/13 patient cases from case reports and case series (46%). The singular quasi-experimental study reported a statistically significant decrease in duration of delirium, time spent in physical restraint, and in benzodiazepine requirement when ECT was used as an adjunct in benzodiazepine withdrawal delirium. When adverse events were described these included mild confusion and memory deficits; all were reported as time limited and reversible. Considerable limitations in the quality of the evidence base were identified, including the risk of selection, publication and reporting bias. Much data reporting on safety and efficacy of ECT in delirium was missing. CONCLUSION There is insufficient literature to support modified ECT as a clinical treatment for delirium. The few studies identified were generally of weak evidence lacking important data on safety and objective outcome measures, and not including populations with broad delirium aetiologies. Further research using more robust methodologies and broader populations (age, aetiology) of people with delirium treated with ECT is needed.
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Affiliation(s)
- Katie Lupke
- Metro North Mental Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, Australia.,Metro South Addiction and Mental Health Service, Brisbane, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia
| | - Andrew Teodorczuk
- Metro North Mental Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia
| | - Sarah Steele
- Metro North Mental Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Uday Kolur
- Metro North Mental Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Anne Wand
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Gail Robinson
- Metro North Mental Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Stephen Parker
- Metro North Mental Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia
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Siskind D, Yen W, Thuzar M, Russell A, Warren N, Kisely S, Kar Ray M, Motamarri B. Outcomes of a co-located approach for metabolic health care for people with schizophrenia. Australas Psychiatry 2022; 30:518-522. [PMID: 35331017 DOI: 10.1177/10398562221080742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Metabolic syndrome is highly prevalent among people with schizophrenia. This study aims to assess the impact on metabolic and attendance outcomes of a co-located, dedicated, endocrinologist-led metabolic clinic in a stand-alone public community mental health service. METHODS Demographic and metabolic data on the first 48 consecutive referrals over a 12-month period were retrospectively collected and analysed. Attendance rates at the co-located clinic were compared to the general hospital obesity and diabetes clinics. RESULTS Clinic attendees had significant reductions in triglycerides and total cholesterol, but not mean weight, BMI, waist circumference, blood pressure or HbA1c. Attendance rates were significantly higher in the co-located clinic compared to the general hospital obesity and diabetes clinics for both initial consult (80.0% vs 51.2%, p < 0.001) and review appointment (64.3% vs 47.6%, p < 0.001). CONCLUSION The co-location of a specialist metabolic clinic within a mental health service resulted in enhanced engagement and improvement of metabolic health in people with schizophrenia.
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Affiliation(s)
- Dan Siskind
- 157829Metro South Addiction and Mental Health Service, Brisbane, Australia; Faculty of Medicine, 1974University of Queensland, Brisbane, Australia
| | - Wesley Yen
- Faculty of Medicine, 1974University of Queensland, Brisbane, Australia; Department of Endocrinology and Diabetes, Princess Alexandra Hospital, Brisbane, Australia
| | - Moe Thuzar
- Faculty of Medicine, 1974University of Queensland, Brisbane, Australia; Department of Endocrinology and Diabetes, Princess Alexandra Hospital, Brisbane, Australia
| | - Anthony Russell
- Faculty of Medicine, 1974University of Queensland, Brisbane, Australia; Department of Endocrinology and Diabetes, Princess Alexandra Hospital, Brisbane, Australia
| | - Nicola Warren
- 157829Metro South Addiction and Mental Health Service, Brisbane, Australia; Faculty of Medicine, 1974University of Queensland, Brisbane, Australia
| | - Steve Kisely
- 157829Metro South Addiction and Mental Health Service, Brisbane, Australia; Faculty of Medicine, 1974University of Queensland, Brisbane, Australia
| | - Manaan Kar Ray
- 157829Metro South Addiction and Mental Health Service, Brisbane, Australia; School of Medicine, Griffith University, Brisbane, Australia
| | - Balaji Motamarri
- 157829Metro South Addiction and Mental Health Service, Brisbane, Australia; School of Medicine, Griffith University, Brisbane, Australia
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Ford H, Griffith S, Warren N, Swayne A, Blum S, Butzkueven H, O'Brien TJ, Velakoulis D, Kulkarni J, Monif M. Psychiatric manifestations of autoimmune encephalitis. Autoimmun Rev 2022; 21:103145. [PMID: 35840036 DOI: 10.1016/j.autrev.2022.103145] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/11/2022] [Indexed: 12/21/2022]
Abstract
Autoimmune encephalitis is increasingly recognized as a cause of psychiatric symptoms. A wide spectrum of psychiatric manifestations have been described which may precede, follow or occur independently of neurologic features. Patients typically respond to immunotherapy, however diagnosis is challenging due to phenotypic heterogeneity. The aim of this review is to provide an overview of the psychiatric features associated with encephalitis mediated by autoantibodies targeting neuronal cell-surface antigens and describe indicators of potential immunopathology underlying psychiatric manifestations.
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Affiliation(s)
- Hannah Ford
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sarah Griffith
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Neuroscience, Monash University, Melbourne, Vic, Australia
| | - Nicola Warren
- School of Medicine, University of Queensland, Brisbane, Australia; Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Adrew Swayne
- School of Medicine, University of Queensland, Brisbane, Australia; Princess Alexandra Hospital, Department of Neurology, Brisbane, Queensland, Australia
| | - Stefan Blum
- School of Medicine, University of Queensland, Brisbane, Australia; Princess Alexandra Hospital, Department of Neurology, Brisbane, Queensland, Australia
| | - Helmut Butzkueven
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Neuroscience, Monash University, Melbourne, Vic, Australia
| | - Terence J O'Brien
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Neuroscience, Monash University, Melbourne, Vic, Australia
| | - Dennis Velakoulis
- Neuropsychiatry, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Psychiatry, The University of Melbourne, Melbourne, Vic, Australia
| | - Jayashri Kulkarni
- Department of Psychiatry, Alfred Hospital, Melbourne, Vic, Australia; Department of Psychiatry, Monash University, Melbourne, Vic, Australia
| | - Mastura Monif
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Neurology, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Neuroscience, Monash University, Melbourne, Vic, Australia.
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Warren N, Gordon E, Pearson E, Siskind D, Hilmer SN, Etherton-Beer C, Hanjani LS, Young AM, Reid N, Hubbard RE. A systematic review of frailty education programs for health care professionals. Australas J Ageing 2022; 41:e310-e319. [PMID: 35801297 PMCID: PMC10084012 DOI: 10.1111/ajag.13096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/27/2022] [Accepted: 05/01/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify and examine the reported effectiveness of education programs for health professionals on frailty. METHODS A systematic review was conducted of articles published up to June 2021, examining the evaluation of frailty training or education programs targeting health professionals/students. The participant demographics, program content and structure, effectiveness assessment methodology and outcomes, as well as participant feedback, were recorded with narrative synthesis of results. RESULTS There were nine programs that have evaluated training of health professionals in frailty. These programs varied with respect to intensity, duration, and delivery modality, and targeted a range of health professionals and students. The programs were well-received and found to be effective in increasing frailty knowledge and self-perceived competence in frailty assessment. Common features of successful programs included having multidisciplinary participants, delivering a clinically tailored program and using flexible teaching modalities. Of note, many programs assessed self-perceived efficacy rather than objective changes in patient outcomes. CONCLUSIONS Despite increasing attention on frailty in clinical practice, this systematic review found that there continues to be limited reporting of frailty training programs.
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Affiliation(s)
- Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Metro South Health, Mental Health, Woolloongabba, Queensland, Australia
| | - Emily Gordon
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Geriatrics, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Ella Pearson
- School of Biomedical Science, University of Queensland, Brisbane, Queensland, Australia
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Metro South Health, Mental Health, Woolloongabba, Queensland, Australia
| | - Sarah N Hilmer
- Kolling Institute, Faculty of Medicine and Health, University of Sydney and Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Christopher Etherton-Beer
- Centre for Health and Ageing, University of Western Australia, Crawley, Western Australia, Australia
| | | | - Adrienne M Young
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Natasha Reid
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Ruth E Hubbard
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Geriatrics, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Abstract
OBJECTIVES Seizures that occur spontaneously after termination of an electroconvulsive therapy (ECT) seizure are termed tardive seizures. They are thought to be a rare complication of ECT, influenced by risk factors that affect seizure threshold. However, there has been limited review of tardive seizures with modified ECT. We aimed to review the literature to provide clinical guidance for the use of ECT after tardive seizures. METHODS PubMed, EMBASE, PsycInfo, and CINAHL databases were searched from inception to May 2021 to identify cases of modified ECT, with evidence of a seizure occurring within 7 days of a terminated ECT seizure. Data for demographic, medical, pharmacological, anesthetic, and ECT variables as well as management strategies were collected. RESULTS There have been 39 episodes of modified ECT-related tardive seizures published over a period of 40 years. In 97.4% of cases, there was at least 1 identified potential risk factor for seizures, including use of a seizure-lowering medication and/or preexisting neurological injury. Major complications were uncommon (<15% of cases); however, 1 fetal death and 1 subsequent suicide were reported. No case was diagnosed with epilepsy, although around 20% continued on antiepileptic medications. More than half of the included patients were retrialed on ECT, with only 15% developing further tardive seizures. CONCLUSIONS Seizures that occurred spontaneously after the termination of an ECT seizure are a rare complication of modified ECT. Recommencing ECT after a tardive seizure may occur after review of modifiable seizure risk factors and with consideration of antiepileptic medication and extended post-ECT monitoring.
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Affiliation(s)
| | | | | | | | - Emily Watson
- Department of Neurology, Princess Alexandra Hospital
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Parker S, Warren N, Hamilton S, Cabral S, Cutbush J. Enhancing the quality of supervision: description and initial outcomes of a blended-learning approach to RANZCP supervisor accreditation. Australas Psychiatry 2022; 30:398-405. [PMID: 32525694 DOI: 10.1177/1039856220928875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evaluation of a blended learning adaptation of the accreditation process for supervisors in the Royal Australian and New Zealand College of Psychiatrists' (RANZCP) Competency-Based Fellowship Program. METHOD The adaption of the accreditation process is described, and a mixed-methods approach was taken in its evaluation. Descriptive statistics are presented for participant responses to and engagement with interactive workshop elements. The Wilcoxon signed ranks test was applied to examine the change in participants' confidence in their understanding of the expectations of a supervisor at the commencement and conclusion of the workshop. Free text evaluative responses were subject to qualitative content analysis. RESULTS Most participants expressed a preference for the blended learning workshop format and indicated that live polling improved the learning experience. Additionally, participants expressed greater confidence in their understanding of the expectations of the supervisor role following workshop completion. CONCLUSIONS The blended learning approach to supervisor training was preferred by participants and may provide a model to be adopted by other training committees and institutions.
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Affiliation(s)
- Stephen Parker
- Metro South Addiction and Mental Health Services (MSAMHS), Australia; and University of Queensland, School of Public Health, Australia
| | - Nicola Warren
- Metro South Addiction and Mental Health Services (MSAMHS), Australia; and University of Queensland, School of Medicine, Australia
| | - Sarah Hamilton
- Metro South Addiction and Mental Health Services (MSAMHS), Australia; and School of Human Services and Social Work Griffith University, Australia
| | - Sidney Cabral
- Metro South Addiction and Mental Health Service (MSAMHS), Australia
| | - Jimsie Cutbush
- Metro South Addiction and Mental Health Service (MSAMHS), Australia
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Siskind D, Orr S, Sinha S, Yu O, Brijball B, Warren N, MacCabe JH, Smart SE, Kisely S. Rates of treatment-resistant schizophrenia from first-episode cohorts: systematic review and meta-analysis. Br J Psychiatry 2022; 220:115-120. [PMID: 35049446 DOI: 10.1192/bjp.2021.61] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Treatment-resistant schizophrenia (TRS) is associated with high levels of functional impairment, healthcare usage and societal costs. Cross-sectional studies may overestimate TRS rates because of selection bias. AIMS We aimed to quantify TRS rates by using first-episode cohorts to improve resource allocation and clozapine access. METHOD We undertook a systematic review of TRS rates among people with first-episode psychosis and schizophrenia, with a minimum follow-up of 8 weeks. We searched PubMed, PsycINFO, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews, and meta-analysed TRS rates from included studies. RESULTS Twelve studies were included, totalling 11 958 participants; six studies were of high quality. The rate of TRS was 22.8% (95% CI 19.1-27.0%, P < 0.001) among all first-episode cohorts and 24.4% (95% CI 19.5-30.0%, P < 0.001) among first-episode schizophrenia cohorts. Subgroup sensitivity analyses by location of recruitment, TRS definition, study quality, time of data collection and retrospective versus prospective data collection did not lead to statistically significant differences in heterogeneity. In a meta-regression, duration of follow-up and percentage drop-out did not significantly affect the overall TRS rate. Men were 1.57 times more likely to develop TRS than women (95% CI 1.11-2.21, P = 0.010). CONCLUSIONS Almost a quarter of people with first-episode psychosis or schizophrenia will develop TRS in the early stages of treatment. When including people with schizophrenia who relapse despite initial response and continuous treatment, rates of TRS may be as high as a third. These high rates of TRS highlight the need for improved access to clozapine and psychosocial supports.
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Affiliation(s)
- Dan Siskind
- School of Clinical Medicine, University of Queensland, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia; and Queensland Centre for Mental Health Research, Faculty of Medicine, University of Queensland, Australia
| | - Stacy Orr
- School of Clinical Medicine, University of Queensland, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
| | - Surabhi Sinha
- School of Clinical Medicine, University of Queensland, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
| | - Ou Yu
- School of Clinical Medicine, University of Queensland, Australia
| | - Bhavna Brijball
- School of Clinical Medicine, University of Queensland, Australia
| | - Nicola Warren
- School of Clinical Medicine, University of Queensland, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
| | - James H MacCabe
- Institute for Psychiatry, Psychology and Neuroscience, King's College London, UK; and National Psychosis Unit, South London and Maudsley NHS Foundation Trust, UK
| | - Sophie E Smart
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, UK
| | - Steve Kisely
- School of Clinical Medicine, University of Queensland, Australia; and Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, Australia
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Pearson E, Siskind D, Hubbard RE, Gordon EH, Coulson EJ, Warren N. Frailty and severe mental illness: A systematic review and narrative synthesis. J Psychiatr Res 2022; 147:166-175. [PMID: 35051715 DOI: 10.1016/j.jpsychires.2022.01.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/02/2022] [Accepted: 01/06/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Emerging evidence suggests that people with severe mental illness (SMI) have an increased risk of frailty. We conducted a systematic review to investigate the prevalence and correlates of frailty, as well as the efficacy of frailty interventions, in this population. METHODS We searched databases from inception to 21 September 2021 for studies that assessed or intervened for frailty in relation to an SMI diagnosis. A narrative synthesis explored the characteristics and adverse health outcomes associated with frailty and the efficacy of interventions. The prevalence of frailty was investigated, and its relationship with age was analysed by a meta-regression. RESULTS Twenty-five studies involving 2499 patients, primarily older adults, were included in the narrative synthesis. Frailty was associated with higher rates of physical comorbidity, cognitive deficits, falls and mortality among those with SMI. The efficacy of a yoga intervention was investigated in one study, without sustained reductions in frailty. The prevalence of frailty varied between 10.2 and 89.7% and was high in comparison to the general population. CONCLUSIONS The prevalence of frailty was high in those with SMI and ranged widely due to heterogeneity of study populations. Assessing frailty enables the identification of patients who could benefit from interventions and assists in treatment-related decision making. Further research is required to develop appropriate frailty interventions for this population.
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Affiliation(s)
- Ella Pearson
- School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia.
| | - Dan Siskind
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia; School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Ruth E Hubbard
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of Geriatrics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Emily H Gordon
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of Geriatrics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Elizabeth J Coulson
- School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Nicola Warren
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia; School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
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Tanzer T, Warren N, McMahon L, Barras M, Kisely S, Brooks E, Wong E, Siskind D. Treatment strategies for clozapine-induced nocturnal enuresis and urinary incontinence: a systematic review. CNS Spectr 2022; 28:1-12. [PMID: 35086595 DOI: 10.1017/s1092852922000050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug reactions, including nocturnal enuresis and urinary incontinence. This side effect can be burdensome and lead to medication nonadherence and psychotic relapse. Evidence to guide treatment of clozapine-induced nocturnal enuresis and urinary incontinence is sparse. We therefore aimed to synthesize the evidence base to guide management for clinicians, patients, and their carers. METHODS We systematically searched PubMed, Embase, PsycInfo, CINAHL, and the Cochrane Trial Registry databases from inception to May 2021 for publications on management of clozapine-induced nocturnal enuresis and urinary incontinence using a PROSPERO preregistered search strategy. RESULTS We identified 22 case reports and case series describing 74 patients. Interventions included clozapine dose reduction, nonpharmacological treatment, and pharmacological treatments. Among pharmacological treatments, desmopressin, oxybutynin, trihexyphenidyl, tolterodine, imipramine, amitriptyline, ephedrine, pseudoephedrine, aripiprazole, and verapamil were associated with complete resolution of nocturnal enuresis and urinary incontinence. Balancing evidence for effectiveness against risk of adverse effects, we developed a management framework for clozapine-induced nocturnal enuresis and urinary incontinence. CONCLUSIONS Following assessment of urological, psychiatric, pharmacological, and common comorbid medical issues, first-line treatments should be nonpharmacological, including bathroom alarms, voiding before bedtime, and nocturnal fluid restriction. If these interventions do not provide adequate relief, aripiprazole should be trialed. Desmopressin may be considered for severe refractory cases, but monitoring for hyponatremia is essential.
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Affiliation(s)
- Timothy Tanzer
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Queensland, Australia
| | - Laura McMahon
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael Barras
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Steve Kisely
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Queensland, Australia
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Emily Brooks
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Emily Wong
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Queensland, Australia
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Tanzer TD, Brouard T, Pra SD, Warren N, Barras M, Kisely S, Brooks E, Siskind D. Treatment strategies for clozapine-induced hypotension: a systematic review. Ther Adv Psychopharmacol 2022; 12:20451253221092931. [PMID: 35633931 PMCID: PMC9136453 DOI: 10.1177/20451253221092931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug effects, including hypotension and dizziness, which have a negative impact on quality of life and treatment compliance. Available evidence for the management of clozapine-induced hypotension is scant. OBJECTIVES Due to limited guidance on the safety and efficacy of pharmacological treatments for clozapine-induced hypotension, we set out to systematically review and assess the evidence for the management of clozapine-induced hypotension and provide guidance to clinicians, patients, and carers. DESIGN We undertook a systematic review of the safety and efficacy of interventions for clozapine-induced hypotension given the limited available evidence. DATA SOURCES AND METHODS PubMed, Embase, PsycINFO, CINAHL, and the Cochrane trial Registry were searched from inception to November 2021 for literature on the treatment strategies for clozapine-induced hypotension and dizziness using a PROSPERO pre-registered search strategy. For orthostatic hypotension, we developed a management framework to assist in the choice of intervention. RESULTS We identified nine case studies and four case series describing interventions in 15 patients. Hypotension interventions included temporary clozapine dose reduction, non-pharmacological treatments, and pharmacological treatments. Midodrine, fludrocortisone, moclobemide and Bovril® combination, and etilefrine were associated with improvement in symptoms or reduction in orthostatic hypotension. Angiotensin II, arginine vasopressin, and noradrenaline successfully restored and maintained mean arterial pressure in critical care situations. A paradoxical reaction of severe hypotension was reported with adrenaline use. CONCLUSION Orthostatic hypotension is a common side effect during clozapine titration. Following an assessment of the titration schedule, salt and fluid intake, and review of hypertensive and nonselective α1-adrenergic agents, first-line treatment should be a temporary reduction in clozapine dose or non-pharmacological interventions. If orthostatic hypotension persists, fludrocortisone should be trialled with monitoring of potassium levels and sodium and fluid intake. Midodrine may be considered second-line or where fludrocortisone is contraindicated or poorly tolerated. For patients on clozapine with hypotension in critical care settings, the use of adrenaline to maintain mean arterial pressure should be avoided. REGISTRATION PROSPERO (Registration No. CRD42020191530).
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Affiliation(s)
| | - Thomas Brouard
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Samuel Dal Pra
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Michael Barras
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, QLD, Australia School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Steve Kisely
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Emily Brooks
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Arnautovska U, Kesby JP, Korman N, Rebar AL, Chapman J, Warren N, Rossell SL, Dark FL, Siskind D. Biopsychology of Physical Activity in People with Schizophrenia: An Integrative Perspective on Barriers and Intervention Strategies. Neuropsychiatr Dis Treat 2022; 18:2917-2926. [PMID: 36544549 PMCID: PMC9763049 DOI: 10.2147/ndt.s393775] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
People with severe mental illness such as schizophrenia experience high physical comorbidity, leading to a 15-20-year mortality gap compared with the general population. Lifestyle behaviours such as physical activity (PA) play important roles in the quest to bridge this gap. Interventions to increase PA engagement in this population have potential to be efficacious; however, their effectiveness can be hindered by low participant engagement, including low adherence and high drop-out, and by implementation of interventions that are not designed to compensate for the cognitive and motivational impairments characteristic for this group. Moreover, and importantly, the negative symptoms of schizophrenia are associated with neurobiological changes in the brain, which-based on principles of biopsychology-can contribute to poor motivation and impaired decision-making processes and behavioural maintenance. To increase PA levels in people with schizophrenia, better understanding of these neurological changes that impact PA engagement is needed. This has the potential to inform the design of interventions that, through enhancement of motivation, could effectively increase PA levels in this specific population. Incorporating strategies that address the dopamine dysregulation associated with schizophrenia, such as boosting the role of reward and self-determined motivation, may improve long-term PA maintenance, leading to habitual PA. Consideration of motivation and behavioural maintenance is also needed to impart health benefits such as prevention of chronic disease, which is associated with currently low PA levels in this high metabolic risk population. Taking a biopsychological perspective, we outline the neural pathways involved in motivation that are impacted by schizophrenia and propose strategies for promoting motivation for and PA engagement from adoption to habit formation.
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Affiliation(s)
- Urska Arnautovska
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.,Metro South Addictions and Mental Health Service, Woolloongabba, QLD, Australia
| | - James P Kesby
- Centre for Mental Health, Griffith University, Nathan, QLD, Australia.,Queensland Centre for Mental Health Research, Wacol, QLD, 4076, Australia
| | - Nicole Korman
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.,Metro South Addictions and Mental Health Service, Woolloongabba, QLD, Australia
| | - Amanda L Rebar
- Motivation of Health Behaviours Lab, Appleton Institute, School of Health, Medical, and Applied Sciences; Central Queensland University, Rockhampton, QLD, Australia
| | - Justin Chapman
- Metro South Addictions and Mental Health Service, Woolloongabba, QLD, Australia.,Centre for Mental Health, Griffith University, Nathan, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.,Metro South Addictions and Mental Health Service, Woolloongabba, QLD, Australia
| | - Susan L Rossell
- Centre for Mental Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, VIC, Australia.,Psychiatry, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Frances L Dark
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.,Metro South Addictions and Mental Health Service, Woolloongabba, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia.,Metro South Addictions and Mental Health Service, Woolloongabba, QLD, Australia.,Queensland Centre for Mental Health Research, Wacol, QLD, 4076, Australia
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Siskind D, Sharma M, Pawar M, Pearson E, Wagner E, Warren N, Kisely S. Clozapine levels as a predictor for therapeutic response: A systematic review and meta-analysis. Acta Psychiatr Scand 2021; 144:422-432. [PMID: 34374073 DOI: 10.1111/acps.13361] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Clozapine levels may be a more useful predictor of therapeutic response than the dose, given the variability in clozapine metabolism between individuals. We therefore systematically reviewed and meta-analysed the impact of clozapine levels on response and/or relapse to provide guidance on optimal clozapine levels. METHODS We systematically searched PubMed, PsycInfo and Embase for studies exploring clozapine levels and response and/or relapse. Our primary meta-analysis was rates of response above and below clozapine level thresholds of 350 ng/ml and 600 ng/ml. Secondary analyses were undertaken of mean clozapine levels, dose and concentration/dose (C/D) ratio and response and/or relapse. A meta-regression by study duration was conducted. RESULTS Twenty studies met inclusion criteria. Clozapine levels above 350 ng/ml were associated with statistically significantly higher rates of response (OR 2.27 95% CI 1.40-3.67, p < 0.001), but not above 600 ng/ml (OR 1.40 95% CI 0.85-2.31, p = 0.19). Higher mean clozapine levels were associated with better rates of response (SMD 0.24, 95% CI 0.00-0.49, p = 0.05), and lower rates of relapse (SMD -0.72, 95% CI -1.26 to -0.19, p = 0.008). By contrast, neither clozapine dose nor C/D ratio was associated with differing rates of response. Similarly, study duration did not affect outcome. CONCLUSIONS Our findings are in keeping with current guidelines that recommend targeting clozapine levels above 350 ng/ml before augmentation is considered. As some clozapine associated ADRs are dose dependent, levels above 600 ng/ml may have an unfavourable risk-benefit ratio.
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Affiliation(s)
- Dan Siskind
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Meghna Sharma
- School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Cairns Base Hospital, Cairns, QLD, Australia
| | - Mrinal Pawar
- School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Ella Pearson
- School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Nicola Warren
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia.,Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
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Siskind D, Russell AW, Suetani S, Flaws D, Kisely S, Moudgil V, Northwood K, Robinson G, Scott JG, Stedman T, Warren N, Winckel K, Cosgrove P, Baker A. CoMET: a randomised controlled trial of co-commencement of metformin versus placebo as an adjunctive treatment to attenuate weight gain in patients with schizophrenia newly commenced on clozapine. Ther Adv Psychopharmacol 2021; 11:20451253211045248. [PMID: 34671454 PMCID: PMC8521414 DOI: 10.1177/20451253211045248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/23/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There is limited evidence on interventions to minimise weight gain at clozapine commencement. We compared the effect of adjunctive metformin versus placebo at clozapine initiation. METHODS People with schizophrenia commencing on clozapine were randomised to either metformin or placebo for 24 weeks. The primary outcome was difference in the change of body weight. Secondary outcomes included comparative rates of weight gain of more than 5%, overall weight gain/loss, and differences in metabolic and psychosis outcomes. RESULTS The study was closed prematurely in March 2020 due to COVID-19 restrictions. Ten participants were randomised to each of the metformin and placebo groups. Eight metformin group and five placebo group participants completed the trial and were included in the analysis. The study was insufficiently powered to detect difference between the metformin and placebo groups for the primary outcome of change in weight (0.09 kg vs 2.88 kg, p = 0.231). In terms of secondary outcomes, people in the metformin group were significantly less likely to gain >5% of their body weight (12.5% vs 80%, p = 0.015) and were more likely to lose weight (37.5% vs 0% p = 0.024) compared to placebo. There was no difference between the groups in terms of adverse drug reactions (ADRs). CONCLUSION While limited by the forced premature closure of the trial due to COVID19, the findings from this randomised controlled trial are promising. Clozapine and metformin co-commencement may be a promising treatment to prevent clozapine-associated weight gain, especially given the low rates of ADRs associated with metformin. This supports the consideration of use of metformin to prevent weight gain in people initiated on clozapine; however, further studies are needed to confirm this finding. TRIAL REGISTRATION ACTRN12617001547336.
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Affiliation(s)
- Dan Siskind
- School of Clinical Medicine, The University of Queensland, c/- MIRT, Level 2 Mental Health, 228 Logan Rd, Woolloongabba, Brisbane, QLD 4102, Australia
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Anthony W. Russell
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Shuichi Suetani
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
- Medical School, Griffith University, Brisbane, QLD, Australia
| | - Dylan Flaws
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
- Metro North Mental Health Services, Brisbane, QLD, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Vikas Moudgil
- Metro North Mental Health Services, Brisbane, QLD, Australia
| | - Korinne Northwood
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Gail Robinson
- Metro North Mental Health Services, Brisbane, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - James G. Scott
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- Metro North Mental Health Services, Brisbane, QLD, Australia
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Terry Stedman
- West Moreton Mental Health Service, Brisbane, QLD, Australia
| | - Nicola Warren
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Karl Winckel
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, QLD, Australia
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Peter Cosgrove
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- West Moreton Mental Health Service, Brisbane, QLD, Australia
| | - Andrea Baker
- Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
- West Moreton Mental Health Service, Brisbane, QLD, Australia
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McKeon G, Parker S, Warren N, Scott JG. The Patient Experience of Recovery Following Anti-NMDA Receptor Encephalitis: A Qualitative Content Analysis. J Neuropsychiatry Clin Neurosci 2021; 33:57-63. [PMID: 32873136 DOI: 10.1176/appi.neuropsych.20030049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined patients' perceptions of the factors affecting their recovery from anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis, which is a rare, severe immune-mediated neurological disorder. METHODS Seven patients completed semistructured interviews exploring their experience of recovery. Participants were interviewed between 7 and 41 months after the initiation of treatment. Interviews were transcribed and subjected to qualitative content analysis. RESULTS Facilitators of recovery included the presence of a support system and treatment-related factors. Barriers to recovery included perceived psychiatric stigma, insufficient illness education, and lifestyle disruptions to accommodate ongoing treatment. Adverse physical, psychological, and neurocognitive sequelae of anti-NMDAR encephalitis continued to affect participants' daily functioning. Most participants described strategies to manage neurocognitive deficits, fatigue, and anxiety. CONCLUSIONS Anti-NMDAR encephalitis contributes to persistent burden on patients, their families, and health services after the resolution of acute symptoms. Physical, psychological, and cognitive changes contribute to long-term disease morbidity. To optimize recovery and reduce disability, further attention must be directed toward illness education, reducing stigma, and role disruption. Longer-term disability support may benefit those who do not fully recover.
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Affiliation(s)
- Gemma McKeon
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - Stephen Parker
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - Nicola Warren
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
| | - James G Scott
- Metro South Addiction and Mental Health Services, Brisbane, Australia (McKeon, Parker, Warren);University of Queensland Centre for Clinical Research, Herston, Australia (McKeon, Scott); Child and Youth Mental Health Group, Queensland Centre for Mental Health Research, Wacol, Australia (McKeon, Scott); School of Medicine, University of Queensland, Herston, Australia (Parker, Warren); and Child and Youth Mental Health Group, Queensland Institute of Medical Research Berghofer Medical Research Institute, Herston, Australia (McKeon, Scott)
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Swayne A, Warren N, Prain K, Gillis D, Wong R, Blum S. Analysing Triggers for Anti-NMDA-Receptor Encephalitis Including Herpes Simplex Virus Encephalitis and Ovarian Teratoma: Results from the Queensland Autoimmune Encephalitis Cohort. Intern Med J 2021; 52:1943-1949. [PMID: 34339078 DOI: 10.1111/imj.15472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Anti-N-methyl-D-Aspartate-Receptor (anti-NMDA-R) encephalitis is a complex autoimmune neuropsychiatric syndrome. Although initially associated with ovarian teratoma, subsequent studies have demonstrated that anti-NMDA-R encephalitis may occur without an identifiable cause or be triggered by viral infection of the central nervous system such as herpes simplex virus encephalitis (HSVE). This study will present details from a Queensland cohort analysing triggering events in patients with anti-NMDA-R encephalitis in an Australian context. METHODOLOGY The authors identified patients with anti-NMDA-R encephalitis diagnosed and managed through public hospitals in Queensland, Australia between 2010 and the end of 2019. Data collected included demographics, clinical presentation, investigation results, management and outcome measurements. RESULTS Thirty-one cases of anti-NMDA-R encephalitis were included in the study. Three cases of anti-NMDA-R encephalitis were triggered by prior HSVE, five cases were associated with ovarian teratoma and twenty-three cases had no identifiable trigger. There were an additional three cases in which anti-NMDA receptor antibodies were present in the context of other disease states but where the patient didn't develop anti-NMDA-R encephalitis. Cases triggered by HSVE or associated with ovarian teratoma experienced a more severe disease course compared to cases with no identifiable trigger. All groups responded to immunosuppressive or immunomodulatory therapy. Analysis of clinical characteristics revealed a complex heterogeneous syndrome with some variability between groups. CONCLUSION In this cohort, the number of cases of anti-NMDA-R encephalitis triggered by HSVE is comparable to those triggered by ovarian teratoma. However, the majority of cases of anti-NMDA-R encephalitis had no identifiable trigger or associated disease process. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Andrew Swayne
- Mater Hospital, Mater Centre for Neurosciences, Brisbane, Queensland, Australia.,The University of Queensland, School of Medicine, Brisbane, Queensland, Australia.,Princess Alexandra Hospital, Department of Neurology, Brisbane, Queensland, Australia
| | - Nicola Warren
- The University of Queensland, School of Medicine, Brisbane, Queensland, Australia.,Princess Alexandra Hospital, Department of Psychiatry, Brisbane, Queensland, Australia
| | - Kerri Prain
- HSQ Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia
| | - David Gillis
- HSQ Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia
| | - Richard Wong
- HSQ Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital Campus, Brisbane, Queensland, Australia.,Princess Alexandra Hospital, Department of Immunology, Brisbane, Queensland, Australia
| | - Stefan Blum
- Mater Hospital, Mater Centre for Neurosciences, Brisbane, Queensland, Australia.,The University of Queensland, School of Medicine, Brisbane, Queensland, Australia.,Princess Alexandra Hospital, Department of Neurology, Brisbane, Queensland, Australia
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Chan F, O'Gorman C, Swayne A, Gillis D, Blum S, Warren N. Voltage-gated potassium channel blanket testing in first-episode psychosis: Diagnostic nihilism? Aust N Z J Psychiatry 2021; 55:817-823. [PMID: 33423505 DOI: 10.1177/0004867420983454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Voltage-gated potassium channel antibodies are implicated in limbic encephalitis and currently included in first-episode psychosis organic screening guidelines. Individuals with high-positive voltage-gated potassium channel titres most commonly present with neurological symptoms as well as sleep, cognitive, behaviour, psychosis and mood disturbance. The significance of low-positive voltage-gated potassium channel antibody titres in psychiatric patients is unclear and has not been previously examined. We aim to describe a statewide cohort of psychiatric patients with low- and high-positive voltage-gated potassium channel titres and explore if this finding influenced clinical management and patient outcomes. METHODS A retrospective review of all voltage-gated potassium channel antibodies testing performed in public psychiatric services in Queensland, Australia, with comparison of the clinical presentation and long-term outcomes of low- and high-positive voltage-gated potassium channel titre cases. Specific antigen targets (leucine-rich glioma-inactivated protein 1 and contactin-associated protein 2 antibodies) were also assessed. RESULTS The overall prevalence of voltage-gated potassium channel antibody positivity in Queensland, public, psychiatric service testing was 0.3% (14/4098), with 12 cases of low-positive voltage-gated potassium channel titre, 2 cases of high-positive (leucine-rich glioma-inactivated protein 1 antibody positive) cases and a voltage-gated potassium channel negative contactin-associated protein 2 antibody positive case. No low-positive case developed neurological abnormalities or had abnormal paraclinical investigations. In comparison, both high-positive voltage-gated potassium channel/leucine-rich glioma-inactivated protein 1 cases and the contactin-associated protein 2 antibody positive case rapidly developed neurological symptoms, had abnormal paraclinical testing and improved only with immunotherapy. There was no later development of encephalitic symptoms in the low-positive cases over an average of 1067 days follow-up. CONCLUSION Voltage-gated potassium channel antibody-associated limbic encephalitis was rare, and always associated with high antibody titres. Low-positive titres were not associated with the development of encephalitis over a long period of follow-up. The value of universal voltage-gated potassium channel antibody screening is unclear, and further prospective studies in first-episode psychosis populations are required.
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Affiliation(s)
- Fiona Chan
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew Swayne
- Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - David Gillis
- Queensland Pathology, Brisbane, QLD, Australia.,Immunology Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Stefan Blum
- Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Mater Centre for Neurosciences, Mater Hospital Brisbane, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health, Princess Alexandra Hospital, Brisbane, QLD, Australia
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Affiliation(s)
- Nicola Warren
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Metro South Addiction and Mental Health, Brisbane, Queensland, Australia
| | - Steve Kisely
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dan Siskind
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Metro South Addiction and Mental Health, Brisbane, Queensland, Australia
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Abstract
OBJECTIVE The clinical teaching of psychiatry to medical students throughout the COVID-19 pandemic has presented opportunities for support, engagement and learning above and beyond usual practice. Like other teaching faculties, we needed to quickly adapt the course material to an online platform. However, for psychiatric teaching, it was also essential to find alternatives to patient interviewing, and to provide support and containment in uncertain times. We aim to describe our philosophical stance and framework for the delivery of our online course. CONCLUSIONS Key components in the delivery of our modified course were the transition to online learning and assessment, developing a suite of surrogate clinical learning experiences, using simulated patients for online interviewing, and attention to student well-being whilst providing a supportive and contained environment for student learning. Supportive leadership and good communication assisted the teaching staff to deliver the course during COVID-19.
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Affiliation(s)
- Taraneh Khoo
- The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Nicola Warren
- The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, QLD, Australia.,Metro South Health Service District, Addiction and Mental Health, Woolloongabba, QLD, Australia
| | - Anna Jenkins
- The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jane Turner
- The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, QLD, Australia.,Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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Swayne A, Warren N, Prain K, Gillis D, O'Gorman C, Tsang BKT, Muller C, Broadley S, Adam RJ, McCombe P, Wong RC, Blum S. An Australian State-Based Cohort Study of Autoimmune Encephalitis Cases Detailing Clinical Presentation, Investigation Results, and Response to Therapy. Front Neurol 2021; 12:607773. [PMID: 33692738 PMCID: PMC7937705 DOI: 10.3389/fneur.2021.607773] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/25/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction: Autoimmune encephalitis is a disorder associated with antibodies directed against central nervous system proteins with variable clinical features. This study aims to add to knowledge of the disease by reporting the details of a cohort of patients with autoimmune encephalitis in Queensland, Australia. Methodology: We surveyed patients with autoimmune encephalitis diagnosed and managed through public hospitals in Queensland, Australia between 2010 and the end of 2019. Cases were identified via case detection through a centralized diagnostic neuroimmunology laboratory (Division of Immunology, HSQ Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia) and a survey of neurologists. Data including demographic details, clinical presentation, investigation results, treatments including immune therapy and outcomes was collected. Results: Sixty cases of antibody positive autoimmune encephalitis were identified. Twenty-eight were of anti-NMDA-receptor encephalitis with other cases associated with antibodies against LGi1, Caspr2, glycine receptor, DPPX, GABAB receptor, IgLON5, GFAP, and SOX1. The number of diagnosed cases, especially of anti-NMDA-receptor encephalitis has markedly increased over the period 2017 to 2019. Clinical presentations were marked by heterogeneous symptom complexes and prolonged hospital admissions. Imaging studies were largely normal or non-specific. There was a response to immune therapy and a low mortality rate. Most cases affected by this disorder were left with ongoing symptoms associated with mild disability. Conclusion: Autoimmune encephalitis in Queensland, Australia is an increasingly common but complex clinical entity marked by heterogeneous presentations, response to immune therapy and outcome results marked by low mortality and incomplete recovery.
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Affiliation(s)
- Andrew Swayne
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Nicola Warren
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Psychiatry, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Kerri Prain
- Health Support Queensland, Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - David Gillis
- Health Support Queensland, Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Cullen O'Gorman
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Benjamin K-T Tsang
- Department of Neurology, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Claire Muller
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Simon Broadley
- Department of Neurology, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Robert J Adam
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Pamela McCombe
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Richard C Wong
- Health Support Queensland, Pathology Queensland Central Laboratory, Division of Immunology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Department of Immunology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Stefan Blum
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, QLD, Australia
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Malliaras P, Rathi S, Burstein F, Watt L, Ridgway J, King C, Warren N. 'Physio's not going to repair a torn tendon': patient decision-making related to surgery for rotator cuff related shoulder pain. Disabil Rehabil 2021; 44:3686-3693. [PMID: 33577359 DOI: 10.1080/09638288.2021.1879945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Rotator cuff related shoulder pain (RCRSP) is a common and disabling shoulder condition and surgical management is becoming more common. The rates and costs of surgical interventions have been on the rise. Understanding decision-making related to surgery and providing adequate information to people with RCRSP may improve patient-centred care and potentially reduce rates of surgery. OBJECTIVES To explore the decision-making processors of people who have undertaken surgery for RCRSP. DESIGN An in-depth thematic analysis. METHOD Interviews were conducted with patients from Melbourne who had had surgical management for RCRSP. Data were analysed using an inductive thematic approach. RESULTS Fifteen participants were recruited. Six key themes emerged: (1) Needing to get it done: "It was necessary to remedy the dire situation"; (2) Non-surgical treatment experience:" I knew that I'd done all I could"; (3) Mechanical problem:" Physio's not going to repair a torn tendon"; (4) Trust in medical professionals "If they told me that I needed to swallow a thousand spiders, I would have done it."; (5) Varied information sources "Dr Google played a big part in it"; (6) Organisational barriers "It was absolutely useless, my insurance." CONCLUSION Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment. While there was strong trust in highly trained surgeons, decision to undergo surgery also drew on questionable pathoanatomical beliefs and instances of inadequate patient information about treatment choices and risks that may be addressed by adopting a more patient-centred care approach.IMPLICATIONS FOR REHABILITATIONUnderstanding decision-making related to surgery and providing adequate information to people with rotator cuff related shoulder pain may improve patient-centred care.Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment.Decision to undergo surgery sometimes drew on questionable pathoanatomical beliefs.There was strong trust in highly trained surgeons but there were instances of inadequate patient information about treatment choices and risks.
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Affiliation(s)
- P Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
| | - S Rathi
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
| | - F Burstein
- Centre for Organisational and Social Informatics, Faculty of Information Technology, Monash University, Victoria, Australia
| | - L Watt
- Anthropology Department, School of Social Sciences, Faculty of Arts, Monash University, Victoria, Australia
| | - J Ridgway
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia.,Physiotherapy Department, Frankston Hospital, Peninsula Health, Victoria, Australia
| | - C King
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia.,Sportsmed Biologic, Victoria, Australia
| | - N Warren
- Anthropology Department, School of Social Sciences, Faculty of Arts, Monash University, Victoria, Australia
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Abstract
BACKGROUND Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an immune-mediated disorder which requires multi-disciplinary treatment including immunomodulation therapy. First presentation is most commonly to psychiatric services and continuing psychiatric care is required to treat disabling symptoms, such as behaviour disturbance, psychosis and catatonia. There is minimal available evidence to guide symptomatic treatment and concern for increased sensitivity to antipsychotics complicates traditional approaches. METHODS All cases of cerebrospinal fluid positive anti-NMDAR encephalitis tested in Queensland, Australia were identified. Demographic, clinical and therapeutic data were collected and reviewed by two independent clinicians. Pre-specified variables reflecting possible treatment side effects were compared. RESULTS The majority of the 30 cases (83%) had early psychiatric symptoms and were treated with antipsychotics (67%), average daily olanzapine equivalence dose of 11.5 mg, prior to immunomodulation therapy. Although there was an 88% reduction in cases with aggression, there was little improvement in psychosis, affective symptoms or catatonia with antipsychotics alone. In the cases with psychiatric symptoms, there was no significant difference in the rate of occurrence of neurological and autonomic symptoms between cases prescribed and not prescribed antipsychotics. CONCLUSIONS Psychiatric input is imperative for both acute and longer-term management of anti-NMDAR encephalitis. Primary symptomatic treatment should remain immunotherapy and surgery. Antipsychotic medications have particular value in managing agitation and aggression. Potential side effects from antipsychotic treatment are difficult to differentiate from progression of anti-NMDAR encephalitis but there was no evidence in this cohort of increased antipsychotic sensitivity. Treatment with psychotropic medication should be individualised and adjusted during the course of the illness.
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Affiliation(s)
- Nicola Warren
- Metro South Addiction and Mental Health, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Cullen O'Gorman
- University of Queensland, Brisbane, Australia
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Gemma McKeon
- Metro South Addiction and Mental Health, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Andrew Swayne
- University of Queensland, Brisbane, Australia
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Stefan Blum
- University of Queensland, Brisbane, Australia
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia
- Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health, Brisbane, Australia
- University of Queensland, Brisbane, Australia
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Affiliation(s)
- Nicola Warren
- School of Medicine, Metro South Addiction and Mental Health, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Dan Siskind
- School of Medicine, Metro South Addiction and Mental Health, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - David Lie
- School of Medicine, Metro South Addiction and Mental Health, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Abstract
OBJECTIVE The authors examined and compared the clinical presentation of CSF positive and negative N-methyl-d-aspartate receptor (NMDAR) antibody. METHODS The investigators performed a retrospective chart review of NMDAR-antibody-positive cases (serum or CSF) involving patients presenting to psychiatric services from 2010 to 2018 in Queensland, Australia. Presentation, progress, investigations, and efficacy of treatment are detailed. RESULTS There were 24 serum or CSF NMDAR-antibody-positive cases and three equivocal serum results. High rates of prodromal cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity were observed in the 16 CSF NMDAR-antibody-positive case patients and two CSF NMDAR-antibody-negative case patients, all evident before neurological deterioration with seizures, movement disorder, and autonomic disturbance occurring in the weeks following admission. The majority of these patients (N=17) were treated successfully with immunomodulatory therapy. The nine remaining patients, who were CSF NMDAR antibody negative or equivocal, did not demonstrate any of these features and improved with psychiatric care alone. CONCLUSIONS These findings suggest that traditional psychiatric care may be appropriate for patients with isolated psychiatric symptoms who have positive serum NMDAR testing when CSF is negative and there are no key clinical features such as cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity. However, if these key features are present, a trial of immunomodulatory treatment should be considered with repeated examination of CSF for neuronal antibodies.
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Affiliation(s)
- Nicola Warren
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Andrew Swayne
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Dan Siskind
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Cullen O'Gorman
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Kerri Prain
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - David Gillis
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
| | - Stefan Blum
- Metro South Addiction and Mental Health Services, Brisbane, Queensland, Australia (Warren, Siskind); the Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia (Warren, Swayne, Siskind, O'Gorman, Blum); the Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); the Mater Centre for Neurosciences, Mater Hospital, Brisbane, Queensland, Australia (Swayne, O'Gorman, Blum); and the Division of Immunology, Pathology Queensland Central Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia (Prain, Gillis)
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Warren N, O'Gorman C, Blum S, Kisely S, Swayne A, Flavell J, Siskind D. Evaluation of the proposed anti-N-methyl-d-aspartate receptor encephalitis clinical diagnostic criteria in psychiatric patients. Acta Psychiatr Scand 2020; 142:52-57. [PMID: 32474904 DOI: 10.1111/acps.13197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The gold standard for diagnosing anti-NMDAR encephalitis is demonstration of the antibody in CSF. Clinical diagnostic criteria have been proposed for when this is not available in a timely manner which is evaluated, in this study, for a psychiatric population. METHODS This study retrospectively assessed the proposed criteria in patients presenting to psychiatric services for the first time with known anti-NMDAR antibody status. Antibody-positive cases were derived from the literature (conception to December 2019) and a state-wide (Queensland, Australia) cohort. Antibody-negative cases were derived from a service-wide (Metro South, Queensland, Australia) cohort of psychiatric cases which underwent antibody testing for routine organic screening. Sensitivity and specificity were calculated at 1 week following admission and the point of discharge. RESULTS The proposed criteria were applied to 641 cases (500 antibody-positive and 141 antibody-negative), demonstrating a sensitivity which increased from around 19% after 1 week to 49% by the point of discharge. Specificity was 100% at both time points. The mean average time to become positive using the proposed criteria was 19.5 days compared to 34.9 days for return of antibody testing. CONCLUSIONS High specificity of the proposed criteria, seen in this study, suggests that cases which are positive can be considered for expedited commencement of treatment. However, if clinical suspicion is high despite criteria being negative, it is essential to test CSF for anti-NMDAR antibody.
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Affiliation(s)
- N Warren
- Metro South Addiction and Mental Health, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - C O'Gorman
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia.,Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - S Blum
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia.,Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - S Kisely
- Metro South Addiction and Mental Health, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - A Swayne
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia.,Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - J Flavell
- Metro South Addiction and Mental Health, Brisbane, Australia
| | - D Siskind
- Metro South Addiction and Mental Health, Brisbane, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Warren N, Flavell J, O'Gorman C, Swayne A, Blum S, Kisely S, Siskind D. Screening for anti-NMDAR encephalitis in psychiatry. J Psychiatr Res 2020; 125:28-32. [PMID: 32203736 DOI: 10.1016/j.jpsychires.2020.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/02/2020] [Accepted: 03/13/2020] [Indexed: 12/19/2022]
Abstract
Anti-NMDAR encephalitis most commonly presents to psychiatric services, so early identification of this disorder is essential. We aim to validate the two screening criteria (Scott et al. and Herken and Pruss) which have been proposed to identify first episode psychosis patients who should have anti-NMDAR antibody testing. The performance of the screening criteria were assessed using anti-NMDAR encephalitis cases published in the literature, and antibody positive and negative cases from a state-wide cohort (Queensland, Australia). Sensitivity, specificity and area under receiver operator characteristic curve analysis was performed. There were 258 anti-NMDAR encephalitis cases and 103 control cases, which demonstrated high performance of both Scott et al. "screening recommended" criteria (sensitivity 97.3%, specificity 85.4%, AUC 0.914) and Herken and Pruss "yellow flags" criteria (sensitivity 91.5%, specificity 83.5%, AUC 0.875). These criteria remained accurate when neurological variables were excluded, and in cases without psychosis. The Scott et al. "screening not recommended", and Herken and Pruss "red flags" criteria did not demonstrate clinical utility for first episode psychosis case screening. The screening criteria with good performance identify an atypical picture of psychiatric presentation with increased risk of anti-NMDAR positivity prior to overt neurological symptoms or investigations and may be beneficial to include in the routine psychiatric assessment process.
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Affiliation(s)
- Nicola Warren
- Metro South Addiction and Mental Health, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia.
| | - Joshua Flavell
- Metro South Addiction and Mental Health, Brisbane, Australia
| | - Cullen O'Gorman
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia; Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Andrew Swayne
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia; Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Stefan Blum
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia; Mater Centre for Neurosciences, Mater Hospital, Brisbane, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
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