Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS)

BACKGROUND

Scales to measure the severity of different dimensions of auditory hallucinations and delusions are few. Biochemical and psychological treatments target dimensions of symptoms and valid and reliable measures are necessary to measure these.

METHOD

The inter-rater reliability and validity of the Psychotic Symptom Rating Scales (PSYRATS: auditory hallucination subscale and delusions subscale), which measure several dimensions of auditory hallucinations and delusions were examined in this study.

RESULTS

The two scales were found to have excellent inter-rater reliability. Their validity as compared with the KGV scale (Krawiecka et al. 1977) was explored.

CONCLUSIONS

It is concluded that the PSYRATS are useful assessment instruments and can complement existing measures.

Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders

OBJECTIVE

Comorbidity of substance abuse disorders with schizophrenia is associated with a greater risk for serious illness complications and poorer outcome. Methodologically sound studies investigating treatment approaches for patients with these disorders are rare, although recommendations for integrated and comprehensive treatment programs abound. This study investigates the relative benefit of adding an integrated psychological and psychosocial treatment program to routine psychiatric care for patients with schizophrenia and substance use disorders.

METHOD

The authors conducted a randomized, single-blind controlled comparison of routine care with a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family or caregiver intervention.

RESULTS

The integrated treatment program resulted in significantly greater improvement in patients' general functioning than routine care alone at the end of treatment and 12 months after the beginning of the study. Other benefits of the program included a reduction in positive symptoms and in symptom exacerbations and an increase in the percent of days of abstinence from drugs or alcohol over the 12-month period from baseline to follow-up.

CONCLUSIONS

These findings demonstrate the effectiveness of a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family intervention over routine psychiatric care alone for patients with comorbid schizophrenia and alcohol or drug abuse or dependence.

Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia

OBJECTIVES

To investigate whether intensive cognitive behaviour therapy results in significant improvement in positive psychotic symptoms in patients with chronic schizophrenia.

DESIGN

Patients with chronic schizophrenia were randomly allocated, stratified according to severity of symptoms and sex, to intensive cognitive behaviour therapy and routine care, supportive counselling and routine care, and routine care alone.

SETTING

Adjunct treatments were carried out in outpatient clinics or in the patient's home.

SUBJECTS

87 patients with persistent positive symptoms who complied with medication; 72 completed treatment.

OUTCOME MEASURES

Assessments of positive psychotic symptoms before treatment and 3 months after treatment. Number of patients who showed a 50% or more improvement in symptoms. Exacerbation of symptoms and rates of readmission to hospital.

RESULTS

Significant improvements were found in the severity (F=5.42, df =2,86; P=0.006) and number (F=4.99, df=2,86; P=0.009) of positive symptoms in those treated with cognitive behaviour therapy. The supportive counselling group showed a non-significant improvement. Significantly more patients treated with cognitive behaviour therapy showed an improvement of 50% or more in their symptoms (chi2=5.18, df=1; P=0.02). Logistic regression indicated that receipt of cognitive behaviour therapy results in almost eight times greater odds (odds ratio 7.88) of showing this improvement. The group receiving routine care alone also experienced more exacerbations and days spent in hospital.

CONCLUSIONS

Cognitive behaviour therapy is a potentially useful adjunct treatment in the management of patients with chronic schizophrenia.

Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes

BACKGROUND

Cognitive-behavioural therapy (CBT) improves persistent psychotic symptoms.

AIMS

To test the effectiveness of added CBT in accelerating remission from acute psychotic symptoms in early schizophrenia.

METHOD

A 5-week CBT programme plus routine care was compared with supportive counselling plus routine care and routine care alone in a multi-centre trial randomising 315 people with DSM-IV schizophrenia and related disorders in their first (83%) or second acute admission. Outcome assessments were blinded.

RESULTS

Linear regression over 70 days showed predicted trends towards faster improvement in the CBT group. Uncorrected univariate comparisons showed significant benefits at 4 but not 6 weeks for CBT v. routine care alone on Positive and Negative Syndrome Scale total and positive sub-scale scores and delusion score and benefits v. supportive counselling for auditory hallucinations score.

CONCLUSIONS

CBT shows transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early schizophrenia.

Anxiety and depression in psychosis: a systematic review of associations with positive psychotic symptoms

OBJECTIVE

This review explores the influence of anxiety and depression on the experience of positive psychotic symptoms, and investigates the possibility of a causal role for anxiety and depression in the emergence and persistence of psychosis.

METHOD

A systematic literature search was undertaken, producing a number of papers which comment on the links between anxiety and depression, and the experience of delusions and hallucinations. In addition, evidence which could contribute to our understanding of the causal role of anxiety and depression was highlighted.

RESULTS

The findings show that both anxiety and depression are associated in meaningful ways with the severity of delusions and hallucinations, the distress they elicit and their content. However, the cross-sectional nature of the majority of studies and the focus on certain symptom subtypes tempers the validity of the findings. Data from non-clinical samples, studies which track the longitudinal course of psychosis and those which examine the impact of anxiety and depression on the prognosis for people experiencing psychosis, offer some support for the possibility of an influential role for anxiety and depression.

CONCLUSION

We conclude that anxiety and depression are related to psychotic symptom severity, distress and content and are also linked with sub-clinical experiences, symptom development, prognosis and relapse. These links may imply that anxiety and depression could be targets for therapeutic intervention. The article concludes with suggestions for further research, highlighting avenues which may circumvent the limitations of the body of work as it stands.

The evolution of insight, paranoia and depression during early schizophrenia

BACKGROUND

How insight, paranoia and depression evolve in relation to each other during and after the first episode of schizophrenia is poorly understood but of clinical importance.

METHOD

Serial assessments over 18 months were made using multiple instruments in a consecutive sample of 257 patients with first episode DSM-IV non-affective psychosis. Repeated measures of paranoia, insight, depression and self-esteem were analysed using structural equation modelling, to examine the direction of relationships over time after controlling for confounds.

RESULTS

Depression was predicted directly by greater insight, particularly at baseline, and by greater paranoia at every stage of follow-up. Neither relationship was mediated by self-esteem, although there was a weak association of lower self-esteem with greater depression and better insight. Paranoia was not strongly associated with insight. Duration of untreated psychosis and substance use at baseline predicted depression at 18 months.

CONCLUSIONS

In first-episode psychosis, good insight predicts depression. Subsequently, paranoia is the strongest predictor. Neither effect is mediated by low self-esteem. Effective treatment of positive symptoms is important in preventing and treating low mood in early schizophrenia.

Tumor necrosis factor α- and interleukin-1β-dependent induction of CCL3 expression by nucleus pulposus cells promotes macrophage migration through CCR1

OBJECTIVE

To investigate tumor necrosis factor α (TNFα) and interleukin-1β (IL-1β) regulation of CCL3 expression in nucleus pulposus (NP) cells and in macrophage migration.

METHODS

Quantitative reverse transcription-polymerase chain reaction and immunohistochemistry were used to measure CCL3 expression in NP cells. Transfections were used to determine the role of NF-κB, CCAAT/enhancer binding protein (C/EBPβ), and MAPK on cytokine-mediated CCL3 promoter activity. The effect of NP-conditioned medium on macrophage migration was measured using a Transwell system.

RESULTS

An increase in CCL3 expression and promoter activity was observed in NP cells after TNFα or IL-1β treatment. Treatment of cells with NF-κB and MAPK inhibitors abolished the effect of the cytokines on CCL3 expression. The inductive effect of p65 and C/EBPβ on the CCL3 promoter was confirmed through gain-of-function and loss-of-function studies. Notably, cotransfection with p50 completely blocked cytokine- and p65-dependent induction. In contrast, c-Rel and RelB had little effect on promoter activity. Lentiviral transduction with short hairpin RNA for p65 (shp65) and shIKKβ significantly decreased the TNFα-dependent increase in CCL3 expression. Analysis of degenerated human NP tissue samples showed that CCL3, but not CCL4, expression correlated positively with the grade of tissue degeneration. Importantly, treatment of macrophages with conditioned medium of NP cells treated with TNFα or IL-1β promoted their migration. Pretreatment of macrophages with an antagonist of CCR1, the primary receptor for CCL3 and CCL4, blocked cytokine-mediated migration.

CONCLUSION

Our findings indicate that TNFα and IL-1β modulate the expression of CCL3 in NP cells by controlling the activation of MAPK, NF-κB, and C/EBPβ signaling. The CCL3-CCR1 axis may play an important role in promoting macrophage infiltration in degenerated, herniated discs.

Potential roles of cytokines and chemokines in human intervertebral disc degeneration: interleukin-1 is a master regulator of catabolic processes

OBJECTIVE

These studies investigated cytokine and chemokine receptor profiles in nucleus pulposus (NP) cells, and the effects of receptor stimulation on mRNA levels of extracellular matrix (ECM) components, degrading enzymes and cytokine and chemokine expression.

METHOD

Immunohistochemistry (IHC) was performed to localise expression of CD4, CCR1, CXCR1 and CXCR2 in human NP tissue samples. Effects of cytokine and chemokine stimulation was performed to investigate effects related to ECM remodelling and modulation of cytokine and chemokine mRNA expression.

RESULTS

IHC identified CD4, CCR1, CXCR1 and CXCR2 expression by NP cells. Differential expression profiles were observed for CD4 and CXCR2 in tissue samples from degenerate and infiltrated IVDs. In vitro stimulations of primary human NP cultures with IL-16, CCL2, CCL3, CCL7 or CXCL8 did not identify any modulatory effects on parameters associated with ECM remodelling or expression of other cytokines and chemokines. Conversely, IL-1 was seen to modulate ECM remodelling and expression of all other cytokines and chemokines investigated.

CONCLUSION

This study demonstrates for the first time that NP cells express a number of cytokine and chemokine receptors and thus could respond in an autocrine or paracrine manner to cytokines and chemokines produced by NP cells, particularly during tissue degeneration. However, this study failed to demonstrate regulatory effects on ECM genes and degradative enzymes or other cytokines and chemokines for any target investigated, with the exception of IL-1. This suggests that IL-1 is a master regulator within the IVD and may exert regulatory potential over a plethora of other cytokines and chemokines.

Cognitive factors in source monitoring and auditory hallucinations

BACKGROUND

In order to elucidate further the cognitive processes underlying auditory hallucinations, an experiment investigating delayed and immediate source monitoring for positive, negative and neutral verbal material was conducted with schizophrenic patients.

METHODS

Patients experiencing auditory hallucinations, patients not experiencing auditory hallucinations and normal subjects participated in a word association task, rating their responses for how much a self-generated thought was their own, how controllable and involuntary it was and their confidence in these ratings. A delayed source monitoring test in which subjects had to recall the source (self or experimenter) of the words from the association task was also administered.

RESULTS

Hallucinators showed a greater bias towards external attribution of their thoughts compared with both control groups for immediate attributions of source, but not for delayed attributions. Hallucinators showed a bias towards external attribution of emotional material for immediate source monitoring and all subjects showed a bias towards misattribution of positive material to an external source and negative material to an internal source for the delayed source monitoring task.

CONCLUSIONS

These findings appear to be most consistent with theories proposing that hallucinations result from an external attributional bias for internal events. The implications of these results for research and practice are also discussed.

An experience sampling study of worry and rumination in psychosis

BACKGROUND

Increasing research effort is being dedicated to investigating the links between emotional processes and psychosis, despite the traditional demarcation between the two. Particular focus has alighted upon two specific anxious and depressive processes, worry and rumination, given the potential for links with aspects of delusions and auditory hallucinations. This study rigorously explored the nature of these links in the context of the daily life of people currently experiencing psychosis.

METHOD

Experience sampling methodology (ESM) was used to assess the momentary links between worry and rumination on the one hand, and persecutory delusional ideation and auditory hallucinations on the other. Twenty-seven participants completed the 6-day experience sampling period, which required repeated self-reports on thought processes and experiences. Multilevel modelling was used to examine the links within the clustered data.

RESULTS

We found that antecedent worry and rumination predicted delusional and hallucinatory experience, and the distress they elicited. Using interaction terms, we have shown that the links with momentary symptom severity were moderated by participants' trait beliefs about worry/rumination, such that they were reduced when negative beliefs about worry/rumination (meta-cognitions) were high.

CONCLUSIONS

The current findings offer an ecologically valid insight into the influence of worry and rumination on the experience of psychotic symptoms, and highlight possible avenues for future intervention strategies.

A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis

BACKGROUND

Recent research indicates that cognitive-behaviour therapy (CBT) can be effective in ameliorating persistent positive symptoms in chronic psychotic patients. The effectiveness of CBT in acute and recent-onset psychosis has been little explored, although a recent pilot study indicated that CBT could significantly improve recovery in acutely psychotic inpatients.

METHOD

Short-term individual CBT was compared to supportive counselling/psychoeducation (SC) as an adjunct to standard inpatient hospital care and medication in 21 inpatients experiencing a recent-onset acute schizophrenic episode.

RESULTS

Both groups showed significant reductions in Brief Psychiatric Rating Scale (BPRS) scores following treatment, although there were no group differences. Time to discharge did not differ significantly between the groups, although there was a greater variance for the SC patients. Two-year follow-up showed no significant differences between the groups, although the number of patients who relapsed, the number of relapses and the time to recurrence of psychotic symptoms was lower in the CBT group than the SC group. Interestingly, the time to readmission was shorter in the CBT group.

CONCLUSIONS

CBT and SC are acceptable treatments for recent-onset acutely psychotic inpatients. A larger randomised controlled trial over multiple hospital sites is warranted.

The cytokine and chemokine expression profile of nucleus pulposus cells: implications for degeneration and regeneration of the intervertebral disc

INTRODUCTION

The aims of these studies were to identify the cytokine and chemokine expression profile of nucleus pulposus (NP) cells and to determine the relationships between NP cell cytokine and chemokine production and the characteristic tissue changes seen during intervertebral disc (IVD) degeneration.

METHODS

Real-time q-PCR cDNA Low Density Array (LDA) was used to investigate the expression of 91 cytokine and chemokine associated genes in NP cells from degenerate human IVDs. Further real-time q-PCR was used to investigate 30 selected cytokine and chemokine associated genes in NP cells from non-degenerate and degenerate IVDs and those from IVDs with immune cell infiltrates (‘infiltrated’). Immunohistochemistry (IHC) was performed for four selected cytokines and chemokines to confirm and localize protein expression in human NP tissue samples.

RESULTS

LDA identified the expression of numerous cytokine and chemokine associated genes including 15 novel cytokines and chemokines. Further q-PCR gene expression studies identified differential expression patterns in NP cells derived from non-degenerate, degenerate and infiltrated IVDs. IHC confirmed NP cells as a source of IL-16, CCL2, CCL7 and CXCL8 and that protein expression of CCL2, CCL7 and CXCL8 increases concordant with histological degenerative tissue changes.

CONCLUSIONS

Our data indicates that NP cells are a source of cytokines and chemokines within the IVD and that these expression patterns are altered in IVD pathology. These findings may be important for the correct assessment of the ‘degenerate niche’ prior to autologous or allogeneic cell transplantation for biological therapy of the degenerate IVD.

Individual cognitive-behavior therapy in the treatment of hallucinations and delusions: a review

The limitations of biochemical treatments in reducing the severity of hallucinations and delusions has led to an increased interest in the investigation of psychological treatments for these symptoms. These investigations have spanned the last 4 decades and have covered a range of psychological approaches from psychoanalytically oriented psychotherapy to behavioral approaches. More recently, findings that some psychotherapies are not effective treatments for psychosis and that cognitive-behavior therapy can be an effective treatment for neurotic disorders have led to increasing interest in the investigation of the effectiveness of cognitive-behavior therapy for psychosis. This review describes and evaluates the research on the cognitive-behavioral treatment of hallucinations and delusions and describes the cognitive models from which the treatments have developed. The conclusion is that, on the whole, the literature provides fairly strong evidence for the efficacy of cognitive-behavioral approaches in the management of chronic psychotic disorders and associated symptoms, although there are a number of areas where further development is necessary.

The morbidity and mortality of pediatric splenectomy: does prophylaxis make a difference?

PURPOSE

The aim of this study was to analyze the incidence of postsplenectomy sepsis morbidity and mortality after prophylaxis, in comparison with our previous 13-year study (1958 to 1970, inclusive).

METHODS

All patients who had splenectomy at the Hospital for Sick Children, Toronto, between 1971 and 1995, inclusive (to give a minimum of 2 years for follow-up), were reviewed for infection and mortality. The criterion for classifying a patient as "infected" was the recovery of an invading encapsulated organism from the blood culture in a patient admitted to the hospital.

RESULTS

Of the 264 patients studied, 10 had a postsplenectomy infection (3.8%); nine occurred in patients who underwent splenectomy between the ages of 0 and 5 years. Infection took place within 2 +/- 3 years (mean +/- SD) after splenectomy for the immunized patients and 11 +/- 5 days (mean +/- SD) for the nonimmunized children. A significant number of patients were admitted for an apparent respiratory infection, but no serum organisms were isolated. One died of overwhelming sepsis, but the responsible organism was not identified.

CONCLUSION

Although there has not been a decrease in the number of splenectomies performed per year, the incidence of infection and mortality has decreased by 47% and 88%, respectively, with prophylaxis.

ADAMTS-1 and -4 are up-regulated following transient middle cerebral artery occlusion in the rat and their expression is modulated by TNF in cultured astrocytes

ADAMTS (a disintegrin and metalloproteinase with thrombospondin motifs) enzymes are a recently described group of metalloproteinases. The substrates degraded by ADAMTS-1, -4 and -5 suggest that they play a role in turnover of extracellular matrix in the central nervous system (CNS). ADAMTS-1 is also known to exhibit anti-angiogenic activity. Their main endogenous inhibitor is tissue inhibitor of metalloproteinases (TIMP)-3. The present study was designed to investigate ADAMTS-1, -4 and -5 and TIMP-3 expression after experimental cerebral ischaemia and to examine whether cytokines known to be up-regulated in stroke could alter their expression by astrocytes in vitro. Focal cerebral ischaemia was induced by transient middle cerebral artery occlusion in the rat using the filament method. Our results demonstrate a significant increase in expression of ADAMTS-1 and -4 in the occluded hemisphere but no significant change in TIMP-3. This was accompanied by an increase in mRNA levels for interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1ra) and tumour necrosis factor (TNF). ADAMTS-4 mRNA and protein were up-regulated by TNF in primary human astrocyte cultures. The increased ADAMTS-1 and -4 in experimental stroke, together with no change in TIMP-3, may promote ECM breakdown after stroke, enabling infiltration of inflammatory cells and contributing to brain injury. In vitro studies suggest that the in vivo modulation of ADAMTS-1 and -4 may be controlled in part by TNF.

A comparison of the long-term effectiveness of distraction and focusing in the treatment of auditory hallucinations

Cognitive-behavioural interventions for patients experiencing neuroleptic resistant auditory hallucinations have fallen into two main categories: those which encourage distraction as a coping strategy, and those which encourage patients to focus on or expose themselves to their hallucinations. A 20-session distraction treatment was compared with an equal length focusing treatment for 19 patients who were experiencing chronic auditory hallucinations. Patients were followed-up for approximately 2 years. No differences were observed between the groups for outcome on symptom severity overall, although the focusers showed a greater belief that their voices were their own thoughts at the final follow-up point. When the two groups were combined, there was a significant reduction in the frequency of hallucinations and the disruption to life caused by them during treatment, although this was not maintained at follow-up. During treatment, there was a significant increase in self-esteem for focusers but a significant decrease for distracters. At 2-year follow-up, both focusers and distracters showed a reduction in self-esteem in comparison to the end of therapy. The results show no overwhelming advantage of one treatment over the other and confirm previous observations of the difficulty of treating hallucinations with cognitive-behaviour therapy (CBT). However, there was some indication that CBT influenced some important clinical variables and further investigation is warranted.

Changing trends in the management of extrahepatic cholangiocarcinoma

A series of 107 patients with cholangiocarcinoma diagnosed between January 1980 and December 1991 is reported. Changing patterns of investigation and treatment in the periods 1980-1985 and 1986-1991 are analysed. There was a decrease in the use of percutaneous transhepatic cholangiography in the second period (86 versus 51 per cent of patients) but increased use of endoscopic retrograde cholangiography (19 versus 71 per cent) and computed tomography (8 versus 59 per cent). The overall resectability rate (17 per cent) was similar to those of other reported series but greater in the second period (8 versus 21 per cent). Palliation by endoscopic and percutaneous stenting was associated with a high incidence of recurrent cholangitis (55 per cent) and jaundice (35 per cent). During the second 6-year period, more effective palliation was achieved by segment III cholangiojejunostomy with a lower incidence of recurrent cholangitis (19 per cent) and jaundice (19 per cent). Overall prognosis for patients with this condition is grim and efforts must usually be aimed at providing the most appropriate palliation.

Aetiology of pancreatic cancer

Curative surgery is possible in only a small minority of patients with pancreatic cancer and, to date, responses to chemotherapy and radiotherapy have been disappointing. To make any impact on the incidence of the disease a clearer understanding of its aetiology is required. This review explores present knowledge of the aetiology and epidemiology of pancreatic cancer.

Is befriending by trained volunteers of value to people suffering from long-term mental illness?

People who suffer from long term mental illness may be vulnerable to loneliness and isolation when living in community settings. Befriending by volunteers may be an effective way of combating such problems and helping clients to develop social networks. The findings of a small scale project to evaluate the views of people suffering from long term mental illness of an organized befriending scheme are reported. Nine subjects who suffer from severe mental illness were interviewed, all subjects felt befriending was helpful to them, and 67% of subjects thought it had improved their confidence when in social situations. Subjects who lived alone indicated a preference to see volunteers at home, whilst those who lived with carers preferred support in going out socially. The value of befriending schemes as part of community care services for this needy client group are discussed.

Acute pancreatitis in children: a 15-year review

AIM

To review the aetiology, presentation, diagnosis, management, and sequelae of acute pancreatitis (AP) in children and to assess the relevance of prognostic criteria used to assess severity in adult AP.

METHOD

A retrospective review (1978 through 1992) of childhood AP managed in three Scottish paediatric centres.

RESULTS

Forty-nine cases of AP (34 male, 15 female) were reviewed (mean age, 7.1 years). The presenting features were abdominal pain and vomiting (80%), abdominal tenderness (73%), and parotid enlargement (22%); back pain was rare (8%). Ultrasound scan (US) findings were abnormal for 24 of 34 patients. Forty-one (82%) were managed conservatively. Six (12%) underwent early laparotomy; three (6%) underwent laparotomy after trauma. Five required subsequent definitive surgery. One patient died. Thirty-five (70%) suffered no sequelae, and five (10%) had further acute pancreatitis. Only half of the eight Imrie prognostic criteria had been recorded in these patients; only three were judged to have severe AP by the criteria. Other "clinically severe" cases were not identified.

CONCLUSION

The most common causes of AP were mumps (39%) and trauma (14%); in 12, no cause was identified. US was the most useful imaging tool. The Imrie criteria were of doubtful value but warrant further prospective analysis and possible modification for children.

Esophageal tamponade in the management of acute variceal hemorrhage

Over a seven-year period, 138 patients with portal hypertension presented on 223 occasions with endoscopically proven acute variceal hemorrhage. Hemorrhage ceased spontaneously on 92 occasions (41%). On 126 occasions (57%) passage of the four-lumen modification of the Sengstaken-Blakemore tube was required, and hemorrhage was successfully controlled in 98%. Intubation was refused on five occasions (2%). Hemorrhage recurred during these 223 admissions on 47 occasions (21%); on 11 occasions a second rebleed occurred and on two occasions, a third. Tamponade was required during all of these rebleeds and arrest of hemorrhage was achieved in 87%. Hemorrhage in patients with poorer modified Child's grade was less likely to cease with intubation. The overall rate of control in the 186 episodes of hemorrhage requiring tamponade was 94%. There were 28 complications attributed to the use of tamponade in 186 episodes of hemorrhage (15%). On 12 occasions these complications proved fatal (6.4%). In four further patients failure of tamponade to control hemorrhage was fatal.

Impact of the COVID-19 pandemic on community antibiotic prescribing in Scotland

Background

Following concerns about increased antibiotic use during the COVID-19 pandemic, trends in community antibiotic prescriptions in Scotland were evaluated.

Methods

The primary care prescription electronic messaging system used in GP practices with NHS contracts provided near real-time data analysis of national data. The main outcome measures were the weekly number of prescriptions for antibiotics generated by prescribers in GP practices in 2020 compared with 2019.

Results

At end of Week 12 2020 (22 March), after a sharp increase, the number of prescriptions commonly used for respiratory infections was 44% higher than the corresponding week in 2019. The number of prescriptions for respiratory antibiotics reduced through April and May 2020, with 34% fewer prescriptions issued by end of Week 22 (31 May) than in the corresponding week in 2019. Reductions were pronounced in all age groups but particularly apparent for prescriptions for children aged 0–4 years. These data were compared with weekly prescriptions for a selection of non-respiratory antibiotics and no difference was seen between 2020 and 2019.

Conclusions

Trends in antibiotic prescription data show that after an initial surge, and following ‘lockdown’ in Scotland, the total number of prescriptions for antibiotics commonly used for respiratory infections fell. We believe this is the first published national evaluation of the impact of COVID-19 on community use of antibiotics. Further analysis of national data is planned to provide a greater understanding of the reasons behind these trends.

Staff expressed emotion and causal attributions for client problems on a low security unit: an exploratory study

This is an exploratory study that sought to investigate a number of measures of staff-patient relationships on a continuing care, low security inpatient facility for patients with severe mental illness. Twenty staff members were assessed for expressed emotion (EE) using the Camberwell Family Interview (CFI) in regard to a client for whom they were a designated key worker. Their spontaneous attributions for the patient's problems were also assessed, along with self-report staff and patient ratings of their expressed and perceived feelings and thoughts about their staff or patient counterpart. The study found that although none of the staff were rated as fulfilling criteria for high EE, there was evidence of some variability in the quality of staff-patient relationships as assessed from the subjective self-report scales of staff and patients. Patients seemed to be sensitive to staff feelings for them: patient ratings of perceived feelings and thoughts from staff were significantly correlated with staff expressed feelings both from the CFI EE ratings and the direct self-report staff measures. Staff tended to view the behaviors of patients they felt less positively disposed toward as more controllable, and this association between less benign explanations of behavior and a more critical attitude is consistent with the attribution research for familial caregivers. The more negatively perceived patient group was found to be more likely to have behavioral disturbances in the 7 months after the relationship ratings were made. This article discusses measurement issues in the assessment of formal caregiver-patient relationships in the light of this and previous studies.