Category: Mental Health Treatment

A Study into an Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic

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Research Paper Title

An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic.

Background

The objective of this quality improvement project was to decrease the amount of benzodiazepines (BZDs) prescribed by providers at a Midwestern university outpatient clinic.

Methods

Clinic providers participated in a brief, live educational intervention combining academic detailing (i.e., the provision of current evidence about BZD) and pharmaceutical detailing (i.e., a sales technique borrowed from pharmaceutical companies).

A 1% decrease in BZD prescribing was set as the measure of success.

Using data from the electronic medical record, the monthly average of BZD prescriptions written within calendar year 2017 (before project launch) was compared to the number written 30 days after the intervention.

Results

Following the intervention, an 80% reduction in BZD prescribing was calculated.

Conclusions

Combined academic and pharmaceutical detailing could be an effective way to change prescribing behaviour in this provider population.

Further investigation is needed to ascertain whether the change in prescribing behaviour can be sustained, and that no harm is being done to patients who are currently dependent on BZD medications.

Reference

Platt, L., Savage, T.A. & Rajagopal, N. (2020) An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic. Journal of Psychosocial Nursing and Mental Health Services. 58(1):39-45. doi: 10.3928/02793695-20191218-08.

What are the Side Effects Associated with a Single Dose of Ketamine in Treatment-Resistant Depression?

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Research Paper Title

Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression.

Background

Concerns about ketamine for treating depression include abuse potential and the occurrence of psychotomimetic effects.

This study sought to comprehensively assess side effects (SEs) associated with a single subanesthetic-dose intravenous ketamine infusion.

A secondary aim was to examine the relationship between Clinician-Administered Dissociative States Scale (CADSS) scores and dissociative symptoms reported on a comprehensive, clinician-administered SE questionnaire.

Methods

Data from 188 participants were pooled from four placebo-controlled, crossover ketamine trials and one open-label study (n = 163 with either treatment-resistant major depressive disorder or bipolar disorder and 25 healthy controls).

SEs were actively solicited in a standardized fashion and monitored over the time-course of each study.

Statistical analyses assessed the effect of drug (ketamine, placebo) on SEs and measured the relationship between CADSS total score and SEs contemporaneously endorsed during structured interviews.

Results

Forty-four of 120 SEs occurred in at least 5% of participants over all trials.

Thirty-three of these 44 SEs were significantly associated with active drug administration (versus placebo).

The most common SE was feeling strange/weird/loopy.

Most SEs peaked within an hour of ketamine administration and resolved completely by two hours post-infusion.

No serious drug-related adverse events or increased ketamine craving/abuse post-administration were observed.

A positive correlation was found between dissociative SEs and total CADSS score.

The post-hoc nature of the analysis; the limited generalisability of a single subanesthetic-dose ketamine infusion; and the lack of formal measures to assess ketamine’s cognitive, urological, or addictive potential.

Conclusions

No long-lasting significant SEs occurred over the approximately three-month follow-up period.

Reference

Acevedo-Diaz, E.E., Cavanaugh, G.W., Greenstein, D., Kraus, C., Kadriu, B., Zarate, C.A. & Park, L.T. (2019) Comprehensive assessment of side effects associated with a single dose of ketamine in treatment-resistant depression. Journal of Affective Disorders. pii: S0165-0327(19)31983-4. doi: 10.1016/j.jad.2019.11.028. [Epub ahead of print].

Linking Collaborative Care & Relapse Prevention for Depression

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Research Paper Title

The role of relapse prevention for depression in collaborative care: A systematic review.

Background

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings.

Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care.

The researchers undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

Methods

The researchers searched for Randomised Controlled Trials (RCTs) of collaborative care for depression.

In addition to published material, they obtained provider and patient manuals from authors to provide more detail on intervention content.

They reported the extent to which collaborative care interventions addressed four relapse prevention components.

Results

93 RCTs were identified.

31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention.

30 (32.3%) did not report relapse prevention approaches.

The researchers did not receive trial materials for approximately half of the trials, which limited their ability to identify relevant features of intervention content.

Conclusions

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk.

Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Reference

Moriarty, A.S., Coventry, P.A., Hudson, J.L., Cook, N., Fenton, O.J., Bower, P., Lovell, K., Archer, J., Clarke, R., Richards, D.A., Dickens, C., Gask, L., Waheed, W., Huijbregts, K.M., van der Feltz-Cornelis, C., Ali, S., Gilbody, S. & McMillan, D. (2019) The role of relapse prevention for depression in collaborative care: A systematic review. Journal of Affective Disorders. pii: S0165-0327(19)30734-7. doi: 10.1016/j.jad.2019.11.105. [Epub ahead of print].

Utility of Add-on Mirtazapine to Clozapine-Responsive Early-Onset Schizophrenia

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Research Paper Title

Add-on mirtazapine to clozapine-responsive early-onset schizophrenia.

Abstract

Early-onset schizophrenia is notorious for poor prognostication and treatment-refractoriness.

Clozapine remains a viable option, albeit off-label, but is clearly underutilised in this population.

Use is typically fraught with panoply of drastic side effects.

Here, the authors report on an adolescent case with schizophrenia that responded ultimately to clozapine.

Add-on mirtazapine was advantageous spanning negative and cognitive symptom domains whilst addressing clozapine-related sialorrhea and urinary incontinence.

This might open new venues for such complicated clinical scenarios.

Reference

Moodliar, S., Naguy, A. & Elsori, D.H. (2019) Add-on mirtazapine to clozapine-responsive early-onset schizophrenia. Psychiatry Research. https://doi.org/10.1016/j.psychres.2019.112701.

Is Varenicline a Useful Target Compound for Improving Cognitive Impairment in Schizophrenia?

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Research Paper Title

Varenicline for cognitive impairment in people with schizophrenia: systematic review and meta-analysis.

Background

People with schizophrenia frequently have cognitive dysfunction, which does not respond to pharmacological interventions. Varenicline has been identified as a potential treatment option for nicotinic receptor dysfunction with a potential to treat cognitive impairment in schizophrenia.

Methods

The researchers conducted a systematic review of Pubmed, Embase, Psycinfo, CINAHL and the Cochrane Schizophrenia Trial Registry for randomised controlled trials of varenicline in people with schizophrenia for cognitive dysfunction.

They excluded trials among people with dementia. They then undertook a meta-analysis with the primary outcome of difference in change of cognitive measures between varenicline and placebo as well as secondary outcomes of difference in rates of adverse events.

They also conducted a sensitivity analysis on smoking status and study duration.

Results

The researchers included four papers in the meta-analysis (n = 339).

Varenicline was not superior to placebo for:

  • Overall cognition (SMD = -0.022, 95% CI -0.154-0.110; Z = -0.333; p = 0.739);
  • Attention (SMD = -0.047, 95% CI -0.199-0.104; Z = -0.613; p = 0.540);
  • Executive function (SMD = -0.060, 95% CI -0.469-0.348; Z =- 0.290; p = 0.772); or
  • Processing speed (SMD = 0.038, 95% CI -0.232-0.308; Z = 0.279; p = 0.780).

There was no difference in psychotic symptoms, but varenicline was associated with higher rates of nausea.

Sensitivity analyses for smoking status and study duration did not alter the results.

Conclusions

Within the present literature, varenicline does not appear to be a useful target compound for improving cognitive impairment in schizophrenia.

Based on these results, a trial would need over 2,500 participants to be powered to show statistically significant findings.

Reference

Tanzer, T., Shah, S., Benson, C., De Monte, V., Gore-Jones, V., Rossell, S.L., Dark, F., Kisely, S., Siskind, D. & Melo, C.D. (2019) Varenicline for cognitive impairment in people with schizophrenia: systematic review and meta-analysis. Psychopharmacology. doi: 10.1007/s00213-019-05396-9. [Epub ahead of print].

What Can We Learning from Nurses’ Experiences of Events involving Physiological Deterioration of Consumers in Acute Inpatient Mental Health Settings?

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Research Paper Title

Clarity, confidence, and complexity: Learning from nurses’ experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings.

Background

The objective of the current study was to capture the experiences of nurses in relation to the acutely physiologically deteriorating consumer.

Improving the physical health care of consumers with mental illness has been widely adopted as a priority for mental health nursing. Much of the effort thus far has focused on routine screening, prevention and treatment of common comorbidities including cardiovascular disease, diabetes mellitus, and cancer.

There has been less focus on the acutely physiologically deteriorating consumer in the mental health setting.

Further study is warranted since this issue poses a set of highly complex challenges for nurses within the inpatient setting.

Methods

An exploratory, descriptive study was employed using focus groups to gather narrative data which was then subject to qualitative analysis.

Eleven mental health inpatient wards within a local health district in Sydney, Australia were studied, comprising ward-based nurses (n = 64) and nurse unit managers (n = 8).

This paper follows the COREQ guidelines for reporting qualitative health research.

Results

Qualitative data analysis revealed three themes central to the nurses’ experience:

  1. Lack of clarity (subthemes: procedures and leadership accountability);
  2. Confidence in the workforce (subthemes: knowledge & skills, training needs, relevant experience, collaboration with emergency and medical teams, stigmatising attitudes); and
  3. Complexity (subthemes: complexity as the new norm, and suitability of the mental health environment).

Conclusions

The themes found in this study can be used to guide and inform health care policy, protocols, education and processes around building a more confident nurse workforce for the acutely physiologically deteriorating consumer.

Findings provide a rich dataset for the generation of measurement tools and protocols to guide physical healthcare and evaluate performance.

Reference

Brunero, S., Everett, B., Ramjan, L.M., Salamonson, Y., Steel, K., Johnson, A.M., Stokes, M., Langdon, R. & Dickens, G.L. (2019) Clarity, confidence, and complexity: Learning from nurses’ experiences of events involving physiological deterioration of consumers in acute inpatient mental health settings. Journal of Clinical Nursing. doi: 10.1111/jocn.15126. [Epub ahead of print].

Reduction of Plasma Procoagulant Activity in Patients with Schizophrenia during Pharmacotherapy

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Research Paper Title

[Reduction of plasma procoagulant activity in patients with schizophrenia during pharmacotherapy: thrombodynamic parameters of coagulation before and after treatment].

Background

To detect plasma procoagulant activity in patients with schizophrenia at admission to the hospital in a state of exacerbation before (point 1) and after (point 2) pharmacotherapy and evaluate plasma and platelet hemostasis abnormalities.

Methods

The study included 80 women, aged from 16 to 57 years, median age 28 years, with schizophrenia with continuous, paroxysmal-progressive or paroxysmal course (F20.00, F20.01, F20.02 according to ICD-10).

In 42 of 80 patients, depressive disorders in the structure of schizophrenia were observed. The thrombodynamic test (TD) was performed on T-2 Trombodynamis device according to the manufacturer’s instructions (Hemacore LLC, Moscow, Russia).

Blood for the TD test was taken in admission to the hospital (point 1) and on discharge (point 2). All patients received standard pharmacotherapy according to their condition.

Results

For the first time, it was established that in the whole group of patients (n=46) thrombodynamic indicators of the rate of growth of the clot: initial velocity (Vin), stationary velocity (Vst) and adjusted for spontaneous clots velocity (V) and the amount of clot for 30 minutes test TD (ClotSize, CS) were significantly higher compared to normal values.

The mean time of occurrence of spontaneous thrombosis (Tsp) was significantly less than 30 min (p<0.0001), indicating rapid, spontaneous thrombosis. Other parameters of TD did not differ significantly from the norm.

As a result of treatment, the initial growth rate of the clot from the activator (Vi) decreased from 58,5 μm/min to 54,5 μm/min; V speed from 37,4 μm/min to 33,5 μm/min; CS clot size from 1249 μm to 1219 μm; clot density – from 24 874 units up to 23 658 units. All these changes are significant.

Such dynamics of plasma haemostasis clearly indicates a significant decrease in the coagulation activity of the blood plasma of patients as a result of treatment.

An increase in the time of appearance of spontaneous clots after treatment (from 23.5 minutes to 30.5 minutes) indicates a decrease in the procoagulant activity of platelet microparticles after treatment, i.e. the reduction of platelet activation as a result of treatment.

Conclusions

The study has shown for the first time that treatment of patients with antidepressants and antipsychotics reduces the generation of spontaneous clots. The treatment of patients with schizophrenia is accompanied by a decrease in the activity of plasma and platelet haemostasis. This is of great practical importance, since hypercoagulation of spontaneous clots in schizophrenic patients aggravates their chronic inflammatory disorders and affects their resistance to treatment.

Reference

Brusov, O.S., Karpova, N.S., Faktor, M.I., Sizov, S.V. & Oleichik, I.V. (2019) [Reduction of plasma procoagulant activity in patients with schizophrenia during pharmacotherapy: thrombodynamic parameters of coagulation before and after treatment]. In Russian. Zhurnal Nevrologii i Psikhiatrii Imeni S.S. Korsakova. 119(10):51-55. doi: 10.17116/jnevro201911910151.

What is the Sustainability of a Biobehavioural Intervention Implemented by Therapists & Sustainment in Community Settings?

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Research Paper Title

Sustainability of a biobehavioral intervention implemented by therapists and sustainment in community settings.

Background

The ultimate aim of dissemination and implementation of empirically supported treatments (ESTs) in behavioural medicine is:

  • Sustainability of the therapist/provider’s EST usage; and
  • Sustainment of EST delivery in the setting.

Thus far, sustainability has been understudied, and the therapist and setting variables that may be influential are unclear.

The purpose of the study was to test the therapists’ sustainability of a cancer-specific EST using a prospective longitudinal design and examine its predictors.

Methods

Oncology mental health therapists (N = 134) from diverse settings (N = 110) completed training in the biobehavioural intervention (BBI) and were provided with 6 months of support for implementation, with no support thereafter. BBI usage (percent of patients treated) was reported at 2, 4, 6, and 12 months.

Using a generalised estimating equation with a logistic link function, 12-month sustainability (a non-significant change in usage from 6 to 12 months) was studied along with therapist, supervisor, and setting variables as predictors.

Results

BBI usage increased through 6 months and, importantly, usage was sustained from 6 (68.4% [95% CI = 62.2%-73.9%]) to 12 months (70.9% [95% CI = 63.6%-77.3%]), with sustainment in 66 settings (60.0%).

Predictors of implementation-to-sustainability usage were therapists’ early intentions to use the BBI (p < .001) and from the setting, supervisors’ positive attitudes toward ESTs (p = .016).

Conclusions

Adding to the DI literature, a health psychology intervention was disseminated, implemented, and found sustainable across diverse therapists and settings.

Therapists and setting predictors of usage, if modified, might facilitate future sustainability/sustainment of ESTs.

Reference

Ryba, M.M., Lo, S.B. & Andersen, B.L. (2019) Sustainability of a biobehavioral intervention implemented by therapists and sustainment in community settings. Translational Behavioral Medicine. pii: ibz175. doi: 10.1093/tbm/ibz175. [Epub ahead of print].

Timely Referrals from Primary Care to Specialty Mental Health, and Back

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Research Paper Title

Provider perspectives on a clinical demonstration project to transition patients with stable mental health conditions to primary care.

Background

Research to improve access to mental healthcare often focuses on increasing timely referrals from primary care (PC) to specialty mental health (SMH).

However, timely and appropriate transitions back to PC are indispensable for increasing access to SMH for new patients.

Methods

The researchers developed and implemented a formalised process to identify patients eligible for transition from SMH to PC.

The FLOW intervention was piloted at a Veterans Health Administration community-based outpatient clinic. Qualitatively examine provider perspectives regarding patient transitions at initiation and termination of the FLOW project.

Sixteen mental health providers and three PC staff completed qualitative interviews about the benefits and drawbacks of FLOW at initiation. Ten mental health providers and one PC staff completed interviews at 12-month follow-up. Primary benefits anticipated at initiation were that FLOW would increase access to SMH, provide acknowledgement of veterans’ recovery, and differentiate between higher and lower intensity mental health services.

Results

SMH providers reported additional perceived benefits at 12-month follow-up, including:

  • Decreased stress over their caseloads; and
  • Increased ability to deliver efficient, effective treatment.

Anticipated drawbacks at initiation were that veterans would get inconsistent care, PC could not offer the same level of care as SMH, and veterans might view transition as a rejection by their SMH provider.

Perceived drawbacks were similar at 12-month follow-up, but there was less frequent endorsement.

Conclusions

Findings highlight need for sustained and frequent provider education regarding:

  1. The appropriate characteristics of individuals eligible for transition; and
  2. Established procedures to ensure care coordination during and after transition.

Reference

Fletcher, T.L., Johnson, A.L., Kim, B., Yusuf, Z., Benzer, J. & Smith, T. (2019) Provider perspectives on a clinical demonstration project to transition patients with stable mental health conditions to primary care. Translational Behavioral Medicine. pii: ibz172. doi: 10.1093/tbm/ibz172. [Epub ahead of print].

Primary Care Physicians & the Mental Health Gap Action Programme (mhGAP)

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Research Paper Title

Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial.

Background

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area.

Non-specialists (such as PCPs)’ training is an internationally supported way to target untreated mental health symptoms.

Methods

The researchers aimed to evaluate the programme’s impact on PCPs’ mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training.

They conducted an exploratory trial with a combination of designs: a pretest-posttest control group design and a one-group pretest-posttest design were used to assess the training’s short-term impact; and a repeated measures design was used to assess the training’s long-term impact.

The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1).

The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers.

Data were collected at baseline, following Group 1’s training, following Group 2’s training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted.

Overall, 112 PCPs were randomised to either Group 1 (n = 52) or Group 2 (n = 60).

Results

The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice.

When comparing pre-training results and results 18 months after training, these changes were maintained.

PCPs reported a decrease in referral rates to specialised services 18 months after training in comparison to pre-training.

Conclusions

The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries.

Future studies should examine relationships among these outcome variables.

Reference

Spagnolo, J., Champagne, F., Leduc, N., Rivard, M., Melki, W., Piat, M., Laporta, M., Guesmi, I., Bram, N. & Charfi, F. (2019) Building capacity in mental health care in low- and middle-income countries by training primary care physicians using the mhGAP: a randomized controlled trial. Health Policy and Planning. pii: czz138. doi: 10.1093/heapol/czz138. [Epub ahead of print].