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Subjective cognitive difficulties are common in mental illness and have a negative impact on role functioning. Little is understood about subjective cognition and the longitudinal relationship with depression and anxiety symptoms in young people.
To examine the relationship between changes in levels of depression and anxiety and changes in subjective cognitive functioning over 3 months in help-seeking youth.
This was a cohort study of 656 youth aged 12–25 years attending Australian headspace primary mental health services. Subjective changes in cognitive functioning (rated as better, same, worse) reported after 3 months of treatment was assessed using the Neuropsychological Symptom Self-Report. Multivariate multinomial logistic regression analysis was conducted to evaluate the impact of baseline levels of and changes in depression (nine-item Patient Health Questionnaire; PHQ9) and anxiety symptoms (seven-item Generalised Anxiety Disorder scale; GAD7) on changes in subjective cognitive function at follow-up while controlling for covariates.
With a one-point reduction in PHQ9 at follow-up, there was an estimated 11–18% increase in ratings of better subjective cognitive functioning at follow-up, relative to stable cognitive functioning. A one-point increase in PHQ9 from baseline to follow-up was associated with 7–14% increase in ratings of worse subjective cognitive functioning over 3 months, relative to stable cognitive functioning. A similar attenuated pattern of findings was observed for the GAD7.
A clear association exists between subjective cognitive functioning outcomes and changes in self-reported severity of affective symptoms in young people over the first 3 months of treatment. Understanding the timing and mechanisms of these associations is needed to tailor treatment.
The Holmboe wave instability is one of the classic examples of a stratified shear instability, usually explained as the result of a resonance between a gravity wave and a vorticity wave. Historically, it has been studied by linear stability analyses at infinite Reynolds number,
, and by direct numerical simulations at relatively low
in the regions known to be unstable from the inviscid linear stability results. In this paper, we perform linear stability analyses of the classical ‘Hazel model’ of a stratified shear layer (where the background velocity and density distributions are assumed to take the functional form of hyperbolic tangents with different characteristic vertical scales) over a range of different parameters at finite
, finding new unstable regions of parameter space. In particular, we find instability when the Richardson number is everywhere greater than
, where the flow would be stable at infinite
by the Miles–Howard theorem. We find unstable modes with no critical layer, and show that, despite the necessity of viscosity for the new instability, the growth rate relative to diffusion of the background profile is maximised at large
. We use these results to shed new light on the wave-resonance and over-reflection interpretations of stratified shear instability. We argue for a definition of Holmboe instability as being characterised by propagating vortices above or below the shear layer, as opposed to any reference to sharp density interfaces.
Electroconvulsive therapy (ECT) is recommended in treatment guidelines as an efficacious therapy for treatment-resistant depression. However, it has been associated with loss of autobiographical memory and short-term reduction in new learning.
To provide clinically useful guidelines to aid clinicians in informing patients regarding the cognitive side-effects of ECT and in monitoring these during a course of ECT, using complex data.
A Committee of clinical and academic experts from Australia and New Zealand met to the discuss the key issues pertaining to ECT and cognitive side-effects. Evidence regarding cognitive side-effects was reviewed, as was the limited evidence regarding how to monitor them. Both issues were supplemented by the clinical experience of the authors.
Meta-analyses suggest that new learning is impaired immediately following ECT but that group mean scores return at least to baseline by 14 days after ECT. Other cognitive functions are generally unaffected. However, the finding of a mean score that is not reduced from baseline cannot be taken to indicate that impairment, particularly of new learning, cannot occur in individuals, particularly those who are at greater risk. Therefore, monitoring is still important. Evidence suggests that ECT does cause deficits in autobiographical memory. The evidence for schedules of testing to monitor cognitive side-effects is currently limited. We therefore make practical recommendations based on clinical experience.
Despite modern ECT techniques, cognitive side-effects remain an important issue, although their nature and degree remains to be clarified fully. In these circumstances it is useful for clinicians to have guidance regarding what to tell patients and how to monitor these side-effects clinically.
Patients diagnosed with schizophrenia or bipolar disorder are at an elevated risk of suicide attempts and suicidal ideation. Although atypical antipsychotics are effective in treating psychotic symptoms, the risk of suicide attempts and suicidal ideation may differ across these agents. We conducted an analysis on reported rates of suicide-related events associated with the use of atypicals.
Proportional reporting rates (PRR) of suicide attempts from the World Health Organization (WHO) database (through June, 2006) were compared across atypical antipsychotics. Using additional information from FDA's AERS (Adverse Event Reporting System; through March, 2006), similar comparisons were made for suicidal ideation, suicide attempts, and completed suicides.
From the WHO database, the PRR for suicide attempts was lowest for clozapine (1.3) followed by aripiprazole (1.5), risperidone (3.3), quetiapine (4.2), ziprasidone (4.7), and olanzapine (5.2). For AERS, the respective PRRs for suicidal ideation, suicide attempts, and completed suicides were: 1.1, 3.3, and 1.9 for clozapine; 3.2, 4.3, and 2.7 for risperidone; 5.6, 2.9, and 5.4 for aripiprazole; 6.9, 4.4, and 6.4 for ziprasidone; 4.3, 4.5, and 7.2 for olanzapine; and 5.6, 4.2, and 9.3 for quetiapine.
AE reporting systems suffer limitations, which include having a problematic denominator and biased reporting. However, AE reporting is a primary tool used to identify a signal through pharmacovigilance. In the data analyzed, variability across atypical antipsychotics seemed evident, and inconsistencies between data were observed. The reasons for these findings are unclear, but these results warrant further investigation in controlled studies.
Effective communication is an essential part of patient-centered care. The complexity of cancer care in older adults makes communication challenging, particularly when older patients have cognitive deficits and lose their autonomy. This paper describes the development, implementation, and evaluation of a communication skills training module for health care providers (HCPs) who work with older adults with cancer, with or at risk of developing cognitive deficits.
Using a pre-post single arm study design, 99 HCPs from a comprehensive cancer center in North-East USA, who worked primarily with geriatric patients, participated in the study. Participants included Advance Practice Providers (including Nurse Practitioners and Physician Assistants; n = 24, 24.2%); nurses (n = 23, 23.2%), social workers (n = 14, 14.1%), physicians (n = 13, 13.1%), and “other” HCPs (including occupational therapists, physical therapists, and psychologists; n = 20, 20.2%). The HCPs participated in a one-day geriatric communication skills training program in groups of 12–15 over a 2-year period. Participants complete pre-post surveys on module evaluation and perception of self-efficacy as well as pre-post video-recorded Standardized Patient Assessment (SPA) to evaluate communication skill uptake.
Most participants evaluated the module positively; over 90% indicated that they agreed or strongly agreed with five of the six module evaluation items. HCPs’ self-efficacy in communicating with cancer patients with cognitive deficits significantly increased from pre- to post-module training. There was a significant increase in the following communication skill use from pre- to post-training: checking patient preferences, declaring agenda, and inviting agenda.
Significance of results
Results demonstrated a successful implementation of the program as evidenced through favorable program evaluation, significant gains in self-efficacy, as well as significant improvement in several communication skills.
Compulsory admission to psychiatric hospital in the United Kingdom (UK) is governed by the Mental Health Act (MHA). There have been concerns that the application of this legislation may be discriminatory, and that there is a trend towards increasing use of coercion.
Aims and objectives:
To evaluate data on MHA assessments in order to determine overall outcomes; and whether there is evidence for a difference in outcomes based on variables such as age, gender, or ethnic group.
A database including around 99% of all such assessments was compiled from information recorded routinely at the time of the assessments by senior social workers who lead the assessments. This was analysed using SPSS statistical software.
There were clear statistical correlations with a number of variables including marital status, living alone and age. There was a slight but significant bias towards using shorter detention periods of up to 28 days for women, rather than longer up to six-month periods. However, despite this there was no overall evidence of gender bias.
This is the largest such study in the published literature and provides clear evidence of outcomes and trends in the use of coercive powers under the Mental Health Act in Norfolk, United Kingdom.
Immune mechanisms have been implicated in the pathogenesis of schizophrenia. This has lead to clinical trials of re-purposing drugs with off-target anti-inflammatory actions. They include the antibiotic minocycline and simvastatin (HMP-Co reductase inhibitor), which decrease microglial activation, and ondansetron a 5-HT3-receptor antagonist that has limited effects on cytokine production. This presentation will address their efficacy and mechanism of action.
1) Update on trials with minocycline including our own positive finding on negative symptoms (PMID: 16959472)
2) Present new results with ondansetron and simvastatin summarised below.
Ondansetron (8mg) and simvastatin (40mg) vs placebos in 2x2 design (PMID: 23782463). Patients aged 18-65, stable treatment, DSM IV schizophrenia-related diagnosis. PANSS and cognition at 0,3,6 months.
The four cells of the 2x2 design contained 302 patients. The interaction between ondansetron and simvastatin was significant at p=.006 reflecting the lower scores in the 3 active treatment groups than in the P+P group. Ondansetron improved verbal (p=.007) and visual list learning (p=.02) with no other treatment effects on cognition.
Minocycline appears to benefit negative symptoms in early psychosis with a minor effect on cognition. Simvastatin had limited effects in our patients with established schizophrenia but its anti-inflammatory effects could be worth investigating in early psychosis. Ondansetron has a significant effect on new learning, which might be expected from its 5-HT3 antagonist properties. This may underlie a benefit on negative symptoms reported by others and us.
With one in ten young people being affected by ill mental health and stigma regularly cited as a factor affecting access to early intervention services, focussing resources on school based stigma reduction strategies seems prudent. ‘Headucate’, a student society, designed a 50 minute workshop which aims to increase mental health literacy and decrease stigma.
Repeated, cross sectional surveys were carried out at three time points; 1) immediately before (n=77), 2) Immediately after (n=81) and 3) three months post workshop (n=73). The surveys were paper based versions of the Reported Intended Behaviours Score (RIBS) and Mental Health Knowledge Scale (MAKS) utilising a social distance scale.
Four year 10 classed (pupils aged 14-15) were recruited. Post hoc t-tests were carried out when one-way ANOVAS were significant.
Disorder knowledge (from MAKS) and intended contact (from RIBS) significantly increased between time points one and two (p<0.01 and <0.004 respectively) but then decreased.
Analysis of the question pertaining to knowing where to access help showed a statistically significant increase (p<0.001) between time points one and two and then a decrease at time three, albeit to a higher value than at time point one (3.45 compared to 3.13, P=0.088).
Headucate workshops offer a low resource option which is well accepted by students. Like other school based stigma reduction strategies, a dramatic increase was seen between immediately before and after indicating that the workshop resonates with the pupils, but there was little sustained change in attitudes.
Against a backdrop of poor mental health education in UK schools a group of students from Norwich Medical School have formed a student society called ‘Headucate’ in order to create, deliver and evaluate an educational intervention for adolescents, initially to be delivered in Norfolk schools.
To create an educational intervention that:
Is the length of a standard lesson
Is age appropriate and acceptable
Contains appropriate signposting
Contains content that challenges common myths and replaces them with knowledge
Contains content that encourages empathy and understanding towards those with mental illnesses
Is easily delivered in the same way each time so that its effectiveness can be evaluated
To create an intervention effective at tackling stigma and empowering adolescents to recognise signs of poor mental health and access services appropriately.
Lesson plan created after consultation with psychiatrists, a psychologist, a GP, a university outreach professional, a teacher and secondary school age children, then trialled and revised.
Interactive workshop produced with 5 sections.
1) Myth vs Fact activity that dispels prevalent myths
2) Scenario based activity to demonstrate that mental health is a spectrum
3) An interactive presentation covering the most common mental illnesses and their symptoms
4) An activity focusing on talking to those with mental illnesses, furthering the scenario from the previous activity
5) A question and answer session. Every student leaves with a leaflet containing appropriate signposting.
We have created an educational intervention ready to be delivered and evaluated.
Mental health education is not compulsory in the UK therefore adolescents have very varied experiences despite half of people with mental health illnesses reporting having experienced symptoms by 14 years old. University students are ideal for delivering a relaxed, educational intervention aimed at this age group, providing an opportunity to for them to learn necessary tools for recognising signs of poor mental health and tackle associated stigma.
To expand Headucate's membership, including other disciplines within the University of East Anglia (UEA) and provide core training enabling members to deliver a school-based educational intervention
Recruitment of members has been a multifaceted approach utilising social media sites such as Facebook and the Headucate website, and oncampus events and ‘awareness campaigns’ including several successful evening talks and lectures.
Three training sessions, which include ‘Introduction to Mental Health’, ‘Workshop run-through’ and ‘Child Protection’, have been developed for all members wishing to partake in the delivery of workshops.
We have recruited approximately 300 members since summer 2012; 70 fully paid members in 2012/13 academic year and currently 45 paid members for 2013/14.
A total of 18 members are fully trained and ready to deliver workshops within schools and 17 other members have just one training session remaining.
We are looking forward to delivering our first workshops in October and building on a successful first year. We are confident we can provide workshops for approximately 600 children per year.
Antidepressants are amongst the most commonly prescribed classes of drugs and their use continues to grow. Adverse outcomes are part of the landscape in prescribing medications and therefore management of safety issues need to be an integral part of practice.
We have developed consensus guidelines for safety monitoring with antidepressant treatments.
To present an overview of screening and safety considerations for pharmacotherapy of clinical depressive disorders and make recommendations for safety monitoring.
Data were sourced by a literature search using Medline and a manual search of scientific journals to identify relevant articles. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content.
A guidelines document was produced after approval by all 19 co-authors. The final document gives guidance on; the decision to treat, baseline screening prior to commencement of treatment, and ongoing monitoring during antidepressant treatment. The guidelines state or reference screening protocols that may detect medical causes of depression as well as screening and monitoring protocols to investigate specific adverse effects associated with antidepressant treatments that may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment.
The implementation of safety monitoring guidelines for treatment of clinical depression may significantly improve outcome, by improving a patient's overall physical health status.
The symptoms of many mental illnesses often begin during high school. Interventions to improve mental health awareness amongst adolescents may lead to improved outcomes. in the UK unfortunately many schools do not fulfil this need and mental health education is not a compulsory part of the curriculum.
To develop and measure the effectiveness of and educational intervention designed to raise awareness and empower adolescents to recognise signs of poor mental health and access services appropriately.
Evaluate the effectiveness of the intervention through baseline and follow up surveys.
Students at Norwich Medical School collaborated with teachers, psychiatrists and general practitioners to design an educational intervention that aims to tackle stigma and raise awareness of mental health conditions among 13-14 year olds in the hope that they can access services when needed, support those around them and look after their mental health. To evaluate effectiveness of the intervention, a knowledge, attitudes and practices survey that utilises a social distance scale that has been adapted for this age group and will be used to gather baseline and follow up data after six months.
We have developed a one-hour educational intervention delivered by medical students, that uses a variety of teaching techniques to raise awareness of mental health issues. We will start implementation in January 2013 so will have baseline effectiveness results shortly after.
Headucate has the potential to fill an important gap in effectively raising awareness of mental health issues in schools.
The genus Pogonophryne is the most species-rich genus of barbeled plunderfishes (Artedidraconidae) and includes more than 25 poorly known species endemic to the Southern Ocean. In this study, we provide new data on the age and reproductive traits of some species of Pogonophryne from the southern Weddell Sea, inferred through otolith reading and histological analyses of gonads. Individual age estimates ranged between 16 and 18 years for Pogonophryne barsukovi and Pogonophryne immaculata and between 10 and 22 years for Pogonophryne scotti. As is commonly found in notothenioids, P. barsukovi followed a group-synchronous type of ovarian development, with pre-vitellogenic and vitellogenic oocytes forming two well-separated egg-size groups. A single spawning female in the sample produced ~1097 eggs and 7.9 eggs g-1. The sample of P. immaculata consisted exclusively of developing males, with testes composed of cysts of spermatogonia, spermatocytes and spermatids. Pogonophryne scotti was the most abundant species, including relatively small males at immature or developing stages of gonad development. Larger females were regressing, being characterized by ovaries with postovulatory follicles and atretic oocytes. Based on the macroscopic and histological analyses of gonads, the spawning season would take place in autumn for P. barsukovi and P. immaculata and in spring–early summer for P. scotti.
National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.
To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.
Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.
A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (−6.3, 95% CI −12.0 to −0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.
SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.
Operational definitions of mania are based on expert consensus rather than empirical data. The aim of this study is to identify the key domains of mania, as well as the relevance of the different signs and symptoms of this clinical construct.
A review of latent factor models studies in manic patients was performed. Before extraction, a harmonization of signs and symptoms of mania and depression was performed in order to reduce the variability between individual studies.
We identified 12 studies fulfilling the inclusion criteria and comprising 3039 subjects. Hyperactivity was the clinical item that most likely appeared in the first factor, usually covariating with other core features of mania, such as increased speech, thought disorder, and elevated mood. Depressive–anxious features and irritability–aggressive behavior constituted two other salient dimensions of mania. Altered sleep was frequently an isolated factor, while psychosis appeared related to grandiosity, lack of insight and poor judgment.
Our results confirm the multidimensional nature of mania. Hyperactivity, increased speech, and thought disorder appear as core features of the clinical construct. The mood experience could be heterogeneous, depending on the co-occurrence of euphoric (elevated mood) and dysphoric (irritability and depressive mood) emotions of varying intensity. Results are also discussed regarding their relationship with other constitutive elements of bipolar disorder, such as mixed and depressive states.
Despite calls for better support to empower people when reassessing their housing in later life, two recent literature reviews highlight a paucity of research on the efficacy of such services. This article reports a qualitative realist evaluation on the efficacy of a UK telephone service providing information on specialist housing to older people. The findings of thirty-one realist interviews with sixteen older people are presented. Information-seekers’ existing tenure (social tenant or private owner-occupier/renter) shaped their experience and utilisation of support. Broadly, however, information was considered too ‘light touch’ to empower older people. However, the widely recognised lack of accessible housing options and reports of non-transparent and unresponsive market practices were also key factors. This study underlines the widely acknowledged need to increase the supply of specialist housing, and recommends that housing options support be reflective of market conditions and be more substantive – including discussion, deliberation, education and advocacy.
We present simultaneous two-dimensional measurements of the velocity and buoyancy fields on a central vertical plane in two-dimensional line plumes: a free plume distant from vertical boundaries and a wall plume, adjacent to a vertical wall. Data are presented in both an Eulerian and a plume coordinate system that follow the instantaneous turbulent/non-turbulent interface (TNTI) of the plume. We present measurements in both coordinate systems and compare the entrainment in the two flows. We find that the value of the entrainment coefficient in the wall plume is greater than half that of the free plume. The reduction in entrainment is investigated by considering a decomposition of the entrainment coefficient based on the mean kinetic energy where the relative contributions of turbulent production, buoyancy and viscous terms are calculated. The reduced entrainment is also investigated by considering the statistics of the TNTI and the conditional vertical transport of the ambient and engulfed fluid. We show that the wall shear stress is non-negligible and that the free plume exhibits significant meandering. The effect of the meandering on the entrainment process is quantified in terms of the stretching of the TNTI where it is shown that the length of the TNTI is greater in the free plume and, further, the relative vertical transport of the engulfed ambient fluid is observed to be 15 % greater in the free plume. Finally, the turbulent velocity and buoyancy fluctuations, Reynolds stresses and the turbulent buoyancy fluxes are presented in both coordinate systems.
We study the dynamical system of a two-dimensional, forced, stratified mixing layer at finite Reynolds number
, and Prandtl number
. We consider a hyperbolic tangent background velocity profile in the two cases of hyperbolic tangent and uniform background buoyancy stratifications, in a domain of fixed, finite width and height. The system is forced in such a way that these background profiles are a steady solution of the governing equations. As is well known, if the minimum gradient Richardson number of the flow,
, is less than a certain critical value
, the flow is linearly unstable to Kelvin–Helmholtz instability in both cases. Using Newton–Krylov iteration, we find steady, two-dimensional, finite-amplitude elliptical vortex structures – i.e. ‘Kelvin–Helmholtz billows’ – existing above
. Bifurcation diagrams are produced using branch continuation, and we explore how these diagrams change with varying
. In particular, when
is sufficiently high we find that finite-amplitude Kelvin–Helmholtz billows exist when
for the background flow, which is linearly stable by the Miles–Howard theorem. For the uniform background stratification, we give a simple explanation of the dynamical system, showing the dynamics can be understood on a two-dimensional manifold embedded in state space, and demonstrate the cases in which the system is bistable. In the case of a hyperbolic tangent stratification, we also describe a new, slow-growing, linear instability of the background profiles at finite
, which complicates the dynamics.