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Antibiotics are frequently prescribed inappropriately for acute respiratory infections in the outpatient setting. We report the implementation of a multifaceted outpatient antimicrobial stewardship initiative resulting in a 12.3% absolute reduction of antibiotic prescribing for acute bronchitis in primary care clinics receiving active interventions.
Major depressive disorder (MDD) is characterised by a recurrent course and high comorbidity rates. A lifespan perspective may therefore provide important information regarding health outcomes. The aim of the present study is to examine mental disorders that preceded 12-month MDD diagnosis and the impact of these disorders on depression outcomes.
Data came from 29 cross-sectional community epidemiological surveys of adults in 27 countries (n = 80 190). The Composite International Diagnostic Interview (CIDI) was used to assess 12-month MDD and lifetime DSM-IV disorders with onset prior to the respondent's age at interview. Disorders were grouped into depressive distress disorders, non-depressive
distress disorders, fear disorders and externalising disorders. Depression outcomes included 12-month suicidality, days out of role and impairment in role functioning.
Among respondents with 12-month MDD, 94.9% (s.e. = 0.4) had at least one prior disorder (including previous MDD), and 64.6% (s.e. = 0.9) had at least one prior, non-MDD disorder. Previous non-depressive distress, fear and externalising disorders, but not depressive distress disorders, predicted higher impairment (OR = 1.4–1.6) and suicidality (OR = 1.5–2.5), after adjustment for sociodemographic variables. Further adjustment for MDD characteristics weakened, but did not eliminate, these associations. Associations were largely driven by current comorbidities, but both remitted and current externalising disorders predicted suicidality among respondents with 12-month MDD.
These results illustrate the importance of careful psychiatric history taking regarding current anxiety disorders and lifetime externalising disorders in individuals with MDD.
Depressive and anxiety disorders are highly comorbid, which has been theorized to be due to an underlying internalizing vulnerability. We aimed to identify groups of participants with differing vulnerabilities by examining the course of internalizing psychopathology up to age 45.
We used data from 24158 participants (aged 45+) in 23 population-based cross-sectional World Mental Health Surveys. Internalizing disorders were assessed with the Composite International Diagnostic Interview (CIDI). We applied latent class growth analysis (LCGA) and investigated the characteristics of identified classes using logistic or linear regression.
The best-fitting LCGA solution identified eight classes: a healthy class (81.9%), three childhood-onset classes with mild (3.7%), moderate (2.0%), or severe (1.1%) internalizing comorbidity, two puberty-onset classes with mild (4.0%) or moderate (1.4%) comorbidity, and two adult-onset classes with mild comorbidity (2.7% and 3.2%). The childhood-onset severe class had particularly unfavorable sociodemographic outcomes compared to the healthy class, with increased risks of being never or previously married (OR = 2.2 and 2.0, p < 0.001), not being employed (OR = 3.5, p < 0.001), and having a low/low-average income (OR = 2.2, p < 0.001). Moderate or severe (v. mild) comorbidity was associated with 12-month internalizing disorders (OR = 1.9 and 4.8, p < 0.001), disability (B = 1.1–2.3, p < 0.001), and suicidal ideation (OR = 4.2, p < 0.001 for severe comorbidity only). Adult (v. childhood) onset was associated with lower rates of 12-month internalizing disorders (OR = 0.2, p < 0.001).
We identified eight transdiagnostic trajectories of internalizing psychopathology. Unfavorable outcomes were concentrated in the 1% of participants with childhood onset and severe comorbidity. Early identification of this group may offer opportunities for preventive interventions.
Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.
Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.
MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.
Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.
Background: Allogeneic bone marrow transplant (BMT) as well as liver, heart, and lung transplant patients have high reported incidence rates of Clostridioides difficile infection (CDI). The prevalence and incidence of asymptomatic colonization with Clostridioides difficile (ACCD) in this group is not known. Methods: ACCD was defined as the presence of C. difficile on screening cultures without positive clinical testing for CDI ±1 week from the date of sampling. Patients undergoing BMT as well as liver, heart, and lung transplants at MUSC between October 2017 and October 2019 were cultured for C. difficile at admission for transplant then once weekly during inpatient admissions and at each outpatient follow-up for 90 days after transplantation. Testing for CDI occurred at the discretion of treating physicians and was done by PCR. Transient ACCD was defined as a positive culture from samples collected <7 days apart, and persistent ACCD was defined as having 2 or more positive cultures collected a minimum of 7 days apart. Results: The baseline prevalences of ACCD were 1 of 5 (20%), 0 of 2 (0%), 1 of 40 (3%), and 2 of 16(13%) for lung, heart, liver and BMT patients, respectively. Of 63 patients, 3 had a pretransplant history of CDI, 2 of whom had baseline ACCD. Incident ACCD occurred in 23 of 63 patients (37%) (Table 1). Overall, ACCD was observed in 30 of 63 patients (48%). Of the 30 patients with ACCD, 14 displayed persistent asymptomatic colonization, whereas 16 displayed transient asymptomatic colonization. Also, 5 patients in the cohort were diagnosed with CDI after transplantation, of whom 3 had ACCD prior to or following CDI. Conclusions: The baseline prevalence of C. difficile colonization in transplant patients (6.3%) was not substantially greater than those observed in recent studies of hospitalized inpatients, but the incidence of new colonization events (37%) was high in this patient population with numerous pretransplant risk factors for CDI.
Cross-national studies have found, unexpectedly, that mental disorder prevalence is higher in high-income relative to low-income countries, but few rigorous studies have been conducted in very low-income countries. This study assessed mental disorders in Nepal, employing unique methodological features designed to maximize disorder detection and reporting.
In 2016–2018, 10714 respondents aged 15–59 were interviewed as part of an ongoing panel study, with a response rate of 93%. The World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI 3.0) measured lifetime and 12-month prevalence of selected anxiety, mood, alcohol use, and impulse control disorders. Lifetime recall was enhanced using a life history calendar.
Lifetime prevalence ranged from 0.3% (95% CI 0.2–0.4) for bipolar disorder to 15.1% (95% CI 14.4–15.7) for major depressive disorder. The 12-month prevalences were low, ranging from 0.2% for panic disorder (95% CI 0.1–0.3) and bipolar disorder (95% CI 0.1–0.2) to 2.7% for depression (95% CI 2.4–3.0). Lifetime disorders were higher among those with less education and in the low-caste ethnic group. Gender differences were pronounced.
Although cultural effects on reporting cannot be ruled out, these low 12-month prevalences are consistent with reduced prevalence of mental disorders in other low-income countries. Identification of sociocultural factors that mediate the lower prevalence of mental disorders in low-income, non-Westernized settings may have implications for understanding disorder etiology and for clinical or policy interventions aimed at facilitating resilience.
Neurocognitive impairments robustly predict functional outcome. However, heterogeneity in neurocognition is common within diagnostic groups, and data-driven analyses reveal homogeneous neurocognitive subgroups cutting across diagnostic boundaries.
To determine whether data-driven neurocognitive subgroups of young people with emerging mental disorders are associated with 3-year functional course.
Model-based cluster analysis was applied to neurocognitive test scores across nine domains from 629 young people accessing mental health clinics. Cluster groups were compared on demographic, clinical and substance-use measures. Mixed-effects models explored associations between cluster-group membership and socio-occupational functioning (using the Social and Occupational Functioning Assessment Scale) over 3 years, adjusted for gender, premorbid IQ, level of education, depressive, positive, negative and manic symptoms, and diagnosis of a primary psychotic disorder.
Cluster analysis of neurocognitive test scores derived three subgroups described as ‘normal range’ (n = 243, 38.6%), ‘intermediate impairment’ (n = 252, 40.1%), and ‘global impairment’ (n = 134, 21.3%). The major mental disorder categories (depressive, anxiety, bipolar, psychotic and other) were represented in each neurocognitive subgroup. The global impairment subgroup had lower functioning for 3 years of follow-up; however, neither the global impairment (B = 0.26, 95% CI −0.67 to 1.20; P = 0.581) or intermediate impairment (B = 0.46, 95% CI −0.26 to 1.19; P = 0.211) subgroups differed from the normal range subgroup in their rate of change in functioning over time.
Neurocognitive impairment may follow a continuum of severity across the major syndrome-based mental disorders, with data-driven neurocognitive subgroups predictive of functional course. Of note, the global impairment subgroup had longstanding functional impairment despite continuing engagement with clinical services.
Chapter 3 provides an overview of two influential pragmatic approaches to reference: Accessibility theory and the Givenness Hierarchy. Both accounts have been claimed to be compatible with relevance theory. However, it has also been claimed relevance theory alone cannot account for the full range of data and that these auxiliary scales of activation are necessary additions. In this chapter these claims are examined, and some objections are raised. The more general objections relate to the nature of the relevance-theoretic approach to utterance interpretation and how scales of encoded activation might fit with this. More specific objections relate to how the activation scale accounts deal with stylistic or so-called special uses of referring expressions. Finally, some examples of proper names in English are briefly discussed to illustrate how highly context sensitive the choices made by speakers can be, and to demonstrate the crucial role played by considerations of style and genre.
Chapter 5 presents a fully procedural analysis of personal pronouns in English. Pronouns, it is argued encode procedures which operate at a sub-personal level. Features including gender, number and person features function purely syntactically and do not contribute directly to the semantics of the overall message. That is, they are not conceptual. Rather, the cognitive processes triggered by use of a pronoun function to constrain potential referents to a sub-personally identifiable set. The differences in interpretation that arise when a speaker chooses to place contrastive prosodic stress on a pronoun are discussed, along with examples where the choice of pronoun does not play a role in reference resolution but contributes to other aspects of the speaker’s overall meaning. The discussion focuses specifically on the communication of expressive effects and has significance not just for our understanding of pronouns, but for our understanding of procedural meaning more generally.
Chapter 4 outlines a procedural relevance-based analysis of the definite determiner the. The definite article, it is argued, signals to the hearer that he should seek out an existing conceptual file on which to resolve reference. The indefinite article, on the other hand, instructs the hearer to open a new conceptual file. As interpretation proceeds, the hearer seeks to align the conceptual content within the nominal of the definite description with that in the target conceptual file. This approach to the contribution that definite descriptions make to speaker meaning is then applied to cases of misdescription and, it is claimed, it also offers fresh perspective on the referential–attributive distinction. Finally, stylistic effects which may arise from the choice and content of definite descriptions are discussed.
Chapter 2 provides an overview of the main ideas and principles of relevance theory. The cognitive and communicative principles of relevance are introduced, along with the notion of procedural meaning. The roles that these principles and concepts play in utterance interpretation are discussed. Attention then turns to reference with an overview of Wilson’s (1992) relevance-based account. The importance of the role of accessibility of context and referents in understanding the process of reference resolution is highlighted. Focus then turns to the cognitive process of referring itself. The act of resolving reference is presented as the process of mapping argument slots in the logical form of an utterance onto conceptual files. Referring expressions are a means by which a speaker can guide a hearer in this process. That is, they are procedural in nature. As with other interpretive processes, reference resolution is driven by the presumption of optimal relevance. The processes of mapping an argument slot onto a conceptual file and enriching that conceptual file are driven from the bottom-up by the semantics of the verb and constrained from the top-down by considerations of relevance.
The final chapter brings together the themes from across the volume and revisits the research questions which have driven the discussion. The main conclusions are briefly summarized and some suggestions are made for possible implications of the work and for future directions.
Chapter 1 introduces the key aims and objectives for the volume in terms of three main research questions. What motivates a speaker to use one expression rather than another in a particular discourse context? How do the components of a referring expression contribute to communication of the speaker’s meaning? In other words, what do referring expressions encode, and how does this interact with the context? What, beyond reference resolution, do referring expressions contribute to the overall speaker’s meaning, and how? The chapter then provides a brief overview of the main concerns of philosophical and stylistic approaches to reference, making links with the pragmatic approach adopted in this volume. Finally, an overview of the rest of the book is provided.
Chapter 6 applies the relevance-based account of referring expressions to the phenomenon of null subjects in non-pro-drop languages. So-called diary-style nulls, it is argued, are ultimately driven by the interaction of effects and effort and therefore by the speaker’s aim of achieving optimal relevance. Three broad categories of null subject use in English are identified: an informal null subject where the omission leads to extra cognitive effects, a pressurized null subject where the speaker’s abilities are the crucial factor, and finally, an ostensively vague null subject, which is driven by the speaker’s preferences. These three categories are not presented as an exhaustive taxonomy of English null subjects, or as theoretically distinct. Rather they emerge as a result of a speaker aiming at optimal relevance in different discourse contexts, and they represent occasions where different elements in the overall equation of optimal relevance drive lexical omissions.