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Patients who can be treated in Primary care should receive their treatment in Primary Care.
We aim to identify depression treatments used by Bedford East Community Psychiatric Team (BECMHT) and hence identify those patients who could be appropriately managed in Primary care.
We identified 299 patients from the BECMHT database with depression (F32,F33, F41.2 and uncoded). Potential patient groups to discharge were identified by analysing these patients’ data; their medications were compared to NICE guidelines and other evidence-based-treatments.
Many patients were on different combinations of medications but there were 153 (51.2%) on one antidepressant only. Half of the patients’ medication was in accordance with NICE guidelines (157/52.5%), 11 patients were on medication with a different evidence-base and 101 patients were on medication without either of these. However, 36.5% of patients had an inter-current psychiatric diagnosis.
Prescribing patterns within BECMHT demonstrate groups of patients who are more likely to need Secondary care, including those with inter-current psychiatric diagnosis and patients on medications that are not backed by NICE or a known evidence-base. Provided adequate symptom control, the patients who could be discharged include those on one antidepressant and patients on medications in conformity with NICE guidelines who do not need monitoring in secondary care. The patient's notes should be reviewed before discharge to ensure adequate future treatment. There should be good communication with Primary care, with joint protocols and the possibility for patients to easily access services appropriate to their needs.
Depression treatment outcomes within British Community Mental Health Teams have not been adequately described.
To describe factors which influence outcome of depression within Bedford East CMHT.
Patients with Depression F32, Recurrent Depression F33, and Depression and Anxiety F42.1 were identified from a database. Factors affecting outcomes, including Suicidal ideation, Alcohol problems, Drug problems, and use of Augmentation therapy, were identified. Outcome as measured by patient discharge was compared in the three groups.
The percentage of each group discharged was 12.24 for F32, 30.53 for F33, and 29.17 for F42.1.
For F32 patients, the percentage of patients with suicidal ideation was 55.10, with alcohol problems was 32.65, with illicit drug problems was 14.28, while the percentage of patients on augmentation strategies was 38.77.
For F33 patients, the percentage of patients with suicidal ideation was 27.37, with alcohol problems was 9.47, with illicit drug problems was 1.05, while the percentage of patients on augmentation strategies was 27.37.
For F42.1 patients, the percentage of patients with suicidal ideation was 25, with alcohol problems was 8.33, with illicit drug problems was 8.33, while the percentage of patients on augmentation strategies was 54.17.
Fewer discharges occurred from the F32 group, mirroring increased suicidality and drug and alcohol use in this group. There is no significant difference in the number of patients using augmentation strategies between the F32 and F33 groups. It does not appear that augmentation strategies for treating depression are having a clear influence on outcomes.
Whilst it is important that we treat patients with depression in primary care if possible there are many patients with depression who will need the more expert support provided in secondary care.
Aims and methods
An Anonymised Database held by the Bedford East Community Mental Health Team was studied to assess what factors were related to the use of Augmentation Strategies to treat resistant depression.
Of the total 282 patients 109 (38.7%) were on augmentation therapy. In the F32 and F33 group just over a third of the patients (35.8% and 37.1%) were on augmentation therapy and in the F41.2 group over a half of patients (56.7%) were on augmentation therapy.
There does seem to be a relationship between the number of risk factors a patient has and the likelihood that they are on augmentation. Particularly strong factors are another psychiatric diagnosis and ‘other suicide risk factors’.
Generally the patients coming to secondary care with more of the specified risk factors are more likely to need augmentation.
Catechol-O-methyltransferase (COMT) has a central role in brain dopamine, noradrenalin and adrenalin signaling, and has been suggested to be involved in the pathogenesis and pharmacological treatment of affective disorders. The functional single nucleotide polymorphism (SNP) in exon 4 (Val158Met, rs4680) influences the COMT enzyme activity. The Val158Met polymorphism is a commonly studied variant in psychiatric genetics, and initial studies in schizophrenia and bipolar disorder presented evidence for association with the Met allele. In unipolar depression, while some of the investigations point at an association between the Met/Met genotype and others have found a link between the Val/Val genotype and depression, most of the studies cannot detect any difference in Val158Met allele frequency between depressed individuals and controls.
In the present study, we further elucidated the impact of COMT polymorphisms including the Val158Met in MDD. We investigated 1,250 subjects with DSM-IV and/or ICD-10 diagnosis of major depression (MDD), and 1,589 control subjects from UK. A total of 24 SNPs spanning the COMT gene were successfully genotyped using the Illumina HumaHap610-Quad Beadchip (22 SNPs), SNPlex™ genotyping system (1 SNP), and Sequenom MassARRAY® iPLEX Gold (1 SNP). Statistical analyses were implemented using PASW Statistics18, FINETTI (http://ihg.gsf.de/cgi-bin/hw/hwa1.pl), UNPHASED version 3.0.10 program and Haploview 4.0 program.
Neither single-marker nor haplotypic association was found with the functional Val158Met polymorphism or with any of the other SNPs genotyped. Our findings do not provide evidence that COMT plays a role in MDD or that this gene explains part of the genetic overlap with bipolar disorder.
In recent years there has been a move towards treating depressed patients in the community.One factor that may reduce the likelihood of discharge from secondary care is suicidality. The aim of this audit was to identify factors associated with continued suicidality among Community patients.
Subjects and methods
We searched an anonymised database of patients and identified all those with previously documented suicidal thoughts or attempts. We also noted the presence of factors such as alcohol problems, drug problems, augmentation therapy and ‘other risk’ factors (e.g. financial problems or homelessness). We assessed the latest clinic letter, to see if patients were still reporting suicidality. We compared the aforementioned factors between the group of patients in which suicidality was still present (group N) and the group of patients in which suicidality was no longer a feature (group Y).
Of the 56 patients with suicidal thoughts or attempts there were 44 in group N (79%) and 12 in group Y (21%). Alcohol problems, drug problems and ‘other’ risk factors were more common among group Y than group N. Conversely, the percentage of patients on augmentation therapy was greater in group N than group Y.
The audit provides an insight into the factors that might influence outcomes among depressed patients.
Although the results are suggestive, it is difficult to make firm conclusions about patient outcomes on the present data. The audit provides a useful starting point, especially in considering the treatment of patients within the CMHT.
Strategies for the treatment of refractory depression include “switching” and “augmentation”. in recent years, there has been particular interest in the use of augmentation.
The purpose of this audit was to define patient factors among people receiving augmentation therapy with either mirtazepine or atypical antipsychotics.
Subjects and methods:
We searched an anonymised database of patients and identified those receiving augmentation with mirtazepine (group A), atypical antipsychotics (group B) or both (group C). for each of the three groups we recorded the following factors: (1) age, (2) sex, (3) suicidal ideation, (4) alcohol problems, (5) drug problems, (6) domestic problems (e.g. debts, child abuse & domestic violence) (7) psychotic symptoms and (8) co-existing physical diagnoses.
Group B spanned a wider range of ages than either of the other two groups. Group A contained the highest proportion of patients with suicidal ideation than either. Alcohol problems were most common in group A, drug problems most common in group B and domestic problems most common in group C. Perhaps unsurprisingly psychotic symptoms were present in a relatively high percentage of patients in group B. there was little difference in physical co-morbidities between the three groups.
The audit reveals some interesting differences in patient factors between the three groups. Knowledge about such differences is useful in practical terms because it allows doctors in the BCMHT to target therapy for different patients towards their specific needs.
Potential augmentation regimes include the addition of atypical antipsychotics or other antidepressants (e.g. mirtazepine). there is growing evidence in the literature to support the efficacy of both the aforementioned augmentation strategies.
The purpose of this audit was to compare patient outcomes between groups receiving different augmentation strategies.
Subjects and methods:
We searched an anonymised database of patients and identified those receiving augmentation with mirtazepine (group A), atypical antipsychotics (group B) or both (group C). for each patient we noted
(1) The discharge status and
(2) The presence of suicidal ideation.
We then looked at clinical notes to find out whether or not patients were still reporting suicidality.
The proportion of patients who had been discharged was highest in group A. the percentage of patients still reporting suicidal thoughts was higher in group B than in groups A or C.
Augmentation with mirtazepine resulted in better outcomes in terms of both discharge rates and in terms of reduction in suicidality than augmentation with atypical antipsychotics. One explanation for this is that mirtazepine augmentation is a more effective method of treatment in patients with refractory depression. However, it is also possible that differences in patient factors (e.g. age and drug problems) between the different treatment groups could contribute to variability in outcomes. A previous audit (Holt et al, 2011) has already confirmed that such differences do exist among the patients being analysed in this audit.
Just how violent was medieval Europe? Traditionally, historians have depicted the Middle Ages as an era of brute strength and underdeveloped empathy, leading to high rates of violence. Yet, the evidence to support this interpretation is highly flawed. While we cannot measure medieval rates of violence with enough accuracy to draw medieval-modern comparisons, we do know that medieval Europeans deemed some forms of violence as not only necessary, but laudable. God’s wrath was the archetype of principled violence wielded by a righteous authority. Spectacles of justice in the form of staged executions, shaming rituals, or torture procedures, when enacted by the church or the state, fell neatly in line with this view of violence as a purgative, removing sin from society before it infected others. This ideology was imposed also on the family, where communities urged patriarchs to govern their dependents with a firm hand. Nevertheless, violence also had its limits. As king in his own home, a patriarch’s conduct might still cross the line between chastisement and cruelty. The law generally sided with figures of authority, but in practice the courts protected both ends of the social and familial hierarchy from abuse.
Acute respiratory tract infections (ARIs) are commonly diagnosed and major drivers of antibiotic prescribing. Clinician-focused interventions can reduce unnecessary antibiotic prescribing for ARIs. We elicited clinician feedback to design sustainable interventions to improve ARI management by understanding the mental framework of clinicians surrounding antibiotic prescribing within Veterans’ Health Administration clinics.
We conducted one-on-one interviews with clinicians (n = 20) from clinics targeted for intervention at 5 facilities. The theory of planned behavior guided interview questions. Interviews were audio recorded and transcribed for qualitative analysis. An iterative coding approach identified 6 themes.
Emergent themes: (1) barriers to appropriate prescribing are multifactorial and include challenges of behavior change; (2) antibiotic prescribing decisions are perceived as autonomous yet, diagnostic uncertainty and perceptions of patient demand can make prescribing decisions difficult; (3) clinicians perceive variation in peer prescribing practices and influences; (4) clinician-focused interventions are valuable if delivered with sensitivity; (5) communication strategies for educating patients are preferred to a shared decisions process; and (6) team standardization of practice and communication are key to facilitate appropriate prescribing. Clinicians perceived audit-and-feedback with peer comparison, academic detailing, and enhanced patient communication strategies as viable approaches to improving appropriate prescribing.
Implementation strategies that enable clinicians to overcome diagnostic uncertainty, perceived patient demand, and improve patient education are desired. Implementation strategies were welcomed, and some were more readily accepted (eg, audit feedback) than others (eg, shared decision making). Implementation strategies should address clinicians’ perceptions of antibiotic prescribing practices and should enhance their patient communication skills.
Chapter 4 explores which voters – general election voters, primary voters, or campaign donors – legislators fear will punish them for compromise. In-person surveys of state legislators confirm that legislators mostly fear punishment from primary voters. Legislators believe that primary voters would prefer that legislators vote to kill compromise bills, worry that these primary voters would punish them if they supported such legislation, and act in response to this concern. Beyond the patterns in surveys of state legislators, congressional roll call votes from 2011 to 2015 show that greater Tea Party support in a district predicted an increased likelihood that Republican House members voted against compromise bills. Together, these results highlight how legislators’ concerns about how primary voters respond to compromise can dissuade legislators from compromising.
Chapter 5 tests whether legislators are accurate in their belief that primary voters are likely to punish them for compromising. Results from a survey experiment suggest that most voters, even most primary voters, reward legislators for making compromises. However, co-partisan primary voters who oppose compromise on a specific issue are willing to punish legislators who vote for the compromise. Although legislators may benefit electorally from supporting compromise, especially in the general election, they have reason to be cautious on compromise bills to avoid voter backlash from subsets of the politically active primary electorate. Just because the subset of voters who punish legislators for compromising is small does not mean it cannot be consequential – a small subset can mobilize a strong challenger, paint a legislators’ behavior as problematic in the eyes of less informed voters, or vote on the basis of a single important vote. Moreover, across many compromise votes a legislator may face, the small groups of voters who oppose each compromise might, when added together, represent a decisive portion of the primary electorate.
Why do legislators sometimes reject compromises that seem within reach and are closer to their preferred policy? Chapter 3 tests various explanations for legislators’ rejection of compromise and presents evidence that the belief that voters are very likely to punish state legislators for compromising reduces legislators’ likelihood of voting for a given compromise proposal by 21 percent. We find a similar effect among local elected officials. This demonstrates the importance of legislators’ views of their constituents and the role that fear of voter punishment plays in the rejection of compromises.
Chapter 7 discusses how to balance representation and accountability with processes that might better insulate legislators from their electoral fear as they seek to negotiate compromises. Ensuring that the public is knowledgeable about elected officials’ decisions is an important facet of democratic accountability. Yet the watchful eye of primary voters may also deter legislators from considering reasonable compromises. Chapter 7 discusses how to balance these two considerations and discusses whether communication with constituents can facilitate compromise. Our findings, as well as the comments from state legislators at the 2017 NCSL Summit, emphasize the importance of communication between legislators and their constituents – explaining the legislative process, justifying choices, and developing a home style that cultivates trust. With greater communication and building of trust, legislators may have leeway to insulate portions of the legislative process from public scrutiny, helping them reach compromises and overcome gridlock to solve pressing problems.