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NeuroStar transcranial magnetic stimulation (TMS) is an effective acute treatment for patients with major depressive disorder (MDD). In order to further understand use of the NeuroStar in a clinical setting, Neuronetics has established a patient treatment and outcomes registry to collect and analyze utilization information on patients receiving treatment with the NeuroStar.
Individual NeuroStar providers are invited to participate in the registry and agree to provide their de-identified patient treatment data. The NeuroStar has an integrated electronic data management system (TrakStar) which allows for the data collection to be automated. The data collected for the registry include Demographic Elements (age, gender), Treatment Parameters, and Clinical Ratings. Clinical assessments are: Clinician Global Impression - Severity of Illness (CGI-S) and thePatient Health Questionnaire 9-item (PHQ-9). De-identified patient data is uploaded to Registry server; an independent statistical service then creates final data reports.
Over 500 patients have entered the NeuroStar Outcomes Registry since Sept 2016. Mean patient age: 48.0 (SD±16.0); 64% Female. Baseline PHQ-9, mean 18.8 (SD±5.0.) Response/Remission Rate, PHQ-9: 61%/33% CGI-S: 78%/59%.
For the initial 500 patients in the Outcomes Registry, approximately 2/3 patients achieve respond and 1/3 patients achieve remission with an acute course of NeuroStar. These treatment outcomes consistent with NeuroStar open-label study data (Carpenter, 2012). The TrakStar data management system makes large scale data collection feasible. The NeuroStarOutcomes Registry is ongoing, and expected to reach 6000 outpatients from more than 47 clinical sites in 36 months.
In the UK almost 60% of people with a diagnosis of schizophrenia who use
mental health services say they are not involved in decisions about their
treatment. Guidelines and policy documents recommend that shared
decision-making should be implemented, yet whether it leads to greater
treatment-related empowerment for this group has not been systematically
To examine the effects of shared decision-making on indices of
treatment-related empowerment of people with psychosis.
We conducted a systematic review and meta-analysis of randomised
controlled trials (RCTs) of shared decision-making concerning current or
future treatment for psychosis (PROSPERO registration CRD42013006161).
Primary outcomes were indices of treatment-related empowerment and
objective coercion (compulsory treatment). Secondary outcomes were
treatment decision-making ability and the quality of the therapeutic
We identified 11 RCTs. Small beneficial effects of increased shared
decision-making were found on indices of treatment-related empowerment (6
RCTs; g = 0.30, 95% CI 0.09–0.51), although the effect
was smaller if trials with >25% missing data were excluded. There was
a trend towards shared decision-making for future care leading to reduced
use of compulsory treatment over 15–18 months (3 RCTs; RR = 0.59, 95% CI
0.35–1.02), with a number needed to treat of approximately 10 (95% CI
5–∞). No clear effect on treatment decision-making ability (3 RCTs) or
the quality of the therapeutic relationship (8 RCTs) was found, but data
For people with psychosis the implementation of shared treatment
decision-making appears to have small beneficial effects on indices of
treatment-related empowerment, but more direct evidence is required.
Suicide and self-harm are prevalent in individuals diagnosed with psychotic disorders. However, less is known about the level of self-injurious thinking and behaviour in those individuals deemed to be at ultra-high risk (UHR) of developing psychosis, despite growing clinical interest in this population. This review provides a synthesis of the extant literature concerning the prevalence of self-harm and suicidality in the UHR population, and the predictors and correlates associated with these events.
A search of electronic databases was undertaken by two independent reviewers. A meta-analysis of prevalence was undertaken for self-harm, suicidal ideation and behaviour. A narrative review was also undertaken of analyses examining predictors and correlates of self-harm and suicidality.
Twenty-one eligible studies were identified. The meta-analyses suggested a high prevalence of recent suicidal ideation (66%), lifetime self-harm (49%) and lifetime suicide attempts (18%). Co-morbid psychiatric problems, mood variability and a family history of psychiatric problems were among the factors associated with self-harm and suicide risk.
Results suggest that self-harm and suicidality are highly prevalent in the UHR population, with rates similar to those observed in samples with diagnosed psychotic disorders. Appropriate monitoring and managing of suicide risk will be important for services working with the UHR population. Further research in this area is urgently needed considering the high rates identified.
In the present study, following the measurement of methane emissions from 160 mature ewes three times, a subset of twenty ewes was selected for further emission and physiological studies. Ewes were selected on the basis of methane yield (MY; g CH4/kg DM intake) being low (Low MY: >1 sd below the mean; n 10) or high (High MY: >1 sd above the mean; n 10) when fed a blended chaff ration at a fixed feeding level (1·2-fold maintenance energy requirements). The difference between the Low- and High-MY groups observed at the time of selection was maintained (P= 0·001) when remeasured 1–7 months later during digesta kinetics studies. Low MY was associated with a shorter mean retention time of particulate (P< 0·01) and liquid (P< 0·001) digesta, less amounts of rumen particulate contents (P< 0·01) and a smaller rumen volume (P< 0·05), but not apparent DM digestibility (P= 0·27) or urinary allantoin excretion (P= 0·89). Computer tomography scanning of the sheep's rumens after an overnight fast revealed a trend towards the Low-MY sheep having more clearly demarcated rumen gas and liquid phases (P= 0·10). These findings indicate that the selection of ruminants for low MY may have important consequences for an animal's nutritional physiology.
Grey matter volume and cortical thickness represent two complementary aspects of brain structure. Several studies have described reductions in grey matter volume in people at ultra-high risk (UHR) of psychosis; however, little is known about cortical thickness in this group. The aim of the present study was to investigate cortical thickness alterations in UHR subjects and compare individuals who subsequently did and did not develop psychosis.
We examined magnetic resonance imaging data collected at four different scanning sites. The UHR subjects were followed up for at least 2 years. Subsequent to scanning, 50 UHR subjects developed psychosis and 117 did not. Cortical thickness was examined in regions previously identified as sites of neuroanatomical alterations in UHR subjects, using voxel-based cortical thickness.
At baseline UHR subjects, compared with controls, showed reduced cortical thickness in the right parahippocampal gyrus (p < 0.05, familywise error corrected). There were no significant differences in cortical thickness between the UHR subjects who later developed psychosis and those who did not.
These data suggest that UHR symptomatology is characterized by alterations in the thickness of the medial temporal cortex. We did not find evidence that the later progression to psychosis was linked to additional alterations in cortical thickness, although we cannot exclude the possibility that the study lacked sufficient power to detect such differences.
Clinical equipoise regarding preventative treatments for psychosis has encouraged the development and evaluation of psychosocial treatments, such as cognitive behavioural therapy (CBT).
A systematic review and meta-analysis was conducted, examining the evidence for the effectiveness of CBT-informed treatment for preventing psychosis in people who are not taking antipsychotic medication, when compared to usual or non-specific control treatment. Included studies had to meet basic quality criteria, such as concealed and random allocation to treatment groups.
Our search produced 1940 titles, out of which we found seven completed trials (six published). The relative risk (RR) of developing psychosis was reduced by more than 50% for those receiving CBT at every time point [RR at 6 months 0.47, 95% confidence interval (CI) 0.27–0.82, p = 0.008 (fixed-effects only: six randomized controlled trials (RCTs), n = 800); RR at 12 months 0.45, 95% CI 0.28–0.73, p = 0.001 (six RCTs, n = 800); RR at 18–24 months 0.41, 95% CI 0.23–0.72, p = 0.002 (four RCTs, n = 452)]. Heterogeneity was low in every analysis and the results were largely robust to the risk of an unpublished 12-month study having unfavourable results. CBT was also associated with reduced subthreshold symptoms at 12 months, but not at 6 or 18–24 months. No effects on functioning, symptom-related distress or quality of life were observed. CBT was not associated with increased rates of clinical depression or social anxiety (two studies).
CBT-informed treatment is associated with a reduced risk of transition to psychosis at 6, 12 and 18–24 months, and reduced symptoms at 12 months. Methodological limitations and recommendations for trial reporting are discussed.
Background: More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. Aims: Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. Method: Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. Results: Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. Conclusions: Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.
Improving health through better nutrition of the population may contribute to enhanced efficiency and sustainability of healthcare systems. A recent expert meeting investigated in detail a number of methodological aspects related to the discipline of nutrition economics. The role of nutrition in health maintenance and in the prevention of non-communicable diseases is now generally recognised. However, the main scope of those seeking to contain healthcare expenditures tends to focus on the management of existing chronic diseases. Identifying additional relevant dimensions to measure and the context of use will become increasingly important in selecting and developing outcome measurements for nutrition interventions. The translation of nutrition-related research data into public health guidance raises the challenging issue of carrying out more pragmatic trials in many areas where these would generate the most useful evidence for health policy decision-making. Nutrition exemplifies all the types of interventions and policy which need evaluating across the health field. There is a need to start actively engaging key stakeholders in order to collect data and to widen health technology assessment approaches for achieving a policy shift from evidence-based medicine to evidence-based decision-making in the field of nutrition.
Evidence regarding overestimation of the efficacy of antipsychotics and
underestimation of their toxicity, as well as emerging data regarding
alternative treatment options, suggests it may be time to introduce patient
choice and reconsider whether everyone who meets the criteria for a
schizophrenia spectrum diagnosis requires antipsychotics in order to
Although antipsychotic medication is the first line of treatment for schizophrenia, many service users choose to refuse or discontinue their pharmacological treatment. Cognitive therapy (CT) has been shown to be effective when delivered in combination with antipsychotic medication, but has yet to be formally evaluated in its absence. This study evaluates CT for people with psychotic disorders who have not been taking antipsychotic medication for at least 6 months.
Twenty participants with schizophrenia spectrum disorders received CT in an open trial. Our primary outcome was psychiatric symptoms measured using the Positive and Negative Syndromes Scale (PANSS), which was administered at baseline, 9 months (end of treatment) and 15 months (follow-up). Secondary outcomes were dimensions of hallucinations and delusions, self-rated recovery and social functioning.
T tests and Wilcoxon's signed ranks tests revealed significant beneficial effects on all primary and secondary outcomes at end of treatment and follow-up, with the exception of self-rated recovery at end of treatment. Cohen's d effect sizes were moderate to large [for PANSS total, d=0.85, 95% confidence interval (CI) 0.32–1.35 at end of treatment; d=1.26, 95% CI 0.66–1.84 at follow-up]. A response rate analysis found that 35% and 50% of participants achieved at least a 50% reduction in PANSS total scores by end of therapy and follow-up respectively. No patients deteriorated significantly.
This study provides preliminary evidence that CT is an acceptable and effective treatment for people with psychosis who choose not to take antipsychotic medication. An adequately powered randomized controlled trial is warranted.
Background: Cognitive behavioural therapy (CBT) can be helpful for many people who experience psychosis; however most research trials have been conducted with people also taking antipsychotic medication. There is little evidence to know whether CBT can help people who choose not to take this medication, despite this being a very frequent event. Developing effective alternatives to antipsychotics would offer service users real choice. Aims: To report a case study illustrating how brief CBT may be of value to a young person experiencing psychosis and not wishing to take antipsychotic medication. Method: We describe the progress of brief CBT for a young man reporting auditory and visual hallucinations in the form of a controlling and dominating invisible companion. We describe the formulation process and discuss the impact of key interventions such as normalising and detached mindfulness. Results: Seven sessions of CBT resulted in complete disappearance of the invisible companion. The reduction in frequency and duration followed reduction in conviction in key appraisals concerning uncontrollability and unacceptability. Conclusions: This case adds to the existing evidence base by suggesting that even short-term CBT might lead to valued outcomes for service users experiencing psychosis but not wishing to take antipsychotic medication.
This paper considers the impact that a number of Australian emergency management policy and operational decisions are having on residential aged care facilities located in the community. For example, all residential aged care facilities applying for new federal government funded aged care places are required to demonstrate a plan for environmental disaster threats such as bushfires and floods. Another example is the adoption of new fire danger rating scale, with the inclusion of an extreme level called “catastrophic”-code red. This inclusion requires all services and community members, living in bushfire-prone areas to decide whether or not to evacuate the day before or morning of a Bureau of Meteorology fire danger index indicating a code red. There is evidence that these policy and operational decisions have been made without fully examining the practical implications, particularly for aged care facilities. While many of the facilities on which these decisions impact see the rational for such decisions, they argue that these decisions have serious implications for their services and patients. Many residential aged care facilities, which are privately operated, historically have not been involved in any state or local government emergency management planning. Therefore, the whole concept of risk assessment, preparation, and planning to increase the absorbing, buffering, and response capacity of their facilities against extreme weather events has become quite overwhelming for some. This paper presents a case study that demonstrates the tension between emergency management policy decisions on an aged care facility, and outlines their issues and response.
Following the devastating March 2009 Victorian bushfire disaster in rural areas of Australia, authorities reviewed strategies designed to protect communities during periods of extreme fire risk. New policy and regulation were introduced and designed to ensure that small rural communities were protected and prepared to confront a wildfire emergency during days of extreme heat or bushfire risk weather. As a result on days of declared ‘catastrophic’ bushfire weather conditions government agencies in South Australia have implemented a policy for schools (including pre-schools) to be temporarily closed. On these days community members are advised to evacuate early to safe regional centres, and to limit travel on country roads. The WADEM Guidelines for Disaster Evaluation and Research demonstrate that Basic Societal Functions (BSFs), such as education, health, transport and others, are interconnected and interdependent. For example in small rural communities in South Australia people may have a number of important roles including being parents, volunteers of emergency services while also being employed as staff of local hospitals. This project reviewed the impact of school closures and other protective measures on the availability of the rural nursing workforce and on rural hospitals. Rural hospitals in Australia are staffed, on average, by 2–8 nurses, service very small communities and are separated by great distances. As a result, small changes in the absentee rate for nurses can have a significant impact on the operation of these hospitals. This paper will argue that policy changes in other sectors, such as education, can impact on societal activities such as childcare, volunteer emergency service work, and hospital staffing, in ways that may not be anticipated unless the impact on all Basic Societal Functions are considered by policymakers.
The physicality of mass gatherings has been well described in the literature. The factors effecting the rate of illness and injury at mass gatherings have been well described and include the type and duration of the event, the type and age of crowd, and the availability of drugs and alcohol. In 2004 Arbon proposed a conceptual model that describes the relationship between the environmental, psychosocial and the biomedical domains of mass gatherings. However to date the science of mass gatherings has focussed on the environmental and biomedical domains. There is minimal evidence to support or describe the psychosocial domain. Current tools available to assess the psychosocial domain are scarce even though it is considered an integral part of a mass gathering event. Berlonghi (1995) and Zietz (2009) proposed two measurements, crowd type and crowd mood respectively. This paper reports on a pilot project undertaken to evaluate how effective these tools are to understand the psychosocial domain of a mass gathering event.
There is a new merging of health economics and nutrition disciplines to assess the impact of diet on health and disease prevention and to characterise the health and economic aspects of specific changes in nutritional behaviour and nutrition recommendations. A rationale exists for developing the field of nutrition economics which could offer a better understanding of both nutrition, in the context of having a significant influence on health outcomes, and economics, in order to estimate the absolute and relative monetary impact of health measures. For this purpose, an expert meeting assessed questions aimed at clarifying the scope and identifying the key issues that should be taken into consideration in developing nutrition economics as a discipline that could potentially address important questions. We propose a first multidisciplinary outline for understanding the principles and particular characteristics of this emerging field. We summarise here the concepts and the observations of workshop participants and propose a basic setting for nutrition economics and health outcomes research as a novel discipline to support nutrition, health economics and health policy development in an evidence and health-benefit-based manner.
Lactic acidosis is a major welfare issue affecting animal health and production systems such as dairy and feedlot beef. We used two bioassays to identify bioactive plants of Australia with the potential to prevent acidosis in ruminants. In the first bioassay, a potentially acidotic environment was induced by adding glucose to rumen fluid and pH and gas production were used to estimate the effect on acid production and microbial fermentation after 5-h incubation. Australian plants (n = 104) were screened for their ability to prevent a decline in the pH without inhibiting normal gas production, and five plants namely Eremophila glabra, Kennedia eximia, Acacia saligna, Acacia decurrens and Kennedia prorepens with such properties were identified. We investigated further the two top ranking plants, E. glabra and K. prorepens, in the second bioassay to determine the extent of their effect in vitro, by extending the incubation to 24 h and measuring d-lactate, and volatile fatty acids (VFA) in addition to pH and gas production. These were measured at 0, 5, 10, 16 and 24 h after inoculation. Eremophilaglabra maintained pH values that were higher and d-lactate concentrations that were lower than the control (P < 0.001), and comparable to the antibiotic-protected environment (AB; 12 μg of virginiamycin/ml). Eremophilaglabra and AB treatments did not restrict fermentation, as judged by gas production and VFA. Kennedia prorepens slowed the decline in pH and reduced the accumulation of lactate but inhibited gas production. We concluded that, in vitro, E. glabra was effective at controlling events that can lead to acidosis and the effect was comparable to that of virginiamycin, while K. prorepens was less effective than E. glabra and also inhibited fermentation.
Cornwall (UK) has suffered extensive arsenic contamination due to the historic mining and processing of mineral ores. Standard procedures for contaminated land risk assessment (DEFRA and Environment Agency, 2002a) are probably unworkable in Cornwall, with a very large number of sites classified as contaminated by arsenic. Methods of measuring the speciation and mobility of arsenic are essential for effective and rapid risk assessments of arsenic contamination.
Three clusters of lysimeters were installed in three different areas of an arsenic-contaminated Cornish site. A novel phosphoric acid microwave extraction technique was applied to the soils removed from the lysimeter holes; HPLC-HG-AFS analysis showed the majority of solid-phase arsenic to be arsenate (AsV). Pore waters obtained from the lysimeters showed variable, relatively low levels of arsenite (AsIII) and arsenate (AsV) to be present (<1–129 μg l–1). Less toxic arsenate predominated in most pore waters, with the presence of minor amounts of arsenite suggesting heterogeneous redox conditions. Pore-water arsenic concentrations were strongly positively related to solid-phase arsenate concentrations.
The use of techniques that assess the speciation of arsenic both in the solid and aqueous phases of a soil provides important information about the mobility of arsenic. The methodology presented in this paper may offer a novel basis for risk assessments of other contaminated sites.