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Treatment-resistant schizophrenia is a major disabling illness which often proves challenging to manage in a secondary care setting. The National Psychosis Unit (NPU) is a specialised tertiary in-patient facility that provides evidence-based, personalised, multidisciplinary interventions for complex treatment-resistant psychosis, in order to reduce the risk of readmission and long-term care costs.
This study aimed to assess the long-term effectiveness of treatment at the NPU by considering naturalistic outcome measures.
Using a mirror image design, we compared the numbers of psychiatric and general hospital admissions, in-patient days, acuity of placement, number of psychotropic medications and dose of antipsychotic medication prescribed before and following NPU admission. Data were obtained from the Clinical Records Interactive Search system, an anonymised database sourced from the South London and Maudsley NHS Trust electronic records, and by means of anonymous linkage to the Hospital Episode Statistics system.
Compared with the 2 years before NPU admission, patients had fewer mental health admissions (1.65 ± 1.44 v. 0.87 ± 0.99, z = 5.594, P < 0.0001) and less mental health bed usage (335.31 ± 272.67 v. 199.42 ± 261.96, z = 5.195 P < 0.0001) after NPU admission. Total in-patient days in physical health hospitals and total number of in-patient days were also significantly reduced (16.51 ± 85.77 v. 2.83 ± 17.38, z = 2.046, P = 0.0408; 351.82 ± 269.09 v. 202.25 ± 261.05, z = 5.621, P < 0.0001). The reduction in level of support required after treatment at the NPU was statistically significant (z = −8.099, P < 0.0001).
This study demonstrates the long-term effectiveness of a tertiary service specialising in treatment-resistant psychosis.
Clozapine is uniquely effective in treatment-resistant psychosis but remains underutilised, partly owing to psychotic symptoms leading to non-adherence to oral medication. An intramuscular formulation is available in the UK but outcomes remain unexplored.
This was a retrospective clinical effectiveness study of intramuscular clozapine prescription for treatment initiation and maintenance in treatment-resistant psychosis over a 3-year period.
Successful initiation of oral clozapine after intramuscular prescription was the primary outcome. Secondary outcomes included all-cause clozapine discontinuation 2 years following initiation, and 1 year after discharge. Discontinuation rates were compared with a cohort prescribed only oral clozapine. Propensity scores were used to address confounding by indication.
Among 39 patients prescribed intramuscular clozapine, 19 received at least one injection, whereas 20 accepted oral clozapine when given an enforced choice between the two. Thirty-six (92%) patients successfully initiated oral clozapine after intramuscular prescription; three never transitioned to oral. Eight discontinued oral clozapine during the 2-year follow-up, compared with 83 out of 162 in the comparator group (discontinuation rates of 24% and 50%, respectively). Discontinuation rates at 1-year post-discharge were 21%, compared with 44% in the comparison group. Intramuscular clozapine prescription was associated with a non-significantly lower hazard of discontinuation 2 years after initiation (hazard ratio 0.39, 95% CI 0.14–1.06) and 1 year after discharge (hazard ratio 0.37, 95% CI 0.11–1.24). The only reported adverse event specific to the intramuscular formulation was injection site pain and swelling.
Intramuscular clozapine prescription allowed transition to oral maintenance in an initially non-adherent cohort. Discontinuation rates were similar to patients only prescribed oral clozapine and comparable to existing literature.
Evidence suggests that healthy older adults with subjective memory complaints are at increased risk of dementia. Subjective Cognitive Impairment (SCI) may precede Mild Cognitive Impairment (MCI) in the clinical continuum of Alzheimer's disease (AD). Attentional deficits may be present early in AD, and associated functional changes have been reported in both MCI and AD. In the present study, activation during divided attention in SCI subjects was investigated using functional magnetic resonance imaging (fMRI). Additionally, amyloid uptake was investigated using 11C-PIB with positron emission tomography (PET).
Brain activation in 11 SCI subjects and 10 controls was compared during a divided attention task using fMRI. Additionally, five SCI subjects and 14 cognitively normal healthy controls underwent 11C-PIB PET scanning. Criteria for diagnosis of SCI were:
1. self-reported memory complaints,
2. objectively normal cognition on detailed neurocognitive testing,
3. absence of psychiatric or causative physical illness,
4. normal activities of daily living and
5. absence of MCI or dementia.
There were no differences in performance between SCI and control groups in terms of cognitive or behavioural measures. However, SCIs had increased activation in left medial temporal lobe, and bilateral thalamus, posterior cingulate and caudate. One SCI subject and one control subject had a pattern of 11C-PIB uptake similar to that seen in AD.
The activation changes identified in SCI may relate to compensatory increased activation in the face of early AD pathology. Larger, longitudinal studies are needed to determine the extent and significance of PIB uptake in SCI.
Several lines of research suggest both dorsal and ventral prefrontal cortical dysfunction in bipolar disorder (BD). We used functional magnetic resonance imaging to compare patterns of brain activation in remitted BD patients and controls whilst performing tasks selected for their relative specificity in engaging either the dorsal (n-back sequential-letter working memory task) or ventral (gambling task) PFC. Seven BD patients were selected from participants of the Maudsley Bipolar Disorder Project on the basis of clinical remission, absence of cognitive deficits, and monotherapy with mood stabilisers. Subjects were individually matched by gender, age, and IQ to an equal number of healthy controls. In the n-back task, group differences were only present in response to increasing memory load. Patients did not show the predicted dynamic response in the dorsal PFC, but had increased activation in the parietal cortices. During the gambling task, controls showed significant activation in the ventral and dorsal PFC; this was attenuated in BD patients where increased activation was seen in lateral temporal and polar regions. Our findings suggest that there are trait abnormalities in dorsal and ventral PFC function in BD that may be more pronounced during tasks that rely on ventral–dorsal PFC interaction.
Exhaustive literature is available in the portrayal of mental illness in the English language films. However no major studies are available around the portrayal of mental health in Bollywood movies which in fact is consumed by nearly 25-30% of the world population.
in the era of unprecedented growth in visual medium, we wish to study the portrayal of mental illness in Bollywood cinema and how effective this medium is to create awareness around mental health and stigma.
Literature search with a specific purpose to identify any available literature on mental illness in South Asian cinema was undertaken. to create a synthesis of portrayal of mental illness, its impact on cultural consumption with its advantages and deficiencies. This was followed by a listing a cluster reviews of Bollywood films that have characters with mental health problems to identify how these illustrate both the condition and reactions to them.
These findings were compared with the literature surrounding mental health and the Indian culture to show if the perceptions correlate. The information was collated to see any patterns and 6 such patterns were identified.
Recognising these motifs are crucial for public and clinician alike in contact with the population open to the influence of these films to not only understand the phenomenology of mental illness in this populace but also some of unique cultural factors, medication, stigma and charting out appropriate management plan. (On-going)
The details of the synthetic factors will be presented in the results and discussion.
Demands on health and social care are growing in quantity and complexity, with resources and staffing not projected to match this. The landmark NHS Long Term Plan calls for services in England to be delivered differently through integrated care systems (ICSs) that will better join commissioners and providers, and health and social care. The scale of these changes is immense, and the detail can feel confusing. However, they are important and will affect all clinicians in the public service. This three-part series provides a primer on integrated care, explaining why it is happening, how services are changing and why clinicians should get involved. In this first article we focus on the changing demographics, and the workforce and financial resources required to address these.
Part 1 of this three-part series on integrated care discussed the drivers for change in healthcare delivery in England set out in the NHS Long Term Plan. This second part explores the evolution of mental health services within the wider National Health Service (NHS), and describes important relevant legislation and policy over the past decade, leading up to the 2019 Long Term Plan. We explain the implications of this, including the detail of emerging structures such as integrated care systems (ICSs) and primary care networks (PCNs), and conclude with challenges facing these novel systems. Part 3 will address the practical local implementation of integrated care.
Harvest weed seed control (HWSC) technology, such as impact mills that destroy weed seeds in seed-bearing chaff material during grain crop harvest, has been highly effective in Australian cropping systems. However, the impact mill has never been tested in soybeans [Glycine max (L.) Merr.] and weeds common to soybean production systems in the midwestern and mid-Atlantic United States. We conducted stationary testing of Harrington Seed Destructor (HSD) impact mill and winter burial studies during 2015 to 2016 and 2017 to 2018 to determine (1) the efficacy of the impact mill to target weed seeds of seven common weeds in midwestern and five in the mid-Atlantic United States, and (2) the fate of impact mill–processed weed seeds after winter burial. The impact mill was highly effective in destroying seeds of all the species tested, with 93.5% to 99.8% weed seed destruction in 2015 and 85.6% to 100% in 2017. The weak relationships (positive or negative) between seed size and seed destruction by impact mill and the high percentage of weed seed destruction by impact mill across all seed sizes indicate that the biological or practical effect of seed size is limited. The impact mill–processed weed seeds that retained at least 50% of their original size, labeled as potentially viable seed (PVS), were buried for 90 d overwinter to determine the fate of weed seeds after winter burial. At 90 d after burial, the impact mill–processed PVS were significantly less viable than unprocessed control seeds, indicating that impact mill processing physically damaged the PVS and promoted seed mortality overwinter. A very small fraction (<0.4%) of the total weed seed processed by the impact mill remained viable after winter burial. The results presented here demonstrate that the impact mill is highly effective in increasing seed mortality and could potentially be used as an HWSC tactic for weed management in this region.