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Despite their documented efficacy, substantial proportions of patients discontinue antidepressant medication (ADM) without a doctor's recommendation. The current report integrates data on patient-reported reasons into an investigation of patterns and predictors of ADM discontinuation.
Face-to-face interviews with community samples from 13 countries (n = 30 697) in the World Mental Health (WMH) Surveys included n = 1890 respondents who used ADMs within the past 12 months.
10.9% of 12-month ADM users reported discontinuation-based on recommendation of the prescriber while 15.7% discontinued in the absence of prescriber recommendation. The main patient-reported reason for discontinuation was feeling better (46.6%), which was reported by a higher proportion of patients who discontinued within the first 2 weeks of treatment than later. Perceived ineffectiveness (18.5%), predisposing factors (e.g. fear of dependence) (20.0%), and enabling factors (e.g. inability to afford treatment cost) (5.0%) were much less commonly reported reasons. Discontinuation in the absence of prescriber recommendation was associated with low country income level, being employed, and having above average personal income. Age, prior history of psychotropic medication use, and being prescribed treatment from a psychiatrist rather than from a general medical practitioner, in comparison, were associated with a lower probability of this type of discontinuation. However, these predictors varied substantially depending on patient-reported reasons for discontinuation.
Dropping out early is not necessarily negative with almost half of individuals noting they felt better. The study underscores the diverse reasons given for dropping out and the need to evaluate how and whether dropping out influences short- or long-term functioning.
Recently, the Health of the Nation Outcome Scales 65+ (HoNOS65+) were revised. Twenty-five experts from Australia and New Zealand completed an anonymous web-based survey about the content validity of the revised measure, the HoNOS Older Adults (HoNOS OA).
All 12 HoNOS OA scales were rated by most (≥75%) experts as ‘important’ or ‘very important’ for determining overall clinical severity among older adults. Ratings of sensitivity to change, comprehensibility and comprehensiveness were more variable, but mostly positive. Experts’ comments provided possible explanations. For example, some experts suggested modifying or expanding the glossary examples for some scales (e.g. those measuring problems with relationships and problems with activities of daily living) to be more older adult-specific.
Experts agreed that the HoNOS OA measures important constructs. Training may need to orient experienced raters to the rationale for some revisions. Further psychometric testing of the HoNOS OA is recommended.
The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries.
Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents.
3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2–4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness.
ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.
People with severe mental illness (SMI) have high rates of chronic disease and premature death.
To explore the strength of evidence for interventions to reduce risk of mortality in people with SMI.
In a meta-review of 16 systematic reviews of controlled studies, mortality was the primary outcome (8 reviews). Physiological health measures (body mass index, weight, glucose levels, lipid profiles and blood pressure) were secondary outcomes (14 reviews).
Antipsychotic and antidepressant medications had some protective effect on mortality, subject to treatment adherence. Integrative community care programmes may reduce physical morbidity and excess deaths, but the effective ingredients are unknown. Interventions to improve unhealthy lifestyles and risky behaviours can improve risk factor profiles, but longer follow-up is needed. Preventive interventions and improved medical care for comorbid chronic disease may reduce excess mortality, but data are lacking.
Improved adherence to pharmacological and physical health management guidelines is indicated.
In 2006, Australia introduced new publicly funded psychological services
for people with affective and anxiety disorders (the Better Access
programme). Despite massive uptake, it has been suggested that Better
Access is selectively treating socioeconomically advantaged people,
including some who do not warrant treatment, and people already receiving
To explore potential disparities in Better Access treatment using
epidemiological data from the 2007 National Survey of Mental Health and
Logistic regression analyses examined patterns and correlates of service
use in two populations: people who used the new psychological services in
the previous 12 months; and people with any ICD–10 12-month affective and
anxiety disorder, regardless of service use.
Most (93.2%) Better Access psychological services users had a 12-month
ICD–10 mental disorder or another indicator of treatment need. Better
Access users without affective or anxiety disorders were not more
socioeconomically advantaged, and received less treatment than those with
these disorders. Among the population with affective or anxiety
disorders, non-service users were less likely to have a severe disorder
and more likely to have anxiety disorder, without a comorbid affective
disorder, than Better Access users. Better Access users comprised more
new allied healthcare recipients than other service users. A substantial
minority of non-service users (13.5%) had severe disorders, but most did
not perceive a need for treatment.
Better Access does not appear to be overservicing individuals without
potential need or contributing to social inequalities in mental
healthcare. It appears to be reaching people who have not previously
received psychological care. Treatment rates could be improved for some
people with anxiety disorders.
The aim of the study was to examine treatment for the initial acute phase of first-episode psychosis at the Early Psychosis Prevention and Intervention Centre. Information regarding treatment was collected from file notes for all patients (n=112). For a subsample of patients (n=68), remission of positive psychotic symptoms was assessed using standardised ratings at 3-month follow-up.
Treatment provided was largely in accordance with recommended treatment strategies. The majority (72%) of patients achieved rapid remission of positive symptoms.
Restrictive practices other than in-patient admission, such as in-patient seclusion, police transport or a community treatment order, can be minimised. The use of low-dose antipsychotic medication is an effective treatment strategy for the initial acute phase of first-episode psychosis.
Providing specialised services to individuals experiencing first-episode psychosis (FEP) is a relatively new endeavour.
To overview developing services for newly diagnosed cases of FEP and the context in which they develop.
This paper describes five model multi-element FEP programmes, outlines recent evaluation studies of FEP services, discusses current evidence gaps relating to the evaluation of complex interventions and specific interventions for FEP and illustrates attempts to examine aspects of clinical work practised at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia.
Considerable progress has been made in terms of influencing practice in the assessment and treatment of early psychosis.
There is need for quality clinical and research efforts to inform and accelerate progress in this burgeoning field.
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