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Remote consultation technology has been rapidly adopted due to the COVID-19 pandemic. However, some healthcare settings have faced barriers in implementation. We present a study to investigate changes in rates of remote consultation during the pandemic using a large electronic health record (EHR) dataset.
The Clinical Record Interactive Search tool (CRIS) was used to examine de-identified EHR data of people receiving mental healthcare in South London, UK. Data from around 37,500 patients were analysed for each week from 7th January 2019 and 20th September 2020 using linear regression and locally estimated scatterplot smoothing (LOESS) to investigate changes in the number of clinical contacts (in-person, remote or non-attended) with mental healthcare professionals and prescribing of antipsychotics and mood stabilisers. The data are presented in an interactive dashboard: http://rpatel.co.uk/TelepsychiatryDashboard.
The frequency of in-person contacts was substantially reduced following the onset of the pandemic (β coefficient: -5829.6 contacts, 95% CI -6919.5 to -4739.6, p<0.001), while the frequency of remote contacts increased significantly (β coefficient: 3338.5 contacts, 95% CI 3074.4 to 3602.7, p<0.001). Rates of remote consultation were lower in older adults than in working age adults, children and adolescents. Despite the increase in remote contact, antipsychotic and mood stabiliser prescribing remained at similar levels.
The COVID-19 pandemic has been associated with a marked increase in remote consultation, particularly among younger patients. However, there was no evidence that this has led to changes in prescribing. Further work is needed to support older patients in accessing remote mental healthcare.
All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: RS has received funding from Janssen, GSK and Takeda outside the submitted work. RP has received funding from Janssen, Induction Healthcare and H
To review patient satisfaction with the change in practice towards telephone consultations during and after the coronavirus disease 2019 pandemic for head and neck cancer follow up.
A retrospective analysis was conducted of head and neck cancer telephone appointments during a six-month period in a tertiary referral centre.
Patients found the telephone consultations beneficial (98 per cent), with 30 per cent stating they were relieved to not have to attend hospital. Patients who travelled further, those with lower stage disease and patients with a greater interval from initial treatment were most satisfied with the telephone consultations. Sixty-eight per cent of patients stated they would be happy to have telephone consultations as part of their regular follow up after the pandemic.
Patients found the telephone consultations beneficial and 30 per cent considered them preferable to face-to-face appointments. This study demonstrates that telephone consultations can be used as an adjunct to face-to-face appointments in an effort to reduce hospital attendances whilst maintaining close follow up.
Much of our current understanding about novel coronavirus disease 2019 (COVID-19) comes from hospitalised patients. However, the spectrum of mild and subclinical disease has implications for population-level screening and control. Forty-nine participants were recruited from a group of 99 adults repatriated from a cruise ship with a high incidence of COVID-19. Respiratory and rectal swabs were tested by polymerase chain reaction (PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Sera were tested for anti-SARS-CoV-2 antibodies by enzyme-linked immunosorbent assay (ELISA) and microneutralisation assay. Symptoms, viral shedding and antibody response were examined. Forty-five participants (92%) were considered cases based on either positive PCR or positive ELISA for immunoglobulin G. Forty-two percent of cases were asymptomatic. Only 15% of symptomatic cases reported fever. Serial respiratory and rectal swabs were positive for 10% and 5% of participants respectively about 3 weeks after median symptom onset. Cycle threshold values were high (range 31–45). Attempts to isolate live virus were unsuccessful. The presence of symptoms was not associated with demographics, comorbidities or antibody response. In closed settings, incidence of COVID-19 could be almost double that suggested by symptom-based screening. Serology may be useful in diagnosis of mild disease and in aiding public health investigations.
The Rapid ASKAP Continuum Survey (RACS) is the first large-area survey to be conducted with the full 36-antenna Australian Square Kilometre Array Pathfinder (ASKAP) telescope. RACS will provide a shallow model of the ASKAP sky that will aid the calibration of future deep ASKAP surveys. RACS will cover the whole sky visible from the ASKAP site in Western Australia and will cover the full ASKAP band of 700–1800 MHz. The RACS images are generally deeper than the existing NRAO VLA Sky Survey and Sydney University Molonglo Sky Survey radio surveys and have better spatial resolution. All RACS survey products will be public, including radio images (with
15 arcsec resolution) and catalogues of about three million source components with spectral index and polarisation information. In this paper, we present a description of the RACS survey and the first data release of 903 images covering the sky south of declination
made over a 288-MHz band centred at 887.5 MHz.
This study aimed to assess the published literature on non-technical skills in otolaryngology surgery and examine the applicability of any research to others’ practice, and to explore how the published literature can identify areas for further development and guide future research.
A systematic review was conducted using the following key words: ‘otolaryngology’, ‘otorhinolaryngology’, ‘ENT’, ‘ENT surgery’, ‘ear, nose and throat surgery’, ‘head and neck surgery’, ‘thyroid surgery’, ‘parathyroid surgery’, ‘otology’, ‘rhinology’, ‘laryngology’ ‘skull base surgery’, ‘airway surgery’, ‘non-technical skills’, ‘non technical skills for surgeons’, ‘NOTSS’, ‘behavioural markers’ and ‘behavioural assessment tool’.
Three publications were included in the review – 1 randomised, controlled trial and 2 cohort studies – involving 78 participants. All were simulation-based studies involving training otolaryngology surgeons.
Little research has been undertaken on non-technical skills in otolaryngology. Training surgeons’ non-technical skill levels are similar across every tested aspect. The research already performed can guide further studies, particularly amongst non-training otolaryngology surgeons and in both emergency and elective non-simulated environments.
Lipids appear to mediate depressive vulnerability in the elderly, however, sex differences and genetic vulnerability have not been taken into account in previous prospective studies.
Depression was assessed in a population of 1040 women and 752 men aged 65 years and over at baseline and after 7-year follow-up. Clinical level of depression (DEP) was defined as having either a score of 16 and above on the Centre for Epidemiology Studies Depression scale or a diagnosis of current major depression on the Mini International Neuropsychiatric Interview. Lipid levels, apolipoprotein E and serotonin transporter linked promoter region (5-HTTLPR) genotypes were evaluated at baseline.
Multivariate analyses adjusted by socio-demographic and behavioral variables, measures of physical health including ischemic pathologies, and genetic vulnerability indicated gender-specific associations between dyslipidemia and DEP, independent of the use of lipid lowering agents or apolipoprotein E status. Men with low LDL-cholesterol levels had twice the risk of prevalent and incident DEP whereas in women low HDL-cholesterol levels were found to be significantly associated with increased prevalent DEP (OR = 1.5) only. A significant interaction was observed between low LDL-cholesterol and 5-HTTLPR genotype, men with s/s or s/l genotype being at increased risk of DEP (OR = 6.0 and 2.7, respectively). No significant gene-environment interaction was observed for women.
DEP is associated with higher atherogenic risk in women (low HDL-cholesterol), whereas the reverse is observed in men (low LDL-cholesterol). Late-life depression may have a complex gender-specific etiology involving genetic vulnerability in men.
Depression is reported to be associated with increased mortality, but underlying mechanisms are uncertain. Associations between anxiety and mortality are also uncertain. In a large population study, we investigated associations between anxiety, depression and mortality over a 3-6 year period. We utilized a unique link between a large regional community survey and a comprehensive national mortality database.
Baseline information on mental and physical health was collected in a population-based health study (n=61,349) (the HUNT-2 study) of adults aged 20 years and over. Anxiety and depressive symptoms were ascertained using the Hospital Anxiety and Depression Scale (HADS). Records were linked with the Norwegian national mortality database.
Case-level depression was a risk-factor for mortality, but case-level anxiety was not (having adjusted for confounding factors). The association between anxiety symptoms and mortality was U-shaped, and anxiety comorbid with depression was associated with lower mortality compared to depression alone. Associations between depression and mortality were partly but not entirely explained by somatic symptoms and conditions, and also physical impairment, but not by smoking, obesity, cholesterol level or blood pressure.
Depression predicted general mortality after adjustment for multiple potential confounding factors. Associations between anxiety symptoms and mortality were U-shaped. Lower mortality was found in comorbid anxiety and depression than in depression alone.
Associations have been described between lower IQ and serious mental illness. Associations between common mental disorders (CMDs) and IQ have received little research. The objective of this study was to investigate the association between verbal IQ and CMD symptoms and diagnoses, and to investigate the role of potential mediating and confounding factors.
Data were analysed from a British national survey with an analysed sample of 8054 people aged 16–74 years. Associations between verbal IQ (NART) and mental symptoms/disorders (CIS-R) were analysed with covariates including education, social class, income, debt, problem drinking, life events, physical health and relationship quality.
CMD was associated with lower IQ. This association was stronger for depressive disorder/symptoms than for generalised anxiety disorder/symptoms. The most important covariates were education, social class, income and relationship quality.
The association between lower IQ and CMD is partly accounted for by adverse social/socioeconomic conditions. Stronger associations for depression than anxiety may indicate an effect of IQ on the way mental distress is communicated.
Depression is reported to increase general mortality. For cause-specific mortality, there is evidence for the effect of depression on cardiac mortality and suicide. Less is known as to other mortality diagnoses. The literature on anxiety in relation to mortality is scarce and conflicting. This study investigates empirically the association between anxiety/depression and cause-specific mortality with particular attention to underlying mechanisms and causes of death.
Employing a historical cohort design we utilized a unique link between a large epidemiological cohort study and a comprehensive national mortality database. Baseline information on physical and mental health (HADS) was gathered from the population based health study (N=61349). Causes of death were registered with ICD-10 diagnoses during 4.4 year follow-up.
Case-level depression increased mortality for all major disease-related causes of death, whereas case-level anxiety and comorbid anxiety/depression did not. The effect of depression was equal in cardiac mortality compared to all other causes combined, and confounding factors were also markedly similar. Accidents and suicide was predicted by comorbid anxiety depression.
Depression is a risk factor for all major disease-related causes of death, and is not limited to cardiac mortality or suicide. Case-level anxiety imposes no increased disease-related mortality, but comorbid anxiety depression predicts external causes of death. As the association between depression and cardiac mortality was comparable to the other causes of death combined, and confounding and mediating factors are markedly similar, future investigation as to mechanisms underlying the effect of depression on mortality should not be limited to CVD mortality.
Autism Spectrum Disorders (ASDs) affect 1% of children and are associated with lifelong psychosocial impairments. The majority of children with ASD will experience co-occurring psychiatric disorders. In the UK, antipsychotics remain unlicensed for use in ASDs, however 10% of children with ASD receive antipsychotic treatment; the co-occurring disorders being targeted by these medications remains unclear.
To examine rates of antipsychotic medication use and identify associated co-occurring disorders among children with ASD receiving psychiatric care.
The sample consisted of 2844 children aged 2 to 17 with a NHS clinician recorded ICD-10 diagnoses for ASD between 2008–2013. Clinical variables extracted from their anonymised electronic patient records included disorder severity, medication use, co-occurring ICD-10 diagnoses, family characteristics, demographics and antipsychotic use.
Of the 2844 children (79% male), the majority (57%) had co-occurring psychiatric diagnoses. 313 (11%) received antipsychotic medication. The proportion of children aged 13 to 17 years and 6 to 12 years prescribed antipsychotics was 19% and 7% respectively. After controlling for socio-demographic factors, disorder severity, specialist treatment, inpatient duration, risk of self harm, violence to others, self injurious behaviour, maltreatment history, parental mental illness, caregiver anxiety, and neighbourhood deprivation, multivariate regression analysis revealed only hyperactivity disorders (O.R 1.94, 95%C.I. 1.32–2.86), psychotic disorders (O.R 5.12 95% C.I. 2.6–10.1), mood disorders (O.R 2.02, 95%C.I. 1.04–3.92) and intellectual disability (O.R 2.89 95% C.I. 1.89–4.71) were associated with anti-psychotic use.
The prescription of antipsychotic medications in this UK ASD clinical sample is strongly associated with specific co-occurring psychiatric disorders and intellectual disability.
Whereas depression as a risk factor for the incidence of activity limitations in the elderly has been confirmed, little attention has been paid to anxiety, despite its high prevalence, with or without comorbid depression.
In a community-dwelling cohort of 1581 participants aged 65 years and over, the association between trait anxiety symptoms (Spielberger State-Trait Anxiety Inventory, third highest tercile) and current DSM-IV anxiety disorder (GAD, PTSD, OCD, panic disorder, agoraphobia or social phobia) at baseline and 7-year incident activity limitations was determined using mixed logistic regression models. Repeated measures of activity limitations included by increased severity level: social restriction (neighbourhood and house confined), mobility (Rosow and Breslau scale) and limitations in instrumental activities of daily living (IADL).
Of the sample, 42% were male and 14.2% had an anxiety disorder at baseline. Adjusting for socio-demographic and health variables, past and present depression and anxiolytic drugs, trait anxiety symptomatology was associated with increased incidence of social restriction (OR (95% CI): 2.46 (1.45–4.16), p = 0.0008) and current anxiety disorder with an increased risk of incident IADL limitation (OR (95% CI): 1.86 (1.01–3.41), p = 0.046). Associations remained significant in participants free of depressive symptoms at baseline (OR (95% CI): 2.92 (1.41–6.05), p = 0.004; OR (95% CI): 3.21 (1.31–7.89), p = 0.011, respectively).
Despite high comorbidity between depressive and anxiety symptoms, both trait symptomatology and anxiety disorder are independently associated with increased incident dependency with a gradient of severity: trait anxiety symptoms associated with incident social restriction and anxiety disorder with incidence of IADL limitations.
Higher all-cause mortality and shorter life expectancies for people with severe mental illness (SMI, including schizophrenia, schizoaffective disorder, and bipolar disorder) have been frequently reported. Cancer contributes a substantial proportion of mortality (20 to 30%) as the second or third leading cause of death among people with SMI. Outcomes of cancer incidence studies in SMI were considerably heterogeneous, varying by cancer types and mental disorders.
To compare the incidence of overall and each type of cancer between people with SMI in southeast London and general population in UK.
Using the anonymised linkage between a regional monopoly secondary mental health service provider covering four southeast London boroughs and a population-based cancer register, we carried out the comparisons of cancer incidences between people with SMI and general population by age- and gender-standardisation in 2011.
Among SMI subjects with cancer (N=105), the most common cancer types were lung and colorectal cancer followed by breast cancer for women and prostate cancer for men in this area. Standardised incidence ratios (SIRs) for all cancers in SMI were 1.19 (95% CI: 0.97-1.44) overall, 2.43 (95% CI: 1.98-2.94) in men (n=61), and 0.98 (95% CI: 0.71-1.31) in women (n=44). Based on relatively small case numbers, raised SIRs were found for lung cancer in men (SIR=7.57, 95% CI: 3.04-15.6) and women (SIR=7.61, 95% CI: 2.79-16.6), and in women for colorectal (SIR=7.85, 95%CI: 2.55-18.32) and breast cancer (SIR=7.86, 95% CI: 4.58-12.59).
Specific pattern of elevated risks of cancer incidence were found for people with SMI.
Compared to the general population, people with schizophrenia have a substantially higher risk of premature mortality which translates into a 10–15 year reduction in life expectancy. The aim of this investigation was to determine if symptoms (including aggression, hallucinations or delusions, and depression) or the environmental and functional status of people with schizophrenia contribute to the high mortality risk observed in this patient group.
We identified cases of schizophrenia, aged ≥15 years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of specific symptoms, activities of daily living (ADLs), living conditions, occupational and recreational activities (Health of the Nation Outcome Scale [HoNOS] subscales) on all-cause mortality over a 4-year observation period (2007-10) using Cox regression.
We identified 4270 schizophrenia cases (170 deaths) in the observation period. After controlling for a broad range of covariates, mortality was not significantly associated with hallucinations and delusions or overactive-aggressive behaviour, but was associated with subclinical depression (adjusted HR 1.5; 95% CI 1.1-2.2) and ADL impairment (adjusted HR 1.8; 95% CI 1.2-2.9).
Severity of symptoms, such as delusions and hallucinations, was less important in predicting mortality than subclinical depression and difficulties carrying out activities of daily living. The overall picture appears to be one where the highest all-cause mortality risk is in service users who are least visible to clinical teams.
Longitudinal cognitive change before and after acetyl cholinesterase inhibitor (AChEI) treatment initiation in Alzheimer's disease has never been described previously in a representative clinical population.
To model longitudinal changes in cognitive function for before and after AChEI prescription.
To further investigate differences in response by cognitive function at treatment initiation.
A retrospective longitudinal analysis was carried out of all 1843 patients from the South London and Maudsley NHS Foundation Trust (a large mental health provider to a catchment population of approximately 1.2 m) who were prescribed AChEIs between 2003–10 and had a minimum of one MMSE score within 1 year before treatment initiation and one MMSE score within 3 years after this. Manually extracted MMSE scores were analyzed over this period using three-piece linear mixed models.
Rates of MMSE change were −1.9 (95% CI −2.3,−1.4) in the year before treatment initiation, +1.3 (0.9,1.7) in the 6 months after treatment initiation, and −2.4 (−2.6,−2.3) from 6 months to 3 years. The difference between pre-treatment and 6-month-post-treatment slopes was −0.6 (−1.8,0.6) at baseline (treatment initiation) MMSE of 25 or over, +2.7 (1.7,3.7) at MMSE 21–24, and +4.6 (3.6,5.7) at MMSE 10–20.
In this naturalistic sample, a clear cognitive response to AChEI treatment was observed over the first six months followed by an unchanged decline. Response was substantially higher for patients with lower MMSE scores at treatment initiation.
Previous research in clinical, community, and school settings has demonstrated positive outcomes for the Secret Agent Society (SAS) social skills training program. This is designed to help children on the autism spectrum become more aware of emotions in themselves and others and to ‘problem-solve’ complex social scenarios. Parents play a key role in the implementation of the SAS program, attending information and support sessions with other parents and providing supervision, rewards, and feedback as their children complete weekly ‘home mission’ assignments. Drawing on data from a school-based evaluation of the SAS program, we examined whether parents’ engagement with these elements of the intervention was linked to the quality of their children’s participation and performance. Sixty-eight 8–14-year-olds (M age = 10.7) with a diagnosis of autism participated in the program. The findings indicated that ratings of parental engagement were positively correlated with children’s competence in completing home missions and with the quality of their contribution during group teaching sessions. However, there was a less consistent relationship between parental engagement and measures of children’s social and emotional skill gains over the course of the program.
The symptoms of bipolar disorder are sometimes misrecognised for unipolar depression and inappropriately treated with antidepressants. This may be associated with increased risk of developing mania. However, the extent to which this depends on what type of antidepressant is prescribed remains unclear.
To investigate the association between different classes of antidepressants and subsequent onset of mania/bipolar disorder in a real-world clinical setting.
Data on prior antidepressant therapy were extracted from 21,012 adults with unipolar depression receiving care from the South London and Maudsley NHS Foundation Trust (SLaM). multivariable Cox regression analysis (with age and gender as covariates) was used to investigate the association of antidepressant therapy with risk of developing mania/bipolar disorder.
In total, 91,110 person-years of follow-up data were analysed (mean follow-up: 4.3 years). The overall incidence rate of mania/bipolar disorder was 10.9 per 1000 person-years. The peak incidence of mania/bipolar disorder was seen in patients aged between 26 and 35 years (12.3 per 1000 person-years). The most frequently prescribed antidepressants were SSRIs (35.5%), mirtazapine (9.4%), venlafaxine (5.6%) and TCAs (4.7%). Prior antidepressant treatment was associated with an increased incidence of mania/bipolar disorder ranging from 13.1 to 19.1 per 1000 person-years. Multivariable analysis indicated a significant association with SSRIs (hazard ratio 1.34, 95% CI 1.18–1.52) and venlafaxine (1.35, 1.07–1.70).
In people with unipolar depression, antidepressant treatment is associated with an increased risk of subsequent mania/bipolar disorder. These findings highlight the importance of considering risk factors for mania when treating people with depression.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Mood instability is an important problem but has received relatively little research attention. Natural language processing (NLP) is a novel method, which can used to automatically extract clinical data from electronic health records (EHRs).
To extract mood instability data from EHRs and investigate its impact on people with mental health disorders.
Data on mood instability were extracted using NLP from 27,704 adults receiving care from the South London and Maudsley NHS Foundation Trust (SLaM) for affective, personality or psychotic disorders. These data were used to investigate the association of mood instability with different mental disorders and with hospitalisation and treatment outcomes.
Mood instability was documented in 12.1% of people included in the study. It was most frequently documented in people with bipolar disorder (22.6%), but was also common in personality disorder (17.8%) and schizophrenia (15.5%). It was associated with a greater number of days spent in hospital (B coefficient 18.5, 95% CI 12.1–24.8), greater frequency of hospitalisation (incidence rate ratio 1.95, 1.75–2.17), and an increased likelihood of prescription of antipsychotics (2.03, 1.75–2.35).
Using NLP, it was possible to identify mood instability in a large number of people, which would otherwise not have been possible by manually reading clinical records. Mood instability occurs in a wide range of mental disorders. It is generally associated with poor clinical outcomes. These findings suggest that clinicians should screen for mood instability across all common mental health disorders. The data also highlight the utility of NLP for clinical research.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The life expectancy gap between people with severe mental illness (SMI) and the general population persists and may even be widening. This study aimed to estimate contributions of specific causes of death to the gap. Age of death and primary cause of death were used to estimate life expectancy at birth for people with SMI from a large mental healthcare case register during 2007–2012. Using data for England and Wales in 2010, death rates in the SMI cohort for each primary cause of death category were replaced with gender- and age-specific norms for that cause. Life expectancy in SMI was then re-calculated and, thus, the contribution of that specific cause of death estimated. Natural causes accounted for 79.2% of lost life-years in women with SMI and 78.6% in men. Deaths from circulatory disorders accounted for more life-years lost in women than men (22.0% versus 17.4%, respectively), as did deaths from cancer (8.1% versus 0%), but the contribution from respiratory disorders was lower in women than men (13.7% versus 16.5%). For women, cancer contributed more in those with non-affective than affective disorders, while suicide, respiratory and digestive disorders contributed more in those with affective disorders. In men, respiratory disorders contributed more in non-affective disorders. Other contributions were similar between gender and affective/non-affective groups. Loss of life expectancy in people with SMI is accounted for by a broad range of causes of death, varying by gender and diagnosis. Interventions focused on multiple rather than individual causes of death should be prioritised accordingly.
There are often substantial delays before diagnosis and initiation of treatment in people bipolar disorder. Increased delays are a source of considerable morbidity among affected individuals.
To investigate the factors associated with delays to diagnosis and treatment in people with bipolar disorder.
Retrospective cohort study using electronic health record data from the South London and Maudsley NHS Foundation Trust (SLaM) from 1364 adults diagnosed with bipolar disorder. The following predictor variables were analysed in a multivariable Cox regression analysis on diagnostic delay and treatment delay from first presentation to SLaM: age, gender, ethnicity, compulsory admission to hospital under the UK Mental Health Act, marital status and other diagnoses prior to bipolar disorder.
The median diagnostic delay was 62 days (interquartile range: 17–243) and median treatment delay was 31 days (4–122). Compulsory hospital admission was associated with a significant reduction in both diagnostic delay (hazard ratio 2.58, 95% CI 2.18–3.06) and treatment delay (4.40, 3.63–5.62). Prior diagnoses of other psychiatric disorders were associated with increased diagnostic delay, particularly alcohol (0.48, 0.33–0.41) and substance misuse disorders (0.44, 0.31–0.61). Prior diagnosis of schizophrenia and psychotic depression were associated with reduced treatment delay.
Some individuals experience a significant delay in diagnosis and treatment of bipolar disorder, particularly those with alcohol/substance misuse disorders. These findings highlight a need to better identify the symptoms of bipolar disorder and offer appropriate treatment sooner in order to facilitate improved clinical outcomes. This may include the development of specialist early intervention services.
Disclosure of interest
The authors have not supplied their declaration of competing interest.