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To examine the costs and cost-effectiveness of mirtazapine compared to placebo over 12-week follow-up.
Economic evaluation in a double-blind randomized controlled trial of mirtazapine vs. placebo.
Community settings and care homes in 26 UK centers.
People with probable or possible Alzheimer’s disease and agitation.
Primary outcome included incremental cost of participants’ health and social care per 6-point difference in CMAI score at 12 weeks. Secondary cost-utility analyses examined participants’ and unpaid carers’ gain in quality-adjusted life years (derived from EQ-5D-5L, DEMQOL-Proxy-U, and DEMQOL-U) from the health and social care and societal perspectives.
One hundred and two participants were allocated to each group; 81 mirtazapine and 90 placebo participants completed a 12-week assessment (87 and 95, respectively, completed a 6-week assessment). Mirtazapine and placebo groups did not differ on mean CMAI scores or health and social care costs over the study period, before or after adjustment for center and living arrangement (independent living/care home). On the primary outcome, neither mirtazapine nor placebo could be considered a cost-effective strategy with a high level of confidence. Groups did not differ in terms of participant self- or proxy-rated or carer self-rated quality of life scores, health and social care or societal costs, before or after adjustment.
On cost-effectiveness grounds, the use of mirtazapine cannot be recommended for agitated behaviors in people living with dementia. Effective and cost-effective medications for agitation in dementia remain to be identified in cases where non-pharmacological strategies for managing agitation have been unsuccessful.
To gather information about psychiatric trainees' use of different information sources and academic materials, a questionnaire was distributed at the London Deanery Annual Psychiatry Trainee Conference and the training programmes of two teaching trusts.
Participants returned 202 out of a total of 300 completed questionnaires (67%). Websites were the most commonly accessed information source ahead of textbooks, abstracts and journals. Year of training correlated positively with journal use and negatively with textbook use. Year of training also correlated positively with frequency of reading three journals published by the Royal College of Psychiatrists and with specific reasons for consulting journals, namely to improve clinical practice and inform trainees' own research.
Respondents reported consulting websites more frequently than more traditional information sources but journals are still a widely used source of information for trainee clinicians. It is important that trainees continue to be equipped with skills to identify and access high-quality information at the point of clinical uncertainty.
The anxiety disorders are a prevalent mental health problem in older age with a considerable impact on quality of life. Until recently there have been few longitudinal studies on anxiety in this age group, consequently most of the evidence to date has been cross-sectional in nature.
We undertook a literature search of Medline, PsycINFO, the Cochrane trials database and the TRIP medical database to identify longitudinal studies which would help elucidate natural history and prognosis of anxiety disorders in the elderly.
We identified 12 papers of 10 longitudinal studies in our Review. This represented 34,691 older age participants with 5,199 with anxiety disorders including anxious depression and 3,532 individuals with depression without anxiety. Relapse rates of anxiety disorders are high over 6 year follow-up with considerable migration to mixed anxiety-depression and pure depressive mood episodes. Mixed anxiety-depression appears to be a poorer prognostic state than pure anxiety or pure depression with higher relapse rates across studies. In community settings treatment rates are low with 7–44% of the anxious elderly treated on antidepressant medications.
To our knowledge this is the first Systematic Review of longitudinal trials of anxiety disorders in older people. Major longitudinal studies of the anxious elderly are establishing the high risk of relapse and persistence alongside the progression to depression and anxiety depression states. There remains considerable under-treatment in community studies. Specialist assessment and treatment and major public health awareness of the challenges of anxiety disorders in the elderly are required.
Previous studies have shown that 17 to 60% of psychiatric trainees have been physically or verbally assaulted. To measure the frequency of assaults and the trainees' reactions, we conducted a retrospective self-reported survey of attendees at MRCPsych teaching courses in south London and at an annual meeting of psychiatric trainees.
Overall, 64% of the questionnaires distributed were returned completed. Of the trainees who responded, 41% had been physically assaulted at least once and 89% had been verbally assaulted. As a result of the assault, 34% of trainees were subsequently more risk aware and 11% were now hesitant to assess patients with a history of violence. There was no association between the level of training or attendance at a breakaway training course and having been subject to physical assault.
Our study showed unacceptable levels of physical and verbal assault on psychiatric trainees and an important effect of those incidents on clinical practice.
We examined the effect on civil sections and the rate of appeals against them of the amendments made to the Mental Health Act 1983 as a result of the Mental Health Act 2007. We gathered data for the year before and after the introduction of these changes.
We found increased use of Section 2 (56.8% before and 65.8% after (P < 0.001)) and decreased use of Section 3 (39.5% before and 31.2% after (P < 0.001)). The number of appeals against civil sections decreased (697 before and 692 after) but there was an 8.0% increase in the proportion of appeals to mental health tribunals. There was a decrease in admissions under these sections (817 before and 733 after).
These changes may be unintended consequences of the new law, resulting in increased workloads for psychiatrists and costs to the National Health Service.
There is insufficient research into the relationship between ethnicity and appeals against detention under mental health legislation. We sought to identify rates and success of appeals in different ethnic groups through a retrospective analysis of all detentions under the Mental Health Act 1983 over 1 year.
We found high rates of appeals overall, with substantial differences between ethnic groups (36 (39%) White British compared with 71 (63%) Black Caribbean (P = 0.0001) and 21 (68%) White Irish (P = 0.01) individuals (Yates corrected chi-squared)). Success rates on appeal were very low in all groups.
There are significant ethnic differences in appeals against detention under the Mental Health Act.
We sought to identify changes in the quality of information in referrals to an old age psychiatry service before and after the introduction of the single assessment process. Referrals were compared in terms of length, legibility, information and clinical utility.
Compared with letters before the introduction of the single assessment process, referrals made on the new forms took longer to read (mean 96 v. 124 s, P=0.001), had more illegible sections (P=0.011), contained less information (P=0.026) and were judged to be less clinically useful (P=0.001).
The introduction of the single assessment process has impaired clinical communication between general practitioners and psychiatrists, and might be prejudicial to patient care.
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