Psychiatry - Research Publications
Now showing items 1-12 of 555
The Post-Anaesthesia N-acetylcysteine Cognitive Evaluation (PANACEA) trial: study protocol for a randomised controlled trial
BACKGROUND: Some degree of cognitive decline after surgery occurs in as many as one quarter of elderly surgical patients, and this decline is associated with increased morbidity and mortality. Cognition may be affected across a range of domains, including memory, psychomotor skills, and executive function. Whilst the exact mechanisms of cognitive change after surgery are not precisely known, oxidative stress and subsequent neuroinflammation have been implicated. N-acetylcysteine (NAC) acts via multiple interrelated mechanisms to influence oxidative homeostasis, neuronal transmission, and inflammation. NAC has been shown to reduce oxidative stress and inflammation in both human and animal models. There is clinical evidence to suggest that NAC may be beneficial in preventing the cognitive decline associated with both acute physiological insults and dementia-related disorders. To date, no trials have examined perioperative NAC as a potential moderator of postoperative cognitive changes in the noncardiac surgery setting. METHODS AND DESIGN: This is a single-centre, randomised, double-blind, placebo-controlled clinical trial, with a between-group, repeated-measures, longitudinal design. The study will recruit 370 noncardiac surgical patients at the University Hospital Geelong, aged 60 years or older. Participants are randomly assigned to receive either NAC or placebo (1:1 ratio), and groups are stratified by age and surgery type. Participants undergo a series of neuropsychological tests prior to surgery, 7 days, 3 months, and 12 months post surgery. It is hypothesised that the perioperative administration of NAC will reduce the degree of postoperative cognitive changes at early and long-term follow-up, as measured by changes on individual measures of the neurocognitive battery, when compared with placebo. Serum samples are taken on the day of surgery and on day 2 post surgery to quantitate any changes in levels of biomarkers of inflammation and oxidative stress. DISCUSSION: The PANACEA trial aims to examine the potential efficacy of perioperative NAC to reduce the severity of postoperative cognitive dysfunction in an elderly, noncardiac surgery population. This is an entirely novel approach to the prevention of postoperative cognitive dysfunction and will have high impact and translatable outcomes if NAC is found to be beneficial. TRIAL REGISTRATION: The PANACEA trial has been registered with the Therapeutic Goods Administration, and the Australian New Zealand Clinical Trials Registry: ACTRN12614000411640 ; registered on 15 April 2014.
Development and validation of a mental health screening tool for asylum-seekers and refugees: the STAR-MH
(BIOMED CENTRAL LTD, 2018-03-16)
BACKGROUND: There is no screening tool for major depressive disorder (MDD) or post-traumatic stress disorder (PTSD) in asylum-seekers or refugees (ASR) that can be readily administered by non-mental health workers. Hence, we aimed to develop a brief, sensitive and rapidly administrable tool for non-mental health workers to screen for MDD and PTSD in ASR. METHODS: The screening tool was developed from an extant dataset (n = 121) of multiply screened ASR and tested prospectively (N = 192) against the M.I.N.I. (Mini International Neuropsychiatric Interview) structured psychiatric interview. Rasch, Differential Item Functioning and ROC analyses evaluated the psychometric properties and tool utility. RESULTS: A 9-item tool with a median administration time of six minutes was generated, comprising two 'immediate screen-in' items, and a 7-item scale. The prevalence of PTSD &/or MDD using the M.I.N.I. was 32%, whilst 99% of other diagnosed mental disorders were comorbid with one or both of these. Using a cut-score of ≥2, the tool provided a sensitivity of 0.93, specificity of 0.75 and predictive accuracy of 80.7%. CONCLUSIONS: A brief sensitive screening tool with robust psychometric properties that was easy to administer at the agency of first presentation was developed to facilitate mental health referrals for asylum-seekers and new refugees.
The impact of substance use on treatment as a compulsory patient
(SAGE PUBLICATIONS LTD, 2019-08-01)
OBJECTIVES: This paper considers the impact of having a diagnosis of substance use disorder on the utilisation of compulsory orders under the Victorian Mental Health Act (2014). METHODS: We analysed the subsequent treatment episodes over 2 years of people who had been on a community treatment order for at least 3 months and determined the odds of a further treatment order if there was a diagnosis of substance use at or about the time the index community treatment order ended. RESULTS: An additional diagnosis of a substance use disorder was coded in 47.7% and was associated with significantly increased odds of a subsequent treatment order in the following 2 years for those with a main diagnosis of schizophrenia (AOR = 3.03, p<0.001) and 'other' disorders (AOR = 11.60, p=0.002). Those with a main diagnosis of mood disorder had a significant increase in odds for an inpatient treatment order if there was an additional substance use disorder diagnosis (AOR = 3.81, p=0.006). CONCLUSIONS: Having an additional diagnosis of substance use disorder was associated with increased likelihood of being placed on an order. This study supports greater emphasis being given to treatment of substance use concurrently with that of mental illness.
Does legislative change affect the use and duration of compulsory treatment orders?
(SAGE PUBLICATIONS LTD, 2019-05-01)
OBJECTIVE: Victoria, Australia, introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimisation of the use and duration of compulsory orders. This paper compares service utilisation and legal status after being on a community treatment order under the Mental Health Act 1986 (Vic) with that under the Mental Health Act 2014 (Vic). METHODS: We obtained two distinct data sets of persons who had been on a community treatment order for at least 3 months and their subsequent treatment episodes over 2 years under the Mental Health Act and/or as an inpatient for the periods 2008-2010 (Mental Health Act 1986) and 2014-2016 (Mental Health Act 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over 2 years. We also considered the mode of discharge - whether by the treating psychiatrist, external body or through expiry. RESULTS: Compared with the Mental Health Act 1986, under the Mental Health Act 2014, index community treatment orders were shorter (mean 227 days compared with 335 days); there was a reduction in the mean number of community treatment orders in the 2 years following the index discharge - 1.1 compared with 1.5 (incidence rate ratio (IRR) = 0.71, 95% confidence interval = [0.63, 0.80]) - and a 51% reduction in days on an order over 2 years. There was a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist under the Mental Health Act 2014 compared to those under the Mental Health Act 1986. The number of orders which were varied to an inpatient order by the authorised psychiatrist was notably greater under the Mental Health Act 2014. CONCLUSION: The reformed Mental Health Act has been successful in its intent to reduce the use and duration of compulsory orders in the community. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.
Evaluating the effectiveness of a website about masculinity and suicide to prompt help-seeking.
(Wiley - John Wiley & Sons, 2019-02-25)
ISSUE ADDRESSED: A website was designed to form the core of a multimedia strategy surrounding the Man Up documentary - a three-part documentary that aimed to address the problem of male suicide in Australia. Together these formed a media-based, public health intervention that explored the link between masculinity and suicide and promoted help-seeking. This is of great importance given the demonstrated link between masculine norms, men's reduced help-seeking and suicidal thinking. This study assesses the website's effectiveness in facilitating help-seeking and fostering conversations about suicide, mental health and help-seeking. Help-seeking indicators included website clicks to helping organisations, downloads of health information from the website and request for help received via emails. METHODS: Google Analytics data, emails to the Man Up team received through the website and open-ended responses to an online survey were analysed. RESULTS: The website reached 43 140 users. Indictors of help-seeking activity on the website included 307 outbound clicks to helping organisations and 802 downloads of health information. Qualitative analysis of emails received and responses to the survey demonstrated that Man Up's messages resonated with viewers and provided further evidence of help-seeking. CONCLUSION: The findings demonstrate that the website provided an important opportunity for people to engage with Man Up and seek help. SO WHAT?: Media-based public health interventions offer enormous potential to provide suicide prevention interventions and promote help-seeking. The website evaluation findings provide insight into the ways in which websites can be used as part of a multimedia strategy to address the problem of male suicide.
Treatment and outcomes of an Australian cohort of outpatients with bipolar I or schizoaffective disorder over twenty-four months: implications for clinical practice
BACKGROUND: The Bipolar Comprehensive Outcomes Study (BCOS) is a 2-year, prospective, non-interventional, observational study designed to explore the clinical and functional outcomes associated with 'real-world' treatment of participants with bipolar I or schizoaffective disorder. All participants received treatment as usual. There was no study medication. METHODS: Participants prescribed either conventional mood stabilizers (CMS; n = 155) alone, or olanzapine with, or without, CMS (olanzapine ± CMS; n = 84) were assessed every 3 months using several measures, including the Young Mania Rating Scale, 21-item Hamilton Depression Rating Scale, Clinical Global Impressions Scale - Bipolar Version, and the EuroQol Instrument. This paper reports 24-month longitudinal clinical, pharmacological, functional, and socioeconomic data. RESULTS: On average, participants were 42 (range 18 to 79) years of age, 58%; were female, and 73%; had a diagnosis of bipolar I. Polypharmacy was the usual approach to pharmacological treatment; participants took a median of 5 different psychotropic medications over the course of the study, and spent a median proportion of time of 100%; of the study on mood stabilizers, 90%; on antipsychotics, 9%; on antidepressants, and 5%; on benzodiazepines/hypnotics. By 24 months, the majority of participants had achieved both symptomatic and syndromal remission of both mania and depression. Symptomatic relapse rates were similar for both the CMS alone (65%;) and the olanzapine ± CMS (61%;) cohorts. CONCLUSIONS: Participants with bipolar I or schizoaffective disorder in this study were receiving complex medication treatments that were often discordant with recommendations made in contemporary major treatment guidelines. The majority of study participants demonstrated some clinical and functional improvements, but not all achieved remission of symptoms or syndrome.
The experience of the use of Community Treatment Orders following recovery-oriented practice training
(PERGAMON-ELSEVIER SCIENCE LTD, 2019-05-01)
States across Australia are changing and adapting policy and laws to deliver mental health services using principles of personal recovery. Yet, the use of Community Treatment Orders (CTOs) remains high in apparent contradiction with this change. As part of the PULSAR trial investigating the outcomes of recovery oriented practice (ROP) training in primary and secondary care services within Metropolitan Melbourne, Victoria, a qualitative study was undertaken to explore the intersection between implementing ROP and working with consumers on CTOs. In-depth interviews were undertaken with consumers with experience being on CTOs and staff of secondary care services, and inductively analysed to identify themes. For consumers, being on a CTO meant lacking choice and control, an emphasis on medication, fear of the threat of hospitalisation, an absence of recovery oriented practice, and staying supported. For staff, recovery oriented practice in the presence of CTOs is challenging, with CTOs being seen to be a primary way to manage risk. Staff supported recovery as a practice, but identified a lack of organisational 'buy in' by services. The findings of this small scale study, embedded in a much larger study about ROP, support other literature that identifies implementing ROP in services that use CTOs as potentially problematic; and that ROP can enhance both consumers and staff experiences of services but, without systemic change, there may not be a significant shift in the use of CTOs, while CTOs also inhibit uptake of ROP.
From rehabilitation to recovery: protocol for a randomised controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke
BACKGROUND: There is much discourse in healthcare about the importance of client-centred rehabilitation, however in the realm of community-based therapy post-stroke there has been little investigation into the efficacy of goal-directed practice that reflects patients' valued activities. In addition, the effect of active involvement of carers in such a rehabilitation process and their subsequent contribution to functional and emotional recovery post-stroke is unclear. In community based rehabilitation, interventions based on patients' perceived needs may be more likely to alter such outcomes. In this paper, we describe the methodology of a randomised controlled trial of an integrated approach to facilitating patient goal achievement in the first year post-stroke. The effectiveness of this intervention in reducing the severity of post-stroke depression, improving participation status and health-related quality of life is examined. The impact on carers is also examined. METHODS/DESIGN: Patients (and their primary carers, if available) are randomly allocated to an intervention or control arm of the study. The intervention is multimodal and aims to screen for adverse stroke sequelae and address ways to enhance participation in patient-valued activities. Intervention methods include: telephone contacts, written information provision, home visitation, and contact with treating health professionals, with further relevant health service referrals as required. The control involves treatment as usual, as determined by inpatient and community rehabilitation treating teams. Formal blinded assessments are conducted at discharge from inpatient rehabilitation, and at six and twelve months post-stroke. The primary outcome is depression. Secondary outcome measures include participation and activity status, health-related quality of life, and self-efficacy. DISCUSSION: The results of this trial will assist with the development of a model for community-based rehabilitation management for stroke patients and their carers, with emphasis on goal-directed practice to enhance home and community participation status. Facilitation of participation in valued activities may be effective in reducing the incidence or severity of post-stroke depression, as well as enhancing the individual's perception of their health-related quality of life. The engagement of carers in the rehabilitation process will enable review of the influence of the broader social context on recovery. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000042347.
Physical therapy as an environmental modulator of genetic determinism in HD: The FIT-HD study
(IOS Press, 2013)
HD has long been viewed as the quintessential example of genetic determinism. However, research has demonstrated that environmental factors play a signifi cant role in modulating the disease process, including the age of onset. In transgenic mouse models of HD, co-author Hannan’s laboratory has demonstrated that environmental enrichment (enhanced motor, cognitive and sensory stimulation) delays onset and progression of motor symptoms and neural degeneration. Introducing an exercise wheel to young HD mice delays onset and progression of motor symptoms, and reverses reduction of brain derived neurotrophic factor in the striatum and hippocampus. Such stimulation has also ameliorated defi cits in learning and memory, as well as depressive behaviours in HD mice. Physical activity (PA) has been found to have benefi cial neural effects in older adults, with increases in hippocampal volume and cognition, apparent even when exercise is limited to later life. We have found that PA improved cognitive function in those at risk of Alzheimer’s disease (AD), and are conducting randomized controlled trials (RCT) investigating this PA program in AD patients, older adults at risk of AD with vascular risk factors or sedentary lifestyle, and in older care recipients and carers. The role of exercise as a potential modifi er is receiving increasing attention in HD. Avoiding passivity was found to be a potential benefi cial modulator in HD, and a PA program improved in motor function in HD patients. However, evidence from RCTs is lacking. AIMS of this study are to: 1) examine the feasibility of our PA program in FIT-HD (by measuring adherence, acceptability, benefi ts, risks); 2) improve physical and mental health and quality of life in HD carriers. HYPOTHESES. Participants randomised to the PA program will: 1) increase PA and adhere to the protocol; have 2) improved quality of life and fi tness, 3) improved sleep, 4) less motor and cognitive decline, 5) improved resting brain state, and 6) have less depressive symptoms, as compared to participants randomised to usual care. Methods: RCT of a validated 24-week PA intervention in HD in Australia. Participants are randomly allocated to an education/usual care group or to a 24-week home-based PA program. Results: PA should be more promoted in the HD community due to multiple health benefi ts. Should our RCT be completed successfully and our hypotheses supported then this could change clinical care of HD.
Cognitive Reserve and Brain Reserve in Prodromal Huntington's Disease
(Cambridge University Press (CUP), 2013-08)
Huntington disease (HD) is associated with decline in cognition and progressive morphological changes in brain structures. Cognitive reserve may represent a mechanism by which disease-related decline may be delayed or slowed. The current study examined the relationship between cognitive reserve and longitudinal change in cognitive functioning and brain volumes among prodromal (gene expansion-positive) HD individuals. Participants were genetically confirmed individuals with prodromal HD enrolled in the PREDICT-HD study. Cognitive reserve was computed as the composite of performance on a lexical task estimating premorbid intellectual level, occupational status, and years of education. Linear mixed effects regression (LMER) was used to examine longitudinal changes on four cognitive measures and three brain volumes over approximately 6 years. Higher cognitive reserve was significantly associated with a slower rate of change on one cognitive measure (Trail Making Test, Part B) and slower rate of volume loss in two brain structures (caudate, putamen) for those estimated to be closest to motor disease onset. This relationship was not observed among those estimated to be further from motor disease onset. Our findings demonstrate a relationship between cognitive reserve and both a measure of executive functioning and integrity of certain brain structures in prodromal HD individuals.
Prediction of manifest Huntington's disease with clinical and imaging measures: a prospective observational study
(Elsevier BV, 2014-12)
Background: Although the association between cytosine-adenine-guanine (CAG) repeat length and age at onset of Huntington's disease is well known, improved prediction of onset would be advantageous for clinical trial design and prognostic counselling. We compared various measures for tracking progression and predicting conversion to manifest Huntington's disease. Methods: In this prospective observational study, we assessed the ability of 40 measures in five domains (motor, cognitive, psychiatric, functional, and imaging) to predict time to motor diagnosis of Huntington's disease, accounting for CAG repeat length, age, and the interaction of CAG repeat length and age. Eligible participants were individuals from the PREDICT-HD study (from 33 centres in six countries [USA, Canada, Germany, Australia, Spain, UK]) with the gene mutation for Huntington's disease but without a motor diagnosis (a rating below 4 on the diagnostic confidence level from the 15-item motor assessment of the Unified Huntington's Disease Rating Scale). Participants were followed up between September, 2002, and July, 2014. We used joint modelling of longitudinal and survival data to examine the extent to which baseline and change of measures analysed separately was predictive of CAG-adjusted age at motor diagnosis. Findings: 1078 individuals with a CAG expansion were included in this analysis. Participants were followed up for a mean of 5·1 years (SD 3·3, range 0·0–12·0). 225 (21%) of these participants received a motor diagnosis of Huntington's disease during the study. 37 of 40 cross-sectional and longitudinal clinical and imaging measures were significant predictors of motor diagnosis beyond CAG repeat length and age. The strongest predictors were in the motor, imaging, and cognitive domains: an increase of one SD in total motor score (motor domain) increased the risk of a motor diagnosis by 3·07 times (95% CI 2·26–4·16), a reduction of one SD in putamen volume (imaging domain) increased risk by 3·32 times (2·37–4·65), and a reduction of one SD in Stroop word score (cognitive domain) increased risk by 2·32 times (1·88–2·87). Interpretation: Prediction of diagnosis of Huntington's disease can be improved beyond that obtained by CAG repeat length and age alone. Such knowledge about potential predictors of manifest Huntington's disease should inform discussions about guidelines for diagnosis, prognosis, and counselling, and might be useful in guiding the selection of participants and outcome measures for clinical trials.
The Stroke and Carer Optimal Health Program (SCOHP) to enhance psychosocial health: study protocol for a randomised control trial
(BioMed Central, 2016)
Background: Stroke is a leading cause of disability and distress, and often profoundly affects the quality of life of stroke survivors and their carers. With the support of carers, many stroke survivors are returning to live in the community despite the presence of disability and ongoing challenges. The sudden and catastrophic changes caused by stroke affects the mental, emotional and social health of both stroke survivors and carers. The aim of this study is to evaluate a Stroke and Carer Optimal Health Program (SCOHP) that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of stroke survivors and their carers. Methods: This study is a prospective randomised controlled trial. It will include a total of 168 stroke survivors and carers randomly allocated into an intervention group (SCOHP) or a control group (usual care). Participants randomised to the intervention group will receive nine (8 + 1 booster) sessions guided by a structured workbook. The primary outcome measures for stroke survivors and carers will be health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE). Secondary outcome measures will include: anxiety and depression (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). Process evaluation and a health economic cost analysis will also be conducted. Discussion: We believe that this is an innovative intervention that engages the stroke survivor and carer and will be significant in improving the psychosocial health, increasing independence and reducing treatment-related costs in this vulnerable patient-carer dyad. In addition, we expect that the intervention will assist carers and stroke survivors to negotiate the complexity of health services across the trajectory of care and provide practical skills to improve self-management.