Bending the curve on psychosis outcomes

Abstract

Comment report; 7 however, of individuals who accepted referral, only 14% actually engaged with stop smoking services to the point of setting a quit date and only 9% stopped smoking for 4 weeks. By contrast, an approach in which opt-out services were integrated into care on a general medical ward achieved much greater uptake of cessation support and roughly doubled the proportion of smokers quitting relative to usual care, dependent on the clinician’s initiative. 8 For these reasons, among others, the UK National Institute for Health and Care Excellence (NICE) issued guidance in 2013 on smoking cessation in secondary care, which for psychiatry includes much care delivered in the community. 5 An integrated systematic approach to treatment of smoking was endorsed, similar to the active intervention tested in SCIMITAR. The research priority now is not to establish whether the systematic approach is more eff ective but how best to integrate smoking services to maximise uptake and delivery in both secondary and primary mental health care services. Examples of good practice in the NHS exist. Cheshire and Wirral Partnership Trust went smoke free in February, 2014. As part of a comprehensive nicotine management policy, 9 the Trust aims to ensure that all patients admitted acutely who smoke are seen and provided with treatment, including provision of nicotine replacement treatment, by a trained cessation practitioner within 15 min. Furthermore, the South London and Maudsley Trust went smoke free in October, 2014, and other Trusts are following suit. Reversing the legacy of high smoking prevalence in mental health populations is not going to be easy or quick, but enough evidence is available to know one place to start. John Britton UK Centre for Tobacco and Alcohol Studies, Division of Epidemiology and Public Health, University of Nottingham, City Hospital, Nottingham NG5 1PB, UK j.britton@outlook.com I declare no competing interests. Health and Social Care Information Centre. Table 2.6: cigarette smoking status among adults, by gender and marital status, 2009. Aug 16, 2011. http://www.hscic.gov.uk/catalogue/PUB00693/smok-eng-2011-tab.xls (accessed March 6, 2015). Royal College of Physicians, Royal College of Psychiatrists. Smoking and mental health: a joint report by the Royal College of Physicians and the Royal College of Psychiatrists. 2013. http://www.rcplondon.ac.uk/sites/ default/fi les/smoking_and_mental_health_-_full_report_web.pdf (accessed March 6, 2015). Szatkowski L, McNeill A. Diverging trends in smoking behaviors according to mental health status. Nicotine Tob Res 2015; 17: 356–60. Chang CK, Hayes RD, Perera G, et al. Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One 2011; 6: e19590. National Institute for Health and Care Excellence. Smoking cessation: acute, maternity and mental health services (PH48). November, 2013. http://www.nice.org.uk/guidance/ph48 (accessed March 6, 2015). Gilbody S, Peckham E, Man M-S, et al. Bespoke smoking cessation for people with severe mental ill health (SCIMITAR): a pilot randomised controlled trial. Lancet Psychiatry 2015; published online April 1. http://dx.doi.org/10.1016/S2215-0366(15)00091-7. National Centre for Smoking Cessation Training. Streamlined secondary care system: project report. June, 2012. http://www.ncsct.co.uk/usr/pub/ ncsct-streamlined-secondary-care-fi nal-report.pdf (accessed March 6, Murray RL, Leonardi-Bee J, Marsh J, et al. Systematic identifi cation and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial. BMJ 2013; 347: f4004. Cheshire and Wirral Partnership NHS Foundation Trust. Nicotine management policy. June 20, 2013. http://www.cwp.nhs.uk/ uploads/2460 (accessed March 6, 2015). Bending the curve on psychosis outcomes Priorities for the development of treatments for psychosis have gradually shifted to early interventions that are designed to soften or even prevent the debilitating course of illness. To “bend the curve”—ie, change the conditions such that individual outcomes improve and societal eff ects of psychotic disorders are reduced, 1 we must advance our understanding of the neurobiological substrates of their most dis- abling symptoms, and use this information to guide mechanistic, hypothesis-driven treatment studies. Although functional outcomes in psychotic dis- orders are closely linked to the severity of negative www.thelancet.com/psychiatry Vol 2 May 2015 symptoms and cognitive impairment, 2 few, if any, pharmacological treatments exist for these disabling symptoms. The need for novel therapeutics that improve function in patients with psychosis is evident in the rates at which these patients are homeless, incarcerated, or reside in long-term residential care facilities. In The Lancet Psychiatry, Joshua Kantrowitz and colleagues 3 convincingly show that a rationally selected modulator of the N-methyl-D-aspartate-type glutamate receptor (NMDAR) might substantially reduce negative symptoms in young people at clinical high risk of developing psychosis. The investigators See Articles page 403