Foundation Trust Biomedical Research Centre Research Articles

Associations of remote mental healthcare with clinical outcomes: a natural language processing enriched electronic health record data study protocol

IntroductionPeople often experience significant difficulties in receiving mental healthcare due to insufficient resources, stigma and lack of access to care. Remote care technology has the potential to overcome these barriers...

Prevalence and Correlates of Obsessive-Compulsive Symptoms in Individuals With Schizophrenia, Schizoaffective Disorder, or Bipolar Disorder.

Objective: Although frequently reported in psychosis, obsessive-compulsive symptoms (OCS) are often not recognized and thus undertreated. We aimed to estimate the prevalence of OCS and obsessive-compulsive disorder (OCD) in patients with schizophrenia, schizoaffective disorder, or bipolar disorder in clinical records and identify clinical associations of OCS co-occurrence.Methods: Data were retrieved from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre case register. The study population was restricted to individuals diagnosed with schizophrenia (ICD F20.x), schizoaffective disorder (ICD F25.x), or bipolar disorder (ICD F31.x) between 2007 and 2015. OCS and OCD were ascertained from structural fields and via Natural Language Processing software applied to free-text records. Clinical characteristics were obtained from Health of the Nation Outcome Scales for the analyses on associations between clinical characteristics and OCS/OCD status using logistic regressions with confounders considered.Results: 22,551 cases of schizophrenia, schizoaffective disorder, or bipolar disorder were identified in the observation window. Among these, 5,179 (24.0%) were identified as having OCS (including an OCD diagnosis) and 2,574 (11.9%) specifically with comorbid OCD. OCS/OCD was associated with an increased likelihood of recorded aggressive behavior (OR = 1.18; 95% CI, 1.10-1.26), cognitive problems (OR = 1.21; 95% CI, 1.13-1.30), hallucinations and delusions (OR = 1.11; 95% CI, 1.04-1.20), and physical problems (OR = 1.17; 95% CI, 1.09-1.26).Conclusions: OCS and OCD are frequently recorded for patients with schizophrenia, schizoaffective disorder, and bipolar disorder and are associated with more severe psychiatric clinical characteristics. Automated information extraction tools hold potential to improve recognition and treatment of co-occurring OCS/OCD for psychosis.

Mapping multimorbidity in individuals with schizophrenia and bipolar disorders: evidence from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register

ObjectivesThe first aim of this study was to design and develop a valid and replicable strategy to extract physical health conditions from clinical notes which are common in mental health...

The challenges and opportunities of mental health data sharing in the UK

The challenges and opportunities of mental health data sharing in the UK

Factors associated with slow progression of cognitive impairment following first dementia diagnosis.

To investigate the extent to which slow progression of dementia after diagnosis might be predicted from routine longitudinal healthcare data, in order to clarify characteristics of people who experience this outcome. A retrospective observational study was conducted using data from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre Case Register. This study included all patients receiving a first dementia diagnosis between 2006 and 2017, restricted to those with a baseline Mini-Mental State Examination (MMSE) score within 6 months of initial diagnosis of dementia and at least one MMSE score after 3 years post-diagnosis. Slow progression was defined as a change in MMSE score of -1, 0 or an increase at the follow-up point. This group was compared to the remainder with an MMSE decline of -2 or more. Overall, 682 patients with slow progression were compared to 1045 with faster progression. In the confounder-adjusted multivariate logistic regression model, slow progression was more likely in younger patients (age 65-74 years; odds ratio: 1.18; 95% confidence intervals: 1.04-1.37), males (1.24; 1.01-1.53), those with moderate or severe dementia according to MMSE, patients with mixed-type dementia (2.06; 1.11-3.82) compared to Alzheimer's disease and less likely in those receiving acetylcholinesterase inhibitor (AChEI) treatment (0.57; 0.46-0.71). Slow dementia progression after diagnosis was common in patients with mixed Alzheimer's and vascular dementia, younger age, males and non-receipt of AChEIs, possibly suggesting non-Alzheimer pathologies and clarifying such predictors is important, as there is currently very limited information on which to base prognosis estimates in post-diagnosis counselling.

Mental health in South East London general hospitals: using electronic patient records to explore associations between psychiatric diagnoses and length of stay in a patient cohort receiving liaison psychiatry input.

Psychiatric illnesses are prevalent in general hospitals and associated with length of stay (LOS). Liaison psychiatry teams provide psychiatric care in acute hospitals and can improve mental health-related outcomes but, to achieve ambitious policy targets, services must understand local need. Using electronic patient records, we investigate associations between psychiatric diagnoses and LOS in South East London hospitals. Patient records were extracted using the South London and Maudsley NHS Foundation Trust Biomedical Research Centre Case Register Interactive Search system. There were 6378 admissions seen by liaison psychiatry aged <65 years between 2011 and 2016. Linear mixed-effects models investigated the impact of psychiatric diagnoses on LOS. Potential confounders included medical diagnoses, gender, age, ethnicity, social deprivation, hospital site and investment per admission. According to marginal means, longer LOS is associated with primary diagnoses of organic disorders (mean: 23 days, 95% CI 20.39-25.61), depressive disorders (mean: 11.03 days, 95% CI 9.74-25.61) and psychotic disorders (mean: 10.63 days, 95% CI 8.75-12.51). Shorter LOS is associated with personality disorders (mean: 6.28 days, 95% CI 4.12-8.45), bipolar affective disorders (mean 6.81 days, 95% CI 3.49-10.14) and substance-related problems (mean 7.53 days, 95% CI 6.01-9.05). Psychiatric diagnoses have differential associations with in-patient LOS. Liaison psychiatry teams aim to mitigate the impact of psychiatric illness on patient and hospital outcomes but understanding local need and the wider context of care provision is needed to maximise potential benefits. M.H. is a consultant liaison psychiatrist for King's College Hospital adult liaison psychiatry team. At the time of writing, H.T. was senior business manager at SLaM psychological medicine and integrated care clinical academic group. These may be considered financial and/or non-financial interests given the implications of findings for service funding.

Can risk assessment predict suicide in secondary mental healthcare? Findings from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register

PurposeThe predictive value of suicide risk assessment in secondary mental healthcare remains unclear. This study aimed to investigate the extent to which clinical risk assessment ratings can predict suicide among people receiving secondary mental healthcare.MethodsRetrospective inception cohort study (n = 13,758) from the South London and Maudsley NHS Foundation Trust (SLaM) (London, UK) linked with national mortality data (n = 81 suicides). Cox regression models assessed survival from the last suicide risk assessment and ROC curves evaluated the performance of risk assessment total scores.ResultsHopelessness (RR = 2.24, 95% CI 1.05–4.80, p = 0.037) and having a significant loss (RR = 1.91, 95% CI 1.03–3.55, p = 0.041) were significantly associated with suicide in the multivariable Cox regression models. However, screening statistics for the best cut-off point (4–5) of the risk assessment total score were: sensitivity 0.65 (95% CI 0.54–0.76), specificity 0.62 (95% CI 0.62–0.63), positive predictive value 0.01 (95% CI 0.01–0.01) and negative predictive value 0.99 (95% CI 0.99–1.00).ConclusionsAlthough suicide was linked with hopelessness and having a significant loss, risk assessment performed poorly to predict such an uncommon outcome in a large case register of patients receiving secondary mental healthcare.

Comparison of clinical outcomes associated with long-acting injectable antipsychotics in people with psychotic disorders: an electronic case register study

BackgroundLong-acting injectable (LAI) antipsychotics have been shown to reduce risk of relapse in people with psychosis. Second generation LAI antipsychotics such as paliperidone palmitate can have fewer side-effects and be better tolerated than first generation LAI antipsychotics. However, paliperidone palmitate is more expensive and there are few data comparing its effectiveness and tolerability with that of other LAI antipsychotics. We sought to address this issue by analysing a large electronic mental health case register. MethodsThe South London and Maudsley NHS Foundation Trust Biomedical Research Centre Case Register was used to obtain data about people who had started treatment with an LAI antipsychotic between April 1, 2011, and Jan 31, 2015. The number of days spent as a psychiatric inpatient and the number of admissions to a psychiatric hospital were analysed using multivariable regression with age, sex, ethnicity, marital status, diagnosis, and London borough of residence as covariates. Findings1281 people had started treatment with LAI antipsychotics. The most frequently prescribed LAI was paliperidone palmitate (n=430, 33·6%) followed by zuclopenthixol decanoate (226, 17·6%), flupentixol decanoate (203, 15·9%), risperidone (160, 12·5%), pipotiazine palmitate (114, 8·9%), haloperidol (71, 5·5%), fluphenazine decanoate (36, 2·8%), aripiprazole (27, 2·1%), and olanzapine embonate (14, 1·1%). There were no significant differences between paliperidone and other LAI antipsychotics in the number of days as an inpatient (β coefficient 5·4 days, 95% CI −57·3 to 68·2) or number of hospital admissions after initiation of treatment (incidence rate ratio 1·07, 95% CI 0·62 to 1·83). InterpretationThe absence of differences in hospital admission after initiation of LAI antipsychotics indicates that the effectiveness of the second generation LAI paliperidone palmitate was similar to that of other LAI antipsychotics. However, the discontinuation rate in the first year of treatment is lower for paliperidone palmitate (35%) than for other LAI antipsychotics suggesting that it is better tolerated. These findings merit consideration in relation to the choice of LAI antipsychotic to prescribe in people with psychotic disorders. FundingNational Institute for Health Research, Medical Research Council.

Cohort profile of the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register: current status and recent enhancement of an Electronic Mental Health Record-derived data resource

PurposeThe South London and Maudsley National Health Service (NHS) Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register and its Clinical Record Interactive Search (CRIS) application were developed in 2008,...

Mortality of people with chronic fatigue syndrome: a retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register.

Mortality associated with chronic fatigue syndrome is uncertain. We investigated mortality in individuals diagnosed with chronic fatigue syndrome in secondary and tertiary care using data from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) register. We calculated standardised mortality ratios (SMRs) for all-cause, suicide-specific, and cancer-specific mortality for a 7-year observation period using the number of deaths observed in SLaM records compared with age-specific and sex-specific mortality statistics for England and Wales. Study participants were included if they had had contact with the chronic fatigue service (referral, discharge, or case note entry) and received a diagnosis of chronic fatigue syndrome. We identified 2147 cases of chronic fatigue syndrome from CRIS and 17 deaths from Jan 1, 2007, to Dec 31, 2013. 1533 patients were women of whom 11 died, and 614 were men of whom six died. There was no significant difference in age-standardised and sex-standardised mortality ratios (SMRs) for all-cause mortality (SMR 1·14, 95% CI 0·65-1·85; p=0·67) or cancer-specific mortality (1·39, 0·60-2·73; p=0·45) in patients with chronic fatigue syndrome when compared with the general population in England and Wales. This remained the case when deaths from suicide were removed from the analysis. There was a significant increase in suicide-specific mortality (SMR 6·85, 95% CI 2·22-15·98; p=0·002). We did not note increased all-cause mortality in people with chronic fatigue syndrome, but our findings show a substantial increase in mortality from suicide. This highlights the need for clinicians to be aware of the increased risk of completed suicide and to assess suicidality adequately in patients with chronic fatigue syndrome. National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London.

Clinical risk assessment rating and all-cause mortality in secondary mental healthcare: the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) Case Register

Mental disorders are widely recognized to be associated with increased risk of all-cause mortality. However, the extent to which highest-risk groups for mortality overlap with those viewed with highest concern by mental health services is less clear. The aim of the study was to investigate clinical risk assessment ratings for suicide, violence and self-neglect in relation to all-cause mortality among people receiving secondary mental healthcare. A total of 9234 subjects over the age of 15 years were identified from the South London and Maudsley Biomedical Research Centre Case Register who had received a second tier structured risk assessment in the course of their clinical care. A cohort analysis was carried out. Total scores for three risk assessment clusters (suicide, violence and self-neglect) were calculated and Cox regression models used to assess survival from first assessment. A total of 234 deaths had occurred over an average 9.4-month follow-up period. Mortality was relatively high for the cohort overall in relation to national norms [standardized mortality ratio 3.23, 95% confidence interval (CI) 2.83-3.67] but not in relation to other mental health service users with similar diagnoses. Only the score for the self-neglect cluster predicted mortality [hazard ratio (HR) per unit increase 1.14, 95% CI 1.04-1.24] with null findings for assessed risk of suicide or violence (HRs per unit increase 1.00 and 1.06 respectively). Level of clinician-appraised risk of self-neglect, but not of suicide or violence, predicted all-cause mortality among people receiving specific assessment of risk in a secondary mental health service.

The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register: development and descriptive data

BackgroundCase registers have been used extensively in mental health research. Recent developments in electronic medical records, and in computer software to search and analyse these in anonymised format, have the potential to revolutionise this research tool.MethodsWe describe the development of the South London and Maudsley NHS Foundation Trust (SLAM) Biomedical Research Centre (BRC) Case Register Interactive Search tool (CRIS) which allows research-accessible datasets to be derived from SLAM, the largest provider of secondary mental healthcare in Europe. All clinical data, including free text, are available for analysis in the form of anonymised datasets. Development involved both the building of the system and setting in place the necessary security (with both functional and procedural elements).ResultsDescriptive data are presented for the Register database as of October 2008. The database at that point included 122,440 cases, 35,396 of whom were receiving active case management under the Care Programme Approach. In terms of gender and ethnicity, the database was reasonably representative of the source population. The most common assigned primary diagnoses were within the ICD mood disorders (n = 12,756) category followed by schizophrenia and related disorders (8158), substance misuse (7749), neuroses (7105) and organic disorders (6414).ConclusionThe SLAM BRC Case Register represents a 'new generation' of this research design, built on a long-running system of fully electronic clinical records and allowing in-depth secondary analysis of both numerical, string and free text data, whilst preserving anonymity through technical and procedural safeguards.