Naturalistic Cohort Study Research Articles

Beyond the Walls: An Evaluation of a Pre-Release Planning (PReP) Programme for Sentenced Mentally Disordered Offenders.

Background: Prison mental health services have tended to focus on improving the quality of care provided to mentally disordered offenders at the initial point of contact with the prison system and within the prison environment itself. When these individuals reach the end of their sentence and return to the community, there is an increased risk of morbidity, mortality, homelessness and re-imprisonment. New models of care have been developed to minimize these risks.Objectives: The objective of this project was to establish a Pre-Release Planning (PReP) Programme with social work expertise, to enhance interagency collaboration and improve continuity of care for mentally disordered offenders upon their release. We aimed to evaluate the first 2 years of the programme by measuring its success at improving the level of mental health support and the security and quality of accommodation achieved by participants upon release in comparison to that reported at time of imprisonment. Additionally, we aimed to explore the impact of these outcomes on rates of re-imprisonment.Methods: A process of participatory action research was used to develop and evaluate the first 2 years of the programme. This was a naturalistic prospective observational whole cohort study.Results: The PReP Programme supported 43 mentally disordered offenders, representing 13.7%, (43/313) of all new assessments by the prison's inreach mental health service during the 2 years study period. When compared with that reported at time of reception at the prison, gains were achieved in level of mental health support (FET p < 0.001) and security and quality of accommodation (FET p < 0.001) upon release. Of those participants seen by the PReP Programme, 20 (46.5%, 20/43) were returned to prison during the 2-years study period. There was no significant relationship between re-imprisonment and gains made in mental health support (FET p = 0.23) or accommodation (FET p = 0.23).Conclusions: We have shown that compared to that reported at time of reception at prison, the level of mental health support and the security of tenure and quality of accommodation both improved upon release following the intervention of the programme. Improved mental health support and accommodation were not associated with lower rates of re-imprisonment.

Influence of religion on obsessive–compulsive disorder: Comparisons between Dutch nonreligious, Roman Catholic, and Protestant patients.

Previous studies have suggested that specific features of religion such as religious denomination and level of religiosity might influence the severity of obsessive- compulsive disorder (OCD) and the occurrence of obsessive- compulsive (OC) cognitions, whereas others could not confirm these findings. The purpose of this study was to elucidate the relation between religion, OCD, and the occurrence of OC cognitions in a Dutch sample of OCD patients. Data were drawn from the baseline assessment of the Netherlands Obsessive Compulsive Disorder Association (NOCDA; Schuurmans et al., 2012) study, which is an ongoing, multicenter, 6-year, longitudinal naturalistic cohort study examining the course of OCD. Participants were 377 outpatients, age 18 years and over, with a lifetime diagnosis of OCD. Neither being religious nor religiosity critically influenced the severity of OCD or the occurrence of OC cognitions. Roman Catholic patients scored significantly higher on anxiety and depression than nonreligious patients, and Roman Catholic patients endorsed significantly more OC cognitions than nonreligious and Protestant patients. These ratings of OC cognitions were not mediated by religious denomination or level of religiosity, but by severity of anxiety and depression, as well as age. The relationship between religious denomination, level of religiosity, and clinical aspects of OCD, which have been described before in the literature, may be spurious and mediated by comorbid psychiatric symptoms, such as anxiety and depression.

Crash Risk and Risky Driving Behavior Among Adolescents During Learner and Independent Driving Periods

PurposeNovice adolescents' crash rates are highly elevated early in licensure, despite substantial practicedriving during the learner period. The objectives of this study were to examine the variability in measures of driving risk among adolescents during the learner and early independent driving periods and evaluate how risk varies by driving experience, gender, time of day, and road surface conditions. MethodsObjective driving data were collected in a naturalistic cohort study of 90 adolescent drivers with learner driving permit and 131 experienced adult drivers. Participants’ private vehicles were equipped with data acquisition system documenting driving kinematics, miles driven, and video recordings of the driver and the driving environment. Crash/near-crash (CNC) and kinematic risky driving (KRD) rates were calculated during the learner and early independent driving periods by gender (female/male), time of day (day/night), and road surface conditions (wet/dry) for adolescents and adults. ResultsCNC and KRD rates of adolescents were similar to adult drivers during the learner period (CNC: incident rate ratio [IRR] = 1.67, confidence interval [CI] = .98–2.82 and KRD: IRR = 1.04, CI = .78–1.40, respectively), but dramatically higher in the first year of independent driving (CNC: IRR = 6.51, CI = 4.03–10.51 and KRD: IRR = 3.95, CI = 2.96–5.26, respectively), and particularly elevated the first 3months of licensure. Adolescent KRD rates were higher for males than females and invariably higher than adult rates during day and night, wet and dry conditions. ConclusionsWhile the learner driving period was relatively safe for adolescents, the transition to independent driving was typified by a dramatic increase in risk among adolescents that was higher than adult rates overall and under varying driving conditions.

Biopsychosocial multidisciplinary rehabilitation in low back pain: A comparison of effects after 12 months in patients older and younger than 65 years

In patients with chronic low back pain (cLBP) guidelines recommend multidisciplinary biopsychosocial rehabilitation (MBR) if other treatments were unsuccessful. However, little is known about the long-term effects of MBR in patients older than 65 years. The objective of this study was to compare the 12 months course of effects of MBR in patients older than 65 years to younger patients. In this naturalistic prospective observational cohort study, 118 participants of a 3-week MBR were included. The MBR comprised exercise therapy, hydrotherapy, occupational therapy, psychological interventions, patient education and instructions to home exercise programs. Outcome was assessed by the condition specific North American Spine Society (NASS) questionnaire pain/function scale and the generic Short-Form 36 Health Survey (SF-36). From the eight SF-36 scales only Physical Functioning (PF), Bodily Pain (BP) and Mental Health (MH) were included in the analyses. Data were collected at the beginning of treatment, after 3 months and after 12 months. Participants were grouped into “Old” or “Young” with the cut-off 65 years. Statistical differences between follow-up and baseline scores were tested by paired t-tests. Standardized Effect Size (ES) was calculated by dividing the difference between entry and follow-up by the standard deviation (SD) of the baseline score. In this study, 59 patients were older than 65 years and 59 were younger. The mean ages of the groups old/young were 70 years and 57years respectively. In the group old 64% of patients were female and in the young group 73% were female. The course of the outcomes and the statistical significance of changes are presented in Table 1 , Table 2 . This study shows that a MBR program in cLBP patients has similar beneficial long-term effects on pain and condition specific function in patients older than 65 years compared to younger patients.

The Longitudinal Effects of Electroconvulsive Therapy on Ictal Interhemispheric Coherence and Its Associations With Treatment Outcome: A Naturalistic Cohort Study.

Electroconvulsive therapy (ECT) is an effective treatment for severe depression. Electroencephalogram (EEG) measures between ECT sessions seem to be related to the antidepressant efficacy of ECT. In this naturalistic cohort study, we examine longitudinal effects of ECT on interhemispheric EEG coherence measures during seizure activity and its relation to the antidepressant efficacy. This study included 65 patients diagnosed with severe depressive disorder. Depressive symptoms were rated according to the Montgomery-Åsberg Depression Rating Scale before and after the course of ECT. Frequency-specific ictal interhemispheric (fp1-fp2) EEG coherence measures were established during the first and each consecutive sixth treatment session. Linear mixed-effect models were used to determine longitudinal changes in ictal coherence measures during the course of ECT and its relation to treatment efficacy. Ictal interhemispheric coherence in the theta and alpha frequency bands increased over the course of treatment, whereas no significant change was found for the delta and beta frequency bands. A main effect of treatment efficacy on the interhemispheric coherence in the delta and theta band was revealed. However, the longitudinal effects of ECT were not associated with treatment efficacy. The current study suggests that interhemispheric coherence during ECT-induced seizures increases over the course of treatment. Furthermore, these longitudinal effects seem to be unrelated to the antidepressant efficacy of ECT. These findings contribute to the understanding of the mechanism of action of ECT.

Biomarker-based subtyping of depression and anxiety disorders using Latent Class Analysis. A NESDA study.

Etiological research of depression and anxiety disorders has been hampered by diagnostic heterogeneity. In order to address this, researchers have tried to identify more homogeneous patient subgroups. This work has predominantly focused on explaining interpersonal heterogeneity based on clinical features (i.e. symptom profiles). However, to explain interpersonal variations in underlying pathophysiological mechanisms, it might be more effective to take biological heterogeneity as the point of departure when trying to identify subgroups. Therefore, this study aimed to identify data-driven subgroups of patients based on biomarker profiles. Data of patients with a current depressive and/or anxiety disorder came from the Netherlands Study of Depression and Anxiety, a large, multi-site naturalistic cohort study (n = 1460). Thirty-six biomarkers (e.g. leptin, brain-derived neurotrophic factor, tryptophan) were measured, as well as sociodemographic and clinical characteristics. Latent class analysis of the discretized (lower 10%, middle, upper 10%) biomarkers were used to identify different patient clusters. The analyses resulted in three classes, which were primarily characterized by different levels of metabolic health: 'lean' (21.6%), 'average' (62.2%) and 'overweight' (16.2%). Inspection of the classes' clinical features showed the highest levels of psychopathology, severity and medication use in the overweight class. The identified classes were strongly tied to general (metabolic) health, and did not reflect any natural cutoffs along the lines of the traditional diagnostic classifications. Our analyses suggested that especially poor metabolic health could be seen as a distal marker for depression and anxiety, suggesting a relationship between the 'overweight' subtype and internalizing psychopathology.

A Six-Year Prospective Study of the Prognosis and Predictors in Patients With Late-Life Depression

To examine the six-year prognosis of patients with late-life depression and to identify prognostic factors of an unfavorable course. The Netherlands Study of Depression in Older Persons (NESDO) is a multisite naturalistic prospective cohort study with six-year follow-up. Three hundred seventy-eight clinically depressed patients (according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision criteria) and 132 nondepressed comparisons were included at baseline between 2007 and 2010. Depression was measured by the Inventory of Depressive Symptomatology at 6-month intervals and a diagnostic interview at 2- and 6-year follow-up. Multinomial regression and mixed model analyses were both used to identify depression-related clinical, health, and psychosocial prognostic factors of an unfavorable course. Among depressed patients at baseline, 46.8% were lost to follow-up; 15.9% had an unfavorable course, i.e., chronic or recurrent; 24.6% had partial remission; and 12.7% had full remission at six-year follow-up. The relative risk of mortality in depressed patients was 2.5 (95% confidence interval 1.26-4.81) versus nondepressed comparisons. An unfavorable course of depression was associated with a younger age at depression onset; higher symptom severity of depression, pain, and neuroticism; and loneliness at baseline. Additionally, partial remission was associated with chronic diseases and loneliness at baseline when compared with full remission. The long-term prognosis of late-life depression is poor with regard to mortality and course of depression. Chronic diseases, loneliness, and pain may be used as putative targets for optimizing prevention and treatment strategies for relapse and chronicity.

T234. BREAKTHROUGH ON ANTIPSYCHOTIC MAINTENANCE MEDICATION: A STUDY-LEVEL META-ANALYSIS AND META-REGRESSION ANALYSIS

BackgroundThe study of psychotic relapse despite ongoing antipsychotic maintenance treatment can serve as a paradigm to study the intrinsic efficacy of antipsychotic drugs, their mechanism of action, the pathophysiology of psychosis, and potentially the evolution of treatment-resistant schizophrenia. This phenotype is referred to as Breakthrough on Antipsychotic Maintenance Medication (BAMM). Despite the fact that the efficacy of long-acting injectable (LAI) treatment (where adherence can be confirmed) has been researched for decades, the study of individuals breaking through LAI treatment has received little attention. A reanalysis of the literature on studies of LAI formulations can serve as an initial approach to understand BAMM in a paradigm not confounded by non-adherence.MethodsWe re-analyzed data from 3 meta-analyses of randomized controlled trials (RCTs), mirror image, and cohort studies including LAIs. We extracted the data of study-defined relapse from each LAI arm, which was our outcome. We also extracted data for various covariates regarding the study design, participant, and LAI treatment characteristics. We conducted a random-effects study-level meta-analysis, and a meta-regression analysis of covariates of interest. We examined the risk of publication bias using the fail-safe test.ResultsIn a pooled analysis of studies from the 3 separate meta-analyses, we identified a total of 51 LAI treatment arms, including 13,071 individuals (mean age=38.8 ± 6.2, 60.5 ± 11.9% male, illness duration=12.1 ± 5.7 years, mean total PANSS score=74.3 ± 7.8). The mean planned follow-up duration was 71.5 ± 37.0 (range=24–154) weeks, and the defined daily dose (DDD) of LAI treatment was 1.1. The pooled weighted relapse rate in a random effects model was 28% (95% CI=24–31%), being 22% (95% CI=15–30%) in RCTs (mean duration= 66.2 wks), 33.0% (95% CI=24–43%) in mirror image studies (mean duration= 55.4 wks), and 30% (95% CI=26–34%) in naturalistic cohort studies (mean duration= 79.4 wks). In a meta-regression analysis, RCT design (p=0.04), and industry sponsorship (p=0.03) were associated with lower relapse rates on LAI treatment, whereas studies conducted in Europe (p=0.03) or North America (p<0.01), and longer duration of follow-up (p<0.01) were associated with greater relapse rates. In the fail-safe test, we found that we would need 4,629 studies to bring the p Value>α, suggesting low risk of bias.DiscussionAbout one in four individuals receiving LAI treatment relapsed according to study definitions, suggesting that this is a relatively common phenomenon, even during assured medication adherence. At the study level, no major differences were observed in terms of sociodemographic characteristics, type of drugs, mean drug daily dose, or baseline severity at study entry in relation to relapse rate in individuals treated with LAIs. The relapse rate though was lower in RCTs, which could reflect a difference in the patient population participating and/or the nature of observation in LAI RCTs. These results suggest either that the examined study design, illness severity and treatment related covariates are limited to identify potential mediators and moderators of BAMM, or that the data about the covariates at the study level was not precise enough to detect clinical characteristics associated with BAMM. Given the relative frequency of BAMM, future research should explore potential mediators and moderators of the failure to maintain response to antipsychotic treatment even during periods of assured adherence. Neurobiological markers, which may be more closely related to the pathophysiology of BAMM, and individual participant data meta-analyses, which can identify clinical predictors with greater precision, should be the next steps.

T233. DEFINING TREATMENT RESPONSE AND RESISTANCE IN FIRST EPISODE SCHIZOPHRENIA

BackgroundAlthough a substantial proportion of individuals with schizophrenia fail to respond to first-line dopaminergic blocking medications and are Treatment Resistant (TR), identifying these subjects prospectively remains challenging. Though clinically defined only after multiple treatment trials, TR is suspected to reflect a stable neurobiological phenomenon that can be identified even at the first episode of schizophrenia (FES). Establishing clear expectations for symptom improvement following antipsychotic initiation would facilitate development of objective thresholds for determining lack of efficacy. The Treatment Response and Resistance in Psychosis (TRIPP; Howes et al, 2017) working group has recently published consensus guidelines which define lack of response as a <20% improvement in psychotic symptoms. However, given that most patients with FES respond robustly to antipsychotics (Robinson et al, 1999), FES specific criteria for prospective identification of TR are warranted. We examined two symptom improvement thresholds across positive and negative symptom domains at 6 months in FES to investigate poor response (PR) as a proxy measure of early TR. We then examined the baseline/early clinical features that best prospectively predicted PR+ status. Given the estimated prevalence of TR is approximately 33%, we hypothesized that a comparable number (ie, 1/3rd) of individuals with FES would meet PR criteria using less a 50% response threshold, rather than a more stringent 20% threshold for determining symptomatic response. Furthermore, we hypothesized that very early lack of response would be associated with PR at 6 months.MethodsData from a longitudinal naturalistic cohort study of patients treated at the Prevention and Early Intervention Program for Psychosis (PEPP) in London, Ontario, Canada collected between 2002 and 2007 were used for this analysis. Only individuals meeting criteria for a primary psychotic disorder that were medication compliant were included. Positive and negative symptoms of psychosis were assessed using the SAPS (Andreasen, 1983) and SANS (Andreasen, 1984) at baseline, and at months 1, 2, 3, and 6. Treatment was administered in a naturalistic setting and followed clinical guidelines for the treatment of FES.ResultsApplying a 20% and 50% symptom improvement threshold for defining PR resulted in 2.2% and 14% rates for positive symptom PR, 33% and 60.9% rates of negative symptom PR, and 12% and 37.0% rates of total symptom PR at 6 months. Logistic regression analyses demonstrated that poor premorbid functioning, having a longer duration of untreated illness, and limited overall treatment response at months one and two were significantly associated with being PR+ (<50% improvement in total symptoms) at 6 months.DiscussionThis is the first study to our knowledge to investigate the symptom response thresholds suggested by TRIPP in FES. Our results suggest that including negative symptoms (either alone, with a 20% criteria for improvement, or in addition to positive symptoms, with a 50% improvement threshold) is necessary to identify the expected proportion of TR subjects prospectively in a FES sample. We propose that failing to achieve at least a 50% improvement in total symptoms, or at least 20% change in negative symptom severity by 6 months may be an early clinical indicator of eventual TR. On an optimistic note, we speculate that it may be possible to determine clozapine-eligibility as early as 6 months by using this approach. However, further studies are warranted to investigate the utility of this symptom threshold criteria in larger samples of patients with FES.

Chronic obsessive-compulsive disorder: prognostic factors.

The course of illness in obsessive-compulsive disorder (OCD) varies significantly between patients. Little is known about factors predicting a chronic course of illness. The aim of this study is to identify factors involved in inducing and in maintaining chronicity in OCD. The present study is embedded within the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, an ongoing multicenter naturalistic cohort study designed to identify predictors of long-term course and outcome in OCD. For this study, 270 subjects with a current diagnosis of OCD were included. Chronicity status at 2-year follow-up was regressed on a selection of baseline predictors related to OCD, to comorbidity and to stress and support. Psychotrauma [odds ratio (OR) 1.98, confidence interval (CI) 1.22-3.22, p = 0.006], recent negative life events (OR 1.42, CI 1.01-2.01, p = 0.043), and presence of a partner (OR 0.28, CI 0.09-0.85, p = 0.025) influenced the risk of becoming chronic. Longer illness duration (OR 1.46, CI 1.08-1.96, p = 0.013) and higher illness severity (OR 1.09, CI 1.03-1.16, p = 0.003) increased the risk of remaining chronic. External influences increase the risk of becoming chronic, whereas the factors involved in maintaining chronicity are illness-related. As the latter are potentially difficult to modify, treatment should be devoted to prevent chronicity from occurring in the first place. Therapeutic strategies aimed at alleviating stress and at boosting social support might aid in achieving this goal.

Person-centered care for older people with dementia in the acute hospital

IntroductionPatients with dementia (PWDs) are often subjected to enforced dependency and experience functional decline and emotional distress during hospital stay. Person-centered care (PCC) with specialized psychosocial interventions, minimally obtrusive medical care, and physical restraints-free practice holds potential to improve patient outcomes. We evaluate the effectiveness of an acute hospital dementia unit (Care for Acute Mentally Infirm Elders [CAMIE]) that adopts a PCC protocol. MethodsProspective naturalistic cohort study whereby PWDs in the CAMIE unit (n = 170) were compared with a control group in usual care wards (n = 60) over 6 months. Assessments included patient demographics, dementia type and stage, comorbidities (Charlson's Comorbidity Index), acute illness severity, Well-Being, Ill-Being, functional status (Modified Barthel Index), agitation levels (Pittsburgh Agitation Scale), and quality of life (EuroQoL), assessed on admission and discharge. Multivariate analysis of covariance examined the effect of CAMIE versus usual care on pre-post outcomes. ResultsCAMIE patients showed statistically significant greater gains in Modified Barthel Index function and Well-Being, decreased Ill-Being and agitation, and greater improvement in EuroQoL index score (effect size: Δ = 0.18) after adjusting for baseline differences that translated to a quality-adjusted life years gain of 0.045, assuming stability over 3 months. Estimating added cost of CAMIE stay over usual care at SGD 1500 (USD 1040) for average length of stay of 15 days per patient, the incremental cost-effectiveness ratio fell within the threshold for cost-effectiveness at USD 23,111. DiscussionPCC for PWDs in acute hospitals not only improves clinical outcomes for patients but is also cost-effective. The results support the adoption of PCC on a wider scale for better care of PWDs.

Association of Environment With the Risk of Developing Psychotic Disorders in Rural Populations

Social determinants are important risk factors for the development of first-episode psychosis (FEP); their effects in rural areas are largely unknown. To investigate neighborhood-level factors associated with FEP in a large, predominantly rural population-based cohort. This study extracted data on referrals for treatment of potential FEP at 6 Early-Intervention Psychosis services from the Social Epidemiology of Psychoses in East Anglia naturalistic cohort study data set, which covered a population of more than 2 million people in a rural area in the East of England for a period of 3.5 years. All individuals aged 16 to 35 years who presented to Early-Intervention Psychosis services and met diagnostic criteria for first episodes of nonaffective psychoses and affective psychoses (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnostic codes F20-33) were included (n = 631). Persons whose disorders had an organic basis (diagnostic codes F06.X) and those meeting the criteria for substance-induced psychosis (diagnostic codes F1X.5) were excluded. We derived 4 neighborhood-level exposures from a routine population data set using exploratory factor analysis (racial/ethnic diversity, deprivation, urbanicity, and social isolation) and investigated intragroup racial/ethnic density and fragmentation. Multilevel Poisson regression was performed to determine associations between incidence rates and neighborhood-level factors, after adjustment for individual factors. Results were reported as incidence rate ratios (IRRs). The study included 631 participants who met criteria for FEP and whose median age at first contact was 23.8 years (interquartile range, 19.6-27.6 years); 416 of 631 (65.9%) were male. Crude incidence of FEP was calculated as 31.2 per 100 000 person-years (95% CI, 28.9-33.7). Incidence varied significantly between neighborhoods after adjustment for age, sex, race/ethnicity, and socioeconomic status. For nonaffective psychoses, incidence was higher in neighborhoods that were more economically deprived (IRR, 1.13; 95% CI, 1.06-1.20) and socially isolated (IRR, 1.11; 95% CI, 1.04-1.19). It was lower in more racially/ethnically diverse neighborhoods (IRR, 0.94; 95% CI, 0.87-1.00). Higher intragroup racial/ethnic density (IRR, 0.97; 95% CI, 0.94-1.00) and lower intragroup racial/ethnic fragmentation (IRR, 0.98; 95% CI, 0.96-1.00) were associated with a reduced risk of affective psychosis. Spatial variation in the incidence of nonaffective and affective psychotic disorders exists in rural areas. This suggests that the social environment contributes to psychosis risk across the rural-urban gradient.

Satisfaction of psychotic patients with care and its value to predict outcomes

BackgroundA key indicator of quality of treatment from the patient's perspective is expressed by satisfaction with care. Our aim was to (i) explore satisfaction and its relation to clinical outcome measures; and (ii) explore the predictive value of satisfaction for the course of outcomes over three years. MethodsData of 654 patients with a non-affective psychosis included in a naturalistic longitudinal cohort study were analyzed. We included 506 males and 148 females with a mean age of 30.47 (SD 7.24) from The Netherlands. Satisfaction was measured with the self-rating Client Satisfaction Questionnaire-8. A wide range of interviewer-rated (e.g., Positive and Negative Symptom Scale) and self-rated (e.g., World Health Organization Quality of Life); outcomes of low, intermediate and high satisfied patients were compared using ANOVA, Chi2 or Kruskal–Wallis tests. The predictive value of satisfaction level on clinical outcomes after three years was tested using regression models. ResultsSatisfaction levels were low (19.4%), intermediate (48.9%) or high (31.7%). High satisfied patients showed significantly better interviewer-rated outcomes, e.g., less severe psychotic symptoms, and self-rated outcomes, e.g., better quality of life, compared to patients with intermediate or low satisfaction. Higher levels of satisfaction with care at baseline predicted a reduction of positive symptoms three years later (B=–.09, P-value=.013). ConclusionsSatisfaction of patients with psychosis is a valuable monitoring measure since high satisfied patients show more favorable outcomes ranging from psychopathological symptoms to quality of life. Further research into explanations of lower levels of satisfaction is commendable in order to improve outcomes.

Mortality in dementia with Lewy bodies compared with Alzheimer’s dementia: a retrospective naturalistic cohort study

ObjectivesTo use routine clinical data to investigate survival in dementia with Lewy bodies (DLB) compared with Alzheimer’s dementia (AD). DLB is the second most common dementia subtype after AD, accounting...

Possible predictors of age at illness onset and illness duration in a cohort study comparing younger adults and older major affective patients

BackgroundMajor affective conditions are associated with significant disability and psychosocial impairment. Whether specific socio-demographic and clinical characteristics may distinguish subgroups of patients in terms of prognosis and illness trajectories is a matter of debate. MethodsThe sample of this naturalistic cohort study included 675 currently euthymic patients with major affective disorders of which 428 (63.4%) were diagnosed with unipolar and 247 (36.6%) with bipolar disorders. ResultsYounger adults with a longer duration of untreated illness and residual inter-episodic symptoms were more likely to be single or divorced, students, with an earlier age of first treatment/hospitalization, longer duration of substance abuse and duration of illness than older patients who were, conversely, more likely to be widowed and retired. Multivariate analyses showed a significant positive contribution to age at illness onset by marital status, nonpsychiatric medications, substance abuse, psychiatric diagnosis (bipolar vs. unipolar), age at first treatment/hospitalization, duration of illness, and current age. According to a further analysis, we also found a significant positive contribution to duration of illness by marital status, educational level, positive history of psychiatric conditions in family, substance abuse, psychiatric diagnosis (bipolar vs. unipolar), age at illness onset, age at first treatment, and certain cardiovascular disorders. ConclusionsThere are substantial socio-demographic and clinical differences that may help to distinguish specific subgroups of patients; however, additional studies are requested to replicate these results and further investigate the main factors underlying our findings.

Early psychosis in central Vietnam: A longitudinal study of short-term functional outcomes and their predictors.

Few longitudinal studies have investigated the functional outcomes of individuals with recent-onset psychotic illness in low- and middle-income countries. To investigate short-term functional remission and its predictors in a central Vietnamese sample. A naturalistic 6-month prospective cohort study recruited 79 patients of public health facilities who had experienced a first episode of schizophrenia or related illness in the past 18 months. Individuals and their family members were interviewed using standardised assessments of community functioning, symptoms, treatment, demographics and various psychosocial variables. Rates of functional remission (i.e. no or minimal impairment) were calculated based on rigorous, culturally appropriate criteria. Generalised estimating equations were used to explore predictors of remission. Rates of global functional remission were 28% at baseline and 53% at follow-up. In individual functional domains, remission was least common for occupational activities, intermediate for relationships and relatively common for daily living activities. Global functional remission was significantly associated with absence of negative and cognitive symptoms, average or better household economic status and unimpaired premorbid functioning. Remission rates appeared similar to those seen in many international intervention studies. However, individuals from poor households had markedly unfavourable outcomes, suggesting the need for community-based interventions targeting low-socioeconomic status (SES) groups.

Apathy in early and late-life depression

BackgroundLate-life depression is thought to differ in clinical presentation from early-life depression. Particularly, late-life depression is considered to be more characterized by apathy than is early-life depression. Lacking convincing evidence, this study examines the presence and associated socio-demographic/clinical characteristics of apathy in older compared to younger depressed persons. MethodsThis cross-sectional study used data from two naturalistic cohort studies, i.e. the Netherlands Study of Depression in Older Persons (NESDO) and the Netherlands Study of Depression and Anxiety (NESDA). These studies included 605 persons (aged 18–93 years) with a major depressive disorder, divided into 217 early-life (< 60 years) and 388 late-life (≥ 60 years) depressed persons. Apathy was considered present if a score of ≥14 on the Apathy Scale. ResultsApathy was strongly associated with age: it was more frequently present in persons with late-life depression (74.5%) than in those with early-life depression (53.5%). Independent of age, the following characteristics were associated with the presence of apathy: male gender, low education, use of benzodiazepines, chronic diseases, and more severe depression. Of all potential risk factors, only former and current smoking was associated with the presence of apathy in older depressed persons but not in younger depressed persons (p-value for age interaction = 0.01). LimitationsNo causal relationships can be drawn due to the cross-sectional design of the study. ConclusionsIn depressed individuals, clinically relevant apathy was more frequently present in older compared to younger persons. Both age groups showed largely the same associated risk factors. Apathy was independently associated with older age, male gender and more severe depression.

Sources of meaning in family caregivers of terminally ill patients supported by a palliative nursing care team: A naturalistic three-month cohort study.

The Sources of Meaning and Meaning in Life Questionnaire (SoMe) was administered to 100 caregivers of terminally ill patients at four measurement timepoints: immediately before the onset of the palliative care (t0), and at 1 week, 1 month, and 3 months after t0. Time-dependent changes were assessed for the completed subsample (n = 24) by means of bivariate linear as well as quadratic regression models. Multivariate regressions with dimensions of meaning in life as dependent variables were performed for the whole sample by means of random-effects models: dependent variables changed over time (four timepoints), whereas regressors remained constant. No significant differences were found for psychosocial and clinical variables or for sources of meaning between the uncompleted and completed subsamples. Growth curve analyses revealed no statistically significant but tendentiously parabolic changes for any dimensions or for single sources of meaning. In multivariate models, a negative association was found between patient age, psychological burden of family caregivers, and changes in total SoMe score, as well as for the superordinate dimensions. According to our hypothesis, sources of meaning and meaning in life seem to remain robust in relatives caring for terminally ill family members during the three-month survey period. A parabolic development pattern of single sources of meaning indicates an adjustment process. An important limitation of our study is the small number of participants compared with larger multivariate models because of high dropout rates, primarily due to the death of three-quarters of the participants during the survey period.

Interventions to improve lifestyle and quality of life in patients with concurrent mental illness and substance use

BackgroundPatients with co-existence of psychiatric disorders and substance use have an increased risk of premature death. This is attributable to a higher prevalence of physical comorbidities and the lifestyle related to substance use. Furthermore, they experience low quality of life (QoL). Studies addressing lifestyle interventions for these patients are warranted.AimsTo investigate the physical health and QoL in patients with co-existence of psychiatric disorders and substance use, and to analyse for changes in their (a) health, (b) substance use and (c) QoL after a 24-month health-promotion programme. Further aims were to investigate associations between (a) QoL and number of interventions, (b) QoL and patient characteristics and (c) QoL and length of participation in the intervention.MethodsIn this naturalistic cohort study, 64 non-selected patients were engaged in health-promoting interventions added to contemporary treatments. QoL and clinical variables were measured at the beginning of and continuously during the programme by means of the WHOQoL-Bref questionnaire.ResultsAt enrolment, the patients’ intake of cannabis and alcohol was high. During follow-up, patients consumed significantly fewer caffeinated beverages (P = 0.038) and fast-food meals (P = 0.018), and slept significantly less (P = 0.032). The average dose of antipsychotic medication increased significantly (P = 0.015). QoL was low at enrolment but improved significantly overall (P = 0.009) and in the psychological (P = 0.020) and environmental domains (P = 0.012) at follow-up. The difference in total QoL was positively associated with the number of interventions attended.ConclusionThis programme shows promise in addressing health promotion for these patients and can easily be integrated into contemporary treatments.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Sources of meaning in family caregivers of terminally ill patients supported by a palliative nursing care team – A naturalistic three-month cohort study

ObjectivesTo identify possible change patterns or robustness in sources of meaning in family caregivers of pre-terminal patients after onset of support at home by an outreach palliative nursing team during a survey period of three months.MethodsOne hundred caregivers of terminally ill patients were included in a prospective observational trial. The Sources of Meaning and Meaning in Life Questionnaire (SoMe) was administered at four points of measurement: T0 (immediately before onset of palliative care); T1 (one week after T0); T2 (one month after T0); T3 (three months after T0). Descriptive statistics, random effects regression analyses; multivariate linear and quadratic regression models were performed for the full (n = 100) as well as for the reduced sample (n = 24).ResultsGrowth curve analyses reveal significant parabolic changes for the dimension “order” and for the subscales “social commitment”, “tradition”, “morality”, and “fun”. All other dimensions or subscales remained stable during the time of the study. Cross-sectional multivariate regression models (T0) showed negative associations of some dimensions with patients’ age and psychological burden of the family caregiver while psychological burden of patients was found to be positively associated with some dimensions. No significant effects of interaction variables with time (linear and quadratic).ConclusionsWith few exceptions, family carers seem to keep a stable sense of meaning in life during the final stage of their relatives’ terminal illness. Particular associations between sources of meaning and age of patients as well as psychological burden both of patients and carers have to be taken into consideration in support planning.Disclosure of interestThe authors have not supplied their declaration of competing interest.