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Purpose: Electronic medical case files of male prisoners in a category B prison in London were studied to establish a prevalence during an eight-month period of the use of and the reasons for prescribing gabapentinoids in prison and also to establish prescribing standards in prison and compliance with these. In addition, the prevalence of co-prescription of gabapentinoids with opioids and antidepressants, particularly tricyclic antidepressants such as amitriptyline, was also assessed in light of the increased risk of respiratory depression resulting in death when these drugs are used in combination. The paper aims to discuss these issues.Design/methodology/approach: A retrospective, SystmOne case-file based survey was undertaken searching by SNOMED CT supplemented by examination of free text, in a category B prison for males (Capacity 1,500 prisoners; Average turnover of prisoners up to 6,000 per year), to establish practice standards related to the prescription of Gabapentinoids in the prison and determine compliance with these.Findings: In total, 109 cases were identified of prisoners having been prescribed gabapentinoids, pregabalin in 66 cases (61 per cent) and gabapentin in 43 cases (39 per cent). In 36 cases (33 per cent) prescriptions were for unlicensed indications. This in fact represented 50 per cent of the cases where the indications were documented. In 51 cases (47 per cent) gabapentinoids were prescribed with an opioid substitute. In 14 cases (13 per cent), prescribed gabapentinoids were diverted to other prisoners.Practical Implications: The initiation of gabapentinoids in prison should be avoided. For prisoners who are also receiving opioid substitutes or are abusing opiates, it may be unsafe to continue on gabapentinoids. Issues raised by this study are likely to apply to other prisons, secure forensic psychiatric facilities and indeed community mental health and primary care as well.Social Implications: Risk of dependance on gabapentinoids including risk of mortality when taken with opioids and opioid substitutes.Originality/value: This is an original study conducted at a category B prison in London. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic globally impacted healthcare provision. Prescribing changes in common medications can be used as a marker for new diagnoses. We describe how the prescribing of specific psychotropics was impacted by the pandemic. Methods: Primary Care Prescribing data for different classes of drugs from March 2017 to February 2022 were considered. To capture the impact during periods of restricted access to health services for new diagnoses/existing conditions, repeat prescriptions/episodic prescribing were included with account taken of historical trends. The pre-pandemic prescriptions issued each month from March 2018 to February 2020 were linearly extrapolated forward to give an expected annual growth (EAG). The monthly average expected prescriptions for the pandemic period (March 2020–February 2022) were compared. Results: Physical health medications had lower monthly prescriptions during the pandemic, most markedly for antibiotics − 12.5% (EAG − 1.3%). Bronchodilator prescribing showed a marked increase in the early pandemic months from March 2020 of 5% (EAG 0.1%). Mental health medication prescribing increased above trend for hypnotics/anxiolytics by 0.2% (EAG − 2.3%), while antidepressants fell by − 0.2% (EAG 5.0%), with no net change for antipsychotics (EAG 2.8%), but a temporary increase in antipsychotic prescribing in the early pandemic period. For all the main antidepressants prescribed in England (Sertraline, Mirtazapine, Venlafaxine, Fluoxetine and Citalopram), prescribing actually decreased in the main pandemic period vs historical trend. Conclusions: The increase in anxiolytic/hypnotic prescribing above trend links to pandemic effects on anxiety/worry. If anything, there was a slight fall in prescribing of the main antidepressants prescribed, which given prevailing circumstances at the time, suggests that access to services may have restricted access to timely assessment. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to examine the prescribed psychotropic medications taken by newly referred people with a range of substance use disorders (SUD) who attend a specialist community addiction service. Design/methodology/approach – Anonymised data on newly referred people (n=1,537) with SUD attending a specialist community addiction service for their first episode of treatment between August 2007 and July 2010 were obtained from the database of the service. Data were cleaned and the percentage of people taking prescribed psychotropic medications at their first episode of treatment was calculated. Findings – More than half (56.1 percent) of people attending the service were taking prescribed antidepressants and anxiolytics at their first episode of treatment whilst 15.2 percent of people were taking prescribed antipsychotics. Alcohol and opioids were the primary referral substances for 77.4 percent and 15.2 percent of people respectively. People referred for "other" substances (cannabis, stimulants, sedatives, hallucinogens, solvents and polydrug use) made up the remaining 7.5 percent and had the highest percentage of prescribed psychotropics (antipsychotics=47 percent, antidepressants and anxiolytics=64.3 percent) compared to those referred for alcohol and opioids (p<0.0005). Originality/value – To the best of the authors' knowledge, this is the first study of psychotropic prescribing among people with a range of SUD in the UK. The high prevalence of psychotropic prescribing raises questions about the appropriateness of these prescriptions and calls for scrutiny of prescribing practice in this group of people. [ABSTRACT FROM AUTHOR]

We would like to draw attention to evidence of substantial bias in the article published in this journal by Jack et al. (BMC Med 18:1-12, 2020). They provide an analysis of antidepressant prescribing to children and young people (CYP; ages 5 to 17) in primary care in England and reported that only 24.7% of CYP prescribed SSRIs for the first time were seen by a child and adolescent psychiatrist—contrary to national guidelines. We believe that their analysis is based on incomplete data that misses a large proportion of specialist mental health contacts. This is because the dataset Jack et al. used to capture specialist mental health contact—The Hospital Episode Statistics (HES) dataset—has poor coverage, as most CYP mental health services do not submit data. We demonstrate the level of underreporting with an analysis of events in a large primary care dataset where there has been a record of definite contact with CYP mental health services. We report that as many as three quarters of specialist CYP contacts with mental health specialists are missed in the HES dataset, indicating that the figure presented by Jack et al. is substantially wrong. [ABSTRACT FROM AUTHOR]

Background: Dementia is a group of symptoms that largely affects older people. The majority of patients face behavioural and psychological symptoms (BPSD) during the course of their illness. Alzheimer's disease (AD) and vascular dementia (VaD) are two of the most prevalent types of dementia. Available medications provide symptomatic benefits and provide relief from BPSD and associated health issues. However, it is unclear how specific dementia, antidepressant, antipsychotic, antianxiety, and mood stabiliser drugs, used in the treatment of depression and dementia subtypes are prescribed in hospital admission, during hospital stay, and at the time of discharge. To address this, we apply multi-dimensional data analytical approaches to understand drug prescribing practices within hospitals in England and Wales.Methods: We made use of the UK National Audit of Dementia (NAD) dataset and pre-processed the dataset. We evaluated the pairwise Pearson correlation of the dataset and selected key data features which are highly correlated with dementia subtypes. After that, we selected drug prescribing behaviours (e.g. specific medications at the time of admission, during the hospital stay, and upon discharge), drugs and disorders. Then to shed light on the relations across multiple features or dimensions, we carried out multiple regression analyses, considering the number of dementia, antidepressant, antipsychotic, antianxiety, mood stabiliser, and antiepileptic/anticonvulsant drug prescriptions as dependent variables, and the prescription of other drugs, number of patients with dementia subtypes (AD/VaD), and depression as independent variables.Results: In terms of antidepressant drugs prescribed in hospital admission, during stay and discharge, the number of sertraline and venlafaxine prescriptions were associated with the number of VaD patients whilst the number of mirtazapine prescriptions was associated with frontotemporal dementia patients. During admission, the number of lamotrigine prescriptions was associated with frontotemporal dementia patients, and with the number of valproate and dosulepin prescriptions. During discharge, the number of mirtazapine prescriptions was associated with the number of donepezil prescriptions in conjunction with frontotemporal dementia patients. Finally, the number of prescriptions of donepezil/memantine at admission, during hospital stay and at discharge exhibited positive association with AD patients.Conclusion: Our analyses reveal a complex, multifaceted set of interactions among prescribed drug types, dementia subtypes, and depression. [ABSTRACT FROM AUTHOR]

Aim: Social inequalities are widened by climate change, which increases extreme temperature events that disproportionally affect the most vulnerable people. While the diseases impacted have been reviewed in the literature, how this reflects upon pharmaceutical consumption remains unknown. We assess that effect on a panel of the most prescribed drug classes in terms of volume in the National Health Service (NHS) database. Subject and methods: A retrospective econometric analysis of NHS prescription data was carried out, focusing on antibiotics, antidepressants and bronchodilators (drugs associated to priority diseases in addition to being among the most prescribed ones) between 2011 and 2018. Data linkage enabled prescriptions to be related to the Index of Multiple Deprivation (IMD), disability adjusted life-years (DALYs) and temperature data. The analysis was then undertaken at lower layer super output areas (LSOAs) level, using fixed-effect negative binomial regression models. Results: Our results show that prescription rates were higher across the most deprived LSOAs, even after adjusting for the associated disease DALYs. In addition, prescription volume also progressively increased under colder temperatures below 15 °C, with an exacerbated effect in the most deprived areas. Conclusion: Therefore, health inequalities in England affect prescription volumes, with higher levels in the most deprived areas which are not fully explained by morbidity differences. Lowest temperature conditions appear to intensify vulnerabilities while hot temperatures do not increase these differences in terms of prescriptions. Populations residing in the most deprived LSOAs could be more sensitive to environmental variables, leading to higher consumption of medicine under cold temperature and increased air pollution. [ABSTRACT FROM AUTHOR]

There is a growing concern that neuroactive chemicals released into the environment can perturb wildlife behaviour. Among these chemicals, pharmaceuticals such as antidepressants and anxiolytics have been receiving increasing attention, as they are specifically prescribed to modify behavioural responses. Many laboratory studies have demonstrated that some of these compounds can affect various aspects of the behaviour of a range of aquatic organisms; however, these investigations are focused on a very small set of neuroactive pharmaceuticals, and they often consider one compound at a time. In this study, to better understand the environmental and toxicological dimension of the problem, we considered all pharmaceuticals explicitly intended to modulate the central nervous system (CNS), and we hypothesised that these compounds have higher probability of perturbing animal behaviour. Based on this hypothesis, we used the classification of pharmaceuticals provided by the British National Formulary (based on their clinical applications) and identified 210 different CNS-acting pharmaceuticals prescribed in the UK to treat a variety of CNS-related conditions, including mental health and sleep disorders, dementia, epilepsy, nausea, and pain. The analysis of existing databases revealed that 84 of these compounds were already detected in surface waters worldwide. Using a biological read-across approach based on the extrapolation of clinical data, we predicted that the concentration of 32 of these neuroactive pharmaceuticals in surface waters in England may be high enough to elicit pharmacological effects in wild fish. The ecotoxicological effects of the vast majority of these compounds are currently uncharacterised. Overall, these results highlight the importance of addressing this environmental challenge from a mixture toxicology and systems perspective. The knowledge platform developed in the present study can guide future region-specific prioritisation efforts, inform the design of mixture studies, and foster interdisciplinary efforts aimed at identifying novel approaches to predict and interpret the ecological implications of chemical-induced behaviour disruption. [ABSTRACT FROM AUTHOR]

In people with mental disorders, adverse general health is well recognized but dental diseases remain underinvestigated. The objective of this study was to investigate risk factors for hospital admissions for dental disorders in patients with severe mental illness (SMI) and/or depressive disorder. De‐identified electronic mental health records from the South London and Maudsley NHS Foundation Trust (SLaM) were linked to national Hospital Episode Statistics (HES) data for analysis. Data were extracted for adults with a diagnosis of SMI (schizophrenia, schizoaffective disorder, bipolar disorder) and/or depression, who had received care at SLaM between 1 January 2010 and 31 March 2017. In the cohort of 18,999 patients thus obtained, the following factors were independently associated with hospital admission for dental disorders: female gender [odds ratio (OR) = 1.48, 95% CI: 1.31–1.68)], Health of the Nation Outcome Scales (HoNOS) problem drinking/drug taking (OR = 1.12, 95% CI: 1.05–1.19), HoNOS physical illness/disability (OR = 1.18, 95% CI: 1.12–.25), diabetes (OR = 1.24, 95% CI: 1.06–1.43), recorded current/past smoking (OR = 1.35, 95% CI: 1.06–1.43), treatment with antidepressant medication (OR = 1.48, 95% CI: 1.31–1.68), and depressive disorder (OR = 1.36, 95% CI: 1.11–1.68). Building on previous research in this population, which indicated a relatively high risk of acute care hospitalizations with dental disorders as discharge diagnoses, a number of demographic and clinical characteristics were found to be independent predictors over a 7‐yr period. Further research into these predictors would facilitate a better understanding of how adverse dental outcomes might be prevented. [ABSTRACT FROM AUTHOR]

Antidepressant prescribing has increased year on year since the introduction of the selective serotonin reuptake inhibitors (SSRIs) in the 1980s. More than 10% of adults in England are now taking antidepressants for depression/anxiety, with a median length of treatment of more than 2 years, but antidepressants can cause side effects and withdrawal symptoms which increase with longer use. Surveys of antidepressant users suggest 30–50% have no evidence‐based indication to continue, but coming off antidepressants is often difficult due to fears of relapse, withdrawal symptoms and a lack of psychological treatments to replace maintenance treatment and prevent relapse. GPs should not prescribe antidepressants routinely for mild depressive/anxiety symptoms. Patients starting antidepressants should be advised that they are to be taken for a limited period only, and that there is a risk of withdrawal problems on stopping them. Prescribers should actively review long‐term antidepressant use and suggest coming off them slowly to patients who are well. The relationship between SSRI dose and serotonin transporter receptor occupancy suggests that hyperbolic tapering regimes may be helpful for patients with troubling withdrawal symptoms who cannot stop treatment within 4–8 weeks, and tapering strips can allow carefully titrated slower dose reduction over some months. Internet and telephone support to patients wanting to reduce their antidepressants is being trialled in the REDUCE programme. More research is needed to establish the incidence of withdrawal symptoms in representative samples of patients coming off antidepressants, and large randomised controlled trials are needed to test different tapering strategies. [ABSTRACT FROM AUTHOR]

Liew et al. (2020) recently published a paper in this journal that analyzed antidepressant prescription trends in the context of the 2016 Brexit referendum and the sociopolitical discord that followed. They present a novel finding that Leave-majority constituencies in England seemed more adversely affected by that discord than Remain-majority constituencies. I offer criticism of their findings and methodology. Using the complete set of available NHS prescription data shows that the trend the authors detect dates from at least mid-2010 and is not associated with the referendum. In terms of methodology, I critique the potential ecological fallacy and issues of false equivalence in their study design. The former stems from the inability to adequately control for demographic heterogeneity within constituencies, and the latter stems from the fact that the populations from which they draw their data are not equivalent in potentially important ways. Finally, I conclude that the key trend the authors detect seems to merely be a geographic artifact. The set of Remain-majority constituencies unintentionally oversamples the areas of England with the lowest rates of antidepressant prevalence, Greater London and the Southeast. Remain-majority constituencies outside of those two regions have roughly the same antidepressant prescription levels as Leave-majority constituencies in all of England. In itself, that is a troubling fact of social epidemiology, but Brexit is associated with it neither spatially nor temporally. [ABSTRACT FROM AUTHOR]

Background: The use of antidepressants in children and adolescents remains controversial. We examined trends over time and variation in antidepressant prescribing in children and young people in England and whether the drugs prescribed reflected UK licensing and guidelines.Methods and Findings: QResearch is a primary care database containing anonymised healthcare records of over 32 million patients from more than 1,500 general practices across the UK. All eligible children and young people aged 5-17 years in 1998-2017 from QResearch were included. Incidence and prevalence rates of antidepressant prescriptions in each year were calculated overall, for 4 antidepressant classes (selective serotonin reuptake inhibitors [SSRIs], tricyclic and related antidepressants [TCAs], serotonin and norepinephrine reuptake inhibitors [SNRIs], and other antidepressants), and for individual drugs. Adjusted trends over time and differences by social deprivation, region, and ethnicity were examined using Poisson regression, taking clustering within general practitioner (GP) practices into account using multilevel modelling. Of the 4.3 million children and young people in the cohort, 49,434 (1.1%) were prescribed antidepressants for the first time during 20 million years of follow-up. Males made up 52.0% of the cohorts, but only 34.1% of those who were first prescribed an antidepressant in the study period. The largest proportion of the cohort was from London (24.4%), and whilst ethnicity information was missing for 39.5% of the cohort, of those with known ethnicity, 75.3% were White. Overall, SSRIs (62.6%) were the most commonly prescribed first antidepressant, followed by TCAs (35.7%). Incident antidepressant prescribing decreased in 5- to 11-year-olds from a peak of 0.9 in females and 1.6 in males in 1999 to less than 0.2 per 1,000 for both sexes in 2017, but incidence rates more than doubled in 12- to 17-year-olds between 2005 and 2017 to 9.7 (females) and 4.2 (males) per 1,000 person-years. The lowest prescription incidence rates were in London, and the highest were in the South East of England (excluding London) for all sex and age groups. Those living in more deprived areas were more likely to be prescribed antidepressants after adjusting for region. The strongest trend was seen in 12- to 17-year-old females (adjusted incidence rate ratio [aIRR] 1.12, 95% confidence interval [95% CI] 1.11-1.13, p < 0.001, per deprivation quintile increase). Prescribing rates were highest in White and lowest in Black adolescents (aIRR 0.32, 95% CI 0.29-0.36, p < 0.001 [females]; aIRR 0.32, 95% CI 0.27-0.38, p < 0.001 [males]). The 5 most commonly prescribed antidepressants were either licensed in the UK for use in children and young people (CYP) or included in national guidelines. Limitations of the study are that, because we did not have access to secondary care prescribing information, we may be underestimating the prevalence and misidentifying the first antidepressant prescription. We could not assess whether antidepressants were dispensed or taken.Conclusions: Our analysis provides evidence of a continuing rise of antidepressant prescribing in adolescents aged 12-17 years since 2005, driven by SSRI prescriptions, but a decrease in children aged 5-11 years. The variation in prescribing by deprivation, region, and ethnicity could represent inequities. Future research should examine whether prescribing trends and variation are due to true differences in need and risk factors, access to diagnosis or treatment, prescribing behaviour, or young people's help-seeking behaviour. [ABSTRACT FROM AUTHOR]

Background: Around one in ten adults take antidepressants for depression in England, and their long-term use is increasing. Some need them to prevent relapse, but 30-50% could possibly stop them without relapsing and avoid adverse effects and complications of long-term use. However, stopping is not always easy due to withdrawal symptoms and a fear of relapse of depression. When general practitioners review patients on long-term antidepressants and recommend to those who are suitable to stop the medication, only 6-8% are able to stop. The Reviewing long-term antidepressant use by careful monitoring in everyday practice (REDUCE) research programme aims to identify safe and cost-effective ways of helping patients taking long-term antidepressants taper off treatment when appropriate.Methods: Design: REDUCE is a two-arm, 1:1 parallel group randomised controlled trial, with randomisation clustered by participating family practices.Setting: England and north Wales.Population: patients taking antidepressants for longer than 1 year for a first episode of depression or longer than 2 years for repeated episodes of depression who are no longer depressed and want to try to taper off their antidepressant use.Intervention: provision of 'ADvisor' internet programmes to general practitioners or nurse practitioners and to patients designed to support antidepressant withdrawal, plus three patient telephone calls from a psychological wellbeing practitioner. The control arm receives usual care. Blinding of patients, practitioners and researchers is not possible in an open pragmatic trial, but statistical and health economic data analysts will remain blind to allocation.Outcome Measures: the primary outcome is self-reported nine-item Patient Health Questionnaire at 6 months for depressive symptoms.Secondary Outcomes: depressive symptoms at other follow-up time points, anxiety, discontinuation of antidepressants, social functioning, wellbeing, enablement, quality of life, satisfaction, and use of health services for costs.Sample Size: 402 patients (201 intervention and 201 controls) from 134 general practices recruited over 15-18 months, and followed-up at 3, 6, 9 and 12 months. A qualitative process evaluation will be conducted through interviews with 15-20 patients and 15-20 practitioners in each arm to explore why the interventions were effective or not, depending on the results.Discussion: Helping patients reduce and stop antidepressants is often challenging for practitioners and time-consuming for very busy primary care practices. If REDUCE provides evidence showing that access to internet and telephone support enables more patients to stop treatment without increasing depression we will try to implement the intervention throughout the National Health Service, publishing practical guidance for professionals and advice for patients to follow, publicised through patient support groups.Trial Registration: ISRCTN:12417565. Registered on 7 October 2019. [ABSTRACT FROM AUTHOR]

Polypharmacy in the elderly, weaning patients off steroids, and reducing the use of antibiotics, antidepressants and opioids were among the topics discussed at the Royal College of Physicians' conference Avoiding Harm from Over‐prescribing held in London in November. Joy Ogden presents some of the highlights of the conference. [ABSTRACT FROM AUTHOR]

Background Depressed patients often focus on negative life events. Effective antidepressant therapy reverses this negative emotional bias (NEB) within 1 week. Clinical therapeutic effect usually requires 4-6 weeks. The value of implementing NEB monitoring for the personalisation of antidepressant therapy is unknown. Objective To estimate the likely outcome and cost consequences of adopting the P1vital Oxford Emotional Test Battery (ETB) for this purpose in routine primary care in England. Methods A hybrid decision analytic model (decision tree plus Markov model) was developed to estimate the cost-effectiveness of ETB monitoring versus no ETB over 52 weeks using quality-adjusted life years (QALYs). Differences in depression severity, episode type and analytical perspectives were considered. Input data were derived from relevant guidelines, literature, national databases, expert opinion and the developers for the year 2013. Multiple sensitivity analyses addressed uncertainty. Findings The mean number of ETB tests is 2.162 per newly diagnosed patient and 2.166 per patient with recurrent depression. The incremental cost-effectiveness of ETB versus 'no ETB' is £4355/QALY from the healthcare perspective. From the broader societal perspective, ETB is more effective and cost saving. Conclusions Monitoring negative emotional bias in primary care in England for personalised antidepressant treatment using ETB seems as an effective and cost-effective option under all considered scenarios (including worst case). Its main economic value seems to lie in reduced productivity loss as opposed to healthcare savings. Clinical implications The test supports accelerated application of evidence-based depression care. Further optimisation and implementation in the ongoing European PReDicT trial is ongoing. [ABSTRACT FROM AUTHOR]

Background: Mental illness is highly prevalent among prisoners. Although psychotropic medicines can ameliorate symptoms of mental illness, prescribers in prisons must balance clinical needs against risks to safety and security. Concerns have been raised at the large number of prisoners reportedly receiving psychotropic medicines in England. Nonetheless, unlike for the wider community, robust prescribing data are not routinely available for prisons. We investigated gender-specific patterns in the prevalence and appropriateness of psychotropic prescribing in English prisons. Methods: We studied 6052 men and 785 women in 11 prisons throughout England. This represented 7.9% of male and 20.5% of female prisoners nationally. Using a cross-sectional design, demographic and prescription data were collected from clinical records of all prisoners prescribed psychotropic medicines, including hypnotic, anxiolytic, antipsychotic, anti-manic, antidepressant and Central Nervous System stimulant medications. Percentages and 95% CIs were used to estimate the prevalence of prescribing. The Prescribing Appropriate Indicators tool was used to determine appropriateness. Prevalence Ratios (PR) were generated to make age-adjusted comparisons between prisoners and the general population using a dataset supplied by the Clinical Practice Research Datalink. Results: Overall, 47.9% (CI 44.4-51.4) of women and 16.9% (CI 16.0-17.9) of men in prison were prescribed one or more psychotropic medicines. Compared with the general population, age-adjusted prescribing prevalence was six times higher among women (PR 5.95 CI 5.36-6.61) and four times higher among men (PR 4.02 CI 3.75-4.30). Undocumented or unapproved indications for prescriptions, not listed in the British National Formulary, were recorded in a third (34.7%, CI 32.5-37.0) of cases, most commonly low mood and personality disorder. Conclusions: Psychotropic medicines were prescribed frequently in prisons, especially among women, and for a wider range of indications than are currently recommended. These findings raise questions about whether the prescribing of psychotropic medicines in prisons is wholly appropriate and proportionate to the level of clinical need. Prisons need to develop a wider array of treatment responses, other than medicines, to effectively tackle mental illness, challenging behaviours and distress. [ABSTRACT FROM AUTHOR]

Background: The National Psychiatric Morbidity Surveys include English cross-sectional household samples surveyed in 1993, 2000 and 2007.Aims: To evaluate frequency of common mental disorders (CMDs), service contact and treatment.Method: Common mental disorders were identified with the Clinical Interview Schedule - Revised (CIS-R). Service contact and treatment were established in structured interviews.Results: There were 8615, 6126 and 5385 participants aged 16-64. Prevalence of CMDs was consistent (1993: 14.3%; 2000: 16.0%; 2007: 16.0%), as was past-year primary care physician contact for psychological problems (1993: 11.3%; 2000: 12.0%; 2007: 11.7%). Antidepressant receipt in people with CMDs more than doubled between 1993 (5.7%) and 2000 (14.5%), with little further increase by 2007 (15.9%). Psychological treatments increased in successive surveys. Many with CMDs received no treatment.Conclusions: Reduction in prevalence did not follow increased treatment uptake, and may require universal public health measures together with individual pharmacological, psychological and computer-based interventions. [ABSTRACT FROM AUTHOR]

BackgroundStudies have linked ethnic differences in depression rates with neighbourhood ethnic density although results have not been conclusive. We looked at this using a novel approach analysing whole population data covering just over one million GP patients in four London boroughs.MethodUsing a dataset of GP records for all patients registered in Lambeth, Hackney, Tower Hamlets and Newham in 2013 we investigated new diagnoses of depression and antidepressant use for: Indian, Pakistani, Bangladeshi, black Caribbean and black African patients. Neighbourhood effects were assessed independently of GP practice using a cross-classified multilevel model.ResultsBlack and minority ethnic groups are up to four times less likely to be newly diagnosed with depression or prescribed antidepressants compared to white British patients. We found an inverse relationship between neighbourhood ethnic density and new depression diagnosis for some groups, where an increase of 10% own-ethnic density was associated with a statistically significant (p < 0.05) reduced odds of depression for Pakistani [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.70–0.93], Indian (OR 0.88, CI 0.81–0.95), African (OR 0.88, CI 0.78–0.99) and Bangladeshi (OR 0.94, CI 0.90–0.99) patients. Black Caribbean patients, however, showed the opposite effect (OR 1.26, CI 1.09–1.46). The results for antidepressant use were very similar although the corresponding effect for black Caribbeans was no longer statistically significant (p = 0.07).ConclusionNew depression diagnosis and antidepressant use was shown to be less likely in areas of higher own-ethnic density for some, but not all, ethnic groups. [ABSTRACT FROM PUBLISHER]

Background: The prevalence of depressive disorder in adults with advanced cancer is around 20 %. Although cognitive behavioural therapy (CBT) is recommended for depression and may be beneficial in depressed people with cancer, its use for depression in those with advanced disease for whom cure is not likely has not been explored.Methods: People aged 18 years and above with advanced cancer attending General Practitioner (GP), oncology or hospice outpatients from centres across England will be screened to establish a DSM-IV diagnosis of depression. Self-referral is also accepted. Eligible consenters will be randomised to a single blind, multicentre, randomised controlled trial of the addition to treatment as usual (TAU) of up to 12 one-hour weekly sessions of manualised CBT versus TAU alone. Sessions are delivered in primary care through Increasing Access to Psychological Care (IAPT) service, and the manual includes a focus on issues for people approaching the end of life. The main outcome is the Beck Depression Inventory-II (BDI-II). Subsidiary measures include the Patient Health Questionnaire, quality of life measure EQ-5D, Satisfaction with care, Eastern Cooperative Oncology Group-Performance Status and a modified Client Service Receipt Inventory. At 90 % power, we require 240 participants to enter the trial. Data will be analysed using multi-level (hierarchical) models for data collected at baseline, 6, 12, 18 and 24 weeks. Cost effectiveness analysis will incorporate costs related to the intervention to compare overall healthcare costs and QALYs between the treatment arms. We will conduct qualitative interviews after final follow-up on patient and therapist perspectives of the therapy.Discussion: This trial will provide data on the clinical and cost effectiveness of CBT for people with advanced cancer and depression. We shall gain an understanding of the feasibility of delivering care to this group through IAPT. Our findings will provide evidence for policy-makers, commissioners and clinicians in cancer and palliative care, and in the community.Trial Registration: Controlled Trials ISRCTN07622709 , registered 15 July 2011. [ABSTRACT FROM AUTHOR]

Purpose -- The purpose of this audit cycle was to compare the clinical practice of treating children and adolescents with moderate to severe depression with the NICE guidelines. The second aim was to recommend changes in practice to improve compliance to the guidelines and reinvestigate the degree of change two years after the initial recommendations. Design/methodology/approach -- A total of 40 patients within Secondary Care with moderate or severe depression were selected. Data were collected, analyzed and recommendations were made. The second phase of the audit cycle was completed after two years, following similar methods. Findings -- On most of the parameters the clinical practice improved in the re-audit, indicating better compliance with the NICE guidelines. However, on a few areas the compliance did not improve or even deteriorated. Research limitations/implications -- The implications of the results were discussed and final recommendations were made based on the findings and the perceived change in practice. Originality/value -- Literature searches revealed no previous audit cycles to have been conducted on CAMHS compliance to NICE guidelines with regards to treating depression. [ABSTRACT FROM AUTHOR]

Background: Depression is common in coronary heart disease (CHD). Affected patients have an increased incidence of coronary symptoms and death. Little is known about how best to manage primary care patients with both CHD and depression. This study is part of the UPBEAT-UK programme of research and was designed to understand general practitioners' (GPs) and practice nurses' (PNs) views and experience of managing depression in CHD. Methods: Individual in-depth interviews with 10 GPs and 12 PNs in South East London. Data were analysed using constant comparison. Results: GPs and PNs had similar views. Distress following diagnosis or a cardiac event was considered to resolve spontaneously; if it endured or became severe it was treated as depression. GPs and PNs felt that psychosocial problems contributed to depression in patients with CHD. However, uncertainty was expressed as to their perceived role and responsibility in addressing these. In this respect, depression in patients with CHD was considered similar to depression in other patients and no coherent management approach specific for depression in CHD was identified. An individualised approach was favoured, but clinicians were unsure how to achieve this in the face of conflicting patient preferences and the treatment options they considered available. Conclusions: GPs and PNs view depression in CHD similarly to depression uncomplicated by physical illness. However, uncertainty exists as to how best to manage depression associated psychosocial issues. Personalised interventions are needed which account for individual need and which enable and encourage clinicians and patients to make use of existing resources to address the psychosocial factors which contribute to depression. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims To investigate whether there were changes in the rate of prescribing of smoking cessation medications in the months leading up to, and after, the introduction of smoke-free legislation in England. Design Interrupted time-series analysis of prescribing rates using Autoregressive Integrated Moving Average (ARIMA) models. Setting A total of 350 general practices in England who contribute data to The Health Improvement Network (THIN) database. Participants Patients in THIN aged 16+ identified from their medical records as smokers. Measurements Monthly rates of prescribing of nicotine replacement therapy (NRT), bupropion and varenicline were calculated from THIN from 2000 to 2009 for all smokers and for subgroups defined by patient sex, age group, history of chronic disease and quintile of the Townsend Index of Deprivation. ARIMA models were built to assess whether there were changes in prescribing before or after the introduction of smoke-free legislation over and above any long-term and seasonal trends. Findings There was a 6.4% (0.7-12.1) increase in prescribing of all smoking cessation medications in the 9 months before the introduction of smoke-free legislation and a 6.4% (1.1-11.7) reduction in the 9-month period afterwards. A 6.2% (1.4-11.0) increase in NRT prescribing and a 13.2% (4.3-22.2) increase in bupropion prescribing occurred in the 6- and 3-month periods, respectively, before smoke-free legislation was introduced, and a 5.5% (2.3-8.7) decline in NRT prescribing and a 13.7% (4.6-22.8) decline in bupropion prescribing in the 9 months post-legislation. The patterns of change in prescribing did not vary with patient demographics. Conclusions Numbers of primary care prescriptions for smoking cessation medications increased prior to the introduction of smoke-free legislation but decreased afterwards, suggesting a temporal displacement in prescribing activity rather than a change in the overall volume of prescribing. Effects observed were consistent across all population subgroups, suggesting that the changes in prescribing will neither widen nor reduce smoking-related health inequalities. [ABSTRACT FROM AUTHOR]

Background Many practices in the UK have computerised information dating back to the 1990s. These health records provide contemporaneous collected longitudinal data for analysis of health trends and their management in primary care over time. Objective This study examines the trends in common mental health problems (CMHPs), prescription of antidepressant, anxiolytics and hypnotics and medical certificates over four years to highlight the strengths and pitfalls in trends analysis using primary care data. Method Relevant clinical information for the first six months of each of the calendar years 2004, 2005, 2006 and 2007 were extracted from participating practices in a London locality and in the North. Results Between 2004 and 2007 recorded episodes of CMHPs rose from 33 to 45 per thousand adults in the northern site, and from 19 to 22 in the London site. Prescriptions of antidepressants, anxiolytics and hypnotics rose (from 381.4 to 418 per thousand adults) in the northern site but did not increase in the London site. Medical certificates increased steadily (from 32.7 to 61.6 per thousand adults with a CMHP) in the London site but not in the northern. Recorded episodes of CMHPs and prescriptions of antidepressants, anxiolytics or hypnotics are much higher in the northern site than the London site; the rate of medical certificates per thousand adults with CMHPs in the northern site is more than ten times that in the London site. Conclusions Demographics, diagnostic and prescribing data are of high quality in primary care, and they could be used more to understand local health needs and inform commissioning decisions. [ABSTRACT FROM AUTHOR]

Dr. Shipman was the worst known serial killer in British history, at least in terms of numbers of victims, and possibly the worst in world history, if politicians are excluded. He killed at least 215 patients and may have begun his murderous career at the age of 25, within a year of finishing his medical training. His case has had a profound impact on the practice of medicine in the United Kingdom. Was he a special case? What were the origins of this behaviour? Could the behaviour have been prevented? It is necessary to learn what we can from a few personal facts and largely circumstantial evidence. He withheld himself from any useful clinical investigation or treatment once he had been taken into custody. Could he have been treated at any stage? Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background. Undertreatment of depression in primary care is common. Efforts to address this tend to overlook the role of patient attitudes. Our aim was to validate and describe responses to a questionnaire about attitudes to depression and its treatment in a sample with experience of moderate and severe depressive episodes. Method. Cross-sectional survey of 866 individuals with a confirmed history of an ICD-b depressive episode in the 12 months preceding interview, recruited from 7271 consecutive general practitioner (GP) attendees in 36 general practices in England and Wales. Attitudes to and beliefs about depression were assessed using a 19-item self-report questionnaire. Results. Factor analysis resulted in a three-factor solution: factor 1, depression as a disabling, permanent state; factor 2, depression as a medical condition responsive to support; and factor 3, antidepressants are addictive and ineffective. Participants who received and adhered to antidepressant medication and disclosed their depression to family and friends had significantly lower scores on factors 1 and 3 but higher scores on factor 2. Conclusions. People with moderate or severe depressive episodes have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment. [ABSTRACT FROM AUTHOR]

Background: Self-harm is a major healthcare problem in the United Kingdom, but monitoring of hospital presentations has largely been done separately in single centres. Multicentre monitoring of self-harm has been established as a result of the National Suicide Prevention Strategy for England.Method: Data on self-harm presentations to general hospitals in Oxford (one hospital), Manchester (three hospitals) and Leeds (two hospitals), collected through monitoring systems in each centre, were analysed for the 18-month period March 2000 to August 2001.Results: The findings were based on 7344 persons who presented following 10,498 episodes of self-harm. Gender and age patterns were similar in the three centres, 57.0% of patients being female and two-thirds (62.9%) under 35 years of age. The largest numbers by age groups were 15-19 year-old females and 20-24 year-old males. The female to male ratio decreased with age. Rates of self-harm were higher in Manchester than Oxford or Leeds, in keeping with local suicide rates. The proportion of patients receiving a specialist psychosocial assessment varied between centres and was strongly associated with admission to the general hospital. Approximately 80% of self-harm involved self-poisoning. Overdoses of paracetamol, the most frequent method, were more common in younger age groups, antidepressants in middle age groups, and benzodiazepines and sedatives in older age groups. Alcohol was involved in more than half (54.9%) of assessed episodes. The most common time of presentation to hospital was between 10 pm and 2 am.Conclusions: Multicentre monitoring of self-harm in England has demonstrated similar overall patterns of self-harm in Oxford, Manchester and Leeds, with some differences reflecting local suicide rates. Diurnal variation in time of presentation to hospital and the need for assessment of non-admitted patients have implications for service provision. [ABSTRACT FROM AUTHOR]

Background: Antidepressant prescribing has been increasing in England. Studies in other countries suggest that while this may be associated with reduced suicide rates, it may also be associated with increased fatal poisoning from antidepressant drugs. We therefore conducted an ecological study to assess the association between prescription rates for antidepressants and suicide or fatal antidepressant-related poisoning in England. Methods: The Office for National Statistics provided information on the number of suicides, antidepressant-related poisoning deaths and populations for England between 1993 and 2002. The Department of Health supplied data on prescriptions for all antidepressants dispensed in England. Associations between prescriptions and deaths were assessed using Spearman's rank correlation coefficient. Results: There were 46,747 suicides, 3,987 deaths involving tricyclic antidepressants and 430 involving selective serotonin re-uptake inhibitors and other antidepressants. Increased antidepressant prescribing was statistically associated with a fall in suicide rates (Spearman's rs = - 0.73, p = 0.02) and fatal poisoning involving tricyclic antidepressants (rs = -0.64, p = 0.05). In contrast, increased prescribing of selective serotonin re-uptake inhibitors and other antidepressants was statistically associated with an increase in fatal poisoning involving these drugs (rs = 0.99, p < 0.001). Conclusion: Increased prescribing of antidepressants may indicate improved diagnosis and treatment of depression in primary care. Our analysis suggests that this was accompanied by lower suicide rates. A decrease in poisoning deaths involving tricyclic antidepressants may suggest a change in preference for using serotonin reuptake inhibitors and other antidepressant drugs for high-risk patients. This may also partially explain the increase in deaths involving these drugs. Due to the ecological nature of the design, we cannot say conclusively whether reduced suicide rates are a direct consequence of increased antidepressant prescribing rates. To confirm these associations, individual level data on prescribing and suicide is needed. [ABSTRACT FROM AUTHOR]

In England and Wales the majority of suicides by poisoning are now attributable to one of five products- paracetamol, dextropropoxyphene, amitriptyline, dothiepin and temazepam. Most of the temazepam deaths occur when it is taken in combination with one or more other products. Co-proxamol (dextropropoxyphene plus paracetamol) and paracetamol account (or the majority of suicides by overdosage of analgesics. The ratio of the number of prescriptions dispensed to the number of fatalities varies considerably between antidepressants. The highest ratio is amongst the older tricyclics. It is lowest for the atypical antidepressants including the newer selective serotonin reuptake inhibitors. The variation in the fatality ratios of these compounds is related to differences in their inherent toxicity and compliance. Recognising the pattern of suicides from overdosage of drugs has important implications for prevention. Safety in overdose must be taken into account when prescribing drugs to patients who are at risk for suicide. [ABSTRACT FROM AUTHOR]