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BackgroundThe efficacy of long-term preventative medication in people who have dementia and other comorbidities is unknown. Electronic health record-based observational studies may play a role in evaluating medicines, and SLaM-CRIS is one such resource. Medication in SLaM-CRIS is extracted from structured and unstructured fields using a natural language processing app. We aimed to compare the results from the medication app with GP prescribing, using an innovative data link with primary care (Lambeth DataNet, LDN) that covers around one-quarter of the SLaM-CRIS population.MethodsA cohort was created of people with both LDN record and SLaM-CRIS record who had received a diagnosis of dementia in either record, in which ascertainment of medication could be compared. Ten classes of medication commonly taken long-term for preventative purposes were studied (aspirin, statins, ACE inhibitors, anticoagulants, beta-blockers, bisphosphonates, calcium with vitamin D, non-aspirin antiplatelets, proton pump inhibitors and antidepressants), plus medications taken for dementia itself. Mentions of these medication classes in SLaM-CRIS from around the time of dementia diagnosis were extracted using a natural language processing application. Prescription issue for the same medications was extracted from LDN in the year of dementia diagnosis and compared with that from SLaM-CRIS on a cohort and individual level.ResultsOur sample included 4410 with documentation of dementia in either SLaM-CRIS or LDN. Estimation of the prevalence of the use of each medication in CRIS was compared to LDN, and was within +/-3 per 100, except for calcium with vitamin D supplement, where SLaM-CRIS prevalence was 13 people per 100 lower than LDN (8.6% vs 21.2%). Medication ascertainment of all groups except calcium with vitamin D supplement showed good agreement (kappa above 0.7), and very good agreement for antidepressants and dementia drugs (kappa above 0.8). Sensitivity was highest for dementia drugs and antidepressants (above 90%), 85% for statins and 75% for aspirin. Restricting to those with a memory clinic referral did not change the levels of agreement.DiscussionRoutinely collected data cannot provide a gold-standard measure of what medications are truly taken by patients with dementia, but several sources can provide a proxy measure. This analysis supports the use of the natural language processing application for medication in SLaM-CRIS to extract medication mentions of relevance to people with dementia, as compared to prescribing from the GP at around the same time. However, some medications show low sensitivity, possibly due to low recording or inconsistency in the text used to record, and enhancement will be needed before studying these medications.

Background The current study used data from an ethnically diverse population from South London to examine ethnic differences in physical and mental multimorbidity among working age (18–64 years) adults in the context of depression and anxiety. Method The study included 44 506 patients who had previously attended Improving Access to Psychological Therapies services in the London Borough of Lambeth. Multinomial logistic regression examined cross-sectional associations between ethnicity with physical and mental multimorbidity. Patterns of multimorbidity were identified using hierarchical cluster analysis. Results Within 44 056 working age adults with a history of depression or anxiety from South London there were notable ethnic differences in physical multimorbidity. Adults of Black Caribbean ethnicity were more likely to have physical multimorbidity [adjusted relative risk ratio (aRRR) = 1.25, 95% confidence interval (CI) 1.15–1.36] compared to adults of White ethnicity. Relative to adults of White ethnicity, adults of Asian ethnicity were more likely to have physical multimorbidity at higher thresholds only (e.g. 4 + conditions; aRRR = 1.53, 95% CI 1.17–2.00). Three physical (atopic, cardiometabolic, mixed) and three mental (alcohol/substance use, common/severe mental illnesses, personality disorder) multimorbidity clusters emerged. Ethnic minority groups with multimorbidity had a higher probability of belonging to the cardiometabolic cluster. Conclusion In an ethnically diverse population with a history of common mental health disorders, we found substantial between- and within-ethnicity variation in rates of physical, but not mental, multimorbidity. The findings emphasised the value of more granular definitions of ethnicity when examining the burden of physical and mental multimorbidity.

Background databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care. Methods a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared. Results 3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer’s dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63–0.85), have multimorbidity (0.87, 0.77–0.98) or consult frequently (0.91, 0.88–0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91–1.06). Discussion there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

BackgroundAccurate recognition and recording of intellectual disability in those who are admitted to general hospitals is necessary for making reasonable adjustments, ensuring equitable access, and monitoring quality of care. In this study we determined the rate of recording of intellectual disability in those with the condition who were admitted to hospital, and factors associated with the condition being unrecorded.Methods and FindingsRetrospective cohort study using two linked datasets of routinely collected clinical data. We identified adults with diagnosed intellectual disability in a large secondary mental healthcare database and used general hospital records to investigate recording of intellectual disability when people were admitted to general hospitals between 2006 and 2019. Trends over time and factors associated with intellectual disability being unrecorded were investigated. We obtained data on 2,477 adults with intellectual disability who were admitted to a general hospital in England at least once during the study period (total number of admissions=27,314; median number of admissions=5). People with intellectual disability were accurately recorded as having the condition during 2.9% (95%CI 2.7-3.1%) of their admissions. Broadening the criteria to include a non-specific code of learning difficulty increased recording to 27.7% (95%CI 27.2-28.3%) of all admissions. Having a mild intellectual disability and being married were associated with increased odds of the intellectual disability being unrecorded in hospital records. We had no measure of quality of hospital care received and could not relate this to the presence or absence of a record of intellectual disability in the patient record.ConclusionsRecognition and recording of intellectual disability in adults admitted to English general hospitals needs to be improved. Staff awareness training, screening at the point of admission, and data sharing between health and social care services could improve care for people with intellectual disability.

PurposeThere is a dearth of literature examining the impact of the COVID-19 pandemic on older people with dual diagnosis referred to mental health services. The purpose of this study was to compare dual diagnosis before and after lockdown in people aged between 55 and 74 with alcohol use.Design/methodology/approachData were collected for people referred to mental health services using an anonymised database of de-identified records to identify people with both substance use disorder alone, or accompanied by co-existing mental disorders.FindingsIn total, 366 older people were assessed with the Alcohol Use Disorders Identification Test (AUDIT), 185 before and 181 after lockdown. People with dual diagnosis were more likely to be referred than those without, after compared to before lockdown (13 and 6%, respectively, p < 0.05). People with any substance use disorder with and without dual diagnosis showed an even greater likelihood of referral after, compared with before, lockdown (61 and 34%, respectively, p < 0.0001). Opioid use more than once a month was more likely to be reported after, compared with before, lockdown (66 and 36%, respectively, p < 0.005).Research limitations/implicationsThe finding of a higher likelihood of opioid use after compared with before lockdown during the COVID-19 pandemic warrants further exploration. There is also further scope for further studies that involve older non-drinkers.Originality/valueA greater likelihood of both dual diagnosis and substance use disorder alone after, compared with before lockdown has implications for both mental health and addiction service provision during a pandemic.

Background: There has been little previous research within mental health services exploring changes in drinking behavior among older people during the COVID-19 pandemic. This study compared alcohol...

Background Risk estimation models integrated into Electronic Health Records (EHRs) can deliver innovative approaches in psychiatry, but clinicians' endorsement and their real-world usability are unknown. This study aimed to investigate the real-world feasibility of implementing an individualised, transdiagnostic risk calculator to automatically screen EHRs and detect individuals at-risk for psychosis. Methods Feasibility implementation study encompassing an in-vitro phase (March 2018 to May 2018) and in-vivo phase (May 2018 to April 2019). The in-vitro phase addressed implementation barriers and embedded the risk calculator (predictors: age, gender, ethnicity, index cluster diagnosis, age*gender) into the local EHR. The in-vivo phase investigated the real-world feasibility of screening individuals accessing secondary mental healthcare at the South London and Maudsley NHS Trust. The primary outcome was adherence of clinicians to automatic EHR screening, defined by the proportion of clinicians who responded to alerts from the risk calculator, over those contacted. Results In-vitro phase: implementation barriers were identified/overcome with clinician and service user engagement, and the calculator was successfully integrated into the local EHR through the CogStack platform. In-vivo phase: 3722 individuals were automatically screened and 115 were detected. Clinician adherence was 74% without outreach and 85% with outreach. One-third of clinicians responded to the first email (37.1%) or phone calls (33.7%). Among those detected, cumulative risk of developing psychosis was 12% at six-month follow-up. Conclusion This is the first implementation study suggesting that combining precision psychiatry and EHR methods to improve detection of individuals with emerging psychosis is feasible. Future psychiatric implementation research is urgently needed.

Purpose The World Health Organisation (WHO) recently ranked air pollution as the major environmental cause of premature death. However, the significant potential health and societal costs of poor mental health in relation to air quality are not represented in the WHO report due to limited evidence. We aimed to test the hypothesis that long-term exposure to air pollution is associated with poor mental health. Methods A prospective longitudinal population-based mental health survey was conducted of 1698 adults living in 1075 households in South East London, from 2008 to 2013. High-resolution quarterly average air pollution concentrations of nitrogen dioxide (NO2) and oxides (NOx), ozone (O3), particulate matter with an aerodynamic diameter 10) and 2.5) were linked to the home addresses of the study participants. Associations with mental health were analysed with the use of multilevel generalised linear models, after adjusting for large number of confounders, including the individuals’ socioeconomic position and exposure to road-traffic noise. Results We found robust evidence for interquartile range increases in PM2.5, NOx and NO2 to be associated with 18–39% increased odds of common mental disorders, 19–30% increased odds of poor physical symptoms and 33% of psychotic experiences only for PM10. These longitudinal associations were more pronounced in the subset of non-movers for NO2 and NOx. Conclusions The findings suggest that traffic-related air pollution is adversely affecting mental health. Whilst causation cannot be proved, this work suggests substantial morbidity from mental disorders could be avoided with improved air quality.

ObjectivesIntroduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.MethodsData were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.ResultsIn a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.ConclusionsFor the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

BackgroundCatatonia, a severe neuropsychiatric syndrome, has few studies of sufficient scale to clarify its epidemiology or pathophysiology. We aimed to characterise demographic associations, peripheral inflammatory markers and outcome of catatonia.MethodsElectronic healthcare records were searched for validated clinical diagnoses of catatonia. In a case–control study, demographics and inflammatory markers were compared in psychiatric inpatients with and without catatonia. In a cohort study, the two groups were compared in terms of their duration of admission and mortality.ResultsWe identified 1456 patients with catatonia (of whom 25.1% had two or more episodes) and 24 956 psychiatric inpatients without catatonia. Incidence was 10.6 episodes of catatonia per 100 000 person-years. Patients with and without catatonia were similar in sex, younger and more likely to be of Black ethnicity. Serum iron was reduced in patients with catatonia [11.6 v. 14.2 μmol/L, odds ratio (OR) 0.65 (95% confidence interval (CI) 0.45–0.95), p = 0.03] and creatine kinase was raised [2545 v. 459 IU/L, OR 1.53 (95% CI 1.29–1.81), p < 0.001], but there was no difference in C-reactive protein or white cell count. N-Methyl-d-aspartate receptor antibodies were significantly associated with catatonia, but there were small numbers of positive results. Duration of hospitalisation was greater in the catatonia group (median: 43 v. 25 days), but there was no difference in mortality after adjustment.ConclusionsIn the largest clinical study of catatonia, we found catatonia occurred in approximately 1 per 10 000 person-years. Evidence for a proinflammatory state was mixed. Catatonia was associated with prolonged inpatient admission but not with increased mortality.

Diabetes self-care may become increasingly challenging as cognition declines. We sought to characterize glycated hemoglobin ARetrospective matched cohort study.Using a linkage between a primary care (Lambeth DataNet) and a secondary mental healthcare database, up to 5 individuals aged ≥65 y with preexisting T2D without dementia were matched to each individual with dementia based on age, sex, and general practice.Comparisons were made for HbAIn 725 incident dementia and 3154 matched comparators, HbAOur study has highlighted important differences in the monitoring, management, and control of diabetes in people with dementia. The effects of frailty and the extent of cognitive impairment on the ability to self-manage diabetes and on glycemic control may need to be considered in treatment guidelines and by primary care.

BackgroundGrowing evidence suggests that air pollution exposure may adversely affect the brain and increase risk for psychiatric disorders such as schizophrenia and depression. However, little is known about the potential role of air pollution in severity and relapse following illness onset.AimsTo examine the longitudinal association between residential air pollution exposure and mental health service use (an indicator of illness severity and relapse) among individuals with first presentations of psychotic and mood disorders.MethodWe identified individuals aged ≥15 years who had first contact with the South London and Maudsley NHS Foundation Trust for psychotic and mood disorders in 2008–2012 (n = 13 887). High-resolution (20 × 20 m) estimates of nitrogen dioxide (NO2), nitrogen oxides (NOx) and particulate matter (PM2.5 and PM10) levels in ambient air were linked to residential addresses. In-patient days and community mental health service (CMHS) events were recorded over 1-year and 7-year follow-up periods.ResultsFollowing covariate adjustment, interquartile range increases in NO2, NOx and PM2.5 were associated with 18% (95% CI 5–34%), 18% (95% CI 5–34%) and 11% (95% CI 3–19%) increased risk for in-patient days after 1 year. Similarly, interquartile range increases in NO2, NOx, PM2.5 and PM10 were associated with 32% (95% CI 25–38%), 31% (95% CI 24–37%), 7% (95% CI 4–11%) and 9% (95% CI 5–14%) increased risk for CMHS events after 1 year. Associations persisted after 7 years.ConclusionsResidential air pollution exposure is associated with increased mental health service use among people recently diagnosed with psychotic and mood disorders. Assuming causality, interventions to reduce air pollution exposure could improve mental health prognoses and reduce healthcare costs.

ObjectivesSickness absence is strongly associated with poor mental health, and mental disorders often go untreated. In this population-based cohort study, we identified people receiving fit notes from their general practitioner (GP) and determined access to mental health treatment stratified by health complaint and demographic variables.DesignLongitudinal study of health records.SettingPrimary care and secondary mental health care in the borough of Lambeth, South London. Forty-five GP practices in Lambeth and the local secondary mental healthcare trust.ParticipantsThe analytical sample included 293 933 working age adults (16–60 years) registered at a Lambeth GP practice between 1 January 2014 and 30 April 2016.Primary and secondary outcome measuresThree indicators of mental healthcare in the year after first fit note were antidepressant prescription, contact with Improving Access to Psychological Therapy (IAPT) services and contact with secondary mental health services.Results75% of people with an identified mental health condition at first fit note had an indicator of mental healthcare in the following year. Black Caribbean and Black African groups presenting with mental disorders were less likely to have a mental healthcare indicator compared with White British groups.ConclusionsThe majority of those with an identified mental health need receive some treatment in the year following a fit note; however, our results suggest Black African and Black Caribbean groups with an identified mental healthcare need have less complete access compared to the White British group.

Background People with schizophrenia have shortened lives. This excess mortality seems to be related to physical health conditions that may be amenable to better primary and secondary prevention. Better continuity of care may enhance such interventions as well as help prevent death by self-injury. Aims We set out to examine the relationship between the continuity of care of patients with schizophrenia, their mortality and cause of death. Method Pseudoanonymised community data from 5551 people with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index. These and demographic variables were related to death certifications of physical illness from the Office of National Statistics and mortal self-injury from clinical data. Data were analysed using generalised estimating equations. Results We found no independent relationship between levels of continuity of care and overall mortality. However, lower levels of relationship continuity were significantly and independently related to death by self-injury. Conclusions We found no evidence that continuity of care is important in the prevention of physical causes of death in schizophrenia. However, there is evidence that declining relationship continuity of care has an independent effect on deaths as a result of self-injury. We suggest that there should be more attention focused on the improvement of continuity of care for these patients.

OBJECTIVES Evidence in mouse models has found that the antidepressant trazodone may be protective against neurodegeneration. We therefore aimed to compare cognitive decline of people with dementia taking trazodone with those taking other antidepressants. METHODS Three identical naturalistic cohort studies using UK clinical registers. We included all people with dementia assessed during 2008-16 who were recorded taking trazodone, citalopram or mirtazapine for at least 6 weeks. Linear mixed models examined age, time and sex-adjusted Mini-mental state examination (MMSE) change in people with all-cause dementia taking trazodone compared with those taking citalopram and mirtazapine. In secondary analyses, we examined those with non-vascular dementia; mild dementia; and adjusted results for neuropsychiatric symptoms. We combined results from the three study sites using random-effects meta-analysis. RESULTS We included 2,199 people with dementia, including 406 taking trazodone, with mean 2.2 years follow-up. There was no difference in adjusted cognitive decline in people with all-cause or non-vascular dementia taking trazodone, citalopram or mirtazapine in any of the three study sites. When data from the three sites were combined in meta-analysis, we found greater mean MMSE decline in people with all-cause dementia taking trazodone compared to those taking citalopram (0·26 points per successive MMSE measurement, 95% CI 0·03-0·49; p = 0·03). Results in sensitivity analyses were consistent with primary analyses. CONCLUSIONS There was no evidence of cognitive benefit from trazodone compared to other antidepressants in people with dementia in three naturalistic cohort studies. Despite preclinical evidence, trazodone should not be advocated for cognition in dementia.

ObjectivesTo investigate changes in daily mental health (MH) service use and mortality in response to the introduction and the lifting of the COVID-19 ‘lockdown’ policy in Spring 2020.DesignA regression discontinuity in time (RDiT) analysis of daily service-level activity.Setting and participantsMental healthcare data were extracted from 10 UK providers.Outcome measuresDaily (weekly for one site) deaths from all causes, referrals and discharges, inpatient care (admissions, discharges, caseloads) and community services (face-to-face (f2f)/non-f2f contacts, caseloads): Adult, older adult and child/adolescent mental health; early intervention in psychosis; home treatment teams and liaison/Accident and Emergency (A&E). Data were extracted from 1 Jan 2019 to 31 May 2020 for all sites, supplemented to 31 July 2020 for four sites. Changes around the commencement and lifting of COVID-19 ‘lockdown’ policy (23 March and 10 May, respectively) were estimated using a RDiT design with a difference-in-difference approach generating incidence rate ratios (IRRs), meta-analysed across sites.ResultsPooled estimates for the lockdown transition showed increased daily deaths (IRR 2.31, 95% CI 1.86 to 2.87), reduced referrals (IRR 0.62, 95% CI 0.55 to 0.70) and reduced inpatient admissions (IRR 0.75, 95% CI 0.67 to 0.83) and caseloads (IRR 0.85, 95% CI 0.79 to 0.91) compared with the pre lockdown period. All community services saw shifts from f2f to non-f2f contacts, but varied in caseload changes. Lift of lockdown was associated with reduced deaths (IRR 0.42, 95% CI 0.27 to 0.66), increased referrals (IRR 1.36, 95% CI 1.15 to 1.60) and increased inpatient admissions (IRR 1.21, 95% CI 1.04 to 1.42) and caseloads (IRR 1.06, 95% CI 1.00 to 1.12) compared with the lockdown period. Site-wide activity, inpatient care and community services did not return to pre lockdown levels after lift of lockdown, while number of deaths did. Between-site heterogeneity most often indicated variation in size rather than direction of effect.ConclusionsMH service delivery underwent sizeable changes during the first national lockdown, with as-yet unknown and unevaluated consequences.

Background Gender disparities in treatment are apparent across many areas of healthcare. There has been little research into whether clozapine prescription, the first-line treatment for treatment-resistant schizophrenia (TRS), is affected by patient gender. Methods This retrospective cohort study identified 2244 patients with TRS within the South London and Maudsley NHS Trust, by using a bespoke method validated against a gold-standard, manually coded, dataset of TRS cases. The outcome and exposures were identified from the free-text using natural language processing applications (including machine learning and rules-based approaches) and from information entered in structured fields. Multivariable logistic regression was carried out to calculate the odds ratios for clozapine prescription according to patients' gender, and adjusting for numerous potential confounders including sociodemographic, clinical (e.g., psychiatric comorbidities and substance use), neutropenia, functional factors (e.g., problems with occupation), and clinical monitoring. Results Clozapine was prescribed to 77% of the women and 85% of the men with TRS. Women had reduced odds of being prescribed clozapine as compared to men after adjusting for all factors included in the present study (adjusted OR: 0.66; 95% CI 0.44–0.97; p = 0.037). Conclusion Women with TRS are less likely to be prescribed clozapine than men with TRS, even when considering the effects of multiple clinical and functional factors. This finding suggests there could be gender bias in clozapine prescription, which carries ramifications for the relatively poorer care of women with TRS regarding many outcomes such as increased hospitalisation, mortality, and poorer quality of life.