2009-2010 Mental health clinical reviews


Amniotic fluid embolism is associated with high morbidity and mortality

20 Dec 2010Registered users

Amniotic fluid embolism (AFE) although rare carries a high risk of severe morbidity and death, a study from Australia has confirmed. Maternity data were assessed over seven years in a cohort of 606,393 deliveries in New South Wales. Twenty cases of AFE were identified giving an incidence of 3.3 per 100,000 deliveries. All were in singleton pregnancies, 79% were in multiparous women. Seven women died; a case fatality rate of 35%. In the six women who died in hospital the perinatal death rate (stillbirths + neonatal deaths) was 50%. Perinatal mortality where the mother survived was 23%. 'I found this study of interest not just because it served as a useful reminder of the condition but also its demographic and delivery associations. Survival appeared strongly linked to rapid high-tech intensivist intervention.'

Tai chi of benefit in fibromyalgia

20 Dec 2010Paid-up subscribers

A single-blind, randomised trial from the USA has found that tai chi significantly improves the health-related quality of life of patients with fibromyalgia. A total of 66 tertiary care patients were randomised to tai chi or a control intervention. Both groups attended two one-hour sessions a week over a period of 12 weeks. The control intervention consisted of 40-minute lectures on various aspects of fibromyalgia followed by 20 minutes of stretching exercises. 'Should we advocate tai chi for our patients with fibromyalgia and/or depression? I am even tempted to suggest that GPs might benefit from tai chi between consultations, although this may disconcert our receptionists! I think the answer is that any form of group exercise is likely to be beneficial, and the choice will probably be determined by what is available locally.'

Antidepressants should be tapered down gradually before stopping

24 Nov 2010Paid-up subscribers

An observational study from Sardinia has found that rapid discontinuation of antidepressants places patients at increased risk of early relapse.There were 398 patients, 261 women and 137 men, included in the study: 224 had a DSM-IV diagnosis of recurrent major depressive disorder, 75 panic disorder and 99 bipolar disorder. Patients were followed up with regular semistructured interviews and rating scale assessments. 'The association between the speed of discontinuation and time to relapse remained highly significant after adjustment for factors known to be associated with increased risk of relapse, including the number of previous episodes, depression severity and shorter duration of antidepressant treatment.However, not all potential confounders were accounted for. It is possible, for example, that those patients who choose to stop their treatment abruptly are more likely to have personality traits or mood cycling disorders which place them at increased risk of relapse.'

Passive smoking increases risk of mental illness

24 Nov 2010Paid-up subscribers

Passive smoking is associated with psychological distress and the risk of developing severe psychiatric illness, a cross-sectional and longitudinal study has found. A total of 8,155 adults, of whom 2,595 were smokers, with no previous history of admission to psychiatric hospital were recruited from the Scottish Health Survey. 'It is unlikely to be helpful if we suggest to patients that their depression has been caused by their partner's smoking habit. Nevertheless, this study provides a useful reminder that we should consider depression within the context of relationships: depression is often preceded by marital problems, and the effects of the depression on the other partner and his/her reaction to it are likely to have an important influence on the future course of both the depression and the relationship.'

Which common antidepressants are safest in overdose?

21 Oct 2010Paid-up subscribers

An observational study from the UK has assessed the relative toxicity of 14 antidepressants. As in previous studies, tricyclics were found to be much more toxic in overdose than SSRIs. 'Venlafaxine and mirtazapine were of intermediate toxicity. When choosing an antidepressant, we need to consider not only toxicity in overdose, but also efficacy, acceptability, teratogenicity and the risk of discontinuation reactions. A recent meta-analysis suggested that sertraline provides the most favourable balance between efficacy and acceptability. According to the present study it possesses the further virtue of having a very low toxicity; case fatality ratio 0.4 (95% CI: 0.2-0.8).'

Low vitamin D linked to depression in the elderly

20 Oct 2010Paid-up subscribers

A cross-sectional study has found an association between depression and lack of vitamin D in older people. Data were provided by the 2005 Health Survey for England, which focussed on the health of older people. This identified a nationally representative sample of community residents aged ≥ 65, of whom 2,070 agreed to participate in this study. 'Recognition and treatment of vitamin D deficiency is important on account of its health consequences: vitamin D deficiency ('

SSRIs associated with cataracts in older patients

20 Sep 2010Paid-up subscribers

A nested case-control study has found an association between current use of SSRIs/venlafaxine and cataracts. The cohort comprised residents of Quebec aged ≥ 65 years who had undergone coronary revascularisation between 1995 and 2004. Clinical and prescribing data were captured prospectively by linked databases. 'If confirmed, the 15% increased risk of cataract development is a further potential hazard of SSRI use in elderly patients. Other important risks are upper GI bleeding, hyponatraemia and fragility fracture. The absolute risk of serious bleeding is small but clinically significant in patients > 80,4 elderly patients are more likely to develop SSRI-induced SIADH and the risk of fragility fracture may be doubled in patients > 50.5.'

Smoking raises risk of depression

20 Jul 2010Paid-up subscribers

A longitudinal cohort study from New Zealand has suggested a unidirectional cause and effect relationship between cigarette smoking and depression, in which smoking increases the risk of developing symptoms of depression. The Christchurch Health and Development Study has followed up a group of 1,265 children who were born in 1977. Participants were studied at ages 18, 21 and 25, when 79-81% of the original cohort attended. 'When case finding among patients with chronic conditions, smoking is yet another important risk factor to add to the list of functional impairment, previous depression, physical inactivity, obesity and maladjustment. More controversially, it has been suggested that we should routinely target smoking cessation when treating depressed smokers.'

Obese patients at risk of depression and vice versa

20 May 2010Paid-up subscribers

There are three lessons for GP practice from this paper: when case finding among patients with chronic conditions, physical inactivity and obesity should suggest the possibility of depression; when treating mild to moderate depression in obese patients, referral to a group exercise programme is likely to be a better option than prescribing antidepressants, which may themselves cause further weight gain; when following up our depressed patients, there is a case for monitoring their BMI (and physical activity levels) as well as the PHQ-9.

Should we simplify the DSM IV criteria for major depression?

16 Apr 2010Paid-up subscribers

The authors suggest that the simpler definition is preferable for two reasons. First, it is easier to remember and will reduce the time needed to make an assessment. Second, for patients with a chronic condition, it avoids the difficulty of deciding whether somatic symptoms are caused by depression or by the physical illness itself. Another group of patients for whom this is often a problem are antenatal and postnatal mothers.

Sexual abuse associated with functional somatic syndromes

15 Mar 2010Paid-up subscribers

The authors recommend that we should routinely ask about sexual abuse in patients who have associated somatic syndromes. Disclosure itself may have a therapeutic benefit and patients may wish to be referred for cognitive therapy.

However, I think some caution is necessary here. The link has not been established by prospective cohort studies, and no trials have yet been carried out to determine whether abuse disclosure is beneficial in patients with FSS. There is a risk that disclosure, if it is not handled sensitively, may exacerbate feelings of shame and guilt.

Telephone follow-up by HCAs improves outcomes in depression

15 Jan 2010Paid-up subscribers

Of those patients whose depression is recognised, less than half will complete a minimal treatment course (≥2 months' antidepressants or four psychotherapy sessions). Case management is a low-cost intervention which can improve outcomes as a result of better adherence and increased recognition of non-responders.

Depression may be overdiagnosed in primary care

01 Oct 2009Paid-up subscribers

Unassisted GP diagnoses of depression are usually wrong. Depression severity measures can play an important role in filtering out some of the false positives, providing the cut-off score is set at the appropriate level.

HPV testing is an effective screening tool for cervical cancer

27 Aug 2009Paid-up subscribers

HPV testing is a more accurate method of predicting cervical cancer than cervical cytology, a large multinational cohort study has shown. After six years' follow-up the rate of cervical cancer was significantly lower in women negative for HPV than in women with negative cytology results. Pooled data on 24,295 women from seven screening programmes in six European countries, including the UK, were analysed. All had a cytological smear and an HPV test at baseline.

Severe abuse in childhood linked to mental health problems in later life

27 Aug 2009Paid-up subscribers

GPs are primarily diagnosticians, not therapists. Nevertheless, the process of diagnosis itself may have therapeutic value, by helping patients to understand their problems and empowering them to address them. It is thought that GPs who provide more complex psychosocial explanations are more likely to achieve this.

Screening for depression in high-risk patients is not effective

01 Jun 2009Paid-up subscribers

Screening for depression in high-risk patients does not appear to be effective and has diverted attention from the need to provide more effective care to patients with recognised depression

Obsessions and compulsions common in young adults

21 May 2009Paid-up subscribers

The authors suggest that screening followed by brief CBT interventions might both reduce symptoms and the risk of progression to OCD. OCD itself often goes unrecognised. Patients may be reluctant to disclose their symptoms because of shame or embarrassment, and fears of stigmatisation. NICE therefore recommends that we should use a six-question screening questionnaire for patients who are at increased risk of OCD. Depression, in particular, commonly occurs in association with OCD and I think a case can be made for asking patients to complete the six-question screen at the same time as the PHQ-9.

Weighing up risks and benefits of antidepressants

25 Apr 2009Paid-up subscribers

My current first choice antidepressant is citalopram (moderate efficacy, high acceptability, low suicide risk, intermediate half-life). While I might be tempted to consider switching to sertraline, I am not yet convinced that this would achieve a clinically significant benefit.

Do depression questionnaires influence GPs' management?

25 Apr 2009Paid-up subscribers

The fact that an almost identical proportion of patients were given antidepressant treatment despite the large discrepancy between the severity ratings would suggest that the questionnaire scores had only a limited influence on the decision whether or not to prescribe. This may reflect a problem with the PHQ-9 threshold: the authors suggest that if this were raised to ≥ 12 this would correlate better with GPs' diagnostic thresholds.

Antipsychotics should be used with caution in dementia

29 Mar 2009Paid-up subscribers

A randomised, placebo-controlled discontinuation trial from the UK has found an increased long-term risk of mortality in those patients with dementia who remained on antipsychotic medication. A total of 165 patients were recruited, of whom 37 withdrew prior to the onset of the 12-month trial period. Of the remaining 128 patients, 64 continued to receive antipsychotic medication and 64 were given a placebo. Most of the patients were prescribed risperidone (67%) or haloperidol (26%) before randomisation. Commenting on the study, Dr Phillip Bland,GP, Dalton-in-Furness, writes, 'The CSM has advised that the risk of stroke is three times higher with risperidone and olanzapine and that they should not be used to treat behavioural symptoms in dementia. The present study, however, did not find evidence of an increase in cerebrovascular deaths. There are several other potential causes of death in patients taking antipsychotics, including arrhythmias, aspiration pneumonia, thromboembolism and falls. All atypical antipsychotics are associated with an increased risk, and the risk is greater for conventional antipsychotics.' He concludes, 'This trial provides a further reminder that we should regularly review our patients with dementia and seek to withdraw antipsychotic medication at the earliest opportunity.'

Antidepressants effective for fibromyalgia

29 Mar 2009Paid-up subscribers

If we are to prescribe antidepressants, providing there are no contraindications, low- dose amitriptyline would appear to be the drug of choice. As yet, however, we do not know how effective this is in a primary care setting nor whether benefits are maintained long term.

Substance abusers with mental illness pose high risk of violence

29 Mar 2009Paid-up subscribers

We live in an increasingly violent society. Nearly a third (31%) of GPs in the BMA survey felt violence had increased over the past year whereas only 0.3% felt it had decreased. Although it is important not to stigmatise mental illness, we need to be alert to patient attributes and situations where there is the potential for conflict and take steps to minimise the risk.

Depression in older patients has a poor prognosis

29 Mar 2009Paid-up subscribers

The authors suggest that the poor prognosis can be linked to inadequate treatment. It is well recognised that only a small proportion of older patients with depression receive treatment, either because of the attitude of the patient and/or doctor or diagnostic difficulties.

Learning difficulties common in the homeless

01 Jan 2009Paid-up subscribers

GPs should be aware that there is increased risk of becoming homeless for those with learning disabilities, and that a significant proportion of the homeless patients they see will have intellectual disability. Health information and advice for the homeless should be provided in an accessible way, potentially supported by appropriate written and visual information.

Aerobic exercise improves cognition in older people

01 Jan 2009Paid-up subscribers

The National Dementia Strategy is to recommend training for GPs in the recognition of early signs of dementia. This is based on evidence that earlier provision of home support and carer support can reduce admissions to care homes. However, we face the problem that, having made an early diagnosis of dementia, we have no treatment to offer which can alter the progression of the disease. A prescription for walking would be an attractive option, but it is not yet clear whether this can achieve a clinically significant effect.