Can clinical practice guide a research agenda?

Articles from this issue of the Bulletin indicate that clinicians are frequently adopting clinical practices that have not been supported by an evidence base. Examples of these practices are prescribing more than one antipsychotic and reserving clozapine for patients who have had multiple antipsychotic trials. This commentary suggests that these practices can be used to define important research questions.     

Editorial: Can neuroscience add to clinical practice?

Neuroscience is advancing rapidly, but has so far generated few applications for clinicians in mental health. Nevertheless, it is time to consider how clinical practice might evolve to use an improving technology for individual patients, and this Editorial explores this by looking at how neuroimaging may lead to objective diagnosis, help in analysing dysfunctions and discovering new treatments and guiding more established ones for child and adolescent mental health disorders.     

What do general medical guidelines say about depression care? Depression treatment recommendations in general medical practice guidelines

PURPOSE OF REVIEW: Depression is one of the most costly and prevalent mental disorders, and it often co-occurs in patients with general medical conditions. This review identifies the extent to which depression treatment is being addressed in guidelines for general medical illness treatment. RECENT FINDINGS: We conducted a review of the literature published within the past year pertaining to depression treatment guidelines in medical care. We also conducted a systematic review of available practice guidelines listed by the Agency for Research and Quality to assess the extent to which depression treatment is being addressed in current general medical treatment guidelines. Overall, only a handful of articles addressed treatment of depression within the context of general medical care, and most only addressed screening. Among 199 available practice guidelines for general medical conditions, only 83 mentioned depression treatment, and the majority of these only addressed depression screening. SUMMARY: To improve outcomes in patients with co-occurring general medical conditions, general medical guidelines should include specific recommendations for treating and co-managing depression. Additional strategies that facilitate the translation of guidelines into routine practice, address the management of multiple chronic illnesses, and reduce the stigma of mental illness are also needed.     

Can medical hypnosis accelerate post-surgical wound healing? Results of a clinical trial

Although medical hypnosis has a long history of myriad functional applications (pain reduction, procedural preparation etc.), it has been little tested for site-specific effects on physical healing per se. In this randomized controlled trial, we compared the relative efficacy of an adjunctive hypnotic intervention, supportive attention, and usual care only on early post-surgical wound healing. Eighteen healthy women presenting consecutively for medically recommended reduction mammaplasty at an ambulatory surgery practice underwent the same surgical protocol and postoperative care following preoperative randomization (n = 6 each) to one of the three treatment conditions: usual care, 8 adjunctive supportive attention sessions, or 8 adjunctive hypnosis sessions targeting accelerated wound healing. The primary outcome data of interest were objective, observational measures of incision healing made at 1,7 weeks postoperatively by medical staff blind to the participants' group assignments. Data included clinical exams and digitized photographs that were scored using a wound assessment inventory (WAI). Secondary outcome measures included the participants' subjectively rated pain, perceived incision healing (VAS Scales), and baseline and post-surgical functional health status (SF-36). Analysis of variance showed the hypnosis group's objectively observed wound healing to be significantly greater than the other two groups', p < .001, through 7 postoperative weeks; standard care controls showed the smallest degree of healing. In addition, at both the 1 and 7 week post-surgical observation intervals, one-way analyses showed the hypnosis group to be significantly more healed than the usual care controls, p < 0.02. The mean scores of the subjective assessments of postoperative pain, incision healing and functional recovery trended similarly. Results of this preliminary trial indicate that use of a targeted hypnotic intervention can accelerate postoperative wound healing and suggest that further tests of using hypnosis to augment physical healing are warranted.     

Nurses making a diagnosis of dementia—a potential change in practice?

OBJECTIVES: To compare nurse initial diagnoses following domiciliary visits with subsequent formal multidisciplinary formulation based upon the full possession of investigations, neuropsychological tests and brain imaging. DESIGN: Retrospective case note study. SETTING: Home-based nurse assessments, secondary care based multidisciplinary memory clinic. PARTICIPANTS: Four hundred and four consecutive referrals over an 18-month period. RESULTS: One hundred and seventy-five patients (43.3%) were diagnosed by the multi-disciplinary team as having a dementia. Seventy-three (41.5%) were classified as Alzheimer's disease, 81 (46%) of mixed sub-type and 20 (11.4%) of vascular origin. Overall nurse-MDT diagnosis agreement was 0.88 (Kappa = 0.82). Together, two nurses were able to detect dementia with 94% accuracy (Kappa = 0.88) Sensitivity was 92% and specificity 96%. The positive and negative predictive values of their judgements were 94% and 98% respectively. Nurses were able to sub-diagnose dementia with 86% (kappa = 0.76) accuracy. Multivariate logistic regression modelling showed a MDT dementia diagnosis to be independently and significantly associated with lower scores on the KOLT and total MMSE, and with the absence of biological markers of depression. Nurse dementia diagnoses were associated with lower KOLT scores and the absence of biological depression markers, high past alcohol consumption or a history of hypercholesteraemia. CONCLUSIONS: In this study, structured initial assessment by a specialist nurse was shown to be an accurate method of determining a diagnosis of cognitive impairment, when compared with formal MDT judgement. The principal benefit of this approach was that signposting to subsequent care pathways was expedited. Arguably, such distributed responsibility affords a viable option for the future detection of early dementia.     

Prescribing of the antidepressant duloxetine: Can local clinical audit findings facilitate medicines management decisions?

Introduction. Discussions regarding the inclusion of a new antidepressant within local formulary lists and prescribing guidelines may be facilitated by audits of local prescribing practice, conducted some months after the drug first becomes available for clinical use. Method. Development of five audit standards and retrospective case-note review of prescribing recommendations for the serotonin-noradrenaline reuptake inhibitor duloxetine, made in five local outpatient clinics. Results. Follow-up data were available for audit in 27 of 43 sets of medical notes. In the majority of patients (84%), the primary diagnosis was recurrent unipolar depressive disorder, the current episode having proven resistant to treatment with two other antidepressants. Where comments were made, notes indicated that 81% of patients that received duloxetine had improved and 94% had tolerated it without reported problems. Conclusions. In this sample, duloxetine prescribing in the first months after it became available appeared to occur within an appropriate patient group. Prospective evaluations in other clinical samples are warranted.     

How does an Alzheimer's disease patient's role in medical decision making change over time?

As persons with Alzheimer's disease (AD) lose their ability to make decisions, someone else has to make decisions for them. We performed a prospective cohort study of 77 AD patient-caregiver dyads to examine when this transition occurs. When dementia severity surpassed a threshold marked by a Mini-Mental State Examination (MMSE) score less than 20, the level of caregiver-reported patient involvement in the medical decision-making process declined (Moderate [MMSE = 19-12]: Odds Ratio [OR] = 2.35, 95% confidence interval [95% CI] = 1.01-5.49; P =.048; Severe [MMSE < 12]: OR = 29.38, 95% CI = 5.98-144.25, P <.001). Furthermore, older patients (OR = 1.06, 95% CI = 1.00-1.12, P =.049) and mounting caregiver burden (OR = 1.12, 95% CI = 1.04-1.26, P =.003) were significant independent predictors of transitions to the caregiver-dominated medical decision-making process. These results provide clinicians with prognostic information that can help caregivers understand how their role in decision making will change over the course of a patient's dementing illness.     

Can an informant questionnaire be used to predict the development of dementia in medical inpatients?

OBJECTIVE: To determine whether elderly medical inpatients without dementia who score >3.31 on the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) are at an increased risk of developing dementia.DESIGN/PARTICIPANTS: Twenty-nine patients with an IQCODE score of >3.31 without dementia and 29 age- and sex-matched controls, from an original sample of 201 medical inpatients over 65, were examined 17-24 months after initial assessment.SETTING: Interviews took place in patients' homes, but all subjects had been recruited while medical inpatients in a general hospital 17-24 months previously.MEASURES: The IQCODE and clinical interview to make DSM-III-R diagnosis of dementia.RESULTS: Ten of the study group and one control had developed dementia since the original assessment.CONCLUSIONS: Non-demented elderly medical inpatients with an admission IQCODE score of >3.31 are more likely to develop dementia than those with an IQCODE score of <3.31. The IQCODE is a sensitive tool for detecting early dementia.     

Can pharmacological and psychological treatment change brain structure and function in PTSD? A systematic review

While there is evidence of clinical improvement of posttraumatic stress disorder (PTSD) with treatment, its neural underpinnings are insufficiently clear. Moreover, it is unknown whether similar neurophysiological changes occur in PTSD specifically after child abuse, given its enduring nature and the developmental vulnerability of the brain during childhood.We systematically reviewed PTSD treatment effect studies on structural and functional brain changes from PubMed, EMBASE, PsycINFO, PILOTS and the Cochrane Library. We included studies on adults with (partial) PTSD in Randomized Controlled Trials (RCT) or pre-post designs (excluding case studies) on pharmacotherapy and psychotherapy. Risk of bias was evaluated independently by two raters. Brain coordinates and effect sizes were standardized for comparability.We included 15 studies (6 RCTs, 9 pre-post), four of which were on child abuse. Results showed that pharmacotherapy improved structural abnormalities (i.e., increased hippocampus volume) in both adult-trauma and child abuse related PTSD (3 pre-post studies). Functional changes were found to distinguish between groups. Adult-trauma PTSD patients showed decreased amygdala and increased dorsolateral prefrontal activations post-treatment (4 RCTs, 5 pre-post studies). In one RCT, child abuse patients showed no changes in the amygdala, but decreased dorsolateral prefrontal, dorsal anterior cingulate and insula activation post-treatment.In conclusion, pharmacotherapy may reduce structural abnormalities in PTSD, while psychotherapy may decrease amygdala activity and increase prefrontal, dorsal anterior cingulate and hippocampus activations, that may relate to extinction learning and re-appraisal. There is some evidence for a distinct activation pattern in child abuse patients, which clearly awaits further empirical testing.     

Is neuroborreliosis a medical emergency?

Although Lyme disease affects the nervous system in many ways (collectively known as neuroborreliosis), only rarely does it present as a medical emergency. In extreme cases, it may cause (1) encephalitis, (2) a rapidly progressive peripheral neuropathy, or (3) a painful truncal radiculopathy that may be confused with a severe visceral process. Knowing when to consider this spirochetosis in the differential diagnosis requires an understanding of its true clinical spectrum, and of an appropriate diagnostic and therapeutic approach.     

Can virtual reality reduce reality distortion? Impact of performance feedback on symptom change in schizophrenia patients

Background and objectivesThere is emerging evidence that the induction of doubt can reduce positive symptoms in patients with schizophrenia. Based on prior investigations indicating that brief psychological interventions may attenuate core aspects of delusions, we set up a proof of concept study using a virtual reality experiment. We explored whether feedback for false judgments positively influences delusion severity.MethodsA total of 33 patients with schizophrenia participated in the experiment. Following a short practice trial, patients were instructed to navigate through a virtual street on two occasions (noise versus no noise), where they met six different pedestrians in each condition. Subsequently, patients were asked to recollect the pedestrians and their corresponding facial affect in a recognition task graded for confidence. Before and after the experiment, the Paranoia Checklist (frequency subscale) was administered.ResultsThe Paranoia Checklist score declined significantly from pre to post at a medium effect size. We split the sample into those with some improvement versus those that either showed no improvement, or worsened. Improvement was associated with lower confidence ratings (both during the experiment, particularly for incorrect responses, and according to retrospect assessment).LimitationsNo control condition, unclear if improvement is sustained.DiscussionThe study tentatively suggests that a brief virtual reality experiment involving error feedback may ameliorate delusional ideas. Randomized controlled trials and dismantling studies are now needed to substantiate the findings and to pinpoint the underlying therapeutic mechanisms, for example error feedback or fostering attenuation of confidence judgments in the face of incomplete evidence.