Publications by authors named "Felicity Ng"

31 Publications

Accelerated theta burst stimulation for the treatment of depression: A randomised controlled trial.

Brain Stimul 2021 Sep-Oct;14(5):1095-1105. Epub 2021 Jul 29.

Epworth Centre for Innovation in Mental Health, Epworth Healthcare and Department of Psychiatry, Monash University, Camberwell, Victoria, Australia.

Introduction: Theta burst pattern repetitive transcranial magnetic stimulation (TBS) is increasingly applied to treat depression. TBS's brevity is well-suited to application in accelerated schedules. Sizeable trials of accelerated TBS are lacking; and optimal TBS parameters such as stimulation intensity are not established.

Methods: We conducted a three arm, single blind, randomised, controlled, multi-site trial comparing accelerated bilateral TBS applied at 80 % or 120 % of the resting motor threshold and left unilateral 10 Hz rTMS. 300 patients with treatment-resistant depression (TRD) were recruited. TBS arms applied 20 bilateral prefrontal TBS sessions over 10 days, while the rTMS arm applied 20 daily sessions of 10 Hz rTMS to the left prefrontal cortex over 4 weeks. Primary outcome was depression treatment response at week 4.

Results: The overall treatment response rate was 43.7 % and the remission rate was 28.2 %. There were no significant differences for response (p = 0.180) or remission (p = 0.316) across the three groups. Response rates between accelerated bilateral TBS applied at sub- and supra-threshold intensities were not significantly different (p = 0.319). Linear mixed model analysis showed a significant effect of time (p < 0.01), but not rTMS type (p = 0.680).

Conclusion: This is the largest accelerated bilateral TBS study to date and provides evidence that it is effective and safe in treating TRD. The accelerated application of TBS was not associated with more rapid antidepressant effects. Bilateral sequential TBS did not have superior antidepressant effect to unilateral 10 Hz rTMS. There was no significant difference in antidepressant efficacy between sub- and supra-threshold accelerated bilateral TBS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.brs.2021.07.018DOI Listing
July 2021

Is death our business? Philosophical conflicts over the end-of-life in old age psychiatry.

Aging Ment Health 2016 14;20(6):583-93. Epub 2015 Apr 14.

c School of Psychology , The University of Adelaide , Adelaide , South Australia.

Objectives: Old age psychiatrists work with end-of-life (EOL) issues and encounter patient deaths, but death and dying have received limited focus in old age psychiatry training and research. This qualitative study explores old age psychiatrists' experience of and approach to working with patients at the EOL.

Method: Australian old age psychiatrists were purposively sampled and interviewed in-depth. Data saturation was achieved after nine participant interviews. Verbatim transcripts were analysed for themes, which were independently verified.

Results: Two dichotomous overarching themes were identified. Death is not our business reflected participants' experience of working in a mental health framework and incorporated four themes: death should not occur in psychiatry; working in a psychiatric treatment model; keeping a distance from death and unexpected death is a negative experience. Death is our business reflected participants' experience of working in an aged care context and incorporated four themes: death is part of life; encountering the EOL through dementia care; doing EOL work and expected death is a positive experience.

Conclusion: Participants reported conflict because of the contradictory domains in which they work. They were comfortable working with patients at the EOL when death was expected, particularly in dementia. By contrast, they struggled with death as an adverse outcome in circumstances influenced by mental health culture, which was characterised by risk management, suicide prevention and a focus on recovery. This study has implications for models of care underpinning old age psychiatry. An integrated person-centred model of care may provide a contextually appropriate approach for practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/13607863.2015.1031636DOI Listing
January 2017

Treatment approaches of palliative medicine specialists for depression in the palliative care setting: findings from a qualitative, in-depth interview study.

BMJ Support Palliat Care 2016 Jun 8;6(2):186-93. Epub 2015 Jan 8.

School of Psychology, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia.

Background: Treatment of depression in the palliative care setting is complicated by varied treatment preferences, a small body of research, and unique challenges associated with the end-of-life. Little is known about the treatment practices of medical practitioners in this setting.

Objective: This study aimed to investigate and characterise the treatment approaches of palliative medicine specialists for depression.

Design: Semistructured, in-depth interviews were conducted to explore explanatory models of depression from palliative medicine specialists, including a focus on treatment. Verbatim interview transcripts were analysed for themes.

Setting/participants: Palliative medicine specialists practising in Australia were recruited and purposively sampled. Nine participants were interviewed to reach data saturation.

Results: Five themes were identified in relation to treatment of depression: (1) guiding principles of treatment; (2) treatment approaches; (3) factors underpinning treatment decisions; (4) difficulties arising in treatment; and (5) interdisciplinary roles. Participants described five distinct treatment approaches, consisting of biological orientation, psychosocial orientation, combination approach, undifferentiated approach and ambivalence. Treatment decisions were contingent on patient, depression, clinician and sociocultural factors. Difficulties included discomfort with treating depression, being inadequately equipped and confronting therapeutic limitations. Treating depression was considered to require multidisciplinary team effort.

Conclusions: Palliative medicine specialists' treatment approaches are linked to their concepts of and causal explanations for depression. Future treatment guidelines could aim to consider specific varieties of depression, be more differentiated in treatment modality and type, and consider decision-shaping factors. Continuing mental health education and the incorporation of psychiatry and psychology into palliative care services may have enduring benefits.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjspcare-2014-000719DOI Listing
June 2016

Depression means different things: A qualitative study of psychiatrists' conceptualization of depression in the palliative care setting.

Palliat Support Care 2015 Oct 21;13(5):1223-30. Epub 2014 Oct 21.

School of Psychology,Faculty of Health Sciences,The University of Adelaide,South Australia,Australia.

Objective: Medical practitioners conceptualize depression in different ways, which adds to the challenges of its diagnosis and treatment, as well as research in the palliative care setting. Psychiatric assessment is often considered the "gold standard" for diagnosis, therefore how psychiatrists conceptualize depression in this setting is pertinent. Our study aimed to investigate this issue.

Method: Psychiatrists working in palliative care in Australia were individually interviewed using a semistructured approach. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes.

Results: Three overarching themes were identified: (1) depression means different things; (2) depression is conceptualized using different models; and (3) depression is the same concept within and outside of the palliative care setting. Participants explicitly articulated the heterogeneous nature of depression and described a different breadths of concepts, ranging from a narrow construct of a depressive illness to a broader one that encompassed depressive symptoms and emotions. However, depressive illness was a consistent concept, and participants considered this in terms of phenotypic subtypes. Participants used three models (spectral, dichotomous, and mixed) to relate various depressive presentations.

Significance Of Results: Psychiatrists did not subscribe to a unitary model of depression but understood it as a heterogeneous concept comprised of depressive illness and other less clearly defined depressive presentations. Given the influence of psychiatric opinion in the area of depression, these findings may serve as a platform for further discussions to refine the concepts of depression in the palliative care setting, which in turn may improve diagnostic and treatment outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S1478951514001187DOI Listing
October 2015

The efficacy of adjunctive N-acetylcysteine in major depressive disorder: a double-blind, randomized, placebo-controlled trial.

J Clin Psychiatry 2014 Jun;75(6):628-36

Deakin University, PO Box 281, Geelong 3220, Australia

Objective: Major depressive disorder (MDD) is one of the most common psychiatric disorders, conferring considerable individual, family, and community burden. To date, treatments for MDD have been derived from the monoamine hypothesis, and there is a paucity of emerging antidepressants, especially with novel mechanisms of action and treatment targets. N-acetylcysteine (NAC) is a redox-active glutathione precursor that decreases inflammatory cytokines, modulates glutamate, promotes neurogenesis, and decreases apoptosis, all of which contribute to the neurobiology of depression.

Method: Participants with a current episode of MDD diagnosed according to DSM-IV-TR criteria (N = 252) were treated with NAC or placebo in addition to treatment as usual for 12 weeks and were followed to 16 weeks. Data were collected between 2007 and 2011.

Results: The omnibus interaction between group and visit for the Montgomery-Asberg Depression Rating Scale (MADRS), the primary outcome measure, was not significant (F₁,₅₂₀.₉ = 1.98, P = .067), and the groups did not separate at week 12 (t₃₆₀.₃ = -1.12, P = .265). However, at week 12, the scores on the Longitudinal Interval Follow-Up Evaluation-Range of Impaired Functioning Tool (LIFE-RIFT) differed from placebo (P = .03). Among participants with a MADRS score ≥ 25, NAC separated from placebo at weeks 6, 8, 12, and 16 (P < .05). Additionally, the rate of change between baseline and week 16 was significant (t₂₂₁.₀₃ = -2.11, P = .036). NAC treatment was superior to placebo at week 16 for secondary readouts of function and clinical impression. Remission and response were greater in the NAC group at week 16, but not at week 12. The NAC group had a greater rate of gastrointestinal and musculoskeletal adverse events.

Conclusions: Being negative at the week 12 end point, and with some positive secondary signals, the study provides only limited support for the role of NAC as a novel adjunctive therapy for MDD. These data implicate the pathways influenced by NAC in depression pathogenesis, principally oxidative and inflammatory stress and glutamate, although definitive confirmation remains necessary.

Trial Registration: www.anzctr.org.au Identifier: ACTRN12607000134426.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4088/JCP.13m08454DOI Listing
June 2014

Palliative medicine specialists' causal explanations for depression in the palliative care setting: a qualitative in-depth interview study.

BMJ Support Palliat Care 2016 Jun 28;6(2):178-85. Epub 2014 Apr 28.

School of Psychology, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia.

Objective: Medical practitioners have different causal explanations for depression, and may have greater difficulty in explaining causality of depression in the palliative care setting. The objective of this study was to investigate and describe the causal explanations of depression in the palliative care setting, from the perspective of palliative medicine specialists.

Methods: Palliative medicine specialists practising in Australia were recruited and purposively sampled. Individual semistructured, in-depth interviews were conducted to explore their explanatory models of depression, including a focus on causal explanations. Nine participants were interviewed to reach data saturation. Interview transcripts were analysed for themes.

Results: Six themes for causal explanations of depression were identified: (1) Depression is inexplicable; (2) Biological explanations-primarily neurotransmitter depletion; (3) Psychological explanations-including reaction to circumstances, inability to accept illness and dying, diminished self, and coping mechanisms; (4) Social explanations-including inadequate social support, and contribution from modern medicine and societal norms; (5) Interrelationships between causal factors-mainly multifactoriality; (6) Different explanation for de novo and pre-existing depressions. Participants also articulated a link between causal explanations and clinical interventions.

Conclusions: Palliative medicine specialists hold causal explanations of depression that align with the biopsychosocial and vulnerability-stress models. They use multiple individual explanations with diverse theoretical underpinnings, and largely view depression as multifactorial in causality. Given that causal explanations are linked to clinical interventions, these findings have implications for clinical practice and medical education.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjspcare-2013-000626DOI Listing
June 2016

How do palliative medicine specialists conceptualize depression? Findings from a qualitative in-depth interview study.

J Palliat Med 2014 Mar 10;17(3):318-24. Epub 2014 Jan 10.

1 Discipline of Psychiatry, University of Adelaide , South Australia, Australia .

Background And Objective: Different professional conceptualizations of depression may complicate the clinical approach to depression in the palliative care setting. This study aimed to explore and characterize how palliative medicine specialists conceptualize depression.

Methods: Palliative medicine specialists (i.e., consultants/attending physicians in palliative medicine) practicing in Australia were recruited. Participants were purposively sampled. Individual semi-structured, in-depth interviews were conducted to explore their conceptualizations of depression. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes.

Results: Four main themes were identified in relation to the conceptualization of depression: (1) depression is a varied concept--it was variously considered as abnormal, a medical problem, an emotional experience, a social product, and an action-oriented construct; (2) depression has unclear boundaries, with differentiation between depression and sadness being especially challenging; (3) depression is different in the palliative care setting--it was seen as more understandable, and distinct from depression that predates life-limiting illnesses; and (4) depression is a challenging issue.

Conclusions: Depression is conceptualized by palliative medicine specialists in divergent, ontologically heterogeneous and ill-defined ways. A unitary concept of depression was not evident in this study. The concepts of depression need to be actively debated and refined in clinical practice, medical education, and research in order for more sophisticated and consistent models to be developed. The distinction of de novo depression from recurrent or persistent forms of depression also warrants further study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/jpm.2013.0378DOI Listing
March 2014

Palliative medicine practitioners' views on the concept of depression in the palliative care setting.

J Palliat Med 2013 Aug 30;16(8):922-8. Epub 2013 May 30.

Discipline of Psychiatry, University of Adelaide, Adelaide, Australia.

Background: Despite its clinical importance in palliative care, depression remains an ambiguous concept.

Objective: The purpose of this study was to explore how medical practitioners working in palliative care conceptualize depression in that setting.

Design: Medical practitioners who attended a palliative medicine conference (N=185) were invited to respond to a questionnaire, which explored their views on the concept of depression in the palliative care context. Descriptive statistics were used to summarize responses, and comparison between groups was conducted using nonparametric statistics. Themes in free-text comments were identified.

Results: Seventy-nine responses were obtained (response rate 43%). Depression was not a unified concept, but was generally considered to be an illness with psychological, spiritual, and existential causes. Respondents were more uncertain about depression being an illness in the palliative care setting compared with other settings, and were ambivalent about its causality. Treatment preferences leaned towards psychological interventions. Depression being different in the palliative care setting was a theme. It was considered to be more prevalent, different in quality, harder to define, and associated with greater barriers to diagnosis and treatment. Conceptual differences were associated with the respondents' area of work, work position, duration of practice, and previous mental health training.

Conclusions: Depression in the palliative care setting is a variable concept for palliative medicine practitioners. The conceptual diversity and complexities of depression in this setting must be acknowledged and further explored in order to develop nuanced approaches in clinical practice and in research.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/jpm.2012.0502DOI Listing
August 2013

The relationship between substance use and posttraumatic stress disorder in a methadone maintenance treatment program.

Compr Psychiatry 2011 Sep-Oct;52(5):562-6. Epub 2010 Dec 15.

Department of Clinical and Biomedical Sciences, University of Melbourne, PO Box 281, Geelong, Victoria 3220, Australia.

Introduction And Aims: Posttraumatic stress disorder (PTSD) is frequently linked with substance abuse. The self-medication hypothesis suggests that some people may use illicit substances in an attempt to self-treat psychiatric symptoms. This study explores the relationship between substance abuse and PTSD symptom clusters in a methadone maintenance population.

Design And Methods: Clients of a methadone maintenance program at a public Drug and Alcohol Service were invited to complete the PTSD Checklist-Civilian Version, a screening tool for PTSD. Information about their history of substance use was also collected.

Results: Eighty clients (43 female, 37 male), aged 35 ± 8.0 years (mean ± SD), participated in the study, of which 52.7% screened positive for PTSD. Severity of marijuana use was significantly associated with a number of reexperiencing and hyperarousal symptoms and with overall severity of PTSD symptoms. Opiate, amphetamine, and benzodiazepine use did not appear to be related to PTSD symptoms.

Discussion And Conclusions: In this sample, marijuana may be used to self-treat certain PTSD symptoms, supporting the self-medication hypothesis. Further research is required to confirm the association between a diagnosis of PTSD and substance use. Given the high prevalence of PTSD in the substance-using population, routine PTSD screening in the substance abuse treatment setting may be justified.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.comppsych.2010.10.001DOI Listing
December 2011

Qualitative methods in early-phase drug trials: broadening the scope of data and methods from an RCT of N-acetylcysteine in schizophrenia.

J Clin Psychiatry 2011 Jul 21;72(7):909-13. Epub 2010 Sep 21.

Department of Clinical and Biomedical Sciences: Barwon Health, University of Melbourne, PO Box 281, Geelong 3220, Victoria, Australia.

Objective: The pharmacokinetic profile of a drug often gives little indication of its potential therapeutic application, with many therapeutic uses of drugs being discovered serendipitously while being studied for different indications. As hypothesis-driven, quantitative research methodology is exclusively used in early-phase trials, unexpected but important phenomena may escape detection. In this context, this study aimed to examine the potential for integrating qualitative research methods with quantitative methods in early-phase drug trials. To our knowledge, this mixed methodology has not previously been applied to blinded psychopharmacologic trials.

Method: We undertook qualitative data analysis of clinical observations on the dataset of a randomized, double-blind, placebo-controlled trial of N-acetylcysteine (NAC) in patients with DSM-IV-TR-diagnosed schizophrenia (N = 140). Textual data on all participants, deliberately collected for this purpose, were coded using NVivo 2, and emergent themes were analyzed in a blinded manner in the NAC and placebo groups. The trial was conducted from November 2002 to July 2005.

Results: The principal findings of the published trial could be replicated using a qualitative methodology. In addition, significant differences between NAC- and placebo-treated participants emerged for positive and affective symptoms, which had not been captured by the rating scales utilized in the quantitative trial. Qualitative data in this study subsequently led to a positive trial of NAC in bipolar disorder.

Conclusions: The use of qualitative methods may yield broader data and has the potential to complement traditional quantitative methods and detect unexpected efficacy and safety signals, thereby maximizing the findings of early-phase clinical trial research.

Trial Registration: www.anzctr.org.au Identifier: ACTRN12605000363684.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4088/JCP.09m05741yelDOI Listing
July 2011

The utility of the Mood Disorders Questionnaire as a screening tool in a methadone maintenance treatment program.

Int J Psychiatry Clin Pract 2010 Jun;14(2):150-3

Department of Clinical and Biomedical Sciences, University of Melbourne, Geelong, Victoria, Australia.

Abstract Objective. Comorbid mental illness amongst methadone maintenance therapy clients may be common and screening may be warranted. The Mood Disorders Questionnaire (MDQ) is a screening tool for bipolar disorder that has been validated in other treatment settings. Its utility for patients with substance use disorders is assessed in this study. Methods. Clients of a methadone maintenance program were invited to complete the MDQ when they attended a public Drug and Alcohol Service for their regular scheduled appointments. Information about their history of substance use was also collected. Results. Eighty clients (43 females, 37 males) aged 35 ± 8.0 years (mean ± SD) participated in the study. Seventy-four clients completed the MDQ of which 36 (48.6%) obtained a positive screen. A check of client files suggested that only three of the 74 participants had a current working diagnosis of bipolar disorder. These three participants had screened positive on the MDQ. Conclusions. There was a high prevalence of manic symptoms reported by participants, suggesting that screening for bipolar disorder in this population may be warranted. However, there is a risk of false positives with the MDQ, as it does not clearly differentiate between symptoms of mania and drug intoxication.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3109/13651501003686828DOI Listing
June 2010

Do we need to flick the switch? The need for a broader conceptualization of iatrogenic course aggravation in clinical trials of bipolar disorder.

Psychiatry Clin Neurosci 2010 Aug 10;64(4):367-71. Epub 2010 May 10.

Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Swanston Centre, Vic. 3220, Australia.

The term 'switching' is often used in bipolar disorder when describing polarity changes in bipolar disorder, but this term is ambiguous and imprecise, and is sometimes used interchangeably with the term 'cycling'. Furthermore, polarity changes in bipolar disorder can be understood in different ways, because their clinical manifestations range from the emergence of subthreshold symptoms to a full episode of the opposite pole. Besides the need to tighten the meaning of the term 'switching', this paper also argues that switching does not adequately describe the complex phenomena that occur with course aggravation of bipolar disorder, such as alteration in episode frequency or amplitude. A more-fine grained approach to course aggravation in bipolar disorder is proposed, which incorporates trans-polar switching, index polarity aggravation, as well as alterations in episodic amplitude, episodic duration, and inter-episode length. This approach has the potential to capture a broader, more fine-grained and clinically relevant picture of the process of aggravation of the bipolar cycle.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1440-1819.2010.02098.xDOI Listing
August 2010

The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments.

Bipolar Disord 2009 Sep;11(6):559-95

Discipline of Psychiatry, School of Medicine, University of Adelaide, SA, Australia.

Objectives: Safety monitoring is an important aspect of bipolar disorder treatment, as mood-stabilising medications have potentially serious side effects, some of which may also aggravate existing medical comorbidities. This paper sets out the International Society for Bipolar Disorders (ISBD) guidelines for the safety monitoring of widely used agents in the treatment of bipolar disorder. These guidelines aim to provide recommendations that take into consideration the balance between safety and cost-effectiveness, to highlight iatrogenic and preventive clinical issues, and to facilitate the broad implementation of therapeutic safety monitoring as a standard component of treatment for bipolar disorder.

Methods: These guidelines were developed by an ISBD workgroup, headed by the senior author (MB), through an iterative process of serial consensus-based revisions. After this, feedback from a multidisciplinary group of health professionals on the applicability of these guidelines was sought to develop the final recommendations.

Results: General safety monitoring recommendations for all bipolar disorder patients receiving treatment and specific monitoring recommendations for individual agents are outlined.

Conclusions: These guidelines are derived from evolving and often indirect data, with minimal empirical cost-effectiveness data available to provide guidance. These guidelines will therefore need to be modified to adapt to different clinical settings and health resources. Clinical acumen and vigilance remain critical ingredients for safe treatment practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1399-5618.2009.00737.xDOI Listing
September 2009

Client-reported reasons for non-engagement in drug and alcohol treatment.

Drug Alcohol Rev 2009 Jul;28(4):372-8

Department of Clinical and Biomedical Sciences, Barwon Health, The University of Melbourne, Geelong, Australia.

Introduction And Aims: To examine client-reported reasons for missed early appointments at a drug and alcohol treatment service and to compare characteristics of those who missed appointments with those who attended.

Design And Methods: Clients who missed a first or second appointment between 1 May and 31 August 2007 at a public community-based outpatient treatment facility were invited to participate in a semistructured telephone interview. This consisted of an open-ended question asking the reason(s) for nonattendance, followed by a questionnaire of items for therapeutic alliance and service satisfaction, perceived impact of substance use and previous treatment experience, mostly rated on Likert scales. Database information on demographic and clinical variables was gathered for all clients who were accepted for treatment within the study time frame. Characteristics of those who missed a first or second appointment (n = 66) were compared with those who attended at least their first two appointments (n = 97).

Results: Of clients who missed their appointments, 80.6% provided reasons for nonattendance, which included extraneous factors (50.0%), service shortcomings (29.7%), no further need for service (16.2%) and motivational ambivalence (4.1%). They generally had high ratings of therapeutic alliance and service satisfaction and identified their substance use as having a negative impact on their lives. Clients who missed appointments were more likely to be male, unmarried and have a history of polysubstance use.

Discussion And Conclusions: Extraneous issues relating to the client may be a dominant obstacle in early treatment engagement. Efforts to overcome these issues may therefore improve early engagement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1465-3362.2009.00054.xDOI Listing
July 2009

Tobacco smoking as a risk factor for major depressive disorder: population-based study.

Br J Psychiatry 2008 Oct;193(4):322-6

Department of Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, PO Box 281, Geelong 3220, Australia.

Background: Smoking is disproportionately prevalent among people with psychiatric illness.

Aims: To investigate smoking as a risk factor for major depressive disorder.

Method: A population-based sample of women was studied using case-control and retrospective cohort study designs. Exposure to smoking was self-reported, and major depressive disorder diagnosed using the Structured Clinical Interview for DSM-IV-TR (SCID-I/NP).

Results: Among 165 people with major depressive disorder and 806 controls, smoking was associated with increased odds for major depressive disorder (age-adjusted odds ratio (OR)=1.46, 95% CI 1.03-2.07). Compared with non-smokers, odds for major depressive disorder more than doubled for heavy smokers (>20 cigarettes/day). Among 671 women with no history of major depressive disorder at baseline, 13 of 87 smokers and 38 of 584 non-smokers developed de novo major depressive disorder during a decade of follow-up. Smoking increased major depressive disorder risk by 93% (hazard ratio (HR)=1.93, 95% CI 1.02-3.69); this was not explained by physical activity or alcohol consumption.

Conclusions: Evidence from cross-sectional and longitudinal data suggests that smoking increases the risk of major depressive disorder in women.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1192/bjp.bp.107.046706DOI Listing
October 2008

Is this D vitamin to worry about? Vitamin D insufficiency in an inpatient sample.

Aust N Z J Psychiatry 2008 Oct;42(10):874-8

Department of Clinical and Biomedical Sciences: Barwon Health, University of Melbourne, Geelong, Australia.

Objective: The aim of the present study was to investigate the relationship between reduced serum vitamin D levels and psychiatric illness.

Method: This study was an audit of serum 25-hydroxyvitamin D (25-OHD) levels measured routinely in a sample of 53 inpatients in a private psychiatric clinic. These levels were compared with those of controls without psychiatric illness.

Results: The median levels of serum 25-OHD were 43.0 nmol L(-1) (range 20-102 nmol L(-1)) in the patient population, 46.0 nmol L(-1) (range 20-102 nmol L(-1)) in female patients (n =33) and 41.5 nmol L(-1) (range 22-97 nmol L(-1)) in male patients (n =20). The proportion of vitamin D insufficiency (serum 25-OHD < or =50 nmol L(-1)) in this patient population was 58%. Furthermore, 11% had moderate deficiency (serum 25-OHD < or =25 nmol L(-1)). There was a 29% difference between mean levels in the patient population and control sample (geometric mean age- and season-adjusted levels: 46.4 nmol L(-1) (95% confidence interval (CI) =38.6-54.9 nmol L(-1)) vs 65.3 nmol L(-1) (95%CI =63.2-67.4 nmol L(-1)), p <0.001).

Conclusion: Low levels of serum 25-OHD were found in this patient population. These data add to the literature suggesting an association between vitamin D insufficiency and psychiatric illness, and suggest that routine monitoring of vitamin D levels may be of benefit given the high yield of clinically relevant findings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/00048670802345516DOI Listing
October 2008

Glutathione: a novel treatment target in psychiatry.

Trends Pharmacol Sci 2008 Jul 4;29(7):346-51. Epub 2008 Jun 4.

Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Geelong, Victoria, Australia.

There is accumulating evidence for oxidative stress mechanisms as common pathophysiological pathways in diverse psychiatric disorders, which offers novel treatment targets in oxidation biology systems. Of these the glutathione system has the most favourable theoretical foundation, given its dominance as the most generic of cellular antioxidants. Clinically, this hypothesis has been supported by several recently published studies that have reported on the efficacy of N-acetylcysteine, a glutathione precursor, in the treatment of various psychiatric disorders. This article outlines the multidimensional evidence that currently exists for oxidative stress mechanisms in psychiatric disorders and specifically discusses glutathione as a promising novel therapeutic target.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.tips.2008.05.001DOI Listing
July 2008

Oxidative stress may be a common mechanism linking major depression and osteoporosis.

Acta Neuropsychiatr 2008 Jun;20(3):112-6

1 Department of Clinical and Biomedical Sciences: Barwon Health, The University of Melbourne, Geelong, Australia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1601-5215.2008.00283.xDOI Listing
June 2008

The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use.

J Eval Clin Pract 2008 Dec 2;14(6):979-83. Epub 2008 May 2.

Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Geelong, Victoria, Australia.

Objective: The Clinical Global Impression Scale (CGI) is established as a core metric in psychiatric research. This study aims to test the validity of CGI as a clinical outcome measure suitable for routine use in a private inpatient setting.

Methods: The CGI was added to a standard battery of routine outcome measures in a private psychiatric hospital. Data were collected on consecutive admissions over a period of 24 months, which included clinical diagnosis, demographics, service utilization and four routine measures (CGI, HoNOS, MHQ-14 and DASS-21) at both admission and discharge. Descriptive and comparative data analyses were performed.

Results: Of 786 admissions in total, there were 624 and 614 CGI-S ratings completed at the point of admission and discharge, respectively, and 610 completed CGI-I ratings. The admission and discharge CGI-S scores were correlated (r = 0.40), and the indirect improvement measures obtained from their differences were highly correlated with the direct CGI-I scores (r = 0.71). The CGI results reflected similar trends seen in the other three outcome measures.

Conclusions: The CGI is a valid clinical outcome measure suitable for routine use in an inpatient setting. It offers a number of advantages, including its established utility in psychiatric research, sensitivity to change, quick and simple administration, utility across diagnostic groupings, and reliability in the hands of skilled clinicians.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1365-2753.2007.00921.xDOI Listing
December 2008

Dual-dual action? Combining venlafaxine and mirtazapine in the treatment of depression.

Aust N Z J Psychiatry 2008 Apr;42(4):346-9

Discipline of Psychological Medicine, University of Sydney, Sydney, New South Wales, Australia.

Objective: Venlafaxine and mirtazapine in combination are increasingly used in clinical practice to treat treatment-refractory depression. Putative efficacy for this combination of antidepressants, beyond that of monotherapy, stems from their synergistic actions. This paper describes a prospective case series that examined the efficacy of the venlafaxine-mirtazapine combination in the treatment of depressed patients who had failed at least one antidepressant trial.

Method: Twenty-two depressed patients with major depression were treated with venlafaxine and mirtazapine in combination for an average of just under 8 weeks. Baseline ratings on the 17-item Hamilton Depression Rating Scale (HAM-D(17)), Montgomery-Asberg Depression Rating Scale (MADRS) and the Clinical Global Impression-Severity Scale (CGI-S) were repeated at end-point, determined by the naturalistic termination of the depressive treatment episode or the discontinuation of the combination treatment due to adverse effects. The length of treatment until end-point was documented for each patient. Descriptive statistics were used on the collated data.

Results: At baseline, mean scores were 28.8 (SD=3.8) for HAM-D(17), 30.1 (SD=5.8) for MADRS, and 4.5 (SD=0.5) for CGI-S, reflecting a cohort at the moderate to severe end of the spectrum. At end-point, mean absolute scores were 10.2 (SD=4.7) for HAM-D(17), 10.8 (SD=4.6) for MADRS, and 2.3 (SD=0.6) for CGI-S. Mean change from baseline was 18.6 (SD=6.4) for HAM-D(17), 19.3 (SD=6.8) for MADRS, and 2.3 (SD=0.6) for CGI-S. Mean duration of treatment was approximately 8 weeks, producing a response rate of 81.8% and a remission rate of 27.3%. Only one patient was unable to tolerate the combination although nearly half (10) had significant side-effects during treatment.

Conclusion: This study demonstrates relatively high response and remission rates that are encouraging and contribute to the efficacy database for this antidepressant combination. Further studies using randomized controlled designs are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/00048670701881587DOI Listing
April 2008

Going up in smoke: tobacco smoking is associated with worse treatment outcomes in mania.

J Affect Disord 2008 Sep 15;110(1-2):126-34. Epub 2008 Feb 15.

University of Melbourne, Victoria, Australia.

Background: This study aimed to compare the treatment responses between smokers and non-smokers in bipolar mania clinical trials.

Methods: Post-hoc analysis was conducted on data collected from three double-blind, randomised controlled trials in bipolar mania that had similar inclusion criteria. Patients were randomised to olanzapine (N=70) or placebo (N=69) for 3 weeks in Trial 1, olanzapine (N=234) or haloperidol (N=216) for 12 weeks in Trial 2, and olanzapine (N=125) or divalproex (N=126) for 47 weeks in Trial 3. This study analysed the Young Mania Rating Scale (YMRS) total scores and Clinical Global Impressions scale for bipolar disorder (CGI-BP) mania severity scores between smokers and non-smokers for each trial and for the pooled data from all three trials, using a mixed-effects model repeated measures approach.

Results: For the pooled data, non-smokers showed superior treatment outcomes on both the YMRS (P=0.002) and CGI-BP (P<0.001), as well as longer time to discontinuation for any cause utilising Kaplan-Meier survival curves. For the individual trials, non-smokers showed greater improvement than smokers on both CGI-BP and YMRS in both treatment arms of Trial 2 (CGI-BP: haloperidol P=0.011, olanzapine P=0.042; YMRS: haloperidol P=0.010, olanzapine P=0.019), and in the olanzapine arm of Trial 3 (CGI-BP: P=0.002; YMRS: P=0.006). No significant difference in outcomes was found between smokers and non-smokers in Trial 1.

Limitations: Post-hoc design, categorical definition of smoking status, unavailable antipsychotic drug levels, confounding effects of trial medications and substance abuse.

Conclusions: Smoking appears to be associated with worse treatment outcomes in mania.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jad.2008.01.018DOI Listing
September 2008

Oxidative stress in psychiatric disorders: evidence base and therapeutic implications.

Int J Neuropsychopharmacol 2008 Sep 21;11(6):851-76. Epub 2008 Jan 21.

Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Geelong, VIC, Australia.

Oxidative stress has been implicated in the pathogenesis of diverse disease states, and may be a common pathogenic mechanism underlying many major psychiatric disorders, as the brain has comparatively greater vulnerability to oxidative damage. This review aims to examine the current evidence for the role of oxidative stress in psychiatric disorders, and its academic and clinical implications. A literature search was conducted using the Medline, Pubmed, PsycINFO, CINAHL PLUS, BIOSIS Preview, and Cochrane databases, with a time-frame extending to September 2007. The broadest data for oxidative stress mechanisms have been derived from studies conducted in schizophrenia, where evidence is available from different areas of oxidative research, including oxidative marker assays, psychopharmacology studies, and clinical trials of antioxidants. For bipolar disorder and depression, a solid foundation for oxidative stress hypotheses has been provided by biochemical, genetic, pharmacological, preclinical therapeutic studies and one clinical trial. Oxidative pathophysiology in anxiety disorders is strongly supported by animal models, and also by human biochemical data. Pilot studies have suggested efficacy of N-acetylcysteine in cocaine dependence, while early evidence is accumulating for oxidative mechanisms in autism and attention deficit hyperactivity disorder. In conclusion, multi-dimensional data support the role of oxidative stress in diverse psychiatric disorders. These data not only suggest that oxidative mechanisms may form unifying common pathogenic pathways in psychiatric disorders, but also introduce new targets for the development of therapeutic interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S1461145707008401DOI Listing
September 2008

The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure.

Acta Neuropsychiatr 2007 Oct;19(5):304-10

1Department of Clinical and Biomedical Sciences - Barwon Health, University of Melbourne, Geelong, Australia.

Objective: This study aimed to test the validity of the 21-item Depression Anxiety Stress Scales (DASS-21) as a routine clinical outcome measure in the private in-patient setting. We hypothesized that it would be a suitable routine outcome instrument in this setting.

Method: All in-patients treated at a private psychiatric hospital over a period of 24 months were included in the study. Data were collected on demographics, service utilization, diagnosis and a set of four routine measures both at admission and discharge. These measures consisted of the Clinical Global Impressions (CGI) scales, Health of the Nation Outcome Scales (HoNOS), the Mental Health Questionnaire (MHQ-14) and DASS-21. The results of these measures were compared.

Results: Of 786 admissions in total, the number of fully completed (ie paired admission and discharge) data sets for the DASS-21 depression, anxiety and stress subscales were 337, 328 and 347, respectively. All subscales showed statistically significant reductions in mean scores from admission to discharge (P < 0.001) and were significantly correlated with all MHQ-14 subscales and significantly related to CGI scale categories. The total DASS-21 and total HoNOS scores were also significantly correlated.

Conclusions: The findings from the present study support the validity of DASS-21 as a routine clinical outcome measure in the private in-patient setting.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/j.1601-5215.2007.00217.xDOI Listing
October 2007

The role of lamotrigine in the management of bipolar disorder.

Neuropsychiatr Dis Treat 2007 Aug;3(4):463-74

Department of Clinical and Biomedical Sciences: Barwon Health, University of Melbourne, Geelong, Victoria, Australia.

Lamotrigine has emerged with a distinct place in the pharmacological treatment of bipolar disorder, with the potential to treat and prevent bipolar depression, which is the dominant and arguably most disabling and under-treated phase of the illness. This review examines the published clinical trials of lamotrigine in bipolar treatment. While the data supports its tolerability and safety, the strongest evidence for its efficacy lies in the prevention of bipolar depression, with weaker evidence for the treatment of acute bipolar depression, refractory unipolar and bipolar depression, and rapid cycling bipolar disorder. The total number of published well designed trials is small, even the maintenance evidence is derived from two studies. However, this relative inadequacy compares favorably with the alternative treatment options for bipolar depression, which are marked by poor efficacy or risk of polarity switch. The designation of lamotrigine as first-line treatment for bipolar depression prophylaxis should be done in cognizance of this context, and it would seem prudent to await greater evidence of efficacy before designating lamotrigine as first-line treatment for other bipolar indications. Further randomized controlled trials are required to consolidate the available findings and to explore the boundaries of lamotrigine's efficacy, which may encompass the soft spectral disorders.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655087PMC
August 2007

The empirical redefinition of the psychometric criteria for remission in bipolar disorder.

J Affect Disord 2008 Feb 26;106(1-2):153-8. Epub 2007 Jul 26.

Barwon Health and The Geelong Clinic, Geelong, Victoria, Australia.

Background: Current definitions of remission for mania and bipolar depression are convention-rather than empirically-based, and their clinical salience is unclear, as few studies have attempted to calibrate them against objective clinical criteria. This study aimed to determine equivalence scores on two widely used clinical rating scales, the Young Mania Rating Scale (YMRS) and Montgomery-Asberg Depression Rating Scale (MADRS), that corresponded with an objective global clinical measure of remission in bipolar disorder patients.

Methods: Data from four pharmacological randomised controlled trials in bipolar I disorder were analysed. Two trials were conducted for bipolar depression (N=410 and 833), and two for manic or mixed episodes (N=136 and 110). In this study, a Clinical Global Impression-Bipolar Version (CGI-BP) severity score of 1 (normal, not at all ill) was used as the primary comparative measure of remission. The mean total YMRS and MADRS scores in the mania and depression studies, respectively, that corresponded with a CGI-BP severity score of 1 were determined.

Results: The mean YMRS score that corresponded with a CGI-BP severity score of 1 was <4 in both trials (2.6 and 3.0, respectively), and the mean corresponding MADRS score was <5 (4.1 and 4.6, respectively).

Limitations: Utilising a psychometric definition of remission.

Conclusions: This study suggests that a cut-off score of <5 on the MADRS and <4 on the YMRS approximates a CGI-BP definition of complete remission. Although lower than conventional cut-off scores, these perhaps better represent clinical reality and patient expectations. In the context of clinical trials, study end-points may be more difficult to reach with lower cut-offs, but the outcomes achieved are more likely to be clinically meaningful.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jad.2007.06.011DOI Listing
February 2008

Effects of a walking program in the psychiatric in-patient treatment setting: a cohort study.

Health Promot J Austr 2007 Apr;18(1):39-42

Department of Clinical and Biomedical Sciences: Barwon Health, University of Melbourne, Victoria, Australia.

Issue Addressed: To assess the effectiveness of a walking program in a psychiatric in-patient unit.

Method: In-patients at a private psychiatric unit were offered the opportunity to participate in a daily morning 40- minute walk led by an activity supervisor. After discharge, outcomes for patients who had regularly participated in the walking group (n=35) and patients who had not participated (n=49) were compared for length of stay during their period of admission and Clinical Global Impression-Severity (CGI-S) and Depression Anxiety Stress Scales (DASS) scores measured at admission and discharge. This was a retrospective analysis of data collected routinely.

Results: There were no significant differences between the two cohorts on most primary outcome measures, including length of stay, DASS scores at admission and at discharge and CGI-S scores at admission. Patients who had not participated in the walking group had a significantly lower score on a single measure, the CGI-S, than patients who had participated (p=0.001).

Conclusions: This study showed no evidence that in-patients benefited from participating in the physical activity program. However, this must be interpreted within the confines of a number of study limitations and, as such, the findings can neither support nor refute the effectiveness of physical activities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1071/he07039DOI Listing
April 2007

The interface between religion and psychosis.

Authors:
Felicity Ng

Australas Psychiatry 2007 Feb;15(1):62-6

Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Geelong, Vic, Australia.

Objective: This paper aims to explore the interface between religion and psychosis, and to comment on its relevance in clinical practice.

Method: The context of religious psychotic phenomena is briefly discussed, leading to an examination of the biological substrates of religious experiences, the hypothesized process of religious psychotic symptom formation, and the clinical implications when assessing religious delusions. A PubMED search was conducted to identify original research and review articles of relevance to the discussion.

Results: Religion is an enduring theme in psychosis, the understanding of which can be assisted by distinguishing between religion as a culture and religiosity as pathology. There are strong arguments for the involvement of temporolimbic instability in the generation of religious psychotic symptoms.

Conclusions: Psychosis can be conceptualized as the manifestation of aberrant perceptual and/or integrative processes. The prevalence of religion as a psychotic theme may be explained by its central cultural role, the implication of temporolimbic overactivity in the pathogenesis of some cases of psychosis, and the tendency to interpret intense or discrepant perceptual events as spiritual. In the clinical setting, the determination of religious delusions can be challenging at times. In addition to seeking advice on unfamiliar religions, a thorough assessment of the dimensions of religious beliefs and symptoms of neurocognitive dysfunction can be useful.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/10398560601083118DOI Listing
February 2007

The effects of physical activity in the acute treatment of bipolar disorder: a pilot study.

J Affect Disord 2007 Aug 19;101(1-3):259-62. Epub 2006 Dec 19.

Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Geelong, Victoria, Australia.

Background: Physical activity has demonstrated efficacy in depression and anxiety, but its potential in the management of bipolar disorder is yet unexplored. This study is a pilot investigation into the effectiveness of an adjunctive walking program in the acute treatment of bipolar disorder.

Methods: This is a retrospective cohort study of all patients admitted over a 24-month period to a private psychiatric unit with a primary diagnosis of bipolar disorder (ICD-10). All patients were invited to participate voluntarily in a walking group during their admissions. Those who reliably attended the walking group (participants) were compared against those who did not attend (non-participants), using the clinician-rated Clinical Global Impression Severity (CGI-S) and Improvement (CGI-I) scales and the self-reported 21-item Depression Anxiety Stress Scales (DASS) as primary outcome measures.

Results: There were 24 admissions for participants and 74 admissions for non-participants. The two groups did not differ significantly in patient demographics or admission CGI and DASS measures, except for a lower DASS Stress subscore for participants (p=0.049). At discharge, the inter-group differences in CGI measures remained non-significant, but participants had significantly lower scores than non-participants for DASS (p=0.005) and all its subscales (Depression p=0.048, Anxiety p=0.002, Stress p=0.01).

Limitations: Methodological limitations include a retrospective design, small sample size, lack of randomisation or control, and indirect measure of manic symptoms.

Conclusions: The results of this trial provide preliminary support for a therapeutic role of physical activity in bipolar disorder, and warrant further investigation with randomised controlled trials.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jad.2006.11.014DOI Listing
August 2007

Combination pharmacotherapy in unipolar depression.

Expert Rev Neurother 2006 Jul;6(7):1049-60

University of Melbourne, Department of Clinical and Biomedical Sciences: Barwon Health, PO Box 281, Geelong, Victoria, Australia.

It is estimated that between 60 and 80% of those with major depressive disorder do not achieve full symptomatic remission from first-line antidepressant monotherapy. Residual depressive symptoms substantially impair quality of life and add to the risk of recurrence. It is now clear that depression would benefit from more vigorous treatment, in order to ameliorate its disease burden. While there are established algorithms in situations of treatment resistance, the use of combination pharmacotherapy in unipolar depression is a relatively under-investigated area of treatment and may be an effective and tolerable strategy that maximizes the available resources. This paper reviews the current evidence for combination pharmacotherapy in unipolar depression and discusses its clinical applications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1586/14737175.6.7.1049DOI Listing
July 2006
-->