Recent trends in primary-care antidepressant prescribing to children and young people: an e-cohort study

BACKGROUND

Concerns relating to increased use of psychotropic medication contrast with those of under-treatment and under-recognition of common mental disorders in children and young people (CYP) across developed countries. Little is known about the indications recorded for antidepressant prescribing in primary care in CYP.

METHOD

This was an electronic cohort study of routinely collected primary-care data from a population of 1.9 million, Wales, UK. Poisson regression was undertaken to model adjusted counts of recorded depression symptoms, diagnoses and antidepressant prescriptions. Associated indications were explored.

RESULTS

3 58 383 registered patients aged 6-18 years between 1 January 2003 and 31 December 2013 provided a total of 19 20 338 person-years of follow-up. The adjusted incidence of antidepressant prescribing increased significantly [incidence rate ratio (IRR) for 2013 = 1.28], mainly in older adolescents. The majority of new antidepressant prescriptions were for citalopram. Recorded depression diagnoses showed a steady decline (IRR = 0.72) while depression symptoms (IRR = 2.41) increased. Just over half of new antidepressant prescriptions were associated with depression (diagnosis or symptoms). Other antidepressant prescribing, largely unlicensed, was associated with diagnoses such as anxiety and pain.

CONCLUSION

Antidepressant prescribing is increasing in CYP while recorded depression diagnoses decline. Unlicensed citalopram prescribing occurs outside current guidelines, despite its known toxicity in overdose. Unlicensed antidepressant prescribing is associated with a wide range of diagnoses, and while accepted practice, is often not supported by safety and efficacy studies. New strategies to implement current guidance for the management of depression in CYP are required.

Proton pump inhibitor therapy is a risk factor for Clostridium difficile-associated diarrhoea

BACKGROUND

Inhibition of gastric acid removes a defence against ingested bacteria and spores, increasing the risk of some forms of gastroenteritis. Previous studies investigating a possible link between acid suppression therapy and Clostridium difficile-associated diarrhoea have reported conflicting results.

AIM

To investigate whether acid suppression therapy is associated with an increased risk of C. difficile-associated diarrhoea. Prospective case-control study of 155 consecutive in-patients with C. difficile-associated diarrhoea.

RESULTS

Antibiotics had been received by 143 (92%) of the C. difficile-associated diarrhoea group and 76 (50%) of the controls during the preceding 3 months. Among those receiving antibiotics, 59 (41%) of the C. difficile-associated diarrhoea group had also received acid suppression, compared with 21 (28%) of controls (OR 1.84, CI 1.01, 3.36, chi(2) = 4.0, P = 0.046). Among the entire C. difficile-associated diarrhoea group 64 (41%) had received acid suppression compared with 40 (26%) of controls (OR 1.99, CI 1.19, 3.31, chi(2) = 7.9, P = 0.005). Logistic regression analyses found that C. difficile-associated diarrhoea was independently associated with: antibiotic use (OR 13.1, 95% CI: 6.6, 26.1); acid suppression therapy (OR 1.90, 95% CI: 1.10, 3.29); and female sex (OR 1.79, 95% CI: 1.06, 3.04).

CONCLUSIONS

The risk of C. difficile-associated diarrhoea in hospitalized patients receiving antibiotics may be compounded by exposure to proton pump inhibitor therapy.

Differences in risk of mortality under 1 year of age between rural and urban areas: an ecological study

OBJECTIVE

To investigate differences in risk of categories and causes of death before 1 year of age between rural and urban areas.

METHODS

Population-based ecological study using Poisson regression analysis of data from all enumeration districts in Wales. Data included all 243,223 registrable births to women resident in Wales, 809 therapeutic and spontaneous abortions, 1302 stillbirths and 1418 infant deaths occurring between 1993 and 1999.

MAIN RESULTS

The relative risk of mortality in rural areas compared with urban areas for all deaths before 1 year of age was 0.89 (95% confidence interval 0.82, 0.98, P=0.02). The risk of mortality in rural areas was significantly lower than in urban areas for all categories of deaths occurring after 7 days of life. The relative risk of death due to infection was significantly lower in rural areas compared with urban areas (P=0.04), with similar results for deaths due to sudden infant death syndrome (P=0.03). After adjusting for social deprivation, there were no significant differences in the risk of death between rural and urban areas.

CONCLUSIONS

While there were significant differences in crude risk between rural and urban enumeration districts for some causes and age groups before 1 year, after adjusting for social deprivation, these differences were not significant. The lack of significant interaction between rurality and deprivation indicated that the relationship between social deprivation and death before 1 year of age was not significantly different in rural areas compared with urban areas. Collaborative public health programmes to tackle deprivation are necessary in both rural and urban areas.

GOAL: a simplified mental test for emergency medical admissions

BACKGROUND

Several scoring systems are used in screening for cognitive impairment, but none are suited to the busy medical assessment environment.

AIM

To construct, validate and assess the reliability of a simple scale (Gwent Orientation and Awareness Listing, GOAL) for this purpose, and to examine its application in consecutive emergency admissions in two general hospitals.

DESIGN

Prospective cohort studies.

METHODS

The validity and reliability of GOAL was assessed in three studies of patients aged > or =65 years who had been pronounced medically fit for discharge. The evaluation studies were carried out over 4-week medical intake periods in each participating hospital.

RESULTS

Correlation of GOAL with the standard 30-point Mini-Mental State Examination was 0.89, and the inter-observer reliability was 0.90. Based on Receiver Operating Characteristics Curves, patients scoring <8 on GOAL were deemed to be cognitively impaired. Assessment by GOAL took half the time required for the widely used Abbreviated Mental Test Score. Of 1037 consecutive patients admitted to two hospitals' acute medical intakes and remaining for >24 h, 952 were able and willing to be scored by GOAL, and of these 201 (21%) 'failed', with a score of <8.

DISCUSSION

Loss of orientation and awareness is common among patients admitted via medical intakes. GOAL is a practical brief screen for identifying and following-up these patients.

Does car ownership reflect socio-economic disadvantage in rural areas? A cross-sectional geographical study in Wales, UK

It is widely believed that area-based deprivation indices that include the car ownership census variable are poor indicators of deprivation in rural areas since car ownership is a necessity of rural life. In this cross-sectional geographical study, we assess whether the relation between lack of car ownership and socio-economic deprivation varies between urban and rural enumeration districts of Wales, UK. We classified the 6376 census enumeration districts in Wales into rural (1636, 26%) and urban (4740, 74%), using the Office for National Statistics' classification based on land use. Rank correlation coefficients between the proportion of households with no car and a range of other proxy deprivation census variables were strongly positive in urban and the most densely populated rural enumeration districts. However, these correlations were weaker in sparsely populated rural enumeration districts, with a declining trend across deciles of population density. Exclusion of the car ownership variable from the Townsend index of deprivation re-categorized rural enumeration districts as more deprived and urban enumeration districts as less deprived compared with the standard Townsend index. Our results suggest that lack of car ownership is a poor proxy for social deprivation in the most sparsely populated rural areas of Wales, and therefore, deprivation indices that include the car ownership variable are less valid for use in rural areas.

Meningococcal disease and social deprivation: a small area geographical study in Gwent, UK

Although meningococcal disease is known to be linked to characteristics of individuals associated with social deprivation, there is only limited evidence of a relation with area-based measures of deprivation. In a small area geographical study, we ascertained 295 confirmed or probable cases occurring between 1996 and 1999 in the socially diverse resident population of Gwent Health Authority, equating to an average annual rate of 13.2 per 100,000. Incidence rates of meningococcal disease increased from 8.1 per 100,000 in the least deprived fifth of enumeration districts to 19.8 per 100,000 in the most deprived fifth, a relative risk of 2.4 (95% CI 1.7-3.6). In Poisson regression, the percentage change in the incidence rate arising from a unit change in the enumeration district Townsend score, was 9.4% (95% CI 6.2-12.6%). Strongest associations were found for the under 5 age group, serogroup B disease and with the overcrowding variable component of the Townsend index. Our study quantifies the strength of the relation between meningococcal disease and social deprivation at small area level and provides further evidence of the need for action to reduce health inequalities.

Randomised controlled trial of ketorolac in the management of corneal abrasions

PURPOSE

To evaluate the role of topical non-steroidal anti-inflammatory agents (NSAIDs) in the management of corneal abrasions with respect to symptoms and healing.

METHODS

The study was designed as a prospective, single center, randomised, placebo controlled, double-blinded trial. Eighty-eight consecutive patients with non-infective, non-contact lens related traumatic or foreign body removal related corneal abrasions were recruited to this study. They were randomised into two groups. Both groups were given a single instillation of Gutt. cyclopentolate 0.5% followed by chloramphenicol eye ointment four times a day until the following day. In addition, the treatment group received topical Ketorolac trometamol 0.5% ophthalmic solution while the control group received placebo Liquifilm tears. Patients were assessed at presentation and about twenty-four hours later for subjective symptoms, abrasion size and any associated complications.

RESULTS

There was no statistical difference in the two groups at base line and twenty-four hour follow-up when assessed for five subjective symptoms of pain, photophobia, grittiness, watering and blurring of vision. However, those receiving topical ketorolac required significantly less additional oral analgesics (p=0.001). There was no difference in the rate of healing.

CONCLUSION

Use of topical ketorolac may be a useful adjunct in the management of corneal abrasions.

Social deprivation and the causes of stillbirth and infant mortality

AIMS

To investigate the relation between social deprivation and causes of stillbirth and infant mortality.

METHODS

Stillbirths and infant deaths in 6347 enumeration districts in Wales were linked with the Townsend score of social deprivation. In 1993-98 there were 211 072 live births, 1147 stillbirths, and 1223 infant deaths. Poisson regression analysis was used to estimate the magnitude of effect for associations between the Townsend score and categories of death by age and the causes of death. The relative risk of death between most and least deprived enumeration districts was derived.

RESULTS

Relative risk of combined stillbirth and infant death was 1.53 (95% CI 1.35 to 1.74) in the most deprived compared with the least deprived enumeration districts. The early neonatal mortality rate was not significantly associated with deprivation. Sudden infant death syndrome showed a 307% (95% CI 197% to 456%) increase in mortality across the range of deprivation. Deaths caused by specific conditions and infection were also associated with deprivation, but there was no evidence of a significant association with deaths caused by placental abruption, intrapartum asphyxia, and prematurity.

CONCLUSIONS

Collaborative public health action at national and local level to target resources in deprived communities and reduce these inequalities in child health is required. Early neonatal mortality rates and deaths from intrapartum asphyxia and prematurity are not significantly associated with deprivation and may be more appropriate quality of clinical care indicators than stillbirth, perinatal, and neonatal mortality rates.

Community exposures to chemical incidents: development and evaluation of the first environmental public health surveillance system in europe

OBJECTIVE

To describe the frequency, nature and location of acute chemical incidents in Wales, and the morbidity in employees, emergency responders and the general public who were exposed.

DESIGN

Active multi-agency community-based surveillance system.

SETTING

Wales, 1993-5.

MAIN OUTCOME MEASURES

Frequency, nature and location of incidents, populations potentially exposed and with symptoms.

RESULTS

Most of the 402 incidents identified were not associated with sites governed by the Control of Industrial Major Accident Hazard Regulations but with smaller industrial sites and commercial premises. About two in every thousand of the estimated 236 000 members of the public considered to be at risk from exposure reported symptoms, which were mainly nausea, headaches, and irritation of the eye, skin and respiratory tract. The most commonly reported chemicals that members of the public were exposed to were smoke toxins, miscellaneous organics, toxic gases and flammable gases. A health authority was reported to be involved in only 34 (8%) of the incidents and in only 3 of the 29 incidents where more than 100 members of the public were exposed.

CONCLUSION

A geographically defined, multi-agency surveillance system can identify high risk locations and types of incidents, together with the chemicals most likely to be involved. Such ongoing surveillance information is essential for appropriate policy making, emergency planning, operational management and training.

Acute health effects of the Sea Empress oil spill

STUDY OBJECTIVE

To investigate whether residents in the vicinity of the Sea Empress tanker spill suffered an increase in self reported physical and psychological symptoms, which might be attributable to exposure to crude oil.

DESIGN

Retrospective cohort study; postal questionnaire including demographic details, a symptom checklist, beliefs about health effects of oil and the Hospital Anxiety and Depression and SF-36 mental health scales.

SETTING

Populations living in four coastal towns on the exposed south Pembrokeshire coast and two control towns on the unexposed north coast.

PATIENTS

539 exposed and 550 unexposed people sampled at random from the family health services authority age-sex register who completed questionnaires.

MAIN RESULTS

Adjusted odds ratios for self reported physical symptoms; scores on the Hospital Anxiety and Depression and SF-36 mental health scales, in 1089 people who responded out of a possible 1585 (69%).

CONCLUSIONS

Living in areas exposed to the crude oil spillage was significantly associated with higher anxiety and depression scores, worse mental health; and self reported headache (odds ratio = 2.35, 95% CI 1.56, 3.55), sore eyes (odds ratio = 1.96, 95% CI 1.06, 3.62), and sore throat (odds ratio = 1.70, 95% CI 1.12, 2.60) after adjusting for age, sex, smoking status, anxiety, and the belief that oil had affected health. People living in exposed areas reported higher rates of physical and psychological symptoms than control areas. Symptoms significantly associated with exposure after adjustment for anxiety and health beliefs were those expected from the known toxicological effect of oil, suggesting a direct health effect on the exposed population.

Investigation of an outbreak of gastroenteritis at a hospital for patients with learning difficulties

Eighty of the 460 patients and staff (attack rate 22%) in a long-stay hospital for patients with learning difficulties became ill in a general outbreak of gastrointestinal infection that followed a buffet style party on one ward. Illness in the cohort of 47 resident patients, relations, and staff who attended that party was associated with having eaten ham, coleslaw, bread rolls, and cheese and pineapple on sticks. Food from the hospital kitchen was supplemented by food brought in and prepared on the ward by staff and patients. The investigation suggested that food items were contaminated either during preparation by staff and patients or during the party when people served themselves. Microbiological and virological investigations were negative, but small round structured virus was thought to be responsible. Hospitals could do more to prevent outbreaks of foodborne infection by undertaking risk assessment as required by the Food Safety Act (General Food Hygiene) Regulations 1995. Purchasers of hospital infection control should ensure compliance with this legislation.

MAFF statutory incident reports in surveillance, prevention, and control of human Salmonella typhimurium infection

We surveyed consultants in communicable disease control (CCDCs) for their views on the current and potential value of Statutory Incident Reports--Salmonella in Animals, Birds and their Products received from the Ministry of Agriculture Fisheries and Food (MAFF), in the surveillance, prevention, and control of Salmonella typhimurium infections in humans. CCDCs from 103 (83%) of 124 district health authorities responded. Most CCDCs in rural areas used the reports either to cross reference information about animal and human isolates or to discuss with environmental health officers. Many believed that the reports' relevance to human infection could be improved if they were sent more quickly. Some CCDCs suggested that it would be useful to cross reference laboratory reports of animal and human infection at regional level and to have personal contact with local veterinary officers of MAFF. Close cooperation between public health doctors and MAFF and a coordinated approach is needed to prevent and control associations between animal and human zoonotic infections.

Associations between human and farm animal infections with Salmonella typhimurium DT104 in Herefordshire

Reports of human infection with Salmonella typhimurium definitive type (DT) 104 have generated considerable interest. We undertook a descriptive study of infections with S. typhimurium DT 104 infection in humans and farm animals in Herefordshire between 1991 and 1993. Laboratory reports of human salmonellosis, sent to the consultant in communicable disease control, were compared with cases identified using Statutory Incident Reports of salmonella in animals, birds and their products, received from the Ministry of Agriculture, Fisheries and Food. Six separate associations of infection between farming families and their livestock were identified. Nine out of 23 human cases, including three family outbreaks, were associated with animal infection. This study suggests that occupationally acquired infection in farmers and their families may be contributing to the national increase in cases, and shows the value of drawing together data from human and animal sources for the surveillance, investigation, and control of human infection with S. typhimurium DT104.