Impact of the Canterbury earthquakes on dispensing of psychiatric medication for children and adolescents: longitudinal quantitative study.

BACKGROUND: Natural disasters are increasing in frequency and impact; they cause widespread disruption and adversity throughout the world. The Canterbury earthquakes of 2010-2011 were devastating for the people of Christchurch, New Zealand. It is important to understand the impact of this disaster on the mental health of children and adolescents. AIMS: To report psychiatric medication use for children and adolescents following the Canterbury earthquakes. METHOD: Dispensing data from community pharmacies for the medication classes antidepressants, antipsychotics, anxiolytics, sedatives/hypnotics and methylphenidate are routinely recorded in a national database. Longitudinal data are available for residents of the Canterbury District Health Board (DHB) and nationally. We compared dispensing data for children and adolescents residing in Canterbury DHB with national dispensing data to assess the impact of the Canterbury earthquakes on psychotropic prescribing for children and adolescents. RESULTS: After longer-term trends and population adjustments are considered, a subtle adverse effect of the Canterbury earthquakes on dispensing of antidepressants was detected. However, the Canterbury earthquakes were not associated with higher dispensing rates for antipsychotics, anxiolytics, sedatives/hypnotics or methylphenidate. CONCLUSIONS: Mental disorders or psychological distress of a sufficient severity to result in treatment of children and adolescents with psychiatric medication were not substantially affected by the Canterbury earthquakes.

Traumatic imagery following glucocorticoid administration in earthquake-related post-traumatic stress disorder: A preliminary functional magnetic resonance imaging study.

OBJECTIVE: Post-traumatic stress disorder involves excessive retrieval of traumatic memories. Glucocorticoids impair declarative memory retrieval. This preliminary study examined the effect of acute hydrocortisone administration on brain activation in individuals with earthquake-related post-traumatic stress disorder compared with earthquake-exposed healthy individuals, during retrieval of traumatic memories. METHOD: Participants exposed to earthquakes with (n = 11) and without post-traumatic stress disorder (n = 11) underwent two functional magnetic resonance imaging scans, 1-week apart, in a double-blind, placebo-controlled, counter-balanced design. On one occasion, they received oral hydrocortisone (20 mg), and on the other, placebo, 1 hour before scanning. Symptom provocation involved script-driven imagery (traumatic and neutral scripts) and measures of self-reported anxiety. RESULTS: Arterial spin labelling showed that both post-traumatic stress disorder and trauma-exposed controls had significantly reduced cerebral blood flow in response to retrieval of traumatic versus neutral memories in the right hippocampus, parahippocampal gyrus, calcarine sulcus, middle and superior temporal gyrus, posterior cingulate, Heschl's gyrus, inferior parietal lobule, angular gyrus, middle occipital gyrus, supramarginal gyrus, lingual gyrus and cuneus, and the left prefrontal cortex. Hydrocortisone resulted in non-significant trends of increasing subjective distress and reduced regional cerebral blood flow in the left inferior frontal gyrus, left anterior cingulate gyrus, middle temporal gyrus, cerebellum, postcentral gyrus and right frontal pole, during the trauma script. CONCLUSION: Findings do not fit with some aspects of the accepted neurocircuitry model of post-traumatic stress disorder, i.e., failure of the medial prefrontal cortex to quieten hyperresponsive amygdala activity, and the potential therapeutic benefits of hydrocortisone. They do, however, provide further evidence that exposure to earthquake trauma, regardless of whether post-traumatic stress disorder eventuates, impacts brain activity and highlights the importance of inclusion of trauma-exposed comparisons in studies of post-traumatic stress disorder.

A systematic review of the psychological impacts of the Canterbury earthquakes on mental health.

OBJECTIVE: This systematic review aims to identify and evaluate all studies that measured psychological distress or mental disorder following the Canterbury earthquakes to establish the psychological consequences of the earthquakes on those exposed. A secondary aim is to outline and emphasise key methodological factors in disaster research. METHOD: Eligible studies were identified following a comprehensive literature search. A quality assessment was undertaken for all included studies. This was followed by methodological and descriptive review. RESULTS: Thirty-one papers measuring psychological distress or mental disorder following the Canterbury earthquakes were identified. These papers reported outcomes from 20 separate studies of which seven were rated high-quality, eight were rated medium and five were rated low-quality. Key methodological findings and outcomes are discussed for each study. CONCLUSION: The Canterbury earthquakes were associated with widespread but not universal adverse effects on mental health. Disaster research quality is assisted by representative samples, repeated measures, and the use of appropriate controls to allow accurate assessments of psychological consequences to be made. Implications for public health: The presence of widespread adverse effects as a result of the earthquakes suggests broad-ranging community initiatives are essential to mitigate the negative consequences of disasters.

Childhood abuse and psychotic experiences in adulthood: findings from a 35-year longitudinal study.

BACKGROUND: The extent to which exposure to childhood sexual and physical abuse increases the risk of psychotic experiences in adulthood is currently unclear.AimsTo examine the relationship between childhood sexual and physical abuse and psychotic experiences in adulthood taking into account potential confounding and time-dynamic covariate factors. METHOD: Data were from a cohort of 1265 participants studied from birth to 35 years. At ages 18 and 21, cohort members were questioned about childhood sexual and physical abuse. At ages 30 and 35, they were questioned about psychotic experiences (symptoms of abnormal thought and perception). Generalised estimating equation models investigated covariation of the association between abuse exposure and psychotic experiences including potential confounding factors in childhood (socioeconomic disadvantage, adverse family functioning) and time-dynamic covariate factors (mental health, substance use and life stress). RESULTS: Data were available for 962 participants; 6.3% had been exposed to severe sexual abuse and 6.4% to severe physical abuse in childhood. After adjustment for confounding and time-dynamic covariate factors, those exposed to severe sexual abuse had rates of abnormal thought and abnormal perception symptoms that were 2.25 and 4.08 times higher, respectively than the 'no exposure' group. There were no significant associations between exposure to severe physical abuse and psychotic experiences. CONCLUSIONS: Findings indicate that exposure to severe childhood sexual (but not physical) abuse is independently associated with an increased risk of psychotic experiences in adulthood (particularly symptoms of abnormal perception) and this association could not be fully accounted for by confounding or time-dynamic covariate factors.Declaration of interestNone.

Earthquake brain: Impairment of spatial memory following long-term earthquake-related stress.

OBJECTIVES: The primary aim of this study was to investigate neuropsychological function in patients with earthquake-related posttraumatic stress disorder, compared with earthquake-exposed but resilient controls. We hypothesised that individuals with posttraumatic stress disorder would have poorer neuropsychological performance on tests of verbal and visuospatial learning and memory compared with the earthquake-exposed control group. The availability of groups of healthy patients from previous studies who had been tested on similar neuropsychological tasks prior to the earthquakes allowed a further non-exposed comparison. METHOD: In all, 28 individuals with posttraumatic stress disorder and 89 earthquake-exposed controls completed tests of verbal and visuospatial learning and memory and psychomotor speed. Further comparisons were made with non-exposed controls who had been tested before the earthquakes. RESULTS: No significant difference in performance on tests of verbal or visuospatial memory was found between the earthquake-exposed groups (with and without posttraumatic stress disorder), but the posttraumatic stress disorder group was significantly slowed on tests of psychomotor speed. Supplementary comparison with historical, non-exposed control groups showed that both earthquake-exposed groups had poorer performance on a test of visuospatial learning. CONCLUSION: The key finding from this study is that there were no differences in verbal or visuospatial learning and memory in individuals with posttraumatic stress disorder compared with similarly earthquake-exposed controls. Compared with non-exposed controls, both earthquake-exposed groups had poorer performance on a test of visuospatial (but not verbal) learning and memory. This offers preliminary evidence suggesting that it is earthquake (trauma) exposure itself, rather than the presence of posttraumatic stress disorder that affects aspects of neuropsychological functioning. If replicated, this may have important implications for how information is communicated in a post-disaster context.

Psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis.

BACKGROUND: Natural disasters are increasing in frequency and severity. They cause widespread hardship and are associated with detrimental effects on mental health.AimsOur aim is to provide the best estimate of the effects of natural disasters on mental health through a systematic review and meta-analysis of the rates of psychological distress and psychiatric disorder after natural disasters. METHOD: This systematic review and meta-analysis is limited to studies that met predetermined quality criteria. We required included studies to make comparisons with pre-disaster or non-disaster exposed controls, and sample representative populations. Key studies were identified through a comprehensive search of PubMed, EMBASE and PsycINFO from 1980 to 3 March 2017. Random effects meta-analyses were performed for studies that reported key outcomes with appropriate statistics. RESULTS: Forty-one studies were identified by the literature search, of which 27 contributed to the meta-analyses. Continuous measures of psychological distress were increased after natural disasters (combined standardised mean difference 0.63, 95% CI 0.27-0.98, P = 0.005). Psychiatric disorders were also increased (combined odds ratio 1.84, 95% CI 1.43-2.38, P < 0.001). Rates of post-traumatic stress disorder and depression were significantly increased after disasters. Findings for anxiety and alcohol misuse/dependence were not significant. High rates of heterogeneity suggest that disaster-specific factors and, to a lesser degree, methodological factors contribute to the variance between studies. CONCLUSIONS: Increased rates of psychological distress and psychiatric disorders follow natural disasters. High levels of heterogeneity between studies suggest that disaster variables and post-disaster response have the potential to mitigate adverse effects.Declaration of interestNone.

The role of peri-traumatic stress and disruption distress in predicting symptoms of major depression following exposure to a natural disaster.

OBJECTIVE: Few studies have examined the contribution of specific disaster-related experiences to symptoms of depression. The aims of this study were to do this by examining the roles of peri-traumatic stress and distress due to lingering disaster-related disruption in explaining linkages between disaster exposure and major depressive disorder symptoms among a cohort exposed to the 2010-2011 Canterbury (New Zealand) earthquakes. METHODS: Structural equation models were fitted to data obtained from the Christchurch Health and Development Study at age 35 ( n = 495), 20-24 months following the onset of the disaster. Measures included earthquake exposure, peri-traumatic stress, disruption distress and symptoms of major depressive disorder. RESULTS: The associations between earthquake exposure and major depression were explained largely by the experience of peri-traumatic stress during the earthquakes (ß = 0.180, p < 0.01) and not by disruption distress following the earthquakes (ß = 0.048, p = 0.47). CONCLUSION: The results suggest that peri-traumatic stress has been under-recognised as a predictor of major depressive disorder.

An evaluation of Health of the Nation Outcome Scales data to inform psychiatric morbidity following the Canterbury earthquakes.

OBJECTIVE: Following the onset of the Canterbury, New Zealand earthquakes, there were widespread concerns that mental health services were under severe strain as a result of adverse consequences on mental health. We therefore examined Health of the Nation Outcome Scales data to see whether this could inform our understanding of the impact of the Canterbury earthquakes on patients attending local specialist mental health services. METHOD: Health of the Nation Outcome Scales admission data were analysed for Canterbury mental health services prior to and following the Canterbury earthquakes. These findings were compared to Health of the Nation Outcome Scales admission data from seven other large District Health Boards to delineate local from national trends. Percentage changes in admission numbers were also calculated before and after the earthquakes for Canterbury and the seven other large district health boards. RESULTS: Admission Health of the Nation Outcome Scales scores in Canterbury increased after the earthquakes for adult inpatient and community services, old age inpatient and community services, and Child and Adolescent inpatient services compared to the seven other large district health boards. Admission Health of the Nation Outcome Scales scores for Child and Adolescent community services did not change significantly, while admission Health of the Nation Outcome Scales scores for Alcohol and Drug services in Canterbury fell compared to other large district health boards. Subscale analysis showed that the majority of Health of the Nation Outcome Scales subscales contributed to the overall increases found. Percentage changes in admission numbers for the Canterbury District Health Board and the seven other large district health boards before and after the earthquakes were largely comparable with the exception of admissions to inpatient services for the group aged 4-17 years which showed a large increase. CONCLUSION: The Canterbury earthquakes were followed by an increase in Health of the Nation Outcome Scales scores for attendees of local mental health services compared to other large district health boards. This suggests that patients presented with greater degrees of psychiatric distress, social disruption, behavioural change and impairment as a result of the earthquakes.

Earthquake Brain: Altered Recognition and Misclassification of Facial Expressions Are Related to Trauma Exposure but Not Posttraumatic Stress Disorder.

OBJECTIVES: The study investigated facial expression recognition (FER) in posttraumatic stress disorder (PTSD) caused by exposure to earthquakes, and in particular whether people with this condition showed a bias toward interpreting facial expressions as threat-related emotions (i.e., as anger, fear, or disgust). The study included a trauma-exposed control group who had been similarly exposed to the earthquakes but had not developed PTSD. We hypothesized that individuals with PTSD would have increased sensitivity to threat-related facial emotions compared with the trauma-exposed control group. This would be shown by increased accuracy in recognition of threat-related emotions and the misinterpretation of neutral expressions to these emotions (i.e., misidentifying them as anger, fear, or disgust). The availability of a group of healthy controls from a previous study who had been tested on a similar task before the earthquakes allowed a further non-exposed comparison. METHOD: Twenty-eight individuals with PTSD (71% female, mean age 42.8 years) and 89 earthquake-exposed controls (66% female, mean age 50.1 years) completed an FER task, which featured six basic emotions. Further comparisons were made with 50 non-exposed controls (64% female, mean age 38.5 years) who had been tested before the earthquakes. RESULTS: There was no difference in sensitivity to threat-related facial expressions (as measured by accuracy in recognition of threat-related facial expressions and the misinterpretation of neutral expressions as threatening) in individuals with PTSD compared with similarly earthquake-exposed controls. Supplementary comparison with an historical, non-exposed control group showed that both earthquake-exposed groups had increased accuracy for the identification of all facial emotions and showed a bias in the misclassification of neutral facial expressions to the threat-related emotions of anger and disgust. CONCLUSION: These findings suggest that it is exposure to earthquakes and repeated aftershocks, rather than the presence of PTSD that affects FER accuracy and misinterpretation. The importance of these biases in both PTSD and trauma-exposed controls needs further exploration and is an area for future research.

Identifying medical students at risk of underperformance from significant stressors.

BACKGROUND: Stress is associated with poorer academic performance but identifying vulnerable students is less clear. A series of earthquakes and disrupted learning environments created an opportunity to explore the relationships among stress, student factors, support and academic performance within a medical course. METHODS: The outcomes were deviations from expected performances on end of year written and clinical examinations. The predictors were questionnaire-based measures of connectedness/support, impact of the earthquakes, safety, depression, anxiety, stress, resilience and personality. RESULTS: The response rate was 77%. Poorer than expected performance on all examinations was associated with greater disruptions to living arrangements and fewer years in the country; on the written examination with not having a place to study; and on the clinical examination with relationship status, not having the support of others, less extroversion, and feeling less safe. There was a suggestion of a beneficial association with some markers of stress. CONCLUSION: We show that academic performance is assisted by students having a secure physical and emotional base. The students who are most vulnerable are those with fewer social networks, and those who are recent immigrants.

The impact of major earthquakes on the psychological functioning of medical students: a Christchurch, New Zealand study.

BACKGROUND: No previous studies have systematically assessed the psychological functioning of medical students following a major disaster. AIM: To describe the psychological functioning of medical students following the earthquakes in Canterbury, New Zealand, and identify predictors of adverse psychological functioning. METHOD: 7 months following the most severe earthquake, medical students completed the Depression, Anxiety and Stress Scale (DASS), the Post-Traumatic Stress Disorder Checklist, the Eysenck Personality Questionnaire, the Connor Davidson Resilience Scale, the Work and Adjustment Scale, and Likert scales assessing psychological functioning at worst and currently. RESULTS: A substantial minority of medical students reported moderate-extreme difficulties on the DASS subscales 7 months following the most severe earthquake (Depression =12%; Anxiety =9%; Stress =10%). Multiple linear modelling produced a model that predicted 27% of the variance in total scores on the DASS. Variables contributing significantly to the model were: year of medical course, presence of mental health problems prior to the earthquakes, not being New Zealand European, and being higher on retrospectively rated neuroticism prior to the earthquakes. CONCLUSION: Around 10% of medical students experienced moderate-extreme psychological difficulties 7 months following the most severe earthquake on 22 February 2011. Specific groups at high risk for ongoing psychological symptomatology were able to be identified.

The impact of learning environment disruption on medical student performance.

OBJECTIVES: This study aimed to quantify the effects of two distinct and separate disruptions caused by earthquakes to a medical school learning environment on two separate cohorts of Year 5 medical students. METHODS: The first disruption was caused by an earthquake of magnitude 7.1 that occurred near the end of the academic year but caused minimal physical damage. The second disruption, to a different cohort of students, was caused by a magnitude 6.3 aftershock that occurred at the beginning of the academic year, caused loss of life and widespread damage to the city, and resulted in the closure of the medical school building for 2 years. Using students from the same class, who spent their year in different unaffected cities, as control subjects, and students from previous years in the same city as historic controls, we developed models to compare actual and predicted performances on end-of-year examinations in each of the two cohorts with those in the three previous unaffected year groups. RESULTS: The predictive models fitted the data well with multiple correlations for the written (R range: 0.69-0.79) and clinical (R range: 0.52-0.69) examinations. Students in the first cohort, for whom the disruption occurred close to end-of-year examinations but had a mild effect on the physical environment, performed slightly (-1.5% to -2.0%) but significantly (p < 0.05) worse than predicted for all three outcomes. Students in the second cohort, who experienced major disruption of their physical environment, performed as expected. CONCLUSIONS: An unexpected disruption that occurred close to examinations, but which had less physical environmental effect, had a greater impact on assessment performance than a more severe disruption and series of disruptions to which students had time to adapt and which they could work around. Two theories are offered to explain the observations.

Suitability and acceptability of computerised cognitive behaviour therapy for anxiety disorders in secondary care.

OBJECTIVE: To evaluate the suitability and acceptability of computerised cognitive behaviour therapy (CCBT). METHOD: Participants were patients who had been referred to a secondary care service in the usual manner, and then offered participation in a randomised controlled trial comparing the efficacy of CCBT with a control condition (waitlist) for patients with a current primary diagnosis of generalised anxiety disorder, panic disorder or social phobia. Data were collected regarding the recruitment and retention of patients, and patient ratings (anchored Likert scales) of treatment credibility, treatment satisfaction, treatment acceptability and telephone support. RESULTS: A total of 1141 referrals were received by the secondary care service. Of the 1141, 748 (66%) were not suitable for the study, 178 (16%) declined to participate and 127 (11%) were not contactable. Therefore, of the 1141 patients referred to the secondary care service, only 88 patients (8%) were eligible and consenting for the study. The single most common reason for patients not being suitable for the study was that the referral was urgent. In a clinical setting where CCBT could be used alongside clinical management, many of these patients may have been suitable for CCBT. Of the patients randomised to treatment (n = 40), 65% completed treatment. Drop-out rates were not significantly different across diagnostic groups. The single most commonly cited reason for not completing treatment was 'too busy'. Patient ratings of treatment were typically favourable (credibility, satisfaction, acceptability and telephone support). CONCLUSIONS: CCBT was typically rated favourably by patients referred to a secondary care service and randomised to treatment. However, only a small minority of patients was eligible and consenting for the trial. Therefore, while CCBT may be an acceptable treatment, its suitability for secondary care settings remains unclear.

Effectiveness of computerised cognitive behaviour therapy for anxiety disorders in secondary care.

OBJECTIVE: This study aimed to compare the effectiveness of computerised cognitive behaviour therapy (CCBT) with a wait list control (WLC) for the treatment of patients with an anxiety disorder (social phobia, panic disorder, generalised anxiety disorder) referred to a specialist, publically funded, outpatient anxiety service. METHOD: Patients with social phobia (n = 37), panic disorder (n = 32) or generalised anxiety disorder (n = 14) were randomised to treatment with either CCBT (n = 40) or WLC (n = 43). Self-report rating scale assessments were conducted at baseline, 12 and 24 weeks. RESULTS: Compared with WLC, the CCBT group improved significantly on approximately half of the self-report primary (the Work and Social Adjustment Scale) and approximately half of the secondary measures at both 12 and 24 weeks (the Liebowitz Social Anxiety Scale, the Penn State Worry Questionnaire, the Generalised Anxiety inventory and the Fear Questionnaire). Effect sizes in this study were moderate. CONCLUSION: This is one of the few studies to investigate CCBT for anxiety disorders in patients in a secondary care service. The results show that CCBT in this secondary care setting has the potential to be beneficial and confirms and extends the findings from previous studies of self-referral or primary care settings.

Redistribution of slow wave activity of sleep during pharmacological treatment of depression with paroxetine but not with nefazodone.

It has been suggested that increase in delta sleep ratio (DSR), a marker for the relative distribution of slow wave activity (SWA) over night time, is associated with clinical response to antidepressant treatment. We examined this index and its relationship to rapid eye movement (REM) suppression before and during long-term treatment with nefazodone, which does not suppress REM sleep, and paroxetine which does. The effect of serotonin (5-HT(2A)) receptor blockade on the evolution of SWA during treatment was also investigated. In a double-blind, randomised, parallel group, 8-week study in 29 depressed patients, sleep electroencephalograms were performed at home at baseline, on night 3 and 10, and at 8 weeks of treatment with either paroxetine or nefazodone. SWA was automatically analysed and a modified DSR (mDSR) was derived, being the ratio of amount of SWA in the first 90 min of sleep to that in the second plus third 90-min periods. At baseline, the pattern of SWA over night time was similar to other reports of depressed patients. mDSR improved over the course of treatment; there was no difference between remitters and non-remitters but there was a significant drug effect and a significant drug x time effect with paroxetine patients having a much higher mDSR after treatment, regardless of clinical status. SWA and REM during antidepressant treatment appear to be interdependent and neither of them alone is likely to predict response to treatment. Higher mDSR did not predict therapeutic response. 5-HT(2A) blockade by nefazodone does not increase SWA above normal levels.

Plasma oxytocin levels in depression and their correlation with the temperament dimension of reward dependence.

Evidence suggests that the neuropeptide oxytocin plays a role in social affiliation. This behaviour may be related more to personality dimensions than specific psychiatric diagnoses. This study investigated the relationship between plasma oxytocin levels and personality dimensions using the Temperament and Character Inventory (TCI) in 60 outpatients with major depression. The strongest correlation was between plasma oxytocin levels and the temperament dimension of Reward Dependence (0.425 Pearson correlation). This suggested that 17% of the variance in plasma oxytocin levels was explained by the Reward Dependence scores. There was a significant positive correlation between plasma oxytocin levels and the Reward Dependence personality dimension.

Acute tryptophan depletion. Part I: rationale and methodology.

OBJECTIVE: Acute tryptophan depletion (ATD) is an experimental technique that has been widely used over the last decade to investigate the role of serotonin (5-HT) in a variety of disorders. This review, the first of two articles, describes the rationale behind this technique and provides detail on how it is applied in research settings. METHOD: The authors outline the development of this technique with reference to the seminal literature and more recent findings from neuroimaging and neuroendocrine studies. This is supplemented by the authors' clinical experience of over 5 years of continuous experimental work with this paradigm in over 50 subjects. RESULTS: Acute tryptophan depletion is a method that significantly reduces central 5-HT in human subjects. Non-serotonergic explanations of the effects of ATD have not been confirmed, supporting the specificity of this method. CONCLUSIONS: The ATD technique is a valid method of manipulating central 5-HT levels. The second article in this series will review the application of ATD in depression, anxiety and other psychiatric conditions.

Acute tryptophan depletion. Part II: clinical effects and implications.

OBJECTIVE: This is the second of two articles reviewing the modern dietary technique of acute tryptophan depletion (ATD), a method of transiently reducing central serotonin levels in both healthy volunteers and clinical populations. This article details the clinical studies to date and discusses the implications of this research methodology. METHOD: The authors present a review of clinical ATD studies collated from a MEDLINE search, unpublished communications and the authors' considerable experience with this paradigm. RESULTS: Following from the initial use of ATD in subjects with depressive illness, studies of anxiety disorders and other psychiatric illnesses have been reported. Sleep, aggressive and cognitive effects are also active areas of research and are reviewed here. CONCLUSIONS: Acute tryptophan depletion remains a useful psychiatric research tool. The findings from the clinical studies reviewed here are summarized and implications for future research detailed.