Emergency rural obstetric transfers in South Australia: a review of the clinical and precipitating factors.

INTRODUCTION: The provision of critical management of obstetric emergencies is a vital service for rural women and their families. Emergency obstetric transfers are indispensable to reduce maternal and neonatal mortality and morbidity because local rural hospitals often do not have the resources or expertise to manage both maternal and neonatal outcomes. However, the transfer of a rural pregnant woman to a higher level, tertiary perinatal centre (TPC) is often stressful for the patient and costly for health services. Currently, little is known about the main reasons for obstetric transfers in rural South Australia, and there is even less information about the management of mothers and babies once they arrive at their destination. The present guidelines for informing the necessity of transferring from a rural or remote area to a TPC are unclear. This study aims to describe the clinical reasons for obstetric transfers from a rural area in South Australia and explore predictive factors of likelihood of delivery on transfer. Additionally, this study aims to determine the outcomes of transfers in terms of location of delivery, timing of delivery and to explore the association between delivery after transfer and clinical reasons for transfer. METHOD: All women from the Riverland region of South Australia who were transferred antenatally at >20 weeks gestational age for an acute admission to a TPC over a 5-year period were included in a retrospective review. Participants were determined from hospital coding data, and medical case notes were retrieved for all participants. The demographic and clinical data, including details of the emergency presentation and outcomes of women transferred to a tertiary hospital, were analysed with descriptive statistics (mean, standard deviation). A logistic regression was performed for predictive factors associated with delivery on transfer. RESULTS: A total of 160 patients were transferred antenatally. A minority of participants delivered on admission (35%). Of the women who were discharged undelivered, 43% eventually delivered at their rural hospital and the remainder delivered later in a tertiary hospital as part of a planned admission. The most common diagnoses for transfer were preterm labour, premature preterm rupture of membranes, antepartum haemorrhage and placental disorders. Delivery on transfer was associated with preterm premature rupture of membranes and pre-eclampsia. Likelihood of delivery on transfer was not increased with preterm gestation, cervical dilation or other presenting diagnosis. There was not an association of increased number of indications for transfer and likelihood of delivering after transfer. CONCLUSION: This study suggests that the rural doctor workforce in the Riverland region appears to be well skilled at identifying obstetric emergencies despite the lack of guidance around what constitutes a high risk perinatal situation. Furthermore, this study quantifies the number of women who would potentially require support services associated with rural perinatal transfers from this area. There was a comparatively lower rate of delivery on transfer and, as such, these women eventually delivered their babies either at their hospital of origin or returned to a metropolitan hospital as part of a planned admission for delivery. Further research is needed about the practical implications of transferring pregnant women to tertiary centres and clinical decision-making tools to improve this process.

Assessing the Effects of Repetitive Transcranial Magnetic Stimulation on Cognition in Major Depressive Disorder Using Computerized Cognitive Testing.

OBJECTIVES: A range of different treatment approaches are available for depression; however, there is an ongoing concern about the cognitive impairment associated with many treatments. This study investigated the effect of treatment with repetitive transcranial magnetic stimulation (rTMS) on cognition in patients with major depressive disorder. Cognition before and after treatment was assessed using a computerized cognitive testing battery, which provided comprehensive assessment across a range of cognitive domains. This was a naturalistic study involving patients attending an outpatient clinical rTMS service. METHODS: A total of 63 patients with treatment-resistant depression completed the IntegNeuro cognitive test battery, a well-validated comprehensive computerized assessment tool before and after receiving 18 or 20 treatments of sequential bilateral rTMS. Change in the various cognitive domains was assessed, and analyses were undertaken to determine whether any change in cognition was associated with a change in rating of depression severity. RESULTS: There was a significant decrease in Hamilton Depression Rating Scale scores from baseline to posttreatment. There was no decline in performance on any of the cognitive tests. There were significant improvements in maze completion time and the number of errors in the maze task. However, these were accounted for by improvement in mood when change in depressive symptoms was included as a covariate. CONCLUSIONS: This open-label study provides further support for the efficacy and safety of rTMS as a treatment option for people with major depressive disorder in a naturalistic clinical setting. Using a comprehensive, robust computerized battery of cognitive tests, the current study indicated that there was no significant cognitive impairment associated with rTMS and that any improvements in cognitive functioning were associated with a reduction in depressive symptoms.

Evaluation of a community-based smoking cessation programme for people with severe mental illness.

OBJECTIVE: To evaluate the effectiveness of a smoking cessation programme for smokers living with mental illness, provided within community mental health services, and determine factors which impact on the rates of cessation. METHODS: One hundred and twenty-nine smoking cessation group programmes were provided within community mental health services in South Australia between 2006 and 2011. Participants' smoking cessation rates were analysed in terms of demographic factors, smoking history, diagnosis and group participation. Participants completed written questionnaires at registration, at the end of each programme and at 12 months. They were also asked to complete the Fagerström rating scale and use the Micro+Smokerlyzer to measure breath carbon monoxide levels. RESULTS: Eight hundred and forty-four smokers living with mental illness registered for the programme. Many continued to be involved in addressing their tobacco use over more than one programme. At the end of their last programme, 581 completed an evaluation and 129 (22.2%) were not smoking. If it is assumed that all who did not complete an evaluation had continued smoking, then the cessation rate was 15.3%. Cessation rates were higher for those who attended more sessions, had decided at registration that they wanted to quit or had a lower level of nicotine dependence. Cessation rates were not significantly affected by gender, diagnosis or the number of years of smoking. CONCLUSIONS: People with mental illness are concerned about their tobacco use and will seek help if this is available. Smoking cessation programmes which are tailored for this group of smokers can be effective and should be provided by mental health and tobacco control services.

Determinants of high rates of smoking among people with psychosis living in a socially disadvantaged region in South Australia.

OBJECTIVE: This study aimed to identify factors associated with the high rates of smoking amongst people with psychosis living in a disadvantaged region in Adelaide, South Australia. METHODS: Data were collected from 402 people with psychosis, aged 18-64 years, who lived in the northern suburbs of Adelaide. This area is disadvantaged on many measures of socioeconomic well-being and people living in this region have higher rates of smoking compared to the general Australian population. We hypothesised that whilst tobacco use by people with psychosis living in this region was primarily associated with mental illness, factors related to social disadvantage also contributed to the high rates of smoking. RESULTS: Approximately 74% of men and 71% of women with psychotic disorders living in the northern suburbs of Adelaide were current smokers. Factors such as unemployment, lower levels of education and receiving government welfare, factors known to be associated with smoking in the general population, were more prevalent in the northern region. Smokers with psychosis were less likely to participate in recreational programs and physical activity, and more likely to use illicit substances and be a victim of crime. They had poorer health and financial outcomes than non-smokers. There were some gender differences: for men with psychosis, employment and having a post-school qualification decreased the risk of smoking while cannabis use increased the risk; for women with psychosis, a diagnosis of alcohol abuse/dependence, using cannabis and being sedentary were risk factors for smoking, while attending recreational programs reduced this risk. CONCLUSION: Smoking rates were strikingly high in both men and women, and particularly high in women when compared with previous research. Our study shows that the risk of smoking is increased by factors related to the social disadvantage of living in the northern Adelaide region. Smoking cessation interventions for people with mental illness should take into account the social context, and also address relevant comorbidities such as drug and alcohol disorders.

Practical considerations in the use of ultrabrief ECT in clinical practice.

OBJECTIVE: Electroconvulsive therapy (ECT) is the most effective treatment for major depression. Brief pulse width (BPW; pulse width, 1.0 m/s) ECT is often associated with cognitive impairment. Ultrabrief (UB; pulse width, 0.3 m/s) ECT is better tolerated and causes less cognitive impairment so has been introduced as an alternative. Previous research has shown that more treatments are needed with UB ECT; however, there has not been any previous research into the impact of prescribing UB ECT on length of stay. METHODS: This study reports naturalistic data collected from 258 inpatients in a private psychiatric hospital for 2 years since the introduction of UB ECT. Clinician and self-rated scales of depression severity and hospital service data were used to evaluate the number of ECT treatments, length of stay, and efficacy. RESULTS: Patients prescribed UB ECT had, on average, 10.9 treatments compared to 8.8 for BPW ECT. They also spent more time in hospital; 30.3 days from the first ECT treatment to discharge compared to 24.7 days for patients prescribed BPW ECT. Excluding patients who switched treatments, 54% of patients prescribed UB ECT responded compared to 66.7% of patients prescribed BPW ECT. More patients (n = 42) switched from UB to BPW than from BPW to UB (n = 3). In the 4 years since the introduction of UB ECT, the number of patients prescribed ECT has increased, and the mean number of treatments per patient (for all patients receiving ECT) has increased from 7.7 to 11.6. CONCLUSIONS: Ultrabrief ECT has significant advantages, reflected in the increased use of ECT since UB ECT became available. However, the greater number of treatments and the increased length of stay have important implications for service delivery, costs, and bed accessibility.

What do 1000 smokers with mental illness say about their tobacco use?

OBJECTIVE: To determine what motivates smokers with mental illness to participate in a smoking cessation or reduction programme and to report their attendance and cessation rates. METHOD: A group programme was provided to assist smokers with mental illness to cease or reduce their use of tobacco. People who registered to address their tobacco use completed a questionnaire which included information about their mental health, tobacco use, and what they wanted to achieve by attending the programme. RESULTS: A total of 1043 smokers living with mental illness contacted the programme and asked for help to address their tobacco use between 2000 and 2011. At the first contact they were smoking an average of 27.4 cigarettes per day and had been smoking for 23.8 years, and 87% said they wanted to quit tobacco and a further 10% wanted to smoke less: 85% said they were concerned about the effect that smoking tobacco was having on their health, 56% were concerned for financial reasons, and nearly half (47.6%) said that they were concerned about both their physical health and their financial situation. In Adelaide, 148 Tobacco Free programmes were provided by mental health services. Of those who attended at least one session and completed an evaluation at the end of the programme, 22.5% reported not smoking. Most remained motivated to continue to address their tobacco use and many registered for a further programme. CONCLUSIONS: Many smokers living with serious mental illness are concerned about the impact of tobacco use on their health and finances and are motivated to address it. Group treatment programmes specifically designed for these people can achieve good cessation rates and should be readily accessible to all smokers with mental illness.

Peer workers' role in smoking-cessation groups for people with mental illness.

OBJECTIVES: The objective of this article is to evaluate the impact of peer workers' involvement as co-leaders in smoking-cessation programmes provided within mental health services. METHOD: Group smoking-cessation programmes were provided for people living with mental illness. Peer workers were involved in the development and delivery of these programmes. Group participants and mental health workers were asked to respond to a questionnaire about their experience of the peer workers. The questionnaire included both Likert scales and qualitative responses. RESULTS: Thirty-three mental health workers and 108 group participants completed the questionnaire. The majority of participants believed that the peer workers increased their confidence, helped them to learn about smoking cessation and promoted well-being. Mental health workers were also positive about the role of peer workers in the groups. CONCLUSIONS: This study supports the role of peer workers providing support and guidance within smoking-cessation programmes for people with mental illness. The results suggest that peer workers make a substantial contribution and that greater peer worker involvement in such programmes is likely to improve their acceptability and efficacy.