April 9th: Prevention and treatment of mental disorders challenge primary care doctors worldwide. Most of them use electronic medical records (EMRs) to keep track of their patients. A team of students and scientists from University of Limerick was led by Dr Cullen and wanted to see how doctors record mental health disorders in their records. They wanted to find out whether these notes can be used for research.
The researchers randomly sampled 690 patients from seven general practices in Ireland (age from18–95, 52% male, 52% low-income).
A mental disorder (most commonly anxiety/stress, depression and problem alcohol use) was recorded in the clinical records of 139 (20%) during the 2-year study period. While most patients with the common disorders had been prescribed medication (i.e. antidepressants or benzodiazepines), a minority had been referred to other agencies or received psychological interventions. ‘Free text’ consultation notes and ‘prescriptions’ were how most patients with disorders were identified. Diagnostic coding alone would have failed to identify 92% of patients with a disorder.
Although mental disorders are common in general practice, this study suggests their formal diagnosis, disease coding and access to psychological treatments are priorities for future research efforts.
Citation for the original study: M. Gleeson, A. Hannigan, R. Jamali, K. Su Lin, J. Klimas, M. Mannix, Y. Nathan, R. O’Connor, C. O’Gorman, C. Dunne, D. Meagher and W. Cullen. Using electronic medical records to determine prevalence and treatment of mental disorders in primary care: a database study. Irish Journal of Psychological Medicine, available on CJO2015. doi:10.1017/ipm.2015.10.
There probably isn’t a simple answer to this question. Everybody has a different experience. My path was one of finding my own funding to do what I liked. Other people get postdocs via other routes, but I’d hope that my story bellow illustrates one of the paths people can take.
My mentor helped me identify funding calls and write funding applications. Then, I applied for everything and some of the applications were successful. Keeping up with the current funding calls via Research Newsletters and email alerts, such as Find A Phd, helped me too. I met the collaborators for my projects at conferences and seminars.
Towards the end of my two-year Cochrane Fellowship, my Irish supervisors offered me two complementary part-time postdoc positions, both of which I accepted. The first was a three-year position in emergency medical science research. The second was a one-year position developing new projects in primary care settings and supervising medical students (2012-13). From a personal perspective, teaching literature reviews to medical students taught me how to address a training gap through addiction research education for medical students.
At the same time, I applied for two other grants. First was a three-year feasibility study in primary care from Health Research Board Ireland (Co-applicant). Second, an INVEST drug abuse fellowship from the National Institute for Drug Abuse – NIDA (Fellow). The feasibility study was a direct result of our efforts to highlight the problem of alcohol consumption among people receiving methadone treatment. We’ve trained family physicians in psychosocial interventions for concurrent problem and drug use disorders. Hence the title for the PINTA study.
Both were successful. Thanks to the patience and flexibility of my supervisors, I was able to combine and merge all of these opportunities. The INVEST postdoctoral fellowship was a six months job in at Oregon Health and Science Universityin Portland, OR, studying implementation of alcohol SBIRT in primary- versus secondary-care based opioid agonist treatment (2013). Our poster at the Annual Symposium of the Society for the Study of Addiction described qualitative component of the study. Training health care professionals in delivering alcohol SBIRT is feasible and acceptable for implementation among opioid agonist patients; however, it is not sufficient to maintain a sustainable change. After INVEST, I returned back to my composite Irish postdoc.
Eight months after the return back to Ireland, and one year before the end of my three-year Irish postdoc, I received another fellowship from the Irish Research Council. This International Career Development Award is co-funded by a European Union scheme called Marie Sklodowska Curie Actions. To improve the addiction medicine education for doctors (BEAMED), I’ll do an external and independent evaluation of the addiction medicine fellowship and plan a similar training in Ireland (2014-17). To learn more about the Marie Cure awards, go to: http://ec.europa.eu/research/mariecurieactions/
The department of health
is reviewing distribution of Naloxone, a drug that reverses overdose, to buddies and families of heroin users. A similar scheme is in use in Britain
. The department is in discussions with the Health service executive
(HSE) to make the emergency drug more widely available. Currently, it is a prescription-only medication and can only be used by the person for whom it is prescribed, or by ambulance crews and medical staff.
On July 6th
, 2012, The Ana Liffey Drug Project
, a national addiction service, set up a Naloxone Advisory Group
. Tony Duffin, the group’s director, said that while the government’s discussions on Naloxone are welcome, it would be more beneficial to fast-track legislative changes. “I don’t know why we haven’t prioritized this in Ireland,” he said. “It’s an innocuous drug. Its only purpose is to stop opioids working. If you haven’t taken opioids, it won’t have any effect. It’s a WHO recommended medicine, so the evidence is clear. It is important that we see it widely available so we can save people’s lives.”
A [our] study* published last week, which was compiled by the medical school at UCD and the Dublin Fire Brigade
recorded 496 overdoses over a 12-month period, 13 of which were fatal. The majority of these were young men on the street, including in affluent areas of south Dublin. Most overdoses occurred in daytime, with a high incidence within 1000 meters radius of addiction services. Gerard Bury
, a professor in general practice at UCD
and one of the authors of the research, said: “Literature from other countries shows that bystanders, peers, or family members of overdose victims are most often the initial emergency responders and are best positioned to intervene immediately when the first overdose symptoms appear. These lay persons save lives if they are provided with Naloxone.”
Bury said Naloxone in a form of intranasal spray, available in America and Scotland, may be a more effective intervention than the injectable type planned by the department. “The Department of Health statement doesn’t indicate any intention to address the issue of the intranasal route, which, they told us, contravened the current regulations,” he said. “There isn’t any of the sense of urgency which you might expect in dealing with a situation in which people are literally dying in the streets.”
To read the magazine article, go to: http://www.thesundaytimes.co.uk/sto/
Dublin ambulances see an opioid overdose every day; many times near the methadone clinics. Do people shoot heroin around methadone clinics? Yes. The common sense confirms anecdotal evidence from everyday experience of clinic staff and methadone users. Although this is no rocket science for most of us, it’s much harder to prove it. Regardless of the location, the high number of overdoses in Dublin calls for an immediate distribution of the heroin antidote – Naloxone. Visit my previous post for more info on our pilot Naloxone project.
Overdose is the most common cause of deaths among heroin users. Our previous research has shown that the ambulances in Dublin see one overdose every day*. Naloxone is a life-saving nasal spray for reversing heroin overdose. It has no addictive properties, no potential for abuse and a low cost. In Ireland, it is currently used by ambulance and emergency care services as an injection into muscle, into the bone or under the skin.
Irish family doctors treat many heroin users users who are in the methadone treatment. This makes family doctors ideal to use naloxone themselves or to show patients how to use it. The new Clinical Practice Guideline of the Pre-hospital Emergency Council of Ireland advises that trained professionals can use intranasal naloxone.
Today, we ran a pilot workshop with doctors in training. It was designed to help trainees identify and manage opioid overdose with naloxone spray. The trainees listened to a short presentation, watched a video clip about how to use naloxone (Figure 1), and tried it themselves. However, they did not get the spray to take home with them.
|Figure 1 Jano simulating overdose in a pilot educational video for general practice trainees
23 young doctors from one postgraduate training scheme in Ireland participated in an hour long lunchtime workshop. We have asked them to self-assess their own knowledge of and attitudes towards naloxone using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales. They did the scales before and after the workshop. Another questionnaire measured the acceptability and satisfaction with workshop. The doctors gave us valuable feedback on the session which will be analysed and published in an academic paper.
The take home message from today is that adequate training is essential for distribution of naloxone through Family Practitioners. In future studies, the knowledge from this pilot may be used to inform a train-the-trainer model. Healthcare professionals and other front-line service providers may be trained to instruct heroin users and their families in overdose prevention and naloxone use. Today’s workshop was timed perfectly, because the deaths due to overdose in the country are peaking.
*Study by: Klimas, J., O’Reilly, M., Egan, M., Tobin, H., Bury, G. (2014) Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services. American Journal of Emergency Medicine (Online July 30) doi: 10.1016/j.ajem.2014.07.017
Healthcare professionals can generate important clinical questions for addiction research. Answering such questions by conducting a Cochrane review of evidence is a satisfying learning process and can contribute to drugs policy. This article summarises the experiences of an addiction medicine researcher conducting a Cochrane review, developing and evaluating a researcher-facilitated programme for medical student research activity in general practice.
|photo credit: theconversation.net
One summer afternoon in 2010, an interview with a family physician in Dublin opened my eyes about talking therapies for drink problems among people who also used other drugs. “Does counselling work for these people?” the doctor asked. “Yes”, I was absolutely convinced about it, but I had no evidence for my faith. Surprised by his interest, I sent him the only two studies on the topic that I knew of; never heard back from him.
I searched for more studies without success. Many studies on general population showed up in my internet search, but none for people who also used other drugs.
This made me doubt my beliefs. At that time, a national funding agency announced a call for Cochrane training fellowships. Cochrane collaboration hosts the largest database of systematic reviews to inform healthcare decisions. Cochrane reviews are the jaguars of medical evidence synthesis. The fellowship was a godsend. I could use the funding to learn from Cochrane gurus and answer the Dublin doctor’s question by making the most of all available literature. My supervisor introduced me to a Cochrane author, Dr Liam Glynn, who reviewed self-management strategies for high blood pressure. He agreed to mentor my fellowship. We booked the title for our review with the Cochrane Drug andAlcohol Review Group in Italy and started to work on it when we got the funding.
The review found very few studies, most of which didn’t have a control group or randomised patients without drink problems; we could not give any recommendations to doctors.
The next step in the quest for the answer, we approached patients with dual drug and alcohol problems and fed their ideas back to the experts. Expert consensus recommendations are standard in the absence of scientific studies. The group had to rely on semi-structured interviews with doctors and patients and “B class” evidence from my review. The result of their consensus was a manual for family doctors.
Having developed the manual, we tested its value to answer our original question: “Does it work?” The new pilot trial encourages doctors to ask people who use illicit drugs about alcohol and to help those with mild problems; severe problems are best treated by a specialist. Sixteen general practices (GPs) in two deprived regions will be randomised to receive the manual-based training or to keep doing what they do. The latter group will be trained later.
When I finished my Cochrane training and review, it was time for me to give back and teach medical students because the fellowships worked on the pay-it-forward model. Equipping the new generation of doctors with critical literature review and appraisal skills was my contribution to the improvement of addiction healthcare delivery. The aim of our teaching project was to create and evaluate a training-through-research programme for medical students, facilitated by a seasoned researcher.
We offered online webinars, methodological advice, mentoring, and one-one interaction. Our medical school emailed all students and we randomly selected a handful needed for our research projects. Collaborators from biostatistics, psychiatry and public health aided the programme. The students presented their work at four conferences and wrote three academic papers for medical journals.
Teaching literature reviews to medical students was a rewarding learning experience. I learned that the quality and commitment of students varies; different expectations led to different work processes and outputs. Some students submitted their work in more finished stage than others; competing priorities precluded achievement of higher standards. The manuscript preparation, submission and publication processes were too long for short student projects, although some students persevered and remained involved until the end.
From a personal perspective, I still don’t know whether counselling works for drink problems in people who also use other drugs, but I’ve learned how to query the literature when doctors need evidence.
This post is based on our presentation at the INMED conference in Belfast, and o recent article in the Substance Abuse journal. References:
- Klimas, J., & Cullen, W. (2014). Addressing a Training Gap through Addiction Research Education for Medical Students: Letter to editor. Substance Abuse. doi: 10.1080/08897077.2014.939802
- Klimas, J., & Cullen, W. (2014). Teaching literature reviews: researcher-facilitated programme to support medical student research activity in general practice. Poster presented at the Annual scientific meeting of the Irish Network of Medical Educators, February 21, Belfast, NI.