Re: Antipsychotic prescribing in care homes before and after launch
of a national dementia strategy: an observational study in English
institutions over a 4-year period. Szczepura et al. (2016) BMJ Open
2016;6:e009882 doi:10.1136/bmjopen-2015-009882
Dear Editor,
We read with interest the recent article by Szczepura and colleagues
on antipsychotic medications in care homes. To summarise, the authors...
Re: Antipsychotic prescribing in care homes before and after launch
of a national dementia strategy: an observational study in English
institutions over a 4-year period. Szczepura et al. (2016) BMJ Open
2016;6:e009882 doi:10.1136/bmjopen-2015-009882
Dear Editor,
We read with interest the recent article by Szczepura and colleagues
on antipsychotic medications in care homes. To summarise, the authors
found that people living with dementia in care homes are often
overprescribed antipsychotic medications, both in terms of dose and
duration of the prescription. We would like to share with readers some of
our work which we have carried out over the last six months at Four
Seasons Health Care (FSHC), an independent provider of approximately 300
care homes throughout the UK.
At FSHC, we have developed a Dementia Care Framework (DCF), to
support the provision of dementia care and facilitate a positive
experience of living with dementia in our homes. The framework is
underpinned by a comprehensive range of standards derived from national
guidance published by NICE, Alzheimer's Society and the Department of
Health. Within the DCF programme, we have developed a specialist
medication management application which requires mandatory completion and
structures a review of all psychotropic medications prescribed for an
individual resident. The DCF review, including the antipsychotic
medication 'App', runs on standard IPads and the information is available
in real-time. The data presented in this letter is from the initial 46
care homes who have completed or are in the process of completing, their
dementia accreditation within the DCF programme. These care homes provide
care for 1,818 residents living with dementia throughout England,
Scotland, Wales and Northern Ireland.
The standards set within the antipsychotic App are that each resident
must have a documented annual review of medication from the resident's GP
and a care plan that clearly indicates the rationale for prescription of
the antipsychotic medication. If these standards are not met, a referral
to the General Practitioner is created and, operating the find and fix
principle that is central to the functionality of the system, the referral
is tracked until it has been completed. The App also prompts staff to
enter all psychotropic medications and the dose, including as required
use, into a pre-programmed algorithm which will automatically trigger an
urgent review process if the dose exceeds the normal therapeutic range
with reference to the British National Formulary.
The medication management App has been designed as an expert system which
does not require specialist knowledge of antipsychotic medications and can
effectively be used by both nursing and care workers.
The medication management application has enabled FSHC to critically
evaluate the use of antipsychotics in 1,818 residents living with dementia
and provide central visibility on this information in real time. Through
our analysis we found that 310 residents (17.05% of total sample) are
currently prescribed antipsychotic medications. The DCF system prompted a
review of these medications and, where appropriate, a specific care plan
to reduce and withdraw the antipsychotic medication through alternative
strategies. We also identified 27 residents where prescribed dose of
medication exceeded the normal therapeutic range, and a rapid review and
resolution of this was driven by the find and fix process within the
system. A total of 62 residents were identified where there was not a
clear rationale provided for the use of the antipsychotic medications and
again the system supported the rapid resolution of this deficit. Finally,
6 residents were identified where a review had not been completed within
the previous 12 months, the find and fix process resolved this. To
summarise, the dementia care framework medication App has enabled our
staff to detect and act on these findings. Furthermore we can report that
the average time taken to resolve these issues is 2 days.
We fully recognise that the sustained administration of antipsychotic
medications can be associated with multiple adverse effects and should be
considered as a last resort for people living with dementia. The report of
Szczepura et al (2016) indicates a continued high utilisation of
antipsychotic medication in care home residents prompting sensationalist
headlines in the public media such as 'chemical cosh still used routinely
to knock out dementia patients in care homes'
http://www.telegraph.co.uk/news/2016/09/20/chemical-cosh-of-powerful-drugs
-still-routinely-used-to-knock-ou/
In our view, the critical 'missing factor' has been the provision of
support and training to care home staff to facilitate the effective
utilisation of a full range of non-pharmacological interventions focused
on the management of the distressed behaviours in dementia that continue
to be inappropriately managed with antipsychotic medication. Furthermore,
training is necessary to help staff identify pain as a key provoking
factor for distressed behaviour in an individual and to ensure effective
management of this is put into place. This essential training for all
staff working with residents living with dementia is also structured and
delivered within the Dementia Care Framework developed within Four
Seasons. We would caution that simply responding to the continued concern
that there is over use of antipsychotic medication, in residents in care
homes living with dementia, by withdrawal of the medication without the
investment being made in equipping staff with the right knowledge and
skills has the very real potential of resulting in more harm and distress
for residents.
It is vital that the findings from a recent article published by
Redshaw et al are not misinterpreted as evidence that parents should be
denied choice after their baby has died. The study reports higher rates of
mental health and relationship difficulties among women who held their
stillborn baby compared with those who saw but did not hold their
stillborn baby.
It is vital that the findings from a recent article published by
Redshaw et al are not misinterpreted as evidence that parents should be
denied choice after their baby has died. The study reports higher rates of
mental health and relationship difficulties among women who held their
stillborn baby compared with those who saw but did not hold their
stillborn baby.
Sands supports the need for research to understand the impact of a
baby's death on families, and we understand the parameters of the study in
question. We are concerned, however, that some may suggest, based on these
findings, that parents should not hold their dead baby. This would be a
retrograde step.
Parents should always be offered the opportunity to see, hold and
spend time with their baby. We know, from supporting thousands of parents,
that many find great comfort in the memories they create at this time and
the opportunity to make their baby a part of their family.
Not all parents will want to hold their baby. It's important that
women and their partners should be supported to make the decision that
feels most manageable for them in their circumstances, and that this
choice is respected.
What's essential is that parents are given genuine choices and time
to reflect and decide what they want. Parents should understand they can
change their mind and options should be sensitively revisited if
appropriate, without giving the impression of pressure.
The recently published 4th edition of Sands' Pregnancy loss and the
death of a baby: guidelines for professionals provides clear guidelines on
the principles of bereavement care. Sands also provides bereavement care
training and many resources to support health professionals working in
this area.
It is worth noting that the women and families in the study were
recently bereaved, and therefore researchers were only able to ask them to
self-report symptoms of anxiety and PTSD at 3 and 9 months after their
baby had died. We know at Sands that the impact of the death of a baby
lasts many years and changes over time.
Since Sands was founded by a group of bereaved parents in 1978, we
have passionately supported parents having the choice over whether to see
and hold their baby. We know many long-ago bereaved mothers who were not
given this choice, and whose grief was compounded by not being able to not
see or hold their own babies.
"I was never allowed to hold our son, only look at him in the
incubator. We were not allowed to be with him when he was dying. No
photographs taken. Things were very different in 1975." (Patricia
Robertson, Argyll and Bute)
"The midwife gently asked me, would you like to see, maybe even hold
your baby? My initial reaction was, NO! See, hold a dead thing? NO! But,
the midwife knew it could be beneficial for me to see and hold my baby,
because she had read the guidance on it in the first edition of the Sands
guidelines, and so she asked again. And I did hold my baby and it is the
best thing I have ever done in my life. I can remember her weight in my
arms, her fat cheeks, her rosebud mouth, her soft hair and I can remember
thinking, this is my daughter not something to be afraid of, someone to be
proud of." (Steven Guy, Northern Ireland)
What this study importantly highlights is that the death of a baby is
a complex and traumatic experience for parents. Given how many women
reported poor well-being in the months after their baby's death, their
support needs are clearly not being met by current NHS services at what is
a very difficult time.
Much more needs to be done in terms of supporting parents both
physically and psychologically in the months after the death of their
baby. Bereavement and follow up care cannot change the feeling of loss
parents may feel, but poor care can compound it.
We would like to thank Vos and Ravnskov et al. for their interest in
the points that we raised in our letter to the editor. We welcome
scientific exchange, and respect these authors' rights to produce
alternate accounts of the veridical world. However, it troubles us that
these alternate accounts are in direct conflict with current best
evidence.
For example, Eddie Vos states that there has never been a placeb...
We would like to thank Vos and Ravnskov et al. for their interest in
the points that we raised in our letter to the editor. We welcome
scientific exchange, and respect these authors' rights to produce
alternate accounts of the veridical world. However, it troubles us that
these alternate accounts are in direct conflict with current best
evidence.
For example, Eddie Vos states that there has never been a placebo
controlled cholesterol-lowering intervention that ended with a mortality
benefit in women, and this includes statins. Yet, with respect to women,
if he directed his attention to the 2015 paper from CTT in The Lancet, he
would learn that statins have the same effectiveness in women and men of
equivalent cardiovascular risk in prevention of major cardiovascular
events. With respect to the endpoint of all-cause mortality, women and men
both had a reduction from statin therapy (women: RR 0.91, 99% CI 0.84-
0.99; men: RR 0.90, 99% CI 0.86-0.95). There was no evidence at all of
heterogeneity (p=0.43).1 As for Ravnskov et al.'s response, they seem to
have merely reinstated misinterpretations from their paper as rebuttals to
our critique of them.
For an appropriate interpretation of evidence on the efficacy and
safety of statin therapy, please refer to this link:
http://www.sciencedirect.com/science/article/pii/S0140673616313575.
1. Efficacy and safety of LDL-lowering therapy among men and women:
meta-analysis of individual data from 174?000 participants in 27
randomized trials. The Lancet, Volume 385, Issue 9976, 1397-1405.
With much interest we read your article about interventions for frequent
attenders of healthcare. Unfortunately and wrongly you did not select or
review the research on this topic by our Dutch research group. Apparently
also the reviewers missed the opportunity to correct this omission. We have already published two reviews on this same topic.(1,2)
With much interest we read your article about interventions for frequent
attenders of healthcare. Unfortunately and wrongly you did not select or
review the research on this topic by our Dutch research group. Apparently
also the reviewers missed the opportunity to correct this omission. We have already published two reviews on this same topic.(1,2)
References
(1) Smits FT, Wittkampf KA, Schene AH, Bindels PJ, Van-Weert HC.
Interventions on frequent attenders in primary care: a systematic
literature review (Provisional abstract). Scandinavian Journal of Primary
Health Care, 2008; 26:111-116.
(2) Haroun D, Smits F, van Etten-Jamaludin F, Schene A, van WH, Ter
RG. The effects of interventions on quality of life, morbidity and
consultation frequency in frequent attenders in primary care: A systematic
review. BMC Public Health, 2016:1-12.
I read this article with interest. It was forwarded to me by a
colleague who overheard me complaining that my local off licence had
recently removed Special Brew under the local RtS scheme.
I would like to describe my own recent experience of the scheme
locally.
I felt anxious when I discovered my local off licence no longer
stocked Special Brew. This is because it forces me to alter my regular
drink...
I read this article with interest. It was forwarded to me by a
colleague who overheard me complaining that my local off licence had
recently removed Special Brew under the local RtS scheme.
I would like to describe my own recent experience of the scheme
locally.
I felt anxious when I discovered my local off licence no longer
stocked Special Brew. This is because it forces me to alter my regular
drinking pattern and it has taken away a control mechanism of purchasing
single a can each day.
Being a member of the 'hidden' Brew Crew - a moderate, high
functioning but nonetheless dependent alcohol user (I even consume my Brew
in a wine glass - how middle class is that?!!), a single can gives me the
units I require, without the additional fluids that come with weaker beers
(and the waking in the night to pee that comes with that) at a price which
I can comfortably sustain. I have been a one-can-a-day man for a number of
years.
Removing this choice presents me with various consumer dilemmas. If I
buy weaker beer, I need more than one can and this increases the price,
involves more fluid, sugar, calories and material waste. Besides, more
beer actually irritates my stomach - a single can doesn't. This would lead
to an increase in units consumed too, along with a hangover and diminished
sleep.
Switching to spirits is a possible effective substitution, but only
if I am able stick to 4-5 units per night and purchase quantities
sufficient to make this cost effective (35cl, 70cl, 100cl). No 10cl
appears to exist, which would be perfect. And even if it did, it would
inevitably increase expenditure significantly. However, try as I might
there is no chance that I would be able to stick to my units with an
opened bottle in the house and this always tends to lead to increased
consumption.
And so, from a one can a day Special Brew drinker, who has relied
upon the product to give me stability over a long period of time, and who
is at risk of higher levels of drinking for the reasons described above
and who would consider other substance use in a finance / intoxication /
impact consideration axis from which other risks inevitably arise, the
policy is a total pain.
I'm sure the RtS policy is not intended to cause substance misuse
problems or increase expenditure in currently regular drinkers, but in my
case both are possible risks.
We have realised that one co-author's affiliation is slightly inaccurate.
Dr Rosa Ayesa Arriola's (author 2) affiliation should be as follows:
Department of Psychiatry, Marques de Valdecilla University Hospital,
IDIVAL, School of Medicine, University of Cantabria, Santander,
Spain. Centro Investigacion Biomedica en Red de Salud Mental (CIBERSAM),
Madrid, Spain.
We have realised that one co-author's affiliation is slightly inaccurate.
Dr Rosa Ayesa Arriola's (author 2) affiliation should be as follows:
Department of Psychiatry, Marques de Valdecilla University Hospital,
IDIVAL, School of Medicine, University of Cantabria, Santander,
Spain. Centro Investigacion Biomedica en Red de Salud Mental (CIBERSAM),
Madrid, Spain.
The prognostic importance of cardiorespiratory fitness (CRF) in men
and women with coronary heart disease (CHD) has been reported within
epidemiological studies (1-3). However, this association has received
limited attention within the context of UK Cardiac Rehabilitation (CR)
services. We therefore read with interest the recent study published in
BMJ Open by Barons and co-investigators (4). The a...
The prognostic importance of cardiorespiratory fitness (CRF) in men
and women with coronary heart disease (CHD) has been reported within
epidemiological studies (1-3). However, this association has received
limited attention within the context of UK Cardiac Rehabilitation (CR)
services. We therefore read with interest the recent study published in
BMJ Open by Barons and co-investigators (4). The authors examined
predictors of long-term survival, including physical fitness, in a cohort
study of predominantly post-myocardial infarction patients (mean age 61
years; 86% male) participating in an NHS outpatient CR programme in
Basingstoke and Alton, Hampshire, UK. Low baseline CRF (< 13 mL.kg-
1.min-1 for women and < 15 mL.kg-1.min-1 for men) in ~1500 patients
estimated by maximal exercise testing was a strong predictor of all-cause
mortality (HR 2.47; 95% CI 1.78 to 3.42), relative to a moderate or high
CRF level (? 22 mL.kg-1.min-1 for men and ? 19 mL.kg-1.min-1 for women)
over 10.7 years follow-up. These findings are timely given the paucity of
epidemiological evidence showing long-term outcomes from the UK CR
setting.
The data from Barons et al. (2015) are consistent with findings from our
own long-term, community-based (non-NHS delivery) CR cohort in Leeds, West
Yorkshire, UK, recently published in BMJ Open (5). We examined more than
650 participants undertaking extended exercise-based rehabilitation.
Routine submaximal, incremental exercise testing found similarly
favourable long-term mortality outcomes associated with baseline fitness
status. Indeed, estimated submaximal cardiorespiratory fitness (sCRF)
level at CR programme entry was the strongest modifiable predictor of long
-term survival, surpassed only by older age and other co-existing CV
disease. Relative to the lowest fit (bottom 20%) in our cohort; moderate
and higher sCRF levels were associated with 40-60% lower risk of death
over a median follow-up period of 14 years.
Barons and co-workers do not explicitly examine the associations between
CRF change during CR and mortality, though report a mean 1.08 MET gain
following 40 minutes of once or twice weekly supervised circuit training
exercise. This is approximately double the submaximal fitness improvement
estimated by Sandercock et al. (6) within 950 patients across four UK CR
centres (following twice weekly CR exercise training, over 8 weeks). The
estimated short-term sCRF improvement in our cohort was approximately 0.8
MET (24 minutes of supervised training, median 2 sessions per week, over
14 weeks). Thus, collectively these data tend to support the contention
that short-term CRF improvements from standard UK CR centres are more
modest than that those reported internationally (7). A novel aspect of our
study was to estimate risk associated with CR-derived fitness change and
the evaluation of this relationship across the sCRF distribution.
Importantly, compatible with some prior studies (8, 9) we found the
largest sCRF improvements occurred among those with the lowest fitness and
a quantifiable reduction in all-cause mortality risk per MET increase
achieved during CR.
Until now, there has been limited published UK-derived evidence supporting
the efficacy of CR in improving mortality outcomes (10-13) and the UK
multi-centre clinical trial (14) reported no survival benefit from CR.
Importantly however, this trial did not consider CRF changes. Our
observation contrasts with recently updated review and meta-analysis (15),
which incorporated point estimates from previous UK trials (11-13) and the
RAMIT trial of West et al. (14), showing modest, non-significant benefits
for all-cause mortality (47 trials: RR: 0.96, 95% CI: 0.88 to 1.04).
Similar non-significant findings were also reported in analysis restricted
to studies with >3 years follow-up (11 trials: RR: 0.91; 95% CI: 0.75
to 1.10). The inclusion of more recent RCT's, conducted in an era of
optimal medical therapy for CHD and within a more varied mix of CHD
patients are potential explanations for these non-significant findings.
However, as acknowledged by the Cochrane investigators, RCT evidence
examining the efficacy of CR is restricted to short-term follow-up of
patients (median 12 months) and thus, has inherent limitations for
assessing all-cause mortality outcomes. Indeed, in our CR cohort only 13%
of participants had died at 10 years, compared to one-third at 14 years.
By utilising indirect estimates of aerobic capacity and submaximal fitness
data (as opposed to direct respiratory gas analysis) we recognise that
both recent UK epidemiological studies (4, 5) cannot precisely quantify
patients' individualised CRF or exercise-based improvement. However, our
findings are likely to be clinically important, in view of the higher
baseline mortality risk of the lowest fit compared to their higher fit
counterparts shown in both cohorts. Given that patients in the Basingstoke
and Alton cohort were maximally tested, it would have been valuable to see
estimated VO2 peak and MET changes from CR associated with long-term
outcomes in their cohort. This area remains poorly characterised and data
from well-controlled studies of supervised exercise training are required
to quantify dose-related improvements in clinical outcomes. Future studies
should evaluate an overall measure of exercise dose, or corresponding
cardiorespiratory fitness level, which could serve as the basis of a
minimal dose recommendation for clinical benefit to better understand the
effect of exercise and CRF change on longer-term recurrent CVD and all-
cause mortality risk.
Together, the study by Barons and co-workers and data from our own
extended, community-based CR cohort carry an important public health
message about the importance of CRF for long-term (> 10 years)
mortality risk in adults with CVD. Both studies demonstrate the more-than-
two-fold adverse prognostic risk associated with low CRF fitness levels at
entry to CR, and thus corroborate observational data from larger CR
cohorts internationally (2, 3, 16). Moreover, our data highlight the
substantive long-term survival benefits associated with improving CRF
levels through exercise-based CR. Together these data have implications
for the delivery of CR and exercise training services. Our findings, in
particular, emphasise the importance of promoting CRF improvement through
supervised and structured exercise within extended community-based
programmes to prolong survival following cardiac events.
References
1. Vanhees L, Fagard R, Thijs L, Staessen J, Amery A. Prognostic
significance of peak exercise capacity in patients with coronary artery
disease. JACC. 1994 Feb;23(2):358-63. PubMed PMID: 8294687.
2. Kavanagh T, Mertens DJ, Hamm LF, Beyene J, Kennedy J, Corey P, et al.
Prediction of Long-Term Prognosis in 12 169 Men Referred for Cardiac
Rehabilitation. Circulation. 2002;106(6):666-71.
3. Kavanagh T, Mertens J, Hamm LF, Beyene J, Kennedy J, Corey P, et al.
Peak Oxygen Intake and Cardiac Mortality in Women Referred for Cardiac
Rehabilitation. JACC. 2003;42(12):2139-43.
4. Barons MJ, Turner S, Parsons N, Griffiths F, Bethell H, Weich S, et al.
Fitness predicts long-term survival after a cardiovascular event: a
prospective cohort study. BMJ Open. 2015;5(10).
5. Taylor C, Tsakirides C, Moxon J, Moxon JW, Dudfield M, Witte KK, et al.
Submaximal fitness and mortality risk reduction in coronary heart disease:
a retrospective cohort study of community-based exercise rehabilitation.
BMJ Open. 2016;6(e011125).
6. Sandercock GR, Cardoso F, Almodhy M, Pepera G. Cardiorespiratory
fitness changes in patients receiving comprehensive outpatient cardiac
rehabilitation in the UK: a multicentre study. Heart. 2013 Jun;99(11):785-
90. PubMed PMID: 23178183.
7. Sandercock G, Hurtado V, Cardoso F. Changes in cardiorespiratory
fitness in cardiac rehabilitation patients: A meta-analysis. International
journal of cardiology. 2011 Dec 27. PubMed PMID: 22206636.
8. Martin B-J, Arena R, Haykowsky M, Hauer T, Austford LD, Knudtson M, et
al. Cardiovascular Fitness and Mortality After Contemporary Cardiac
Rehabilitation. Mayo Clinic proceedings Mayo Clinic. 2013;88(5):455-63.
9. Mandic S, Myers J, Oliveira RB, Abella J, Froelicher VF. Characterizing
differences in mortality at the low end of the fitness spectrum in
individuals with cardiovascular disease. European journal of
cardiovascular prevention and rehabilitation : official journal of the
European Society of Cardiology, Working Groups on Epidemiology &
Prevention and Cardiac Rehabilitation and Exercise Physiology. 2010
Jun;17(3):289-95.
10. Bertie J, King A, Reed N, Marshall AJ, Ricketts C. Benefits and
weaknesses of a cardiac rehabilitation programme. Journal of the Royal
College of Physicians of London. 1992;26(2):147-51.
11. Bethell HJN, Mullee MA. A controlled trial of community based coronary
rehabilitation. British heart journal. 1990;64 (6):370-5.
12. Carson P, Phillips R, Lloyd M, Tucker H, Neophytou M, Buch NJ, et al.
Exercise after myocardial infarction: a controlled trial. Journal of the
Royal College of Physicians of London. 1982;16(3):147-51.
13. Bell JM. A comparison of a multi-disciplinary home based cardiac
rehabilitation programme with comprehensive conventional rehabilitation in
post-myocardial infarction patients [PhD]: University of London; 1998.
14. West RR, Jones DA, Henderson AH. Rehabilitation after myocardial
infarction trial (RAMIT): multi-centre randomised controlled trial of
comprehensive cardiac rehabilitation in patients following acute
myocardial infarction. Heart. 2012 Apr;98(8):637-44. PubMed PMID:
22194152.
15. Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, et
al. Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease:
Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol. 2016 Jan
5;67(1):1-12. PubMed PMID: 26764059. Epub 2016/01/15. eng.
16. Martin BJ, Hauer T, Arena R, Austford LD, Galbraith PD, Lewin AM, et
al. Cardiac rehabilitation attendance and outcomes in coronary artery
disease patients. Circulation. 2012 Aug 7;126(6):677-87. PubMed PMID:
22777176.
I read the article by Cassidy et al. with interest [1]. The authors
examined the associations among sleep duration, physical activity and
television viewing in adults with special reference to combination of
cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Adjusted
odds ratios (95% confidence intervals) of patients with CVD for low
physical activity, high TV viewing and poor sleep duration were 1.23 (1.20...
I read the article by Cassidy et al. with interest [1]. The authors
examined the associations among sleep duration, physical activity and
television viewing in adults with special reference to combination of
cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Adjusted
odds ratios (95% confidence intervals) of patients with CVD for low
physical activity, high TV viewing and poor sleep duration were 1.23 (1.20
to 1.25), 1.42 (1.39 to 1.45) and 1.37 (1.34 to 1.39), respectively. In
addition, adjusted odds ratios (95% confidence intervals) of patients with
CVD and T2DM for low physical activity, high TV viewing and poor sleep
duration were 1.71 (1.64 to 1.78), 1.92 (1.85 to 1.99) and 1.52 (1.46 to
1.58), respectively. Low physical activity, high TV and poor sleep
duration were more prominent in patients with CVD and T2DM by adjusting
several confounders. I have some concerns on their study.
First, Patterson et al. examined the associations among sleep
duration, physical activity and sedentary behavior in adults [2]. They
reported that short and long sleep duration were associated with
cardiovascular risk behaviors such as physical inactivity and sedentary
behavior. Cassidy et al. categorized short and short sleep duration as
"poor sleep duration", and additional lifestyle effects in patients with
CVD and/or T2DM existed. I agree with their study result that short and
long sleep duration were both risks for CVD and T2DM, although causal
association cannot be confirmed by a cross-sectional study.
Second, there is a sex difference on the relationship between Sleep
duration and obesity [3]. Li et al. also reported the effect of sleep
duration on the incidence of metabolic syndrome (MetS), presenting short
and long sleep duration as a risk for MetS in men [4]. In contrast, there
was no significant association in females. Cassidy et al. handled a large
sample and stratified analysis by sex is recommended for their analyses.
Finally, working status is closely related to sleep duration and
lifestyle factors [5,6]. In addition, there is a bi-directional
association between short sleep duration and mental health [7]. In any
case, further studies are needed to confirm the association between sleep
duration, physical activity and television viewing and CVD and/or T2DM by
considering several additional variables.
References
1. Cassidy S, Chau JY, Catt M, et al. Cross-sectional study of diet,
physical activity, television viewing and sleep duration in 233,110 adults
from the UK Biobank; the behavioural phenotype of cardiovascular disease
and type 2 diabetes. BMJ Open 2016;6:e010038.
2. Patterson F, Malone SK, Lozano A, et al. Smoking, Screen-Based
Sedentary Behavior, and Diet Associated with Habitual Sleep Duration and
Chronotype: Data from the UK Biobank. Ann Behav Med 2016 doi:
10.1007/s12160-016-9797-5
3. Sun W, Huang Y, Wang Z, et al. Sleep duration associated with body
mass index among Chinese adults. Sleep Med 2015;16:612-6.
4. Li X, Lin L, Lv L, et al. U-shaped relationships between sleep
duration and metabolic syndrome and metabolic syndrome components in
males: a prospective cohort study. Sleep Med 2015;16:949-54.
5. Grano N, Vahtera J, Virtanen M, et al. Association of hostility
with sleep duration and sleep disturbances in an employee population. Int
J Behav Med 2008;15:73-80.
6. Yu E, Rimm E, Qi L, et al. Diet, Lifestyle, Biomarkers, Genetic
Factors, and Risk of Cardiovascular Disease in the Nurses' Health Studies.
Am J Public Health 2016;106:1616-23.
7. Yoo H, Franke WD. Sleep habits, mental health, and the metabolic
syndrome in law enforcement officers. J Occup Environ Med 2013;55:99-103.
Dear Editor:
We were interested in the recent article by Redshaw et al. which reported
higher rates of mental health and relationship difficulties among women
who held their stillborn baby.1 We agree this is an important topic, but
after reviewing the article in depth, we would like to raise several
concerns.
(1) We note that this was a retrospective survey with a 30.2%
response rate in which just 3% of wome...
Dear Editor:
We were interested in the recent article by Redshaw et al. which reported
higher rates of mental health and relationship difficulties among women
who held their stillborn baby.1 We agree this is an important topic, but
after reviewing the article in depth, we would like to raise several
concerns.
(1) We note that this was a retrospective survey with a 30.2%
response rate in which just 3% of women did not see and 16% did not hold
their baby; these limitations were acknowledged but we believe they also
restrict the ability to draw broad conclusions. (2) There was little
exploration into the reasons why women did not hold their babies and if
they had any regrets about their decisions. While four out of five women
reported they did not hold because they could not or did not want to, the
study did not account for the fact that women who declined may be
fundamentally different at baseline, so that mental health outcomes may be
due to underlying differences in mothers rather than their choices or
experiences at birth. (3) While the authors emphasize that holding was
associated with a trend toward worse mental health outcomes, their actual
multivariable analyses show that at 9 months, the only statistically
significant difference was higher odds of anxiety. Pre-existing anxiety
could contribute to a woman's hesitance to hold the baby after delivery
and separately serves as a predictor of postpartum mental health. (4)
Even though there are many validated, widely-tested measures to assess
postpartum depression,2-5 anxiety,6 and PTSD,7, 8 in both live birth and
bereaved mothers, this study used non-validated self-report measures which
leads to the need for very cautious interpretation of the results. (5)
The factors which have been demonstrated to be strong predictors of
postpartum depression and PTSD include prior mental health conditions,
interpersonal violence, and lack of social support.9-12 This study did
not measure or control for any of these factors. (6) Another issue not
addressed in this article is the well-acknowledged preference by parents
to be given the option to see or hold their baby and strong evidence that
the majority of women are satisfied with their decision.10, 13 Events
surrounding the birth of a stillborn baby can have lasting impact on how a
mother experiences, remembers, and copes with this event.14 The decision
to see or hold a stillborn baby warrants additional investigation, but
research must adjust for the known confounders which have been shown to
predict development of mental health problems. Moreover, there should be
recognition that the experience of a mother at the time of delivery is
complex, and multiple pre-existing and intrapartum factors may affect
subsequent outcomes and grief.
In summary, we believe it is not possible to reach a conclusion from
this study about whether the decision to see or hold a stillborn baby is
detrimental or helpful to bereaved parents and urge research to gain a
more nuanced understanding of the factors which contribute to parental
experiences at the time of delivery and which may influence long-term
mental health outcomes. We strongly urge health care providers to continue
to offer women the option to hold their stillborn baby, and to make this
offer in a respectful, supportive, and normative manner.
No author has any conflicts of interest to declare.
?
References
1. Redshaw M, Henderson J. Fathers' engagement in pregnancy and
childbirth: evidence from a national survey. BMC Pregnancy Childbirth.
2013;13:70.
2. Myers ER, Aubuchon-Endsley N, Bastian LA, et al. Efficacy and
Safety of Screening for Postpartum Depression. Comparative Effectiveness
Review 106. Agency for Healthcare Research and Quality Publication No. 13-
EHC064-EF. 2013.
3. Boyle FM, Vance JC, Najman JM, Thearle MJ. The mental health
impact of stillbirth, neonatal death or SIDS: prevalence and patterns of
distress among mothers. Soc Sci Med. Oct 1996;43(8):1273-1282.
4. Ji S, Long Q, Newport DJ, et al. Validity of depression rating
scales during pregnancy and the postpartum period: impact of trimester and
parity. J Psychiatr Res. Feb 2011;45(2):213-219.
5. Dennis CL. Can we identify mothers at risk for postpartum
depression in the immediate postpartum period using the Edinburgh
Postnatal Depression Scale? Journal of Affective Disorders. Feb
2004;78(2):163-169.
6. Ross LE, McLean LM. Anxiety disorders during pregnancy and the
postpartum period: A systematic review. J Clin Psychiatry. Aug
2006;67(8):1285-1298.
7. Youngblut JM, Brooten D, Cantwell GP, Del Moral T, Totapally B.
Parent Health and Functioning 13 Months After Infant or Child NICU/PICU
Death. Pediatrics. Oct 7 2013.
8. Murphy S, Shevlin M, Elklit A. Psychological Consequences of
Pregnancy Loss and Infant Death in a Sample of Bereaved Parents. Journal
of Loss & Trauma. Jan 1 2014;19(1):56-69.
9. Cerulli C, Talbot NL, Tang W, Chaudron LH. Co-occurring intimate
partner violence and mental health diagnoses in perinatal women. J Womens
Health (Larchmt). Dec 2011;20(12):1797-1803.
10. Gold KJ, Leon I, Boggs ME, Sen A. Depression and Posttraumatic
Stress Symptoms After Perinatal Loss in a Population-Based Sample. J
Womens Health (Larchmt). Mar 2016;25(3):263-269.
11. Gold KJ, Boggs ME, Muzik M, Sen A. Anxiety disorders and
obsessive compulsive disorder 9 months after perinatal loss. General
Hospital Psychiatry. Nov-Dec 2014;36(6):650-654.
12. Surkan PJ, Radestad I, Cnattingius S, Steineck G, Dickman PW.
Social support after stillbirth for prevention of maternal depression.
Acta Obstet Gynecol Scand. 2009;88(12):1358-1364.
13. Radestad I, Surkan PJ, Steineck G, Cnattingius S, Onelov E,
Dickman PW. Long-term outcomes for mothers who have or have not held their
stillborn baby. Midwifery. Aug 2009;25(4):422-429.
14. Lisy K, Peters MD, Riitano D, Jordan Z, Aromataris E. Provision
of Meaningful Care at Diagnosis, Birth, and after Stillbirth: A
Qualitative Synthesis of Parents' Experiences. Birth. Mar 2016;43(1):6-19.
Re: Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period. Szczepura et al. (2016) BMJ Open 2016;6:e009882 doi:10.1136/bmjopen-2015-009882
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Dear Editor
It is vital that the findings from a recent article published by Redshaw et al are not misinterpreted as evidence that parents should be denied choice after their baby has died. The study reports higher rates of mental health and relationship difficulties among women who held their stillborn baby compared with those who saw but did not hold their stillborn baby.
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Dear Editor: We were interested in the recent article by Redshaw et al. which reported higher rates of mental health and relationship difficulties among women who held their stillborn baby.1 We agree this is an important topic, but after reviewing the article in depth, we would like to raise several concerns.
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