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Medicine, Reading notes, Uncategorized

Saturday Morning Journal Club

This week the formal presentations were given by an old age psychiatrist. I’m less interested in what he said than what we can do to live well in old age. The first paper followed people through retirement, and found that it was generally not a bad thing. I have some doubts: more time asleep and exercising is good for you, but screen time — which may mean TV — is generally bad for you. In retirement as in work. The full paper is open access, for the interested.

Chord diagram of the net superdomain time flows.
The time around the circumference of the circle represents the total time flux (in and out) for each superdomain. The arrowheads represent the direction of the flow. For example, a total of about 90 min/day flowed in and out of the Chores superdomain. Most flowed in from Work, Transport and Social, but there was a small outflow to Screen Time and Sleep.

Following retirement, mental health significantly improved. About 40% of the time previously spent in work was replaced by household chores, and 20% each by sleep, screen time, and quiet time (e.g. reading). Importantly, changes in time use were significantly associated with changes in depression, stress and self-esteem, with small-to-moderate effect sizes. In particular, replacing work time with physical activity and sleep was always associated with improvements on all measures of mental health, while replacing work with screen time and social activities was always associated with decrements, albeit more modest.

The changes in use of time across retirement identified in this study are, by and large, consistent with those identified in previous studies. For example, both cross-sectional [34–36] and longitudinal [37] studies have shown increases in time spent in household chores post-retirement, particularly among men. In addition, Sprod et al’s [38] systematic review of changes in sedentary behaviour across retirement identified increased time spent in sleep and screen time.

Cite>Olds T, Burton NW, Sprod J, Maher C, Ferrar K, Brown WJ, et al. (2018) One day you’ll wake up and won’t have to go to work: The impact of changes in time use on mental health following retirement. PLoS ONE 13(6): e0199605. https://doi.org/10.1371/journal.pone.0199605

Returning to last week’s Journal Club, I had not read a very important article in that issue. The ICD-11 is the international diagnostic system (DSM 5 is a US modification published before ICD 11 was finalized, and with difficulty can be made compatible with it). The reliability of diagnoses has been tested internationally with about 400 clinicians interviewing around 1700 patients. From the paper…

Clinician raters were provided with the ICD?11 diagnostic guidelines being tested and were asked to review them prior to the training session. The training session reviewed central features of the ICD?11 diagnostic guidelines in those areas covered by the protocols and their differences with ICD?10. The sessions used a standard set of slides developed by the WHO. Interactive exercises provided an opportunity for practice in applying the guidelines to case vignettes. The only difference between Protocol 1 and Protocol 2 was that, for the former, clinician raters were informed that they were required to assess for schizophrenia and other primary psychotic disorders and for mood disorders, as well as for any other area they deemed relevant in arriving at a diagnostic formulation, while for the latter they were required to assess for mood disorders, anxiety and fear?related disorders, and disorders specifically associated with stress. No other instruction was given about how to approach the interview, and it was left to the judgment of the clinician raters to determine how best to perform the assessment, according to their professional training and usual practice, as will be the case when the ICD?11 is implemented.

Training sessions lasted for approximately two hours per protocol (i.e., approximately four hours for sites that were doing both Protocol 1 and Protocol 2). Training sessions were therefore not dissimilar to those that clinicians might realistically receive when the ICD?11 is implemented in their countries.

The kappa estimates were almost perfect for schizophrenia (0.87) and bipolar I disorder (0.84); substantial for schizoaffective disorder (0.66), delusional disorder (0.69), bipolar II disorder (0.62), single episode depressive disorder (0.64), recurrent depressive disorder (0.74), generalized anxiety disorder (0.62), agoraphobia (0.62), and adjustment disorder (0.73); and moderate for acute and transient psychotic disorder (0.45), dysthymic disorder (0.45), panic disorder (0.57), post?traumatic stress disorder (0.49), and the newly introduced diagnosis of complex post?traumatic stress disorder (0.56).

In general, point estimates of kappa were lower for disorders for which smaller samples were obtained. The higher number of diagnoses of primary psychotic and mood disorders reflects the type of settings (55% inpatient) and the nature of the centers (tertiary and secondary care) involved in the reliability arm of EIFS.

The estimates of kappa were precise for all diagnoses for which it was calculated (confidence interval <0.5; standard error <0.1). The lower bound estimates of the confidence interval for kappa were higher than 0.4 (fair reliability) for 13 of the 16 disorders. However, the lower bound estimates were only in the fair range (from 0.2 to 0.4) for acute and transient psychotic disorder (0.27), dysthymic disorder (0.28), and post?traumatic stress disorder (0.33).Reed, G. M., Sharan, P. , Rebello, T. J., Keeley, J. W., Elena Medina?Mora, M. , Gureje, O. , Luis Ayuso?Mateos, J. , Kanba, S. , Khoury, B. , Kogan, C. S., Krasnov, V. N., Maj, M. , de Jesus Mari, J. , Stein, D. J., Zhao, M. , Akiyama, T. , Andrews, H. F., Asevedo, E. , Cheour, M. , Domínguez?Martínez, T. , El?Khoury, J. , Fiorillo, A. , Grenier, J. , Gupta, N. , Kola, L. , Kulygina, M. , Leal?Leturia, I. , Luciano, M. , Lusu, B. , Nicolas, J. , Martínez?López, I. , Matsumoto, C. , Umukoro Onofa, L. , Paterniti, S. , Purnima, S. , Robles, R. , Sahu, M. K., Sibeko, G. , Zhong, N. , First, M. B., Gaebel, W. , Lovell, A. M., Maruta, T. , Roberts, M. C. and Pike, K. M. (2018), The ICD?11 developmental field study of reliability of diagnoses of high?burden mental disorders: results among adult patients in mental health settings of 13 countries. World Psychiatry, 17: 174-186. doi:10.1002/wps.20524

The diagnostic systems we have are evolving, and flawed: being over certain is an error. But this is minor. A letter in the BMJ notes that we have been seduced by proxy measures. Lowering cholesterol and Blood Pressure should lead to people being healthier, but… we are now seeing the cost from side effects.

The triumph of Rose’s vision for his population strategy would come with its incorporation, as the Quality and Outcomes Framework, in the 2004 general medical services contract, with family doctors financially remunerated for success in hitting targets for numbers of patients treated.15 But the QOF’s perverse incentives have, if inadvertently, put Rose’s population strategy to the test. For if everyone’s physiological variables are indeed too high, then shifting the bell curve, albeit by pharmaceutical means, should have the effect he predicted of markedly reducing the prevalence of circulatory disorders. On the contrary: “The introduction of QOF was not associated with significant changes in mortality for the diseases targeted by the programme.”16 So the population was not “sick” after all but has certainly been made sick by the iatrogenic consequences of that profligate prescribing.

“History is a high point of advantage from which alone we can see the age in which we live,” wrote G K Chesterton. It is sincerely to be hoped that a better historical appreciation by the profession of the exploitation by the drug industry of the false doctrine of the population strategy (to its immensely profitable advantage) might provide the necessary incentive to reversing the burden of medication imposed on the many.

The obstacle remains that prominent epidemiologists remain wedded to the population strategy and remain vocal advocates of mass medicalisation. “[The population strategy] is now so widely accepted it is hard to realise how radical it was,” argues Michael Marmot. “It has changed our whole approach to improving health.”17 Their goose is cooked, and we should not hesitate in emphatically saying so.

Always consider the wisdom of the ancient medical fraternity. Firstly, do no harm. The models of health are not health. And proxy measures of illness are not health.

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