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Introduction The burden of mental disorders is rising worldwide. Around one in six people suffer from mental disorders, with the highest prevalences in North America, Western Europe, North Africa, the [...], Problem Mental ill health in the United Kingdom of Great Britain and Northern Ireland has been a major driver of labour market exclusion through sickness absence, reduced productivity and job loss. Approach A government-supported programme for improving access to psychological therapies was launched in 2008 and expanded across England in 2010. The aim was to provide evidence-based treatments for people with common mental disorders through three principal strategies: (i) routine session-by-session outcome monitoring; (ii) integration with the wider care system; and (iii) delivery of psychological therapies as part of a stepped-care approach. Local setting Access to effective psychological therapies was previously low in the United Kingdom. In 2010, only about 35% of people with moderately severe mental disorders were in specialist or non-specialist treatment. Relevant changes The accessibility of quality mental health services has increased, as has the efficiency of the country's mental health system. The numbers of people entering treatment have increased steadily from 0.43 million in 2012-2013 to 1.09 million in 2018-2019. The recovery rate of patients in treatment increased from 42.8% to 52.1% during 2012-2018. The number of people moved off sick pay and benefits rose from 3683 to 18 039 over the same period. Lessons learnt A clinical guideline on psychological therapies is a prerequisite for increasing the accessibility and efficiency of mental health services. An integrated approach allows mental health services to have better reach. Routine collection of patient-level outcome data plays an important role in the value and function of the mental health care system. Probleme La maladie mentale au Royaume-Uni de Grande-Bretagne et d'Irlande du Nord a ete l'un des principaux facteurs d'exclusion du marche du travail a cause de l'absenteisme pour raisons de sante, de la baisse de productivite et de la perte d'emploi. Approche Un programme d'amelioration de l'acces aux therapies psychologiques, soutenu par le gouvernement, a ete lance en 2008 et s'est etendu a travers l'Angleterre en 2010. Le but etait de proposer des traitements reposant sur des donnees factuelles aux personnes presentant des troubles mentaux courants, grAce a trois strategies majeures: (i) un suivi des resultats au fil des seances; (ii) une integration au sein du systeme de soins global; et, enfin, (iii) la mise en place de therapies psychologiques dans le cadre d'une approche par paliers. Environnement local Lacces a des therapies psychologiques efficaces etait auparavant difficile au Royaume-Uni. En 2010, seulement 35% des gens souffrant de troubles mentaux relativement graves suivaient un traitement specialise ou non specialise. Changements significatifs Laccessibilite a des soins de sante mentale de qualite s'est amelioree, tout comme l'efficacite du systeme de sante mentale du pays. Le nombre d'individus ayant entame un traitement a augmente de facon constante, evoluant de 0,43 million en 2012-2013 a 1,09 million en 2018-2019. Le pourcentage de guerison des patients traites a grimpe de 42,8% a 52,1% entre 2012 et 2018. En outre, le nombre de personnes ayant mis fin a leurs prestations ou indemnites de maladie est passe de 3680 a 18 039 sur la meme periode. Lecons tirees Une directive clinique relative aux therapies psychologiques est l'une des conditions prealables necessaires au developpement de l'accessibilite et de l'efficacite des soins de sante mentale. Une approche integree permet aux services de sante mentale de toucher un plus large public. La collecte systematique des donnees sur les resultats observes chez les patients joue un role crucial dans la qualite et le fonctionnement du systeme de soins de sante mentale. Situacion En Gran Bretana e Irlanda del Norte, las enfermedades mentales han sido uno de los principales motores de la exclusion del mercado laboral a traves de las bajas por enfermedad, la reduccion de la productividad y la perdida de empleo. Enfoque En 2008 se puso en marcha un programa apoyado por el gobierno para mejorar el acceso a las terapias psicologicas, que se amplio a toda Inglaterra en 2010. El objetivo era proporcionar tratamientos basados en la evidencia para personas con trastornos mentales comunes a traves de tres estrategias principales: (i) seguimiento rutinario de los resultados sesion tras sesion; (ii) integracion con el sistema de atencion mas amplio; y (iii) prestacion de terapias psicologicas como parte de un enfoque de atencion escalonada. Marco regional Antes, el acceso a terapias psicologicas eficaces era escaso en el Reino Unido. En 2010, solo un 35% de las personas con trastornos mentales moderadamente graves recibian tratamiento especializado o no especializado. Cambios importantes El acceso a los servicios de salud mental de calidad ha aumentado, al igual que la eficiencia del sistema de salud mental del pais. Las cifras de personas que entran en tratamiento han aumentado de forma constante, pasando de 0,43 millones en 2012-2013 a 1,09 millones en 2018-2019. La tasa de recuperacion de los pacientes en tratamiento aumento del 42,8% al 52,1% durante 2012-2018. El numero de personas que dejaron de recibir pagas por enfermedad y prestaciones aumento de 3.680 a 18. 039 durante el mismo periodo. Lecciones aprendidas Una guia clinica sobre terapias psicologicas es un requisito previo para aumentar la accesibilidad y la eficacia de los servicios de salud mental. Un enfoque integrado permite que los servicios de salud mental tengan un mejor alcance. La recogida rutinaria de datos de resultados a nivel de paciente desempena un papel importante en el valor y la funcion del sistema de atencion a la salud mental.

Author(s): Shanquan Chen 1,*, Annabel C. Price 1,2, Rudolf N. Cardinal 1,2, Sinéad Moylett 1,3, Anne D. Kershenbaum 2, James Fitzgerald 1,2, Christoph Mueller 4,5, Robert Stewart 4,5, John T. [...], Background Dementia with Lewy bodies (DLBs) is a common cause of dementia but has higher mortality than Alzheimer's disease (AD). The reasons for this are unclear, but antidementia drugs (including acetylcholinesterase inhibitors [AChEIs] and memantine) symptomatically benefit people with DLB and might improve outcomes. We investigated whether AChEIs and/or memantine were associated with reduced hospital admissions and mortality. Methods and findings We performed a retrospective cohort study of those diagnosed with DLB between 1 January 2005 and 31 December 2019, using data from electronic clinical records of secondary care mental health services in Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), United Kingdom (catchment area population approximately 0.86 million), as well as linked records from national Hospital Episode Statistics (HES) data. Eligible patients were those who started AChEIs or memantine within 3 months of their diagnosis (cases) and those who never used AChEIs or memantine (controls). Outcomes included admission, length of stay, and mortality. Cox proportional hazard and linear regression models were used. Of 592 patients with DLB, 219 never took AChEIs or memantine, 100 took AChEIs only, and 273 took both AChEIs and memantine. The cohorts were followed up for an average of 896 days, 981 days, and 1,004 days, respectively. There were no significant differences in the cohorts' baseline characteristics, except for socioeconomic status that was lower in patients who never took AChEIs or memantine (X.sup.2 = 23.34, P = 0.003). After controlling for confounding by sociodemographic factors (age, sex, marital status, ethnicity, socioeconomic status), antipsychotic use, antidepressant use, cognitive status, physical comorbidity, anticholinergic burden, and global health performance, compared with patients who never took AChEIs or memantine, patients taking AChEIs only or taking both had a significantly lower risk of death (adjusted hazard ratio (HR) = 0.67, 95% CI = 0.48 to 0.93, p = 0.02; adjusted HR = 0.64, 95% CI = 0.50 to 0.83, P = 0.001, respectively). Those taking AChEIs or both AChEIs and memantine had significantly shorter periods of unplanned hospital admission for physical disorders (adjusted coefficient -13.48, 95% CI = [-26.87, -0.09], P = 0.049; adjusted coefficient -14.21, 95% CI = [-24.58, -3.85], P = 0.007, respectively), but no difference in length of stay for planned admissions for physical disorders, or for admissions for mental health disorders. No significant additional associations of memantine on admission, length of stay, and mortality were found (all P > 0.05). The main limitation was that this was a naturalistic study and possible confounds cannot be fully controlled, and there may be selection bias resulting from nonrandom prescription behaviour in clinical practice. However, we mimicked the intention-to-treat design of clinical trials, and the majority of baseline characters were balanced between cohorts. In addition, our series of sensitivity analyses confirmed the consistency of our results. Conclusion In this study, we observed that use of AChEIs with or without memantine in DLB was associated with shorter duration of hospital admissions and decreased risk of mortality. Although our study was naturalistic, it supports further the use of AChEIs in DLB.

Author(s): Shanquan Chen 1,*, Benjamin R. Underwood 1,2, Peter B. Jones 1,2,3, Jonathan R. Lewis 2, Rudolf N. Cardinal 1,2 Introduction Dementia is the leading cause of death and disability [...], Background Dementia is the leading cause of death in elderly Western populations. Preventative interventions that could delay dementia onset even modestly would provide a major public health impact. There are no disease-modifying treatments currently available. Lithium has been proposed as a potential treatment. We assessed the association between lithium use and the incidence of dementia and its subtypes. Methods and findings We conducted a retrospective cohort study comparing patients treated between January 1, 2005 and December 31, 2019, using data from electronic clinical records of secondary care mental health (MH) services in Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), United Kingdom (catchment area population approximately 0.86 million). Eligible patients were those aged 50 years or over at baseline and who had at least 1 year follow-up, excluding patients with a diagnosis of mild cognitive impairment (MCI) or dementia before, or less than 1 year after, their start date. The intervention was the use of lithium. The main outcomes were dementia and its subtypes, diagnosed and classified according to the International Classification of Diseases-10th Revision (ICD-10). In this cohort, 29,618 patients (of whom 548 were exposed to lithium) were included. Their mean age was 73.9 years. A total of 40.2% were male, 33.3% were married or in a civil partnership, and 71.0% were of white ethnicity. Lithium-exposed patients were more likely to be married, cohabiting or in a civil partnership, to be a current/former smoker, to have used antipsychotics, and to have comorbid depression, mania/bipolar affective disorder (BPAD), hypertension, central vascular disease, diabetes mellitus, or hyperlipidemias. No significant difference between the 2 groups was observed for other characteristics, including age, sex, and alcohol-related disorders. In the exposed cohort, 53 (9.7%) patients were diagnosed with dementia, including 36 (6.8%) with Alzheimer disease (AD) and 13 (2.6%) with vascular dementia (VD). In the unexposed cohort, corresponding numbers were the following: dementia 3,244 (11.2%), AD 2,276 (8.1%), and VD 698 (2.6%). After controlling for sociodemographic factors, smoking status, other medications, other mental comorbidities, and physical comorbidities, lithium use was associated with a lower risk of dementia (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.40 to 0.78), including AD (HR 0.55, 95% CI 0.37 to 0.82) and VD (HR 0.36, 95% CI 0.19 to 0.69). Lithium appeared protective in short-term ([less than or equal to]1-year exposure) and long-term lithium users (>5-year exposure); a lack of difference for intermediate durations was likely due to lack of power, but there was some evidence for additional benefit with longer exposure durations. The main limitation was the handling of BPAD, the most common reason for lithium prescription but also a risk factor for dementia. This potential confounder would most likely cause an increase in dementia in the exposed group, whereas we found the opposite, and the sensitivity analysis confirmed the primary results. However, the specific nature of the group of patients exposed to lithium means that caution is needed in extending these findings to the general population. Another limitation is that our sample size of patients using lithium was small, reflected in the wide CIs for results relating to some durations of lithium exposure, although again sensitivity analyses remained consistent with our primary findings. Conclusions We observed an association between lithium use and a decreased risk of developing dementia. This lends further support to the idea that lithium may be a disease-modifying treatment for dementia and that this is a promising treatment to take forwards to larger randomised controlled trials (RCTs) for this indication.