Background: Reserpine is an effective antihypertensive drug, but its role in routine practice has declined such that it is rarely used. This is largely based on the assumption that reserpine causes depression. This assumption was a foundation for the original monoamine hypothesis of depression. However, there remains conflicting evidence as to whether reserpine causes depression, and no systematic review of available evidence. Aims: We systematically reviewed evidence on effects of reserpine on depressive and related symptoms (e.g. anxiety, suicidal ideation). Method: Electronic searches of MEDLINE, Embase and PsycINFO were conducted to identify studies up to 14 February 2021. Studies of any methodological design involving reserpine-treated and reserpine-untreated conditions, in any adult human population, were included and a narrative synthesis of findings was undertaken. Risk of bias (RoB) was examined using ROBINS-I. Results: Of the 35 studies meeting inclusion criteria, 9 were randomised controlled trials. Eleven studies reported some depressogenic effects, 13 reported no effect and 11 reported putative antidepressant effects. Studies identifying depressive effects were more likely to examine people without psychiatric disorders at baseline, while studies identifying a potential antidepressant effect tended to treat fewer participants for shorter durations, at higher doses. Around one-third of studies conducted in people with psychiatric disorders showed beneficial effects on depression symptoms. 30/35 studies were at high RoB. Conclusions: Associations between reserpine and depression are inconsistent and limited by a lack of high-quality evidence. Due to reserpine’s apparently complex effects, we urge nuance rather than simplicity surrounding the monoamine hypothesis of depression.
The South London and Maudsley Community Rehabilitation Psychiatry team aims to provide long-term and holistic care to patients with enduring mental illness. This letter concisely outlines our response to the coronavirus pandemic, including the standard operating procedure we introduced and, at a trust level, the changes made to clozapine monitoring. We were surprised by the expectations of our patients during the pandemic: we found that unwell patients or their carers would contact our service first, ahead of 111, primary care or emergency services for advice and treatment. In response, we took on a deliberative first-responder role. Perhaps this is to be expected for a specialty that provides holistic long-term care to its patients. We think this is of interest to other mental health teams, primary care, community psychiatry teams and the lay reader.
SUMMARY The Royal College of Psychiatrists’ continuing professional development (CPD) module on clinical ethics in psychiatry by Pearce & Tan describes some common ethical dilemmas in psychiatric practice and the work of clinical ethics committees in analysing these dilemmas. In this article we build upon their work and offer additional exploration of the nature of ethical dilemmas in psychiatry. We also build upon the models of reasoning that are described in the module and suggest ways for psychiatrists to think about ethical dilemmas when a clinical ethics committee is not available.
AimsThe South London and Maudsley High Support Rehabilitation Team supports a cohort of 120 long-term rehabilitation patients in the densely populated London borough of Southwark.COVID-19 has a high transmission rate and is more lethal amongst the elderly, ethnic minorities and those with comorbidities.For these reasons, COVID-19 poses a particular challenge to our patients. Most have significant comorbidities, live communally, engage infrequently with primary care and take high-risk medications like clozapine. Many are from black and minority ethnic backgrounds.During the Spring coronavirus wave, we found that unwell patients or their carers would contact our service for advice ahead of 111, primary care or emergency services.In response we designed a standard operating procedure to guide our response to possible cases. This aimed to ensure our advice and management for patients drew upon the latest emerging evidence.We audited our work and the burden of disease within our service until November 2020.MethodAt a team level, we introduced same-day remote assessments structured around a standard operating procedure incorporating the latest primary care and national guidelines.At a trust level, treatment guidelines were amended permitting consultant discretion when deciding whether an urgent blood count was required for those unwell on clozapine, and routine blood count monitoring was extended to 3 months for eligible patientsResultBy November 2020 we had only one confirmed case of COVID-19 on our caseload. This patient required ITU and recovered. Seven patients were judged ‘suspected’ to have suffered COVID-19 and eight were possible cases. One supported living accommodation had a possible outbreak.ConclusionWe are surprised to have had just one confirmed case of COVID-19, despite the vulnerability of our cohort. The attentiveness of our patients and their carers to government guidelines will have contributed to this figure. They have shown remarkable resilience.This pandemic has prompted trust-wide changes to clozapine monitoring and perhaps a permanently less intensive monitoring regime for some patients.That our patients contacted our team ahead of 111, primary care or emergency services may reflect the close trust they place in us to support them through difficulty. It is fitting for a service aiming to provide holistic care that our scope should have expanded in this way during the pandemic. Community rehabilitation services are well placed to act as first responders.
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