General practitioners' and psychiatrists' attitudes towards antidepressant withdrawal.

BACKGROUND: There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects. AIMS: To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms. METHOD: Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert. RESULTS: Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned. CONCLUSIONS: Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines

Remote primary care consultations for people living with dementia during the COVID-19 pandemic: experiences of people living with dementia and their carers

BACKGROUND: COVID-19 has accelerated remote healthcare provision in primary care, with changes potentially permanent. The implementation of remote provision of healthcare needs to hear from vulnerable populations, such as people living with dementia. AIM: To understand the remote healthcare experiences of patients living with dementia and their family carers during the COVID-19 pandemic. DESIGN AND SETTING: Qualitative interviews with community-based patients living with dementia and their carers during early months (May-August 2020) of the COVID-19 pandemic in England. METHODS: Semi-structured interviews were conducted remotely by telephone or video call with 30 patients living with dementia and 31 carers. Data were analysed using thematic analysis. RESULTS: Three main themes were derived relating to: 1) proactive care at the onset of COVID-19 restrictions, 2) avoidance of healthcare settings and services, and 3) difficulties with remote healthcare encounters. People living with dementia and their carers felt check-up calls were reassuring but limited in scope and content. Some avoided healthcare services, wishing to minimise COVID-19 risk, reduce NHS burden, or encountering technological barriers. Difficulties in remote consultations included lack of prompts to remember problems, dealing with new emerging problems, rescheduling/missed calls, and inclusion of the person with dementia's voice. CONCLUSION: While remote consultations could be effective, pro-active calls could be more structured around needs, and consideration should be given to replace non-verbal prompts to describe problems, particularly for new health concerns. In continuing remote consultations, it is important to facilitate engagement with patients living with dementia and their carers to ensure best practice

Exploring how triads of people living with dementia, carers and health care professionals function in dementia health care: A systematic qualitative review and thematic synthesis

BACKGROUND: Many qualitative studies report the post-diagnostic care experiences of carers and people living with dementia; however, this is not often accompanied by opportunities to hear the corresponding views of their health care professionals and how this triadic relationship functions. The aim of this review was to identify and thematically synthesize the experiences of health care services reported by people living with dementia, their carers and health care professionals. METHODS: Medline, PsycINFO, Embase and CINAHL were searched from inception to 31 July 2019 for qualitative research including people living with dementia, carers and health care professionals. Data were coded and thematically synthesised using NVivo. RESULTS: Medline, PsycINFO, Embase and CINAHL were searched from inception to 31 July 2019 for qualitative research including people living with dementia, carers and health care professionals. Data were coded and thematically synthesised using NVivo. DISCUSSION: The interactions and complexity of triadic dementia care relationships further our understanding of how to improve dementia care. Awareness of possible diverging attitudes highlights areas of necessary improvement and further research into facilitating engagement, such as when multiple professionals are involved or where there are mismatched expectations of the roles of triad members. In order to operate efficiently as a triad member, professionals should be aware of how pre-existing relations can influence the composition of a triad, encourage the involvement of the person living with dementia, clarify the expectations of all parties, establish trusting relationships and enable communication within the direct triad and beyond

Climate change mitigation for agriculture: water quality benefits and costs

New Zealand is unique in that half of its national greenhouse gas (GHG) inventory derives from agriculture--predominantly as methane (CH4) and nitrous oxide (N2O), in a 2:1 ratio. The remaining GHG emissions predominantly comprise carbon dioxide (CO2) deriving  from  energy  and  industry  sources.  Proposed strategies to  mitigate  emissions  of  CH4  and  N2O  from  pastoral  agriculture in New Zealand are: (1) utilising extensive and riparian afforestation of pasture to achieve CO2 uptake (carbon sequestration); (2) management of nitrogen through budgeting and/or the use of nitrification inhibitors, and minimising soil anoxia to reduce N2O emissions; and (3) utilisation of alternative waste treatment technologies to minimise emissions of CH4. These mitigation measures have associated co-benefits and co-costs (disadvantages) for rivers, streams and lakes because they affect land use, runoff loads, and receiving water and habitat quality. Extensive afforestation results in lower specific yields (exports) of nitrogen (N), phosphorus (P), suspended sediment (SS) and faecal matter and also has benefits for stream habitat quality by improving stream temperature, dissolved oxygen and pH regimes through greater shading, and the supply of woody debris and terrestrial food resources. Riparian afforestation does not achieve the same reductions in exports as extensive afforestation but can achieve reductions in concentrations of N, P, SS and faecal organisms. Extensive afforestation of pasture leads to reduced water yields and stream flows. Both afforestation measures produce intermittent disturbances to waterways during forestry operations (logging and thinning), resulting in sediment release from channel re-stabilisation and localised flooding, including formation of debris dams at culverts. Soil and fertiliser management benefits aquatic ecosystems by reducing N exports but the use of nitrification inhibitors, viz. dicyandiamide (DCD), to achieve this may under some circumstances impair wetland function to intercept and remove nitrate from drainage water, or even add to the overall N loading to waterways. DCD is water soluble and degrades rapidly in warm soil conditions. The recommended application rate of 10 kg DCD/ha corresponds to 6 kg N/ha and may be exceeded in warm climates. Of the N2O produced by agricultural systems, approximately 30% is emitted from indirect sources, which are waterways draining agriculture. It is important therefore to focus strategies for managing N inputs to agricultural systems generally to reduce inputs to wetlands and streams where these might be reduced to N2O. Waste management options include utilising the CH4 resource produced in farm waste treatment ponds as a source of energy, with conversion to CO2 via combustion achieving a 21-fold reduction in GHG emissions. Both of these have co-benefits for waterways as a result of reduced loadings. A conceptual model derived showing the linkages between key land management practices for greenhouse gas mitigation and key waterway values and ecosystem attributes is derived to aid resource managers making decisions affecting waterways and atmospheric GHG emissions

Mental time travel ability and the mental reinstatement of context for crime witnesses.

Mental time travel ability marks how well the phenomenological aspects of events are mentally re-experienced during recall. The Cognitive Interview (CI) elicits eyewitness information. One of its techniques, Mental Reinstatement of Context (MRC), asks eyewitnesses to reinstate the incident's context mentally before recall. Fifty-six participants watched a simulated crime video. Self-report measures were then taken to estimate general mental time travel ability. Participants were questioned subsequently about the video. Eyewitness performance under MRC was compared with the CI's Report Everything (RE) technique, wherein eyewitnesses recall everything they can but with no invitation to mentally reinstate the context. There was no effect of interview condition on accuracy of recall; however, general mental time travel ability was positively associated with the amount of correct and incorrect information produced under MRC, but not RE, conditions. This is the first empirical demonstration that MRC instructions engage the mental time travel capacities they purport to

A qualitative study exploring the difficulties influencing decision making at the end of life for people with dementia

BACKGROUND: Dementia is a progressive neurodegenerative condition characterized by declining functional and cognitive abilities. The quality of end of life care for people with dementia in the UK can be poor. Several difficult decisions may arise at the end of life, relating to the care of the person with dementia, for example management of comorbidities. OBJECTIVE: To explore difficulties in decision making for practitioners and family carers at the end of life for people with dementia. DESIGN: Qualitative methodology using focus groups and semi-structured interviews and thematic analysis methods. SETTINGS AND PARTICIPANTS: Former (n=4) and current (n=6) family carers of people with experience of end of life care for a person with dementia were recruited from an English dementia voluntary group in 2015. A further 24 health and care professionals were purposively sampled to include a broad range of expertise and experience in dementia end of life care. RESULTS: Four key themes were identified as follows: challenges of delivering coherent care in dynamic systems; uncertainty amongst decision makers; internal and external conflict amongst decision makers; and a lack of preparedness for the end of life. Overarching difficulties such as poor communication, uncertainty and conflict about the needs of the person with dementia as well as the decision maker's own role can characterize decision making at the end of life. CONCLUSIONS: This study suggests that decision making at the end of life for people with dementia has the potential to be improved. More planning earlier in the course of dementia with an on-going approach to conversation may increase preparedness and family carers' expectations of end of life

Decolonising occupational science education through learning activities based on a study from the Global South

If occupational science education is to become more globally relevant, it must highlight more voices and practices from diverse communities. Learning about occupational justice from the perspectives of Global South communities addresses cognitive injustice and the need to decolonise occupational science education. This paper offers some critical reflections concerning the author’s pedagogic approach, and the ways his research about olive growing in Palestine (Simaan, 2018) informed students’ learning about occupational justice. It focuses on the processes in which students and lecturers engaged within a decolonising approach to occupational science education. A learning activity based on pedagogical processes of ‘conscientization’ (Freire, 1996), critical reflexivity (Whiteford & Townsend, 2011) and intercultural translation (Santos, 2014) is discussed, and lessons learnt by lecturer and students about themselves, their communities, and occupational science are reflected upon. Selected students’ reflections, which illustrate how they positioned themselves in relation to the community studied, and how they interrogated their own reactions to learning about daily lives in Palestine, are discussed. These processes demonstrate the benefits of highlighting local knowledge on occupational justice produced by Global South groups, and how this knowledge might begin to address cognitive injustice and the need to decolonise occupational science pedagogy. More empirical and theoretical work is needed in occupational science education regarding intercultural translations concerning occupational justice, and means of doing and knowing from diverse Global South perspectives