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Recorded Atypical Hallucinations in Psychotic and Affective Disorders and Associations with Non-Benzodiazepine Hypnotic Use

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Recorded Atypical Hallucinations in Psychotic and Affective Disorders and Associations with Non-Benzodiazepine Hypnotic Use Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-025216 on 28 September 2018. Downloaded from Recorded atypical hallucinations in psychotic and affective disorders and associations with non-benzodiazepine hypnotic use: the South London and Maudsley Case Register Karen Isabel Birnie,1 Robert Stewart,2,3 Anna Kolliakou2 To cite: Birnie KI, Stewart R, ABSTRACT Strengths and limitations of this study Kolliakou A. Recorded atypical Objectives Hallucinations are present in many conditions, hallucinations in psychotic notably psychosis. Although under-researched, atypical ► This was a large study involving 43 339 patients. and affective disorders hallucinations, such as tactile, olfactory and gustatory and associations with non- ► The prospective study design reduced recall bias. (TOGHs), may arise secondary to hypnotic drug use, benzodiazepine hypnotic use: ► The natural language processing (NLP) tool, devel- particularly non-benzodiazepine hypnotics (‘Z drugs’). the South London and Maudsley oped to recognise references to tactile, olfactory and This retrospective case-control study investigated the Case Register. BMJ Open gustatory hallucinations (TOGHs) from a naturalistic frequency of TOGHs and their associations with prior Z 2018;8:e025216. doi:10.1136/ data source, has great potential for applicability in drug use in a large mental healthcare database. bmjopen-2018-025216 other data sources. Methods TOGHs were ascertained in 2014 using a ► Prepublication history for ► This study used routine healthcare records, thus bespoke natural language processing algorithm and were this paper is available online. requiring clinicians to recognise and record TOGHs analysed against covariates (including use of Z drugs, To view these files, please visit accurately. demographic factors, diagnosis, disorder severity and the journal online (http:// dx. doi. ► We were not able to conclude that medication use other psychotropic medications) ascertained prior to 2014. org/ 10. 1136/ bmjopen- 2018- always antedated TOGHs. 025216). Results In 43 339 patients with International Classification of Diseases, Tenth Edition schizophreniform or affective Received 8 July 2018 disorder diagnoses, 324 (0.75%) had any TOGH recorded Revised 20 August 2018 (0.54% tactile, 0.24% olfactory, 0.06% gustatory bipolar disorder (approximately 70% and Accepted 23 August 2018 5 hallucinations). TOGHs were associated with male gender, 25%, respectively). Tactile, olfactory and http://bmjopen.bmj.com/ black ethnicity, schizophreniform diagnosis and higher gustatory hallucinations (TOGHs) are disorder severity on Health of the National Outcome recognised to occur in psychotic disorders, Scales. In fully adjusted models, tactile and olfactory but have received substantially less investiga- hallucinations remained independently associated with tion. In samples with either schizophrenia or prior mention of Z drugs (ORs 1.86 and 1.60, respectively). severe mental illness more generally, tactile Conclusions We successfully developed a natural hallucination prevalences have ranged from language processing algorithm to identify instances of 3 6–8 TOGHs in the clinical record. TOGHs overall, tactile and 15% to 27%, and are recognised to be asso- olfactory hallucinations were shown to be associated with ciated with substance abuse and withdrawal on October 1, 2021 by guest. Protected copyright. 9 © Author(s) (or their prior mention of Z drugs. This may have implications for regardless of diagnosis. The prevalence of employer(s)) 2018. Re-use the diagnosis and treatment of patients with comorbid olfactory hallucinations has ranged from permitted under CC BY-NC. No sleep and psychiatric conditions. 15% to 27%,6 7 although this is likely to be commercial re-use. See rights and permissions. Published by an underestimate because of the tendency for BMJ. traditional questionnaires to examine hallu- 10 1Department of Health INTRODUCTIOn cinations generally rather than by modality. Psychology, King’s College Although hallucinations are not necessarily The prevalence of gustatory hallucinations London, London, UK abnormal experiences, they are commonly has ranged from 4% to 14%.6 7 Hypnotic use 2Department of Psychological associated with psychotic and organic disor- in the general population has been found to Medicine, King’s College 1 2 London, London, UK ders. They can occur in any sensory be associated with higher reported tactile and 11 3South London and Maudsley modality, although the most commonly gustatory hallucinations and hallucinations NHS Foundation Trust, London, reported hallucinations in patients with in all/most modalities have been described as UK schizophrenia are auditory and visual with increased in people receiving non-benzodiaz- Correspondence to estimated prevalences of around 70%, and epine hypnotics, specifically ‘Z drugs’ (zolp- 3 4 12 13 Karen Isabel Birnie; ranging from 15% to 60%, respectively. idem, zopiclone or zaleplon), possibly karen. birnie@ kcl. ac. uk Similar prevalences have been described in potentiated by other psychotropic agents.14 Birnie KI, et al. BMJ Open 2018;8:e025216. doi:10.1136/bmjopen-2018-025216 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-025216 on 28 September 2018. Downloaded from However, these observations have largely been derived to identify linguistic patterns indicating a true reference case studies and small samples. to any of the three hallucination types (ie, rather than The aim of this study was to ascertain the frequency of negation statements, irrelevant mentions or mentions TOGHs in a large sample of people with schizophreni- of the symptom occurring in someone other than the form or affective disorder diagnoses receiving mental patient). Having developed the algorithm using General health services, and to test a hypothesised association Architecture for Text Engineering (GATE) software,19 between TOGHs and Z drug use. it was tested on another 500 annotated records (gold standard set), and achieved a precision score (positive predictive value) of 0.91 and a recall (sensitivity) score of METHODS 1.00. Deploying the algorithm over the complete dataset Setting of 20 924 instances, 17 066 were identified as true posi- The South London and Maudsley NHS Foundation Trust tive references to TOGHs. Binary outcome variables were (SLaM) is one of Europe’s largest mental healthcare thereby created representing the occurrence of halluci- providers, serving a geographic catchment of four South nations in each or any modality (olfactory, tactile, gusta- London boroughs (Croydon, Lambeth, Lewisham and tory, any of the three). Southwark) with approximately 1.2 million residents. Since 2006, an electronic health records system has been Covariates used throughout SLaM, and the Clinical Record Inter- Covariates were extracted to indicate status at the index active Search (CRIS) system, developed in 2008, allows date (1 January 2014). Demographic factors comprised researchers to retrieve de-identified information from age, gender and recorded ethnicity—the latter catego- 15 16 these records for around 280 000 cases to date. CRIS rised into three groups: black background (including has been approved as a database for secondary analysis Caribbean, African and any other black background), by the Oxfordshire Research Ethics Committee C (Ethics white background (British, Irish and any other white ID: 08/H0606/71+5) and a service user-led committee background) and other (including mixed or multiple 17 provides oversight for projects using these data. ethnic backgrounds). Regarding clinical factors, the sample was categorised Study population into those who had previously received a diagnosis of The baseline sample derived from CRIS comprised a schizophreniform disorder, a mood disorder diagnosis cohort of all patients, aged 18–65 years on 1 January 2014, or both. In addition, we made use of the Health of the who had received a diagnosis of a schizophrenia-related Nations Outcome Scales (HoNOS) assessment, routinely disorder (extracted using ICD-10 code: F2x) and/or a 20 administered in UK mental health services, including mood/affective disorder (ICD-10 code: F3x) prior to that the total score (an indicator of overall functioning), and date. Case records from the cohort were then searched the score relating to alcohol and substance use problems for instances of TOGHs between 1 January 2014 and 31 http://bmjopen.bmj.com/ (categorising the problem as present on the basis of a December 2014. score of 2 or more on the 0–4 scale), extracting scores Patient involvement closest to the index date. We did not directly incorporate patient and public Hypnotic agent use before the index date was deter- involvement (PPI) into this particular study but the SLaM mined from structured medication fields in the record, BRC Case Register used in the analysis was developed supplemented by a natural language processing algo- with extensive PPI and is overseen by a committee that rithm which ascertains recorded pharmacotherapy from includes service-user representatives. open-text fields. Ascertained agents were classified into on October 1, 2021 by guest. Protected copyright. Z drugs (zopiclone, zaleplon and zolpidem) and all Outcome: tactile, olfactory and gustatory hallucinations other hypnotics licensed for use in insomnia or where A pre-existing natural language processing algorithm sedation is needed (diazepam, flurazepam, loprazolam, designed to detect mentions of hallucinations in text lorazepam, lormetazepam, nitrazepam,
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