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- A social issue that will substantially impact Japan 20 years later: Measures to address social withdrawal need to be promptly promoted28 November 2017
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- The Fake Booty - A rare case of gluteal application of antipsychotics in a trans-woman with gluteal augmentation11 August 2017
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- Establishing cost-effective institution based psychological services in medical schools of developing countries19 March 2017
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- Bashing psychiatry: personal experience of a medical student and an aspiring psychiatrist from Pakistan23 February 2017
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- Does section 63 of the Mental Health Act contravene the autonomous rights of mentally competent patients?27 October 2015
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- Understanding patient experience of foundation doctors' involvement in their care – an important knowledge gap28 September 2015
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- Deliberate Foreign Body Ingestion as Primary Form of Severe Self-Harming Behaviour in Borderline Personality Disorder8 June 2015
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- The importance of measures to encourage appropriate use of mobile phones and related devices by young students: Preventing deterioration in mental and physical health and encouraging adequate sleep18 March 2015
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- Recent de-criminalisation of suicide attempts in the Indian sub-continent (Deletion of Section 309 of the Indian Penal Code):Thoughts of a UK-based Consultant Psychiatrist of Indian origin6 February 2015
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- The importance of coordinated clinical and social medicine efforts to discourage the use of 'legal high drugs' in Japan9 January 2015
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- Self-medication with "bath salts" for symptoms of ADHD followed by severe psychosis and hyperkinetic symptoms7 November 2014
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- A vulnerable young person unable to obtain a psychiatric bed until detained under the Mental Health Act9 September 2014
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- SUCCESSFUL TREATMENT OF LAMOTRIGINE INDUCED TOXIC EPIDERMAL NECROLYSIS IN A PATIENT OF BIPOLAR DISORDER: A CASE REPORT10 July 2014
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- Re:Cardiovascular fitness in males at age 18 and risk of serious depression in adulthood: Swedish prospective population-based study. BJP 2012; 201:352-359.9 January 2013
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- Importance of investigating the reason for the rapid increase in the number of suicides in Japan in May and June, 201127 March 2012
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- GRANULOCYTE - COLONY STIMULATING FACTOR (FILGRASTIM) AS A RESCUE THERAPY IN CLOZAPINE INDUCED AGRANULOCYTOSIS13 January 2012
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- Re: "Praying with a patient constitutes a breach of professional boundaries in psychiatric practice" Poole, et al., 199:94-98doi:10.1192/bjp.bp.111.09652930 November 2011
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- Successful treatment of methamphetamine-induced delusional parasitosis with sertindole and sertralin14 March 2011
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- A new treatment for stigmatizing scars after deliberate self-harm in borderline personality disorder4 March 2010
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- Acute generalized exanthematous pustulosis induced after adding Lamotrigine to Divalproex: a case re3 July 2009
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- Specificity of teachers and health professionals in referred pervasive developmental disorder childr27 August 2008
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- Emergence of obsessive-compulsive symptoms during clozapine treatment in a pair of monozygotic twins17 July 2008
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- Methadone effects on Driving and the importance of notifying the Driver and Vehicle Licensing agency1 February 2007
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- 28 November 2017A social issue that will substantially impact Japan 20 years later: Measures to address social withdrawal need to be promptly promoted
Social withdrawal refers to "staying at home for 6 months or longer without going to school or work and interacting little with anyone other than family members".1 The 2004 survey reported that about 320,000 households in Japan include an individual who is socially withdrawn1, and 1.18% of individuals ages 20–49 indicated that they had become socially withdrawn at some point. Various factors underlie social withdrawal. Over the past few years, the issue of social withdrawal has garnered considerable attention in Japan of all 47 prefectures nationwide.Show More
The 2016 survey by the Cabinet Office suggested that about 540,000 individuals ages 15–39 were socially withdrawn nationwide.2 According to the survey to ascertain the extent of social withdrawal in each prefecture, individual surveys have been conducted or the extent of social withdrawal has been determined in 18 of 47 prefectures nationwide, surveys are underway in 2 prefectures, and plans are to conduct the survey (it has already been planned) in 1 prefecture. The number of individuals who were socially withdrawn was specifically estimated in 12 of those prefectures, and the number of individuals age 40 or over who were socially withdrawn was estimated in 9 of the 12 prefectures mentioned. In 5 of those 9 prefectures, individuals age 40 or over who were socially withdrawn outnumbered individuals age 39 or younger who were socially withdrawn.2
According to one study of 150 municipal offices that provided...Conflict of Interest:
None declared.
- 12 November 2017How physical is reality?
An argument repeatedly leveled against psychiatry as a proper science can be summarized in the following statement:" psychiatry deals with the realm of the subjective which invariably and often synonymously taken to indicate the realms of the nonphysical". However, advances in modern science no longer supports a Newtonian type physical reality or a Cartesian object-subject duality which often referred to as common wisdom!
To most people, reality is made of stuff, that is matter, and matter is made of elementary particles. However, when physicists looked into the behavior of these particles, they were up for a surprise! Electrons for example treated in quantum mechanics as point particles with mass and charge. This notwithstanding, an electrons' position(alternatively speed) is theoretically meaningless as its potentially spread out everywhere in the universe! Moreover, and despite its corpuscular nature, an electron can behave like a wave, but unlike sound waves, an electron wave is a probability wave whereby a high amplitude provides a higher chance of finding the electron once subject to an act of measurement. Furthermore, and in another blow to physical reality, it was found that when two elementary particles interact and then go separate ways, they nevertheless remain in contact, so that measurement on particle A will instantly influence the results we obtain from measurement on particle B no matter how far apart they are in the universe! Surpris...Show MoreConflict of Interest:
None declared.
- 31 October 2017Effects of Stigma on caregivers - An Inconvenient Truth
New research once again underlines the importance of further investigations of the consequences of stigma attached to mental illness, namely stigma such as prejudice and discrimination experienced by caregivers of people with mental illness. In this case the considerable economic implications for caregivers, who often make up informal means of support for people with mental illness, are commonly ignored (1) (2) (3). According to the authors, caregivers who experience stigma may take time off work, give up employment, or forego leisure to provide support; to overlook these economic effects would be serious, given that many people with mental illness rely on families, friends and others for support (1).Show More
Evidence from around the world shows that stigma on caregivers affects heavily and do not differ significantly from country to country or from one society to another (2) (3) (4) (5) (8). The interest in stigma of caregivers appeared in early publications from the 60s by which a person is stigmatized by virtue of association with another stigmatized individual, which has been referred to as 'courtesy' or 'associative' stigma (6) According to Larson et al., family stigma contains the stereotypes of blame, shame, and contamination where e.g. public attitudes which the blame is attributed to poor parenting skills which led to the child's mental illness (7). In turn he concludes, the stigma process negatively impacts individuals in numerous ways in which family members may a...Conflict of Interest:
None declared.
- 28 October 2017On the edge of a total collapse.
In many countries, inequalities in mental health services and infrastructure are enormous. Flawed management of mental health facilities, reduction of the number of beds, and insufficient financing has created a situation in which the architecture of existing mental health hospitals often resembles that of first asylums, rather than places dedicated to treatment. Programs and reforms aimed at the improvement of mental healthcare consistently omit issues that could lead to the upgrading of the infrastructure of mental health services(1).
The ongoing reforms of mental healthcare services include the decentralisation and dissemination of resources. All the issues covered by the reforms represent a huge step forward. Unfortunately, all these attempts might be undermined by the current state of existing mental health infrastructure(2). Patients are mostly hospitalised in conditions that do not provide for basic needs. Therapy is carried out in unsuitable buildings such as former military barracks, palaces, warehouses, or historical buildings which need renovation or immediate closure.
Facilities used by psychiatric units that have been adapted to human occupation or not were originally intended for therapeutic functions often do not meet statutory act requirements for medical entities. Many have rooms which act as passages between other rooms, which is unacceptable from both the perspective of hospital design practice. In many cases it is not possible to allocate...Show MoreConflict of Interest:
None declared.
- 27 October 2017Suggestions for improvements to undergraduate psychiatric education, from a recent MBChB graduate
As someone who was keen on psychiatry from the start of medical school, I recall looking forward to the handful of preclinical psychiatry lectures with great anticipation. Finally, I would find answers to questions which had plagued me since secondary school: why don't people with eating disorders just eat normally? Why do people deliberately injure themselves? Why can't substance addicts just stop using? What is it that prevents someone with OCD leaving their house?
The undergraduate psychiatry curriculum covered the risk factors, prevalence and impacts of psychiatric disorders, formal lists of the criteria by which we define them, a basic introduction to the neurobiological processes thought to underpin them, and the principles of treatment. However, my most urgent questions about what the patients may be thinking, and what might be driving some of their most puzzling symptoms went unanswered. The patients remained something of a 'black box', difficult to understand and even harder to empathise with.
I found that the greatest leaps forward in understanding came from other sources entirely. A short discussion with an insightful friend and eating disorder sufferer introduced to me the idea that extreme diet restriction is often a way to feel safe and in control of something when everything feels frightening. Undertaking a library project on non-suicidal self-injury I encountered the putative mechanisms by which it temporarily reduces aversive mental states. A...Show MoreConflict of Interest:
None declared.
- 6 October 2017The sanitised public face of mental illness
Dear Editor,
Psychiatry has reached a turning point in recent years with the huge increase in public discussion of mental illness, and the normalisation of talking about emotional difficulties. For the most part, this has been a positive move, giving a vocabulary to those experiencing psychological distress to share their problems. However I believe that as a profession, we have stood by and allowed this change to develop in a way that actually does a disservice to our most vulnerable patients.
Mental illness is now understood by most of the public through the lens of the celebrity confessional. This has become so prevalent that it is by now almost a cliché – the celebrity who superficially appears to have all their ducks in a row reveals their struggles with mental illness in an autobiographical interview, and is then widely praised for raising awareness. Many people identify with the difficulties expressed by these celebrities, and I do not doubt that these people are helped hugely by the discovery that they are not alone. However the reality is that many people with mental illness, particularly the most vulnerable, are not at-all represented by the celebrity-confessional. There is no space in the current public discourse for the middle-aged patient with schizophrenia who cannot live independently and has been too unwell to hold down a job for twenty years. There is no space for the elderly patient with severe depression for whom even eating is a struggle....Show MoreConflict of Interest:
None declared.
- 2 October 2017Burnout syndrome and depression are not the same thing
Bianchi et al. commented on my e-letter in which I affirmed that 'Burnout syndrome (BOS) is distinct from depression and should be elevated to the status of an occupational disease' [2], claiming that it is important to distinguish 'published opinion' from 'scientific evidence' [1]. Based on their own studies, they argue in support of their personal theory, confuting the burnout construct and suggesting an overlap between burnout and depression, that burnout is not a specifically job-related phenomenon and that it is simply a depressive condition [1]. To promote this personal theory, Bianchi et al. have repeatedly criticised several researchers whose counterclaims are based on scientific evidence from over 40 years of literature on BOS. In response, Maslach and Leiter wrote: 'Research has demonstrated that the two constructs are distinct: burnout is job-related and situation-specific, as opposed to depression, which is more general and context-free' [3]. Contrasting Bianchi, Maslach and Leiter maintained that 'studies confirm that burnout and depression are not independent. Each state has implications for the other. However, that relationship is far from saying that burnout and depression are the same mental illness' [3]. The difference between burnout and depression is an ancient and well-known problem. Indeed, when the construct of burnout first appeared in the 1970s, it was defined under the label 'old wine in a new bottle'. Therefore, much past research had raised the...Show MoreConflict of Interest:
None declared.
- 25 September 2017A potential medication for Cannabis Use Disorder in Adolescents
Cannabis is the most frequently used recreational substance among adolescents in the United States [1]. About 2.7% of adolescents met the diagnostic criteria for cannabis use disorder during 2014 [1]. Effective treatment modalities can positively affect the prognosis of cannabis use disorder. While the efficacy of psychosocial interventions has been reported in previous studies, there are only limited psychopharmacological options for cannabis use disorder. N-acetylcysteine is a pro-drug which has been considered in clinical trials for its efficacy for cannabis use disorder [2]. N-acetylcysteine (NAC) causes the reverse drug-induced down-regulation of the cysteine-glutamate exchanger which reduces compulsive behaviors related to addiction in animal studies [2]. Glutamate plays an important role in the addiction disorders which suggests that the focus should be on restoring the glutamatergic function [3]. Abstinence is encouraged in those who abuse cannabis but general ly have poor outcomes [3]. With NAC, there is less abuse potential and better outcomes have been reported in those who have reduced cannabis cravings after having NAC [3]. In a 4-week trial conducted by Gray et al., (2010), 24 participants were given NAC 1200 mg twice daily and had four weekly visits to assess efficacy and safety. The participants were encouraged to gradually decrease their marijuana use without any additional psychosocial interventions [2]. A daily marijuana use diary was completed and turne...Show MoreConflict of Interest:
None declared.
- 20 September 2017Haloperidol-induced acute liver injury: Letter to editor
Delirium is an acute failure of brain function, characterized by fluctuating level of consciousness, necessitating integrated supportive care along with identification and treatment of underlying cause [1-2]. The Confusion Assessment Method (CAM) is a tool to diagnose these patients [2]. Antipsychotics are used to target the combative and psychotic symptoms of delirium but requires cautious monitoring due to heightened risk of side effects [1-2].Show More
We present the case of 53-year-old Caucasian male brought with altered mental status, hypotension and incomprehensible speech. The patient was found unresponsive following wellness check request placed by neighbors who had not seen him for several days. Patient was found emaciated, dehydrated, and mute with erythematous rash in his mouth. Patient was oriented only to himself but not to time and place. Chest x-ray revealed bilateral pulmonary infiltrates and abnormal renal function tests were observed. Both legs had gangrenous ulcers, more severe on right foot. Past medical history was notable for peripheral vascular disease, requiring recent vascular surgery on both legs. Liver function tests (LFTs) upon presentation were, aspartate aminotransferase (AST): 166, alanine transaminase (ALT): 102, alkaline phosphatase: 111, and albumin: 2.2. Immediate treatment was focused on hydration, antibiotics, and initiation of alcohol withdrawal protocol due to suspected alcohol use.
During hospital stay, he had disorganized thou...Conflict of Interest:
None declared.
- 5 September 2017Decriminalization of Suicide: A Letter to Editor
Suicide is a public health concern which continues to plague people around the globe [1]. It is prevalent among all geographies, ethnicities, and religions. Suicide is the second leading cause of death among persons aged 15-29-years-olds globally [1]. About 78% of suicides occur in low and middle-income countries (LMIC) [2]. Numerous risk factors have been associated with suicidal behaviors including the previous history of the suicidal attempt, mental health disorders, substance use, disaster, exposure to violence and abuse, and sense of isolations [2].Show More
Tackling the stigma [3] associated with suicidal behavior is one of the key challenges in helping people struggling with suicidal behaviors. Moreover, in contrast to the high income countries, LMIC exhibit disproportionate access to psychotherapeutic and counseling services owing to poor understanding of suicide, a lack of infrastructure and poor treatment seeking behaviors. In addition to aforementioned reasons, criminalization of suicidal behaviors among many nations, also contributes to the complexity of this issue [3]. This criminalization of suicide is a topic of debate among the key stakeholders such as the health care providers, advocacy groups, law makers, and governments. There are still countries around the globe which continue to legalize suicide attempt as a criminal offense [4]. These countries are mainly from the African and South Asian regions including Kenya, Malawi, Rwanda, Nigeria, Tanzania, Ghana,...Conflict of Interest:
None declared.
- 18 August 2017Let's mind and bridge the gap
Review by the Mental Health Tribunal is a safeguard for patients detained under the Mental Health Act for an effective appeal mechanism that ensures legal protection of liberty of detained patients. The right to apply to the tribunal against detention is underpinned by the right to liberty under Article 5 of the European Convention of Human Rights. However, if patients lack capacity to appeal and are unable to access the tribunal process, the safeguards are in reality meaningless and tokenistic. Studies exploring the association between capacity to request a tribunal and frequency of completed tribunal hearings found that patients with capacity received more completed hearings per year than those without, both overall, and by patient application (1).Show More
The European Court of Human Rights judgement in the case of MH v the United Kingdom, held that "special safeguards" need to be in place in order to protect the rights of persons who lack capacity to challenge the lawfulness of their detention under the Mental Health Act (2). MH, was a woman with Down's Syndrome and severe learning disabilities and was admitted to hospital under Section 2 of the Mental Health Act. The judgement is significant, and ensures equality of access of safeguards for patients who are deemed to be incapacitated and puts their rights at par with those with capacity. The Code of Practice states that when a patient lacks capacity to request a reference to a Tribunal, Hospital Managers...Conflict of Interest:
None declared.
- 12 August 2017From training to clinical practice: A call to end the use of the phrase 'commit* suicide'
It is widely accepted that the stigma surrounding mental health negatively impacts upon service provision and help-seeking behaviour [1]. Inappropriate language can perpetuate stigma. Addressing insensitive terminology is therefore a fundamental component of suicide prevention strategies.
The phrase 'commit* suicide' has gained significant opposition due to its negative connotations with regards to illegality and immorality; it is inconsistent with the global context, in which suicide has been decriminalised in most countries [2]. Furthermore the phrase fails to capture the psychological distress, social tragedy and public health burden associated with suicide. Instead, alternatives such as 'died by suicide' are more reflective of the nature of suicide as a cause of death.
The problems with the phrase 'commit* suicide' have been explicitly highlighted in both media guidelines [3] and the house style for Royal College of Psychiatrists publications [4]. Yet to date, it remains in common use within both academia and clinical practice. Amongst the three leading suicide-specific academic journals, 34% of articles published since the year 2000 used the word 'commit*' in relation to an act of self-harm or suicide [5]. As a psychiatry trainee I also notice its frequent use amongst colleagues and seniors, and within teaching courses and revision notes.
As clinicians and researchers we hold a collective responsibility to work with those who have lived experie...Show MoreConflict of Interest:
None declared.
- 11 August 2017The Fake Booty - A rare case of gluteal application of antipsychotics in a trans-woman with gluteal augmentation
Letter to the Editor
The Fake Booty -
A rare case of gluteal application of antipsychotics in a trans-woman after gluteal augmentation.
Luedecke, D; Wiedemann, K; Schöttle, D
TO THE EDITOR: Individuals suffering from psychotic disorders and substance use disorders (SUDs) are at heightened risk of experiencing episodes of agitation and violent behavior.1 Aggression and violence are major reasons for compulsory treatment to protect patients and staff.2 While a higher incidence of SUDs in transgender individuals has been described, rates of psychotic disorders are not elevated compared to the general population.3 Transsexualism rates range from 1:8,300–1:400,000 for female-to-males (FM) and 1:2,900–1:100,000 for male-to-females (MF) in various countries, while data from registries show that sex reassignment surgery (SRS) is very common.4
We present a case of a trans-woman in severe psychotic agitation and SUD who was treated with intramuscular medication, before the staff became aware of her gluteal augmentation.
Case ReportShow More
A 36-year-old Asian trans-woman diagnosed with schizophrenia was admitted to our clinic in January 2016. Due to paranoia, auditory hallucinations and intoxication with alcohol she showed strong verbal and physical violent behavior. Since non-pharmacologic management was not successful we treated the patient with intramuscular haloperidol and additional diazepam.
Only afterwards we learned that the patient...Conflict of Interest:
None declared.
- 7 August 2017'Burnout syndrome': distinguishing published opinion from scientific evidence
Chirico [1] commented on a debate that we recently opened in The Lancet regarding the weakness of the burnout construct and the depressive nature of the 'burnout syndrome' [2, 3]. In his comment, Chirico [1] affirms that burnout is distinct from depression and should be elevated to the status of occupational disease. Problematically, the author's recommendations rely on a view of burnout that is disproven by facts.
First, Chirico [1] claims that cynicism—one of the three defining components of burnout—clearly distinguishes burnout from depression. This claim is mistaken. Indeed, the symptoms covered by the cynicism component of burnout, such as unconcern and loss of emotional involvement, irritability, or disengagement, are commonly observed in depressed individuals [4]. Depressed mood is even viewed as an important aspect of such disinvestment processes [5]. Thus, what Chirico [1] presents as a 'well-known' fact is no fact at all.
Second, according to Chirico [1], 'it is indisputable that burnout is a type of work-related strain'. When making such a statement, the author ignores the growing debate regarding the actual determinants of the symptoms assessed by burnout measures. Interestingly, in a recent study of Swiss health professionals (to be published), fewer than half of the participants considered their job to be the main cause of their symptoms of burnout. At a more general level, Chirico [1] neglects the possibility that an individual be stressed at w...Show MoreConflict of Interest:
None declared.
- 3 August 2017Historic 1st: FDA Requests Opioid Opana ER Pulled From the Market
Dear Editor:
In June 2017, in an unprecedented move, the Food and Drug Administration (FDA) advised Endo Pharmaceuticals to remove Opana ER (oxymorphone hydrochloride) from the market (1). This is the first time the FDA has requested that a currently marketed opioid product be removed from the market because of safety concerns. The request follows an independent advisory panel of experts vote of 18 -8 in March 2017 that Opana ER's risks outweighed its benefit. The decision shows a significant change in fighting the opioid epidemic in the U.S.
The FDA approved Opana ER for the treatment of moderate to severe pain in 2006. It was subsequently marketed aggressively achieving annual sales in 2011 of $384 million, which represented 14% of the Endo's total profits (2). Beginning in 2012, it was marketed in a new formulation intended to boast its abuse-deterrent properties. Although the FDA approved the reformulated version, it denied a labeling request for abuse-deterrence. Now, the FDA determined that the reformulated drug was easily susceptible to abuse in an injectable form. Its use in this manner was associated with HIV and Hepatitis C outbreaks and thrombotic microangiopathy among intravenous drug users (1) A survey following an outbreak of HIV/HCV infections in Scott County, IN, found that 88% of IV drug users primarily used Opana ER and 90% were HCV-Positive and 57% HIV-Positive ( 3).
The United States is in the midst of a crisis of opioid abuse, addic...Show MoreConflict of Interest:
None declared.
- 30 July 2017Observing Our Psychiatric Practice
Medicine is defined by both cultural perception and scientific discovery. As we depart from the era of paternalism, we face modern practice: we value reflective learning, measure quality of life and advocate patient-centered care. I understand this through my observational learning as a medical student. Now in final year, my most alarming memories relate to the mounting challenge of mental health.Show More
Psychiatry is a culturally growing, financially shrinking specialty. The medical profession acknowledges the huge burden of mental health, but a subtle stigma remains within our community. A primary shortcoming in our care lies in our attitude; we hold preconceptions about mental health patients, undermine the medical expertise of our Psychiatrists and neglect our own mental well-being. From the A&E alcoholic with suicidal intent, to the General Practice widow with anxiety, these time-wasters will be greeted, eventually, with angry mutterings and extended waiting times. There is no quick fix for these patients, and after our failed prevention strategies, the best treatment we appear to offer is an off-site psychiatric hospital.
The negative perception strikes again during career choice discussions, where any enthusiasm for this specialty is battered down with a distinct mixture of mockery and disappointment: 'but why do you want to give up real medicine?'. The separation between mental and physical health occurs early in our medical training - immediatel...Conflict of Interest:
None declared.
- 17 July 2017Is it time to consider Burnout Syndrome an occupational disease?
The recent correspondence between Bianchi et al.,1 who theorise burnout syndrome (BOS) is a depressive condition, and Epstein and Privitera,2 who consider it a form of work-related distress, deals with a hot topic: the aetiology of burnout. Over recent years, many scholars have been debating this issue by developing many models and theories.3 For instance, some scholars had previously suggested BOS be considered a mental adjustment disorder, and others emphasised the differences between BOS and work-related stress strain.4 I agree with Epstein and Privitera that burnout is basically conceptualised as a breakdown in the caregiver-patient relationship or between people and their work. Indeed, despite the absence of consensual diagnostic criteria, since the 1970s, BOS has been described and originally considered a reaction to interpersonal stressors on the job.5 Especially in the helping professions, it is well-known that cynicism toward one's own patients is the distinguishing feature of burned-out workers that is absent in depression, adjustment disorders and other types of work-related strain. Therefore, it is indisputable that burnout is a type of work-related strain. Recently, psychosocial risks and work-related stress have been considered among the most challenging issues in occupational safety and health. Many countries worldwide have accepted mental and behavioural disorders on their national lists of occupational diseases, and a few countries, such as the Netherlands...Show MoreConflict of Interest:
None declared.
- 9 July 2017The use of SSRIs in Pediatric PTSD: A letter to editor.
Trauma can have a wide range of implications among children and adolescents leading to an increased risk of depression, anxiety, post-traumatic stress disorder (PTSD), aggression, and substance use disorders. A survey among youth in the United States reported that around 80% of children and adolescents faced at least one traumatic event in their childhood [1]. A significant proportion of these children and adolescents develop PTSD as a result of these traumatic experiences, thus, warranting evidence-based psychotherapeutic and psychopharmacological treatment options [1]. While the trauma-focused psychotherapies have strong evidence recommending their efficacy for PTSD among the pediatric population, the evidence regarding the pharmacological treatment is minimal. At present, the psychopharmacological interventions for pediatric PTSD include antiadrenergic medications, second-generation antipsychotics, and antiepileptic agents [1]. Despite the frequent use of SSRIs in pediatric PTSD, there is minimal to no evidence recommending the use of SSRIs in this population pediatric PTSD [1].Show More
Our goal is to review the evidence for use of SSRIs in pediatric PTSD. Sertraline and paroxetine have been FDA-approved for PTSD in adults but there is minimal evidence suggesting the benefits of SSRIs in children and adolescents [1]. However, their use has been recommended in patients struggling with comorbid depression and anxiety, considering their evidence of depressive and anxie...Conflict of Interest:
None declared.
- 13 June 2017Adolescent suicide and media: an epidemic of romanticizing suicide and celebrity idealism
Recently, entertainment industry has attracted strong criticism from the medical community especially the mental health professionals; for glorifying suicide among the adolescents, in the Netflix series 13 reasons why. The peaceful, romantic and provocative portrayal of suicidality in the entertainment industry and the news media may have detrimental effects on social and psychological wellbeing of individuals. It may also legitimize suicide especially among teens suffering from intrapersonal and interpersonal predicaments. In our clinical experience, we have noticed negative effects of this negligent media coverage of suicide and deaths on adolescent mental health.Show More
The glorified portrayal of suicide is also evident in the, historical narratives and the romantic literature, classic music and paintings among other forms of art. For instance, Goethe's novel The sorrows of young Werther, portraying the suicide of the protagonist after the death of his beloved. This had led to an epidemic of suicide among the European youngsters, imitating the behavior of Werther.
Much later, this phenomenon led to coining of the term "Werther effect" by Phillips (1974), who described the relationship between portrayal of suicide in the media and subsequent risk of suicidal behavior among the readers, in his landmark study (1). Fortunately, the increasing trend in suicide among the American adolescents is matched by an explosive rise in research output on related research studies....Conflict of Interest:
None declared.
- 13 June 2017Should psychiatrists be prescribing exercise for depression?
Depression remains one of the world's leading physical and mental health issues, currently affecting over 350 million people globally; but a significant proportion of depressed patients do not access or receive effective treatment.1 Antidepressants and psychotherapy are well recognised as the treatments of choice for depression; but what if a there was another treatment psychiatrists could prescribe that was comparably effective, economical, and easily accessible?
Depression is a mental illness in which the mind-body relationship is highly prominent. The illness develops in response to the negative effects of allostatic overload on neural circuitry, through neuroendocrine, autonomic, immune, and metabolic mechanisms; and evidence suggests that exercise can help treat depression through its epigenetic effects on cellular and molecular level brain function. In particular, exercise reduces depressive symptoms through stimulating endorphin release, increasing neurogenesis via brain derived neurotrophic factor (BDNF), and buffering the damaging effects of stress (or allostatic overload) via the hypothalamic-pituitary adrenal axis (HPA).2 Exercise also encourages social interaction and engagement, improves physical co-morbidities such as diabetes mellitus and cardiovascular disease, and significantly improves a patient's sense of well-being, and quality of life.
Furthermore, exercise has been shown to be moderately more effective than control interventions in tre...Show MoreConflict of Interest:
None declared.
- 10 June 2017why form over content ?
"Establishing a relationship between particular biochemical processes and the clinical data of illness requires a scientifically rational approach to behavioral and psychosocial data, for these are the terms in which most clinical phenomena are reported by patients " G. Engel(1).
Many scientists across different disciplines do find the need of physical explanations (cells, atoms) to some form of an understanding (meaning) that can potentially be communicated, very intriguing indeed. So eloquently put by Niels Bohr, the father of atomic theory: "Any account of experience even in atomic physics must ultimately rest on the use of concepts indispensable for a conscious recording of sense impressions" (2). In quantum theory an act of measurement entails the integration of observer's choice into the micro-world (collapse of wave function) and the registration of results via the classical language of the macro-world (space, time).
Karl Jaspers and out of many contributions to psychiatry, he too advocated a distinction between understanding and causal explanations. According to Jaspers, while the former operates within the phenomenological sphere of consciousness, the latter belongs to the realm of natural sciences and uses measurement (3). Moreover, he emphasized form over content as a core feature for a proper understanding of patient's experiences. In Jaspers' view, a delusional belief may not necessarily be false or out of keep with the patient's cultural or r...Show MoreConflict of Interest:
None declared.
- 5 June 2017the hippocampus
It is a long time since schizophrenia was the core subject for clinical Psychiatry, if it ever was, or will be again, delivery of services lapsing under competing mental health conditions with prior political imperatives. Luckily academic studies have maintained interest, subsequent to HM's surgical hippocampal disaster, many corroborating the crucial importance of brain hippocampal neurogenesis status in managing experience into memory, although clinical practice interest lags.
Importantly, hippocampal neurogenesis in continuing schizophrenia is half only of what is required normally.Show More
It is a disaster for those with schizophrenia. for , they do not, cannot reliably, call on updated experience to get through their daily living, nor prime themslves for their more immediate future,without much more time, and by restricting the flow of incoming stimuli
/information . They are overloaded.
This situation is worse if the illness arrives in adolescence.Those whose illness arrives later will have had the chance to accumulate some settled relationships, work and domestic skills.
Less reliable hippocapal memory management needs to be emphasised when providing a clinical service.
Insufficiently informed community workers need more instruction, when they visit, on the imperfect memory and reduced capacity, that will likely be present in conversational interviews.
More time is needed to accommodate changes in daily living happeni...Conflict of Interest:
None declared.
- 4 June 2017Three scientifically proven reasons to involve caregivers more than ever before
The latest booklet from WHO (January 2017) provides estimates of the prevalence of depression and anxiety disorders at the global and regional level. Despite the fact, that the total number of people with depression was estimated to exceed 300 million and nearly that number again suffers from a range of anxiety disorders, the report doesn't seem to take into considerations that caregivers also are at risk of being added to the statistics. The good news is, if we look at science, caregivers may actually be a key answer to these devastating numbers.
First at all over the past 30 years of research into this topic has confirmed that continued involvement of caregivers is crucial to the recovery process of people with mental illness. Families play a vital role in supporting people with long-term mental illness in the treatment, in the community and are focal in the social networks of people with mental illness. Studies have now demonstrated clear gains for people with mental illness in terms of reductions in relapses and hospitalizations. Moreover, a positive impact on the outcome of several mental disorders, the well-being of caregivers and socioeconomically.
Secondly, the presence in a family of a person with a severe mental disorder is often related to a significant objective and subjective burden on the other family members. Not only is such a situation likely to affect the well-being of the caregivers and compromise their long-term ability to support the pe...Show MoreConflict of Interest:
None declared.
- 1 June 2017Fidget Spinners – a toy which targets Autism Spectrum Disorder symptoms in ADHD?
I note the interest in Fidget Spinners, which many claim were developed to help children with ADHD manage stressful situations, such as the classroom. I wondered initially why many such spinners have moveable metal parts which do not contribute to the main spinning action of the spinner. However watching a child briefly play with a fidget spinner is like watching a child with Autism Spectrum Disorder (ASD) engrossed in the behaviour we often call "stimming" or a stereotypical behaviour pattern. The metal parts of the fidget spinner create stimulating patterns when spun, much like the effect of spinning the reverse side of a Compact Disc or the hologram we use in the Autism Diagnostic Observation Schedule assessment1. It appears that the fidget spinner is acting both to give the child with ADHD an opportunity to fidget and also provides an opportunity for visual stimulation, much like that sought out by children with ASD. It appears that the creator of the fidget spinner has acknowledged that children with ADHD frequently also present with autistic symptoms, as has been shown in a number of studies2,3,4. This does not however explain the current craze for fidget spinners in the general population!
1. Lord C, Risi S, Lambrecht L, Cook JEH, Leventhal, BL, DiLavore, PC, et al. The Autism Diagnostic Observation Schedule-Generic: A standard measure of social communication deficits associated with the spectrum of autism. Journal of Autism and Developme...Show MoreConflict of Interest:
None declared.
- 31 May 2017Mandatory Prescribers' Education of Pain, End-Of-Life Care And Addiction
To the Editor,
New York has become the latest state to pass a law to help curb opiate addiction by requiring special training in pain and addiction management for clinicians who prescribe controlled substances. This law requires clinicians who want to obtain or maintain a medical license to complete training in effective and safe pain management, end-of-life care and addiction before July 1st, 2017 and then once every three years thereafter [1]
For the last two decades, opiate therapy was considered safe and had become the mainstay for the treatment of chronic pain in the United States. This treatment strategy, along with aggressive marketing and promotional campaigns by pharmaceutical companies, led to an exponential growth in the use of prescription opiate medications for the treatment of pain, other than the realm of active cancer, palliative care or end-of-life care [2]. This has led to an opiate use crisis in the country; now an average of 91 people die from an opiate overdose daily [3].
Pain is ubiquitous, the most common reason for all medical visits. The human, economic and social cost of untreated, under-treated and over-treated pain is a public health concern everywhere. New York State has taken the right step in mandating medically-accepted curricula and competency-based training programs for all medical professionals. This plan is necessary to avoid addiction, overdose and death from excessive use of opiates.
Pain management educati...Show MoreConflict of Interest:
None declared.
- 31 May 2017Response to Schnyder et al., Association between mental health-related stigma and active help-seeking: systematic review and meta-analysis
In their systematic review and meta-analysis on the association between mental health-related stigma and active help-seeking, Schnyder et al find that negative help-seeking attitudes and personal stigma are associated with less actual help-seeking. The authors connect these findings to a recommendation for anti-stigma campaigns to "target these personal attitudes rather than broad public opinion." However, this recommendation cannot be extrapolated from the types of studies they reviewed. Moreover, it over-emphasises help-seeking as the key outcome and does not adequately consider the importance of changing wider social acceptance in broader domains related to, for example, disclosure at work or support from family and friends.
Schynder et al. reviewed studies evaluating the association between stigma and actual help-seeking at the individual level. They did not assess how public-level attitudes correlated with actual help-seeking in the population, which would have required cluster-level analyses. Their individual stigma-to-help-seeking association is different from concluding that campaigns targeting the general public are not helpful to improve help-seeking at a population level. Because Schnyder and colleagues did not include evaluations of broad public anti-stigma campaigns on care seeking, their recommendation against such efforts risks misleading policy makers, health care practitioners, researchers and advocates.
In contrast to Schnyder et al.'s rec...Show MoreConflict of Interest:
None declared.
- 21 May 2017Response to eLetter-Maximizing Mental Status Examination, published on March 2017
Joshi et al1 proposed that mental status examination heavily depends on checklists and jargons. In their experience, difficulties in describing patient's affect and thought with the use of jargons are encountered. They mentioned that jargons are subjective and their use leads to loss of important data particular to a patient. I have some comments to share:
The debate on clinician's subjectivity and objectivity in psychiatry is historical. Mental Status Examination in particular, is an objective tool that is used to describe a patient's mental state at the time of evaluation. Role of objective attitude and unbiased recording of MSE is important. It is to make sure that examiner's subjectivity does not color the psychopathology and chances of misdiagnosis reduced. Use of jargons, in addition to increasing efficiency in documentation; is designed to facilitate communication between clinicians. It syncs two clinicians' understanding of the case both cross-sectionally and longitudinally. Inconsistent use of terms are criticized in clinical and research practices. Lack of common definitions can make it impossible to converge ideas on diagnosis, symptom monitoring, prevalence reporting and generalization of treatments.
It is a commonly seen that trainees have difficulty in eliciting psychopathology and differentiating between the ones that share a border such as 'constricted', 'blunted', 'flat' affect. One way of avoiding confusion is that trainees are thorough wit...Show MoreConflict of Interest:
None declared.
- 18 May 2017Imitation Injury Among Children - an overlooked phenomenon
Imitation injury is a fairly rare presentation and has been under-researched, but it is recognized that such acts are fatal. Some case reports and anecdotes demonstrating imitation injury are available. For example, Davies(1) described five cases of children jumping out of the window in Spiderman costume or initiating a flight like Superman without a planned landing strategy. United News of India reported that a TV serial influenced children to imitate the superhero or endanger themselves to be rescued. Some anecdotes include the reenactments of self-harming stunts seen on MTV series Jackass in spite of disclaimers. Incidents recorded in the US and Europe ranged from jumping on the hood of a driving car to setting self on fire. Influence of Need for Speed game causing road injuries due to street car racing were reported in Canada. An adolescent from India reportedly injected mercury in his arm after watching the movie 'X-Men' to gain superpowers. Hurley and colleagues(2) (2006) upon review of records of 139 children in burn department, found that five patients had potential copy-cat type mechanisms leading to their injuries, including one patient who had made a home-made bomb. These reports which span over 15 years suggest that despite it being a rare occurrence, imitation injury is life threatening and can have implications for public health policy.
Reports of copycat injuries are mostly published in pediatrics, burn injury and trauma journals but it has not been...Show MoreConflict of Interest:
None declared.
- 7 April 2017Intrapersonal Basis of Sudden Suicidal Tendencies
A million people commit suicide annually worldwide. 1 Many more people, especially the young and middle-aged, attempt suicide. 1 It is the tenth leading cause of death overall; third between the ages of 15- to 24-years, and fourth among 25- to 44-year-old.2 Suicidal behavior has been studied in great detail in the context of psychiatric disorders and socioeconomic stressors.3 It is intriguing when a person without the previous history of psychiatric disorder and with no or minimal psychosocial stressor claim his life; for such group of individuals, suicides can be an impulsive act, with the decision being made just minutes or hours before that act. When a bio-psychosocially healthy person commits suicide, a lot of conspiracy theories surface, which are sometimes very farfetched. 4 It is important to understand the possible psychological underpinnings of sudden suicidal tendencies in a healthy individual with a very low magnitude of distress.Show More
Human beings can acquire pathologies by either extrinsic factors (e.g. microorganisms, inflammatory processes, unhealthy lifestyle, psychological or physical trauma) or intrinsic factors; where our bodies' own systems, genes, and enzymes are malfunctioning.5 All present theories of suicide are centralized around these two factors: extrinsic (psychosocial stressors) and intrinsic (genetic inheritance and chemical imbalance of neurotransmitters). 6
Autoimmunity, where body defense system attacks its own body, is an imp...Conflict of Interest:
None declared.
- 27 March 2017Suicide after Reversible Methamphetamine-Induced Toxic Leukoencephalopathy
Dear editorShow More
Toxic leukoencephalopathy can occur with substance abuse; manifestations include impaired cognitive function, personality change, coma, and death. However, prognosis may be relatively favorable (1). As there are no published reports of methamphetamine-induced toxic leukoencephalopathy, the prognosis remains unclear. Research suggests methamphetamine users may experience comorbid depression at all stages of use, including abstinence (2). We report a case of suicide after reversible methamphetamine-induced toxic leukoencephalopathy.
A 35-year-old divorced Taiwanese man had a history of illicit drug use, primarily methamphetamine, due to depression. In July 2016, he appeared forgetful, could not understand questions, isolated himself in his room, and was unable to live independently; symptoms persisted for 2 weeks. His property owner brought him to the emergency department, where a brain CT showed no abnormalities. A urine screening examination was negative for methamphetamine and opiates. The patient was admitted to the psychiatric ward on suspicion of methamphetamine withdrawal or retarded depression. After admission, symptoms including poor concentration, lack of spontaneous speech, and impaired self-care. Escitalopram (10 mg/day) was prescribed for possible retarded depression with no effect. An electroencephalogram to rule out organic causes revealed mild abnormality. Brain magnetic resonance imaging (MRI) revealed acute toxic leukoencephalopathy....Conflict of Interest:
None declared.
- 19 March 2017Establishing cost-effective institution based psychological services in medical schools of developing countries
Medical students and practicing physicians are trained in a Spartan like environment, aspiring for competence and perfection, necessitated by their sacred profession [1]. They have distinct personalities, with their own vulnerabilities that may put them at a higher risk of developing psychopathologies such as anxiety, depression, sleep disturbances and suicidal ideation and attempts [1, 2, 3]. They also report poor life styles and dietary practices, high stress and burnout levels, low mental well-being, and highly prevalent comorbid medical conditions [3].Show More
Despite these thoroughly researched statistics, most of the medical schools in developing countries, fail to provide psychological services to their students. There is less awareness, and the stigma towards psychiatry and mental health still prevails among the medical fraternity. This deters them from seeking mental healthcare in a timely manner. This vicious cycle, not only puts a strain on the physician-patient and interpersonal relationships, but also results in a preventable economic loss and poor work efficiency [4].
Keeping these facts in context, we would like to propose a few cost-effective strategies to counter these norms:
1) Medical schools should establish small institution based psychological services providing individual, group and couple counselling services. This can be done under the aegis of existing departments of clinical psychiatry and behavioral sciences.
2) Annual surveys sh...Conflict of Interest:
None declared.
- 9 March 2017Maximizing the Mental State Exam
The mental state exam is an indispensable tool that summarizes the totality of the mental health provider's observations of a patient's behaviors while the patient is in view before, during, and after the interview [1,2]. It should convey a clear snapshot of the patient at that particular moment. Another provider should be able to pick out that particular patient from a waiting room after reading the mental state exam. We opine that the mental state exam may be becoming a formality during documentation. In an effort to increase efficiency due to time constraints, we are now commonly using checklists and jargon to mark the mental state exam. We may be losing sight of what we are trying to convey when we conduct a mental state exam using checklists and jargon in an attempt to increase efficiency. Returning to describing what we are hearing from and seeing of our patients in a narrative tone may be more valuable instead of marking checklists and writing jargon. The two of the more common areas from our experiences where this is applicable are the description of affect and thought process.
When describing a patient's affect, we often use terms such as "constricted", "blunted", or "flat" (as examples). What do these terms really mean? These terms are subjective and are often used interchangeably to describe a limited or lack of emotional response. One person's "constricted" can be another person's "restricted." If the purpose of the affect section is to des...Show MoreConflict of Interest:
None declared.
- 23 February 2017Bashing psychiatry: personal experience of a medical student and an aspiring psychiatrist from Pakistan
Psychiatry, ever since its inception has attracted little support from the mainstream specialties of medicine. It has suffered stigmatization from fellow physicians as well as the general public (1, 2). It has also been portrayed negatively by the media and the film industry. Although the psychiatrist fraternity has campaigned whole heartedly to change these norms [3], the stigma still persists, more markedly in the developing and third world countries (1).Show More
Research has indicated that a third of medical students are put off their career choice as a direct result of this bashing from consultants practicing "main-stream" specialties of medicine (2). I had chosen psychiatry as my passion and a specialty of interest as a third year medical student in Pakistan. I have been actively involved in campaigning for a positive image of psychiatry in my medical school. Not only have I been vocal against the bashing of psychiatrists in Pakistan (1, 4) but also tried to inspire my peers.
Despite my work and demonstrated passion for the field of mental health, I have faced humiliating comments and name calling from my peers, and senior physicians and surgeons. I am sure my voice resonates with that of many other young medical students. What would happen, if this prevailing stigma, stops the young generation from opting psychiatry? How would non-psychiatrist physicians deal with the high morbidity, economic burden, and productive years lost to mental illnesses? I do agree that...Conflict of Interest:
None declared.
- 20 February 2017Burnout in psychiatry
To the Editor: Burnout in psychiatry has become an increasing problem that has gained more visibility due to social media and changes in healthcare practices. Shanafelt et al. evaluated the prevalence of burnout and satisfaction with work-life balance in U.S. physicians in 2011 and 2014 [1]. Their study revealed an increase in overall physician burnout from 45.5% in 2011 to 54.4% in 2014 (p < .001), with a statistically significant increase in psychiatrists reporting burnout in that same time span (p<0.05) [1].
There is no single definition to describe burnout. A popular conceptualization is that burnout is a psychological syndrome that emerges as a response to chronic interpersonal workplace stressors [2]. Each psychiatrist manifests burnout differently. Overwhelming exhaustion, feelings of cynicism, and a lack of accomplishment are examples of observable indicators of burnout [2]. There are six domains in which person-job mismatches can increase the likelihood of provider burnout: workload, control, reward, community, fairness, and values [2].
In addition to the person-job imbalances in those domains, psychiatry has unique risk factors that further contribute to burnout. Workplace variables such as too much work, long working hours, chronic staff shortages, an aggressive administrative environment, a lack of support from management, and poor relationships with management/supervisors have been found to be more stressful to psychiatrists tha...Show MoreConflict of Interest:
None declared.
- 17 January 2017Brief ethical comment
Dear Sir
I have read that US Common Law prohibits psychiatrists from commenting publicly on those they have not treated*, and I believe this was also echoed by our President, Sir Simon Wessely. Normally I would agree with this view, but these are not normal times. It seems to me that we are talking about persons who have had a large effect on the public and for whom the evidence for mental disorder is public, usually in the media. There is therefore another argument to be made , that the ethic is not absolute but proportionate, it depends upon the magnitude of the effect on the public. It also depends on the reliability of the evidence. When extremely worrying events occur – such as political assassination – people are anxious and not surprisingly ask a psychiatrist for an understanding, if they have one. It seems to me that it then becomes incumbent on the psychiatrist to respond if asked and rather than looking po-faced and reciting the mantra that we have not treated this individual, to give a considered answer, based on the evidence, and a view on its reliability. Of course an opinion must never be made public before an imminent court case.
Yours sincerely
Dr. R.L.Symonds
* The Goldwater Rule , from US common law Goldwater v Ginzberg United States Appeal Court 18-07-1969 (414 F:2d 324), mentioned in Guardian article by Hannah Jane Parkinson, 30-11-16.Conflict of Interest:
None declared.
- 16 January 2017Trazodone Induced Suicide Ideations
Although trazodone has U.S. Food and Drug Administration (FDA) approval for the treatment of depression, it is more commonly prescribed for its off-label use as a sedative (1). Antidepressants have been associated with an increased risk of suicide ideations in children, adolescents, and young adults, leading the FDA to place "black box" warnings on package inserts for these medications (2). The following case report details a patient who developed suicide ideations with trazodone and subsequent resolution of suicide ideations upon its discontinuation. A Pubmed MEDLINE® search did not yield previously published case reports on this topic. Some post-marketing surveys such as the one conducted by Eckerd Pharmacies comparing trazodone and fluoxetine indicated an increased risk of suicide ideations with trazodone but there is limited research regarding an association (3).
Case Report:
A non-elderly adult patient was being treated in an outpatient mental health clinic for Posttraumatic Stress Disorder (PTSD) for two years. When he initially presented to the clinic, he was prescribed trazodone 50mg for PTSD-related insomnia. One week later, the patient reported that trazodone was not effective and it was subsequently discontinued. Mirtazapine was initiated for insomnia at that visit. At a follow-up visit two months later, citalopram was added to alleviate his anxiety symptoms. Over the following six months, citalopram was increased...Show MoreConflict of Interest:
None declared.
- 10 January 2017The Economic Cost of Segregating Mental and Physical Healthcare in the UK
In the 17th Century, René Descartes outlined his philosophy of "mind-body dualism". This segregation between mind and body has caused a mechanical view of healthcare, with medicine evolving to treat mental and physical ailments as separate. In this letter, the economic cost of this pervasion will be outlined, highlighting the urgent need for change.
The World Health Organisation defines health as "as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". [1] Since the NHS was founded in 1948, patients have been led through a pathway which separates their physical health from their mental health. 30% of primary care patients with chronic medical conditions and up to 80% of those with health complexity have mental health comorbidity, yet primary care clinics rarely include onsite mental health professionals and only one in eight patients receive evidence-based mental health treatment [2]. It is only recently that patients are demanding a more holistic approach to their care, driving change towards parity of esteem between treatment of mental and physical conditions.
Mental health problems affect individuals and their families but also the economy, with absences and lost productivity bearing a significant monetary cost. It has been estimated that mental health problems cost the UK around £70 billion (around 4.5% of GDP) in lost working days, reduced productivity at work and higher benefits payments. [3]...Show MoreConflict of Interest:
None declared.
- 27 November 2016De novo-occurrence of obsessive–compulsive symptoms (OCS) under aripiprazole: a case report
Several case reports, case series and systematic evaluation of obsessive-compulsive symptoms (OCS) induced by atypical antipsychotics have been published. Most cases concern the use of clozapine (1) or quetiapine (2). Rarely, risperidone and olanzapine have been implicated too (3). Authors described improvement of OCS induced by atypical antipsychotics with aripiprazole combination (4). To our knowledge, no OCS associated with aripiprazole has been described. We report a case of aripiprazole-induced OCS.Show More
A 49-year-old female with a 20-years history of bipolar disorder was treated by lithium medication 1000 mg/d since several years. The patient had no other psychotropic drugs and no other relevant medical history. Aripiprazole was introduced at 10 mg/d because of hypomanic symptoms, but was increased to 15 mg/d because of no efficacy. Ten days after aripiprazole increase, the patient reported OCS with intrusive thoughts and images with themes of "unacceptable ideas of harm". The Y-BOCS score was 20/40. There was no evidence of substance misuse, akathisia or extra-pyramidal symptoms. No other concomitant medication was introduced. These OCS improved completely few days after decrease and discontinuation of aripiprazole. The Y-BOCS score was then at 0.
In this case, aripiprazole's imputability according a validated causality algorithm, the Naranjo algorithm (5), was "probable" with a total score 8 (maximal score is 13) (Table 1). OCS evolution was compatible with...
Attachment(s)Conflict of Interest:
None declared.
- 22 November 2016Fear of iatrogenic effect: Handling the denial to access participants.
Research has consistently shown little or no empirical support for iatrogenic effect – the idea that talking or asking about self-harm and/or suicide leads to suicidal thoughts or behaviour – in research on self-harm and suicide involving adolescent/young participants (1-3). Again, institutional review boards (IRB) ensure that researchers adopt sound methodological positions, take steps to ensure participants' mental health safety and/or make provision to ameliorate any emotional discomfort resulting from participating in studies on self-harm and suicide (4).Show More
However, there are reports that some gatekeepers (e.g., heads of schools, heads of charity organisations and parents/guardians) adamantly decline researchers access to conduct studies with adolescents on self-harm or suicide because of the fear of iatrogenic effect (e.g. 5). Presumably, this challenge may be much pronounced in socio-cultural contexts where open discussion about death and suicide is tabooed. This can be particularly frustrating when the target populations of the study are 'hard-to-reach' (e.g., street adolescents, young people orphaned by HIV/AIDS etc.), and the protocols for the study have received verifiable ethical approval from credible institutional review boards.
In response to the denial to access participants due to gatekeepers' expressed fear of iatrogenic effect, some researchers choose to skip such gatekeepers and their institutions or adolescent wards and pursue the participant...Conflict of Interest:
None declared.
- 27 October 2016Inquiries after Homicide
Comments made by carers, after an Inquiry a homicide where the perpetrator was a patient receiving NHS mental healthcare provision, express their concerns that their observations about perpetrator behaviour did not receive a proper attention by the teams delivering that care.
Many previousInquiry Reports following a homicide committed by patients receiving NHS mental care provision, list this failing to receive or act upon information in observations from carers involved in that care.
A simple directive to mental health teams would bring an end to this kind of disaster.
In the response from a second Internal Inquiry to such an event in Cornwall, an accepted recommendation for avoiding such a disregard for carer observations, by the Trust was that the
weekly meetings of all mental health teams should follow an agreed agenda
that would record those present and the outcomes expected from any deliberative decisions.
The localTrust carer sub-committee added to this agenda, that 'any Carer Issues' would be an item in the agenda.of the weekly team meetings
Adopted by all Mental Health Trusts, this practice would be a sufficient reminder that carers who express risk concerns should not be ignored or disregarded in any future similar situations
yours ssincerely
David H Yates. FRC Psych
{ Wintergreen ,St jidgey, Wadebridge. Cornwall PL27 7RE
01208 816035Conflict of Interest:
None declared.
- 27 October 2016What doesn't work is important
To the Editor: When medicines or non-pharmacologic interventions yield positive results in clinical trials, those treatments make headlines in the media (including social media) and the positive results are more likely to be published in prestigious and higher-impact journals [1]. However, negative results do not garner the same attention. They get published but less frequently and with more delays [1,2]. We need more negative studies published in the medical literature and available in public domains. Negative results are equally important if not more so than positive results.
Negative results would allow providers to discard ineffective therapies from their armamentarium. They would allow consumers to save money and time chasing treatments that are not efficacious. Just as effective treatments have side effects, so do ineffective treatments. However, the benefits of effective treatments can potentially outweigh the risks of side effects and treating those side effects. Using ineffective treatments can result in additional costs of treating those side effects and an increased risk of morbidity/mortality. Ineffective interventions can create a false sense of security that the patient is being "treated" and can also interfere with development of new treatments as many would believe that a treatment is already available [3]. Negative results would reduce the risk of duplicative studies by different groups in different countries and may also contain import...Show MoreConflict of Interest:
None declared.
- 15 October 2016Yellow September, Stigma and Suicide Prevention
In addition to the higher burden associated to mental illness as comparing to several others medical conditions in terms of years lived with disability (YLDs) (1), the mortality rates for suicide – almost all likely associated to psychiatric disorders (2) – have not changed in the last decades, a different trend that has been occurring for other diseases such as leukemia and heart disease (3). The etiology of suicide is multifactorial with evidences ranging from genetic (4) to social determinants (5); thus, in order to change this reality and to prevent it, it is necessary to broad the range of our interventions.Show More
Despite advances in both the genomic (4) and neuroimaging (6) fields which increase the possibilities for a better understanding of the biological mechanisms associated to suicide and to identify biomarkers that could predict suicidal behavior, there are not previsions on when such knowledge arising from neuroscience will provide accurate, personalized and affordable information for suicide prevention. Nevertheless, the problem is present here and now and the question is whether we already have enough scientific evidence at present that, if implemented in the health care system and properly translated for the general population, could help to change the current situation.
In the systematic review of Zalsman et al. (2016), within the level 1 evidence for suicide prevention strategies reported by the authors, there were interventions as pharmacologic...Conflict of Interest:
None declared.
- 13 October 2016Augmentation of Clozapine with Minocycline – case report
Schizophrenia is a difficult to treat condition, with 25-30% of patients demonstrating treatment-resistance, a hurdle that must be overcome(1). Due to our limited understanding of schizophrenia's aetiology, treatments have largely been restricted to those with anti-dopaminergic action. However, recent hypotheses propose an inflammatory and immune basis for schizophrenia and a novel route for directing future treatments(1).
Patient 'A' is a man in his late 50s, who presented to Psychiatric Services in his early twenties. He is detained under the Mental Health Act, with a diagnosis of treatment-resistant schizophrenia.
Early regimens employed an array of antipsychotic medications, including clozapine, with limited success. Since 1991 a variety of failed clozapine augmentations have been trialled, including: chlorpromazine, thioridazine, haloperidol, amisulpiride and most recently risperidone, all were given at therapeutic doses for adequate trials. Consequently the lesser-known agent, minocycline, was trialled as of November 2015.
Minocycline, an antibiotic from the tetracycline family, is hoped to offer neuroprotective effects that are independent of its antibiotic function(2).
Cytokines produced by CNS microglial cells have been linked to neuropathology in schizophrenia. A myriad of studies exploiting numerous approaches, including PET scans, animal and autopsy studies have suggested a microglial root for schizophrenia(1).
It is here mi...Show MoreConflict of Interest:
None declared.
- 9 October 2016Technology induced variation in expression of bipolar disorder psychopathology
Researchers have observed that emotions play an important role as facilitator in use of social media, especially in the context of information seeking ,support and social sharing behavior.(1)Emotions motivate and move the person 's in their ongoing interactions with the environment(with offline or online contact), to move them towards or away from something or someone depending on the reinforcement one derive from them. Unstable individuals (usually men) are frequent users of online activities .(2)) Positive experiences and reinforcement (cognitive, emotional and behavioural) are associated with recurring media use.(3 ).An inverse association has been observed for negative emotions and online activity. (4) It is one of its kind report regarding the role of information technology in expression of psychiatric conditions. The present case will examine the use of social media and its effect on psychopathology expression on a person with mania.
A 25 year old patient presented with an episode of mania characterized by increased self-esteem, elated mood, expansive ideas, grandiose delusions, increased speech, restlessness and decreased need for sleep, triggered by non adherence to treatment.He was referred for management of technology addiction to Service for healthy use of technology(SHUT clinic). SHUT clinic is the first of its kind in India to manage technology addiction. He has had a previous episode of mania and two episodes of depression. However, the presentation of...Show MoreConflict of Interest:
None declared.
- 31 August 2016Prenatal exposure to antidepressants and risk for autism
To the editors,
The pharmacologic treatment of depression during pregnancy presents a clinical dilemma for physicians and their patients as they weigh the risks and benefits of treatment choices. Untreated depression has been linked with adverse outcomes for women and their infants but antenatal use of antidepressants may also confer some risks.Show More
A growing issue of concern involves the elevated rate of autism reported among children exposed to antidepressants prenatally, particularly selective serotonin reuptake inhibitors (SSRIs). Of twelve studies, six have found a significant association with autism spectrum disorders (reviewed in Pedersen 2015; Boukris et al 2016; Castro et al 2016; Malm et al 2016). Most of the studies controlled for important confounding factors including parental age and family history of psychiatric illness, although other as yet-unidentified factors may have influenced the results.
Nevertheless, there are biologically plausible reasons for concern about exposing fetal brains to serotonergic antidepressants. An abnormally high level of circulating serotonin was one of the earliest findings in autism research and the "hyperserotonemia of autism" is considered a well-characterized biomarker in autism research (Janusonis 2010). Serotonin plays a critical role in early brain development and serotonergic abnormalities have been speculated to produce abnormalities in brain circuitry that are linked with auti...Conflict of Interest:
None declared.
- 25 August 2016Tooth or Consequences: Dental Disease in the Mentally Ill
To the Editor: Dental carries and periodontal disease are approximately 3.4 times more common in the mentally ill as compared to the general population [1]. Untreated dental disease can lead to emotional and physical consequences [2]. It is important for psychiatrists to understand the scope of this problem as well as the causes and prevention of dental disease among the mentally ill.
Symptoms of mental illness can contribute to poor dental health. A lack of motivation commonly found in depression and schizophrenia can result in a reduced desire to engage in proper dental hygiene. Disorganized thinking, delusional beliefs about dentition, specific dental phobias, or manic symptoms could interfere with the ability to understand the consequences of poor dental hygiene. Eating disorders involving vomiting and malnutrition can erode enamel and weaken tooth structure. The downward drift commonly found in those with mental illness could result in difficulty accessing dentists or an inability to afford dental procedures. Illicit substance use and smoking tobacco products also increase risk of dental disease.
Medications commonly used for mental illness can have an adverse impact on dental health. Antipsychotic medications can result in involuntary movements such clenching and/or grinding of teeth, which can lead to new dental problems or worsen existing conditions [2]. Psychotropic medications (e.g. antidepressants, antipsychotics, anticonvulsants) can pre...Show MoreConflict of Interest:
None declared.
- 22 August 2016TERRORISM AND PSYCHIATRY:SHOULD THERE BE A NEXUS?
Sir, Words:478Show More
To the Editor for publication
Terrorism and psychiatry : Should there be a Nexus?
From Afghanistan to Nigeria, from Pakistan to France, never before in the history of the existence of man, has the world ever been plagued with terror as now. The deluge of terrorism in recent years has made phenomenal threat to civilization, tourism and global peace. It sensitizes the quiescent nerves of racism, fear, fanaticism and outright bigotry.. It stands as a major block to peaceful co-existence and toleration of rights extended to what is perceived as 'foreign'.
We are all too aware of the disastrous consequences each terror attack brings. The now familiar cases of deaths, injuries, short and long term morbidities both in economic and psychological adjustment for survivors and their families . The gory pictures of wanton destruction, that have all become too common on our TV sets.
Ever since 9/11, the world has sought to develop workable strategies to combat the rising wave of terrorism. Often, these, Knee-jerk reactions following each terror attack , highlights the porosity of security strategies and failure of intelligence.
Undoubtedly, identifying would - be personalities for radicalization, potential recruits for terrorists and ideologies propelling such dastardly acts are possible intelligence pathways being explored for stemming the tide of terr...Conflict of Interest:
None declared.
- 12 July 2016Remember DEMENTIAS: a mnemonic for delirium etiologies
To the Editor: Delirium is an acute disturbance of attention or awareness that is accompanied by a change in baseline cognition that is not due to a neurocognitive disorder, underlying medical condition(s), substance intoxication/withdrawal, toxin exposure, or combination of the above mentioned factors (1). Considered a medical emergency, delirium is often unrecognized due to its fluctuating nature, its overlap with neurocognitive disorders, lack of formal cognitive assessments, underappreciation of its clinical consequences, and failure to consider the diagnosis important (2). Early detection of delirium and subsequent management of this condition can reduce the risk for morbidity and mortality, decrease potential healthcare costs, and reduce impairment in functioning (2).
There are numerous etiologies that can result in delirium. It is difficult to memorize all of these etiologies. A common mnemonic that providers have used to remember the differential diagnoses is "I WATCH DEATH" (3). I propose an alternative mnemonic "DEMENTIAS" to assist providers recall the multiple etiologies of delirium. The components of DEMENTIAS are:
D: drugs (narcotics, sedative-hypnotics, anticholinergics, etc.) and deficiencies (e.g. thiamine, Vitamin B12, folate)
E: endocrine abnormalities (e.g. thyroid, parathyroid) and environmental factors (e.g. bladder catheter, sleep deprivation, use of physical restraints, hypothermia, heat stroke)
M: metabolic (anem...Show MoreConflict of Interest:
None declared.
- 21 June 2016The importance of long-term psychiatric care following the 2016 Kumamoto Earthquake
At 9:26 PM on April 14, 2016, an earthquake with a magnitude of 6.5 struck Kumamoto Prefecture [1]. The hypocenter of the earthquake was in Kumamoto City and the earthquake registered a seismic intensity of 7 on the Japan Meteorological Agency (JMA) scale. The earthquake was soon followed by 6 earthquakes with a seismic intensity of around 6.0. One of these earthquakes struck at 1:25 AM on April 16 with a magnitude of 7.3 and a seismic intensity of 7, and this quake was considered to be the main shock [1]. As of April 17, the earthquakes had caused 42 deaths. Following the aftershock that struck at 3:55 AM on April 16, the number of evacuees abruptly increased, and there were as many as 183,882 evacuees from affected areas [2]. According to a report by Kumamoto City, the City had as many as 2,045 evacuees due to the 2016 Kumamoto Earthquakes as of 7:00 PM on June 5, 2016 [3].Show More
There were 1,093 tremors with a seismic intensity of 1 or greater from April 14 to 30 (64.3 tremors/day), 520 tremors (16.8 tremors/day) from May 1 to 31, and 44 tremors (8.8 tremors/day) from June 1 to 5 [4].
The number of residents who had to be relocated still numbers in the several thousand. This figure is smaller than the number of residents who evacuated after the main shock of the 2016 Kumamoto Earthquakes. In addition, tremors have decreased in frequency compared to the number of tremors immediately following the earthquakes, but tremors are still registering. In other w...Conflict of Interest:
None declared.
- 6 June 2016The issue of Syrian refugees in Turkey
Following the outburst of the Syrian Conflict in March 2011, millions of Syrians have been forced to leave their homes. The conflict has initially generated a huge wave of internal migration within Syria—mostly toward the Turkish, Lebanese, and Jordanian borders. After the sharp increase in the intensity of conflict in late 2011, the internal migration wave has changed nature and transformed into a wave of refugees flowing into the neighboring countries (1). Turkey hosts the largest population of Syrian refugees among the countries neighboring Syria. The initial presence of Syrian refugees on Turkish territory, which was considered temporary at the beginning of the crisis, has now become a permanent one. The permanent nature of the situation is now affecting the psychology and reactions of both the host and incoming communities.
United Nations High Commissioner for Refugees (UNHCR) estimates that more than half of the Syrian refugees are children, and according to UNICEF, 74% of them are not attending school (2). The Government of Turkey currently hosts close to 280.000 refugees in 25 camps, with ongoing costs associated with health, education, food security and social and other services offered. Despite enormous efforts from the government, local authorities and generosity from host communities, many of the 90% of Syrian refugees that live outside of camps in urban and rural areas are often unaccounted for, and are surviving under very challenging circumstances. A...Show MoreConflict of Interest:
None declared.
- 29 March 2016One Mind, one too many
Current diagnostic manuals in psychiatry rely heavily on operational definitions which hold that meaning is constituted in empirical operations (processes of measurement). Partly, proposed by Bridgman (1), an operational definition is a criterion by which we may ascribe ontological (things in themselves) status to an unobservable construct. Later on, Bridgman had to tweak his initial claim by suggesting that an operational definition was a necessary, but not sufficient, constituent for scientific meaning. On the other hand, Jaspers' phenomenological view seems to have fared better as he adopted the view that the psychiatrist should, at least for a time, set aside any explanatory or even therapeutic ambition and instead focus on the descriptive task. However, he by no means entertained the operationalist idea of a purely atheoretical approach (2), and explicitly emphasized the need to apply presuppositions which form a necessary part of understanding. Indeed, earlier operational hopes seem to confront the fact that the clinician is able to correctly use the diagnostic operational criteria only on the condition of him/her having prior conceptual grasp and experience-based familiarity with such diagnostic concepts(2). Therefore, issues of context, prevailing scientific view at the time, and personal experience will unavoidably be part of the sociology of diagnosis. It just seems increasingly plausible that we are unable to capture phenomenology as it is, but more likely as we...Show MoreConflict of Interest:
None declared.
- 11 March 2016Porencephaly Presenting With ADHD and Seizure Disorder: A Rare Case Report
To the Editor: Porencephaly is a rare neurological condition characterised by the development of cerebrospinal fluid filled spaces within the brain parenchyma.1 It has been associated with neurological sequalae like visual loss, nystagmus, seizures, spastic hemiparesis, developmental delay and intellectual disability.2Show More
A 5 year old boy, studying in kindergarten, presented to the psychiatry outpatient department with hyperactivity, inability to sit still, frequently getting into squabbles with children at school and also at home since last one year. His mother reported that he would often lose objects at school, not follow teacher's instructions and often disrupt classroom activities with his impulsivity. The child was born out of non-consanguineous marriage at term without any complications. Motor milestones were attained on time. However, the language milestones were delayed for which the mother had consulted a paediatrician. He was diagnosed with mild intellectual disability with Intelligence quotient of 56. He developed GTCS at 3 years of age, which was controlled on valproate 300mg/day. Family history of psychiatric or medical disorder was negative.
Mental status examination revealed ill sustained eye to eye contact, kept fidgeting in his chair, repeatedly getting up and running around in the interview room. Haematological investigations were normal. MRI brain revealed a large porencephalic cyst in the right frontal lobe with confluent areas of gliosis in r...Conflict of Interest:
None declared.
- 6 March 2016Liver Transplantation for Phenelzine-associated Acute Liver Failure
A 46 year-old female was hospitalized for severe depression. She suffered no physical ailments and had no history of alcohol or drug abuse. Her medical treatment included venlafaxine exel 2x150mg, lometazepam 2mg and trazodone 100mg taken for over one year and alprazolam 0.5mg taken sporadically. Because she failed to improve venlafaxine and trazodone were stopped for two weeks and the patient was placed under a tyramine-free diet before commencing phenelzine at a dose of 3x15mg daily. Rapid clinical improvement was noted with reduction of fatigue and anxiety, improvement of concentration and resumption of social and professional activities. Two months later the patient began to complain again of tiredness accompanied by nausea and epigastric discomfort. Blood analysis showed severe hepatic cytolysis (ALT:31N), hyperbilirubinemia (total 8.5mg/dl, direct 7.7mg/dl) and mild cholestasis (ALP :2N). Anamnesis revealed no exposition to hepatotoxic substances or indications of a possible suicide attempt. The patient patient was jaundiced but showed no signs of encephalopathy. Absence of fever, skin rash and eosinophilia pleaded against immuno-allergic liver disease. Serologies for viral hepatitis A, B and C, EBV, CMV and autoimmune hepatitis were negative. Abdominal ultrasound showed slight liver enlargement, non-dilated bile ducts and a permeable liver vasculature. Two weeks after the onset of jaundice the patient developped encephalopathy and rapidly became comatose. Orthotopic...Show MoreConflict of Interest:
None declared.
- 3 March 2016"Psychoactive Substances Act 2016- Unknown Unknowns"
"Legal highs", also known as NPS or Novel Psychoactive Substances will be made illegal from the 6th April 2016 when the Psychoactive Substances Act 2016 comes into force. The effect of these drugs on the mental health of users is now receiving more attention than ever before, with the Prison services recently reporting the enormous strain they are being placed under having to manage the severe consequences on both the mental and physical health of their prisoners.
We do not know what will happen when the Act comes into force in England with regards to continuing use. In Ireland, the publication of their Psychoactive Substances Act has led to an increase in the use of the drugs, with the highest usage in Europe being reported in their 16-24y age group. In Poland, their ban has witnessed a similar trend in the increase in use.
Our experience has found that the effect on the mental health of our service users has been, in certain cases, devastating. Moreover, our staff have reported being overwhelmed and ill-prepared to meet the challenges associated with the increase in aggression, violence and medical emergencies. We have observed a surge of admission with patients presenting with agitated and aggressive behaviour. This presentation has been observed in patients admitted for the first time but also in very well-known individuals that never had a history of violence. We have also observed, anecdotally, that legal high use was associated with a higher incidenc...Show MoreConflict of Interest:
None declared.
- 17 February 2016Stigma and architecture of mental health facilities.
Stigma associated with mental illness is very common. Patients face prejudices, stereotypes, misunderstanding, discrimination, and self-stigma. They are afraid of being labelled. Another fear is the fear of mental health services, which makes patients avoid taking up treatment (1). Apprehension of treatment increases when a patient has to be treated in a psychiatric hospital. Fear of stigma associated with a facility appears. For many patients, hospitals become their home for weeks or months. Despite all improvements introduced to mental health facilities, they are still labelled and stigmatised. Psychiatric hospitals are often associated with a penitentiary, an asylum, or a substitute of a panopticon. The stereotypical image of a psychiatric hospital is inseparably linked with this object.
Architecture of psychiatric hospitals is sometimes referred to as the architecture of madness. That applies both to the architectural form and quality of built environment. Very often, architecture not only fails to guarantee appropriate conditions of stay, but it is also inadequate for its function. Some psychiatric hospitals were not adapted to the changing requirements for health care facilities, and in some cases they were not designed to accommodate people. That creates inappropriate spatial and functional connections and results in inability to introduce required changes, provide particular technical conditions, and create suitable environment for patients.
Popula...Show MoreConflict of Interest:
None declared.
- 4 February 2016Virtual anxiety : Technology mediated expression of social anxiety
Social anxiety is considered to be one of the most important risk factors for predisposing the person to develop problematic internet use .1,2 Social anxiety has been viewed as bringing dysfunction in individuals life style because it interferes with establishing and maintaining social relationships and limited one's access to social support .3 Socially anxious people use various 'safety behaviors' which reduce their anxiety and increases avoidance behavior. Studies have shown that individuals with high levels of social anxiety prefer online social interaction to face-to-face interaction and developed problematic use of internet .1,4 5.The available of literature are suggestive of use of internet (social media and online gaming) as a method of managing the social situations. It is first of its kind case to document the presence of virtual anxiety.
The present case sought consultation with SHUT clinic (Service of Healthy Use of technology) for management of video game addiction. It is India's first tech deaddiction clinic. A 22 year old male, educated upto 12th standard came for consultation along with parents. He came with the presenting complaints of feeling of sadness, loss of motivation for daily activities, social anxiety, extreme avoidance and feeling of worthlessness. Clinical interview revealed the use of social media and multiplayer online game for the last 3 years. User reported anxiety in going out and talking to others. Due to this, he started preferring...Show MoreConflict of Interest:
None declared.
- 26 December 2015What does the suicide of C tell us?
C was a 50-year-old female, London based socialite, who obtained High Court approval to refuse treatment.1 She subsequently died, thus completing suicide. The case raises many questions, including whether personality disorder impairs competency.
However, it also tells us something about suicide - which is widely believed to be a response to mental disorder. Newspaper reports tell that C had recently ended a relationship, leaving her in straitened circumstances. She had taken an overdose resulting in kidney and liver damage and needed dialysis, at least in the short term, to survive. She had previously been diagnosed with breast cancer but had refused treatment because weight loss would prevent her wearing a bikini. She told the court she did not want to become old, poor or ugly.
King's College Hospital NHS Foundation Trust was represented by psychiatrist Dr S, who made the diagnosis of narcissistic personality disorder and opined this impaired "the functioning of her mind". Two other practitioners, Dr R and Professor P, gave supporting opinions.
Thus, three experts could find no mental disorder other than narcissistic personality, and Judge Alistair MacDonald found that C had sufficient mental capacity to decide to end her life.
Newspaper and other reports in 2004 told that Dr Harold Shipman, before his suicide, was regularly visited in Wakefield Prison by qualified professionals and no mental disorder was found.2
Psychological autopsi...Show MoreConflict of Interest:
None declared.
- 17 December 2015Oxybutynin for clozapine induced nocturnal enuresis.
Clozapine belongs to atypical antipsychotic of the dibenzodiazepine class. Clozapine is commonly used in treating, treatment resistant schizophrenia.Show More
Clozapine can cause several serious side effects such as agranulocytosis, seizures, hypotension, sialorrhoea, constipation, weight gain and nocturnal enuresis.
Nocturnal enuresis is a less known side-effect; reports estimate that it occurs in 0.23% (Aronowitz et al, 1995) and also can lead to poor medication compliance.
The patient, 35 year old, with long history of schizoaffective disorder was initiated on Clozapine. Clozapine was titrated over a period of 8 weeks up to 850mg in divided doses daily. As this patient reached this high dose of clozapine and within a week he starting complaining about bed wetting and initially he did not report but it was discovered by the domestic lady who reported it to the nursing team. It was apparent that the patient did not disclose it due to embarrassment and it would have been very likely that he could have stopped clozapine.
Another patient, 25 year of age and on clozapine 400mg OD, developed urinary incontinence much later on and responded well to Oxybutynin 5mg OD.
To control enuresis these patients were prescribed Oxybutynin 5mg at bed time and they responded well to this and appeared satisfied with in a few days. These patients were also advised to follow some measures such as emptying bladder before retiring.
Oxybutynin is an anticholinergic medi...Conflict of Interest:
None declared.
- 25 November 2015Possible delayed effect of unemployment on suicide in Spain
Suicide and suicide spectrum behaviours are influenced by personal (micro-socioeconomic) and social (macro-socioeconomic) issues(1). The latter include factors associated with economic crises (mainly unemployment but also personal debts and home foreclosures) have been consistently associated with increases in suicide rates (2), but a causal relationship between the current economic crisis and an increase in the suicide rate is not clear (3). Some recent data show that the effect of unemployment on suicide could be delayed (4). This finding could be relevant when establishing preventive policies (5).Show More
We studied the effect of time on the association between unemployment and suicide, using the official data about completed suicides and unemployment from the database of the National Statistics Institute (INE) and the National Employment Institute of Spain to assess the annual variations in unemployment figures and to correlate them with the annual change in the number of suicides. A Pearson correlation coefficient between unemployment trends and suicide trends was calculated both for the same year and after 1-6 years. We calculated seven different correlation coefficients: the first one matching the values for change in unemployment with changes in suicidality and the others comparing the unemployment trend with the suicide trend from one to six years after.
The correlation between annual change in unemployment and annual change in suicides varies depending on the...
Attachment(s)Conflict of Interest:
None declared.
- 27 October 2015Rapid onset resistant dystonia with low dose of Levosulpiride
A 40 years old female patient presented at emergency of a tertiary care hospital with complains of involuntary contraction of muscles of upper trunk and neck resulting in abnormal posture, involuntary movement of lower lips and of upper trunk for past 4 months with increasing intensity. Past history revealed that her initial complains was mainly of abnormal sensation in the ear with multiple somatic complaints for which she consulted an otorhinolaryngologist 1 year back who after initial treatment referred her to a psychiatrist considering her symptoms to be psychosomatic. A provisional diagnosis of anxiety disorder was made. She took Amitriptyline 10mg for 1 month and Levosulpiride 25mg for 4 months with moderate improvement of symptoms but following which the involuntary contraction of upper trunk and neck started which was soon followed by involuntary movement of lower lip and involuntary movement of both upper limbs. Initially the symptoms were mild but gradually increased in intensity. She had no past or current history of substance abuse nor any previous antipsychotic use or any past or family history of neurological disorder. On admission Abnormal Involuntary Movement Scale (AIMS) was applied, which came out to be positive with a global severity score of 4 and a total severity score of 20. Routine investigations revealed no abnormalities. T1 weighted MRI of brain was done which revealed mild cerebral atrophic changes. A provisional diagnosis of dystonia caused by Le...Show MoreConflict of Interest:
None declared.
- 27 October 2015Comfort internet browsing: the trend to alter mood states
Problematic internet use has been associated with psychiatric distress as well
for seeking online social comfort .1,2These emotional feelings increase the risk of developing internet addiction 3 There is dearth of documentation in internet addiction literature, whether psychological understanding terminologies like comfort eating, emotional eating & stress eating (to manage typically depression, anxiety, anger) is applicable to understand mood related online activities, though review indicates its association with co morbid psychological conditions. Available study in eating disorder indicates increased and decreased food intake was being associated with negative mood states .4 The case reported for management of excessive use of internet browsing at SHUT clinic (service for Healthy Use of Technology). It is India's first clinic to manage technology addiction.
A 26 years old user presented with the complaints of obsession-compulsive disorder and psychosocial dysfunctions(decreased social interaction, occupational and sleep disturbance) for the last 5 years. Premorbidly, user was found have anxious avoidant traits. The user has been on pharmacological treatment for above mentioned complaints and maintaining improvement. Clinical interview and internet addiction test was used to assess the user. Clinical interview revealed average use of 1-2 hours a day. It increased to 7 to 8 hours in situations characterised by increased dysphoric mood states. The usag...Show MoreConflict of Interest:
None declared.
- 27 October 2015Does section 63 of the Mental Health Act contravene the autonomous rights of mentally competent patients?
Section 63 of the Mental Health Act (MHA) states that the consent of a detained patient 'shall not be required for any medical treatment given to him for the mental disorder from which he is suffering' [1]. Significantly, there is no stipulation that a formal assessment of mental capacity is required prior to providing treatment to a detained patient. This apparent assumption in favour of mental incapacity is highly controversial as it is contrary to the principles of Mental Capacity Act (MCA) [2] and has led to proposals that mental capacity assessments should be mandatory for detained patients [3]. This is a very pragmatic recommendation but even if it were to be implemented, there are still several ethical and practical dilemmas that surround these patients and these shall now be explored via a hypothetical scenario involving two detained mentally ill patients – Patient X and Patient Y. Both patients are refusing treatment for their mental disorder and following a mental capacity assessment, Patient X is found to have capacity to make decisions about their treatment whereas Patient Y does not have capacity. Patient Y is relatively straightforward as they have been deemed to have a mental disorder severe enough to warrant detention under the MHA and have also been found to lack capacity under the MCA and thus treatment in their best interests can be justified.Show More
Patient X is more complicated and generates two interesting themes for debate. Firstly, is it possibl...Conflict of Interest:
None declared.
- 28 September 2015Refugees and Hosts: Tensions and Opportunities
Today, thousand of migrants are fleeing war, violence, repressive regimes and extreme poverty seeking refuge in new lands. Leaving behind them an ugly reality of life, they endure great hardship and violence on their journey only to arrive at a destination where restrictive policies often deny them adequate help with their basic needs: survival, wellness, freedom and identity (1). Each migrant's journey is a personal one. For some the process takes a few weeks; others may remain in mid-journey for generations. Some are seeking survival; others a better life.
Worldwide, refugees are seen as a cause of instability rather than people in need of protection. . Even for poor host countries-often at first hospitable- a shortage of resources quickly strain them (2). Migrants have become part of the global discussion about security with tensions breaking at a border crossing somewhere in the world almost every day.
News reports document the plight of refugees kept without shelters or on shores of receiving countries leading to a human morass of horrendous conditions. The host community attitude can often be suspicious and mistrustful as migrants are frequently portrayed as harboring infections dangerous to the host community (3). But it is the refugee community which is most at risk for disease and poor health outcomes. They are a vulnerable group whose health needs (physical and mental) require special consideration. They face hardship in their pre-journey (stres...Show More
Attachment(s)Conflict of Interest:
None declared.
- 28 September 2015Understanding patient experience of foundation doctors' involvement in their care – an important knowledge gap
In the UK there has been a long-standing problem recruitingsufficient trainees into psychiatric programmes, the Royal College of Psychiatrists has made concerted efforts to recruit more high calibre UK medical graduates1. In 2012, the overall fill rate for psychiatry CT1 posts was 83% (but increasing to 97% in 2013) with much of the deficit being met by international graduates. Studies in recent years have looked into factors which affect trainees' career choice regardingpsychiatry with reasons given by trainees for not considering psychiatry including a lack of respect from medical peers, perceived threat of violence and under-resourcing2. This has prompted interest in the experience of foundation doctors in psychiatry to generate a greater understanding of whether or not, and how, psychiatry placements influence decisions to become a psychiatrist; evidence is emerging that such placements can increase the likelihood of foundation trainees applying for core psychiatry training3.
Several studies have explored psychiatry patients' experiences of medical students' involvement in their care, andbenefit is suggested4,5.Medical student contact can improve the quality of care for patients, for example through allowing them to develop an illness narrative5.If it is accepted that a positive educational experience of a foundation placement in psychiatry increases the likelihood of applicati...Show MoreConflict of Interest:
None declared.
- 23 August 2015Disabling Blushing: Treatment options
Blushing is common but infrequent in most people, so physicians rarely consider it a disabling condition. This is changing as more blushers seek help, even surgery, from health professionals. Also, researchers now attend more to blushing in its own right or as part of social anxiety disorder (SAD). As DSM-5 states, blushing is a hallmark physical response of SAD.
We should differentiate non-disabling normal blushing which is expected in certain situations from blushing that causes distress and impedes a person's social interactions. A recent study found heterogeneity in blushers regarding their blushing. SAD patients who complain of blushing blush more often and/or have greater overall arousal in social situations than people who do not complain of blushing (1). Also, other evidence suggests a possible influence of less-active serotonin transporter (5-HTT) genetic variants on SAD patients' tendency to blush, which strengthens the idea that serotonergic dysfunction may affect the pathogenesis of SAD and of psychophysiological arousal in particular (2).
Some argue that blushing is always normal as it is adaptive in social situations for the individual and for the group, so it may not make sense to treat people for blushing. However, though turning red may have positive aspects, the blushing experience is not the same for everyone and those who seek medical help do so because their blushing impairs their quality of life. Furthermore, the fact that a symptom...Show MoreConflict of Interest:
None declared.
- 18 August 2015Dialectical behaviour therapy in politics?
Wolfgang Sperling and Helge H. Müller
Friedrich-Alexander University Erlangen-Nuremberg, Department of Psychiatry and Psychotherapy, Erlangen, Germany
Remarkably, the psychopathological phenomenon of a loss of logical control may not be limited to single individuals. In 2010, we postulated that a global panic reaction phenomenon in a stock exchange is an irrational, norm-deviant, community-based development that is comparable to the course of loss of logical control in an individual person (Sperling, Biermann & Maler, 2009).
Borderline personality disorder (BPD) is Cluster B personality disorder that is characterised by emotional instability. Primary symptoms include splitting or black-and-white thinking, which is a shift from idealising others to devaluing them. Other symptoms include a disturbed sense of identity, intense or uncontrollable emotional triggers that lead to chaotic interpersonal relationships, self-harming behaviour, impulsivity, marked sensitivity to, and negative criticism. These symptoms do not seem to be temporary. Instead, they are appear to be perm...Show MoreConflict of Interest:
None declared.
- 6 July 2015The Psychiatry of Entrepreneurship as a Pathway to International Security
Psychiatry specializes in the medicine of the mind and behavior, which uses a multi-disciplinary approach to help people to live healthy, meaningful, and safe lives. With today's increasingly knowledge-based creative economies, the physical and mental safety and well-being of people allows innovation to grow and societies to thrive. A unifying central goal of psychiatry is to promote mental health, and to create an inclusive dialogue on wellness that fosters open communication and access to timely information among a diverse global audience. The British Journal of Psychiatry with the launch of BJPsych Open provides a new forum with the social media capability for this type of worldwide conversation, bringing together academia, industry, non-profit organizations, governments, and individuals.
The psychiatry of entrepreneurship is emerging as a new field which recognizes the current mental health issues of those individuals and communities participating in the startup venture formation process.[1] While entrepreneurship is often associated with hubs of innovation such as California's Silicon Valley and London's Silicon Roundabout, the importance of mental health to the startup process is by no means limited to only developed economies. Maslow's hierarchy of needs as adapted for entrepreneurship teaches that conditions of well-being and safety are prerequisites for creative individuals to fully realize their innovation potential. New evidence suggests that entrep...Show MoreConflict of Interest:
None declared.
- 8 June 2015Is it time to review the MRCPsych examinations?
The MRCPsych examinations are the qualifying examinations for membership with the Royal College of Psychiatry and are generally undertaken in the second and third year of core training. In combination with workplace-based assessments and the Annual Review of Competency (ARCP) the exams are essential to progressing to advanced training and eventually a Certificate of Completion of Training (CCT). The exams currently involve three multiple choice (MCQ) format papers and a single clinical skills examination consisting of 16 varied stations (CASC).
No one doubts that to pass the exams necessitates a significant investment of time and energy, which detracts from trainees' experience on clinical placements, other educational opportunities, and their personal lives. Trainees' efforts should be rewarded with a process of learning and enrichment that develops their skills and knowledge, not simply another 'hoop to jump through' on their way through training. The MRCPsych courses offered by training hospitals go some way towards providing additional education, however it is significant that trainees universally rely upon practice questions rather than course attendance to pass exams. Some trainees will even pay for additional privately-run courses that focus solely on preparation for the exams. This suggests a fundamental disconnection between the exams and the learning objectives of training programs that, in my opinion, needs to be bridged.
The cu...Show More
Attachment(s)Conflict of Interest:
None declared.
- 8 June 2015Deliberate Foreign Body Ingestion as Primary Form of Severe Self-Harming Behaviour in Borderline Personality Disorder
Self-harm in borderline personality disorder (BPD) is common, with 60-70% of patients deliberately harming themselves and 10% eventually going to kill themselves (1). We report a rare case of acute- onset primary deliberate foreign body ingestion (DFBI) in a patient with BPD that has caused on-going psychiatric hospitalizations, more than 100 endoscopic interventions but has not shown any transition into other self- harming modalities.
Case Report:
A 22-year-old female was admitted to our emergency room after a series of psychogenic seizures. In the psychiatric exploration she reported the urge to swallow a large knife and investigated her surroundings for objects....Show MoreConflict of Interest:
None declared.
- 8 June 2015Cost effectiveness of Paediatric Liaison CAMH Services
Given the close links between child physical and mental health and the actual gap between paediatric physical and mental services, the desirability of hospital paediatric liaison mental health services (PL CAMHS) may be regardedas self-evident.Nevertheless dedicated PL CAMHSs in the UK are few and far between(1), and they are also highlyvulnerable to service cuts.
Hospital liaison mental health services for adult patients were given renewed impetus by evidencethat,in addition to effects on health and wellbeing, theycan reduce hospital admissions and health costs (2).
Although there has hardly been any research into the financial implications of PL CAMHS, the indications are that they are also likely to be cost effective. Child psychiatrists working in PL settings easily cite examples of children incurring high health service costs through extensivemedical contacts, investigations and hospital admissionsfor what turn out to be hidden underlying psychiatric problems.
Somatoform disorder presentations with functional physical symptoms are common reasons for referral to PL CAMHS teams (3) and can be successfully and cost effectively treated with evidence informed interventions. North and Eminson(4) described the case of an 11-year old girl with a somatoform pain disorder and documented how the medical costs incurred over the two years prior to the PL CAMHS referral reduceddrastically thereafter.
The health costs of paediatric functional physical sym...Show MoreConflict of Interest:
None declared.
- 22 April 2015The Post-2015 Sustainable Development Agenda – Are We Doing Mental Health Justice?
In current times of increasing global conflict, we must address the psychosocial needs associated with population-wide exposure to disease, death, and distress. One chief example of this is in the Ebola Outbreak in West Africa, where adequate provision of mental care will be essential in combating the long-term sequelae of the disease.1 This year also marks the target date for the Millennium Development Goals, which have led to worldwide improvements in health and well-being over just 25 years. Global leaders are now finalizing a new set of objectives for global development: the Sustainable Development Goals (SDGs).
It is known that lack of investment in the mental health of populations is a key driver of poverty and inequality.2 The World Health Organization recently hosted its first Ministerial Conference on Global Action Against Dementia, in March 2015. Ministers from around the world came together for the first time to discuss the global problems posed by dementia. Renewed focus on mental health post-2015 will prove valuable in addressing population demands and achieving universal health coverage.
Despite the increased awareness of mental health issues, political commitment to reduce the global burden of mental illness is limited. Of the 17 currently proposed UN post-2015 SDGs, only one is health-related.3 Within this broad goal to improve health, three objectives are dedicated to maternal health and reproductive care, yet only one mentions mental healt...Show MoreConflict of Interest:
None declared.
- 23 March 2015Evolutionary Ideas
The interaction between the genetic structure with which we are born and the impact of the environment in which we are nurtured has increasingly come into focus. There has for some time been evidence from studies of rhesus monkeys that early environments and specifically the nature of the relationship between the infant monkey and the mother/caregiver, or lack of caregiver, has a profound effect on the development of the infant's brain itself as well as its functioning.
Stephen Suomi runs the Laboratory of Comparative Ethology at the National Institute of Child Health and Human Development in Bethesda, Maryland USA. He has established that there is a group of rhesus monkeys which exhibits deficits in neurobehavioural functioning in infancy, increased risk taking, poor control of aggression and low serotonin metabolism during juvenile and adolescent development, and excessive affinity for alcohol when it is offered in early adulthood – a highly artificial situation. (It is not hard to see parallels with humans.) These features he found to be associated with a specific polymorphism of the serotonin transporter (5-HTT) gene; however what he and his colleagues then established was that the variations in brain biochemistry and the manifest negative behaviour only occurred when the infant had been separated from the mother and "brought up" by their peers and were thus deprived of consistent maternal care. By contrast those with this polymorphism brought up by good mother...Show MoreConflict of Interest:
None declared.
- 20 March 2015Entering the Dragons Den; A fairytale of leadership and management development
The message from the medical profession is that all doctors should attain leadership and management competences in addition to clinical knowledge to be an effective practitioner. As a trainee there is little opportunity to establish a footing in this role and develop relevant competencies.Show More
This is a story of one registrar who entered the Dragons lair and emerged a more rounded practitioner. This fairytale begins with an opportunity to present a business proposal to a panel of medical education leads within TEWV NHS Trust, akin to the NHS version of the BBC's Dragons Den.
I focused on my work within liaison mental health where there was a noted a surge of referrals relating to delirium diagnosis and management. Staff on the acute wards appeared to lack confidence in identifying cases and managing behaviours relating to it.
Following a literature search there was evidence, albeit limited, relating to the benefit of simple ward based teaching interventions, there was more evidence for multi-dimensional approach which led to a greater effect size.
I formulated a business proposal to bid for resources from an innovation budget by the Trust Medical Education department, then took my stand before the Dragons. Stating this was a daunting experience is an understatement. I created my first business plan to develop a small teaching package, with a lightweight shield of evidence and experience I had it scrutinised by the fire breathing panel.
I returned...Conflict of Interest:
None declared.
- 18 March 2015The importance of measures to encourage appropriate use of mobile phones and related devices by young students: Preventing deterioration in mental and physical health and encouraging adequate sleep
Measures to foster mental health among young people are important (1). The current excessive use of smartphones and mobile phones by students in Japan and elsewhere in the world is likely to have a number of effects that warrant attention. Detailed studies of school/academic, family, and health problems related to mobile phones must be conducted, and measures to prevent those problems must be implemented.Show More
Media reports from February 9, 2015 described the results of a survey of smartphone use among students in Japan (2,3). The survey indicated that roughly 39% of elementary school students, 60% of junior high school students, and 96% of high school students use smartphones. Smartphone use was most prevalent among female high school students (98.1%). The average amount of smartphone or mobile phone use per day was approx. 1 h for elementary and junior high school students, 4.1 h for male high school students, and 7 h for female high school students. Approximately 24% of the female high school students surveyed use a smartphone or mobile phone from 0:00–3:00 a.m.
The use of electronic devices in childhood can cause a lack of sleep, and such use can also cause daytime fatigue and lessened physical activity. One study cited the need to consider implementing measures to prevent the excessive use of smartphones and mobile phones, as part of school health programs (4). A large-scale survey of approx. 18,000 junior high school and high school students in Japan reveale...Conflict of Interest:
None declared.
- 17 March 2015Depression and the Media: A Change in Media Perception Can Change Minds
Depressive disorders are a leading cause in the Global Burden of Disease. With regularity,scientific publications as well as mass media discuss the disease itself and most successful therapies which is currently Cognitive Behavioral Therapy (CBT) [1,2].It is often argued that a combination of e.g. inadequate social comparison processes, negative cognitive beliefs, and low coping skills is fundamental to CBT. Surprisingly, the importance of including mass media in discussions concerning the success of CBTs is almost completely disregarded. At the same time, cumulative evidence in the field of media research shows that mass media massively influence human emotions [3], cognition, and behavior [4]. Since mass media are consumed by nearly everyone, they can thus influence the depressive patient in diverse.
Here, we want to make the case for a "false consensus bias" between patients' media use and experts' opinions about the impact of mass media on therapeutic success within CBT. And, we want to direct at non-stationary therapists and stationary clinicians who are experts in treating depressive disorders: On the one hand, depressed patients who were not completely media abstinent often presume strong media influences on themselves in the context of depression. On the other hand, clinicians often ascribe nearly no influence to mass media within CBT. In this sense, patients will not make their media experiences a topic of discussion within CBT since they consider such expe...Show MoreConflict of Interest:
None declared.
- 13 March 2015ToMShow More
ToM(theory of mind) is defined as the capacity to detect and reason about other people's mental states e.g. beliefs, intentions(1). This rather narrow definition, in my opinion, has inadvertently kept out so much evidence pertaining to decision making and behavioural economics theories. A deficit in ToM was proposed as a predisposing factor for persecutory delusions (2) as well as schizophrenia and autism. However, thi...Conflict of Interest:
None declared.
- 6 February 2015Recent de-criminalisation of suicide attempts in the Indian sub-continent (Deletion of Section 309 of the Indian Penal Code):Thoughts of a UK-based Consultant Psychiatrist of Indian originSection 309 of the Indian Penal Code was deleted in India in December 2014. This de -criminalizes suicide attempts in India . A brave and decisive move but what are the different facets of mental illness in India? I have been a Consultant Psychiatrist for over 6 years in the UK. Being of Indian origin (With strong links professionally and personally in India) and working with serious mental illness, high risk and suicidality on...Show MoreConflict of Interest:
None declared.
- 6 February 2015Just Passing ThroughShow More
Modified release medications are known to improve (Osterberg, 2005) patient compliance with medication plans, but we write to raise alertness of a situation where the lengthened time of absorption may result in the desired drug dose not being attained, and where preparation design may result in patient concern.
A 62 year old gentleman with a history of recurrent depressive disorder since at least...Conflict of Interest:
None declared.
- 6 February 2015The Politics of ResearchShow More
It's great to see the BJP opening a mature and professional dialogue on the relevance of psychedelic medicine for psychiatric and psychotherapeutic treatments. These dialogues, as the two editorials by Ben Sessa, Matthew Johnson, and David Nutt stated, were abruptly aborted at the end of the 60's, after widespread recreational use led to knee jerk political and regulatory reactions. 40 years of research censorship might...Conflict of Interest:
None declared.
- 9 January 2015The importance of coordinated clinical and social medicine efforts to discourage the use of 'legal high drugs' in JapanShow More
Drug-related problems continue to be a serious and increasing social issue.1-3 Japan has recently suffered a spate of traffic accidents involving the use of 'legal high drugs', i.e., drugs that are not illegal but provide a 'high' similar to that obtained with cannabis or other illegal substances. The number of deaths in Japan linked to legal high drugs in approximately two-year period since 2012 was 41, and the media...Conflict of Interest:
None declared.
- 9 January 2015Re:Referendum MadnessShow More
While Taylor et al are justified in reporting the psychiatric downside of the Scottish independence referendum, an upside is worth mentioning. For a brief time, asking, "Is there a big vote coming up?" gave busy Scottish psychiatrists a cognitive assessment unsurpassable in brevity and sensitivity.
It was hard, on 19 September, waking up to the Addenbrooke's again.
Conflict of Interest:...Conflict of Interest:
None declared.
- 8 January 2015Occlusal dysesthesia responded to Gabapentin - a rare case reportShow More
Dysesthesia is defined as an unpleasant abnormal sense of touch. It often presents as pain but may also present as an inappropriate, but not discomforting, sensation. Occlusal dysesthesia, or "phantom bite," is characterized by the feeling of a biting sensation in the absence of any apparent damage to oral or maxillofacial structures or tissue, usually in patients that have undergone recent dental surgery1,2. The patien...Conflict of Interest:
None declared.
- 8 January 2015Mirtazapine associated increased libido following the termination of anti-HCV therapyShow More
To the Editor,
As we know, several types of antidepressant, especially selective serotonin reuptake inhibitors (SSRIs), have sexual dysfunction as a side effect.1-3 Most of these cases have decreased libido, impotence, or orgasm disorder following the antidepressant prescription. However, a few cases are diagnosed with antidepressant-related increased libido. Here, we want to present the case of a woman who had...Conflict of Interest:
None declared.
- 19 December 2014Challenges faced by CAMHS psychiatrists - a case presentationShow More
Psychotropic medication as the mainstay for managing challenging behaviour for children and adolescents with intellectual disability is not regarded as good practice. "Behaviour" has no formal diagnostic status, and no clear connections to psychotic illness1. However at times, the nature of the presentation is such that despite intensive input from multidisciplinary team (MDT), the CAMHS psychiatrist has no option but to...Conflict of Interest:
None declared.
- 15 December 2014Referendum MadnessShow More
On September 18th, 2014, Scotland saw 85% of the electorate vote on independence from the UK. Over the subsequent weeks, the Intensive Home Treatment Team (an alternative to psychiatric hospitalisation) in Edinburgh has seen a number of individuals who mentally decompensated during and after the referendum. Here we present an overview of these cases, and reflect on the relationship between public events and an individua...Conflict of Interest:
None declared.
- 5 December 2014Medically unexplained symptoms with mobile phone useShow More
The use of mobile phones has increased dramatically, with over 3 billion people currently using mobile phone worldwide & India has the second largest mobile phone users .1,2With the increased use of mobile phones, report of the development of symptoms such as headache, sleep disturbance, memory loss, dizziness, and burning sensations during or after mobile phone use have been frequently seen among the users.3,4 Users...Conflict of Interest:
None declared.
- 5 December 2014Information technology use: implication for expression of psychopathologyShow More
The use of technology serves as a cost effective way to gather information as well as to relate to others. The usage of information technology do manifest as excessive use or as a way of coping with environment. Internet use is being associated with depression,distress, loneliness and decreased social interaction.1,2 Even subjects with psychiatric disabilities (95%) reported searching the Internet for diagnosis-specific...Conflict of Interest:
None declared.
- 7 November 2014Simulation of mental health act assessmentsShow More
Dear Editor,
As a junior trainee working in psychiatry I have been present at only a handful of mental health act assessments. Most recently I was present at a very difficult assessment because the person being assessed was very much on the boarder of being detainable. This young man was clearly trying very hard to fight his case and I really felt the fear and emotion with which he fought his corner not to be deta...Conflict of Interest:
None declared.
- 7 November 2014Psychopathology: the new epoche attitudeShow More
Psychopathology must stand for what it ever has been: the basic science for all psychiatric knowledge. So do Stanghellini and Broome (1) claim in their editorial referring to Jaspers' phenomenological approach. Yet we here wish to carry on the debate further than a Jasperian approach which is likely to be caught up in the natural vs human sciences opposition. The core issue may therefore be phrased as follows: is psycho...Conflict of Interest:
None declared.
- 7 November 2014Self-medication with "bath salts" for symptoms of ADHD followed by severe psychosis and hyperkinetic symptomsShow More
Dear Editors,
The abuse of synthetic cathinones ("bath salts") has been increasing worldwide (1). Here we would like to present a case of abuse, raising several issues that, to our knowledge, have not been considered, yet. Mr. W., a 23-year old man, was admitted to a psychiatric inpatient ward of the Medical University of Vienna because of a psychotic disorder with auditory hallucinations complicated by long-term...Conflict of Interest:
None declared.
- 7 November 2014ATPD: Unrecognized or Atypical Mixed affective state?Show More
Acute and transient psychotic disorder (ATPD) is defined as a brief psychosis with acute onset and polymorphous symptomatology1 and has consistently been demonstrated to be diagnostically unstable in follow-up studies, leading to implications for further research and status review.2 The overall stability rates of ATPD diagnosis in follow-up studies ranges from 34.0% to 73.0% over 1-5 years, converting mainly to Bipolar a...Conflict of Interest:
None declared.
- 10 October 2014Electronic Monitoring of Forensic Patients- author's replyWe welcome the correspondence of both Simpson and Penney and Watson et al to our recent editorial on electronic monitoring (EM). We had hoped the article would stimulate a balanced discussion about this complex issue. We entirely agree with the view expressed in both letters that trust and therapeutic alliance between the patient and the treating team is a critical component of the recovery process. We do not believe however tha...Show MoreConflict of Interest:
None declared.
- 23 September 2014Limitations in value of psychiatric rating scales in medico-legal practiceShow More
During recent years rating scales, such as those for depression, post -traumatic symptoms and substance misuse, have been increasingly used in preparing medico-legal reports but it may not be clearly understood by the courts that:
i) Most scales were not originally designed for medico-legal work and are not used regularly in everyday clinical practice. They are mostly used in research involving large samples of pat...Conflict of Interest:
None declared.
- 23 September 2014Culture bound Pica - first report from IndiaShow More
Dear Editor, Pica relates to the habit of eating non- food items of non nutritive value (1). Pica is prevalent among certain cultures and communities. The Chagga females of Africa are well known for their culture of eating soil relating it to the best outcomes in fertility and reproduction (2). Kaolin or chalk eating is observed among the residents of Georgia (3). In certain parts of Haiti, the eatables made out of mud a...Conflict of Interest:
None declared.
- 18 September 2014Re: Psychopathology as the basic science of psychiatry.Show More
The editorial written by Stanghellini and Broome outlined a fundamental issue, often neglected by the scientific community, of contemporary psychiatry: its relationship with psychopathology. Since the introduction of the DMS III, as outlined by Nancy Andreasen1 in an editorial a few years ago, American and subsequently Anglo-Saxon psychiatry have started the process of detaching itself from the study and t...Conflict of Interest:
None declared.
- 9 September 2014Measurement of depression and anxiety problems has not kept up with theory and evidenceShow More
I am concerned that the measurement of depression and anxiety problems is falling behind the theory and evidence. This is a central concern because measurement fundamentally shapes conceptualisation, research and clinical practice. This letter is a call to re-start the scientific cycle again so that current knowledge regarding depression and anxiety problems once again closely underpins endeavours to measure these const...Conflict of Interest:
None declared.
- 9 September 2014The stigma attached to borderline personality disorder- Deep rooted and untreatable?Show More
Dear Editor
Working as a health care assistant in psychiatry I regularly encountered negative descriptions of BPD patients, adjectives such as "difficult", "attention seeking", "manipulative", "demanding" and "treatment resistant" were regularly used. Now as a medical student opinion of this group of patients remains similar, with some expressing the view that mental health services are unable to help individua...Conflict of Interest:
None declared.
- 9 September 2014Psychological Formulation: A Naked Emperor?Show More
Psychiatry is of course "used to being attacked by external parties with antidiagnosis and antitreatment agendas" (Nutt, Goodwin, Bhugra, Fazel and Lawrie , 2014) often by fellow clinical psychologists who argue that 'psychological formulation' is a superior way of understanding people with mental distress and the natural successor to diagnosis. "Diagnosis has itself become a dirty word, regarded as simile for 'labelling'...Conflict of Interest:
None declared.
- 9 September 2014A vulnerable young person unable to obtain a psychiatric bed until detained under the Mental Health ActShow More
It was with a sense of familiarity that I read recent BBC news article entitled "Patients sectioned 'because of pressure on beds'" . As a core trainee currently working in child and adolescent liaison psychiatry in a busy central London hospital, it is unfortunately a situation I am facing with increasing frequency. In particular, I was reminded of a patient I was involved with in recent weeks; a seventeen year old adole...