Advances in Psychiatric Treatment recent issues

[Editorials] The needs of new consultants

Beezhold, J. — 2008-08-29

This editorial discusses the needs of new consultants with reference to existing research and attempts made to meet these needs both within the Royal College of Psychiatrists and elsewhere. Some future challenges for new consultant psychiatrists are identified and discussed. Initiatives that can help meet their needs on a personal and also on an organisational level are suggested. A call is made for new consultants to take control of their own destiny using tried and tested methods and thereby creating hope for their future.

[Editorials] Delivering race equality in mental health services

Lau, A. — 2008-08-29

‘Delivering race equality’ is a 5-year action plan for tackling race inequalities in mental healthcare in England and Wales, based on the main themes of improved services, better community engagement and better information. The perception is that clinical teams have not been sufficiently engaged with the plan and progress is slow. This article shares insights from the author’s work across government departments over the past 2 years and explores the potential for linking up different initiatives across the patient care pathway in support of the plan’s delivery. A summary of conclusions from a pilot survey of consultant psychiatrists, commissioned by the Department of Health in June 2007, addresses the main controversial areas in the action plan, with suggestions for improvement. Areas for clinical engagement are identified that exploit new funding, investment and policy initiatives. Examples of good practice are offered.

[Articles] Atypical antipsychotics in bipolar disorder: the treatment of mania

Cookson, J. — 2008-08-29

The development of atypical antipsychotics has stimulated research on the treatment of mania. Several well-established options now exist for monotherapy of mania. None of the atypicals has shown greater efficacy than haloperidol in improving manic symptoms, but they all produce fewer extrapyramidal side-effects and they may differ in their effects on depressive symptoms. Combinations of an antipsychotic with lithium or valproate offer further options, with somewhat greater efficacy in treating mania but also with more side-effects.

[Articles] 'Public psychiatry': a neglected professional role?

Smith, M. J. — 2008-08-29

The importance of mental health to our social, financial and physical well-being has gained better recognition in recent years. The work of psychiatry is to understand, prevent and treat mental illness, and should therefore be of compelling interest to the public. Yet few care about the profession or practice of psychiatry other than psychiatrists themselves. The public and the profession would both benefit from a ‘conversation’ about practical, moral and political aspects of contemporary mental health. This should be a dialogue of equals, distinct from didactic approaches to ‘public education’ or from a ‘media psychiatry’ that exists primarily to entertain. This discourse would help to improve care, diminish stigma, promote recovery and improve the status of the profession itself. This article proposes that this kind of ‘public psychiatry’ should take its place as one of four interdependent professional domains.

[Articles] 'Public psychiatry': a challenge for the profession?: INVITED COMMENTARY ON... 'PUBLIC PSYCHIATRY'

Yeomans, D., Drake, F. — 2008-08-29

Michael Smith’s article considering the present and future of ‘public psychiatry’ assumes the continued existence of psychiatry following a conversation with the public. But what if the public does not want psychiatry?

[Articles] CADASIL: a guide to a comparatively unrecognised condition in psychiatry

Taylor, M. H., Doody, G. A. — 2008-08-29

This guide to the neurological disorder cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is specifically targeted at psychiatrists. The aims are to enhance awareness, provide educational clinical information and offer practical guidance on management of the disorder. An overview of diagnostic algorithms and recent research is also provided.

[Articles] Night Sister

2008-08-29

[Articles] Self-determination theory: a framework for the recovery paradigm

Mancini, A. D. — 2008-08-29

Recovery is an increasingly important concept in mental health services research and policy-making. However, despite burgeoning interest in the concept, no overarching theoretical or empirical framework has been offered to support its key ideas. Further, it is often unclear how recovery ideas translate into routine practices of mental health programmes and practitioners. In this article, a theoretical framework for recovery ideas is derived from self-determination theory, a widely researched and empirically validated theory of human need fulfilment. I discuss the conceptual overlap of self-determination theory and recovery ideas, and, using key motivational concepts, develop a typology of recovery-oriented practices for three hypothetical programme types (controlling, traditional/paternalistic and recovery oriented). I describe existing measures of recovery-oriented practice and consider the implications of self-determination theory for measurement of and research on recovery-oriented practice.

[Articles] Another step towards understanding recovery?: INVITED COMMENTARY ON... SELF-DETERMINATION THEORY

Abbott, P. — 2008-08-29

Self-determination theory has been offered as a potential theoretical framework for recovery. It has been argued that a concept as wide-ranging as recovery seems likely to require a number of theoretical frameworks, including self-determination theory, which appears to be particularly applicable to the clinical and social dimensions of this concept. With its emphasis on social competence and environmental support, self-determination theory may be particularly useful as a framework for considering recovery in client groups with higher levels of service need associated with disability or risk.

[Articles] Keeping PACE: fitness to be interviewed by the police

Ventress, M. A., Rix, K. J. B., Kent, J. H. — 2008-08-29

The second half of the 20th century witnessed a number of serious miscarriages of justice that resulted from improper police interviewing of suspects and unreliable and false confessions. To prevent miscarriages of justice involving people with mental disorder or particular mental vulnerabilities, psychiatrists have a role in determining the fitness to be interviewed of persons suspected of criminal offences. In this article, the role of the psychiatrist in assessing fitness to be interviewed is set against the background of the latest revisions of the Codes of Practice of the Police and Criminal Evidence Act 1984 and relevant case law in England and Wales.

[Articles] Applying telecare in dementia: what psychiatrists need to know

Siotia, R., Simpson, C. — 2008-08-29

Recent technological advancements have been used to help people with dementia remain independent. These are reviewed and case vignettes are used to explain their use in common scenarios. The ethical perspective and current evidence are explored in the context of telecare use.

[Articles] Article 3 of the Human Rights Act 1998: implications for clinical practice

Curtice, M. — 2008-08-29

The Human Rights Act 1998 was introduced into UK law in 2000. It must be considered in all clinical cases, including mental health review tribunals. The number of mental health cases brought to the European Court of Human Rights that breach Article 3 has been very few. However, Article 3 will need to be considered in the clinical setting in complaints arising from conditions of detention, seclusion, control and restraint. This article analyses the case law, illustrating its evolution and also demonstrating the fundamental and core concepts that underpin the Act that can be used in clinical practice.

[Correspondence] Recovery and medical model - yes, science does matter

Mountain, D., Shah, P. J. — 2008-08-29

[Correspondence] Fragile male, not fragile-X

Kraemer, S. — 2008-08-29

[Correspondence] Smoking bans and clozapine levels

Ashir, M., Petterson, L. — 2008-08-29

[Correspondence] Personality disorder in older adults: a pilot treatment model

Scott, L. M. A., Kemp, E. — 2008-08-29

[Correspondence] Catatonia in present day society

Morgan, S. A., Hank, D., Rogers, D. — 2008-08-29

[Editorials] Recovery and the medical model

Mountain, D., Shah, P. J. — 2008-06-30

The recovery approach is much in vogue, initiated by the user movement and embraced by politicians. Users and politicians have a variety of opinions about how it fits with professional psychiatric practice – some view recovery and professional practice as compatible, others view them as mutually exclusive, naming professional practice the ‘medical model’. This editorial explores the relationship between the medical model and the recovery approach. We argue that both have multiple points of similarity, and that applying the medical model to the recovery approach has the potential to significantly influence psychiatric practice.

[Articles] Is there a science of recovery and does it matter?: INVITED COMMENTARY ON... RECOVERY AND THE MEDICAL MODEL

Holloway, F. — 2008-06-30

In this issue of APT Mountain & Shah seek to reconcile the currently fashionable ‘recovery’ paradigm of mental healthcare with the distinctly unfashionable ‘medical model’ of psychiatric practice. I argue that their article raises more questions than it answers – not least whether the recovery concept is amenable to empirical analysis.

[Articles] Inflammation and its relevance to psychiatry

Cavanagh, J., Mathias, C. — 2008-06-30

Depression is increasingly recognised as a major public health problem worldwide. The heterogeneity of this condition implies that there may be several neurobiological pathways to depression. This article attempts to explore a pathway that links depression with the inflammatory response. Associations linking inflammation and chronic immune activation with depression have been noted, particularly in the context of (a) medical disorders with inflammatory pathophysiology and (b) immunotherapy for cancer and hepatitis C. Acute coronary syndrome is given as an example of how the inflammatory process might result in depression, and potential mechanisms are discussed. These include: direct action of pro-inflammatory cytokines on the serotonin system, with specific reference to the serotonin transporter; action of cytokines on the hypothalamic–pituitary–adrenal axis; and effects of pro-inflammatory cytokines on neurogenesis in the hippocampus. Reference is made to the potential anti-inflammatory effects of antidepressant drugs and antidepressant effects of anti-inflammatory treatments.

[Articles] Big boys don't cry: depression and men

Branney, P., White, A. — 2008-06-30

Men are a numerical minority group receiving a diagnosis of, and treatment for, depression. However, community surveys of men and of their mental health issues (e.g. suicide and alcoholism) have led some to suggest that many more men have depression than are currently seen in healthcare services. This article explores current approaches to men and depression, which draw on theories of sex differences, gender roles and hegemonic masculinity. The sex differences approach has the potential to provide diagnostic tools for (male) depression; gender role theory could be used to redesign health services so that they target individuals who have a masculine, problem-focused coping style; and hegemonic masculinity highlights how gender is enacted through depression and that men’s depression may be visible in abusive, aggressive and violent practices. Depression in men is receiving growing recognition, and recent policy changes in the UK may mean that health services are obliged to incorporate services that meet the needs of men with depression.

[Articles] Big boys do cry: INVITED COMMENTARY ON ... BIG BOYS DON'T CRY

Smith, M. J. — 2008-06-30

Do men comprise a minority group whose distress would be better understood by positing a new ‘male depressive syndrome’? Or have gender differences been overemphasised for political reasons that are clinically unhelpful? An unedifying list of mistaken categories of depression advocates caution.

[Articles] The Dying Child: a poem by John Clare

2008-06-30

[Articles] Disability rights and mental health in the UK: recent developments of the Disability Discrimination Act

Sayce, L., Boardman, J. — 2008-06-30

The Disability Discrimination Act, passed by Parliament in 1995 and amended in 2001 and 2005, covers people in Britain with physical or mental impairments that have a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities. The Act has been important in setting a framework for good practice and it can stimulate more systemic change through formal investigations of organisations or whole sectors, and through the Disability Equality Duty, in force since December 2006. The Disability Discrimination Act has implications for people working in mental health services when they are considering employment and educational opportunities for service users, and when they are considering how to redress systemic disadvantage, including inequalities in physical health.

[Articles] Neuropathica diabolica

Bourke, J., Turner, B. — 2008-06-30

In 1951 Asher described chronic factitious disorder characterised by dramatic presentations, histories and recurrent admissions. Asher initially described three types of presentation – acute abdominal (laparotamophilia migrans), haemorrhagic (haemorrhagia histrionica) and neurological (neuropathica diabolica). Factitious disorder is now included in both DSM–IV and ICD–10. Numerous case reports exist but the evidence base for effective management strategies remains relatively sparse. It is an uncommon disorder most often encountered in liaison psychiatry that remains difficult to manage and characteristically stimulates strong countertransference reactions in the teams involved. Psychiatric involvement remains vital in such cases although poor engagement is often a significant obstruction. As an illustration, we present a vignette based on case of a previously unreported variant of the neurological category involving Guillain-Barré syndrome.

[Articles] Confidentiality in Munchausen's syndrome: INVITED COMMENTARY ON... Neuropathica diabolica

Farmer, A. E. — 2008-06-30

This commentary questions whether the usual ethical and legal requirements for maintaining confidentiality of individuals who fabricate illness should be breached in order to prevent further harm to themselves as well as cost to society. A case report of an individual with Munchausen’s syndrome submitted for publication in Advances in Psychiatric Treatment provoked considerable Editorial discussion regarding the absence of written informed consent from the individual described. It is hoped that this commentary will widen the debate regarding the requirement for confidentiality in the exceptional circumstances of patients with Munchausen’s syndrome.

[Articles] Improving mental healthcare for ethnic minorities

McKenzie, K. — 2008-06-30

Multicultural societies offer a significant challenge to mental health services. Different groups have different rates of illness, illness models, ideas of what a suitable pathway of care is and what suitable care looks like. Trying to set up services to meet all these needs can be difficult. There may need to be modifications in clinical practice, service configuration and the way services are commissioned. Ethnic minority communities face complex problems and, consequently, strategies to deal with them can be complex, requiring support from the non-statutory sector, social services and other branches of medicine. Service development often needs research, staff training, race-equality schemes and sufficient funding to make change possible. I offer here a scheme for considering how to think through service development in this area as well as introducing the government strategy, Delivering Race Equality.

[Articles] The active management of delirium: improving detection and treatment

Meagher, D., Leonard, M. — 2008-06-30

The management of delirium requires careful consideration of the potential value both of pharmacological interventions and of a range of non-drug strategies. Although placebo-controlled studies of delirium treatment are lacking, less robust evidence can still inform practice. This review makes the case for more active management of delirium on the basis of recent studies of prevention, early identification and treatment both during an episode and managing the aftermath in survivors. A drug-treatment algorithm for delirium advising how drug treatments can be tailored to the specific needs of individual patients is described.

[Articles] Rural mental health

Nicholson, L. A. — 2008-06-30

A significant proportion of people live and work in rural areas, and rural mental health is important wherever psychiatry is practised. There are inherent difficulties in conducting rural research, due in part to the lack of an agreed definition of rurality. Mental health is probably better in rural areas, with the exception of suicide, which remains highest in male rural residents. A number of aspects of rural life (such as the rural community, social networks, problems with access, and social exclusion) may all have particular implications for people with mental health problems. Further issues such as the effect of rural culture on help-seeking for mental illness, anonymity in small rural communities and stigma may further affect the recognition, treatment and maintenance of mental health problems for people in rural areas. Providing mental health services to remote and rural locations may be challenging.

[Articles] What can the science of well-being tell the discipline of psychiatry - and why might psychiatry listen?

Hanlon, P., Carlisle, S. — 2008-06-30

There is a field of knowledge that speaks of the promotion of positive mental health, well-being and happiness yet it may not be well-known to all psychiatric practitioners. Economists, geneticists, positive psychologists, evolutionary psychologists, neuroscientists and sociocultural researchers have all contributed to what might be termed the emerging science of well-being. This article provides a brief introduction to this complex topic. We outline some of the findings, theories and arguments from this comparatively new but burgeoning research area. We also rehearse some critical responses to this field which indicate that both the evidence on well-being and the implications for practice and policy might be less straightforward than researchers sometimes imply. We conclude by suggesting that psychiatrists, as leaders in the field of mental health, might want to consider the implications (positive and negative) of well-being research for the development of their own discipline and professional practice.

[Editorials] Deliberate practice and CPD in psychiatry

Bhugra, D. — 2008-04-30

Deliberate practice (the seeking of situations in which one’s skills are challenged and thus improved) is key to the acquisition of clinical expertise. This editorial outlines the philosophy of deliberate practice and potential difficulties in making use of it in psychiatry.

[Editorials] Psychiatry and the arts: new interfaces?

Green, J. — 2008-04-30

I discuss the productive interface between psychiatry and the arts in the 20th century and ask whether such an interface is likely to remain as vibrant into the 21st. I review how new models of mental functioning that have an impact on current psychiatric practice have a wider cultural relevance. This editorial looks forward to a series of articles in future issues of APT which will explore some of these ideas in more detail.

[Articles] Mentalisation and metaphor in poetry and psychotherapy

Holmes, J. — 2008-04-30

People turn to poetry and to psychotherapy when in states of heightened emotion – love, elation, despair, death and loss. Through the analysis of a particular poem this article suggests that there are formal similarities between poetry and psychotherapy that can illuminate the workings of the latter. Perhaps the most overarching of these is mentalisation: the capacity to ‘think about feelings’ or to be ‘mind-minded’. Finding the ‘right words in the right order’ is a task for therapists and their patients as well as for poets, since the appropriate image or metaphor can mirror or evoke feelings in the listener in a way that facilitates empathic attunement. If feelings can be objectified, their power to distress or overwhelm is mitigated. Thus, poetry and psychotherapy are similarly concerned with processes of repair of the human experiential and communicative fabric.

[Articles] Detained - what's my choice? Part 1: Discussion

Roberts, G., Dorkins, E., Wooldridge, J., Hewis, E. — 2008-04-30

Choice, responsibility, recovery and social inclusion are concepts guiding the ‘modernisation’ and redesign of psychiatric services. Each has its advocates and detractors, and at the deep end of mental health/psychiatric practice they all interact. In the context of severe mental health problems choice and social inclusion are often deeply compromised; they are additionally difficult to access when someone is detained and significant aspects of personal responsibility have been temporarily taken over by others. One view is that you cannot recover while others are in control. We disagree and believe that it is possible to work in a recovery-oriented way in all service settings. This series of articles represents a collaborative dialogue between providers and consumers of compulsory psychiatric services and expert commentators. We worked together, reflecting on the literature and our own professional and personal experience to better understand how choice can be worked with as a support for personal recovery even in circumstances of psychiatric detention. We were particularly interested to consider whether and how detention and compulsion could be routes to personal recovery. We offer both the process of our co-working and our specific findings as part of a continuing dialogue on these difficult issues.

[Articles] Continuing the dialogue: INVITED COMMENTARY ON ...DETAINED - WHAT'S MY CHOICE? PART 1

Copeland, M. E., Mead, S. — 2008-04-30

We consider the value of dialogue between healthcare professionals and mental health service users with severe mental illnesses. Discussion with the service user before, during and after a psychiatric crisis should help services to offer choice even to individuals under compulsory detention.

[Articles] 'To God' and 'The Silent One': poems by Ivor Gurney

2008-04-30

[Articles] A values-based perspective on good practice in compulsion: INVITED COMMENTARY ON ... DETAINED - WHAT'S MY CHOICE? PART 1

Fulford, K. W. M., King, M. — 2008-04-30

We outline how the values-based approach adopted in training materials supporting the Mental Health Act 2007 for England and Wales will complement recovery-based practice in compulsory psychiatric detention.

[Articles] Detained - what's my choice? Part 2: Conclusions and recommendations

Dorkins, E., Roberts, G., Wooldridge, J., Hewis, E. — 2008-04-30

We have developed this succession of articles as a series of iterative steps, each seeking to uphold the recovery values of co-working and collaboration, looking for agreement and commonality but valuing equally diverse viewpoints and difference. Our conclusion is that this is the beginning of a creative dialogue on choice as a route to recovery for people who are psychiatrically detained. We commend our method of engaging with the inevitable tensions and dilemmas by: clarifying the story behind difficult interactions, identifying the relevant guiding principles and jointly working to explore from different viewpoints what can be done to promote recovery.

[Articles] Problem psychiatrists?

Margerison, N. — 2008-04-30

This article focuses mainly on issues regarding doctors’ clinical performance (capability) and behaviour (conduct), and is aimed at medical managers who deal them. It covers identifying problems and how to manage them, describes typical underpinning (disciplinary) frameworks and sets out the role of the UK’s National Clinical Assessment Service and other external bodies in more serious cases.

[Articles] How to implement a smoke-free policy

Cormac, I., McNally, L. — 2008-04-30

It takes courage, leadership and planning to successfully implement a smoke-free policy in mental health settings. The content of the policy is crucial in setting parameters for implementation. Management and clinicians should work closely together to develop and coordinate the implementation strategy, ensuring that resources are effectively used and deadlines are met. Key success factors are effective management at both central and local levels, as well as consultation with service users, carers and staff to gain support for the policy and obtain suggestions for improvement. Other important factors are advance planning, recruitment of experienced staff, effective communication and extensive training of staff in smoking cessation support. Local teams should develop appropriate procedures based on the policy. They should work closely with the central management team. The resources developed and obtained by local teams should be shared throughout the organisation and should be tailored to meet the needs of particular services.

[Articles] Review of smoking cessation treatments for people with mental illness

Campion, J., Checinski, K., Nurse, J. — 2008-04-30

This article reviews the current literature regarding treatments for smoking cessation in both the general population and in those with mental health problems. The gold-standard treatment for the general population is pharmacotherapy (nicotine replacement therapy, bupropion or varenicline) coupled with individual or group psychological support. This is also effective in helping people with mental illness to reduce or quit smoking, but care must be taken to avoid adverse medication interactions and to monitor antipsychotic medication in particular as cigarette consumption reduces.

[Articles] Smoking by people with mental illness and benefits of smoke-free mental health services

Campion, J., Checinski, K., Nurse, J., McNeill, A. — 2008-04-30

Smoking is the largest single cause of preventable illness in the UK. Those with mental health problems smoke significantly more and are therefore at greater risk. The new Health Act (2006) will require mental health facilities in England to be completely smoke-free by 1st July 2008. This article reviews the current literature regarding how smoking affects both the physical and mental well-being of people with mental health problems. It also considers the effects of smoke-free policy in mental health settings.

[Articles] Medical history-taking in psychiatry

Phelan, M., Blair, G. — 2008-04-30

A good medical history is an essential starting point in ensuring that the physical health needs of people with severe mental illness are addressed. Psychiatrists have an important role in helping to tackle the general ill health, excess of undiagnosed physical illness and reduced survival rates among their patients. To do this they need to use their medical training, communication skills and regular contact with patients. Assessments should include family history, past and current physical health, medication, lifestyle, healthcare and physical symptoms. Some groups of patients will need more detailed assessments.

[Articles] IQ tests as aids to diagnosis and management in early schizophrenia

Harrison-Read, P. — 2008-04-30

Intellectual and other more specific neurocognitive impairments in schizophrenia are important for understanding the aetiology of the condition and its likely outcome. However, these impairments are not usually considered important for supporting a diagnosis in suspected early schizophrenia. IQ testing is widely available and probably acceptable to most people likely to be experiencing the early stages of psychosis and who might be unable or unwilling to disclose details of their history and mental state or to cooperate with more comprehensive neuropsychological assessment. Although in general IQ tests have only limited diagnostic value in schizophrenia, the finding of a substantial decline in IQ score from the estimated premorbid level may be helpful in supporting a provisional diagnosis of early schizophrenia in cases without organic signs in which the clinical picture is unclear or incomplete. More important, the results of IQ tests may contribute to a better understanding of patients’ impairments and assist clinical management in a number of ways, as illustrated here by three fictional case studies.