Shared care planning in borderline personality and forensic psychiatry
The joint development of personalised crisis or care plans between patients and mental healthcare staff offers patients greater control over their care, reduces levels of perceived coercion and serves to enhance the therapeutic alliance. At face value, implementing these would offer major advantages for patients with borderline personality disorder, an illness characterised by high levels of instability in their interpersonal interactions and increased risk of self-harm and suicide, and also for patients in contact with forensic services, commonly characterised by increased risk of interpersonal violence. Borschmann and colleagues (pp. ) found that although it was feasible to develop shared care plans with patients with borderline personality disorder, this did not lead to a significant decrease in episodes of self-harm. It also did not offer any significant benefits in reducing health or social care costs. Using a similar approach, Troquete and colleagues (pp. ) employed a shared care planning approach within an out-patient forensic service, but again did not find any significant benefits in reduction of violent incidents. In both studies, there was an overall reduction of self-harm and violent incidents respectively, but this reduction was evident in both the active intervention and the control arms of these studies. Both articles discuss the difficulty of recruiting into these studies, and a likelihood that they are underpowered, but draw somewhat different conclusions. Troquete et al suggest that shared decision-making may have little to offer in reducing offending for those in contact with forensic services; Borschmann et al conclude that it is possible that the shared care model is an effective intervention for patients with borderline personality disorders and recommend further research.
Attempted suicide, non-suicidal self-injury and self-poisoning
Two editorials discuss the virtues of a proposed new diagnostic category, non-suicidal self-injury (NSSI), within DSM-5. Butler & Malone (pp. ) review the diagnostic heterogeneity within people presenting with NSSI and support the potential utility of a distinction between NSSI and suicide attempts. However, Kapur and colleagues (pp. ) take a different view of the data, highlighting difficulties in applying this classification in practice; they conclude that this distinction would only serve to unnecessarily stigmatise a number of (mostly young) people, without offering any clear scientific benefit. One issue that they raise applies to people that take an overdose; self-poisoning cannot be included as an NSSI, despite evidence that up to a quarter of patients presenting with self-poisoning may not have suicidal intent. Follow-up data of people who have self-poisoned suggest relatively high rates of repetition over the next 4 years; Carter and colleagues (pp. ) report a trial of a postcard intervention with 5-year follow-up in this sample. They demonstrated a halving of self-poisoning events during the follow-up in the postcard intervention group. They review possible mechanisms for its effect and conclude that this intervention makes good sense, particularly given the low-cost of implementation.
Fetal exposure to antidepressants and antipsychotics; depression and dementia
Mental disorders and psychotropic drugs can influence the development of the fetus, but the specificity and strength of the association, and underlying mechanisms, remain unclear. Jensen and colleagues (pp. ) found decreased Apgar scores 5 minutes after birth in babies exposed to selective serotonin reuptake inhibitors during pregnancy, while this was not evident in those with exposure to older and newer antidepressants. Their design enabled them to confirm that this association did not arise as a consequence of the depressive illness, or related lifestyle factors. An editorial by Abel (pp. ) examines the risks of fetal exposure to antipsychotic medication and reports that the data are too limited to draw any clear conclusions; there is preliminary evidence of an association of antipsychotic medication with increased congenital malformations and prematurity, but it is not possible to remove the confounding effects of the illness itself, medication adherence, risks of individual antipsychotics or groups and core lifestyle variables such as smoking and an increased body mass index. She reviews the problems with the current data, and makes the case for improved observational studies in the future, based on sound epidemiological principles. There is a clear association between depression in late life and the risk of Alzheimer's dementia, but other dementia subtypes have not been examined in detail. Diniz and colleagues (pp. ) carried out a systematic review and meta-analysis of the literature on late-life depression and found an increased risk of both Alzheimer's dementia and vascular dementia, with a greater risk of vascular relative to Alzheimer's dementia. The authors suggest that depression and associated lifestyle factors may be potentially modifiable risk factors for preventing or delaying dementia.
Relationships: child-teacher and academic psychiatry
Positive relationships promote healthy development in children. Good-quality relationships between teachers and pupils can attenuate the links between children's background and their scholastic achievements. In a study by Lang and colleagues (pp. ), only 2.5% of parents considered their child to have a problematic relationship with teachers. Problematic relationships were associated with psychiatric disorder in the children, with a stronger association in older children. The authors suggest that these difficulties could be ameliorated by improved teacher training with regard to mental health and classroom management techniques, offering the opportunity to reduce the negative outcomes for pupils. Priebe et al (pp. ) highlight the importance of this interpersonal and social aspect in understanding mechanisms underlying mental illness, particularly at a time when there is a focus on making psychiatry an attractive career choice for doctors. They suggest that there has been limited progress with the prevailing focus on neurobiological research in psychiatry, and a greater integration with a social perspective offers the best way to make significant progress.