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In this editorial we look at the implications of organisational changes to the National Health Service and financial constraints on addiction psychiatrists, and how creativity and adaptability could be the key to fostering survival and sustainability of subspecialties in danger of extinction.
Tackling discrimination, stigma and inequalities in mental health is a major UK government objective yet people with intellectual disability (also known as learning disability in UK health services) continue to suffer serious stigma and discrimination. We examine the effect of viewing pictures of a person with intellectual disability on stigmatised attitudes. The 20-point Attitude to Mental Illness Questionnaire (AMIQ) was used to assess stigmatised attitudes. Members of the general public were randomised to complete the questionnaire having looked at a good (attractive) or bad (unattractive) photograph of a person with intellectual disability.
Questionnaires were received from 187 participants (response rate 74%). The mean AMIQ stigma score for the bad photo group was 1.3 (s.e. = 0.3, median 1, interquartile range (IQR) = 0–3, n = 82). The mean AMIQ score for the good photo group was 2.8 (s.e. = 0.3, median 3, IQR = 1–5, n = 105). The difference in AMIQ stigma score was highly significant (two-sided P = 0.0001, median difference 2, Mann–Whitney U-test).
Looking at a good (attractive) picture of a person with intellectual disability significantly reduces reported stigmatised attitudes, whereas a bad (unattractive) picture has no effect.
To investigate the complementarities of staff and service users' experiences of shame in psychiatric in-patient settings. Qualitative methods were used by means of focus group interviews in two compositions – staff and service users. Data were transcribed and thematically analysed.
Service user group transcripts revealed four prominent themes: ‘loss of value’, ‘loss of adulthood and autonomy’, ‘loss of subjectivity’ and ‘shaming or blaming of others’. Staff group transcripts also revealed two themes one of which overlapped with service users (‘shaming or blaming of others’) and one of which was distinct (‘entrapment’).
Shame processes may be elicited by caregiving and impede treatment. Staff find themselves in the predicament of provoking the problems they intend to address. Suggestions are made as to how to respond to this dilemma and practically improve aspects of the in-patient care process to reduce shame.
Risk assessment has been widely adopted in mental health settings in the hope of preventing harms such as violence to others and suicide. However, risk assessment in its current form is mainly concerned with the probability of adverse events, and does not address the other component of risk – the extent of the resulting loss. Although assessments of the probability of future harm based on actuarial instruments are generally more accurate than the categorisations made by clinicians, actuarial instruments are of little assistance in clinical decision-making because there is no instrument that can estimate the probability of all the harms associated with mental illness, or estimate the extent of the resulting losses. The inability of instruments to distinguish between the risk of common but less serious harms and comparatively rare catastrophic events is a particular limitation of the value of risk categorisations. We should admit that our ability to assess risk is severely limited, and make clinical decisions in a similar way to those in other areas of medicine – by informed consideration of the potential consequences of treatment and non-treatment.
Recent surveys have highlighted widespread criticisms of the use of workplace-based assessments (WPBAs) in psychiatric training. We describe our systematic review of psychiatric WPBAs, including a ‘surgical dissection’ of their format and process. From our review, we identified seven overarching WPBA themes, and have drawn on these to make further recommendations to strengthen the wider acceptability of WPBAs in psychiatric settings. We hope this will encourage further debate on ways of improving these tools, rather than them becoming side-lined as ‘top-down’ tick-box exercises.
This cross-sectional study investigated the evolution of intentions among medical students to pursue a career in psychiatry and the factors that might discourage them from becoming a psychiatrist. A questionnaire survey was sent to medical students in years 1–5 at Aberdeen University.
From 918 students, 467 (51%) returned useable responses. Proportions of students across the 5-year groups who definitely or probably intended to become psychiatrists remained fairly stable at 4–7%. In their final year, psychiatry remained a possible career option for a further 17% of students. The most potent discouraging factor was the perception of poor prognoses among psychiatric patients. Perceptions of a lack of scientific/evidence base reduced enthusiasm for becoming a psychiatrist. Issues relating to the prestige of the specialty were also important.
If recruitment to the specialty is to improve, these negative perceptions among students should be addressed by their teachers and more widely within psychiatry.