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There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.
Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan–Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.
Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.
Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.
The recent DSM-5 criteria for delirium can lead to different rates of delirium and different case identification.
The aims of this study were to determine how the new DSM-5 criteria might differ from the previous DSM-IV in detecting rates of delirium in elderly medical inpatients and to investigate the agreement between different methods, including the DSM III, DSM III-R, DSM-IV and DSM-5 criteria.
Prospective, observational study of elderly patients aged 70+ admitted under the acute medical teams in a regional general hospital. Each participant was assessed within 3 days using the DSM-5, and DSM-IV criteria plus the DRS-R98, CAM and MoCA scales.
The studied sample included 200 patients. The prevalence rates of delirium for each diagnostic system/scale were respectively for DSM-5 n=26 (13.0%), DSM-IV n=39 (19.5%), DRS-R98 n=27 (13.5%) and for CAM n=34 (17.0%). Using tetrachoric correlation coefficients the agreement between DSM-5 and DSM-IV was statistically significant (rhotetr=0.64, SE= 0.1, p<0.0001). Similar significant agreement was found between the four methods.
DSM-IV identifies more delirium cases compared to any other method and DSM-5 is the more restrictive. These classification systems identify different cases of delirium. This could have clinical, financial and research implications. However, both classification systems (and their antecedents) have significant agreement in the identification of the same concept (delirium). Clarity of diagnosis is required for classification but also has implications for prediction of outcomes, further research looking at outcomes could assist a more in depth evaluation of the DSM-5 criteria.
Siblings’ relationships have been seen as determinants of emotional and personal development. Although Greece is assumed a country with strong family bonds there is not empirical research in this area. Similarly Ireland is traditionally viewed as a country with strong family values.
In an attempt to conduct a comparative study of siblings’ relations the lack of a Greek valid instrument was obvious. The Sibling Relationship Questionnaire (SRQ) is a widely used scale which is a self reported measurement of this relationship.
Thus, in an attempt to employ an easily administered and valid measure, to assess sibling relationships, but also to be able to compare the results across countries the SRQ was the scale of choice.
a random sample of 185 adolescents aged 13 to 18 years old. SRQ has been translated (forward and backwards) to Greek language. Concurrent validity, internal consistency, test-retest reliability and agreement between children-parents versions of the translated scale were investigated.
The concurrent validity ranged from 0.29 to 0.68, the overall internal consistency (Cronbach's alpha) was equal to 0.86 and the test-retest reliability (Spearman's rho) ranged from 0.58 to 0.78. Agreement between children-parents versions was significant only when mothers do the rating.
Thus it seems that the translated Greek version of SRQ is a valid and reliable instrument to be used in the measurement of sibling relationships in Greek population, and can be used as a measurement for multinational clinical research and comparison with findings from other countries.
The prevalence of aDHD in adult population has been estimated at 2.5%. Higher rates (23.9%) have been reported among adult mental health service ( aMHS) users.
To estimate the prevalence of aDHD among adult MH users in west county Ireland.
all consecutive patients attending any of 5 Sligo/Leitrim aMHS were invited to participate. Participants completed the adult aDHD Self-Report Scale ( aSRS) and the wender Utah Rating Scale (WURS). Clinical notes were reviewed to identify those with preexisting aDHD diagnosis. Exclusion criteria applied were: age: less 18 or above 65, illiterate, non-English speaking patients.
From 792 attending the clinics, n = 59 (47 aged above 65, 10 severe learning difficulties and 2 non-English speaking) were excluded. Ninety-three (11.7%) decline to participate, giving a total of n = 640 (87% eligible response rate). Mean age was 41.27 (SD: 12.8), and 336 (52.5%) were females. Three had diagnosis of aDHD. Two hundred and thirteen (33.8%) met criteria on the WURS for childhood onset aDHD and 238 (37.5%) participants met caseness on the aSRS. applying more stringent criteria of scoring on both scales, suggested 125 (19.5%) with unrecognised aDHD.
While recall bias (WURS) and the possibility of overlapping symptoms with other major psychiatric disorders in adulthood need to be considered, the use of both screening reduces these confounders and suggests a very high rate of aDHD. Given the low number previously identified, this becomes a clinical priority, both to offset the negative trajectories associated with untreated aDHD, but also to effect optimal treatments in comorbid conditions.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Traditionally psychomotor subtypes have been investigated in patients with delirium in different settings and it has been found that those with hypoactive type is the largest proportion, often missed and with the worst outcomes.
Aims and objectives
We examined the psychomotor subtypes in an older age inpatients population, the effects that observed clinical variables have on psychomotor subtypes and their association with one year mortality.
Prospective study. Participants were assessed using the scales CAM, APACHE II, MoCA, Barthel Index and DRS-R98. Pre-existing dementia was diagnosed according to DSM-IV criteria. Psychomotor subtypes were evaluated using the two relevant items of DRS-R98. Mortality rates were investigated one year after admission day.
The sample consisted of 200 participants [mean age 81.1 ± 6.5; 50% female; pre-existing cognitive impairment in 126 (63%)]. Thirty-four (17%) were identified with delirium (CAM+). Motor subtypes of the entire sample was: none: 119 (59.5%), hypo: 37 (18.5%), mixed: 15 (7.5%) and hyper: 29 (14.5%). Hypoactive and mixed subtype were significantly more frequent to delirious patients than to those without delirium, and none subtype more often to those without delirium. There was no difference in the hyperactive subtype between those with and without delirium. Hypoactive subtype was significant associated with delirium and lower scores in MoCA (cognition), while mixed was associated mainly with delirium. Predictors for one-year mortality were lower MoCA scores and severity of illness.
Psychomotor disturbances are not unique to delirium. Hypoactivity, this “silent epidemic” is also part of a deteriorated cognition.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
To date, there are no recent studies identifying the prevalence of parasites of human and veterinary importance in dogs and cats in Ireland. The interaction between pets and wildlife species in the environment is an important source of parasite exposure to canids and felines, and one likely to be heightened in the stray animal population. This study aimed to establish the prevalence of endoparasites in unowned dogs and cats in County Dublin, Ireland. Feces from stray dogs (n = 627) and cats (n = 289) entering a rehoming centre were collected immediately after defecation. The main parasitic agents detected were ascarids (15.52 and 30.26%), Cystoisospora (3.27 and 3.69%), Giardia spp. (6.02 and 1.84%) and lungworms (0.64 and 2.08%), in dogs and cats respectively. Animals younger than 3 months of age were more likely to be infected with ascarids (P < 0.001) and Cystoisospora spp. (P = 0.008 and P = 0.014) than older animals. All lungworms were morphologically identified and dogs were infected with Angiostrongylus vasorum (0.48%) and Crenosoma vulpis (0.16%) whereas cats were only infected with Aelurostrongylus abstrusus (2.08%). This represents the first prevalence study of stray animals in Ireland. Data collected will inform the treatment and in addition, the future monitoring and control studies of parasite populations.
There is renewed interest in the inverse association between psychiatric hospital and prison places, with reciprocal time trends shown in more than one country. We hypothesised that the numbers of admissions to psychiatric hospitals and committals to prisons in Ireland would also correlate inversely over time (i.e. dynamic measures of admission and committal rather than static, cross-sectional numbers of places).
Publicly available activity statistics for psychiatric hospitals and prisons in Ireland were collated from 1986 to 2010.
There was a reciprocal association between psychiatric admissions and prison committals (Pearson r=−0.788, p<0.001), an increase of 91 prison committals for every 100 psychiatric hospital admissions foregone.
Penrose’s hypothesis applies to admissions to psychiatric hospitals and prisons in Ireland over time (dynamic measures), just as it does to the numbers of places in psychiatric hospitals and prisons in Ireland and elsewhere (static, cross-sectional measures). Although no causal connection can be definitively established yet, mentally disordered prisoners are usually known to community mental health services. Psychiatric services for prisons and the community should be linked to ensure that the needs of those currently accessing care through prisons can also be met in the community.
To systematically review studies from Irish prisons that estimate the prevalence of major mental illness, alcohol and substance misuse, and homelessness at the time of committal.
Healthcare databases were searched for studies quantifying the point prevalence for each outcome of interest. Searches were augmented by scanning of bibliographies and searches of governmental and non-governmental websites. Proportional meta-analyses were completed for each outcome.
We found eight, six and five studies quantifying the point prevalence of major mental illness, substance misuse, and homelessness respectively. Considerable heterogeneity was found for each subgroup (except psychosis where substantial heterogeneity was observed) and random effects models were used to calculate pooled percentages. The pooled percentage for psychotic disorder was 3.6% [95% confidence interval (CI) 3.0–4.2%], for affective disorder 4.3% (95% CI 2.1–7.1%), for alcohol use disorder 28.3% (95% CI 19.9–37.4%), for substance use disorder 50.9% (95% CI 37.6–64.2%) and for those who were homeless on committal 17.4% (95% CI 8.7–28.4%).
Estimates for the prevalence of psychotic illness and substance abuse amongst Irish prisoners are in keeping with international estimates of morbidity in prisons, whilst those for affective disorders are lower. The prevalence of homelessness in committal to Irish prisons is higher than some international estimates. Rates for psychoses, alcohol and substance misuse as well as homelessness in Irish prisons are significantly higher than the general population prevalence of these vulnerabilities. A need for service development is discussed.
Introduction: Run to Quit is a national community-based program that combines smoking cessation support with physical activity through learn to run group-based curriculum, self-help and smoking cessation materials. The program is currently in a three-year scaling up phase.
Aims: The aim of the current study is to explore participant experiences of the Run to Quit program after its first year, and identify potential areas of improvement for future iterations of the program.
Methods: Participants (n = 55) were interviewed over the phone at the end of the 10-week program. Participant interviews were recorded and transcribed. A thematic analysis was conducted.
Results/Findings: Participants were satisfied with the program. Strengths of the program were the group aspect, supervised participation and the running. Weaknesses were seen as the variability in walking and running abilities and inadequate engagement by the Smokers Helpline. Many people who successfully quit smoking reported using additional quit aids. Non-completers of the program gave mostly logistical and personal reasons for dropout.
Conclusions: Overall, Run to Quit was well received by participants. Multiple health behaviour interventions at a scalable level appear feasible. Based on participant feedback, key recommendations to improve the program in the future include greater tailoring to walking or running preference, and increasing engagement with the Smokers Helpline.
Accurate and reproducible patient positioning is a critical step in radiotherapy for breast cancer. This has seen the use of permanent skin markings becoming standard practice in many centres. Permanent skin markings may have a negative impact on long-term cosmetic outcome, which may in turn, have psychological implications in terms of body image. The aim of this study was to investigate the feasibility of using a semi-permanent tattooing device for the administration of skin marks for breast radiotherapy set-up.
Materials and methods
This was designed as a phase II double-blinded randomised-controlled study comparing our standard permanent tattoos with the Precision Plus Micropigmentation (PPMS) device method. Patients referred for radical breast radiotherapy were eligible for the study. Each study participant had three marks applied using a randomised combination of the standard permanent and PPMS methods and was blinded to the type of each mark. Follow up was at routine appointments until 24 months post radiotherapy. Participants and a blind assessor were invited to score the visibility of each tattoo at each follow-up using a Visual Analogue Scale. Tattoo scores at each time point and change in tattoo scores at 24 months were analysed by a general linear model using the patient as a fixed effect and the type of tattoo (standard or research) as covariate. A simple questionnaire was used to assess radiographer feedback on using the PPMS.
In total, 60 patients were recruited to the study, of which 55 were available for follow-up at 24 months. Semi-permanent tattoos were more visible at 24 months than the permanent tattoos. Semi-permanent tattoos demonstrated a greater degree of fade than the permanent tattoos at 24 months (final time point) post completion of radiotherapy. This was not statistically significant, although it was more apparent for the patient scores (p=0·071) than the blind assessor scores (p=0·27). No semi-permanent tattoos required re-marking before the end of radiotherapy and no adverse skin reactions were observed.
The PPMS presents a safe and feasible alternative to our permanent tattooing method. An extended period of follow-up is required to fully assess the extent of semi-permanent tattoo fade.
This study estimates the symptomatology of attention deficit–hyperactivity disorder (ADHD) in adult mental health services (AMHS) outpatient clinics.
All consecutive patients attending any of the outpatients’ clinics in Sligo/Leitrim AMHS were invited to participate. Participants completed the Adult ADHD Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) self-report. Clinical notes were reviewed to identify those with a pre-existing ADHD diagnosis.
From 822 attending the clinics, 62 did not meet inclusion criteria, 97 declined to participate and 29 had incomplete data in either of the screening scales, leaving 634 (77%) eligible for full study analysis. Mean age was 40.38 (s.d.: 12.85), and 326 (51.4%) were females. In total, 215 (33.9%) screened positive on the WURS for childhood onset ADHD and 219 (34.5%) participants scored positive on the ASRS. Applying a more stringent criteria of scoring above cut-offs on both scales, suggested 131 (20.7%) screened positive on both. Only three (2.3%) had a prior clinical diagnosis.
This preliminary study suggests the possibility of relatively higher rates of ADHD in a general AMHS than previously thought, however, given the possibility of overlapping symptoms with other major psychiatric disorders in adulthood and recall bias further research is needed before drawing firm conclusions.
Research on post-traumatic stress disorder (PTSD) course finds a substantial proportion of cases remit within 6 months, a majority within 2 years, and a substantial minority persists for many years. Results are inconsistent about pre-trauma predictors.
The WHO World Mental Health surveys assessed lifetime DSM-IV PTSD presence-course after one randomly-selected trauma, allowing retrospective estimates of PTSD duration. Prior traumas, childhood adversities (CAs), and other lifetime DSM-IV mental disorders were examined as predictors using discrete-time person-month survival analysis among the 1575 respondents with lifetime PTSD.
20%, 27%, and 50% of cases recovered within 3, 6, and 24 months and 77% within 10 years (the longest duration allowing stable estimates). Time-related recall bias was found largely for recoveries after 24 months. Recovery was weakly related to most trauma types other than very low [odds-ratio (OR) 0.2–0.3] early-recovery (within 24 months) associated with purposefully injuring/torturing/killing and witnessing atrocities and very low later-recovery (25+ months) associated with being kidnapped. The significant ORs for prior traumas, CAs, and mental disorders were generally inconsistent between early- and later-recovery models. Cross-validated versions of final models nonetheless discriminated significantly between the 50% of respondents with highest and lowest predicted probabilities of both early-recovery (66–55% v. 43%) and later-recovery (75–68% v. 39%).
We found PTSD recovery trajectories similar to those in previous studies. The weak associations of pre-trauma factors with recovery, also consistent with previous studies, presumably are due to stronger influences of post-trauma factors.
Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.
The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18–22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI).
One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.
Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.
The reported incidence of the metastrongylid nematode Angiostrongylus vasorum, that infects dogs and other canids, is increasing worldwide outside recognized endemic foci. This apparent expansion of the parasite's range is causing concern to veterinary clinicians as the disease caused in dogs can be life threatening and its treatment is not straightforward. The red fox is thought to be a reservoir host for dogs. To investigate the spatial distribution of infection in foxes in Ireland, the hearts and lungs of 542 foxes from all over Ireland were examined. The incidence of infection was found to be 39·9% [95% confidence interval (CI) 35·7–44·1] with positive samples occurring in each of the country's 26 counties. This report confirms that the parasite is endemic in Ireland and the overall prevalence is the second highest in Europe. This is the first survey of A. vasorum infection in Irish foxes and highlights the potential exposure of the Irish dog population to high risk of cross-infection. Additionally, Crenosoma vulpis was found in seven of the foxes, a parasite not previously reported in the Irish fox.
In many epidemiological studies, women have been observed to consume psychotropic medication more often than men. However, the consistency of this relationship across Europe, with differences in mental health care (MHC) resources and reimbursement policies, is unknown.
Questions on 12-month psychotropic use (antidepressants, benzodiazepines, antipsychotics, mood stabilizers) were asked to 34,204 respondents from 10 European countries of the EU-World Mental Health surveys. Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria were used to determine 12-month prevalence of mood/anxiety disorders using the Composite International Diagnostic Interview (v3.0).
For all participating countries, women were significantly more likely than men to use psychotropic medication within the previous 12 months (overall-OR = 2.04, 95% CI: 1.81–2.31). This relationship remained significant after adjusting for common sociodemographic factors (age, income level, employment status, education, marital status) and country-level indicators (MHC provision, private household out-of-pocket expenditure, and Gender Gap Index). In multivariable gender-stratified risk-factor analysis, both women and men were more likely to have taken psychotropic medication with increasing age, decreasing income level, and mental health care use within the past 12 months, with no significant differences between genders. When only including participants with a mental disorder, gender differences overall were still significant with any 12-month mood disorder but not with any 12-month anxiety disorder, remaining so after adjusting for sociodemographic characteristics and country-level indicators.
Women use psychotropic medication consistently more often than men, yet reasons for their use are similar between genders. These differences also appear to be contingent on the specific mental disorder.
Quality end-of-life care requires effective communication skills, yet medical and nursing students report limited opportunities to develop these skills, and that they lack confidence and the related competence.
Our purpose was to design, implement, and evaluate an educational intervention employing simulated patient actors to enhance students' abilities to communicate with dying patients and their families.
A study employing a mixed-methods design was conducted with prequalification nursing and medical students recruited from a London university. The first phase involved focus groups with students, which informed the development of an educational intervention involving simulated patient actors. Questionnaires measuring students' perceptions of confidence and competence levels when communicating with dying patients and their families were administered before and after the intervention.
The themes from focus groups related to responding to grief and anger, difficulties dealing with emotions, knowing the “right thing” to say, and a lack of experience. A significant increase (p < 0.5) in competence and confidence from baseline levels followed participation in the simulated scenarios.
Significance of Results:
Simulation was found to be an effective means of preparing students to communicate with dying patients and their families. The opportunity to develop communication skills was valued. Integration of educational interventions employing simulated patient actors into nursing and medical curricula may assist in improving the care provided to patients at the end of life.
Older prisoners are the fastest growing group of prisoners in most countries. They have high rates of physical and psychiatric co-morbidity, compared to community dwelling older persons and also compared with other prisoner groups. Very high rates of mental illness have been found in remand (pre-trial) prisoners when compared with other prisoner groups; however to date there have been no studies examining older male and female remand prisoners.
A retrospective chart review was conducted of all remands, to a male and a female prison, over a six and half-year period. Demographic data were collected pertaining to psychiatric and medical diagnoses and seriousness of offending.
We found rising numbers of older prisoners amongst male remand prisoners. Older remand prisoners had very high rates of affective disorder and alcohol misuse. They had rates of psychotic illnesses and deliberate self-harm comparable to younger remand prisoners. High rates of vulnerability were found among older prisoners and older prisoners had a greater need for general medical and psychiatric services than younger prisoners. We also found comparable offending patterns with younger prisoners and high rates of sexual offending among the older male prisoner group.
Given the ageing population of many countries it is likely the numbers of older prisoners will continue to grow and given their high levels of both physical and psychiatric illness this will have implications for future service delivery.
‘R staging’ is a new ultrasonographic scoring system developed and used by our specialist head and neck radiologist for reporting sonographic risk of malignancy to those at our thyroid multidisciplinary team meeting. This study aimed to: classify the R staging system, examine its relationship with the eventual histopathological diagnosis and define its clinical utility.
The pre-operative ultrasound scans of 78 patients were assigned an R status by our specialist head and neck radiologist. The final histopathology report for each thyroid nodule was used as the ‘gold standard’ for analysis.
When thyroid nodules were classified as low risk (R stages 1–3) or high risk (R stages 4–5) for malignancy, the sensitivity of R staging was 74.2 per cent and specificity was 80.9 per cent. An R5 status was 100 per cent predictive of malignancy.
Our results compare favourably with other suggested ultrasonographic staging systems for thyroid nodules.