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A User's Guide to Melancholy takes Robert Burton's encyclopaedic masterpiece The Anatomy of Melancholy (first published in 1621) as a guide to one of the most perplexing, elusive, attractive, and afflicting diseases of the Renaissance. Burton's Anatomy is perhaps the largest, strangest, and most unwieldy self-help book ever written. Engaging with the rich cultural and literary framework of melancholy, this book traces its causes, symptoms, and cures through Burton's writing. Each chapter starts with a case study of melancholy - from the man who was afraid to urinate in case he drowned his town to the girl who purged a live eel - as a way into exploring the many facets of this mental affliction. A User's Guide to Melancholy presents in an accessible and illustrated format the colourful variety of Renaissance melancholy, and contributes to contemporary discussions about wellbeing by revealing the earlier history of mental health conditions.
Perceived stigma may be an unintended consequence of tobacco denormalization policies among remaining smokers. Little is known about the role of perceived stigmatization in cessation behaviours.
To test if perceived public smoker stigma is associated with recent attempts to cease smoking and future cessation plans among adult daily smokers.
Using merged data from the biennial national survey Norwegian Monitor 2011 and 2013 (N daily smokers = 1,029), we performed multinomial and ordinal regression analyses to study the impact of perceived public stigma (measured as social devaluation and personal devaluation) on recent quit attempts, short-term intention to quit and long-term intention to quit, controlling for confounders. One additional analysis was performed to investigate the relationship between stigma and intention to quit on quit attempts.
A significant association between perceived social devaluation and recent quit attempts was found (OR 1.76). Perceived stigma was not associated with future quit plans. Personal devaluation was not associated with any cessation outcome. The role of perceived social devaluation on quit attempts was mainly found among smokers with intentions to quit.
These findings indicate that stigma measured as social devaluation of smokers is associated with recent quit attempts, but not with future quit plans.
We evaluated the relationship between local MRSA prevalence rates and antibiotic use across 122 VHA hospitals in 2016. Higher hospital-level MRSA prevalence was associated with significantly higher rates of antibiotic use, even after adjusting for case mix and stewardship strategies. Benchmarking anti-MRSA antibiotic use may need to adjust for MRSA prevalence.
The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal.
To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP.
A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers.
The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors.
Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.
Low-frequency repetitive transcranial magnetic stimulation (rTMS) of the prefrontal cortex has been shown to have a statistically and clinically significant anti-depressant effect. The present pilot study was carried out to investigate if right prefrontal low-frequency rTMS as an add-on to electroconvulsive therapy (ECT) accelerates the anti-depressant effect and reduces cognitive side effects.
In this randomised, controlled, double-blind study, thirty-five patients with major depression were allocated to ECT+placebo or ECT+low-frequency right prefrontal rTMS. The severity of depression was evaluated during the course using the Hamilton scale for depression (the 17-item as well as the 6-item scale) and the major depression inventory (MDI). Furthermore, neuropsychological assessment of cognitive function was carried out.
The study revealed no significant difference between the two groups for any of the outcomes, but with a visible trend to lower scores for MDI after treatment in the placebo group. The negative impact of ECT on neurocognitive functions was short-lived, and scores on logical memory were significantly improved compared to baseline 4 weeks after last treatment. The ECT-rTMS group revealed generally less impairment of cognitive functions than the ECT-placebo group.
The addition of low-frequency rTMS as an add-on to ECT treatment did not result in an accelerated response. On the contrary, the results suggest that low-frequency rTMS could inhibit the anti-depressant effect of ECT.
I pose a simple question, which can be given a very short answer: ‘Follow the money.’ The prize was unparalleled, England's wealth unmatched in Scandinavia. But a more elaborate answer would lie in the inevitability of a path set before Cnut was born. Viking raids had become a campaign of conquest; Cnut had grown up as his father Svein Forkbeard had pursued and won the English kingdom. By the time of Svein's death, Cnut had staked so much on succeeding to his father's crown, and in such a one-sided manner, that he had no alternative. His older brother Harald had succeeded to the Danish throne; Cnut's sole hope of gaining royal power lay in England.
Cnut the Great has been called ‘England's Viking king’. In order to understand the importance of his Viking heritage to his conquest of England in 1016, we therefore need to take a preliminary look at who Vikings were and what they did. Viking activity was about exploitation, the exploitation of other people, other communities and other societies. It was about the appropriation of resources belonging to others. This was, as Peter Sawyer insisted, ‘normal Dark Age activity’. The word ‘Viking’ was used in Old English to gloss the Latin ‘Cilix’, a Cilician, and the Cilicians were notorious pirates in antiquity. A Viking was not just any Scandinavian of the ‘Age of the Vikings’, therefore; he was, more specifically, a pirate from Scandinavia.
Peter Sawyer has claimed that ‘The Age of the Vikings began when Scandinavians first attacked western Europe and it ended when those attacks ceased.’ In the British Isles, Viking activity by people from Scandinavia began in the late eighth century when Beaduheard, the king's reeve who mistook the first Danish raiders in England for traders, lost his life for trying to bring them to the royal vill. A number of exposed monasteries were then plundered by Vikings who killed the monks and made away with whatever was precious to them: gold and silver, books or cattle. In the following century increasingly large Viking fleets appeared in England, as well as on the Continent, to loot towns and landscapes.
The common recommendation that adults with onset of mental illness after the age of 65 should receive specialised psychogeriatric treatment is based on limited evidence.
To compare factors related to psychiatric acute admission in older adults who have no previous psychiatric history (NPH) with that of those who have a previous psychiatric history (PPH).
Cross-sectional cohort study of 918 patients aged ≥65 years consecutively admitted to a general adult psychiatric acute unit from 2005 to 2014.
Patients in the NPH group (n = 526) were significantly older than those in the PPH group (n = 391) (77.6 v. 70.9 years P < 0.001), more likely to be men, married or widowed and admitted involuntarily. Diagnostic prevalence in the NPH and PPH groups were 49.0% v. 8.4% (P < 0.001) for organic mental disorders, 14.6% v. 30.4% (P < 0.001) for psychotic disorders, 30.2% v. 55.5% (P < 0.001) for affective disorders and 20.7% v. 13.3% (P = 0.003) for somatic disorders. The NPH group scored significantly higher on the Health of the Nation Outcome Scale (HoNOS) items agitated behaviour; cognitive problems; physical illness or disability and problems with activities of daily living, whereas those in the PPH group scored significantly higher on depressed mood. Although the PPH group were more likely to report suicidal ideation, those in the NPH group were more likely to have made a suicide attempt before the admission.
Among psychiatric patients >65 years, the subgroup with NPH were characterised by more physical frailty, somatic comorbidity and functional and cognitive impairment as well as higher rates of preadmission suicide attempts. Admitting facilities should be appropriately suited to manage their needs.
Introduction: Emergency patients with decreased level of consciousness often undergo intubation purely for airway protection from aspiration. However, the true risk of aspiration is unclear and intubation poses risks. Anecdotally, experienced emergency physicians often defer intubation in these patients while others intubate to decrease the perceived clinical and medico-legal consequences. No literature exists on the intubation practices of emergency physicians in these cases. Methods: An online questionnaire was circulated to members of the Canadian Association of Emergency Physicians. Participants were asked questions regarding two common clinical cases with decreased level of consciousness : (1) acute, uncomplicated alcohol intoxication and (2) acute, uncomplicated seizure. For each case, providers’ perceptions of aspiration risk, the standard of care, and the need for intubation were assessed. Results: 128 of the 1546 Canadian physicians contacted (8.3%) provided responses. Respondents had a median of 15 years of experience, 88% had CCFP-EM or FRCPC certification, and most worked in urban centers. When intubating, 98% agreed they were competent and 90% agreed they were well supported. A minority (17.4%) considered GCS < 8 an independent indication for intubation. For the alcohol intoxication case, 88% agreed that aspiration risk was present but only 11% agreed they commonly intubate. Only 17% agreed intubation was standard care, and only 0.8% felt their colleagues always intubate such patients. For the seizure case, 65% agreed aspiration risk existed but only 3% agreed they commonly intubate, 1% felt colleagues always intubated, and 5% agreed intubation was standard of care. Additional factors felt to compel intubation (394 total) and support non-intubation (366 total) were compiled and categorized; the most common themes emerging were objective evidence of emesis or aspiration, other standard indications for intubation, head trauma, co-ingestions, co-morbidities and clinical instability. Conclusion: It is acceptable and standard practice to avoid intubating a select subset of intoxicated and post-seizure emergency department patients despite aspiration risk. Most physicians do not view the dogma of “GCS 8, intubate” as an absolute indication for intubation in these patients. Future research is aimed at identifying key factors and evidence supporting intubation for the prevention of aspiration, as well as the development of a validated clinical decision rule for common emergency presentations.
The experience of childhood trauma is linked to more severe symptoms and poorer functioning in severe mental disorders; however, the mechanisms behind this are poorly understood. We investigate the relationship between childhood trauma and sleep disturbances in severe mental disorders including the role of sleep disturbances in mediating the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.
In total, 766 participants with schizophrenia-spectrum (n = 418) or bipolar disorders (n = 348) were assessed with the Childhood Trauma Questionnaire. Sleep disturbances were assessed through the sleep items in the self-reported Inventory of Depressive Symptoms. Clinical symptoms and functioning were assessed with The Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale. Mediation analyses using ordinary least squares regression were conducted to test if sleep disturbances mediated the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.
Symptoms of insomnia, but not hypersomnia or delayed sleep phase, were significantly more frequent in participants with childhood trauma experiences compared to those without. Physical abuse, emotional abuse, and emotional neglect were significantly associated with insomnia symptoms. Insomnia symptoms partly mediate the relationship between childhood trauma and the severity of positive and depressive/anxiety symptoms, in addition to poorer functioning.
We found frequent co-occurrence of childhood trauma history and current insomnia in severe mental disorders. Insomnia partly mediated the relationship between childhood trauma and the severity of clinical symptoms and functional impairment.
Depressed patients tend to under-estimate their everyday memory function. Whether this under-estimation is related to the depressive state, or whether it represents underlying personality traits present also between or after depressive episodes, is not clear.
Comparisons of subjective memory evaluation as measured by the Everyday Memory Questionnaire (EMQ) were made between sub-groups with Current Depression (N=14), Previous Depression (N=19), and Healthy Controls (N=10). Analyses were adjusted for effects of sociodemographic variables, use of medication, and premorbid intellectual abilities (Similarities sub-test (WASI)). To assess the relationship between affective state and subjective memory function irrespective of actual memory performance, adjustment for objective memory performance as represented by the Total recall sub-task from CVLT and Long-delayed free recall from RCFT was included in a final step in the ANCOVA model.
The overall crude relationship between group and EMQ total score was significant (F(2,40)=4.11, p=0.011, eta sq.= .17). In posthoc follow-up tests, the Currently Depressed reported significantly lower on EMQ than both Previously Depressed and Controls (Dunnett's C test, p= .018 and p= .034, respectively). However, after adjustment for relevant confounders and mediators, both the Previously and Currently Depressed performed significantly worse on EMQ compared to Controls (overall ANCOVA F(2,33)=9.22, p= .001, eta sq.= .36; pairwise follow-ups p= .001 and p= .011, respectively).
Depressed patients’ under-estimation of their memory function is independent of mood state and it may represent a vulnerability or personality structure involving negative cognitive patterns that may be successfully targeted by cognitive therapy.
Wake therapy (sleep deprivation) is known to induce a rapid amelioration of depressive symptoms. Recently, techniques using bright light therapy and sleep time control have been developed to sustain the acute response of wake therapy.
The aim of this study was to establish the efficacy of these new methods and to control for the placebo response by incorporating an active control group.
Patients with an actual diagnosis of unipolar or bipolar major depression were randomized to either a wake group or an exercise group and followed for 9 weeks. All patient were treated with duloxetine 60 mg daily. After a one week medication run-in phase, all patient were admitted to an open ward for six days: The wake group had 3 wake nights during their stay in combination with daily bright light treatment and sleep time control and the exercise-group started their exercise program. Bright light and exercise were continued for the whole study period.
Patients in the wake group had a statistically significant larger improvement from immediately after wake therapy and maintained for the rest of the study period. At end of study the Wake group achieved a response / remission rate of 70.2 % and 45.6 %. The exercise group had a response/remission rate of 42.2 % and 23.1 %
The chronotherapeutic intervention induced a rapid and sustained response superior to the response seen in the exercise group.
Elevation of serum cortisol is found in many patients with major depressive disorder (MDD) and may be due to a chronic dysfunction in the feedback regulation in the Hypothalamic-Pituitary-Adrenal axis. Saliva cortisol is a valid indicator of serum cortisol. The predictive value of saliva cortisol for remission of depressive symptomatology was investigated.
Saliva cortisol was measured in a sub-sample (N=19) with unipolar MDD according to DSM-IV. Mean score on the Montgomery Aasberg Depression Rating Scale (MADRS) was 26.8 (standard deviation 3.7, range 22-32). At follow-up, two years later, mean MADRS was 13.6 (SD 10.7, range 0-37). In a linear regression model, saliva cortisol at baseline was entered as independent variable and MADRS-score at follow-up as dependent variable.
A significant correlation between the level of saliva cortisol at baseline and MADRS-score at follow-up was found (R=0.33, P=0.036). After adjustment for MADRS at baseline, the level of saliva cortisol explained 21% of the variance in MADRS at follow-up (P=0.018). After further adjustment for age, gender, and use of antidepressant medication, the model still produced significant results (R2=0.50, P=0.026).
Higher level of saliva cortisol is predictive of less improvement in depressive symptomatology over time in unipolar MDD. This finding is in line with a model in which higher secretion of cortisol is associated with a more chronic course in depression. It underlines the importance of biological correlates as predictors of outcome in psychiatric disorders.
It is often reported that patients with diabetes have increased risk of suffering from major depression (1). We wanted to study the frequency of depression in an special unit for diabetes at the University Hospital.
Fiftythree patients were recuited at this outpatient clinic. They were diagnosed using the structured clinical intervju MINI (2).
Of the 53 patients with diabetes, 12 (23%)had an ongoing depressive episode. In addition 8 patients had suffered from previous episodes of depression. Thus 20(38%) had a lifetime history of major depression. Of the 12 patients with an ongoing depression, 58% had a first degree relative with psychiatric disorder, in contrast to 33% in those with no history of depression.
The propotion of depressive disorders in patients with poorly regulated diabetes, is very high. An astonishing finding is the very high frequency of first degree relatives with affective disorders.
It may be speculated that diabetes and depression have some pathophysiological features in common (3).
Mild hypercortisolemia is a biological marker found in a subset of patients with major depression. The cause is supposed to be a malfunction in the corticosteroid receptor. Long standing cortisol excess is toxic to nerve cells and especially the hippocampus seem vulnerable to hypercortisolemia. The well known memory and concentration difficulties found in stress and depressive illnesses are supposed to be partly caused by deterioration of the function of the hippocampus.
The cortisol awakening response(CAR)were measured in saliva by repeated saliva specimens (awakening, 20 min and 60 minutes after awakening) in patient participating in a double blind study using a fixed dosage of sertraline and randomised to either dim or bright light treatment. Cortisol measurements were made before medication and light treatment started. The hypothesis, stated in the protocol, was that saliva cortisol would have a predictive validity of the short term depression outcome.
A statistically significant increase in cortisol levels were found during the first hour after awakening. The area under the curve (AUC) from the CAR results was calculated and was found to have a statistically significant predictive validity for depression scores and remission at endpoint. Thus a statistically significant higher proportion of patient with low CAR values were in remission compared to patient with high CAR values. This effect was predominantly seen in the bright light treated group.
Patients with a high CAR were less likely to attain remission at endpoint. The high CAR seemed to block the effect of light treatment.
Maternal depression is a notable concern, yet little evidence exists on its economic burden in low- and middle-income countries.
This study assessed societal costs and economic outcomes across pregnancy to 12 months postpartum comparing women with depression with those without depression. Trial registration: ClinicalTrials.gov: NCT01977326 (registered on 24 October 2013); Pan African Clinical Trials Registry (www.pactr.org): PACTR201403000676264 (registered on 11 October 2013).
Participants were recruited during the first antenatal visit to primary care clinics in Khayelitsha, Cape Town. In total, 2187 women were screened, and 419 women who were psychologically distressed were retained in the study. Women were interviewed at baseline, 8 months gestation and at 3 and 12 months postpartum; the Hamilton Rating Scale for Depression was used to categorise women as having depression or not having depression at each interview. Collected data included sociodemographics; health service costs; user fees; opportunity costs of accessing care; and travelling expenses for the women and their child(ren). Using Markov modelling, the incremental economic burden of maternal depression was estimated across the period.
At 12 months postpartum, women with depression were significantly more likely to be unemployed, to have lower per capita household income, to incur catastrophic costs and to be in a poorer socioeconomic group than those women without depression. Costs were higher for women with depression and their child(ren) at all time points. Modelled provider costs were US$805 among women without depression versus US$1303 in women with depression.
Economic costs and outcomes were worse in perinatal women with depression. The development of interventions to reduce this burden is therefore of significant policy importance.
Insomnia is a common sleep disorder for patients with depression. This has a major impact on the quality of life for the individual. A randomized controlled trial (RCT) will address the use of music as a non-pharmacological treatment to reduce insomnia in depression.
Objectives and method
The aim is to investigate, whether music listening is effective to:
– improve sleep quality;
– reduce symptoms of depression;
– improve quality of life;
– limit or replace medication.
A RCT will address the use of music as a treatment modality in depression using an explanatory mixed methods design. In the first phase of the study, patient data is collected from 3D accelerometer, log files from a new app for iPad called ‘the music star’ and questionnaires (MDI, HAM, PSQI and WHO-QOL). ‘The music star’ is an app for iPad used to select music from special designed playlists developed by Danish music therapists in psychiatry. An exploratory follow-up (semi-structured interviews) aims to explain quantitative results from accelerometer and ‘the music star’ log files. Participants enrolled are registered at the clinic for unipolar and bipolar affective disorders at Aalborg University Hospital – Psychiatry. The participants test whether a sound pillow and special designed playlists is effective to reduce insomnia in depression in a 4 week period.
Results and conclusions
A feasibility study has been conducted on 11 participants showing positive results in terms of participation and sleep quality.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
A well-known symptom for patients with depression and bipolar diagnosis is poor quality of sleep. This has a major impact on the quality of life for the individual. Most recently, an article in the Cochrane Review, Music for insomnia in adults, concludes that music may be effective for improving sleep quality in adults with insomnia symptoms .
A Research Project at Aalborg University Hospital, Psychiatry, in Denmark has been initiated involving psychiatrists and nurses from an outpatient unit and researchers and music therapists from the Music Therapy Research Clinic at the hospital in an innovative collaboration. A pilot project is started, where patients with depression are given a sound pillow with special designed playlists, offering selected calm music for the patients to use at home for a period of 30 days. The listening periods are registered by the patients. Questionnaires are filled out before and after the listening period. A short semi-structured interview is taking place four times throughout the listening period and as a follow-up, when patients come in for control.
The aim is to investigate, whether music listening is helpful to improve sleep quality and quality of life, and to investigate if music listening can limit or replace medication. Discussion of first results.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
This review discusses the need for consistency in mass-gathering research and evaluation from a psychosocial perspective.
Mass gatherings occur frequently throughout the world. Having an understanding of the complexities of mass gatherings is important to determine required health resources. Factors within the environmental, psychosocial, and biomedical domains influence the usage of health services at mass gatherings. A standardized approach to data collection is important to identify a consistent reporting standard for the psychosocial domain.
This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2018. Data were analyzed and categorized using the existing minimum data set as a framework.
In total, 31 manuscripts met the inclusion criteria. The main variables identified were use of alcohol or drugs, crowd behavior, crowd mood, rationale, and length of stay.
Upon interrogating the literature, the authors have determined that the variables fall under the categories of alcohol or drugs; maladaptive and adaptive behaviors; crowd behavior, crowd culture, and crowd mood; reason for attending event (motivation); duration; and crowd demographics. In collecting psychosocial data from mass gatherings, an agreed-upon set of variables that can be used to collect de-identified psychosocial variables for the purpose of making comparisons across societies for mass-gathering events (MGEs) would be invaluable to researchers and event clinicians.