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Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders.
To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs).
We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094).
A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1–9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9–11.3%) compared with LMICs (4.3%, 95% CI 2.6–6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%).
Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.
Depression is a common, serious, but under-recognised problem in multiple sclerosis (MS). The primary objective of this study was to assess whether a rapid visual analogue screening tool for depression could operate as a quick and reliable screening method for depression, in patients with MS.
Patients attending a regional MS outpatient clinic completed the Emotional Thermometer 7 tool (ET7), the Hospital Anxiety and Depression Scale – Depression Subscale (HADS-D) and the Major Depression Inventory (MDI) to establish a Diagnostic and Statistical Manual, 4th edition (DSM-IV) diagnosis of Major Depression. Full ET7, briefer subset ET4 version and depression and distress thermometers alone were compared with HADS-D and MDI. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and receiver operating characteristic (ROC) curve were calculated to compare the performance of all the screening tools.
In total, 190 patients were included. ET4 performed well as a ‘rule-out’ screening step (sensitivity 0.91, specificity 0.72, NPV 0.98, PPV 0.32). ET4 performance was comparable to HADS-D (sensitivity 0.96, specificity 0.77, NPV 0.99, PPV 0.37) without need for clinician scoring. The briefer ET4 performed as well as the full ET7.
ET are quick, sensitive and useful screening tools for depression in this MS population, to be complemented by further questioning or more detailed psychiatric assessment where indicated. Given that ET4 and ET7 perform equally well, we recommend the use of ET4 as it is briefer. It has the potential to be widely implemented across busy neurology clinics to assist in depression screening in this under diagnosed group.
The Improving Access to Psychological Therapies (IAPT) programme started in 2008, but it contained little provision for specifically meeting the needs of Black, Asian and minority ethnic (BAME) groups. The purpose of this evaluation was to describe the experience of transition from BAME community mental health worker (CMHW) to IAPT low-intensity psychological wellbeing practitioner (PWP) in order to identify possible gains and losses for the former communities served, and the factors that might contribute to successful training of people with BAME expertise. Four former CMHWs who had transitioned into working as PWPs were interviewed. Semi-structured interviews were used. The data were analysed using thematic analysis. Six major themes were identified with the benefits of training emerging as an important factor for the participants in enhancing their role. Three of the themes interconnected and focused on the impact for BAME communities in terms of access to service and barriers. Evident in the interviews were descriptions of adaptations that were made as a result of CMHW having access to both new and old skills. Finally, two themes focused on the participant recommendations as to how IAPT services might become more culturally responsive. The findings suggest that there can be significant benefits for services to provide IAPT training to people already providing culturally specific services. The participants reported that low-intensity cognitive behavioural therapy (LICBT) was effective, but only when cultural sensitive adaptations were made. The evaluation has some clear recommendations as to how IAPT services might seek to offer culturally responsive CBT. Suggestions for carrying out further practice-based evaluations are made.
The ventricular assist device is being increasingly used as a “bridge-to-transplant” option in children with heart failure who have failed medical management. Care for this medically complex population must be optimised, including through concomitant pharmacotherapy. Pharmacokinetic/pharmacodynamic alterations affecting pharmacotherapy are increasingly discovered in children supported with extracorporeal membrane oxygenation, another form of mechanical circulatory support. Similarities between extracorporeal membrane oxygenation and ventricular assist devices support the hypothesis that similar alterations may exist in ventricular assist device-supported patients. We conducted a literature review to assess the current data available on pharmacokinetics/pharmacodynamics in children with ventricular assist devices. We found two adult and no paediatric pharmacokinetic/pharmacodynamic studies in ventricular assist device-supported patients. While mechanisms may be partially extrapolated from children supported with extracorporeal membrane oxygenation, dedicated investigation of the paediatric ventricular assist device population is crucial given the inherent differences between the two forms of mechanical circulatory support, and pathophysiology that is unique to these patients. Commonly used drugs such as anticoagulants and antibiotics have narrow therapeutic windows with devastating consequences if under-dosed or over-dosed. Clinical studies are urgently needed to improve outcomes and maximise the potential of ventricular assist devices in this vulnerable population.
Understanding the relative risks of maintenance treatment versus discontinuation of antipsychotics following remission in first episode psychosis (FEP) is an important area of practice.
A systematic review and meta-analysis. Prospective experimental studies including a parallel control group were identified to compare maintenance antipsychotic treatment with total discontinuation or medication discontinuation strategies following remission in FEP.
Seven studies were included. Relapse rates were higher in the discontinuation group (53%; 95% CIs: 39%, 68%; N = 290) compared with maintenance treatment group (19%; 95% CIs: 0.05%, 37%; N = 230). In subgroup analyses, risk difference of relapse was lower in studies with a longer follow-up period, a targeted discontinuation strategy, a higher relapse threshold, a larger sample size, and samples with patients excluded for drug or alcohol dependency. Insufficient studies included psychosocial functioning outcomes for a meta-analysis.
There is a higher risk of relapse for those who undergo total or targeted discontinuation strategies compared with maintenance antipsychotics in FEP samples. The effect size is moderate and the risk difference is lower in trials of targeted discontinuation strategies.
Declaration of interest
A.T. has received honoraria and support from Janssen-Cilag and Otsuka Pharmaceuticals for meetings and has been has been an investigator on unrestricted investigator-initiated trials funded by AstraZeneca and Janssen-Cilag. He has also previously held a Pfizer Neurosciences Research Grant. S.M. has received sponsorship from Otsuka and Lundbeck to attend an academic congress and owns shares in GlaxoSmithKline and AstraZeneca. J.H. has attended meetings supported by Sunovion Pharmaceuticals.
OBJECTIVES/SPECIFIC AIMS: Background: Delirium is a well described form of acute brain organ dysfunction characterized by decreased or increased movement, changes in attention and concentration as well as perceptual disturbances (i.e., hallucinations) and delusions. Catatonia, a neuropsychiatric syndrome traditionally described in patients with severe psychiatric illness, can present as phenotypically similar to delirium and is characterized by increased, decreased and/or abnormal movements, staring, rigidity, and mutism. Delirium and catatonia can co-occur in the setting of medical illness, but no studies have explored this relationship by age. Our objective was to assess whether advancing age and the presence of catatonia are associated with delirium. METHODS/STUDY POPULATION: Methods: We prospectively enrolled critically ill patients at a single institution who were on a ventilator or in shock and evaluated them daily for delirium using the Confusion Assessment for the ICU and for catatonia using the Bush Francis Catatonia Rating Scale. Measures of association (OR) were assessed with a simple logistic regression model with catatonia as the independent variable and delirium as the dependent variable. Effect measure modification by age was assessed using a Likelihood ratio test. RESULTS/ANTICIPATED RESULTS: Results: We enrolled 136 medical and surgical critically ill patients with 452 matched (concomitant) delirium and catatonia assessments. Median age was 59 years (IQR: 52–68). In our cohort of 136 patients, 58 patients (43%) had delirium only, 4 (3%) had catatonia only, 42 (31%) had both delirium and catatonia, and 32 (24%) had neither. Age was significantly associated with prevalent delirium (i.e., increasing age associated with decreased risk for delirium) (p=0.04) after adjusting for catatonia severity. Catatonia was significantly associated with prevalent delirium (p<0.0001) after adjusting for age. Peak delirium risk was for patients aged 55 years with 3 or more catatonic signs, who had 53.4 times the odds of delirium (95% CI: 16.06, 176.75) than those with no catatonic signs. Patients 70 years and older with 3 or more catatonia features had half this risk. DISCUSSION/SIGNIFICANCE OF IMPACT: Conclusions: Catatonia is significantly associated with prevalent delirium even after controlling for age. These data support an inverted U-shape risk of delirium after adjusting for catatonia. This relationship and its clinical ramifications need to be examined in a larger sample, including patients with dementia. Additionally, we need to assess which acute brain syndrome (delirium or catatonia) develops first.
The idea that the churches became agents of empire through their missionary activity is very popular, but it is too simple. Established Churches, such as those of England and Scotland, could certainly be used by government, usually willingly; so could the Roman Catholic Church in the empires of other countries. But the position of the smaller churches, usually with no settler community behind them, was different. This study examines the effects of the Chilembwe Rising of 1915 on the British Churches of Christ mission in Nyasaland (modern Malawi). What is empire? The Colonial Office and the local administration might view a situation in different ways. Their decisions could thus divide native Christians from the UK, and even cause division in the UK church itself, as well as strengthening divisions on the mission field between different churches. Thus, even in the churches, imperial actions could foster the African desire for independence of empire.
Political observers, campaign experts, and academics alike argue bitterly over whether it is more important for a party to capture ideologically moderate swing voters or to encourage turnout among hardcore partisans. The behavioral literature in American politics suggests that voters are not informed enough, and are too partisan, to be swing voters, while the institutional literature suggests that moderate candidates tend to perform better. We speak to this debate by examining the link between the ideology of congressional candidates and the turnout of their parties’ bases in US House races, 2006–2014. Combining a regression discontinuity design in close primary races with survey and administrative data on individual voter turnout, we find that extremist nominees—as measured by the mix of campaign contributions they receive—suffer electorally, largely because they decrease their party’s share of turnout in the general election, skewing the electorate towards their opponent’s party. The results help show how the behavioral and institutional literatures can be connected. For our sample of elections, turnout appears to be the dominant force in determining election outcomes, but it advantages ideologically moderate candidates because extremists appear to activate the opposing party’s base more than their own.
One year of antipsychotic treatment from symptom remission is recommended following a first episode of psychosis (FEP).
To investigate the effectiveness of commonly used antipsychotic medications in FEP.
A retrospective cohort study of naturalistic treatment of patients (N = 460) accepted by FEP services across seven UK sites. Treatment initiation to all-cause discontinuation determined from case files.
Risk of treatment discontinuation is greatest within 3 months of treatment initiation. Risperidone had longest median survival time. No significant differences were observed in time to discontinuation between commonly used antipsychotics on multivariable Cox regression analysis. Poor adherence and efficacy failure were the most common reasons for discontinuation.
Effectiveness differences appear not to be a current reason for antipsychotic choice in FEP. Adherence strategies and weighing up likely adverse effects should be the clinical focus.
The behavior of marine-terminating ice sheets, such as the West Antarctic ice sheet, is of interest due to the possibility of rapid grounding-line retreat and consequent catastrophic loss of ice. Critical to modeling this behavior is a choice of basal rheology, where the most popular approach is to relate the ice-sheet velocity to a power-law function of basal stress. Recent experiments, however, suggest that near-grounding line tills exhibit Coulomb friction behavior. Here we address how Coulomb conditions modify ice-sheet profiles and stability criteria. The basal rheology necessarily transitions to Coulomb friction near the grounding line, due to low effective stresses, leading to changes in ice-sheet properties within a narrow boundary layer. Ice-sheet profiles ‘taper off’ towards a flatter upper surface, compared with the power-law case, and basal stresses vanish at the grounding line, consistent with observations. In the Coulomb case, the grounding-line ice flux also depends more strongly on flotation ice thickness, which implies that ice sheets are more sensitive to climate perturbations. Furthermore, with Coulomb friction, the ice sheet grounds stably in shallower water than with a power-law rheology. This implies that smaller perturbations are required to push the grounding line into regions of negative bed slope, where it would become unstable. These results have important implications for ice-sheet stability in a warming climate.
The ecological value of the stranding record is often challenged due to the complexity in quantifying the biases associated with multiple components of the stranding process. There are biological, physical and social aspects that complicate the interpretation of stranding data particularly at a population level. We show how examination of baseline variability in the historical stranding record can provide useful insights into temporal trends and facilitate the detection of unusual variability in stranding rates. Seasonal variability was examined using harbour porpoise strandings between 1992 and 2014 on the east coast of Scotland. Generalized Additive Mixed modelling revealed a strong seasonal pattern, with numbers increasing from February towards a peak in April. Profiling seasonality this way facilitates detection of unusual variations in stranding frequencies and permits for any change in the incidence of strandings to be quantified by evaluation of the normalized model residuals. Consequently, this model can be used to identify unusual mortality events, and quantify the degree to which they deviate from baseline. With this study we demonstrate that a described baseline in strandings allows the detection of abnormalities at an early stage and can be used as a regional framework of reference for monitoring. This methodology provides means to quantify and partition the variability associated with strandings data and is a useful first step towards improving the stranding record as a management resource.
Motivated by the reopening mechanics of strongly collapsed airways, we study the steady propagation of an air finger through a collapsed oil-filled channel with a single compliant wall. In a previous study using fully compliant elastic tubes, a ‘pointed’ air finger was found to propagate at high speed and low pressure, which, if clinically accessible, offers the potential for rapid reopening of highly collapsed airways with minimal tissue damage (Heap & Juel Phys. Fluids, vol. 20 (8), 2008, 081702). The mechanism underlying the selection of that pointed finger, however, remained unexplained. In this paper, we identify the required selection mechanism by conducting an experimental study in a simpler geometry: a rigid rectangular Hele-Shaw channel with an elastic top boundary. The constitutive behaviour of this elasto-rigid channel is nonlinear and broadly similar to that of an elastic tube, but unlike the tube, the channel’s cross-section adopts self-similar shapes from the undeformed state to the point of first near wall contact. The ensuing simplification of the vessel geometry enables the systematic investigation of the reopening dynamics in terms of increasing initial collapse. We find that for low levels of initial collapse, a single centred symmetric finger propagates in the channel and its shape is set by the tip curvature. As the level of collapse increases, the channel cross-section develops a central region of near opposite wall contact, and the finger shape evolves smoothly towards a ‘flat-tipped’ finger whose geometry is set by the strong depth gradient near the channel walls. We show that the flat-tipped mode of reopening is analogous to the pointed finger observed in tubes. Its propagation is sustained by the vessel’s extreme cross-sectional profile at high collapse, while vessel compliance is necessary to stabilise it. A simple scaling argument based on the dissipated power reveals that this reopening mode is preferred at higher propagation speeds when it becomes favourable to displace the elastic channel wall rather than the viscous fluid.
Expansion of early intervention services to identify and clinically manage at-risk mental state for psychosis has been recently commissioned by NHS England. Although this is a welcome development for preventive psychiatry, further clarity is required on thresholds for definition of such risk states and their ability to predict subsequent outcomes. Intervention studies for these risk states have demonstrated that a variety of interventions, including those with fewer adverse effects than antipsychotic medication, may potentially be effective but they should be interpreted with caution.
Amidst the violent upheavals of the end of empire and the Cold War, international organizations developed a basic framework for holding State and non-State armed groups to account for their actions when taking prisoners. The International Committee of the Red Cross (ICRC) placed itself at the very centre of these developments, making detention visiting a cornerstone of its work. Nowhere was this growing preoccupation with the problem of protecting detainees more evident than apartheid South Africa, where the ICRC undertook more detention visits than in almost any other African country. During these visits the ICRC was drawn into an internationalized human rights dispute that severely tested its leadership and demonstrated the troubled rapport between humanitarianism and human rights. The problems seen in apartheid South Africa reflect today's dilemmas of how to protect political detainees in situations of extreme violence. We can look to the past to find solutions for today's political detainees − or “security detainees” as they are now more commonly called.
Dietary advice is fundamental in the prevention and management of type 2 diabetes (T2DM). Advice is improved by individual assessment but existing methods are time-consuming and require expertise. We developed a twenty-five-item questionnaire, the UK Diabetes and Diet Questionnaire (UKDDQ), for quick assessment of an individual’s diet. The present study examined the UKDDQ’s repeatability and relative validity compared with 4 d food diaries.
The UKDDQ was completed twice with a median 3 d gap (interquartile range=1–7 d) between tests. A 4 d food diary was completed after the second UKDDQ. Diaries were analysed and food groups were mapped on to the UKDDQ. Absolute agreement between total scores was examined using intra-class correlation (ICC). Agreement for individual items was tested with Cohen’s weighted kappa (κw).
South West of England.
Adults (n 177, 50·3 % women) with, or at high risk for, T2DM; mean age 55·8 (sd 8·6) years, mean BMI 34·4 (sd 7·3) kg/m2; participants were 91 % White British.
The UKDDQ showed excellent repeatability (ICC=0·90 (0·82, 0·94)). For individual items, κw ranged from 0·43 (‘savoury pastries’) to 0·87 (‘vegetables’). Total scores from the UKDDQ and food diaries compared well (ICC=0·54 (0·27, 0·70)). Agreement for individual items varied and was good for ‘alcohol’ (κw=0·71) and ‘breakfast cereals’ (κw=0·70), with no agreement for ‘vegetables’ (κw=0·08) or ‘savoury pastries’ (κw=0·09).
The UKDDQ is a new British dietary questionnaire with excellent repeatability. Comparisons with food diaries found agreements similar to those for international dietary questionnaires currently in use. It targets foods and habits important in diabetes prevention and management.
Early intervention for psychosis (EIP) is a model of service delivery that aims to support young people with first-episode psychosis by providing the best available treatments, supporting recovery and preventing relapse. In this editorial, we review the evidence for EIP, how the model has developed since its inclusion in the NHS policy implementation guideline for mental health in 2001, challenges and areas of ongoing debate, and future development.
The Beaded Burial central to F101 within Cahokia’s mound 72Sub1 has been fundamental to some cosmological explanations of the founding of this North American precolumbian polity. The central burial, identified as two males surrounded by retainers, has been interpreted as paradigmatic of a paramount chiefdom, or conversely, as a mythic cosmogram. Recent bioarchaeological reanalysis and two independent osteological studies of F101 and associated burials have identified the presence of male/female pairs, numerous females, and at least one child, suggesting that previous explanations privileging the male Red Horn association should be reexamined. We suggest that 72Sub1 is most likely correlated with ritual practices promoting world creation, renewal, and fertility symbolism.