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Health and social care face growing and conflicting pressures: mounting complex needs of an ageing population, restricted funding and a workforce recruitment and retention crisis. In response, in the UK the NHS Long Term Plan promises increased investment and an emphasis on better ‘integrated’ care. We describe key aspects of integration that need addressing.
Declaration of interest
D.K.T. and S.S.S. are on the editorial board of the British Journal of Psychiatry and executives of the Academic Faculty at the Royal College of Psychiatrists. A.J.B.J., H.P. and Z.M. have roles at the Royal College of Psychiatrists that include evaluation of integrated care systems. A.J.B.J. is married to Dr Sarah Wollaston, Member of Parliament for Totnes and Chair of the Health Select Committee.
Severe mental illness (SMI) is thought to be associated with lower diet quality and adverse eating behaviours contributing towards physical health disparities. A rigorous review of the studies looking at dietary intake in psychotic disorders and bipolar disorder is lacking.
To conduct a systematic, comprehensive evaluation of the published research on dietary intake in psychotic disorders and bipolar disorder.
Six electronic databases were searched for studies reporting on dietary intakes in psychotic disorders and bipolar disorder. Dietary-assessment methods, and dietary intakes, were systematically reviewed. Where possible, data was pooled for meta-analysis and compared with healthy controls.
In total, 58 eligible studies were identified. People with SMI were found to have significantly higher dietary energy (mean difference 1332 kJ, 95% CI 487–2178 kJ/day, P = 0.002, g = 0.463) and sodium (mean difference 322 mg, 95% CI 174–490 mg, P < 0.001, g = 0.414) intake compared with controls. Qualitative synthesis suggested that higher energy and sodium intakes were associated with poorer diet quality and eating patterns.
These dietary components should be key targets for preventative interventions to improve weight and other physical health outcomes in people with SMI.
Declaration of interest
S.B.T. and E.T. have clinical dietitian appointments within the South Eastern Sydney Local Health District and do not receive any further funding.
The role that vitamin D plays in pulmonary function remains uncertain. Epidemiological studies reported mixed findings for serum 25-hydroxyvitamin D (25(OH)D)–pulmonary function association. We conducted the largest cross-sectional meta-analysis of the 25(OH)D–pulmonary function association to date, based on nine European ancestry (EA) cohorts (n 22 838) and five African ancestry (AA) cohorts (n 4290) in the Cohorts for Heart and Aging Research in Genomic Epidemiology Consortium. Data were analysed using linear models by cohort and ancestry. Effect modification by smoking status (current/former/never) was tested. Results were combined using fixed-effects meta-analysis. Mean serum 25(OH)D was 68 (sd 29) nmol/l for EA and 49 (sd 21) nmol/l for AA. For each 1 nmol/l higher 25(OH)D, forced expiratory volume in the 1st second (FEV1) was higher by 1·1 ml in EA (95 % CI 0·9, 1·3; P<0·0001) and 1·8 ml (95 % CI 1·1, 2·5; P<0·0001) in AA (Prace difference=0·06), and forced vital capacity (FVC) was higher by 1·3 ml in EA (95 % CI 1·0, 1·6; P<0·0001) and 1·5 ml (95 % CI 0·8, 2·3; P=0·0001) in AA (Prace difference=0·56). Among EA, the 25(OH)D–FVC association was stronger in smokers: per 1 nmol/l higher 25(OH)D, FVC was higher by 1·7 ml (95 % CI 1·1, 2·3) for current smokers and 1·7 ml (95 % CI 1·2, 2·1) for former smokers, compared with 0·8 ml (95 % CI 0·4, 1·2) for never smokers. In summary, the 25(OH)D associations with FEV1 and FVC were positive in both ancestries. In EA, a stronger association was observed for smokers compared with never smokers, which supports the importance of vitamin D in vulnerable populations.
Climate change is increasingly recognized as a global threat, and is already contributing to record-breaking hurricanes and heat waves. To prevent the worst impacts, attention is now turning to climate engineering - the intentional large-scale modification of the environment to reduce the impact of climate change. The two principal methods involve removing some carbon dioxide from the atmosphere (which could consume huge amounts of land and money, and take a long period of time), and reducing the amount of solar radiation reaching the earth's surface, perhaps by spraying aerosols into the upper atmosphere from airplanes (which could be done quickly but is risky and highly controversial). This is the first book to focus on the legal aspects of these technologies: what government approvals would be needed; how liability would be assessed and compensation provided if something goes wrong; and how a governance system could be structured and agreed internationally.
The significant proportion of schizophrenia patients refractory to treatment, primarily directed at the dopamine system, suggests that multiple mechanisms may underlie psychotic symptoms. Reinforcement learning tasks have been employed in schizophrenia to assess dopaminergic functioning and reward processing, but these have not directly compared groups of treatment-refractory and non-refractory patients.
In the current functional magnetic resonance imaging study, 21 patients with treatment-resistant schizophrenia (TRS), 21 patients with non-treatment-resistant schizophrenia (NTR), and 24 healthy controls (HC) performed a probabilistic reinforcement learning task, utilizing emotionally valenced face stimuli which elicit a social bias toward happy faces. Behavior was characterized with a reinforcement learning model. Trial-wise reward prediction error (RPE)-related neural activation and the differential impact of emotional bias on these reward signals were compared between groups.
Patients showed impaired reinforcement learning relative to controls, while all groups demonstrated an emotional bias favoring happy faces. The pattern of RPE signaling was similar in the HC and TRS groups, whereas NTR patients showed significant attenuation of RPE-related activation in striatal, thalamic, precentral, parietal, and cerebellar regions. TRS patients, but not NTR patients, showed a positive relationship between emotional bias and RPE signal during negative feedback in bilateral thalamus and caudate.
TRS can be dissociated from NTR on the basis of a different neural mechanism underlying reinforcement learning. The data support the hypothesis that a favorable response to antipsychotic treatment is contingent on dopaminergic dysfunction, characterized by aberrant RPE signaling, whereas treatment resistance may be characterized by an abnormality of a non-dopaminergic mechanism – a glutamatergic mechanism would be a possible candidate.
In this second part of a two-article review on malingering we consider the challenges of presenting clinical and psychometric findings. Numerous clinical and demographic factors are statistically associated with malingering but applying them to an individual case risks challenges to the expert psychiatric witness's evidence. Although psychometric data can usefully help strengthen or challenge a diagnosis, expert witnesses must recognise and report the limitations of these tests. We recommend that psychiatric expert witnesses do not try to look for or to link any external incentives with clinical findings, and indeed we suggest that they should, other than exceptionally, avoid using the term ‘malingering’. It is the job of the court, not the expert witness, to ascertain an individual's credibility and motives. We suggest a framework for presenting expert psychiatric evidence in this area.
• Appreciate clinical and sociodemographic factors associated with malingering, and the challenges to applying these in individual cases
• Understand the legal scrutiny to which the reporting of psychometric data might be exposed
• Appreciate the roles of the expert witness and the court, and have a suitable framework for reporting expert psychiatric evidence in such cases
Malingering is the dishonest and intentional production of symptoms. It can cause considerable difficulty as assessment runs counter to normal practice, and it may expose clinicians to testing medicolegal situations. In this first part of a two-article review, we explore types of psychiatric malingering and their occurrence across a range of common and challenging scenarios, discussing presentations that may help delineate true from feigned illness. A framework is provided for undertaking an assessment where malingering is suspected, including recommendations on clinician approach, the use of collateral information, and self-evaluation of biases. The uses, and limitations, of psychometric tests are discussed, including ‘general’, malingering-specific and ‘symptom validity’ scales.
• Understand the challenges of determining ‘real’ from ‘malingered’ symptomatology across a range of psychiatric conditions
• Have a rational strategy for approaching a clinical assessment where malingering is suspected
• Appreciate the role and limitations of various psychometric tests that can be used in such assessments
Theatre is predominantly a social form. Social history, which invites perspectives from “below,” stories of resistance, and awareness of how social organization stratifies, has had a profound effect on theatre studies since the 1970s. A wide scholarly purview on performative forms dates from the later nineteenth century, but social history changed awareness about historical contiguities of categories of community, amateur, and folk performance; tensions and exchanges among court, community, and professional performance constituencies; as well as greater respect for nonliterary traditions and unwritten forms of preservation and lineage. Social history, in short, prompted questions about who made theatre and how it mattered to the people who partook of it, including those who made it as well as others who consumed it, rather than more narrowly determining what constituted theatre (or drama) worthy of posterity. This approach—society as a group with common territory and interactions, enveloping each individual—could not be investigated as theatre history without a commensurate interest in culture. That is to say, not culture as the pinnacle of elites' achievements, but rather any social group's interpretation and use of common beliefs and values patterned by behavior and practices into religion, behavioral protocols, cuisine, and so on, including the arts. Wariness of a narrow elite construal of culture may be what keeps theatre historians from calling our field “cultural history,” for, though we embrace the ambit of social history, cultural history often comes in through the side door of sociological or anthropological theory. Cultural expressions are evident via how a society socializes, interacts, and adapts in ways that make the contours of the society legible to those within it, as well as differentiated from those who are outside it.
Whether genetic factors influence the associations of fatty acids with the risk of sudden cardiac arrest (SCA) is largely unknown. To investigate possible gene–fatty acid interactions on SCA risk, we used a case-only approach and measured fatty acids in erythrocyte samples from 1869 SCA cases in a population-based repository with genetic data. We selected 191 SNP in ENCODE-identified regulatory regions of fifty-five candidate genes in fatty acid metabolic pathways. Using linear regression and additive genetic models, we investigated the association of the selected SNP with erythrocyte levels of fatty acids, including DHA, EPA and trans-fatty acids among the SCA cases. The assumption of no association in non-cases was supported by analysis of publicly available datasets containing over 8000 samples. None of the SNP–fatty acid associations tested among the cases reached statistical significance after correction for multiple comparisons. One SNP, rs4654990 near PLA2G2A, with an allele frequency of 0·33, was nominally associated with lower levels of DHA and EPA and higher levels of trans-fatty acids. The strongest association was with DHA levels (exponentiated coefficient for one unit (1 % of total fatty acids), 0·90, 95 % CI 0·85, 0·97; P = 0·003), indicating that for subjects with a coded allele, the OR of SCA associated with one unit higher DHA is about 90 % what it is for subjects with one fewer coded allele. These findings suggest that the associations of circulating n-3 and trans-fatty acids with SCA risk may be more pronounced in carriers of the rs4654990 G allele.
We are concerned with the prospects for democracy under the conditions of modernity: two words that need not so much definition as exploration.
When in 1950 Hannah Arendt visited Martin Heidegger for the first time after the Second World War, they went for long walks and she sought to engage him in conversation as to how one was to think of the events that had transpired since their last encounter in 1934. Her early book The Origins of Totalitarianism and the later The Human Condition were her most extended attempts to come to grips with this new world (although one should mention Eichmann in Jerusalem here as well).
This is our problem also – at least one of our problems – if democracy is the activity of a people coming together to deal with what they have in common; that is my first attempt at an exploration. I take it that any theory of democracy must determine an appropriate democratic response to the particular set of problems that confront a given people (or peoples) at a particular time. These problems vary importantly, and what one thinks are the predominant problems of the time may be different from what they in fact are. Identification of the nature of particular problems is thus the first and most important step. As an example: if one understands the problem connected to the practice of segregation in the USA in the first two-thirds of the past century as a problem of civil rights, one will tend to think the appropriate response to be the achievement of voting rights. Such, I might note, was the conclusion of Robert Dahl in his 1956 A Preface to Democratic Theory. If one understands segregation as a problem of ressentiment, the achievement of one's identity by the negation of another's, a democratic response requires something additional.
I cannot here given more than an indication of what I think the most important problems that shape this world are. Partly out of lack of adequate knowledge of some of the parts of the world that are of concern to this volume, but more significantly out of the conviction that different peoples have different problems, I am going to restrict myself to the Anglo-American-European West in the twentieth century.