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In this overview we discuss the role of psychiatry in managing delirium in acute hospital admissions. We briefly discuss the role psychiatry can offer in four main domains: (a) assessment; (b) management; (c) recovery; and (d) paradigm, education and research. In the assessment section we discuss accurately detecting delirium in the context of comorbid mixed neuropsychiatric syndromes, including depression and dementia, and the clinical importance of delirium subtyping. The management section briefly outlines pharmacological and non-pharmacological approaches to delirium and their evidence-based rationale. The recovery section focuses on the effect delirium can have on cognitive decline, mental health and long-term health, including functional outcome and need for institutional care after hospital discharge. Finally, we outline the role of psychiatry in delirium research and education. We hope that this article will encourage clinicians to reflect on their current practice and consider holistic and evidence-based care for this vulnerable population in the acute hospital setting.
To determine the metacognitive deficits and behavioural and emotional regulation deficits among a group of children undergoing treatment for ADHD and to compare these with the hyperactivity/inattentive and behavioural assessments which contributed to the diagnosis.
Children and adolescents referred for ADHD assessment to a community Child & Adolescent Mental Health Service were assessed using clinical assessment, SNAP-IV, FTF and BRIEF rating scales. Comorbidities were assessed using clinical assessment and screened using the FTF. Clinical assessment included interview of parents, relatives and relevant school supervisors. The BRIEF scale was used to advise on specific executive function difficulties.
A total of 25 children and adolescents had complete assessments as part of routine clinical practice. There were particular groups which demonstrated elevated behavioural regulation difficulties; in the group with higher metacognition scores, groups were identified that had higher initiation and working memory deficits, higher planning and organisational deficits, or a mixture of all 5 items being elevated.
It is advantageous to complete an executive function assessment as part of ADHD assessment in clinical practice as it allows more detailed management advice to be given to teachers and support/special needs teachers and parents. It may also demonstrate successful patient-specific indicators of treatment response and outcome measures among those children who have high ADHD-related executive function deficits but whose core ADHD Hyperactive/Impulsive symptoms remain highly rated.
Childhood ADHD typically presents with comorbidites. Assessment tools for developmental screening vary greatly in length and complexitity, and parental preference has an impact on the usefulness of clinical tools in routine practice.
To determine among a group of children which ones may benefit from occupational therapy, speech and language therapy and educational progress re-assessment as part of routine clinical assessment for ADHD with the intention to improve service delivery.
Children were referred on a routine basis to a community clinic for ADHD assessment. SNAP-IV, FTF and BRIEF rating scales were administered. The FTF was used as a parent-rated screen for general development; it is a 200-item questionairre and includes sections on motor skills, speech and language skills and variety of other areas.
A review of freely available developmental questionaires was conducted. The FTF was introduced on a trial basis as a balance between the typical shorter scale of the SDQ and longer time needed for the DAWBA.
The parents of 25 children completed the FTF as part of routine clinical assessment for ADHD. Along with identifying groups of children who could benefit from further allied-healthcare assessment, the majority of parents had no difficulty with the length, although minority did report difficulty with understanding the language. Diagnoses were confirmed using SNAP-IV and clinical interview and assessment. Executive function scores were compared to FTF executive function screening scores.
Routine screening of developmental comorbidities may help with the development of patient -related outcome measures.
This presentation examines the neuroscience of criminal autistic psychopathy.
It will examine persons described by Hans Asperger who enjoy “sadistic” acts. It is only a very small number of persons with autism who show criminal autistic psychopathy.
This can have fatal consequences for the victims. Some of the acts are of the nature of “experiments” by the persons with autism. This presentation will examine ways of identifying persons with this condition. The vast majority of persons with autism are highly moral.
There is evidence for a new diagnostic category “criminal autistic psychopathy”.
In this presentation Michael Fitzgerald will investigate the evidence for the clinical, genetic, and other evidence for the overlap between Autism and Attention Deficit Hyperactivity Disorder.
He will examine the questions of a similar underlying pathophysiological process and alternately a number of pathologies leading to the same clinical presentation. He will examine clinical and epidemiological overlap, overlap mechanisms, deficits in social interaction in Attention Deficit Hyperactivity Disorder, and genome wide gains in Attention Deficit Hyperactivity Disorder and Autism, candidate gene studies as well as neurochemical and treatment issues.
The issue of overlap between ADHD and Autism is being increasingly recognised.
This paper will examine Criminal Autistic Psychopathy. The vast majority of persons with autism and Asperger's syndrome are highly ethical. A tiny minority who end up in prison or in criminal activities not leading to prison have major empathy and interpersonal difficulties. These can lead to fatal acts of aggression. This paper focuses on differential diagnosis, neuropsychology, neurochemistry, and neuroimaging studies of this very serious and important condition even though it is rare.
Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed psychiatric disorder in childhood (estimated global prevalence 3–5%). ADHD symptoms and impairments frequently continue into adulthood, but data on lifelong impact are limited.
The Lifetime Impairment Survey aimed to evaluate the extent of lifetime impairment of individuals with ADHD in six European countries. We analysed the responses obtained from adults with/without ADHD regarding their current situation.
The survey was developed by a committee of ADHD specialists and implemented by a market research organization. Participants were recruited from a database of 487,533 volunteers, and answered questions on ADHD diagnosis and current experiences. Survey items were combined into scales/scores evaluating different areas of impairment. Mean scale scores for ADHD and controls were compared. Cross-country comparisons of impairment scales were also performed.
A total of 629 adults with ADHD and 736 controls participated. ADHD was diagnosed after a median of 22 months and after consulting a median of two physicians. Impairments reported by adults with ADHD were significantly greater (p < 0.001) than controls in most areas investigated, including work, social and relationship functioning, mood/temper control, rule-breaking behaviour, self-organization/planning, and financial difficulties. Analyses of variance showed that the country effect on impairment scores was generally negligible, explaining only 1–3% of the observed variance.
Compared with controls, the impairments reported by adults with ADHD suggest a continued impact of the condition on both personal and professional life; no substantial cross-cultural differences were observed.
The Lifetime Impairment Survey assessed impairment and symptoms of attention-deficit/hyperactivity disorder (ADHD) in children/adolescents from six European countries. Parents/caregivers of children/adolescents aged < 20 years with ADHD (ADHD group; n = 535) and without ADHD (control group; n = 424) participated in an online survey. History of ADHD diagnosis was self-reported. ADHD and control groups were compared using impairment and symptom scales; higher scores indicate greater impairment. Mean (SD) age at ADHD diagnosis was 7.0 (2.8) years, following consultation of 2.7 (2.6) doctors over 20.4 (23.9) months. Parents/caregivers (64%; 344/535) reported frustration with some aspect of the diagnostic procedure; 74% (222/298) were satisfied with their child's current medication. ADHD had a negative impact on children/adolescents in all aspects of life investigated. The ADHD group had a higher mean (SD) school impairment score (2.7 [0.7]) compared with the control group (2.1 [0.7]; P < 0.001) and were more likely to be in the bottom of their class (P < 0.001). These data provide insights into impairments associated with ADHD in childhood/adolescence, and identify areas for improvement in its management and treatment.
Antidepressants are amongst the most commonly prescribed classes of drugs and their use continues to grow. Adverse outcomes are part of the landscape in prescribing medications and therefore management of safety issues need to be an integral part of practice.
We have developed consensus guidelines for safety monitoring with antidepressant treatments.
To present an overview of screening and safety considerations for pharmacotherapy of clinical depressive disorders and make recommendations for safety monitoring.
Data were sourced by a literature search using Medline and a manual search of scientific journals to identify relevant articles. Draft guidelines were prepared and serially revised in an iterative manner until all co-authors gave final approval of content.
A guidelines document was produced after approval by all 19 co-authors. The final document gives guidance on; the decision to treat, baseline screening prior to commencement of treatment, and ongoing monitoring during antidepressant treatment. The guidelines state or reference screening protocols that may detect medical causes of depression as well as screening and monitoring protocols to investigate specific adverse effects associated with antidepressant treatments that may be reduced or identified earlier by baseline screening and agent-specific monitoring after commencing treatment.
The implementation of safety monitoring guidelines for treatment of clinical depression may significantly improve outcome, by improving a patient's overall physical health status.
Optimism is associated with reduced cardiovascular disease risk; however, few prospective studies have considered optimism in relation to hypertension risk specifically. We investigated whether optimism was associated with a lower risk of developing hypertension in U.S. service members, who are more likely to develop high blood pressure early in life. We also evaluated race/ethnicity, sex and age as potential effect modifiers of these associations.
Participants were 103 486 hypertension-free U.S. Army active-duty soldiers (mean age 28.96 years, 61.76% White, 20.04% Black, 11.01% Hispanic, 4.09% Asian, and 3.10% others). We assessed optimism, sociodemographic characteristics, health conditions, health behaviours and depression status at baseline (2009–2010) via self-report and administrative records, and ascertained incident hypertension over follow-up (2010–2014) from electronic health records and health assessments. We used Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), and adjusted models for a broad range of relevant covariates.
Over a mean follow-up of 3.51 years, 15 052 incident hypertension cases occurred. The highest v. lowest optimism levels were associated with a 22% reduced risk of developing hypertension, after adjusting for all covariates including baseline blood pressure (HR = 0.78; 95% CI = 0.74–0.83). The difference in hypertension risk between the highest v. lowest optimism was also maintained when we excluded soldiers with hypertension in the first two years of follow-up and, separately, when we excluded soldiers with prehypertension at baseline. A dose–response relationship was evident with higher optimism associated with a lower relative risk (p < 0.001). Higher optimism was consistently associated with a lower risk of developing hypertension across sex, age and most race/ethnicity categories.
In a diverse cohort of initially healthy male and female service members particularly vulnerable to developing hypertension, higher optimism levels were associated with reduced hypertension risk independently of sociodemographic and health factors, a particularly notable finding given the young and healthy population. Results suggest optimism is a health asset and a potential target for public health interventions.
Culture-based studies, which focus on individual organisms, have implicated stethoscopes as potential vectors of nosocomial bacterial transmission. However, the full bacterial communities that contaminate in-use stethoscopes have not been investigated.
We used bacterial 16S rRNA gene deep-sequencing, analysis, and quantification to profile entire bacterial populations on stethoscopes in use in an intensive care unit (ICU), including practitioner stethoscopes, individual-use patient-room stethoscopes, and clean unused individual-use stethoscopes. Two additional sets of practitioner stethoscopes were sampled before and after cleaning using standardized or practitioner-preferred methods.
Bacterial contamination levels were highest on practitioner stethoscopes, followed by patient-room stethoscopes, whereas clean stethoscopes were indistinguishable from background controls. Bacterial communities on stethoscopes were complex, and community analysis by weighted UniFrac showed that physician and patient-room stethoscopes were indistinguishable and significantly different from clean stethoscopes and background controls. Genera relevant to healthcare-associated infections (HAIs) were common on practitioner stethoscopes, among which Staphylococcus was ubiquitous and had the highest relative abundance (6.8%–14% of contaminating bacterial sequences). Other HAI-related genera were also widespread although lower in abundance. Cleaning of practitioner stethoscopes resulted in a significant reduction in bacterial contamination levels, but these levels reached those of clean stethoscopes in only a few cases with either standardized or practitioner-preferred methods, and bacterial community composition did not significantly change.
Stethoscopes used in an ICU carry bacterial DNA reflecting complex microbial communities that include nosocomially important taxa. Commonly used cleaning practices reduce contamination but are only partially successful at modifying or eliminating these communities.
Background Attention-deficit/hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that often persists into adulthood and old age. Yet ADHD is currently underdiagnosed and undertreated in many European countries, leading to chronicity of symptoms and impairment, due to lack of, or ineffective treatment, and higher costs of illness.
Methods The European Network Adult ADHD and the Section for Neurodevelopmental Disorders Across the Lifespan (NDAL) of the European Psychiatric Association (EPA), aim to increase awareness and knowledge of adult ADHD in and outside Europe. This Updated European Consensus Statement aims to support clinicians with research evidence and clinical experience from 63 experts of European and other countries in which ADHD in adults is recognized and treated.
Results Besides reviewing the latest research on prevalence, persistence, genetics and neurobiology of ADHD, three major questions are addressed: (1) What is the clinical picture of ADHD in adults? (2) How should ADHD be properly diagnosed in adults? (3) How should adult ADHDbe effectively treated?
Conclusions ADHD often presents as a lifelong impairing condition. The stigma surrounding ADHD, mainly due to lack of knowledge, increases the suffering of patients. Education on the lifespan perspective, diagnostic assessment, and treatment of ADHD must increase for students of general and mental health, and for psychiatry professionals. Instruments for screening and diagnosis of ADHD in adults are available, as are effective evidence-based treatments for ADHD and its negative outcomes. More research is needed on gender differences, and in older adults with ADHD.
Reappraisal, an adaptive emotion regulation strategy, is associated with frontal engagement. In internalizing psychopathologies (IPs) such as anxiety and depression frontal activity is atypically reduced suggesting impaired regulation capacity. Yet, successful reappraisal is often demonstrated at the behavioral level. A data-driven approach was used to clarify brain and behavioral relationships in IPs.
During functional magnetic resonance imaging, anxious [general anxiety disorder (n = 43), social anxiety disorder (n = 72)] and depressed (n = 47) patients reappraised negative images to reduce negative affect (‘ReappNeg’) and viewed negative images (‘LookNeg’). After each trial, the affective state was reported. A cut-point (i.e. values <0 based on ΔReappNeg-LookNeg) demarcated successful reappraisers. Neural activity for ReappNeg-LookNeg, derived from 37 regions of interest, was submitted to Principal Component Analysis (PCA) to identify unique components of reappraisal-related brain response. PCA factors, symptom severity, and self-reported habitual reappraisal were submitted to discriminant function analysis and linear regression to examine whether these data predicted successful reappraisal (yes/no) and variance in reappraisal ability.
Most patients (63%) were successful reappraisers according to the behavioral criterion (values<0; ΔReappNeg-LookNeg). Discriminant function analysis was not significant for PCA factors, symptoms, or habitual reappraisal. For regression, more activation in a factor with high loadings for frontal regions predicted better reappraisal facility. Results were not significant for other variables.
At the individual level, more activation in a ‘frontal’ factor corresponded with better reappraisal facility. However, neither brain nor behavioral variables classified successful reappraisal (yes/no). Findings suggest individual differences in regions strongly implicated in reappraisal play a role in on-line reappraisal capability.
Recently published work as described by the authors highlighted the extent of Complement activity in bovine milk. Localised mastitis infection occurring in the mammary glands of dairy cows is readily detectable by the levels of somatic cells in milk. Thus, it is opportune to monitor Complement activity in milks in association with the animal's innate immune response to mammary infection. Preliminary screening of milk samples taken randomly showed that milk with a high somatic cell count (SCC) reduced growth of the Complement-sensitive strain E. coli O111 to a greater extent (P < 0·05) than when the marker microorganism was grown in milk heated for the purpose of inactivating Complement. A follow-up study set out to determine the effect on Complement activity when a sub-clinical mastitis infection was induced in the mammary gland of four lactating dairy cows. The effect of Str. dysgalactiae spp. dysgalactiae inoculation into selected individual udder quarters of the mammary glands of each animal was followed by monitoring of SCC levels in the milks from the segregated udder samples during subsequent milking. At 72 and 96 h post inoculation (PI), the SCCs for the challenged quarter were increased compared to normal values. At the same time, the bactericidal sequestration assay identified increased E. coli O111 inhibition that can be directly linked to greater Complement activity in those quarter milks affected by induced inflammation. Thus, it can be identified that the high SCC milks were more effective in limiting E. coli O111 growth. Milks from the unchallenged quarters in all four cows were significantly less effective at reducing growth of the assay strain (P < 0·05).
An ELISA assay targeting specific activation components of the Complement pathways confirmed that greater bacterial inhibition observed during the bactericidal sequestration assay was attributable to higher Complement activity in the milk samples from the affected quarters, i.e., with higher SCC. The induced infection was confirmed as self-limiting in three of the affected animals and their SCC returned to normal levels within 14 d PI, while the fourth cow required brief antibiotic intervention.
This study aims to investigate existing evidence for the effectiveness of psychological treatments and/or antidepressant medication as a treatment for those diagnosed with moderate levels of depression.
A PRISMA systematic review of articles using electronic research databases (2000–2014) was conducted to identify studies investigating the effectiveness of psychotherapy and/or medication as a treatment for people with moderate levels of depression. Search terms included moderate depression, psychotherapy and/or medication, depressive disorders, antidepressants, psychotherapy, mental health services, and randomized-controlled trial (RCT). The included studies were then assessed, extracted, and synthesised.
A total of 14 studies met the inclusion criteria (11 RCTs and three additional studies) for this review. The findings of the systematic review indicate that there is limited evidence available specific to the treatment of moderate depression and that this research seems to suggest that psychotherapy or combined treatment has a beneficial effect.
Given that depression is one of the biggest challenges the world faces at present, further research is required to examine the effectiveness of treatment for different levels of depression severity.
The 7 and 13-valent pneumococcal conjugate vaccines (PCVs) have reduced the incidence of invasive pneumococcal disease (IPD) in children in many countries. The objective of this work was to assess the impact of PCVs and potential herd-protection in older adults in Ireland. IPD notification and typing data from adults ⩾65 years of age from July 2007 to June 2016 was assessed using national surveillance data. There was a 94% reduction in PCV7 serotypes from 2007–2008 to 2015–2016, incidence rate ratio (IRR 0·05, P < 0·0001). However, there was no decline in the additional PCV13 (PCV13-7) serotypes over the same period (IRR 0·90) nor in comparison with the pre-PCV13 period 2009–2010 (IRR 0·92). The incidence of serotypes in the 23-valent pneumococcal polysaccharide vaccine only (PPV23-PCV13) and non-vaccine types (NVTs) increased significantly (IRR 2·17, P = 0·0002 and IRR 3·43, P = 0·0001 respectively). Consequently, the overall IPD incidence rate in adults has remained relatively unchanged (from 28·66/100 000 to 28·88/100 000, IRR 1·01, P = 0·9477). Serotype 19A and NVTs were mainly responsible for penicillin resistance in recent years. The decline of PCV7 serotypes indicate that the introduction of PCV7 resulted in herd-protection for adults. However, increases in PPV23-PCV13 and NVTs suggest that changes in vaccination strategy amongst older adults are needed to build on the success of PCVs in children.
Not only is depression associated with increased inflammation but inflammation is a risk factor for the genesis of depression. Many of the environmental risk factors for depression are transduced through inflammatory signaling. Anti-inflammatory agents show promise for the management of depression in preclinical, epidemiological, and early clinical studies. This opens the door to the potential for anti-inflammatory agents to treat and prevent depression. There are no evidence-based pharmacotherapies for depression prevention.
ASPREE-D, aspirin in the prevention of depression in the elderly, is a sub study of ASPREE, which explores the potential of aspirin to prevent a range of inflammation related disorders in the elderly. With a sample size of 19,114, and a duration of 5 years, this placebo controlled study will be one of the largest randomized controlled trials in psychiatry and will provide definitive evidence on the ability of aspirin to prevent depression.
This paper presents the rationale for the study and presents a summary of the study design.
ASPREE-D may not only define novel therapy but will provide mechanistic proof of concept of the role of inflammation in depression.