To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Acute non-traumatic intracerebral haemorrhage (ICH) has a poor prognosis and is the least treatable form of acute stroke. Although less common than acute ischaemic stroke, ICH causes greater premature loss of productive life years on a global scale due to its predilection to affect people at younger ages with devastating consequences. Prognosis from ICH is related to location, initial volume and speed of expansion of the haematoma, and associated intraventricular haemorrhage. Care in a specialised stroke or neurointensive care unit improves outcome. Surgical haematoma evacuation should be pursued as for patients with cerebellar haemorrhage with neurologic deterioration, hydrocephalus, orsd brainstem compression. Haematoma evacuation may be considered, as a life-saving measure, in patients with coma or large haematoma with mass effect. Minimally-invasive surgery in stable patients is of uncertain benefit and is being evaluated in RCTs. Clinicians should not routinely use haemostatic therapies where there is no evidence of coagulopathy or anticoagulant use. When coagulopathy is present, early corrective measures should be taken. Early moderate intensity BP lowering to a systolic BP target of 140 mmHg is reasonable. Medical therapies to reduce mass effect and intracranial pressure should not be used routinely, but hyperventilation and hypertonic saline or colloidal osmotic agents are reasonable in patients with imminent herniation as a bridge to definitive neurosurgical intervention. Corticosteroids should be avoided. Novel neuroprotective approaches hold promise.
Psychosis, and in particular auditory verbal hallucinations (AVHs), are associated with adversity exposure. However, AVHs also occur in populations with no need for care or distress.
This study investigated whether adversity exposure would differentiate clinical and healthy voice-hearers within the context of a ‘three-hit’ model of vulnerability and stress exposure.
Samples of 57 clinical and 45 healthy voice-hearers were compared on the three ‘hits’: familial risk; adversity exposure in childhood and in adolescence/adulthood.
Clinical voice-hearers showed greater familial risk than healthy voice-hearers, with more family members with a history of psychosis, but not with other mental disorders. The two groups did not differ in their exposure to adversity in childhood [sexual and non-sexual, victimisation; discrimination and socio-economic status (SES)]. Contrary to expectations, clinical voice-hearers did not differ from healthy voice-hearers in their exposure to victimisation (sexual/non-sexual) and discrimination in adolescence/adulthood, but reported more cannabis and substance misuse, and lower SES.
The current study found no evidence that clinical and healthy voice-hearers differ in lifetime victimisation exposure, suggesting victimisation may be linked to the emergence of AVHs generally, rather than need-for-care. Familial risk, substance misuse and lower SES may be additional risk factors involved in the emergence of need-for-care and distress.
First episode psychosis (FEP) patients who use cannabis experience more frequent psychotic and euphoric intoxication experiences compared to controls. It is not clear whether this is consequent to patients being more vulnerable to the effects of cannabis use or to their heavier pattern of use. We aimed to determine whether extent of use predicted psychotic-like and euphoric intoxication experiences in patients and controls and whether this differs between groups.
We analysed data on patients who had ever used cannabis (n = 655) and controls who had ever used cannabis (n = 654) across 15 sites from six countries in the EU-GEI study (2010–2015). We used multiple regression to model predictors of cannabis-induced experiences and to determine if there was an interaction between caseness and extent of use.
Caseness, frequency of cannabis use and money spent on cannabis predicted psychotic-like and euphoric experiences (p ⩽ 0.001). For psychotic-like experiences (PEs) there was a significant interaction for caseness × frequency of use (p < 0.001) and caseness × money spent on cannabis (p = 0.001) such that FEP patients had increased experiences at increased levels of use compared to controls. There was no significant interaction for euphoric experiences (p > 0.5).
FEP patients are particularly sensitive to increased psychotic-like, but not euphoric experiences, at higher levels of cannabis use compared to controls. This suggests a specific psychotomimetic response in FEP patients related to heavy cannabis use. Clinicians should enquire regarding cannabis related PEs and advise that lower levels of cannabis use are associated with less frequent PEs.
Daily use of high-potency cannabis has been reported to carry a high risk for developing a psychotic disorder. However, the evidence is mixed on whether any pattern of cannabis use is associated with a particular symptomatology in first-episode psychosis (FEP) patients.
We analysed data from 901 FEP patients and 1235 controls recruited across six countries, as part of the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study. We used item response modelling to estimate two bifactor models, which included general and specific dimensions of psychotic symptoms in patients and psychotic experiences in controls. The associations between these dimensions and cannabis use were evaluated using linear mixed-effects models analyses.
In patients, there was a linear relationship between the positive symptom dimension and the extent of lifetime exposure to cannabis, with daily users of high-potency cannabis having the highest score (B = 0.35; 95% CI 0.14–0.56). Moreover, negative symptoms were more common among patients who never used cannabis compared with those with any pattern of use (B = −0.22; 95% CI −0.37 to −0.07). In controls, psychotic experiences were associated with current use of cannabis but not with the extent of lifetime use. Neither patients nor controls presented differences in depressive dimension related to cannabis use.
Our findings provide the first large-scale evidence that FEP patients with a history of daily use of high-potency cannabis present with more positive and less negative symptoms, compared with those who never used cannabis or used low-potency types.
A higher incidence of psychotic disorders has been consistently reported among black and other minority ethnic groups, particularly in northern Europe. It is unclear whether these rates have changed over time.
We identified all individuals with a first episode psychosis who presented to adult mental health services between 1 May 2010 and 30 April 2012 and who were resident in London boroughs of Lambeth and Southwark. We estimated age-and-gender standardised incidence rates overall and by ethnic group, then compared our findings to those reported in the Aetiology and Ethnicity of Schizophrenia and Other Psychoses (ÆSOP) study that we carried out in the same catchment area around 10 years earlier.
From 9109 clinical records we identified 558 patients with first episode psychosis. Compared with ÆSOP, the overall incidence rates of psychotic disorder in southeast London have increased from 49.4 (95% confidence interval (CI) 43.6–55.3) to 63.1 (95% CI 57.3–69.0) per 100 000 person-years at risk. However, the overall incidence rate ratios (IRR) were reduced in some ethnic groups: for example, IRR (95% CI) for the black Caribbean group reduced from 6.7 (5.4–8.3) to 2.8 (2.1–3.6) and the ‘mixed’ group from 2.7 (1.8–4.2) to 1.4 (0.9–2.1). In the black African group, there was a negligible difference from 4.1 (3.2–5.3) to 3.5 (2.8–4.5).
We found that incidence rates of psychosis have increased over time, and the IRR varied by the ethnic group. Future studies are needed to investigate more changes over time and determinants of change.
The development of effective preventions for psychosis is hindered by conceptual challenges underlying diagnosis and the fact that few of the many biological risk factors identified to date are sufficiently well understood to form the basis of a targeted intervention. On the other hand, a great deal is known of the psychosocial conditions that increase the lifetime risk of most mental illnesses: surely enough to justify better resourcing of interventions focused on antenatal care and the emotional well-being of children from the early years through adolescence, where as much as a half of all mental ill health has its roots.
Although patients value evidence-based therapeutic activities, little is known about nurses' perceptions.
To investigate whether implementing an activities training programme would positively alter staff perceptions of the ward or be detrimental through the increased workload (trial registration: ISRCTN 06545047).
We conducted a stepped wedge cluster randomised trial involving 16 wards with psychology-led nurse training as the intervention. The main outcome was a staff self-report measure of perceptions of the ward (VOTE) and secondary outcomes measuring potential deterioration were the Index of Work Satisfaction (IWS) and the Maslach Burnout Inventory (MBI). Data were analysed using mixed-effects regression models, with repeated assessments from staff over time.
There were 1075 valid outcome measurements from 539 nursing staff. VOTE scores did not change over time (standardised effect size 0.04, 95% CI –0.09 to 0.18, P = 0.54), neither did IWS or MBI scores (IWS, standardised effect size 0.02, 95% CI –0.11 to 0.16, P = 0.74; MBI standardised effect size –0.09, 95% CI –0.24 to 0.06, P = 0.24). There was a mean increase of 1.5 activities per ward (95% CI –0.4 to 3.4, P = 0.12) and on average 6.3 more patients attended groups (95% CI –4.1 to 16.6, P = 0.23) following training. Staff feedback on training was positive.
Our training programme did not change nurses' perceptions of the ward, job satisfaction or burnout. During the study period many service changes occurred, most having a negative impact through increased pressure on staffing, patient mix and management so it is perhaps unsurprising that we found no benefits or reduction in staff skill.
High continuity of care is prized by users of mental health services and lauded in health policy. It is especially important in long-term conditions like schizophrenia. However, it is not routinely measured, and therefore not often evaluated when service reorganisations take place. In addition, the impact of continuity of care on clinical outcomes is unclear.
We set out to examine continuity of care in people with schizophrenia, and to relate this to demographic variables and clinical outcomes.
Pseudoanonymised community data from 5552 individuals with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index (MMCI). These and demographic variables were related to clinical outcomes measured with the Health of the Nation Outcome Scales (HoNOS). Data were analysed using generalised estimating equations and multivariate marginal models.
There was a significant decline in MMCI and significant worsening of HoNOS total scores over 11 years. Higher (worse) HoNOS scores were significantly and independently related to older age, later years and both lower MMCI and more teams caring for the individual in each year. Most HoNOS scales contributed to the higher total scores.
There is evidence of declining continuity of care in this 11-year study of people with schizophrenia, and of an independent effect of this on worse clinical outcomes. We suggest that this is related to reorganisation of services.
Maudsley International was set up to help improve people's mental health and well-being around the world. A variety of programmes have been developed by Maudsley International over the past 10 years, for planning and implementing services; building capacity; and training and evaluation to support organisations and individuals, professionals and managers to train and develop health and social care provisions. Maudsley International's model is based on collaboration, sharing expertise and cultural understanding with international partners.
Public involvement in disinvestment decision making in health care is widely advocated, and in some cases legally mandated. However, attempts to involve the public in other areas of health policy have been accused of tokenism and manipulation. This paper presents research into the views of local health care leaders in the English National Health Service (NHS) with regards to the involvement of citizens and local communities in disinvestment decision making. The research includes a Q study and follow-up interviews with a sample of health care clinicians and managers in senior roles in the English NHS. It finds that whilst initial responses suggest high levels of support for public involvement, further probing of attitudes and experiences shows higher levels of ambivalence and risk aversion and a far more cautious overall stance. This study has implications for the future of disinvestment activities and public involvement in health care systems faced with increased resource constraint. Recommendations are made for future research and practice.
Monozygotic (MZ) and dizygotic (DZ) twins participate in research that partitions variance in health, disease, and behavior into genetic and environmental components. However, there are other innovative roles for twins in medical research. One such way is involving MZ and/or DZ twins in co-twin control-designed randomized controlled trials (RCTs). To our knowledge, no reviews have been conducted that summarizes the involvement of twins in RCTs. Therefore, we conducted a systematic literature search using the U.S. Clinical Trials Database, NHS electronic databases, MEDLINE, EMBASE, and PsychINFO for RCTs on publications involving MZ and/or DZ twins as RCT participants. Out of the 186,027 clinical trials registered in the U.S. clinical trial register ClinicaTrails.gov, only six RCTs used twins as participants. From 1,598 articles identified in our search, 50 peer-reviewed English language publications met our pre-defined inclusion criteria. Sample sizes for RCTs have ranged from a total number of participants from 2 to 1,162; however, 32 (64%) studies had a sample size of 100 or less, and of those, 12 (24%) had fewer than 10. Both MZ and DZ twins have been recruited to the RCTs. In most instances (33/50) each twin from a pair were assigned to different study arms. Most of those studies included MZ twins only. Despite the methodological advantages, the use of MZ and DZ twins as participants in interventional RCTs appeared limited. The continuous development of innovative twin designs, especially RCTs, indicates that twin research can extend beyond the more widely recognized heritability estimates.
The term mild cognitive impairment has been associated with a varying degree of clinical utility and controversy. The concept has been introduced to try and define a pre-dementia period associated with underlying neurodegenerative pathology and a higher likelihood of the person developing a dementia syndrome. As scientific understanding improves then the definition of MCI rightly adapts, meaning that the MCI concept is prone quite rightly to frequent evolution. We consider that we are a long way away from the concept having evolved to a point where it can be embedded with confidence in clinical practice as a diagnosis but should remain as a term primarily for use in research.
The Neolithic in north-east Asia is defined by the presence of ceramic containers, rather than agriculture, among hunter-gatherer communities. The role of pottery in such groups has, however, hitherto been unclear. This article presents the results of organic residue analysis of Neolithic pottery from Sakhalin Island in the Russian Far East. Results indicate that early pottery on Sakhalin was used for the processing of aquatic species, and that its adoption formed part of a wider Neolithic transition involving the reorientation of local lifeways towards the exploitation of marine resources.
According to one definition of social exclusion, ‘An individual is socially excluded if he or she does not participate in key activities of the society in which he or she lives’ (Burchardt et al, 2002, p. 30). These key activities include education, employment, access to leisure facilities and civic participation. As this book documents, people who have mental illness are often excluded from some if not all of these activities. Those with the more severe forms of disorder are unlikely to be employed, more likely to reside in shared and subsidised accommodation, live in material poverty, rely on welfare benefits, and have restricted social networks and limited access to opportunities and leisure facilities in the community. Explaining this exclusion is tricky because it clearly arises in part from the nature of mental illness. Some of the more severe disorders begin in childhood and impair educational attainment that in turn limits occupational opportunity in adult life; people with depression withdraw from social contact and those with chronic schizophrenia neglect their environment. But clearly, as the term exclusion implies, much of the problem lies not with the mentally ill person but with the rest of us – how we structure society, the rules and regulations that facilitate access to education and employment, and how we go about organising assistance for the disadvantaged. Some mentally ill people, coming from a migrant group perceived as competing for jobs and resources or who are marginalised because they do not speak English or have a black skin, can have a double or triple whammy, as evidenced by the striking over-representation of some of these groups in coercive treatment settings (Bermingham et al, 1996; Coid et al, 2000; Audini & Lelliott, 2002).
How we organise care is itself confounded by our prejudices and beliefs about the capabilities of the mentally ill person and how much we generalise from observing a specific impairment to an assumption of global incompetence. On the one hand is the view that the affected individual is essentially powerless to change their state and the caring response is therefore one of doing ‘for’ the individual. On the other hand is the belief that however profound is the appearance of the disability, people have the capacity to make positive adaptations, so that providing care is a matter of teaching and giving advice to help the individual solve or work round their problems.
Research into the use of digital technology to deliver treatment for psychosis is turning up some fascinating applications, but enthusiasm for these products must be tempered with a realistic appraisal of the steps from initial proof of concept to a marketable device.
A trend toward greater body size in dizygotic (DZ) than in monozygotic (MZ) twins has been suggested by some but not all studies, and this difference may also vary by age. We analyzed zygosity differences in mean values and variances of height and body mass index (BMI) among male and female twins from infancy to old age. Data were derived from an international database of 54 twin cohorts participating in the COllaborative project of Development of Anthropometrical measures in Twins (CODATwins), and included 842,951 height and BMI measurements from twins aged 1 to 102 years. The results showed that DZ twins were consistently taller than MZ twins, with differences of up to 2.0 cm in childhood and adolescence and up to 0.9 cm in adulthood. Similarly, a greater mean BMI of up to 0.3 kg/m2 in childhood and adolescence and up to 0.2 kg/m2 in adulthood was observed in DZ twins, although the pattern was less consistent. DZ twins presented up to 1.7% greater height and 1.9% greater BMI than MZ twins; these percentage differences were largest in middle and late childhood and decreased with age in both sexes. The variance of height was similar in MZ and DZ twins at most ages. In contrast, the variance of BMI was significantly higher in DZ than in MZ twins, particularly in childhood. In conclusion, DZ twins were generally taller and had greater BMI than MZ twins, but the differences decreased with age in both sexes.
Tom Craig, Professor of Social and Community Psychiatry, Health Services Research, Institute of Psychiatry, London,
Helen Killaspy, Professor of Rehabilitation Psychiatry, Mental Health Sciences Unit, University College London
Rehabilitation is defined by the World Health Organization (1980) as the application of measures aimed at reducing the impact of disabling and handicapping conditions and enabling people with a disability to achieve social integration. Implicit in this definition are two components: first, an active process through which a person adapts or acquires the skills needed to mitigate the constraints of disease; and second, an acknowledgement that there may also need to be changes in the environment, including the attitudes of people without a disability, if optimal social integration is to be achieved.
For William Anthony, product champion of psychiatric rehabilitation in the USA, rehabilitation involves ‘improving the psychiatrically disturbed person's capabilities and competence’ by bringing about ‘behavioural improvement in their environment of need’ (Anthony et al, 1984: 140). In subtle contrast, Douglas Bennett (1978), whose views strongly influenced UK practice, emphasised helping individuals adapt to their deficits in personal skills by ‘making best use of [their] residual abilities in order to function in as normal environment as possible’.
Psychiatric rehabilitation is frequently defined as the activity of a set of specialist services. an alternative formulation would be in terms of the needs or characteristics of people who would benefit from rehabilitation inputs. wykes & holloway (2000) defined the potential client group as people with severe and long-term mental illnesses who have both active symptomatology and impaired social functioning as a consequence of their mental illness. from this definition they argued that rehabilitation services should have the joint aims of minimising the symptoms of illness and promoting the social inclusion of clients.
Recent years have seen a growing focus on mental health rehabilitation in the UK. Killaspy et al (2005) collated responses from rehabilitation practitioners into a contemporary definition:
A whole systems approach to recovery from mental illness that maximises an individual's quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and leads to successful community living through appropriate support (p. 163).