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The aim of the current study was to explore the effect of gender, age at onset, and duration on the long-term course of schizophrenia.
Twenty-nine centers from 25 countries representing all continents participated in the study that included 2358 patients aged 37.21 ± 11.87 years with a DSM-IV or DSM-5 diagnosis of schizophrenia; the Positive and Negative Syndrome Scale as well as relevant clinicodemographic data were gathered. Analysis of variance and analysis of covariance were used, and the methodology corrected for the presence of potentially confounding effects.
There was a 3-year later age at onset for females (P < .001) and lower rates of negative symptoms (P < .01) and higher depression/anxiety measures (P < .05) at some stages. The age at onset manifested a distribution with a single peak for both genders with a tendency of patients with younger onset having slower advancement through illness stages (P = .001). No significant effects were found concerning duration of illness.
Our results confirmed a later onset and a possibly more benign course and outcome in females. Age at onset manifested a single peak in both genders, and surprisingly, earlier onset was related to a slower progression of the illness. No effect of duration has been detected. These results are partially in accord with the literature, but they also differ as a consequence of the different starting point of our methodology (a novel staging model), which in our opinion precluded the impact of confounding effects. Future research should focus on the therapeutic policy and implications of these results in more representative samples.
This study reports on the changes in stress, anxiety, and depressive symptoms of subscribers after 3 months using Text4Hope, a supportive text messaging program designed to provide support during the pandemic.
Standardized self-report measures were used to evaluate perceived stress (measured with the Perceived Stress Scale-10 [PSS-10]), anxiety (measured with the General Anxiety Disorder Scale 7 [GAD-7]), and depressive symptoms (measured with the Patient Health Questionnaire [PHQ-9]), at baseline and 3rd month (n = 373).
After 3 months of using Text4Hope, subscribers’ self-reports revealed significant (p< 0.001) mean score reductions compared with baseline on: the GAD-7 by 22.7%, PHQ-9 by 10.3%, and PSS-10 scores by 5.7%. Reductions in inferred prevalence rates for moderate to high symptoms were also observed, with anxiety demonstrating the largest reduction (15.7%).
Observed Text4Hope-related reductions in psychological distress during COVID-19 indicate that Text4Hope is an effective, convenient, and accessible means of implementing a population-level psychological intervention.
The DESCANT (Dementia Early Stage Cognitive Aids New Trial) intervention provided a personalised care package to improve the cognitive abilities, function and well -being of people with early-stage dementia and their carers by providing a range of memory aids, with training and support for use. This presentation will explore findings from a goal attainment scaling exercise undertaken within a multi-site pragmatic randomised trial, part of a NIHR-funded research programme ‘Effective Home Support in Dementia Care: Components, Impacts and Costs of Tertiary Prevention.’
The aim was to describe the Goal Attainment Scaling (GAS) approach developed; investigate the types of goals identified by people with dementia and their carers and subsequent attainment; and explore the role of Dementia Support Practitioners (DSPs) in the process. This GAS exercise was designed by researchers, a clinical psychologist, a clinician and a DSP. Goal setting and attainment were conducted with the person with dementia and their carer and recorded by DSPs. Data were obtained from 117 intervention records and semi-structured interviews with five DSPs delivering the intervention across seven NHS Trusts in England and Wales. The GAS exercise was conducted as planned with goals and extent of involvement in the exercise tailored to individual participants and engagement was high. Demographic characteristics from the trial baseline dataset were analysed. Measures were created from intervention records to permit quantification and descriptive analysis. Interviews were professionally transcribed and subject to thematic analysis to identify salient themes.
A total of 293 goals were identified across the 117 participants. From these 17 goal types were distinguished across six domains: self -care; household tasks; daily occupation; orientation; communication; and well-being and safety. A measure of goal attainment appropriate to both the client group and a modest intervention was obtained. On average participants had evidenced some improvement regarding goals set. Qualitative findings suggested overall DSPs were positive about their experience of goal setting. Although several challenges were identified, if these were overcome, measuring goal attainment was generally viewed as straightforward. GAS can be used in the context of a psychosocial intervention for people with early-stage dementia to identify and measure attainment of personalised care goals.
The seroprevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) IgG antibody was evaluated among employees of a Veterans Affairs healthcare system to assess potential risk factors for transmission and infection.
All employees were invited to participate in a questionnaire and serological survey to detect antibodies to SARS-CoV-2 as part of a facility-wide quality improvement and infection prevention initiative regardless of clinical or nonclinical duties. The initiative was conducted from June 8 to July 8, 2020.
Of the 2,900 employees, 51% participated in the study, revealing a positive SARS-CoV-2 seroprevalence of 4.9% (72 of 1,476; 95% CI, 3.8%–6.1%). There were no statistically significant differences in the presence of antibody based on gender, age, frontline worker status, job title, performance of aerosol-generating procedures, or exposure to known patients with coronavirus infectious disease 2019 (COVID-19) within the hospital. Employees who reported exposure to a known COVID-19 case outside work had a significantly higher seroprevalence at 14.8% (23 of 155) compared to those who did not 3.7% (48 of 1,296; OR, 4.53; 95% CI, 2.67–7.68; P < .0001). Notably, 29% of seropositive employees reported no history of symptoms for SARS-CoV-2 infection.
The seroprevalence of SARS-CoV-2 among employees was not significantly different among those who provided direct patient care and those who did not, suggesting that facility-wide infection control measures were effective. Employees who reported direct personal contact with COVID-19–positive persons outside work were more likely to have SARS-CoV-2 antibodies. Employee exposure to SARS-CoV-2 outside work may introduce infection into hospitals.
Precision medicine is a new approach that considers differences in genes, environment, and lifestyle in an attempt to tailor treatments for individual patients. Psychiatry, as a discipline, has historically relied on clinical judgement and phenomenology-based diagnostic guidelines and has yet to take full advantage. This editorial provides an insight into the expanding role of precision medicine in psychiatry, both in research and clinical practice. It discusses the application of genetics and subgroup stratification in increasing response rates to therapeutic interventions, mainly focusing on major depressive disorder and schizophrenia. It presents an overview of machine learning techniques and how they are being integrated with traditional research methods within the field. In the context of these developments, while emphasizing the considerable potential for moving toward precision psychiatry, we also acknowledge the inherent challenges.
Irish medical schools attract an increasingly diverse student population and produce graduates who will practise in many parts of the world. There are particular implications in this for the planning and delivery of the undergraduate psychiatry curriculum. In all countries, mental health services struggle for equitable resourcing, and mental health care within general medical services remains relatively neglected. The traditional undergraduate psychiatry offering has been justifiably criticised for being excessively oriented towards secondary care when the vast majority of medical graduates will pursue careers in primary care or in specialties other than psychiatry. Recently published articles in the Irish Journal of Psychological Medicine address the current challenges and opportunities in providing an undergraduate experience that better prepares students for the mental health aspects of medical practice in a global context. We summarise and discuss these contributions and the recent Royal College of Psychiatrists publication Choose Psychiatry: Guidance for Medical Schools.
The aim of the current study was to explore the changing interrelationships among clinical variables through the stages of schizophrenia in order to assemble a comprehensive and meaningful disease model.
Twenty-nine centers from 25 countries participated and included 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Multiple linear regression analysis and visual inspection of plots were performed.
The results suggest that with progression stages, there are changing correlations among Positive and Negative Syndrome Scale factors at each stage and each factor correlates with all the others in that particular stage, in which this factor is dominant. This internal structure further supports the validity of an already proposed four stages model, with positive symptoms dominating the first stage, excitement/hostility the second, depression the third, and neurocognitive decline the last stage.
The current study investigated the mental organization and functioning in patients with schizophrenia in relation to different stages of illness progression. It revealed two distinct “cores” of schizophrenia, the “Positive” and the “Negative,” while neurocognitive decline escalates during the later stages. Future research should focus on the therapeutic implications of such a model. Stopping the progress of the illness could demand to stop the succession of stages. This could be achieved not only by both halting the triggering effect of positive and negative symptoms, but also by stopping the sensitization effect on the neural pathways responsible for the development of hostility, excitement, anxiety, and depression as well as the deleterious effect on neural networks responsible for neurocognition.
Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses.
The Cavan–Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life.
Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct.
There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.
As research into psychotic illness evolves along established lines, insights are emerging that deviate from those lines and challenge more fundamentally our understanding. On the background of a new generation of studies on first-episode psychosis, investigations across the gene–environment interface and the intersection with ‘normal’ human mentation heighten these concerns. Using findings from the Cavan-Monaghan First Episode Psychosis Study (CAMFEPS) as an exemplar, we here review the complexity of these challenges from the perspective of this real-world setting. They range from trans-diagnostic epidemiology and clinical characterisation, through molecular genetics, social milieu, developmental pathobiology and functional outcome across arbitrary diagnostic boundaries, to the evidence base for early intervention and more radical conceptualisations and structures for provision of mental health care.
Catherine Esnouf, Institut National de la Recherche Agronomique (INRA), Paris,Marie Russel, Institut National de la Recherche Agronomique (INRA), Paris,Nicolas Bricas, Centre de Co-opération Internationale en Recherche Agronomique pour le Développement (CIRAD), Paris
Regional and global food systems are constantly evolving, thus the contextual elements presented in Chapter 1 are likely to evolve, and food systems will be transformed. Because it is impossible to predict the food systems of tomorrow, we have adopted a foresight approach in order to try and understand possible future changes. Our approach, which is presented in the first part of this chapter, has therefore mainly been based on identifying the main drivers of the transformation of food systems. This work was the fruit of collective discussions by a multidisciplinary group made up of some 15 experts. The plurality of their views and their areas of competence allowed them to analyse the potential impacts of the different evolutions identified relative to the sustainability of food systems in terms of their nutritional, economic, social, cultural, environmental and territorial dimensions. This step of the analysis also enabled us to highlight a certain number of points at issue, which are presented in the second part of the chapter; this does not end with a presentation of different scenarios (as might have been expected), but concludes with the three transversal messages arising from debate by this workshop: issues linked to inequalities of access to food, territorial dynamics and the governance of food systems.
Food systems evolving under the effects of various factors
Through the identification of factors underlying the transformation of food systems, it appears clearly that some trends have already been identified (see, in particular, Chapter 1 on the context and the challenges of food systems, and the retrospective analysis described in Chapter 2). Nevertheless, these trends involve a certain number of questions and uncertainties, notably regarding the nature and degree of their potential effects. These uncertainties thus open the way to contrasting scenarios for food systems throughout the world (see Figure 9.1).
We report on the case of a middle-aged woman with a complex psychiatric history in whom atypical intrusive imagery identified in the mental status examination appeared to represent an emergence of childhood dissociative phenomena. These new symptoms led to the reappraisal of her clinical presentation and a diagnostic re-evaluation that they represented a re-emergence of childhood post-traumatic stress disorder secondary to sexual abuse. We discuss the phenomenology identified in our patient with the aim of increasing awareness of unusual symptoms in adults with a history of childhood sexual abuse and the importance of the mental state examination in eliciting and classifying such phenomena.
We report on the case of a middle aged lady who was referred by her GP with what appeared to be a case of first episode psychosis. Following assessment and investigation an underlying cerebellar tumour was identified. Our aim is to draw attention to the ongoing debates regarding the possible role of the cerebellum in psychosis and cognition and on neuroimaging as a diagnostic modality in cases of first episode psychosis.
Objectives: This study (a) describes the clinical and demographic profile of urban to rural migrants attending a psychiatric outpatient clinic and (b) explores the impact of the move on patients' mental health and lifestyle.
Methods: A self-rated questionnaire distributed to 207 consecutive outpatients requested demographic and clinical information from migrant and non-migrant patients. A focus group study among a purposeful sample of 10 migrant patients explored participants perceptions of the move and its impact on mental health.
Results: One hundred and one patients (48.8%) returned the questionnaire. Most migrant responders described housing affordability as influencing their decision and were generally satisfied with the move. However, half reported reduced access to social amenities. Over half of the migrant outpatients had a previous psychiatric history and were mostly unemployed despite being home-owners. Predominant focus group themes included the perceived need to leave the city for the relative safety and calm of rural living as well as post-migration concerns regarding future isolation and diminished levels of support.
Conclusion: Clinicians and service providers in rural areas should be informed by an awareness of the potential mental health implications of counter-urbanisation.
A Vision for Change, the report of the Expert Group on Mental Health Policy asserts as one of its key recommendations the enhancement and formalisation of links between specialist mental health services and primary care. As part of a higher training post in psychiatry a consultation-liaison service was provided by a senior registrar in three rural general practices. This paper describes the experience of this initiative from an educational perspective and discusses the broader implications for Irish psychiatric training. With an emerging emphasis on collaborative mental health care there needs to be an appreciation of the specific set of skills that psychiatry trainees must learn in order to be effective in primary care settings. The tandem development of the appropriate services and training in an Irish context will require dedicated funding and resources.