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There is growing evidence for yoga's neurobiological effects in people with psychiatric disorders. Postulated mechanisms of action include: (a) modulation of the hypothalamic–pituitary–adrenal (HPA) axis; (b) enhancement of GABAergic neurotransmission; (c) autonomic modulation; and (d) neuroendocrinological effects. Yoga as a therapeutic intervention in psychiatric disorders appears promising and merits further attention in clinical practice and research.
Dr Séamus Mac Suibhne (Sweeney), consultant psychiatrist and writer, who died on 8 September 2019, was a unique, much admired figure in Irish psychiatry. His interests ranged from clinical care to philosophy, from medical education to history, from innovative technology to the natural world. He was a dedicated family man as well as a doctor, scholar and writer who moved between academic fields with ease and erudition. As a clinician, he consistently placed compassion at the centre of care. Séamus’s work appeared in the Lancet, BMJ, British Journal of Psychiatry, International Journal of Social Psychiatry and Irish Journal of Psychological Medicine, among other publications. He also wrote for the Guardian, Spectator, Scotsman and Times Literary Supplement. Séamus had a particular passion for better acknowledgement and treatment of mental illness among psychiatrists, and his compelling advocacy on this theme is one of his lasting legacies.
This article reviews the development of forensic psychiatry and mental health services in Australia for the international reader. It covers the legacy of a series of colonial systems that have contributed to a modern health service that interacts with justice systems. The development of relevant legislation, hospitals, prison services, community, and courts services is reviewed. The training and academic development of professionals is covered. Gaps in service delivery and future directions are considered.
In this report, we explore a case of symptoms consistent with menstrual psychosis. In order to do this, a review of the literature relating to this topic was conducted and a report was written. This is a case of a previously well adolescent female who experienced psychotic symptoms in the pre-menstrual phase of her cycle and became well soon after her menstrual period began. These episodes were prevented by aripiprazole, but recurred once medication was withdrawn. We conclude that psychosis in some women may have a relationship with the menstrual cycle. In women presenting with psychosis, it may be appropriate to note menstrual variation in symptoms. This could have a potential role in individualisation of treatment for women with psychotic disorders.
Many studies have reported associations between prenatal stress and the development of psychotic, anxiety and depressive disorders; however, to date no studies have investigated potential associations with personality disorders.
This study investigated potential associations between exposure to prenatal stress and personality disorder in offspring.
In a subsample (N = 3626) of a large Finnish birth cohort, we used logistic regression models to examine associations between self-reported maternal stress during pregnancy, collected monthly during antenatal clinic appointments, and personality disorder in offspring. Familial and outcome information were obtained by linking data from the Finnish Hospital Discharge Register and the Finnish Population Register.
Compared with those unexposed, children exposed to any maternal stress during gestation had three times the odds of developing a personality disorder (odds ratio 3.28, 95% CI 1.75–6.15, P < 0.0001). Those exposed to moderate stress had three times the odds (odds ratio 3.13, 95% CI 1.42–6.88, P = 0.005) and those exposed to severe stress had seven times the odds (odds ratio 7.02, 95% CI 2.08–23.66, P = 0.002) of developing a personality disorder. These associations remained after adjusting for parental psychiatric history, comorbid psychiatric diagnoses, prenatal smoking and antenatal depression.
Exposure to stress during gestation increases the odds of personality disorder in offspring, independent of other psychiatric disorders. These results suggest the assessment of maternal stress and well-being during pregnancy may be useful in identifying those at greatest risk of developing personality disorder, and highlight the importance of prenatal care for good maternal mental health during pregnancy.
To assess the perception of Ghanaian medical students about factors influencing their career interest in psychiatry and to explore gender differences in these perceptions.
This is a cross-sectional quantitative survey of 5th and 6th year medical students in four public medical schools in Ghana. Data were analyzed with descriptive and inferential statistics using SPSS version 20.
Responses were obtained from 545 medical students (response rate of 52%). Significantly, more male medical students expressed that stigma is an important consideration for them to choose or not to choose a career in psychiatry compared to their female counterparts (42.7% v. 29.7%, respectively). Over two-thirds of the medical students perceived that psychiatrists were at risk of being attacked by their patients, with just a little over a third expressing that risk was an important consideration for them to choose a career in psychiatry. There were no gender differences regarding perceptions about risk. Around 3 to 4 out of 10 medical students will consider careers in psychiatry if offered various incentives with no gender differences in responses provided.
Our study presents important and novel findings in the Ghanaian context, which can assist health policy planners and medical training institutions in Ghana to formulate policies and programs that will increase the number of psychiatry residents and thereby increase the psychiatrist-to-patient ratio in Ghana.
The history of psychiatry and homosexuality illuminates how stigma develops in the professions, how it is linked to cultural values and religious attitudes and how it affects patients. Homosexuality was medicalised as a disorder in the late 19th century and this led to treatments to change it. Same-gender contacts between men were decriminalised in many countries in the 1960s and 1970s, but – as recently as the 1980s – 30% of doctors in the USA did not think that gay students should be admitted to medical school and 40% would not allow gay doctors to specialise in paediatrics or psychiatry. Lesbians and gay men were effectively debarred from training in the main psychoanalytical schools in the USA and the UK. Although mainstream psychological treatments to make gay and bisexual people heterosexual fell into disrepute in the 1980s, so-called conversion or reparative treatments took their place and are still practised today. Transgender people have been the target of similar disapproval and attitudes towards them have been even slower to change than those towards lesbians and gay men. This stigma had consequences on the health, well-being and social inclusion of those who were lesbian, gay, bisexual and transgender (LGBT). This history suggests we need to examine where psychiatry and psychology are making similar mistakes today.
To increase the proportion of patients with no psychotropic drug discrepancies at the community mental health team (CMHT)–general practice interface. Three CMHTs participated. Over a 14 month period, quality improvement methodologies were used: individual patient-level feedback to patient's prescribers, run charts and meetings with CMHTs.
One CMHT improved medicines reconciliation accuracy and demonstrated significant reductions in prescribing discrepancies. One in three (119/356) patients had ≥1 discrepancy involving 20% (166/847) of all prescribed psychotropics. Discrepancies were graded as: ‘fatal’ (0%), ‘serious’ (17%) and ‘negligible/minor harm’ (83%) but were associated with extra avoidable prescribing costs. For medicines routinely supplied by secondary care, 68% were not recorded in general practice electronic prescribing systems.
Improvements in medicines reconciliation accuracy were achieved for one CMHT. This may have been partly owing to a multidisciplinary team approach to sharing and addressing prescribing discrepancies. Improving prescribing accuracy may help to reduce avoidable drug-related harms to patients.
We reappraise the psychiatric potential of calcium channel blockers (CCBs). First, voltage-gated calcium channels are risk genes for several disorders. Second, use of CCBs is associated with altered psychiatric risks and outcomes. Third, research shows there is an opportunity for brain-selective CCBs, which are better suited to psychiatric indications.
Declaration of interest
E.M.T. and P.J.H. hold an unrestricted educational grant from Johnson & Johnson to work on the molecular neurobiology of calcium channels.
Over the twentieth century, the Lunacy Office (renamed the Court of Protection in 1947) was responsible for appointing ‘receivers’ to manage the property of adults in England who were found incapable of managing their own affairs. Tens of thousands of people were in this position by the 1920s, and numbers continued to grow until after Second World War. This article uses the archives of the Office to examine the evolution of the concept of mental incapacity over the first half of the twentieth century, offering a corrective to the popular impression that the time before the Mental Capacity Act of 2005 was an era of ignorance and bad practice. It examines the changing ways in which being ‘incapable’ was understood and described, with particular reference to shifting ideas of citizenship. I argue that incapacity was not always seen as absolute or permanent in the first half of the century, that models of incapacity began to include perceived vulnerability in the interwar period and that women in particular were seen in this way. From the 1940s, though, the profile of those found incapable was changing, and the growing welfare state and its principles of employment and universality saw the idea of incapacity narrowing and solidifying around knowledge deficits, especially among the elderly. This brings the history of the Lunacy Office into the twentieth century and connects it to current concerns around assessments of mental capacity today.
Objectives: Patients with body dysmorphic disorder (BDD) have difficulty in recognising facial emotions, and there is evidence to suggest that there is a specific deficit in identifying negative facial emotions, such as sadness and anger. Methods: This study investigated facial emotion recognition in 19 individuals with BDD compared with 21 healthy control participants who completed a facial emotion recognition task, in which they were asked to identify emotional expressions portrayed in neutral, happy, sad, fearful, or angry faces. Results: Compared to the healthy control participants, the BDD patients were generally less accurate in identifying all facial emotions but showed specific deficits for negative emotions. The BDD group made significantly more errors when identifying neutral, angry, and sad faces than healthy controls; and were significantly slower at identifying neutral, angry, and happy faces. Conclusions: These findings add to previous face-processing literature in BDD, suggesting deficits in identifying negative facial emotions. There are treatment implications as future interventions would do well to target such deficits.
Workforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression.
Those most likely to apply were White, privately educated older doctors with below average performance at medical school.
To reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.
Objectives: To evaluate the attitudes and perceptions of psychiatrists and psychiatry residents regarding neurosurgical procedures for treating psychiatric disorders and to identify potential barriers to patient referral. Methods: A survey consisting of 25 questions was created using SurveyMonkey and was distributed to psychiatrists and psychiatry residents in Quebec. The study was approved by the McGill University Health Center’s Research Ethics Board. Descriptive statistics and Friedman’s test were performed using SPSS software. Results: A total of 99 participants, including 64 residents and 35 psychiatrists, completed more than 75% of the survey and were included in data analysis. Overall, participants were significantly (p < 0.0005) more comfortable in referring patients suffering from treatment-resistant obsessive–compulsive disorder than from treatment-resistant major depressive disorder and preferred to refer patients for deep brain stimulation (DBS) rather than for anterior cingulotomy/capsulotomy (AC). Only 11.43% of psychiatrists had ever referred a patient for AC or DBS, and 34.69% of respondents felt that these procedures were dangerous. Lack of knowledge (82.83%) was viewed as the principal limiting factor, and 57.58% of respondents identified ≥6 different barriers to patient referral. The majority of participants (69.39%) were interested in improving their knowledge on psychiatric neurosurgery, and 82.65% felt that this subject should be included in the psychiatry residency curriculum. Conclusion: Overall, participants acknowledged having many limitations to referring patients for neurosurgical interventions. While informative conferences discussing neuromodulation/neuroablation could easily address many barriers, further studies are required to assess how these could change attitudes and patterns of referral.
Unbearable suffering is a key criterion in legally granting patients' euthanasia requests in Belgium yet a generally accepted definition of unbearable suffering remains elusive. The ability to understand and assess unbearable suffering is essential, particularly in patients with psychiatric conditions, as the underlying causes of these conditions are not always apparent. To enable research into when and why suffering experiences incite patients with psychiatric conditions to request euthanasia, and to help explore preventive and curative perspectives, the development of an assessment instrument is needed.
To improve the cognitive validity of a large initial item pool used to assess the nature and extent of suffering in patients with psychiatric conditions.
Cognitive validity was established via two rounds of cognitive interviews with patients with psychiatric conditions with (n = 9) and without (n = 5) euthanasia requests.
During the first round of cognitive interviews, a variety of issues relating to content, form and language were reported and aspects that were missing were identified. During the second round, the items that had been amended were perceived as sufficiently easily to understand, sensitive to delicate nuances, comprehensive and easy to answer accurately. Neither research topic nor method were perceived as emotionally strenuous, but instead as positive, relevant, comforting and valuable.
This research resulted in an item pool that covers the concept of suffering more adequately and comprehensively. Further research endeavours should examine potential differences in suffering experiences over time and in patients with psychiatric conditions with and without euthanasia requests. The appreciation patients demonstrated regarding their ability to speak extensively and openly about their suffering and wish to die further supports the need to allow patients to speak freely and honestly during consultations.
Among healthy volunteers in psychiatric brain functional magnetic resonance imaging (fMRI) research studies, the prevalence of incidentalomas can be as high as 34%, of which 10% show clinical significance. An incidentaloma is a lesion found by coincidence without clinical symptoms or suspicion. Like lesions and other types of accidental findings, it is found in healthy individuals recruited to take part in psychiatric studies. The prevalence of these accidental findings among specific psychiatric populations remains unknown. However, a precise understanding of cerebral neuroanatomy, neuroradiological expertise, and an appropriate choice of fMRI exploration sequences will increase the sensitivity of identifying these accidental findings and enable researchers to address their clinical relevance and nature. We present recommendations on how to appropriately inform patients or participants of the accidental findings. Additionally, we propose specific suggestions pertaining to the clinical research setting aimed for investigators and psychiatrists. Unlike current articles pertaining to incidentaloma, the current report provides a distinct focus on psychiatric issues and specific recommendations for studies involving psychiatric patients.
Twenty U.S. states permit the indefinite detention of civilly committed sex offenders after the end of their prison sentences if their dangerousness is due to a “mental abnormality.” This article explores the origins of one such law by examining its predecessor, the Minnesota Psychopathic Personality Act of 1939. Passed in the wake of a panic over sex crimes and upheld by the Supreme Court in 1940, Minnesota’s psychopath statute extended a 1917 eugenics law providing for the compulsory civil commitment and institutionalization of “defectives” to persons alleged to have a psychopathic personality. Analyzing the 1917 and 1939 laws together shows how one state’s psychopath statute had less to do with psychiatric authority than with the legal and administrative framework established by Progressive-era eugenics. From the 1910s until today, dubious claims about the ability of science to identify potential criminals legitimized politically popular, but constitutionally questionable, forms of administrative and social control.
Looking at the physical damage caused by the Syrian war, one can begin to imagine the scale of the psychological toll that eight years of crisis have taken on the Syrian people. In a country where mental health was still considered an emerging field before the war, Syrians are working to address and manage the mental health and psychological effects of war. Despite this disastrous situation, there appears to have been significant progress in the field of mental health during the crisis. This article explores the mental health situation in Syria prior to 2011, the effects of the crisis on Syrians, and how these have been managed in recent years. It concludes by citing some examples of progress that have been made in mental health care in Syria and discussing some of the challenges that remain to be addressed.
Euthanasia or assisted suicide (EAS) for psychiatric disorders, legal in some countries, remains controversial. Personality disorders are common in psychiatric EAS. They often cause a sense of irremediable suffering and engender complex patient–clinician interactions, both of which could complicate EAS evaluations.
We conducted a directed-content analysis of all psychiatric EAS cases involving personality and related disorders published by the Dutch regional euthanasia review committees (N = 74, from 2011 to October 2017).
Most patients were women (76%, n = 52), often with long, complex clinical histories: 62% had physical comorbidities, 97% had at least one, and 70% had two or more psychiatric comorbidities. They often had a history of suicide attempts (47%), self-harming behavior (27%), and trauma (36%). In 46%, a previous EAS request had been refused. Past psychiatric treatments varied: e.g. hospitalization and psychotherapy were not tried in 27% and 28%, respectively. In 50%, the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%) relying on cross-sectional psychiatric evaluations focusing on EAS eligibility, not treatment. Physicians evaluating such patients appear to be especially emotionally affected compared with when personality disorders are not present.
The EAS evaluation of persons with personality disorders may be challenging and emotionally complex for their evaluators who are often non-psychiatrists. These factors could influence the interpretation of EAS requirements of irremediability, raising issues that merit further discussion and research.
National information on mental health services in the Philippines indicates that there are substantial gaps and inconsistencies in the delivery of mental healthcare. The recently enacted Mental Health Act legislation provides a platform for the delivery of comprehensive and integrated mental health services. However, there remain many challenges in the provision of accessible and affordable mental healthcare.
Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations.