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John Thompson describes how Martin Luther and John Calvin treated conscience. For Luther, natural conscience is beset by knowing that a person can never meet the rigorous requirements of the law. Faith can relieve a person’s downtrodden conscience, which would otherwise condemn him. Once a person accepts the favor of God that flows solely from trusting him, his conscience is liberated. He knows he can do nothing himself to merit that favor. His conscience is freed “to trust God’s promise of mercy and forgiveness.” The highest functioning conscience for Luther, then, is the one that does not depend on its own goodness or perfection. Calvin teaches that, though a person’s conscience is a natural faculty, it is marred and affected by the fall. Once a person is saved, however, his conscience is transformed so that he desires to obey the will of God found in the law. This is true even though adherence to the law will not add in the least to his salvation. For this reason, Calvin created a catechism to train and chasten Genevan Christians’ consciences. Calvin also helped to establish the Geneva consistory, which was less a disciplinary body, and rather “a school for consciences.”
Difficulties in parent-child interaction are easily observed and are a potential target for early intervention. This study aimed to assess the utility of observation of parent-child interaction in the first year of life in identifying children at risk of developing later psychopathology, using a rigorous systematic review method.
EMBASE, CINAHL, PsycINFO, MIDIRS, MEDLINE and Cochrane Library databases were searched using MeSH terms and keywords, and reference lists screened. Two authors independently reviewed papers for inclusion and completed data extraction. All peer reviewed papers studying the association between an independent observation of parent-child interaction and later childhood psychopathology in community-based samples were included. Studies based on ‘high risk’ samples (studies exclusively examining cohorts with a sibling or parent with a mental illness or studies of low birth weight or premature infants and those with other physical comorbidities) were excluded. Results were synthesised qualitatively due to high heterogeneity.
18,226 papers were identified, nine were included in this study. Childhood psychopathology was associated with fewer positive parent-infant interactions, lower parent vocalisation frequency and lower levels of adult speech and activity. Maternal sensitivity was inversely related to separation anxiety and oppositional defiant/conduct disorders were associated with lower shared look rates. Disruptive behaviour disorders were associated with higher frequency of child vocalisation. Pervasive developmental disorders were associated with ‘abnormal’ maternal infant interactions, as assessed by community health nurses using a standardised measure.
Included studies reported small samples, and several of these samples overlapped. Some studies were of poor quality, but were included due to a paucity of available data. The findings may therefore have limited generalisability. Difficulties in parent-child interaction are easily observed and assessments could be made by non-specialists such as health visitors or general practitioners. Such difficulties may be an early indicator of later childhood psychopathology. Childhood psychiatric diagnoses (with the exception of Autistic Spectrum Disorders) appear associated with level of maternal activity (vocalisation, physical activity, positive parenting and shared attention). Assessments may identify at-risk families for early intervention, but further work is required to develop and validate reliable methods for risk stratification in community-based practice.
The COVID-19 pandemic has impacted community mental health, but the effect on psychiatric admissions is unknown. We investigated factors contributing to acute psychiatric admissions, and whether this changed during the first UK lockdown.
A retrospective case-note review study with an exploratory mixed-methods design was used to examine factors in psychiatric admissions following the first UK 2020 lockdown compared to the same time periods in 2019 and 2018.
Themes of psychopathology, risk, social stressors, community treatment issues, and physical health concerns were generated. The mean number of codes per case was 6⋅19 (s.d. = 2⋅43), with a mean number of categories per case of 3⋅73, (s.d. = 0⋅98). Changes in routines and isolation were common factors in the study year; accommodation and substance abuse were more prominent in the control year. Relationship stressors featured strongly in both groups. There were significantly more women (χ2(1, N = 98) = 20⋅80, p < 0⋅00001) and older adults (χ2(1, N = 98) = 8⋅61, p = 0⋅0033) in the study group than the control. Single people, compared to those in a relationship (χ2(1, N = 45) = 4.46, p = 0⋅035), and people with affective disorders compared to psychotic disorders ((χ2(1, N = 28) = 5.19, p = 0⋅023), were more likely to have a COVID-19 related admission factor.
The COVID-19 pandemic amplified pre-existing psychosocial vulnerabilities with a disproportionate psychiatric admissions impact on the mental health of women, the elderly and those with affective disorders.
Alterations in cerebral blood flow (CBF) may contribute to the development of depression, and serve as a novel biomarker. The aim of this review is to summarise and synthesise the available evidence on alterations in cerebral haemodynamics in depressive disorders relative to healthy control populations.
MEDLINE (1946- present), EMBASE (1947– present), Web of Science (1970–present), PsycINFO (1984–present), CINAHL (1976–present) and CENTRAL were searched using a predefined search strategy. Studies which compared the cerebral haemodynamics of adult patients (>18 years old) with depressive disorders against healthy controls (HC), by any imagining modality, were included. Studies with varying severity and chronicity of depressive disorder were included. A meta-analysis was conducted in four groups: 1) CBF (ml/min/100g) 2) Cerebral blood flow velocity (CBFv) (cm/s) 3) Combined CBF and CBFv 4) Ratio of uptake of radiotracer. A random effects model was used and heterogeneity and publication bias were assessed. Data are presented as mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (95% CI). A narrative synthesis of the remaining studies was performed.
87 studies met the inclusion criteria. CBF (ml/min/100g) was significantly reduced in patients with depression compared to HC (15 studies, 538 patients, 416 HC, MD: −2.24 (95% CI −4.12, −0.36), p = 0.02, I2 = 64%). There were no statistically significant differences between patients and controls in the other three outcomes. CBFv (cm/s): 6 studies, 305 patients, 198 HC, MD: −1.23 (95% CI −6.10, 3.64, p = 0.62, I2 = 65%. Combined CBF and CBFv: 20 studies, 804 patients, 573 HC, SMD: −0.16 (95% CI −0.32, 0.01), p = 0.06 I2 = 51%. Ratio of uptake of radiotracer: 3 studies, 60 patients, 53 HC, MD: −0.11 (95% CI −0.11, 0.11), p = 1.00, I2 = 0%). The narrative synthesis revealed varying results, with many studies identifying a decrease in CBF in depressed patients compared to controls, but other studies identifying an increase, or mixed results. Multiple regions of impairment were identified, including the anterior cingulate cortex and prefrontal cortex.
There was a statistically significant reduction in CBF in depressed patients compared to controls. The narrative synthesis revealed varying results, however specific regions of interest have been identified. Further research is needed to explore the effect of antidepressant medication, utilising different imaging modalities, and at different levels of disease severity.
To monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.
Antipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.
The records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.
We identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.
There is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.
The aim of this quality improvement project is to improve identification and management of mood disorder in patients over 65 years admitted to Royal Surrey County Hospital (RSCH) with hip fractures by introducing a standardised assessment tool to guide appropriate interventions.
The signs of depression in the elderly can be subtle and often go unnoticed. The multidisciplinary team (MDT) at RSCH observed that low mood could negatively impact on a patient's recovery, affecting pain thresholds and leading to poor engagement with rehabilitation. Proactive identification and management of mood disorder is an important part of Comprehensive Geriatric Assessment but not routinely performed in patients with hip fracture admitted to RSCH.
Notes and discharge summaries of patients with hip fracture admitted over a four-month period were retrospectively reviewed to establish if patients were screened for low mood. A mood screening tool was chosen and implemented prospectively over a four-month period. Occupational therapists and junior doctors completed a Cornell Score for all patinets. Those identified with depression or probable depression were issued verbal advice, an information leaflet and follow-up arranged.
Ninety-eight patients were included in the retrospective cohort. No patients were formally identified as having depression or probable depression, and there was no indication that mood was considered or assessed at any point during admission. During the four-month prospective period, 90 patients were admitted to RSCH with hip fracture and 86 patients (96%) were screened for low mood. Four patients were excluded due to a terminal prognosis. Of the patients screened, 9% had major depression and 16% probable depression. Feedback from our occupational therapists and doctors was positive, with the tool being relatively easy to use in patients with or without cognitive impairment. Much of the assessment could be incorporated into their initial assessment or in gaining collateral history from next of kin. Anecdotally, considering patients psychological well-being had a positive impact on inpatient therapy sessions guided the MDT in supporting the patient appropriately.
Implementation of a standardised and validated mood screening tool enabled us to identify that a quarter (25%) of the patients admitted following a hip fracture had, or probably had depression. This allowed us to intervene with simple measures such as verbal advice and an information leaflet and consider pharmacological intervention where appropriate.
To develop a new service model that engages and improves the provision of palliative care to PWUS.
Although people who use substances (PWUS) continue to die prematurely compared to the general population, they are now more likely to die from chronic diseases rather than from drug-related deaths. Challenges to providing palliative care to PWUS include delayed care-seeking behaviours, complex drug interactions and lack of healthcare provider experience.
An informal factorial analysis elucidated population needs through: a review of local databases to estimate the prevalence of palliative need, a thematic review into the deaths of patients in specialist drug services and, a survey of health practitioners’ knowledge and attitudes. These informed the service development phase which involves three key components: 1. A systems approach to increasing patient identification, incorporating key multi-disciplinary stakeholders across hospital- and community-based care 2. Targeted training of healthcare providers and 3. Medicines management for symptom palliation amidst concurrent substance use (including substitution treatments).
The palliative needs of PWUS are under-identified: the local substance service was not partaking in the palliative referral pathway. Only 7% of a local hospice's annual caseload was recognised as having substance use problems. The care pathway was described as fragmented. Although >80% of surveyed palliative care practitioners had experienced caring for PWUS, confidence and knowledge around managing withdrawal, pain and opioid substitution therapies was poor.
A new pathway is designed to identify PWUS and in their last year of life at key treatment points e.g., accident and emergency, ward-based care. The pathway will then streamline referrals to relevant specialist services depending on complexity of palliative/dependency need. Teaching resources and prescribing guidelines have been developed in collaboration with secondary care pain specialists.
Diabetes is more prevalent in people with mental illness than in the general population. Those with both mental illness and diabetes are more likely to have poor glycaemic control. Clients with mental illness and diabetes are less likely to receive the 9 NICE recommended annual diabetic care processes than the general population. In 2017, the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) and the Royal College of Psychiatrists released guidance recommending that inpatient psychiatric admissions should be used as an opportunity to complete diabetic care processes, and a named staff member should be responsible for this.
We aimed to review local compliance with this JBDS-IP guidance, increase knowledge and improve local care for clients living with both mental illness and diabetes.
We reviewed the notes of all current inpatients to general, forensic or learning disability wards at our centre and identified all patients with a known diagnosis of Diabetes. We identified which of the 9 care processes had been completed (or had the most recent result documented, or had a plan made for completion) during this admission. We identified if a named staff member was responsible for completing processes on each ward, and whether the care processes were documented in the patients’ notes.
We identified 18 current diabetic inpatients at our centre (14% of inpatients). We found that none of these patients had a diabetic care processes review documented and none of these patients had had a foot check and urinary albumin performed during admission, or had the last community result identified and documented. We found that less than 15% of patients had a documented plan concerning the completion of retinal screening. One ward had a named staff member responsible for reviewing their diabetic patients’ screening. However, 6/9 care processes had been completed in the significant majority of patients (>75%).
Our centre is not compliant with the guideline audited. We have implemented a plan to increase awareness of care processes through posters, teaching (at junior and consultant level), creating documentation templates and ensuring wards nominate a staff member to review care processes. We have organised a re-audit. Organising foot examination, renal function testing and retinal screening during admission for clients who may have complicated social situations and may not be aware of (or be non adherent with) the long term management of their diabetes has the potential to significantly reduce morbidity in this client subgroup.
This chapter explores drummers’ experiences inside recording studios from social, spatial, and technological viewpoints to highlight the drummer’s place in the creative processes of making popular music recordings. Through our ongoing ethnographic research in studios, this chapter draws from observational fieldnotes when both authors were acting as ethnographers and drummers (‘drummer-as-ethnographer’) and a series of semi-structured interviews with eight drummers of varied backgrounds and experiences. Our analyses critique widely-accepted beliefs about drummers (or in Bourdieu’s terms “Doxa”) by spotlighting three key areas: (1) the social spaces of drummers in studios (i.e. where drummers ‘belong’, or not); (2) the production of social identities in studios (i.e. who drummers are in relation to power hierarchies within the recording process); and (3) the knowledge and involvement of drummers within the creative process of record-making (i.e. what drummers ‘know’ and are able to do with their knowledge in studios). We conclude the chapter by highlighting that although they are often overlooked, drummers are vital actors within the social, spatial, and technological worlds of the recording studio.
The workhouse remains a totemic institution for social historians, yet we still know very little about the day-to-day experiences of the indoor poor. Nowhere is this clearer than in discussions about workhouse clothing, which remain overwhelmingly negative in the literature and consistent with the predominant view of the workhouse as a place of suffering and humiliation. Yet more often than not, this view is based on relatively shallow empirical foundations and tends to rely on anecdotal evidence or on the uncritical use of subjective sources such as photographs, newspaper editorials and other cultural products. This article takes a different approach by looking again at the whole range of meanings that workhouse clothing held for paupers and those who oversaw its allocation, and at the practical and symbolic usages to which it was put by them. On the basis of this evidence the authors argue that, contrary to the orthodox view, workhouse clothing was rarely intended to be degrading or stigmatising; that it would have held very different meanings for different classes of paupers; and that, far from being a source of unbridled misery, paupers often found it to be a source of great strategic and practical value.
Children born very preterm (VP) display altered growth in corticolimbic structures compared with full-term peers. Given the association between the cortiocolimbic system and anxiety, this study aimed to compare developmental trajectories of corticolimbic regions in VP children with and without anxiety diagnosis at 13 years.
MRI data from 124 VP children were used to calculate whole brain and corticolimbic region volumes at term-equivalent age (TEA), 7 and 13 years. The presence of an anxiety disorder was assessed at 13 years using a structured clinical interview.
VP children who met criteria for an anxiety disorder at 13 years (n = 16) displayed altered trajectories for intracranial volume (ICV, p < 0.0001), total brain volume (TBV, p = 0.029), the right amygdala (p = 0.0009) and left hippocampus (p = 0.029) compared with VP children without anxiety (n = 108), with trends in the right hippocampus (p = 0.062) and left medial orbitofrontal cortex (p = 0.079). Altered trajectories predominantly reflected slower growth in early childhood (0–7 years) for ICV (β = −0.461, p = 0.020), TBV (β = −0.503, p = 0.021), left (β = −0.518, p = 0.020) and right hippocampi (β = −0.469, p = 0.020) and left medial orbitofrontal cortex (β = −0.761, p = 0.020) and did not persist after adjusting for TBV and social risk.
Region- and time-specific alterations in the development of the corticolimbic system in children born VP may help to explain an increase in anxiety disorders observed in this population.
Carfentrazone-ethyl is one of few herbicides labeled for control of silvery-thread moss (STM) in golf course putting greens, but common use rates are up to three times higher than for broadleaf weeds. Our objective was to determine the efficacy of a single postemergence application of carfentrazone-ethyl for STM control in greenhouse and field dose response studies. In the greenhouse, carfentrazone-ethyl was applied at 0, 14, 28, 56, 112, and 224 g ai ha−1 to pots containing established STM and creeping bentgrass. Percent gametophyte injury was visually estimated at 14, 28, 49, and 77 d after treatment (DAT). Shoot viability was determined by excising shoots from treated pots and plating them in petri dishes containing sand. The 28 and 49 DAT ED90 (dose required to cause 90% gametophyte injury) were 26.8 and 54.3 g ha−1, respectively; both of these doses are substantially lower than the label rates for long- and short-term control, respectively. All doses reduced the viability of transplanted shoots at 10 DAT compared to untreated STM; however, regrowth occurred in all petri dishes by 17 DAT. Field studies were initiated in Manhattan, Kansas and San Luis Obispo, California to corroborate greenhouse results. Averaged across locations, carfentrazone-ethyl applied at 56 and 112 g ha−1 caused 76% and 84% STM injury at 14 DAT, but quickly reduced to 45% and 48% STM injury by 28 DAT, respectively. In greenhouse and field studies, STM recovery did not occur until after 2 wk after treatment (WAT), which indicates the label-stipulated application interval of 2 wk is too short. Our research suggests 56 g ha−1 can provide similar burndown control of STM as compared to the highest label rate (112 g ha−1), and turfgrass managers should consider extending the reapplication interval to 3 or 4 wk when moss recovery is observed.
In this retrospective cohort study of patients presenting to a national direct-to-consumer medical practice, we found that provider geographic location is a stronger driver of antibiotic prescribing than patient location. Physicians in the Northeast and South are significantly more likely than physicians in the West to prescribe antibiotics for upper respiratory infection and bronchitis.
Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.
The present study explored the influence of romantic love on the expression of several obsessive–compulsive disorder (OCD) characteristics, including symptom severity, symptom dimensions, age at onset, sensory phenomena (SP), and developmental course, as well as other related comorbid disorders. It was hypothesized that love-precipitated OCD would be associated with a set of distinct characteristics and exhibit greater rates of comorbid disorders.
The analyses were performed using a large sample (n = 981) of clinical patients with a primary diagnosis of OCD (Females = 67.3%, M age = 35.31).
Love-precipitated OCD was associated with greater severity of SP and later age at onset of obsessions. However, symptom severity, symptom dimension, developmental course, and psychiatric comorbidities were not associated with love-precipitated OCD.
It was concluded that romantic love does shape the expression of OCD, especially with regard to SP and onset age. These findings encourage further exploration to determine its clinical significance as a phenotype.
Women with underlying cardiac conditions have an increased risk of adverse pregnancy outcomes. Counselling reproductive age women with heart disease is important to assist them in deciding whether to pursue pregnancy, to ensure their best cardiovascular status prior to pregnancy, and that they understand the risks of pregnancy for them and baby. This also provides an opportunity to explore management strategies to reduce risks. For this growing cohort of women, there is a great need for pre-conceptual counselling.
This retrospective comparative audit assessed new referrals and pre-conceptual counselling of women attending a joint obstetric–cardiology clinic at a tertiary maternity centre in a 12-month period of 2015–2016 compared with 2018–2019. This reflected the timing of the introduction of a multidisciplinary meeting prior to clinics and assessed the impact on referrals with the introduction of the European Society of Cardiology guidelines.
Data were reviewed from 56 and 67 patients in respective audit periods. Patient’s risk was stratified using modified World Health Organization classification.
Less than 50% of women with pre-existing cardiac conditions had received pre-conceptual counselling, although half of them had risks clearly documented. The majority of patients had a recent electrocardiograph and echocardiogram performed prior to counselling, and there was a modest improvement in the number of appropriate functional tests performed between time points. One-third of patients in both cohorts were taking cardiac medications during pregnancy.
There was a significant increase in the number of pregnant women with cardiac disease and in complexity according to modified World Health Organization risk classification. While there have been improvements, it is clear that further work to improve availability and documentation of pre-pregnancy counselling is needed.
This study examined children's duration of attention to negative emotions (i.e., anger, sadness, fear) as a mediator of associations among maternal and paternal unsupportive parenting and children's externalizing symptoms in a sample of 240 mothers, fathers, and their preschool children (Mage = 4.64 years). The multimethod, multi-informant design consisted of three annual measurement occasions. Analysis of maternal and paternal unsupportive parenting as predictors in latent difference changes in children's affect-biased attention and behavior problems indicated that children's attention to negative emotions mediated the specific association between maternal unsupportive parenting and children's subsequent increases in externalizing symptoms. Maternal unsupportive parenting at Wave 1 predicted decreases in children's attention to negative facial expressions of adults from Wave 1 to 2. Reductions in children's attention to negative emotion, in turn, predicted increases in their externalizing symptoms from Wave 1 to 3. Additional tests of children's fearful distress and hostile responses to parental conflict as explanatory mechanisms revealed that increases in children's fearful distress reactivity from Wave 1 to 2 accounted for the association between maternal unsupportive parenting and concomitant decreases in their attention to negative emotions. Results are discussed in the context of information processing models of family adversity and developmental psychopathology.