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To examine the impact of the first full year of the COVID-19 pandemic and its associated restrictions on the volume and nature of psychiatric presentations to an emergency department (ED) in a large academic hospital.
Anonymised clinical data on psychiatric presentations to the ED were collected for the 52-week period from the start of the COVID-19 pandemic and compared with corresponding 1 year periods in 2019 and 2018.
There was a significant increase in psychiatric presentations overall to the ED during the first year of the COVID-19 pandemic compared to previous years, in contrast to a reduction in total presentations for all other specialties. There was a marked increase in psychiatric presentations of those below 18 years, and in the 30–39 years and 40–49 years age groups, but a decrease in the 18–29 years group. There was a significant increase in anxiety disorder presentations but a decrease in alcohol related presentations. There was no significant change observed in the rates of presentations for self-harm or suicidal ideation.
Psychiatric presentations to the ED have increased during the first year of the COVID-19 pandemic in contrast to a decrease in presentations for other medical specialties, with this increase being driven by out-of-hours presentations. The fourfold increase in presentations of young people below the age of 18 years to the ED with mental health difficulties is an important finding and suggests a disproportionate burden of psychological strain placed on this group during the pandemic.
To determine if the initial COVID-19 societal restrictions, introduced in Ireland in March 2020, impacted on the number and nature of psychiatry presentations to the emergency department (ED) of a large academic teaching hospital.
We examined anonymised clinical data of psychiatry presentations to the ED during the initial 8-week period of COVID-19 restrictions. Data from corresponding 8-week periods in 2018 and 2019 were also extracted for comparison.
Psychiatry presentations to ED reduced by 21% during the COVID-19 restrictions, from 24/week to 19/week when compared with corresponding periods in 2018/2019 (Poisson’s Rate Test estimate of difference −5.2/week, 95% CI 1.3–9.1, p = 0.012). Numbers attending for out-of-hours assessment remained unchanged (81 v. 80), but numbers seeking assessment during normal hours decreased (71 v. 114). We observed increased presentations from the <18 age group, but decreased presentations from the 18 to 29 age group (Pearson’s Chi-Square 20.363, df = 6, p = 0.002). We recorded an increase in anxiety disorders during the initial COVID-19 restrictions (31 v. 23), and a reduction in alcohol disorders (28 v. 52). The proportion of presentations with suicidal ideation (SI) or self-harm as factors remained unchanged.
Rates of emergency presentation with mental illness reduced during the initial COVID-19 restrictions. This may represent an unmet burden of mental health needs. Younger people may be experiencing greater distress and mental illness during the current crisis. More people sought help for anxiety disorders during the COVID-19 restrictions compared with corresponding data from 2018 and 2019.
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 study was designed to establish and evaluate the impact of a 6-week Balint group on empathy and resilience in fourth-year medical students during their psychiatry rotation.
This prospective study used the Jefferson Scale of Empathy – Student Version and the Brief Resilience Scale before and after 6-week Balint groups. Participating students also completed a qualitative assessment of their experience.
Students who participated were enthusiastic regarding the value of Balint groups in promoting self-reflection and gaining insight into self- and patient-care dynamics. There was a significant difference in empathy scores pre- and post-Balint intervention. There was no significant difference in resilience scores.
The establishment of a 6-week Balint group for fourth-year medical students was successful in increasing empathy. Students reported a positive view of Balint and its beneficial role in this study group.
Remission and recovery rates for people with first-episode psychosis (FEP) remain uncertain.
To assess pooled prevalence rates of remission and recovery in FEP and to investigate potential moderators.
We conducted a systematic review and meta-analysis to assess pooled prevalence rates of remission and recovery in FEP in longitudinal studies with more than 1 year of follow-up data, and conducted meta-regression analyses to investigate potential moderators.
Seventy-nine studies were included representing 19072 patients with FEP. The pooled rate of remission among 12301 individuals with FEP was 58% (60 studies, mean follow-up 5.5 years). Higher remission rates were moderated by studies from more recent years. The pooled prevalence of recovery among 9642 individuals with FEP was 38% (35 studies, mean follow-up 7.2 years). Recovery rates were higher in North America than in other regions.
Remission and recovery rates in FEP may be more favourable than previously thought. We observed stability of recovery rates after the first 2 years, suggesting that a progressive deteriorating course of illness is not typical. Although remission rates have improved over time recovery rates have not, raising questions about the effectiveness of services in achieving improved recovery.
Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a form of encephalitis occurring primarily in women and associated with antibodies against NR1 or NR2 subunits of the NMDA receptor. As a potentially treatable differential for symptoms and signs seen in neurology and psychiatric clinics, clinicians practising across the lifespan should be aware of this form of encephalitis. Common clinical features include auditory and visual hallucinations, delusions, behavioural change (frequently with agitation), impaired consciousness, motor disturbance (ranging from dyskinesia to catatonia), seizures, and autonomic dysfunction. We present a review of the literature on the disorder, including its clinical presentation, differential diagnosis, epidemiology, treatment and prognosis.
We present four cases of confirmed anti-NMDA receptor encephalitis; three presented initially with serious psychiatric symptoms and the other developed significant psychiatric symptoms during the initial phase of illness. Brain biopsy findings of one patient are also described. Psychiatrists should consider anti-NMDA receptor encephalitis in patients presenting with psychosis and additional features of dyskinesias, seizures and catatonia, particularly where there is no previous history of psychiatric disorder.
Catatonia is a neuro-psychiatric disorder that can occur in medical, psychiatric and drug-induced conditions but is often unrecognised. A 64 year-old woman was admitted to hospital for assessment of a significant deterioration in her ability to communicate and function normally so that she had become completely dependent on others for all activities of daily living for nearly three years. Outpatient medical and psychiatric assessments failed to clarify diagnosis. On admission to a general hospital, the neurology team initially believed she had a Parkinson's-like syndrome but after further investigation and comprehensive multidisciplinary assessment, including neuro-psychiatric review, she was diagnosed with catatonia. She was subsequently admitted to a psychiatric hospital where she received electro-convulsive therapy and changes to her psychotropic medication regimen. She responded well to treatment and within a short period of time was able to function independently again.
Objectives: This study examined and compared the number and pattern of referrals from neurosurgery and neurology specialist services to the inpatient liaison neuropsychiatry service in the years 2002 and 2005. We estimated the prevalence of psychiatric illness and evaluated the results of subsequent psychiatric assessment and follow-up of all patients reviewed by the neuropsychiatry service.
Methods: The medical notes of those patients referred to the neuropsychiatry team were retrospectively examined to obtain appropriate information on assessment and management of these cases.
Results: There were 544 referrals over the two years selected for study. Rates of referral to the inpatient neuropsychiatry service increased overall by 35% between 2002 and 2005. Overall, referrals from neurology comprised 85%, neurosurgery 15%. Patients with epilepsy comprised the majority of referrals (36%). A total of 378 (73%) had an acute psychiatric disorder and this group had a significantly higher rate (p = 0.01) of past psychiatric disorder (40%) than that in those with no acute mental illness (33%). Depressive episode was the most frequent acute psychiatric diagnosis (38%), followed by anxiety and organic psychiatric disorder (both 15%). Overall, 21% of patients diagnosed with acute mental illness were referred on discharge to the neuropsychiatry outpatient clinic for specialist follow up and the remainder followed-up by either local mental health teams or their GP.
Conclusions: These findings provide clear evidence that further resources should be allocated to expanding neuropsychiatry mental health services to improve detection and management of mental illness in this vulnerable patient group.
Objectives: To examine the prevalence, psychiatric co-morbidity and management of psychogenic non-epileptic seizures (PNES) in patients admitted to a tertiary referral Epilepsy Monitoring Unit (EMU).
Methods: Medical records of patients admitted to the EMU between 2003 and 2005 were examined and data from neurological, neuropsychiatric and neuropsychological assessments were analysed.
Results: Over a three year period 224 patients were referred to the EMU and 44 (20%) were diagnosed with psychogenic non-epileptic seizures (PNES). A total of 13 people (6%) were diagnosed with both PNES and epilepsy. Of those diagnosed with PNES 34 (75%) were referred to psychology services for cognitive behavioural therapy (CBT) and 26 (58%) were followed-up by psychiatry services.
Conclusions: The prevalence rates for PNES and co-existing PNES and epilepsy are consistent with previous reports. Rates of psychiatric co-morbidity were less than would be expected in this clinical population. Clear evidence-based guidelines to manage people with PNES are required.
Autism-spectrum disorder is increasingly recognised, with recent studies estimating that 1% of children in South London are affected. However, the biology of comorbid mental health problems in people with autism-spectrum disorder is poorly understood.
To investigate the brain anatomy of people with autism-spectrum disorder with and without psychosis.
We used in vivo magnetic resonance imaging and compared 30 adults with autism-spectrum disorder (14 with a history of psychosis) and 16 healthy controls.
Compared with controls both autism-spectrum disorder groups had significantly less grey matter bilaterally in the temporal lobes and the cerebellum. In contrast, they had increased grey matter in striatal regions. However, those with psychosis also had a significant reduction in grey matter content of frontal and occipital regions. Contrary to our expectation, within autism-spectrum disorder, comparisons revealed that psychosis was associated with a reduction in grey matter of the right insular cortex and bilaterally in the cerebellum extending into the fusiform gyrus and the lingual gyrus.
The presence of neurodevelopmental abnormalities normally associated with autism-spectrum disorder might represent an alternative ‘entry-point’ into a final common pathway of psychosis.
We studied the functional neuroanatomy of social behaviour in
velo-cardio-facial syndrome (VCFS) using a facial emotional processing task
and functional magnetic resonance imaging in adults with this syndrome and
controls matched for age and IQ. The VCFS group had less activation in the
right insula and frontal brain regions and more activation in occipital
regions. Genetically determined abnormalities in pathways including those
involved in emotional processing may underlie deficits in social cognition
in people with VCFS.
Autistic spectrum disorders (ASD), are a group of disorders characterised by qualitative abnormalities in social and emotional behaviour and are associated with restricted, stereotyped and repetitive interests and activities. There has been considerable understanding of ASD in recent years. This educational review paper focuses on four areas of interest and relevance to trainees preparing for the membership examination of the Royal College of Psychiatrists (MRCPsych): (a) diagnosing ASD; (b) epidemiology of ASD; (c) aetiology, including genetic, cognitive and neurochemical/neuropathological theories in ASD; and (d) treatment of ASD. Relevant papers are discussed and recommendations for further reading are provided.
Autistic-spectrum disorder is approximately half as common as schizophrenia but its cause remains unknown. Recent studies have begun to clarify the underlying neuroanatomical abnormalities and brain-behaviour relationships in autism. In the past decade, great advances have been made in our understanding of the neurobiological basis of autism.
Velo-Cardio-Facial Syndrome (VCFS) is a genetic disorder caused by the deletion of part of chromosome 22. It occurs in approximately one in 4000 births and there are now more than 100 physical phenotypic features reported. VCFS affects every major system in the body and this 2005 book was the first to describe its full clinical impact. It has been authored by leading international VCFS clinicians/researchers. The focus is on clinical issues with chapters devoted to psychiatric disorders (with the sufferer showing very high levels of schizophrenia), neuroimaging, speech and language disorders, as well as cardiac, ENT, gastrointestinal, ophthalmic and urological manifestations. Molecular genetics, immunodeficiency and genetic counselling are also covered, and practical approaches to diagnosis and treatment described. As VCFS is seen as a paradigm for other microdeletion disorders, this book will not just appeal to clinicians seeing VCFS patients, but also to those interested in other genetic disorders.
Kieran C. Murphy, Professor and Chairman, Department of Psychiatry at the Royal College of Surgeons in Dublin, Ireland,
Peter J. Scambler, Professor of Molecular Medicine, Institute of Neurology, London
Kieran C. Murphy, Education and Research Centre, Royal College of Surgeons of Ireland,Peter J. Scambler, Institute of Child Health, University College London
The term velo-cardio-facial syndrome (VCFS) was coined almost 30 years ago and at that time VCFS was thought to be a very rare congenital malformation. Molecular analysis subsequently revealed that VCFS is associated with deletions encompassing genes mapping to chromosome 22q11, and since that discovery VCFS has been studied intensively by clinicians, geneticists and developmental biologists. Part of this interest is sparked by the relative frequency of the deletion; at 1 in 4000 live births VCFS is the most common microdeletion syndrome known in man.
VCFS patients may present at many different clinics given the protean nature of the condition – over 100 different manifestations have been described in the literature. This book attempts to summarise the rapid progress that has recently been made in understanding and treating people with VCFS. We hope that publication of this book will be useful for several reasons: (1) professionals studying or treating one aspect of VCFS are often relatively unaware of the involvement of other systems and this book will assist them in obtaining a more holistic view of people with VCFS; (2) VCFS may been seen as a paradigm for other less common microdeletion disorders and experience with VCFS may help to direct research and treatment strategies across a range of other microdeletion disorders; (3) while this book emphasises the clinical issues relevant to VCFS, it also reflects the increasing recognition that an understanding of relatively rare disorders such as VCFS can tell us much about more common conditions, such as predisposition to psychiatric illness; (4) the study of the embryological basis for the structural malformations observed in VCFS is helping to uncover some basic mechanisms of developmental biology.