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A number of community based surveys have identified an increase in psychological symptoms and distress but there has been no examination of symptoms at the more severe end of the mental health spectrum.
Aims
We aimed to analyse numbers and types of psychiatric presentations to inform planning for future demand on mental health services in light of the COVID-19 pandemic.
Method
We analysed electronic data between January and April 2020 for 2534 patients referred to acute psychiatric services, and tested for differences in patient demographics, symptom severity and use of the Mental Health Act 1983 (MHA), before and after lockdown. We used interrupted time-series analyses to compare trends in emergency department and psychiatric presentations until December 2020.
Results
There were 22% fewer psychiatric presentations the first week and 48% fewer emergency department presentations in the first month after lockdown initiated. A higher proportion of patients were detained under the MHA (22.2 v. 16.1%) and Mental Capacity Act 2005 (2.2 v. 1.1%) (χ2(2) = 16.3, P < 0.0001), and they experienced a longer duration of symptoms before seeking help from mental health services (χ2(3) = 18.6, P < 0.0001). A higher proportion of patients presented with psychotic symptoms (23.3 v. 17.0%) or delirium (7.0 v. 3.6%), and fewer had self-harm behaviour (43.8 v. 52.0%, χ2(7) = 28.7, P < 0.0001). A higher proportion were admitted to psychiatric in-patient units (22.2 v. 18.3%) (χ2(6) = 42.8, P < 0.0001) after lockdown.
Conclusions
UK lockdown resulted in fewer psychiatric presentations, but those who presented were more likely to have severe symptoms, be detained under the MHA and be admitted to hospital. Psychiatric services should ensure provision of care for these patients as well as planning for those affected by future COVID-19 waves.
HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities.
Design:
Longitudinal study
Participants:
A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March–May 2016 and followed up March–May 2017.
Measurements:
HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records.
Results:
In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9–53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0–28.6 n = 16) was observed.
Conclusions:
HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.
This article examines the extent to which a recent law reform initiative in New South Wales (NSW), Australia—the draft Aboriginal Cultural Heritage Bill 2018 (NSW)—advances the general principles outlined in the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP). The examination reveals some improvements on the current legal framework and some concerning proposals that distance the NSW government from the UNDRIP principles. Key concerns include a proposed transfer of administrative responsibility to Aboriginal bodies with no corresponding guarantee of funding; the continued vesting of key decision-making powers in government; inept provisions for the protection of secret knowledge; and lower penalties for harming cultural heritage than for related offences in existing environmental and planning legislation. Given the bill’s weaknesses, the article explores pragmatic alternatives to better advance the UNDRIP principles.
The ‘16Up’ study conducted at the QIMR Berghofer Medical Research Institute from January 2014 to December 2018 aimed to examine the physical and mental health of young Australian twins aged 16−18 years (N = 876; 371 twin pairs and 18 triplet sets). Measurements included online questionnaires covering physical and mental health as well as information and communication technology (ICT) use, actigraphy, sleep diaries and hair samples to determine cortisol concentrations. Study participants generally rated themselves as being in good physical (79%) and mental (73%) health and reported lower rates of psychological distress and exposure to alcohol, tobacco products or other substances than previously reported for this age group in the Australian population. Daily or near-daily online activity was almost universal among study participants, with no differences noted between males and females in terms of frequency or duration of internet access. Patterns of ICT use in this sample indicated that the respondents were more likely to use online information sources for researching physical health issues than for mental health or substance use issues, and that they generally reported partial levels of satisfaction with the mental health information they found online. This suggests that internet-based mental health resources can be readily accessed by adolescent Australians, and their computer literacy augurs well for future access to online health resources. In combination with other data collected as part of the ongoing Brisbane Longitudinal Twin Study, the 16Up project provides a valuable resource for the longitudinal investigation of genetic and environmental contributions to phenotypic variation in a variety of human traits.
The pan-Canadian Oncology Drug Review (pCODR) evaluates new cancer drugs for public funding recommendations. While pCODR's deliberative framework evaluates overall clinical benefit and includes considerations for exceptional circumstances, rarity of indication is not explicitly addressed. Given the high unmet need that typically accompanies these indications, we explored the impact of rarity on oncology HTA recommendations and funding decisions.
Methods
We examined pCODR submissions with final recommendations from 2012 to 2017. Incidence rates were calculated using pCODR recommendation reports and statistics from the Canadian Cancer Society. Indications were classified as rare if the incidence rate was lower than 1/100,000 diagnoses, a definition referenced by the Canadian Agency for Drugs and Technologies in Health. Each pCODR final report was examined for the funding recommendation/justification, level of supporting evidence (presence of a randomized control trial [RCT]), and time to funding (if applicable).
Results
Of the ninety-six pCODR reviews examined, 16.6 percent were classified as rare indications per above criteria. While the frequency of positive funding recommendations were similar between rare and nonrare indication (78.6 vs. 75 percent), rare indications were less likely to be presented with evidence from RCT (50 vs. 90 percent). The average time to funding did not differ significantly across provinces.
Conclusion
Rare indications appear to be associated with weaker clinical evidence. There appears to be no association between rarity, positive funding recommendations, and time to funding. Further work will evaluate factors associated with positive recommendations and the real-world utilization of funded treatments for rare indications.
In his Confessions, Augustine condemns “concupiscentia oculorum” (“the lust of the eyes”) as being the product of a “vana et curiosa cupiditas” (“vain and curious desire”) that distracts human beings from meditating on God and directs them to terrestrial rather than heavenly destinations. Yet in one of the most poetic passages of Book 10, he writes, “et eunt homines mirari alta montium et ingentes fluctus maris et latissimos lapsus fluminum et oceani ambitum et gyros siderum” (“people are moved to wonder by mountain peaks, by vast waves of the sea, by broad waterfalls on rivers, by the all-embracing extent of the ocean, by the revolutions of the stars”) (10.8.15). A passage on the memory's capacity to produce infinite space – Augustine sees these sites “in memoria… spatiis tam ingentibus quasi foris viderem” (“inwardly in my memory… with the same vast spaces between, as if I saw them abroad”) – takes a sharp detour as he contemplates how human beings move through and are moved by the world around them. People were and are still inspired to traverse the globe in search of its highest peaks and widest canyons, and upon arrival they are stirred by the earth's beauty, power, and grandeur. Even those most dedicated to a “life of the mind” (e.g., Augustine) find themselves drawn toward what lies beyond their books’ bindings. This suggests the impact of mobility on the human experience, underscored still further in the Confessions by the fact that venturing outside will reveal a world that is itself remarkably kinetic. The image Augustine offers is not a static artistic rendering of the natural world – a “landscape” in its original sense from the Dutch landschap – but a place in motion, where water flows and falls, the ocean embraces, and stars revolve. Despite his best efforts to turn his eyes toward God, Augustine is seduced by celestial, terrestrial, and embodied movements, both sensed and thereafter seen in memoria.
Leading up to the fourteenth century, observations like these became increasingly common as pilgrimage, commerce, warfare, and disease encouraged bodies to move through space.
In the late fourteenth century, economic forces destabilized national and regional identities defined by geographical fixity. The period is remarkable instead for the importance of movement; tumultuous sociopolitical conditions and new mobilities brought about by the rise of mercantilism challenged the idea that identity could be unambiguously expressed in space. In this chapter, I reprioritize movement by showing that Chaucer's Canterbury Tales is a register of fourteenth-century England's itinerant identity. The disorderly potential of mobility is staged in the Cook's Tale and the Canon's Yeoman's Tale. In these fictions, London and its suburbs succumb to unregulated social and spatial mobility, resulting in a fragmented and dissolute placelessness. The frame narrative then contains this potentiality, offering economics as a lens through which to understand and regulate such placelessness. In so doing, it renders itinerancy a powerful expression of spatial and social identity, which finds meaning and coherence in networks rather than stable, sealed spaces.
The disruptive potential of unregulated social and spatial mobility was felt in the late Middle Ages. As Christian Zacher notes in his monograph Curiosity and Pilgrimage (1976), motion and travel came to exemplify a wandering, errant, and unstable frame of mind for fourteenth-century moralists. As opposed to life pilgrimage – a devotional practice that entailed seeking the New Jerusalem without traversing the globe (peregrinatio in stabilitate) – place pilgrimage became an outlet for curiositas, or mental wandering. The threat of curiositas had plagued theologians and philosophers since Augustine. In Book 10 of his Confessions, Augustine admits to having committed concupiscentia oculorum (the lust of the eyes):
praeter enim concupiscentiam carnis, quae inest in delectatione omnium sensuum et voluptatum, cui servientes depereunt qui longe se faciunt a te, inest animae per eosdem sensus corporis quaedam non se oblectandi in carne, sed experiendi per carnem vana et curiosa cupiditas nomine cognitionis et scientiae palliata. quae quoniam in appetitu noscendi est, oculi autem sunt ad noscendum in sensibus principes, concupiscentia oculorum eloquio divino appellata est. (10.35.54)
For besides that concupiscence of the flesh which consisteth in the delight of all senses and pleasures, wherein its slaves, who go far from Thee, waste and perish, the soul hath, through the same senses of the body, a certain vain and curious desire, veiled under the title of knowledge and learning, not of delighting in the flesh, but of making experiments through the flesh.
Chaucer's attention to structured mobilities and hybridity in the frame narrative is significant not only because it redefines the Pilgrims’ Way and the bodies that circulate on and around it, but also because it comes to bear on the interplay between tales. This dramatic and literary interplay has been well established, and nowhere is it more apparent than in Fragment One, where settings evolve from the classical past to the familiar present, genres degenerate from romance to fabliau to fragment, and sex acts multiply, culminating in the prostitution of the Cook's Tale. Noting the significance of Fragment One to the narrative game of The Canterbury Tales, Lee Patterson writes that the Knight's Tale “functions in an important sense as the other against which the project of The Canterbury Tales is ultimately defined; and it therefore appropriately begins the game of quiting that will at once include and counter it.” And Helen Cooper observes that in the interplay between the Knight, Miller, and Reeve, Chaucer “constantly adds or adapts details to bring the [tales] together,” and in so doing “ensures that the tales are read initially in a specific relation to each other.” This relational practice of quiting has generated an abundance of critical conversation, but scholarship on the subject has not yet considered how mobility affects the tellers’ rhetorical play. In this chapter, I argue that movement in the Miller's Tale and the Reeve's Tale serves to position them within a sequence of quiting that ultimately parodies the Knight's meticulous regulation of politicized mobility. The Knight celebrates the ideological and actual practice of stasis, evincing its inherent value to chivalric fiction and its material practice as an imitation of stable and eternal god(s). He consequently denigrates movement, associating it with characters he deems politically and socially inferior. Meanwhile, the Miller and Reeve challenge this disparagement of movement and instead empower mobile bodies, celebrating chaos over order, and liberty over political, social, and religious bonds.
In the Knight's Tale, the Knight constructs a narrative around a preeminently chivalric character. He introduces the Duke Theseus as “lord and governour” who was “in his tyme swich a conquerour / That gretter was ther noon under the soone” (1. 861–3).
The queering of sealed, stationary bodies that occurs as part of the quiting game in the First Fragment also manifests in individual tales on the Canterbury pilgrimage. A careful consideration of the Clerk's Tale, in particular, shows that movement authorizes female bodies who thoughtfully deploy it within the context of existing, patriarchal systems. Unlike Alison, though, whose leaky body dismantles marital, architectural, natural, and even sexual categories, Griselda stages resistance from within hegemonic structures. By expressing powerful iterations of movement from within, she reveals the instability of the status quo without having to tear doors from their hinges (à la John of the Miller's Tale), while also staging the potential for female empowerment through mobility and dispersal. In this chapter, I will begin by demonstrating that Griselda's perceived steadfastness is in fact a constant willingness to yield, resulting in a surplus of movement that, unlike the surplus of the Reeve's Tale, operates in accordance with current understandings of Christian virtue and wifely obedience. Though this surplus is frequently read as an “emptiness,” we might benefit from recognizing it instead as an “overfullness” that renders the female body enigmatic while denying the possibility of male inscription – the body is always already being inscribed. Moreover, by figuring her mobility in terms of fluidity, the Clerk evokes a liquid ecology that merges Griselda's tidal body with its physical environs to dismantle borders and boundaries. To evoke the language of contemporary social scientists, Griselda proves that “neither boundaries nor relations mark the difference between one place and another. Instead, sometimes boundaries come and go, allow leakage or disappear altogether, while relations transform themselves without fracture.” Griselda's movement has this very effect, erasing boundaries and transforming relations to reveal innovative, agentified ways of being.
Critics have repeatedly seen Griselda as lacking agency. Kathryn McKinley insists that she “has been purged of any human perplexity, anguish, or struggle which might be the indicators of an authentic subjectivity,” and in emphasizing her “stoic endurance” and “patience” critics including Marga Cottino-Jones and Alfred Kellogg suggest Griselda is only capable of deploying passive or static virtue.