SummaryProfessional practice explicitly focused on supporting the recovery of those it serves is broadly backed by an emerging profile of necessary knowledge, key skills and innovative collaborations, although there is no universally accepted practice ‘model’. This article outlines these components and discusses the associated need for change in the culture of provider organisations along with implementation of wider social and economic policies to support peoples' recovery and social inclusion. This is a values-led approach supported by persuasive advocacy and international endorsement but still in need of further development, systematic evaluation and confirmatory evidence.
SummaryThe World Health Organization (WHO) has indicated that 8–12% of couples worldwide experience infertility, and in recent years the number seeking treatment has dramatically increased. The diagnosis and therapy put a heavy psychological and physical burden on most patients, female and male. The incidence of depression in couples presenting for infertility treatment is significantly higher than in comparable fertile couples. Anxiety is significantly higher in infertile couples than in the general population. Professionals have become aware of the importance of providing educational interventions to address patients' fears and concerns, and to better prepare patients for the demands of treatment. Health professionals should follow a patient-centred approach to provide for the specific needs of the couple. Women in general have a positive attitude to seeking psychological help in the form of cognitive-behavioural therapy, couples counselling and infertility counselling.Learning Objectives•Learn about the incidence rates of infertility and its impact on the mental health of the couple.•Know about infertility treatment and its psychological impact.•Learn about the different management strategies that can be helpful in the treatment of mental illness associated with infertility.
SummaryThis article reviews the recent changes to the DSM diagnostic classification of feeding and eating disorders with particular reference to children and adolescents. The common clinical presentations of the ‘atypical’ feeding and eating problems of middle childhood and early adolescence are reviewed using clinical case vignettes, and the limited evidence base regarding management is summarised. There are many gaps in the evidence base and this is likely to be an area of rapid development for the field subsequent on the new terminology outlined in DSM-5.Learning Objectives•Be able to describe the recent changes in terminology of DSM-5 for eating disorders in children and adolescents.•Be able to provide information to young people and parents on the short- and long-term medical consequences of low weight in children.•Be able to assess risk in children presenting with atypical eating disorders.
SummarySingapore is a multi-ethnic Asian society with a unique sociocultural and economic background. This is an overview of the characteristics of psychiatry in this nation in terms of service provision, mental health funding, education and training, and the challenges it faces in the midst of an evolving mental health landscape. Over the past 5 years, Singapore has maintained a closer tie with the Royal College of Psychiatrists through the the College's Membership examination.
SummaryThis article presents evidence for the efficacy of psychosocial interventions for people with dementia and their carers. The evidence base is not yet robust enough to clearly suggest which interventions are most suited for which environment. However, from our literature review there appears to be reason to use music therapy, aromatherapy, life story work, animal-assisted therapy and post-diagnosis/carer support work. We focus on both the traditional outcome measures of behavioural and psychological symptoms of dementia (BPSD) and the more difficult to measure, but equally important, person-centred outcomes of nonpharmacological interventions, as their properties are distinctly different from those of pharmacological agents.Learning Objectives•Be aware of the range of psychosocial interventions.•Have a better understanding of the possible outcomes from given interventions.•Be aware of the paradigm shift from managing BPSD to a person-centred approach that focuses on the patient's well-being and quality of life.
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BackgroundCognitive behavioural therapy for people with schizophrenia is a psychotherapeutic approach that establishes links between thoughts, emotions and behaviours and challenges dysfunctional thoughts. There is some evidence to suggest that cognitive behavioural therapy for people with psychosis (CBTp) might be an effective treatment for people with schizophrenia. There are however, limitations in its provision due to available resource and training issues. One way to tackle this issue might be to offer a brief version of CBTp.ObjectivesTo review the effects of brief CBTp (6 to 10 regular sessions given in less than 4 months and using a manual) for people with schizophrenia compared with standard CBTp (12 to 20 regular sessions given in 4 to 6 months and using a manual).Search methodsWe searched the Cochrane Schizophrenia Group's Trials Register (August 21, 2013 and August 26, 2015) which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO and registries of Clinical Trials. There are no language, date, document type, or publication status limitations for inclusion of records in the register. We inspected all references of the selected articles for further relevant trials. We also contacted experts in the field regarding brief CBTp studies.Selection criteriaRandomised controlled trials involving adults with schizophrenia or related disorders, comparing brief cognitive behavioural therapy for people with psychosis versus standard CBTp.Data collection and analysisTwo review authors independently screened and assessed studies for inclusion using pre-specified inclusion criteria.Main resultsWe found only seven studies which used a brief version of CBTp, but no study compared brief CBTp with CBTp of standard duration. No studies could be included.Authors' conclusionsCurrently there is no literature available to compare brief with standard CBTp for people with schizophrenia. We cannot, therefore, conclude whether brief CBTp is as effective, less effective or even more effective than standard courses of the same therapy. This lack of evidence for brief CBTp has serious implications for research and practice. Well planned, conducted and reported randomised trials are indicated.
SummaryThere is growing evidence from smaller evaluative studies in the USA and anecdotal papers in the UK that supported volunteering can help recovery and can be a pathway into paid work for people with serious and fluctuating mental health conditions. It allows the person to take risks and test out a working environment. This opportunity can integrate their experience of mental illness into a valued identity and provides opportunities to engage with a world of work. We recommend that mental health professionals consider ways of providing volunteering opportunities as part of a recovery-oriented service within their organisations.LEARNING OBJECTIVESAppreciate the benefits patients gain from volunteering.Understand the principles of a supported volunteering scheme.Appreciate the potential value to the patient of volunteering within health and social care settings.
SummaryThe past few decades have witnessed the synthesis of Buddhist mindfulness practice with the Western psychological paradigm, leading to the development of a variety of mindfulness-based interventions. These are delivered to various populations to treat a wide range of physical and psychological disorders, and several protocols have been implemented and evaluated, mostly, if not exclusively, in open or out-patient treatment settings. Little attention has been given to the definition of criteria, guidelines and protocols for the use of mindfulness in residential settings such as in-patient psychiatric wards, secure and forensic services, prisons, nursing homes and hospices. In this article, we discuss the rationale, advantages and obstacles to delivering mindfulness-based interventions in residential treatment settings, with specific reference to forensic settings. We also discuss the problem of developing robust outcome data and recommendations for future research.Learning Objectives•Understand the advantages and challenges of introducing mindfulness-based interventions in in-patient settings.•Understand how mindfulness-based interventions can be adapted to accommodate individual patient psychopathology.•Understand how mindfulness-based interventions can be adapted to specialist clinical settings such as forensic units.
SummaryAntisocial personality disorder is a complex condition carrying high rates of comorbidity and mortality for individuals as well as harmful consequences for their families and society. Despite the publication of National Institute for Health and Care Excellence (NICE) guidelines for the disorder, the evidence base and provision of effective treatments remain inadequate, and the belief that the condition is untreatable remains widespread among psychiatrists and other professionals. This article highlights current diagnostic controversies and summarises the evidence for conceptualising antisocial personality disorder as a disorder of attachment. Informed by this developmental perspective, we provide a framework for the management and treatment of adults with antisocial personality disorder, highlighting the importance of creating a safe setting and recommending adaptations of therapeutic technique to facilitate the engagement of this ‘treatment-rejecting’ patient population. We conclude with an outline of the current government policy on the treatment of high-risk offenders with personality disorder.LEARNING OBJECTIVESKnow the current diagnostic criteria and epidemiology of antisocial personality disorder.Evaluate the evidence that antisocial personality disorder can be conceptualised as a disorder of attachment, and use a developmental framework to inform treatment interventions.Gain an understanding of psychological approaches to antisocial personality disorder.
SummaryCognitive and memory testing are a common part of clinical practice, but professional concerns are sometimes raised that the individual being tested might be feigning deficits. Most clinicians have limited experience and training in detecting malingering in such cognitive testing, and the very issue raises considerable ethical dilemmas. Nevertheless, psychiatric work faces ever greater potential for legal scrutiny, and failure to appropriately evaluate potential malingering risks professional embarrassment and distress. There is a need for clinicians to make themselves aware of the ways in which malingered behaviour might be evaluated through the clinical history, the use of routine psychometric testing and, particularly, the use of symptom validity (‘malingering’) tests. This article describes these factors and gives guidance on the appropriate reporting of findings.Learning Objectives•Better understand the complexities in cognitive assessment where malingering is suspected.•Understand the types and limitations of the major symptom validity tests.•Be better prepared to produce documentation and reports stating test findings.
SummaryPsychiatrists are wanting in Sweden and many other countries. Among Swedish efforts to improve specialist training in psychiatry and to make a future psychiatric career attractive is a national course-based project named METIS. An evaluation of METIS courses run between 2007 and 2012 revealed that, in parallel with the initiative, the number of doctors obtaining proofs of specialist competence in psychiatry increased by more than a third. This article outlines current specialist training in Sweden and describes how the 40-hour METIS programme fits within it.
SummaryYoung adults and adolescents who experience a first episode of psychosis are faced with important issues and choices concerning their future mental health. Individual and family psychological treatments and psychosocial supportive measures are now well recognised interventions for this group of individuals. This article considers the complexity surrounding medication management after the initial recovery from psychosis. The discussion focuses particularly on the medical treatments, developmental considerations and roles of psychiatrists in improving outcomes for this group of patients.Learning Objectives•Understand the potential benefits and risks of maintenance antipsychotics for young people recovering from first-episode psychosis.•Have an improved knowledge of psychological and developmental concepts that can underpin young people's decision-making regarding maintenance medication for mental illness.•Be able to develop a range of (age-appropriate) strategies to assist medication decision-making.
SummaryBenjamin Britten's opera Peter Grimes premiered in 1945 and has since enjoyed lasting popular and critical acclaim. Its central character is a fisherman driven to suicide by circumstances beyond his control. It has a wide political and social resonance and is a testament to the damaging psychological effects of exclusion and stigma.
SummaryThe media offers opportunities for psychiatrists to communicate with a wide and varied audience, thereby influencing the views of the public and policy makers on mental health issues. There are many different types of media outlet, including daily news media, documentary makers, specialist media, features and comment, and new media. The Science Media Centre is an independent press office that aims to help ensure that the views of scientists, clinicians and researchers are heard in the UK national news media when their area of expertise hits the headlines. In the news media, journalists work to tight time frames and often focus on sensational and controversial topics, presenting challenges for those wanting to engage. For experts to work effectively with the news media it helps to understand more about the way the media works and how to develop necessary skills. Psychiatrists who do work successfully with the media can help ensure that the public receive accurate information about mental health problems, and gain an appreciation of the importance of research in the field and a better understanding of the role of the psychiatrist.
SummaryPatrick Hamilton's (1904–1962) books are filled with gin and jealousy and depict obsessive desire in oppressive circumstances. His early financial success funded his heavy drinking, but also allowed him to write some of the best fiction of the 20th century. Following a depressive illness towards the end of his short life he never wrote again, leaving his final series of novels unfinished, the villain forever escaping justice. Hangover Square, set on the eve of the Second World War, tells the tense story of a man whose ambivalence for the woman he is pursuing (who has no interest in him) is manifested in two psychological states, between which he flips without warning. In one state he yearns for her, yet in the other has only one purpose – to kill her. Hamilton precisely describes a number of mental symptoms while not convincing readers of the implied diagnosis of schizophrenia. However, the similarities with a late-19th century French fuguer are clear and perhaps this condition provides a better frame for the main character's experiences.
BackgroundAdolescent substance use is a major problem, in and of itself and because it acts as a risk factor for other problem behaviours. As substance use during adolescence can lead to adverse and often long-term health and social consequences, it is important to intervene early on in order to prevent progression to more severe problems. Brief interventions have been shown to reduce problematic substance use among adolescents and are especially useful for individuals who have moderately risky patterns of substance use. Such interventions can be conducted in school settings. This review set out to evaluate the effectiveness of brief school-based interventions for adolescent substance use.ObjectivesTo evaluate the effectiveness of brief school-based interventions on reducing substance use and other behavioural outcomes among adolescents compared to another intervention or assessment-only conditions.Search methodsWe searched 10 electronic databases and six websites on evidence-based interventions, and the reference lists of included studies and reviews, from 1966 to March 2013. We also contacted authors and organisations to identify any additional studies.Selection criteriaWe included randomised controlled trials that evaluated the effects of brief school-based interventions for substance-using adolescents.The primary outcomes were reduction or cessation of substance use. The secondary outcomes were engagement in criminal activity and engagement in delinquent or problem behaviours related to substance use.Data collection and analysisWe used the standard methodological procedures outlined by The Cochrane Collaboration, including the GRADE approach for evaluating the quality of evidence.Main resultsSix studies involving 1139 participants were included in this review. Overall the quality of evidence was moderate in the information provision comparison, and low or very low in the assessment only comparison. Reasons for downgrading the quality included risk of bias of the included studies, imprecision and inconsistency. Our findings suggested that compared to information provision only, brief interventions (BIs) did not have a significant effect on any substance use (three studies, 732 participants, standardised mean difference (SMD) -0.06; 95% confidence interval (CI) -0.20 to 0.09) or delinquent-type behaviour outcomes among adolescents (two studies, 531 participants, SMD -0.26; 95% CI -0.54 to 0.02). When compared to assessment-only controls, BIs had some significant effects on substance use and delinquent-type or problem behaviours, but high levels of heterogeneity existed between studies and it was not always possible to pool the results. When the comparison was with assessment-only conditions, studies of individual interventions that measured BI effectiveness reported significantly reduced substance use in general and in two studies reduced frequency of alcohol use specifically. When the data were pooled, BIs reduced cannabis frequency (SMD -0.22; 95% CI -0.45 to -0.02) across three studies (n = 407). Cannabis quantity was also reduced by BIs in comparison to assessment only (SMD -60.27; 95% CI -66.59 to -53.95) in one study (n = 179). However, the evidence for studies that compared brief interventions to assessment-only conditions was generally of low quality. Brief interventions also had mixed effects on participants' delinquent or problem behaviours.Authors' conclusionsThere was limited quality evidence that brief school-based interventions were more effective in reducing substance use than the assessment-only condition, but were similar to information provision. There is some evidence for the effectiveness of BI in reducing adolescent substance use, particularly cannabis, when compared to assessment only. However, it is premature to make definitive statements about the effectiveness of brief school-based interventions for reducing adolescent substance use. Further high quality studies examining the relative effectiveness of BIs for substance use and other problem behaviours need to be conducted, particularly in low- and middle-income countries.
Summary Should the law be changed to allow health professionals to assist mentally competent, terminally ill people to end their own lives? In this article Philip Graham (P.G.) puts the arguments in favour of such a change in the law and Julian Hughes (J.H.) opposes these arguments. J.H. then sets out why he believes such a law should not be passed and P.G., in turn, sets out counterarguments. Before concluding comments, both P.G. and J.H. independently make brief closing statements supporting their own positions. LEARNING OBJECTIVES Understand the differences between various types of ‘assisted dying’. Appreciate some of the ethical arguments in favour of and against changes in the law on assisted dying in the UK. Understand some of the empirical data involved in arguments about assisted dying.
BackgroundDepression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychotherapy, but some people may prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression.ObjectivesTo determine the effectiveness of exercise in the treatment of depression.Search strategyWe searched Medline, Embase, Sports Discus, PsycINFO, the Cochrane Controlled Trials Register, and the Cochrane Database of Systematic Reviews for eligible studies in March 2007. In addition, we hand-searched several relevant journals, contacted experts in the field, searched bibliographies of retrieved articles, and performed citation searches of identified studies. We also searched www.controlled-trials.com in May 2008.Selection criteriaRandomised controlled trials in which exercise was compared to standard treatment, no treatment or a placebo treatment in adults (aged 18 and over) with depression, as defined by trial authors. We excluded trials of post-natal depression.Data collection and analysisWe calculated effect sizes for each trial using Cohen's method and a standardised mean difference (SMD) for the overall pooled effect, using a random effects model. Where trials used a number of different tools to assess depression, we included the main outcome measure only in the meta-analysis.Main resultsTwenty-eight trials fulfilled our inclusion criteria, of which 25 provided data for meta-analyses. Randomisation was adequately concealed in a minority of studies, most did not use intention to treat analyses and most used self-reported symptoms as outcome measures. For the 23 trials (907 participants) comparing exercise with no treatment or a control intervention, the pooled SMD was -0.82 (95% CI -1.12, -0.51), indicating a large clinical effect. However, when we included only the three trials with adequate allocation concealment and intention to treat analysis and blinded outcome assessment, the pooled SMD was -0.42 (95% CI -0.88, 0.03) i.e. moderate, nonsignificant effect. The effect of exercise was not significantly different from that of cognitive therapy. There was insufficient data to determine risks and costs.Authors' conclusionsExercise seems to improve depressive symptoms in people with a diagnosis of depression, but when only methodologically robust trials are included, the effect sizes are only moderate and not statistically significant. Further, more methodologically robust trials should be performed to obtain more accurate estimates of effect sizes, and to determine risks and costs. Further systematic reviews could be performed to investigate the effect of exercise in people with dysthymia who do not fulfil diagnostic criteria for depression.
SummaryWe consider key facets of the concept of mental health recovery and how they are reflected in other concepts that run through the emerging focus on public mental healthcare. We widen the scene to portray the niche into which recovery fits and show how it and recent research indicate why psychiatrists should use the social sciences more widely to complement neuroscience.
