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Researchers from the NIHR Oxford Health Biomedical Research Centre (a partnership between the University of Oxford and the Oxford Health NHS Foundation Trust), like many others across the country, are responding to the call to support frontline NHS services and meet the challenge of COVID-19.
A national survey of neuropsychiatry training experiences.
AIMS AND METHOD: Neuropsychiatry training in the UK currently lacks a formal scheme or qualification, and its demand and availability have not been systematically explored. We conducted the largest UK-wide survey of psychiatry trainees to examine their experiences in neuropsychiatry training. RESULTS: In total, 185 trainees from all UK training regions completed the survey. Although 43.6% expressed interest in a neuropsychiatry career, only 10% felt they would gain sufficient experience by the end of training. Insufficient access to clinical rotations was the most common barrier, with significantly better access in London compared with other regions. Most respondents were in favour of additional neurology training (83%) and a formal accreditation in neuropsychiatry (90%). CLINICAL IMPLICATIONS: Strong trainee interest in neuropsychiatry contrasts with the limited training opportunities currently available nationally. Our survey highlights the need for increased neuropsychiatry training opportunities, development of a formalised training programme and a clinical accreditation pathway for neuropsychiatry in the UK.
A summary review of the development of using a brief imagery-competing task intervention (ICTI) for reducing intrusive memories of psychological trauma: applications in healthcare settings for both staff and patients.
Psychological trauma for those utilising and delivering healthcare is common, and in particular the experience of repeated and unwanted intrusive memories (IM) of the trauma can occur. There are several psychological interventions that have been shown to be effective with the full syndrome of Post Traumatic Stress Disorder (PTSD), but researchers have only recently explored targeted interventions for IMs. This review provides a summary of a body of work on a behavioural technique called "Imagery Competing Task Intervention" (ICTI) for intrusive memories after trauma by Holmes and colleagues. The papers presented outline the underlying cognitive science, the historical development of the intervention, and its application to various different populations in healthcare settings including clinical tests of efficacy. Settings and populations include traumatic events experienced by emergency department patients and emergency caesarean section patients, as well as after work-related trauma experienced by intensive care staff and wider healthcare staff. Timing of ICTI intervention delivery has included the same day of trauma, within 72 h and for older memories weeks, months (or years) post-trauma. The intervention has been delivered with a guided session, which in some studies is in person and some remotely via digital health application. There is a brief overview of other related interventions. The ICTI approach shows potential scalability in trauma laden environments such as healthcare, where exposure is unlikely to be limited or managed and symptoms such as subclinical IMs are common. As such the intervention could be used in a preventing-and-treating approach and in subclinical-to-clinical samples who have IMs after exposure to psychological trauma. Future research would be needed to test ICTI as an intervention for the full syndrome of PTSD.
The Use of EQ-5D in the Middle East and North Africa Region: A Systematic Literature Review.
INTRODUCTION: The EQ-5D is the most commonly used preference-based measure of health-related quality of life. There is limited evidence about the use of the EQ-5D in the Middle East and North Africa (MENA) region. This study aimed to systematically identify, review, summarize, and synthesize the published literature on using the EQ-5D in this region. METHODS: A systematic literature review was conducted, according to the PRISMA 2020 guidelines, using PubMed, Cochrane, PsycINFO, and CINAHL and covering the period up to 30 August 2024. Studies using any version of the EQ-5D in adults or youth in the MENA region were included. Pilot studies, guidelines, study protocols, and reviews were excluded. Key study characteristics and outcomes assessed included study design, clinical area, population, type of EQ-5D data reported, reference value set used, and mode of administration. Title/abstract screening was conducted independently by two reviewers to assess eligibility for inclusion. Two researchers completed full-text screening and extracted data using a standardized form. Disagreements were referred to a third reviewer if not resolved by discussion. Results were summarized in systematic evidence tables. RESULTS: After removing duplicates, 18,034 references were considered for title/abstract screening. In total, 184 studies were included with a total sample size of 128,164 subjects. Of the included single-country studies, 42% were reported in Iran, 20% in Saudi Arabia, and 11% in Jordan. Patient populations were investigated in 86% of the studies, 23% of which targeted endocrine diseases. Study design was observational in 57% and experimental in 14% of the studies. Only 10% of the included studies applied the EQ-5D in an economic evaluation. The EQ-5D-3L version was used in 40% of the studies. However, the trend is towards a greater use of the 5L version in more recent years. Twenty percent of the studies reported EQ-5D results using the index score, frequencies of severity levels per dimension, and visual analog scale scores. EQ-5D modes of administration and funding sources were not reported in 16% and 20% of the studies, respectively. CONCLUSION: There is an increased use of the EQ-5D in the MENA region, especially since 2020. In the region, the use of the EQ-5D is more prevalent in clinical studies than in economic evaluation studies. The reporting heterogeneity indicates the need for guidance in reporting EQ-5D study results in this region.
Pramipexole in addition to mood stabilisers for treatment-resistant bipolar depression: the PAX-BD randomised double-blind placebo-controlled trial.
BACKGROUND: There are limited options currently recommended in National Institute for Health and Care Excellence guidelines for the treatment of bipolar depression. Pramipexole has been shown to improve mood symptoms in two small pilot studies in such patients. OBJECTIVES: Primary: to evaluate the clinical effectiveness of pramipexole versus placebo alongside routine mood-stabilising medications over 12 weeks in patients with treatment-resistant bipolar depression. Secondary: evaluate the impact of pramipexole on mood and anxiety, psychosocial function, cost-effectiveness, and safety and tolerability over 48 weeks. DESIGN: Multicentre, randomised, placebo-controlled trial of pramipexole versus placebo in addition to standard-of-care mood stabilisers. Clinicians, researchers and participants were blinded throughout the duration of the study. Pre-randomisation stage (to adjust antipsychotics or commence mood stabilisers where required) before randomisation. Weekly online assessments of mood and anxiety from randomisation to week 52, with psychosocial function, quality of life and healthcare resource utilisation assessments conducted at regular intervals. SETTING: Twenty-one National Health Service trusts and Health Boards across England and Scotland. PARTICIPANTS: Patients aged 18 years and over with a diagnosis of treatment-resistant bipolar depression currently under secondary care mental health services. Aim to randomise 290 participants. INTERVENTIONS: Pramipexole or matched placebo orally once daily, titrated from 0.25 mg to maximum of 2.5 mg (salt weight) depending on efficacy and tolerability. MAIN OUTCOME MEASURES: Depression - Quick Inventory for Depressive Symptomology; anxiety - Generalised Anxiety Disorder-7-item scale; psychosocial functioning - Work and Social Adjustment Scale; hypomania/mania - Altman Self-rating Scale of Mania; tolerability - Treatment Satisfaction Questionnaire for Medication; well-being and quality of life - EuroQol-5 Dimensions, five-level version, ICEpop CAPability measure for Adults and Oxford CAPabilities questionnaire-Mental Health tools. RESULTS: Thirty-nine participants randomised (18 to pramipexole and 21 to placebo) with 36 providing data for the primary analysis. Pramipexole led to greater reductions in depressive symptoms at 12 weeks compared to placebo [4.4 (4.8) vs. 2.1 (5.1)]: a medium-sized (d = -0.72) but not statistically significant difference (95% confidence interval -0.4 to 6.3; p = 0.087). There were some statistically significant positive effects of pramipexole on secondary outcomes (reduction in depressive symptoms at 36 weeks, response and remission rates at trial exit, psychosocial function). Pramipexole was associated with an increased rate of hypomania/manic symptoms, but this appeared to be reduced by coadministration with an antipsychotic. General tolerability of pramipexole was good. There were significant annual gains in health-related quality of life and capability-well-being and tendency towards reduced health and social care costs. LIMITATIONS: Small sample size and variable follow-up period due to recruitment during COVID-19 pandemic and the trial closing early. Participants limited to those in secondary care mental health services. All assessments only available in English. CONCLUSIONS: No change in clinical practice can be recommended as there was not a significant difference between pramipexole and placebo on the primary efficacy outcome measure. However, there was evidence of positive effects of pramipexole on mood, psychosocial function and quality of life. FUTURE WORK: Replication in a larger population and research to investigate the impact of coadministration of antipsychotics alongside pramipexole. TRIAL REGISTRATION: This trial is registered as ISRCTN72151939 and EudraCT 2018-2869-18. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/154/01) and is published in full in Health Technology Assessment; Vol. 29, No. 21. See the NIHR Funding and Awards website for further award information.
A prospective study of risk factors and new prediction model for inpatient aggression in a Turkish forensic psychiatric cohort with psychotic illness
Background: Aggression among psychiatric inpatients causes harm and disrupts care. While often linked to modifiable risk factors, their role remains unclear, and many prediction tools overlook them. This study aimed to assess the relationship between risk factors and inpatient aggression among forensic patients with psychotic disorders in Turkiye and to develop a population-specific prediction model. Methods: Eight static and ten dynamic risk factors were assessed. Dynamic factors were collected fortnightly, with the outcome defined as any physical or verbal aggression between assessment rounds. Multilevel logistic regression analyses assessed the association between dynamic risk factors and outcomes. A new population-specific prediction model was developed by refitting the previously developed elsewhere (FOxWeb). Models incorporating fixed effects were used to assess predictive performance. Results: Over four months, 102 forensic psychiatric inpatients underwent 811 dynamic risk assessments, with 603 aggressive incidents recorded. Forty-two patients were involved in at least one incident. Many dynamic factors were significantly associated with outcomes in both univariable and multivariable analyses. The total dynamic score was a significant predictor, improving the discrimination of the fixed-effects model (AUC = 0.84, 95 % CI: 0.81–0.87) compared to the model using static factors alone (AUC=0.73, 95 % CI: 0.69–0.77). Conclusion: Combining dynamic and static factors in the prediction model showed strong performance for assessing aggression risk. Refitting existing prediction models to specific populations may offer enhanced performance, but this requires external validation in independent samples as development models may be overfitted. Highly quality predicative models could enhance interventions, optimize resource use, and improve clinical decision-making.
Neurotransmitter modulation of human facial emotion recognition
Human facial emotion recognition (FER) is an evolutionarily preserved process that influences affiliative behaviours, approach/avoidance and fight-or-flight responses in the face of detecting threat cues, thus enhancing adaptation and survival in social groups. Here, we provide a narrative literature review on how human FER is modulated by neurotransmitters and pharmacological agents, classifying the documented effects by central neurotransmitter systems. Synthesising the findings from studies involving functional neuroimaging and FER tasks, we highlight several emerging themes; for example, noradrenaline promotes an overall positive bias in FER, while serotonin, dopamine and gamma-aminobutyric acid modulate emotions relating to self-preservation. Finally, other neurotransmitters including the cholinergic and glutamatergic systems are responsible for rather non-specific pro-cognitive effects in FER. With the ongoing accumulation of evidence further characterising the individual contributions of each neurotransmitter system, we argue that a sensible next step would be the integration of experimental neuropharmacology with computational models to infer further insights into the temporal dynamics of different neurotransmitter systems modulating FER.
THE OXFORD CHARACTER PROJECT*
The Oxford Character Project (OCP) is an interdisciplinary research and education project at the University of Oxford. Established in 2014, its work joins theoretical and empirical research in virtue ethics, character development and leadership education with the design and delivery of character and leadership development programmes. Its aim is to advance character-based leadership and leadership education through strategic partnerships in the United Kingdom and around the world. This chapter presents the work of the OCP, focusing on: (1) the OCP’s approach to character education, (2) the connection between character and leadership that is manifested in several educational programmes, (3) the OCP’s research on character, culture and leadership in UK business and (4) the OCP’s research on global leadership.
Knowledge, Attitudes, and Experiences of Self-Harm and Suicide in Low- and Middle-Income Countries.
Background: Over three-quarters of suicides occur in low- and middle-income countries (LMICs) and a better understanding of this behavior within these settings is crucial. Aim: To investigate stakeholders' knowledge, attitudes, and experiences of self-harm and suicide in LMICs. Method: A systematic search was conducted using British Nursing Index, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Embase, MEDLINE, PsycINFO, and Social Sciences electronic databases from inception to March 2022, combined with hand-searching reference lists. The search was updated using the PubMed Similar Articles function in February 2024. Analysis followed a modified narrative synthesis approach. Results: One hundred and fifty-four articles met the inclusion criteria, of which 60 included relevant quantitative data. Attitudes toward suicide were often contradictory although, overall, were negative and suicide literacy was poor. Healthcare staff reported lacking training in this area. Willingness to seek help was linked to suicide literacy and attitudes toward suicide. Limitations: Heterogeneity of included studies. Conclusion: Tackling stigma and improving awareness of suicide and self-harm in LMICs are needed to facilitate suicide prevention. Training should include people with lived experience of suicide and self-harm. The complex and contradictory influences of age, gender, religious, and cultural beliefs and lived experience must be considered.
‘Not Angels but Humans’ An Exploratory Qualitative Study of Female Nurses With Lived Experience of Self-Harm and Suicidal Behaviours
Aims: To explore the experiences of qualified nurses who have lived experience of self-harm (with or without suicidal intent) during nursing training or practice. Specifically, to examine characteristics and contributing factors and ideas for tailored suicide prevention interventions. Design: Exploratory qualitative study. Methods: Individual semi-structured interviews were conducted with eight qualified female nurses who had self-harmed during nursing training or practice. Participants were recruited from three NHS hospital Trusts. Data were collected between June and September 2023 and analysed using reflexive thematic analysis. Results: Four themes were generated: (1) ‘I don't think work triggered it, but I don't think it helped’: characteristics and contributors to self-harm, (2) ‘You're a nurse now you can't talk about that’: nursing culture and barriers to workplace support seeking, (3) ‘Are you a nurse or are you a lived experience practitioner – can you be both?’: navigating a dual identity as a nurse with lived experience and (4) ‘We need the permission that it's ok to put us first’: workplace support and suggestions for suicide prevention. Conclusion: Participants described their experiences of self-harm, including citing a range of contributory factors, with occupational issues being particularly salient. Cultural expectations and stigma prevented help-seeking and unique challenges regarding being both a clinician and an individual who has self-harmed were described. Reflections and perspectives on workplace and independent mental health support for nurses were shared. Implications for the Profession: Potential avenues for suicide prevention interventions tailored for the nursing profession may include challenging nursing culture and promoting help-seeking, peer support opportunities and implementation of education surrounding mental health and well-being in nursing curricula. Reporting Method: Reporting complied with the COREQ. Patient or Public Contribution: The topic guide and participant information sheet were developed in consultation with a group of qualified and student nurses with lived experience of suicidal thoughts and behaviours.
Cognitive behavioural therapy for sleep problems in psychosis: systematic review of effectiveness and acceptability.
BACKGROUND: Sleep problems are common among people with psychosis. Research suggests poor sleep is causally related to psychosis, anxiety and depression. AIMS: This review investigates the effectiveness and acceptability of cognitive-behavioural therapy (CBT) in targeting sleep problems in people with and at risk of psychosis. METHOD: Four databases were searched in line with PRISMA guidelines. Eligible studies either evaluated (a) CBT targeting sleep problems in people with or at risk of psychosis, or (b) subjective experiences of this treatment. Articles not published in peer-review journals were excluded. Treatment effectiveness was investigated for sleep, psychosis and other clinical outcomes. Acceptability was evaluated using qualitative data, drop-out rates, adverse events and relevant questionnaires. Adaptations to standard treatment protocols were described. Research quality was appraised using Cochrane Risk of Bias tools for randomised and non-randomised trials, and a checklist was developed for qualitative papers. RESULTS: Of the 975 records identified, 14 were eligible. The most common CBT target was insomnia. Treatment protocols were typically adapted by omitting sleep restriction. Large effect sizes were reported for sleep outcomes; however, effects for other clinical outcomes were less clear. Qualitative data and acceptability outcomes suggest that treatment was received positively by participants. CONCLUSIONS: CBT is an effective and acceptable treatment for sleep problems in people with and at risk of psychosis. However, our conclusions are limited by few good-quality studies and small samples. Further gold-standard research is required to inform evidence-based guidelines.
Paranoia and unusual sensory experiences in Parkinson's disease.
OBJECTIVES: There has been limited exploration into the nature and development of psychotic experiences (PEs) in Parkinson's disease (PD). We aimed to comprehensively assess the frequency, severity, and associated distress of paranoia and unusual sensory experiences (USEs) in PD, and to assess what variables are significantly associated with these experiences, focussing on psychological processes central to understanding PEs in non-PD groups. METHOD: A questionnaire battery was completed by 369 individuals with PD with a mean age of 66 years and mean time since diagnosis of 5 years. Recruitment was via Parkinson's UK, social media, and local community groups. For a subset of measures, comparisons were made to age-matched controls using pre-existing data. RESULTS: 182 (49%) participants reported USEs, including almost half of those not taking dopaminergic medication. For 83 (23%), the experience was distressing. Paranoia across the sample was significantly lower than in age-matched controls. However, specific paranoid concerns around abandonment (16%) and spousal betrayal (10%) were reported by some. Depression, anxiety, loneliness, and stigma and desire for support with PEs were high across the sample. Almost all psychological variables were significantly associated with PEs in structural equation models. CONCLUSION: PEs in PD are common, even in those not taking dopaminergic medication. For a small subset, these experiences are distressing and not resolved by existing treatment. Cognitive-affective variables like depression and anxiety could play a maintaining role in PEs in PD thus providing easy avenues for trialling intervention.
Explaining and understanding in psychopathology.
Psychoanalytical methodology has been described as causal explanation or hermeneutic understanding. This methodological dichotomy has been introduced into psychopathology by Karl Jaspers. Contemporary authors' contributions in the area are discussed. Although these authors accept a role for both methods, they agree with Jaspers that psychoanalysis should be subjected to the logical limitations of hermeneutic analysis. A logical framework for the interaction of explaining with understanding is presented and discussed in relation to psychiatric research.
Further evidence that reading ability is not preserved in Alzheimer's disease.
BACKGROUND: Pre-morbid intelligence level is routinely assessed in Alzheimer's disease using the National Adult Reading Test (NART). This practice is based on the assumption that pronunciation of irregular words remains unaffected by the disease process. Recent reports have suggested that reading ability may become compromised in moderately demented subjects. METHOD: Sixty-eight probably Alzheimer patients were classified into stages of severity (minimal, mild and moderate) using the Mini-Mental State Examination (MMSE). NART and demographic equations were used to estimate pre-morbid ability. RESULTS: A significant correlation emerged between dementia severity and reading ability, NART v. MMSE scores, r = 0.46, P < 0.01. When the total sample was subdivided into moderate, mild and minimal subgroups, significant between-group differences emerged, despite the groups being well matched for age, sex, and years of full-time education. Pre-morbid IQ, as estimated by demographic regression equations, did not correlate with dementia severity. CONCLUSION: NART performance is compromised in moderate Alzheimer disease, and the measure provides a serious underestimate of pre-morbid IQ in patients with an MMSE of 13 or less.
Follow-up study of depression in the elderly. Clinical and SPECT data.
BACKGROUND: Imaging studies in depression of the elderly are often small and highly selective. AIMS: To investigate a large group of elderly depressed patients in order to assess changes in clinical, imaging and neuropsychological variables at follow-up. METHOD: Patients (n = 175, age range 65-91 years) with clinical depression were identified from consecutive local referrals. Clinical interviews, neuropsychological tests and SPECT scans were carried out at referral and at two-year follow-up. RESULTS: Of 84 re-examined patients, 46.5% were well, 9.5% were ill, 33% partially recovered and 11% had developed dementia. Duration of illness before index assessment was the only factor to predict outcome. Thirty-nine patients could be scanned and followed up. There were no differences between patients with good or poor depressive outcome on SPECT. Ten clinically improved patients could be re-examined with SPECT. There were relative increases in right cingulate gyrus and right cerebellum at follow-up. CONCLUSIONS: The patients group was comparable with other studies showing high levels of residual depressive symptoms. Activity changes in limbic cortex are implicated in depression of old age.