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Workplace assessment in crisis? The way forward.
A recent Royal College of Physicians' study on assessment raises serious questions for workplace assessment. To address these, a system is recommended that bridges the gap from competence to performance and integrates supervised learning events (SLEs) that are formative in purpose with summative assessment of performance by entrustable professional activities (EPAs).
How psychotropic drugs are used; an explanatory paradigm
Traditionally, two divergent approaches are used to explain the mechanism of action of psychotropic drugs. The dominant "Disease-centred" view emphasises the biochemical imbalance caused by 'illnesses'. In contrast the "Drug-centred" view emphasises the psychoactive properties of these drugs and their ability to induce an 'altered-state' of mind. In this article we propose a new paradigm for classifying the therapeutic uses of psychotropic drugs based on the relation between their psychoactive effects and symptoms of indicated mental illness; as well as their clinical responses e.g. emerging tolerance, paradoxical initial worsening and being recommended for long/short term use. Based on this premise, therapeutic uses of psychotropic drugs can be placed on a continuum between two distinguishable modes. We define these modes as "Psycho-antagonistic" and "Psycho-agonistic". 105 therapeutic uses of 85 psychotropic drugs are placed on this continuum; 74% on the Psycho-agnostic spectrum and 25% on the Psycho-antagonistic side. Hypnotic agents used for insomnia are clear examples of Psycho-antagonistic mode of use. Citalopram for treatment of Panic disorder is a clear example of using a drug in Psycho-agonistic mode. Only the therapeutic use of Lithium for bipolar affective disorder could not be allocated to any mode and considered as borderline. The paradigm highlights the possibility of initial worsening in majority of therapeutic uses of psychotropic drugs and importance of using lower doses. Further studies and clinical trials are needed to explore the full extent of the clinical implications of this paradigm in psychiatry and perhaps in other branches of medicine.
Intellectual disabilities: improving access to therapeutic communities
Copyright © 2016 John Wiley & Sons, Ltd Access to specialised therapeutic communities (TCs) for people with intellectual disabilities (IDs) such as ‘Camphill communities’ and ‘TCs plus’ is limited and patchy in the UK. Nonetheless, the emphasis for some time now has been to enable people with IDs to access mainstream services, which have a legal duty to make reasonable adjustments to facilitate this. Here, the authors propose a set of recommendations in order to improve the access of people with ID to mainstream therapeutic communities and enhance the services they receive.
What is the best available evidence for using homeopathy in patients with intellectual disabilities?
OBJECTIVE: The debate about the effectiveness of homeopathy hits the headlines from time to time. Reported evidences for the role of homeopathy in psychiatric illness relevant to people with intellectual disabilities are patchy and inconsistent. In this review we summarize the best available evidence for the use of homeopathy to treat the psychiatric disorders common in this population. METHODS: Systematic literature review was conducted through February 2012 to July 2012 in AMED, CINHAL, BNI, EMBASE, MEDLINE, PSYCHINFO and GOOGLE SCHOLAR. In the next steps thirty eight homeopathic associations were contacted and a top-up literature search was done on Scopus and World of Science databases till March 2014. Twelve relevant clinical trials were identified and included in this study. The quality of each trial was assessed by the Oxford quality scoring system (Known as Jadad score) as well as subjective review by two reviewers independently (good versus poor). Findings : The largest body of evidence pertained to the use of homeopathy in the treatment of attention deficit hyperactivity disorder (ADHD). There is heterogeneity in the quality of trials and also the outcome of studies but overall our findings suggest some potential for using homeopathy in ADHD. Current evidences do not support the use of homeopathy for treatment of speech and language difficulties. There was only one trial concerning the use of homeopathy in Autistic Spectrum Disorder. This was of a poor quality and unable to provide any recommendation. CONCLUSION: Whilst acknowledging the risk of publication and language bias in our study, the currently available evidences are neither conclusive nor comprehensive enough to give us a clear picture for the use of homeopathy in patients with intellectual disabilities. There are large gaps in the body of evidence concerning the role of homeopathy in the treatment of common disorders in intellectual disability, such as autism, challenging behavior or developmental arrest in childhood.
Thyroid dysfunction in Down's syndrome secondary to risperidone
Here, the authors discuss a patient with mild intellectual disability and Down's syndrome who appeared to experience deterioration in her well controlled thyroid function twice, secondary to higher dosages of risperidone for treatment of her delusional disorder. The case therefore suggests that thyroid function monitoring may be of value in individuals predisposed to thyroid dysfunction who are commenced on antipsychotic therapy, especially risperidone.
Beyond “Evidence-Based Medicine” in “Detained Patients"
AimsTreatments without robust evidence are not recommended. However, some patients detained in secure hospitals might need novel approaches such as: off-license use of medication, use of psychological (rather than their biological) effects of drugs. In addition, some detained patients may request for unconventional treatments they believe in. In community and capacitous patients, the clinician's role is advisory and the burden is on the patient to make the final decision and access such treatments privately. However, in a detained patient (with or without capacity), it may fall on the Responsible Clinician (RC) to deny or facilitate access to such interventions. Currently, there is no guidance for such circumstances. We have presented three real cases followed by proposing a flowchart to guide RCs.MethodsCase 1 (2019–2020): X with mild Learning Disability (LD) and mixed personality disorder detained under Section 3 with no leave to community. X asked for Hypericum which has been helpful with her headaches in the past. X had capacity to make that decision.Case 2 (1996–97): Y with mild LD and aggressive behaviours responding instantly to any injection. Y lacked capacity so injections of distilled water was tried in his best interest, with equal positive effect. The question was about using distilled water as rapid tranquilisation with no side effects.Case 3 (2020–21): Z with a treatment-resistant psychosis who has been unwell for months and detained in four different PICUs. Z's father requested N Acetyl Cysteine which had historical calming and sedative effects for Z.ResultsThe main issue in case 1 is the conflict between the patient's Human Rights and RC's Duty of care. Here the patient could be potentially deprived of their right to make an ‘unwise decision’ should the RC bar her access to a treatment which lacks evidence but is privately available to public. This can be construed as an infringement of Article 8 of Human Rights.The issue in case 2 and 3 is rather different. Here the conflict is between the RC's duty of care to provide evidence-based treatments and the patient's “best interest” which seems to be an intervention without robust evidence.ConclusionWe have developed a flowchart to help RCs by navigating amongst several competing/ conflicting legal and ethical concepts such as: Patient's wish/Human rights, Patient's capacity, Bolam test, “Medical Treatment” Under Section 63, 62 or 58 of Mental Health Act 1983, Best interest, Second Opinion (SOAD) and advice from court.
Considering capacity to use sex toys in secure care: two case reports
The promotion and enabling of vulnerable and long‐stay inpatients’ sexualities is a largely neglected practice. This paper offers a novel contribution to the existing literature by considering the assessment of capacity to use sex toys. It describes the development of a set of guidelines and application of these in two clinical cases. It is hoped that the paper will provide a start point from which the guidelines could be scrutinised and refined by professional bodies and legal review.
Ethnic disparity in mental health legislation at the point of inpatient entry: pilot review in detained adolescents with developmental disorders
Purpose: Ethical concerns about the use of the Mental Health Act (MHA) have led to calls for developmental disorders to be removed from the list of mental disorders for which individuals can be detained. In parallel, there are long-standing concerns of ethnic disparity in the application of the MHA. Nonetheless, the impact of the intersections of developmental disorder diagnosis, adolescence and ethnicity on the application of the MHA is unknown. This study aims to explore ethnic differences in MHA sections and the factors accounting for this, in an adolescent inpatient developmental disorder service. Design/methodology/approach: File reviews were conducted to explore differences in MHA status, as well as demographic, clinical and risk factors that may account for this, between 39 white British and ethnic minority adolescents detained to a specialist inpatient developmental disorder service. Findings: Consistent with adult literature, adolescents of an ethnic minority were overrepresented in the sample and were significantly more likely to be detained on Part III or “forensic” sections of the MHA than White British counterparts, with five times greater risk. Analyses revealed no significant differences between ethnic minority and white British participants on demographic variables, clinical needs, risk behaviours, risk measures nor application of restrictive practices and safeguarding procedures. Practical implications: National audits exploring patterns of detention under the MHA across adolescent developmental disorder populations need to include analysis of intersections to ensure that the MHA is used as a means of last resort and in an equitable manner. Originality/value: To the best of the authors’ knowledge, this paper is the first comprehensive exploration of the impact of ethnicity on detention patterns in ethnic minority and White British populations.
Development of the learning disability physical activity questionnaire (LDPAQ)
Purpose: People with learning disabilities can be affected by complex health needs and their life expectancy is significantly reduced. Physical activity has a role in enhancing quality of life and better management of multiple health issues in this population especially if they are individually tailored to the service users’ abilities and care needs. Considering the complexities of communication, there is a need for a specific physical activity assessment tool in people with learning disabilities. Design/methodology/approach: A multidisciplinary team of experts devised the Learning Disability Physical Activity Questionnaire (LDPAQ) as a tool to measure physical activity. The tool was tested within community and inpatient settings. Findings: An easy-read, picture-based, self-reported and concise questionnaire with options relevant to people with learning disabilities was developed. Feedback from the audit confirmed ease of use and high levels of respondent satisfaction. A small-scale audit of the tool also confirmed the need for promoting physical activity within this population. Originality/value: The LDPAQ is a novel questionnaire that aims to be a universally applicable tool for the assessment of physical activity status in people with learning disabilities. It is designed to be used by people with learning disabilities themselves, professionals and organisations. Further research is needed to explore the full potential of this tool.
Connectome dysfunction in patients at clinical high risk for psychosis and modulation by oxytocin.
Abnormalities in functional brain networks (functional connectome) are increasingly implicated in people at Clinical High Risk for Psychosis (CHR-P). Intranasal oxytocin, a potential novel treatment for the CHR-P state, modulates network topology in healthy individuals. However, its connectomic effects in people at CHR-P remain unknown. Forty-seven men (30 CHR-P and 17 healthy controls) received acute challenges of both intranasal oxytocin 40 IU and placebo in two parallel randomised, double-blind, placebo-controlled cross-over studies which had similar but not identical designs. Multi-echo resting-state fMRI data was acquired at approximately 1 h post-dosing. Using a graph theoretical approach, the effects of group (CHR-P vs healthy control), treatment (oxytocin vs placebo) and respective interactions were tested on graph metrics describing the topology of the functional connectome. Group effects were observed in 12 regions (all pFDR
A systematic review and qualitative meta-synthesis of first-hand conceptualisations of nonsuicidal self-injury (NSSI)
Nonsuicidal self-injury (NSSI) is a growing phenomenon that correlates with significantly negative outcomes including psychopathology, hospitalisation and suicide; however, there exists little consensus on how to best understand it. This lack of conceptual consensus risks inconsistent clinical practice in a population that often reports poor experiences of professional support, therefore an understanding of how individuals conceptualise their own NSSI without attempting to fit it into existing causal and functionalist models is needed. This review sought to examine and synthesise first-hand conceptualisations of NSSI in existing qualitative literature using interpretive phenomenological synthesis. A systematic database search of qualitative literature was conducted, including interviews with individuals with experience of NSSI across all ages and settings, published in English from 1950 to 2022. Twenty-three studies were included in the final meta-synthesis. Three superordinate themes were generated via the synthesis: (1) NSSI is embedded in the social world; (2) NSSI is symbolic and communicative; and (3) NSSI represents taking back agency. This synthesis, comprised of both reported data and the themes identified by the researchers in the papers, highlighted that NSSI is a diverse behaviour that is inextricably linked with sociocultural context and that, paradoxically, it can be simultaneously communicative and private. This research urges an introspective examination of how clinicians and researchers in the field conceptualise NSSI and how this juxtaposes with how individuals who engage in the behaviour conceptualise it.
NHS Health Check attendance is associated with reduced multiorgan disease risk: a matched cohort study in the UK Biobank
Background: The NHS Health Check is a preventive programme in the UK designed to screen for cardiovascular risk and to aid in primary disease prevention. Despite its widespread implementation, the effectiveness of the NHS Health Check for longer-term disease prevention is unclear. In this study, we measured the rate of new diagnoses in UK Biobank participants who underwent the NHS Health Check compared with those who did not. Methods: Within the UK Biobank prospective study, 48,602 NHS Health Check recipients were identified from linked primary care records. These participants were then covariate-matched on an extensive range of socio-demographic, lifestyle, and medical factors with 48,602 participants without record of the check. Follow-up diagnoses were ascertained from health records over an average of 9 years (SD 2 years) including hypertension, diabetes, hypercholesterolaemia, stroke, dementia, myocardial infarction, atrial fibrillation, heart failure, fatty liver disease, alcoholic liver disease, liver cirrhosis, liver failure, acute kidney injury, chronic kidney disease (stage 3 +), cardiovascular mortality, and all-cause mortality. Time-varying survival modelling was used to compare adjusted outcome rates between the groups. Results: In the immediate 2 years after the NHS Health Check, higher diagnosis rates were observed for hypertension, high cholesterol, and chronic kidney disease among health check recipients compared to their matched counterparts. However, in the longer term, NHS Health Check recipients had significantly lower risk across all multiorgan disease outcomes and reduced rates of cardiovascular and all-cause mortality. Conclusions: The NHS Health Check is linked to reduced incidence of disease across multiple organ systems, which may be attributed to risk modification through earlier detection and treatment of key risk factors such as hypertension and high cholesterol. This work adds important evidence to the growing body of research supporting the effectiveness of preventative interventions in reducing longer-term multimorbidity.
Statistical analysis plan for a cluster randomised controlled trial to compare screening, feedback and intervention for child anxiety problems to usual school practice: identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i).
BACKGROUND: The Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i) trial is being conducted to establish whether 'screening and intervention', consisting of usual school practice plus a pathway comprising screening, feedback and a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety), bring clinical and health economic benefits compared to usual school practice and assessment only - 'usual school practice', for children aged 8-9 years in the following: (1) the 'target population', who initially screen positive for anxiety problems according to a two-item parent-report child anxiety questionnaire - iCATS-2, and (2) the 'total population', comprising all children in participating classes. This article describes the detailed statistical analysis plan for the trial. METHODS AND DESIGN: iCATS-i2i is a definitive, superiority, pragmatic, school-based cluster randomised controlled trial (with internal pilot), with two parallel groups. Schools are randomised 1:1 to receive either screening and intervention or usual school practice. This article describes the following: trial objectives and outcomes; statistical analysis principles, including detailed estimand information necessary for aligning trial objectives, conduct, analyses and interpretation when there are different analysis populations and outcome measures to be considered; and planned main analyses, sensitivity and additional analyses. TRIAL REGISTRATION: ClinicalTrials.gov ISRCTN76119074. Registered on 4 January 2022.
Evaluating functional brain organization in individuals and identifying contributions to network overlap
Individual differences in the spatial organization of resting-state networks have received increased attention in recent years. Measures of individual-specific spatial organization of brain networks and overlapping network organization have been linked to important behavioral and clinical traits and are therefore potential biomarker targets for personalized psychiatry approaches. To better understand individual-specific spatial brain organization, this paper addressed three key goals. First, we determined whether it is possible to reliably estimate weighted (non-binarized) resting-state network maps using data from only a single individual, while also maintaining maximum spatial correspondence across individuals. Second, we determined the degree of spatial overlap between distinct networks, using test-retest and twin data. Third, we systematically tested multiple hypotheses (spatial mixing, temporal switching, and coupling) as candidate explanations for why networks overlap spatially. To estimate weighted network organization, we adopt the Probabilistic Functional Modes (PROFUMO) algorithm, which implements a Bayesian framework with hemodynamic and connectivity priors to supplement optimization for spatial sparsity/independence. Our findings showed that replicable individual-specific estimates of weighted resting-state networks can be derived using high-quality fMRI data within individual subjects. Network organization estimates using only data from each individual subject closely resembled group-informed network estimates (which was not explicitly modeled in our individual-specific analyses), suggesting that cross-subject correspondence was largely maintained. Furthermore, our results confirmed the presence of spatial overlap in network organization, which was replicable across sessions within individuals and in monozygotic twin pairs. Intriguingly, our findings provide evidence that overlap between 2-network pairs is indicative of coupling. These results suggest that regions of network overlap concurrently process information from both contributing networks, potentially pointing to the role of overlapping network organization in the integration of information across multiple brain systems.
Conduct disorder - a comprehensive exploration of comorbidity patterns, genetic and environmental risk factors.
Conduct disorder (CD), a common mental disorder in children and adolescents, is characterized by antisocial behavior. Despite similarities with antisocial personality disorder (ASPD) and possible diagnostic continuity, CD has been shown to precede a range of adult-onset mental disorders. Additionally, little is known about the putative shared genetic liability between CD and adult-onset mental disorders and the underlying gene-environment interplay. Here, we interrogated comorbidity between CD and other mental disorders from the Norwegian Mother, Father and Child Cohort Study (n = 114 500) and investigated how polygenic risk scores (PRS) for mental health traits were associated with CD/CD traits in childhood and adolescence. Gene-environment interplay patterns for CD was explored with data on bullying and parental education. We found CD to be comorbid with several child and adult-onset mental disorders. This phenotypic overlap corresponded with associations between PRS for mental disorders and CD. Additionally, our findings support an additive gene-environment model. Previously conceptualized as a precursor of ASPD, we found that CD was associated with polygenic risk for several child- and adult-onset mental disorders. High comorbidity of CD with other psychiatric disorders reflected on the genetic level should inform research studies, diagnostic assessments and clinical follow-up of this heterogenous group.