Acute mental health admissions in inner London: changes in patient characteristics and clinical admission thresholds between 1988 and 1998

Aims and Method

We undertook a retrospective case-note review of three cohorts of mental health admissions to determine the extent to which patient and service characteristics changed between 1988 and 1998. Changes in clinical admission thresholds were investigated by a psychiatrists' review of handwritten medical admission assessments.

Results

Patients admitted in 1998 were demographically less stable and clinically more complex than those admitted 10 years earlier. Clinical admission thresholds remained consistent.

Clinical Implications

Our findings suggest that the perceived increase in pressure on psychiatric services over this period was a response to a change in population need. This study highlights important questions about the clinical decision-making process leading to use of alternatives to admission and the appropriateness of acute admissions.

Relatives of patients with severe psychotic disorders: factors that influence contact frequency. Report from the UK700 trial

BACKGROUND

The isolation experienced by many patients with severe psychotic disorders is generally assumed to be due to their social withdrawal. An alternative possibility is that relatives avoid frequent contact with patients because they find the situation distressing.

AIMS

To examine the predictors of frequent patient-relative contact, in particular the role of relatives' experience.

METHOD

UK700 trial data were used to determine baseline predictors of frequent contact and establish whether relatives' experience at baseline predicted continued frequent contact 2 years later.

RESULTS

Neither characteristics associated in the literature with relatives' 'burden' nor relatives' experience predicted patient-relative contact frequency. Instead, the predictors were mainly demographic.

CONCLUSIONS

Many relatives experience considerable distress, but the evidence does not suggest that they avoid frequent contact with the patient as a consequence.

Suicidal behaviour in psychosis: prevalence and predictors from a randomised controlled trial of case management: report from the UK700 trial

BACKGROUND

It is unclear whether intensive case management influences the prevalence of suicidal behaviour in patients with psychosis.

AIMS

To compare the effect of intensive case management and standard care on prevalence of suicidal behaviour in patients with chronic psychosis.

METHOD

Patients with established psychosis (n = 708) were randomised either to intensive case management or to standard care. The prevalence of suicidal behaviour was estimated at 2-year follow-up and compared between treatment groups. Suicide attempters and non-attempters were compared on multiple socio-demographic and clinical variables to identify predictors of suicidal behaviour.

RESULTS

There was no significant difference in prevalence of suicidal behaviour between treatment groups. Recent attempts at suicide and multiple recent hospital admissions best predicted future attempts.

CONCLUSIONS

Intensive case management does not appear to influence the prevalence of suicidal behaviour in chronic psychosis. Predictors identified in this study confirm some previous findings.

Changes in "withdrawal symptoms" following discontinuation of low-dose diazepam

The intensity of putative benzodiazepine withdrawal symptoms was evaluated as part of a double blind placebo-controlled study of benzodiazepines and behaviour therapy in the management of agoraphobia. During the first phase of that study, some subjects were switched from low dose diazepam to placebo, and others remained on diazepam. Symptoms were evaluated in long-term benzodiazepine users (n = 30) and non-users n = 32) when they first entered the study and 4 weeks later, after both groups had been randomized to either diazepam or placebo, using eight analog rating scales measuring commonly reported withdrawal symptoms. At baseline, both users and non-users reported a substantial number of symptoms, with higher levels in the more anxious patients, but no differences between groups. After the transition to either diazepam or placebo, the users switched to placebo reported significantly higher levels of symptoms than users switched to diazepam and non-users combined. Multiple regression analysis suggested that the increase in symptoms was associated with the increase in anxiety, which was higher in the withdrawing group than the other three groups. These results raise questions concerning the extent to which withdrawal symptoms uniquely characterize benzodiazepine withdrawal. They confirm the common assumption that an increase in symptoms often accompanies withdrawal from benzodiazepines, but suggest that such symptoms are not so intense as to make withdrawal excessively difficult, at least in low-dose users.

Effects of concurrent diazepam treatment on the outcome of exposure therapy in agoraphobia

In a study designed to evaluate the impact of benzodiazepine use on the outcome of behaviour therapy, 91, severe, chronic agoraphobics (46 BDZ users and 45 non-users) were randomly allocated on a double-blind basis to in vivo exposure with low-dose diazepam (ED) or placebo (EP). Drug doses were adjusted on the basis of weekly psychiatric assessments over weeks 1-4. Patients had 8 x 2 hr exposure sessions (weeks 5-12) and were then withdrawn from medication (weeks 13-16). Re-assessments were completed at weeks 4, 12 and 16, and follow-up assessments at approx 20, 46 and 72 weeks. In the analysis of the results, the clinical outcome was evaluated in relation to the therapeutic regime (ED vs EP) and prior BDZ use (users vs non-users). The results showed that the ED group had greater changes in anxiety than the EP group during the drug manipulation phases (anxiety increasing during BDZ withdrawal). There were no group differences in agoraphobic symptoms and no evidence that the outcome of the behavior therapy was significantly affected by concurrent BDZ treatment. There were significant improvements in agoraphobic symptoms over the treatment period, with no evidence for relapse of treatment gains on withdrawal from BDZ, nor for differential responses over the one year follow-up. Initial differences between users and non-users were less marked than expected, although there was a trend for more drop-outs among users across both ED and EP groups.

The Emanuel Miller Memorial Lecture 1992. The theory and practice of resilience

The aim of this paper is to identify a theoretical framework which may provide a meaningful context for developing practical interventions to build upon the concept of resilience. In so doing I shall briefly consider the importance of the concept, what is known about it, and then focus on a specific facet of the problem: intergenerational transmission of maladaptive relationship patterns and resilience to such a threat.

Measuring the ghost in the nursery: an empirical study of the relation between parents' mental representations of childhood experiences and their infants' security of attachment

This paper presents a summary of the Anna Freud Centre-University College London, Parent-Child Project. Its most important finding was that the security of the infants' relationship with both parents at 12 and 18 months could be predicted on the basis of qualitative aspects of the parents' accounts of their own childhoods collected before the birth of the child. This confirmed Selma Fraiberg's observations concerning the reemergence of childhood conflicts at early stages of childbearing. Possible mechanisms mediating this link are explored with particular reference to the role of the parents' accurate mental representations of the infants' mental world.

Psychotherapy in borderline and narcissistic personality disorder

Psychodynamic concepts about borderline personality disorder are reviewed and the literature concerning psychotherapeutic treatment of this group is examined. The treatment contexts considered include: psychoanalysis and intensive (expressive) psychoanalytic psychotherapy, supportive psychotherapy, group psychotherapy, family therapy, in-patient treatment, the therapeutic community, cognitive-behavioural approaches, and combinations of drugs and psychotherapy. The practical implications of recent follow-up studies for intervention strategies are considered.

The prolonged benzodiazepine withdrawal syndrome: anxiety or hysteria?

In an attempt to establish whether prolonged withdrawal symptoms after stopping intake of benzodiazepines is caused by return of anxiety, hysteria, abnormal illness behaviour or the dependence process itself producing perhaps a prolonged neurotransmitter imbalance, a group of such patients suffering prolonged withdrawal symptoms (PWS) was compared on a range of psychophysiological measures with matched groups of anxious and conversion hysteria patients and normal controls. It was found that the psychophysiological markers of anxiety were not marked in the PWS group; nor were the averaged evoked response abnormalities found to be associated with cases of hysterical conversion in evidence. The PWS group were hard to distinguish from normal controls on the basis of psychophysiological measures and thus it was felt to be unlikely to be an affective disturbance. It was concluded that PWS is likely to be a genuine iatrogenic condition, a complication of long-term benzodiazepine treatment.

Adaptive probit estimation and body size: the evaluation of a new psychophysical technique

Studies of body size estimation are frequently used to identify body-image disturbances in clinical populations. No clear pattern of results has, however, so far emerged. One reason for this may be that studies confound non-sensory influences on performance deriving from motivational components with the observer's discriminative sensitivity. This study introduces an adaptive version of the method of constant stimuli and probit analysis (APE) to determine independently bias and threshold in the estimation of four body parts for two samples of undergraduate students. In the first study, test-retest reliability coefficients were obtained for body-size estimates, using the traditional technique and the new method. Estimates of subjective body size obtained by the new method were shown to have higher test-retest reliabilities than those obtained using traditional techniques. The stability of sensitivity estimates was in the .8-.9 range. In a second study we attempted to validate the new technique by comparing the body-size estimates of male and female observers. Independent bias and sensitivity estimates were found to be significantly different. Female observers were more likely to overestimate the size of their chest and waist whilst underestimating face size. There was no difference overall between the accuracy of male and female observers. Perceptual sensitivity did not differ significantly overall, but whilst female subjects showed a particularly low threshold for waist size, male observers showed the same specific sensitivity for thigh width. The extension of this method of measuring body-image distortions to relevant clinical populations is recommended.

Benzodiazepine research: current findings and practical consequences

The recent research literature on the effects of benzodiazepines is reviewed, with special emphasis on findings relevant for the practising clinician. The mode of action, patterns of use and abuse potential of benzodiazepines are discussed. The evidence on the risks of dependency and possible drawbacks of long-term use are examined. The possible effects of benzodiazepine use on psychological treatments are also examined, and factors that should be considered while treating benzodiazepine users are discussed.

The natural history of tolerance to the benzodiazepines

Dependence on benzodiazepines following continued use is by now a well-documented clinical phenomenon. Benzodiazepines differ in their dependence potential. The present studies were aimed at examining the possibility that differential rates of tolerance development might account for differences in dependence risk. Four studies are reported. The first three studies concerned normal subjects. The development of tolerance over a fifteen day period was demonstrated for three different benzodiazepines (ketazolam, lorazepam and triazolam) using two paradigms. Tolerance in terms of a reduction in effectiveness of a repeated given dose was most notable for the benzodiazepine with a medium elimination half-life (lorazepam) for physiological, behavioural and subjective measures. In the case of the drug with the longest elimination half-life (ketazolam) reduction in effectiveness could only be assumed to be occurring if account was taken of the steady increase in plasma concentrations of active metabolites. For this drug it seemed that the physiological measures were those most likely to demonstrate the development of tolerance. Although triazolam showed few significant drug effects on this paradigm (testing being 12 hours after ingestion of this short half-life benzodiazepine), tolerance was seen to develop on some subjective measures. Using an alternative method of testing tolerance, assessing responses to a diazepam challenge dose, a high degree of tolerance on two-thirds of the measures was observed in subjects when pretreated with the benzodiazepine with the most marked accumulation of active metabolites (ketazolam). The other two drugs also led to tolerance development on a range of measures; this was more marked for lorazepam than triazolam. Blunting of the growth hormone response to diazepam was the most sensitive and reliable method of detecting tolerance to the benzodiazepines. Symptoms on discontinuation of the two weeks' intake of the benzodiazepines were marked for all the drugs but unrelated to either the tolerance induced or the elimination half-life of the particular drug. A further clinical study revealed that tolerance persisted in a group of long-term benzodiazepine users for between four months and two years following complete abstinence from the drug. These patients appeared to be less affected by diazepam in terms of its commonly observed subjective effects, regardless of their original medication. These ex-long-term users of benzodiazepines were, however, more likely to manifest two specific types of effects--immediate 'symptom' reduction and exacerbation of 'withdrawal symptoms' over the subsequent week.(ABSTRACT TRUNCATED AT 400 WORDS)

A follow-up study of patients treated for benzodiazepine dependence

By interviewing and administering questionnaires to 63 patients one to five years after treatment for benzodiazepine dependence the long-term success rate was examined together with factors associated with outcome. Fifty-four per cent of patients had permanently withdrawn from medication at follow-up. Most of those who were successful continued to experience psychiatric symptoms after discharge. Significantly more women than men managed to withdraw from medication. Outcome was not related to previous benzodiazepine regimen, psychiatric history or experiences of withdrawal. It is argued that psychological adjuncts should be included in the treatment of benzodiazepine dependence in order to prevent relapse.

The effects of the benzodiazepine antagonist Ro 15-1788 on psychophysiological performance and subjective measures in normal subjects

Ro 15-1788 is an imidazodiazepine which was initially described as a pure benzodiazepine antagonist lacking in intrinsic actions. Although recent animal work has shown the drug to have differing intrinsic actions depending on the dose, the majority of studies on human subjects conclude that it is a pure antagonist of benzodiazepines. Two oral doses of Ro 15-1788 (30 mg and 100 mg) were compared with 5 mg diazepam and placebo in their intrinsic effects on a range of psychophysiological, performance and subjective measures in 12 healthy adult subjects. At both these doses Ro 15-1788 showed a mixture of agonist (benzodiazepine-like) effects and other non-benzodiazepine-like effects on the variables measured. Although there was no clear-cut dose-response relationship, the results suggested a predominance of benzodiazepine-like effects at the higher dose on physiological measures whilst the lower dose was observed to have greater effects on a number of behavioural and subjective dimensions. The subjective changes were the opposite of those normally found for benzodiazepines.