La lutte continue: Louis Mars and the genesis of ethnopsychiatry

The scientific contributions of Western mental health professionals have been lauded and leveraged for global mental health responses to varying degrees of success. In recent years, the necessity of recognizing the inefficiencies of solely etic and Western-based psychological intervention has been reflected in certain decolonial scholars like Frantz Fanon gaining more recognition. Despite this urgent focus on decolonial psychology, there are still others whose work has historically and contemporarily not received a great deal of attention. There is no better example of such a scholar than Dr. Louis Mars, Haiti's first psychiatrist. Mars made a lasting impact on the communities of Haiti by shifting the conversation around Haitian culture and the practice of how people living with a mental illness were treated. Further, he influenced the global practice of psychiatry by coining "ethnopsychiatry" and asserting that non-Western culture should be intimately considered, rather than stigmatized, in treating people around the world. Unfortunately, the significance of his contributions to ethnopsychiatry, ethnodrama, and the subsequent field of psychology has effectively been erased from the disciplinary canon. Indeed, the weight of Mars' psychiatric and political work deserves focus. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"I was Close to Helping him but Couldn't Quite get There": Psychiatrists' Experiences of a Patient's Death by Suicide

OBJECTIVES

A patient's death by suicide is a common experience for psychiatrists, ranging from 33% to 80%, however, research about the impact of patient suicide on psychiatrists is limited to a few survey studies. This study had three main objectives: (1) understanding the emotional and behavioural impact of a patient's suicide on psychiatrists, (2) exploring if and how the experience of a patient's suicide results in changes in psychiatrist practice patterns, and (3) understanding the tangible steps that psychiatrists and institutions take to manage the emotional and behavioural impact of patient suicide on psychiatrists.

METHODS

Eighteen psychiatrists were recruited using snowball sampling and interviewed to collect demographic data, followed by an in-depth exploration of their experiences of patient suicide. Interviews were then transcribed verbatim and analysed using constructivist grounded theory.

RESULTS

Study participants described strong emotional reactions in response to patient suicide. Emotional reactions were mediated by a physician, patient, relationship and institutional factors. While psychiatrists did not change the acuity or setting of their practice in response to patient suicide, they made several changes in their practice, including increased caution regarding discharges and passes from inpatient units, more thorough documentation and continuing education about suicide.

CONCLUSIONS

Patient suicide has a profound impact on psychiatrists and based on the findings of this study, we propose steps that psychiatrists and institutions can take to manage the emotional, psychological and behavioural burden of this event.

ENIGMA-DTI: Translating reproducible white matter deficits into personalized vulnerability metrics in cross-diagnostic psychiatric research

The ENIGMA-DTI (diffusion tensor imaging) workgroup supports analyses that examine the effects of psychiatric, neurological, and developmental disorders on the white matter pathways of the human brain, as well as the effects of normal variation and its genetic associations. The seven ENIGMA disorder-oriented working groups used the ENIGMA-DTI workflow to derive patterns of deficits using coherent and coordinated analyses that model the disease effects across cohorts worldwide. This yielded the largest studies detailing patterns of white matter deficits in schizophrenia spectrum disorder (SSD), bipolar disorder (BD), major depressive disorder (MDD), obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and 22q11 deletion syndrome. These deficit patterns are informative of the underlying neurobiology and reproducible in independent cohorts. We reviewed these findings, demonstrated their reproducibility in independent cohorts, and compared the deficit patterns across illnesses. We discussed translating ENIGMA-defined deficit patterns on the level of individual subjects using a metric called the regional vulnerability index (RVI), a correlation of an individual's brain metrics with the expected pattern for a disorder. We discussed the similarity in white matter deficit patterns among SSD, BD, MDD, and OCD and provided a rationale for using this index in cross-diagnostic neuropsychiatric research. We also discussed the difference in deficit patterns between idiopathic schizophrenia and 22q11 deletion syndrome, which is used as a developmental and genetic model of schizophrenia. Together, these findings highlight the importance of collaborative large-scale research to provide robust and reproducible effects that offer insights into individual vulnerability and cross-diagnosis features.

The challenge of ensuring affordability, sustainability, consistency, and adaptability in the common metrics agenda

Mental health research grapples with research waste and stunted field progression caused by inconsistent outcome measurement across studies and clinical settings, which means there is no common language for considering findings. Although recognising that no gold standard measures exist and that all existing measures are flawed in one way or another, anxiety and depression research is spearheading a common metrics movement to harmonise measurement, with several initiatives over the past 5 years recommending the consistent use of specific scales to allow read-across of measurements between studies. For this approach to flourish, however, common metrics must be acceptable and adaptable to a range of contexts and populations, and global access should be as easy and affordable as possible, including in low-income countries. Within a measurement landscape dominated by fixed proprietary measures and with competing views of what should be measured, achieving this goal poses a range of challenges. In this Personal View, we consider tensions between affordability, sustainability, consistency, and adaptability that, if not addressed, risk undermining the common metrics agenda. We outline a three-pronged way forward that involves funders taking more direct responsibility for measure development and dissemination; a move towards managing measure dissemination and adaptation via open-access measure hubs; and transitioning from fixed questionnaires to item banks. We argue that now is the time to start thinking of mental health metrics as 21st century tools to be co-owned and co-created by the mental health community, with support from dedicated infrastructure, coordinating bodies, and funders.

Psychiatry in the Time of COVID: Credibility, Uncertainty, and Self-Reflection

ABSTRACT

Public trust in the credibility of medicine and physicians has been severely tested amid the COVID-19 pandemic and growing sociopolitical fissures in the United States. Physicians are being asked to be ambassadors to the public of scientific information. Psychiatrists have an opportunity to help the public understand and accept a "new normal" during a time of such uncertainty. Using a case example, we review the impact of uncertainty and fear on scientific and medical credibility. Although the pandemic provides an opportunity for systemic change, the consequences of any change remain unknown. To help patients navigate the uncertainty, we conclude by offering four guidelines to clinicians: the public has little interest in understanding the scientific method; we need to acknowledge that we do not have all the answers; credibility and trustworthiness are linked to our ability to be trusted, believable messengers; and we can retain scientific credibility while acknowledging uncertainty.

Potential biomarkers of major depression diagnosis and chronicity

BACKGROUND

Molecular biomarkers are promising tools to be routinely used in clinical psychiatry. Among psychiatric diseases, major depression disorder (MDD) has gotten attention due to its growing prevalence and morbidity.

METHODS

We tested some peripheral molecular parameters such as serum mature Brain-Derived Neurotrophic Factor (mBDNF), plasma C-Reactive Protein (CRP), serum cortisol (SC), and the salivary Cortisol Awakening Response (CAR), as well as the Pittsburgh sleep quality inventory (PSQI), as part of a multibiomarker panel for potential use in MDD diagnosis and evaluation of disease's chronicity using regression models, and ROC curve.

RESULTS

For diagnosis model, two groups were analyzed: patients in the first episode of major depression (MD: n = 30) and a healthy control (CG: n = 32). None of those diagnosis models tested had greater power than Hamilton Depression Rating Scale-6. For MDD chronicity, a group of patients with treatment-resistant major depression (TRD: n = 28) was tested across the MD group. The best chronicity model (p < 0.05) that discriminated between MD and TRD included four parameters, namely PSQI, CAR, SC, and mBDNF (AUC ROC = 0.99), with 96% of sensitivity and 93% of specificity.

CONCLUSION

These results indicate that changes in specific biomarkers (CAR, SC, mBDNF and PSQI) have potential on the evaluation of MDD chronicity, but not for its diagnosis. Therefore, these findings can contribute for further studies aiming the development of a stronger model to be commercially available and used in psychiatry clinical practice.

Using a Patient Safety/Quality Improvement Model to Assess Telehealth for Psychiatry and Behavioral Health Services Among Special Populations During COVID-19 and Beyond

Telehealth has been rapidly deployed in the environment of the Coronavirus 2019 (COVID-19) pandemic to help meet critical mental health needs. As systems of care use telehealth during the pandemic and evaluate the future of telehealth services beyond the crisis, a quality and safety framework may be useful in weighing important considerations for using telehealth to provide psychiatric and behavioral health services within special populations. Examining access to care, privacy, diversity, inclusivity, and sustainability of telehealth to meet behavioral and psychiatric care needs in geriatric and disadvantaged youth populations can help highlight key considerations for health care organizations in an increasingly electronic health care landscape.

Telepsychiatry in Low- and Middle-Income Countries During COVID-19: Pandemic, Barriers, and Road Model

ABSTRACT

To date, there is lack of specific effective treatment or vaccine for the SARS-CoV-2, and clinical and laboratory research is still ongoing to find successful drugs. Therefore, prevention to be infected through social distancing and isolation is the most effective way. However, all the other physical and mental illnesses continue to exist, if possible even more burdened by the emergency situation and social distancing. The COVID-19 pandemic, especially in many low- and middle-income countries, has caused a deeper gap in seeking psychiatric help. In this scenario, telepsychiatry could play a decisive role in implementing clinical care for frail patients and ensuring continuous mental care. Therefore, we felt the urge to write this article to express our hope that the old health care system at this time of crisis, as we know it, can offer the chance to implement pervasive care technologies that perfectly fit current psychiatric needs.

Realizing the Promise of Learning Organizations to Transform Mental Health Care: Telepsychiatry Care As an Exemplar

To address the global mental health crisis exacerbated by the COVID-19 pandemic, an urgent need has emerged to transform the accessibility, efficiency, and quality of mental health care. The next suite of efforts to transform mental health care must foster the implementation of "learning organizations," that is, organizations that continuously improve patient-centered care through ongoing data collection. The concept of learning organizations is highly regarded, but the key features of such organizations, particularly those providing mental health care, are less well defined. Using telepsychiatry care as an example, the authors of this Open Forum concretely describe the key building blocks for operationalizing a learning organization in mental health care to set a research agenda for services transformation.

Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review

Despite the increased morbidity and mortality associated with psychiatric illnesses, there remains a substantial level of inaccuracy of the initial psychiatric diagnoses given by nonpsychiatric physicians. This study examines the accuracy of initial psychiatric diagnoses by non-psychiatric physicians at the McGill University Health Center (MUHC).We conducted a retrospective chart review for all consultations requested from the consultation-liaison psychiatry service at MUHC. We included all the consultations from January 1, 2018, to December 30, 2018, and excluded patient data with established psychiatric diagnoses. In all requested consults, each diagnosis of a referring physician was compared with the final diagnosis given by the C-L psychiatry team. Conformity between the 2 was validated as accurate.Of the 980 referred inpatients, 875 were enrolled. Patients ranged in age and those older than 70 years constituted the largest group: 54.4% were male. For 467 patients (55.20%), the initial diagnostic impression given by the referring physicians agreed with the final diagnosis made by the C-L psychiatry team, while in 379 patients (44.80%), the initial diagnostic impression was not consistent with the final diagnosis made by the C-L team.Diagnostic impressions of neurocognitive and substance use disorders were highly accurate, but this was not the case when the referring physicians suspected depression or bipolar, personality, or psychotic disorders. This study shows that around half of the referrals were accurately diagnosed, which evinces that nonpsychiatric physicians' knowledge regarding psychiatric conditions is not optimal and that might negatively impact screening and treating these conditions.

Your Liberty or Your Gun? A Survey of Psychiatrist Understanding of Mental Health Prohibitors

This first-of-its-kind national survey of 485 psychiatrists in nine states and the District of Columbia (DC) finds substantial evidence of clinicians being uninformed, misinformed, and misinforming patients of their gun rights regarding involuntary commitments and voluntary inpatient admissions. A significant percentage of psychiatrists (36.9%) did not understand that an involuntary civil commitment triggered the loss of gun rights, and the majority of psychiatrists in states with prohibitors on voluntary admissions (57%) and emergency holds (56%) were unaware that patients would lose gun rights upon voluntary admission or temporary commitment. Moreover, the survey found evidence that psychiatrists may use gun rights to negotiate "voluntary" commitments with patients: 15.9% of respondents reported telling patients they could preserve their gun rights by permitting themselves to be voluntarily admitted for treatment, in lieu of being involuntarily committed. The results raise questions of whether psychiatrists obtained full informed consent for voluntary patient admissions, and suggest that some medical providers in states with voluntary admission prohibitor laws may unwittingly deprive their patients of a constitutional right. The study calls into question the fairness of state prohibitor laws as policy, and - at minimum - indicates an urgent need for psychiatrist training on their state gun laws.

Association between mental disorders and somatic conditions: protocol for an umbrella review

INTRODUCTION

Although several systematic reviews (SRs)/meta-analyses (MAs) on the association between specific mental disorders and specific somatic conditions are available, an overarching evidence synthesis across mental disorders and somatic conditions is currently lacking. We will conduct an umbrella review of SRs/MAs to test: 1) the strength of the association between individual mental disorders and individual somatic conditions in children/adolescents and adults; 2) to which extent associations are specific to individual mental and somatic conditions .

METHODS AND ANALYSIS

We will search a broad set of electronic databases and contact study authors. We will include SRs with MA or SRs reporting the effect size from individual studies on the association between a number of somatic and mental conditions (as per the International Classification of Diseases, 11th Revision). We will follow an algorithm to select only one SR or MA when more than one are available on the same association. We will rate the quality of included SRs/MAs using the AMSTAR-2 tool. We will assess to which extent mental disorders are selectively associated with specific somatic conditions or if there are transdiagnostic, across-spectra or diagnostic spectrum-specific associations between mental disorders and somatic conditions based on the Transparent, Reporting, Appraising, Numerating, Showing (TRANSD) recommendations.

DISCUSSION

The present umbrella review will shed light on the association between mental health disorders and somatic conditions, providing useful data for the care of patients with mental health disorders, in particular for early detection and intervention. This work might also add insight to the pathophysiology of mental health conditions, and contribute to the current debate on the value of a transdiagnostic approach in psychiatry.

Psychosocial impact of COVID-19

BACKGROUND

Along with its high infectivity and fatality rates, the 2019 Corona Virus Disease (COVID-19) has caused universal psychosocial impact by causing mass hysteria, economic burden and financial losses. Mass fear of COVID-19, termed as "coronaphobia", has generated a plethora of psychiatric manifestations across the different strata of the society. So, this review has been undertaken to define psychosocial impact of COVID-19.

METHODS

Pubmed and GoogleScholar are searched with the following key terms- "COVID-19", "SARS-CoV2", "Pandemic", "Psychology", "Psychosocial", "Psychitry", "marginalized", "telemedicine", "mental health", "quarantine", "infodemic", "social media" and" "internet". Few news paper reports related to COVID-19 and psychosocial impacts have also been added as per context.

RESULTS

Disease itself multiplied by forced quarantine to combat COVID-19 applied by nationwide lockdowns can produce acute panic, anxiety, obsessive behaviors, hoarding, paranoia, and depression, and post-traumatic stress disorder (PTSD) in the long run. These have been fueled by an "infodemic" spread via different platforms of social media. Outbursts of racism, stigmatization, and xenophobia against particular communities are also being widely reported. Nevertheless, frontline healthcare workers are at higher-risk of contracting the disease as well as experiencing adverse psychological outcomes in form of burnout, anxiety, fear of transmitting infection, feeling of incompatibility, depression, increased substance-dependence, and PTSD. Community-based mitigation programs to combat COVID-19 will disrupt children's usual lifestyle and may cause florid mental distress. The psychosocial aspects of older people, their caregivers, psychiatric patients and marginalized communities are affected by this pandemic in different ways and need special attention.

CONCLUSION

For better dealing with these psychosocial issues of different strata of the society, psychosocial crisis prevention and intervention models should be urgently developed by the government, health care personnel and other stakeholders. Apt application of internet services, technology and social media to curb both pandemic and infodemic needs to be instigated. Psychosocial preparedness by setting up mental organizations specific for future pandemics is certainly necessary.

Misconceptions About Working in Correctional Psychiatry

Incarcerated individuals have high rates of mental disorders and substance use disorders compared with the general population, yet correctional facilities in the United States have difficulty recruiting mental health professionals. This has led to shortages in the availability of clinicians who can provide psychiatric care in these settings. During training and in practice, mental health professionals may develop misconceptions about correctional psychiatry that deter them from the field. This article examines common misconceptions about working in correctional psychiatry, including that correctional psychiatry provides unnecessary care to criminals, supports mass incarceration, is dangerous work, represents a less respectable subspecialty, and excludes clinicians from teaching and research opportunities. This article seeks to provide a resource for mental health professionals considering working with incarcerated patients.

Significant difference in knowledge between English and Danish psychiatrists

Purpose

The purpose of the study was to investigate if differences in levels of knowledge existed between Danish and English training and specialist psychiatrists. This is important in the context of the free (and growing) movement of the medical workforce across European Union (EU) countries’ borders.

Methods

A complete balanced two-way factorial study design was used. Ten training and ten specialist psychiatrists were recruited in each country from reputable, university hospitals. They answered 50 multiple choice questions (MCQs), translated into the appropriate language, consisting of four subcategories of questions: psychology (15 MCQs), psychopharmacology (10 MCQs), neuroscience (five MCQs) and psychopathology (20 MCQs). No memory or other types of aids were allowed at the knowledge test. A two-way analysis of variance was used to analyse the total knowledge score (number of correct answers) and the component subscores. Levene’s test of equality of error variances was used to test for variance homogeneity.

Results

There were significant differences in total knowledge and psychology knowledge by country and level of training. UK doctors scored 3.10 points higher than Danish doctors, with 95% confidence interval (0.97, 5.23). The knowledge of the specialists was also significantly superior to that of the training psychiatrists, with 2.30 higher score, 95% confidence interval (0.17, 4.43). In the sub-categories only the scores in the psychology section were significantly different. UK doctors scored 2.30 higher than Danish doctors, with 95% confidence interval (1.15, 3.45). Specialists scored 1.20 higher than non-specialists with 95% confidence interval (0.05, 2.35).

Conclusions

The results indicate that there is a significant difference in level of knowledge between psychiatrists in these two EU-countries, England and Denmark. This difference seemed to be chiefly the result of different knowledge of psychology. The disparity could be a result of the fundamentally different post-graduate training system in psychiatry in the two countries. Surprisingly, the differences in total knowledge and psychology knowledge between countries were larger than the differences between levels of training. The difference in knowledge is worrying taking into consideration that there is free movement of the workforce, including doctors, across the EU. The results here need further confirmation in future studies with greater numbers, more countries involved and perhaps additional measurements to MCQs.

Acne vulgaris and risk of depression and anxiety: A meta-analytic review

BACKGROUND

Several studies have shown an association of acne vulgaris with depression and anxiety, but a quantitative review has not yet been conducted.

OBJECTIVE

We sought to conduct a systematic review and meta-analysis that elucidates the association of acne vulgaris with depression and anxiety.

METHODS

A systematic review and meta-analysis of literature published before October 1, 2019 from the PubMed, PsycINFO, MEDLINE, and Cochrane databases was conducted. We used a metaanalytic approach to perform a random effects analysis comparing individuals with and without acne. Subgroup analyses between studies included age, study setting, and geographic region.

RESULTS

Forty-two studies were included. We found a significant association of acne vulgaris with depression (r = 0.22 [95% confidence interval 0.17-0.26, P < .00001]) and anxiety (r = 0.25 [95% confidence interval 0.19-0.31, P < .00001]). Subgroup analyses and comparisons showed moderating influences based on factors including age, study setting, and geographic region.

LIMITATIONS

Inconsistency between publications regarding acne and outcome ascertainment, data reporting, and studies with no control group posed considerable barriers to synthesizing all available published literature.

CONCLUSIONS

Because of an increased risk for depression and anxiety, clinicians should pursue aggressive treatment of acne and consider psychiatric screening or referrals.

Physical Examination Skills Among Chief Residents in Psychiatry: Practices, Attitudes, and Self-Perceived Knowledge

OBJECTIVES

The authors investigated the attitudes, self-perceived competence, and the need for a dedicated curriculum on physical examination skills among chief residents in psychiatry.

METHODS

A voluntary 28-item web-based questionnaire was distributed to psychiatry chief residents in the USA between January 2019 and February 2019.

RESULTS

Of 181 chief residents, 79 (response rate, 44%) completed the online survey. The majority of chief residents want to improve their physical exam skills (64%) and believe that there should be a targeted curriculum aimed at incorporating these skills into everyday psychiatric practice (63%). However, most (57%) chief residents reported that they only conduct physical exams on a few selected patients (< 25% of the time) and almost half (48%) last used a stethoscope a year ago, if not longer. Self-perceived competence and comfort level with neurology-related exam findings was especially low: only 35% could identify discrepant neurological findings and 33% elicit Hoover's sign of leg paresis. A significant majority (86%) believed that performing a physical exam would not interfere with the therapeutic relationship.

CONCLUSIONS

Although chief residents in psychiatry believe that developing competence in physical examinations is important to their education, the current educational landscape does not support the development of these skills. Future educational strategies should focus on addressing this need.

Mendelian randomisation for nutritional psychiatry

Nutritional psychiatry is a growing area of research, with several nutritional factors implicated in the cause of psychiatric ill-health. However, nutritional research is highly complex, with multiple potential factors involved, highly confounded exposures and small effect sizes for individual nutrients. This Personal View considers whether Mendelian randomisation provides a solution to these difficulties, by investigating causality in a low-risk and low-cost way. We reviewed studies using Mendelian randomisation in nutritional psychiatry, along with the potential opportunities and challenges of using this approach for investigating the causal effects of nutritional exposures. Several studies have identified nutritional exposures that are potentially causal by using Mendelian randomisation in psychiatry, offering opportunities for further mechanistic research, intervention development, and replication. The use of Mendelian randomisation as a foundation for intervention development facilitates the best use of resources in an emerging discipline in which opportunities are rich, but resources are often poor.

Competing Professional Knowledge Claims About Mental Capacity in the Court of Protection

This article analyses the role of evidence in resolving Court of Protection proceedings, drawing on qualitative data obtained from observations of the Court of Protection, a review of Court of Protection case files and interviews with social workers. It is argued that there is a hierarchy of professional evidence in mental capacity law. Psychiatric evidence is at the top of this hierarchy, whereas social work evidence is viewed as a less persuasive form of knowledge about mental capacity. The article argues that this is because mental capacity law views psychiatric evidence as a form of objective and technical expertise about capacity, whereas social work evidence is viewed as a form of subjective, experiential knowledge. In challenging this hierarchy, it is instead argued that mental capacity law should place greater weight on experiential knowledge emanating from a relationship with the subject of the proceedings, rather than elevating the status of psychiatric evidence about mental capacity.

[Not Available]

INTRODUCTION

Therapeutic relationship in forensic psychiatry is believed to be affected by the coercive setting and the role conflict of the therapists as both treaters and court-appointed experts. The aim of the study was to examine and compare the therapeutic relationship in forensic and general psychiatric settings.

MATERIAL AND METHODS

52 forensic patients and 66 general psychiatric patients filled in the Psychopathy Personality Inventory - Revised (PPI-R), the Inventory of Interpersonal Problems - German Version (IIP-D), the Questionnaire on Motivation for Psychotherapy (Fragebogen zur Erfassung der Psychotherapiemotivation (FPTM)) as well as the Working Alliance Inventory - Short Revised (WAI-SR). We applied descriptive analyses, calculated univariate t-tests as well as multivariate T-tests and performed general linear models.

RESULTS

The quality of the therapeutic alliance does not differ significantly between forensic and general psychiatric patients. Moreover, patients of forensic psychiatry consider therapeutic techniques applied by their therapists as more valuable for achieving their therapeutic aims than patients of the general psychiatry.

DISCUSSION

The therapeutic relationship in forensic psychiatry is as viable as in general psychiatry. This can be regarded as a result of the long-term therapy in the context of forensic psychiatry which allows more time to be spent on relationship building than in a general psychiatry setting where therapy is limited to a few weeks.

A new conception and subsequent taxonomy of clinical psychological problems

BACKGROUND

A taxonomy of the objects of study, theory, assessment, and intervention is critical to the development of all clinical sciences. Clinical psychology has been conceptually and administratively dominated by the taxonomy of an adjacent discipline - psychiatry's Diagnostic and statistical manual of mental disorders (DSM). Many have called for a 'paradigm shift' away from a medical nosology of diseases toward clinical psychology's own taxonomy of clinical psychological problems (CPPs), without being able to specify what is to be listed and classified.

MAIN TEXT

An examination of DSM's problems for clinical psychology, especially its lack of clinical utility, and a search for the essence of CPPs in what clinical psychologists actually do, leads to the proposal that: The critical psychological-level phenomenon underlying CPPs is the occurrence of 'problem-maintaining circles' (PMCs) of causally related cognitions, emotions, behaviours, and/or stimuli. This concept provides an empirically-derived, theory-based, treatment-relevant, categorical, essentialist, parsimonious, and nonstigmatizing definition of CPPs. It distinguishes psychological problems in which PMCs have not (yet?) formed, and which may respond to 'counseling', clinical psychological problems in which active PMCs require clinical intervention, and psychopathological problems which are unlikely to be 'cured' by PMC-breaking alone.

CONCLUSION

A subsequent classification and coding system of PMCs is proposed, and expected benefits to research, communication, and the quality of case formulation in clinical psychology are described, reliant upon a development effort of some meaningful fraction of that which has been devoted to the DSM.

[Open-door psychiatry and community mental health work]

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

[Empirical investigation to assess the quality of psychiatric treatment]

BACKGROUND

Quality of treatment is of increasing importance in psychiatry. Since the 1950s psychiatry has developed plenty of psychological and occupational approaches in addition to an arsenal of biological procedures. These treatment options have contributed to markedly lower the residence times in psychiatric medical centers to about 3 or 4 weeks.

METHOD

The quality of treatment of a psychiatric clinic was evaluated on the basis of a limited number of parameters and in a short time. The data of 657 patients were evaluated.

RESULTS

The patients profited significantly from the treatment, particularly when specific therapies were available as in depression or schizophrenia. About ¼ of the patients received no psychoactive drugs. Most of the patients could be discharged from hospital within 3 weeks. The legal basis of hospitalization did not play a decisive role in the success of treatment. Most of the patients were after-treated by general practitioners.

CONCLUSION

The result underlines the effectiveness of psychiatric treatment, but also the importance of cooperation between inpatient and outpatient treatment.

[Psychiatric textbooks from National Socialism and the censorial practice in the Soviet Occupation Zone and early GDR]

The Allied Forces policy of denazification and demilitarization during the early post-war period has had a lasting impact on medical disciplinary cultures in all occupation zones of Germany. By means of various control procedures, the conceptuality and linguistic design, the style and normative horizon of medical literature were reconstituted. This article examines this change using the example of psychiatry and neurology in the Soviet Occupation Zone. It deals with the neurological psychiatric textbook as a central medium of disciplinary communication and reconstructs how the knowledge in this field was processed and prepared in complex negotiation processes between authors, publishers and censors. The focus is on institutionalized filters of limited production of discourses and thus the archival holdings of censorship authorities, which have not yet been evaluated. The evaluation results are presented here with a focus on psychiatry and neurology and illustrated with selected case studies.

Teaching psychiatry to large groups in society

BACKGROUND

There is a need to educate a range of professionals in caring for individuals with long-term mental disability who reside within our communities. Empathy alone is insufficient. The Kognus 4-Step Education Program was developed to achieve this goal.

METHOD

The program consisted of independent courses, including an 18-session basic course on psychiatric disability (on-site or online), advanced courses, and highly specialized training programs (Nidotherapy/Peer Consultation). Experts lectured together with clients with psychiatric disabilities. We first report Swedish reforms in which institutionalized patients were relocated to semi-independent individual households. We then describe the design and implementation of the education program. Approximately 50% of participants who were younger than 36 years old lacked any healthcare education. The participants' backgrounds, perceptions, participation in the education program, and costs are presented.

RESULTS

Between 2009 and 2014, 8959 participants attended the Kognus psychiatry courses online or on-site in Stockholm (basic on-site course, n = 2111; online course, n = 4480; advanced courses, n = 2322; highly specialized programs, n = 46). A total of 73% of the participants satisfactorily attended the basic sessions on-site compared with 11% of the online participants. The developers conducted the education program for the first 3 years. Thereafter, another course provider continued the program with other types of participants. The program was perceived to be equally interesting and meaningful to participants with low and high levels of education, demonstrating the generalizability of the program. The quality of the basic and advanced courses was rated as 4.4 and 4.3, respectively, on a 5-point Likert scale.

CONCLUSIONS

Personnel without appropriate education who work with people with psychiatric/intellectual disabilities can be educated in large numbers. The Kognus program represents a novel and successful way of training people who have no formal education about some essentials of good mental healthcare. Moreover, the model can be easily implemented elsewhere.

Objectivity in science and law: A shared rescue strategy

The ideal of objectivity is in crisis in science and the law, and yet it continues to do important work in both practices. This article describes that crisis and develops a shared rescue strategy for objectivity in both domains. In a recent article, Inkeri Koskinen (2018) attempts to bring unity to the fragmented discourse on objectivity in the philosophy of science with a risk account of objectivity. To put it simply, she argues that we call practitioners, processes, and products of science objective when they identify and manage certain important epistemic risks. We endorse this view and attempt to tailor Koskinen's strategy to the problem of objectivity in the legal context. To do so, we develop a novel notion of phronetic risk, and argue that we call practitioners, processes, and products of law objective when they identify and manage certain important epistemic and/or phronetic risks. Our attempt to rescue objectivity is especially important for work at the intersection of law and psychiatry. For that intersection represents a place where skeptical worries about objectivity in science and law work in tandem to pose serious critical challenges to contemporary practice; and our rescue strategy represents a promising way to negotiate those challenges.

Healthcare curriculum influences on stigma towards mental illness: Core psychiatry course impact on pharmacy, nursing and social work student attitudes

BACKGROUND AND PURPOSE

Attitudes towards disclosure of a psychiatric diagnosis and directed at persons with mental illness have represented negativity and stigma. The purpose of this study was to identify stigma towards mental illness among health profession students in pharmacy, nursing, and social work programs, and identify if primary psychiatric coursework in each curriculum has an impact on students' perceptions.

EDUCATIONAL ACTIVITY AND SETTING

Pharmacy, nursing and social work students were surveyed pre- and post-primary didactic psychiatry coursework (pre-course = 154 total; 95 pharmacy, 47 nursing, 12 social work; post-course = 128 total; 79 pharmacy, 38 nursing, and 11 social work) using the Opening Minds Scale for Health Care Providers (OMS-HC). The OMS-HC contains 12-questions evaluated on a five-point Likert scale ranging from 12 to 60 points, with lower scores indicating less stigma towards mental illness. Student results were compared to the large sample of healthcare student and provider responses used in validating the OMS-HC survey tool.

FINDINGS

Students' pre-course mean score on the OMS-HC was 30.6 ± 5.47 (pharmacy = 30.9, nursing = 31, social work = 26.3) and post-course mean score was 31.05 ± 6.82 (pharmacy = 32.24, nursing = 29.89, social work = 26.55). These scores illustrate negative stigma among students and also are similar to existing research identifying a disparity among the healthcare professions. Coursework did not appear to improve stigma toward mental illness.

SUMMARY

The current education of healthcare providers does not appear to change students' stigma, suggesting educational gaps requiring attention.

Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental)

BACKGROUND

Recommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking.

METHOD

The French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments.

RESULTS

The expert guidelines combine scientific evidence and expert clinician's opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression.

CONCLUSION

These guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

[Should the psychiatrist of the future become a multi-specialist or a super-specialist?]

The subject of psychiatry is not easy to define and is characterised by considerable complexity of dysfunctional human behaviour. What does this mean for the training of psychiatrists? Is further differentiation with a strong specialisation from the start of the training process the only option to develop the discipline?<br/> AIM: To formulate a strategic direction for the future training of psychiatrists in the Netherlands and Belgium.<br/> METHOD: Personal reflection by two senior psychiatrists from the Netherlands and Belgium.<br/> RESULTS: The profile of the psychiatrist of the future is that of a multi-specialist. It is desirable to keep the training programme broad and to develop sufficient competencies for young colleagues to enjoy throughout their careers: in addition to the clinical competencies in diagnostics and treatment, it concerns cooperation, communication, leadership (organisation), and professionalism. Psychotherapeutic skills are essential. Specialisation after the formal education is almost inevitable. Of the current focus areas (geriatric psychiatry, child and adolescent psychiatry and adult psychiatry), especially adult psychiatry should be further differentiated. The professional associations should facilitate the transfer from one sub-area to another sub-area without extensive administrative work. The enthusiasm of medical students for psychiatry should be actively stimulated, based on a new professional profile.<br/> CONCLUSION: Throughout the entire program (4 years in the Netherlands, 5 years in Belgium) learning general competencies (truncus communis) must be advocated. These competencies must form the basis for a deepening or specialisation after the training. This should ensure that psychiatrists can move relatively smoothly from one sub-area to another. The psychiatrist as a multi-specialist.

[Heterogeneity in psychiatry training in Europe: competition or collaboration?]

The European Union strives towards a mutual recognition of qualifications for medical specialists. Already in 1993, the European Union of Medical Specialists drafted non-binding quality criteria for every medical specialty. In psychiatry, however, European standardisation and quality control of the different national training programmes is currently still lacking.<br/> AIM: To describe the heterogeneity of psychiatric postgraduate training in Europe and its ensuing challenges.<br/> METHOD: We used the scientific literature and results from surveys conducted with European trainees between 2016 and 2018. <br/> RESULTS: Psychiatric training differed throughout Europe in terms of format, content and working conditions. The minimum duration of training in the European Union ranged from 4 to 7 years. Regarding content, the position of psychotherapy differed significantly between countries. Finally, the differences in subjective learning experiences were influenced by organisational variables, such as working hours and availability of supervision.<br/> CONCLUSION: Despite all efforts to harmonise psychiatry training in Europe, in practice there has been little progress towards this goal. Nevertheless, information on the differences in training variables between countries has become more readily available, and trainees may use this knowledge to actively shape their own education.

[The care standard 'Depressive disorders']

The care standard 'Depressive disorders' describes the complete patient journey for patients with depressive symptoms and disorders from the age of 8 years onwards.<br/> AIM: To describe the most important recommendations in this care standard.<br/> METHOD: The care standard is an adaptation of the existing guidelines for depression, supplemented with practical knowledge from professionals and patients' values and preferences.<br/> RESULTS: Core elements in the care for depression are an appropriate use of care and a focus on relapse prevention. A combination of psychotherapy and medication is indicated for persistent depression and more sessions of psychotherapy might be required. There is some evidence for the use of repetitive transcranial magnetic stimulation in treatment-resistant depression.<br/> CONCLUSION: The care standard is an important instrument to improve the quality of care for depression at both the organisational and the regional level.

[Potential of participatory action research for clients, professionals and researchers in mental healthcare]

In participatory action research (par), researchers, practitioners and the community engage in a research process together. This research approach has the potential to assist in bridging the research-practice gap by starting from practice needs and using joint expertise and experiences to enrich scientific knowledge, optimise clinical practice and empower stakeholders from different backgrounds.<br/> AIM: To discuss the potential benefits of par for clients, professionals and researchers in the field of mental healthcare.<br/> METHOD: Starting from the literature on par, fundamental characteristics and benefits of this research approach in the field of mental healthcare are described and illustrated with an example from practice.<br/> RESULTS: par in mental healthcare can contribute to enriching prepositional and practical knowledge, facilitate positive social change in care delivery, empower all stakeholders, and ultimately make a significant contribution to the integration of research and practice.<br/> CONCLUSION: par is valuable for clients, professionals and researchers in a variety of projects in mental healthcare.

[From treatment-resistant epilepsy to psychosis: Literature review and case report]

The authors present a case in which they describe the challenges posed by the diagnosis of epileptic patients who suffer a psychotic episode. They also give a detailed account of current practice guidelines in French psychiatry, as well as a discussion regarding the art of everyday clinical practice.

Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS): guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings

The Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS) for Inpatient Care guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings are available in full at: www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. This article summarizes the guidelines and recommendations. Commissioners are urged to ensure that the needs of people with diabetes and severe mental illness are specifically addressed in contracts with providers of inpatient care, and to avoid financial or other barriers to cross-organizational working and to ensure that patient-structured education is commissioned to meets the complex needs of people with diabetes and severe mental illness. Acute trusts are asked to develop joint pathways with mental health providers and facilitate multidisciplinary working and to screen for mental ill health in those admitted with acute complications of diabetes whose aetiology is unclear or not medically explained. Mental health trusts should create a diabetes register, screen for diabetes, particularly in those prescribed second-generation antipsychotics and ensure that staff are trained in managing and avoiding hypoglycaemia, and the safe use of insulin. Finally, clinical teams should ensure that all staff can access training in diabetes and mental health to support them to care for people with both diabetes and severe mental illness, develop local pathways for joint working and ensure best practice tariff criteria are met for diabetic ketoacidosis and hypoglycaemia, and for children and young people with diabetes.

The Psychiatry Major: A Curricular Innovation to Improve Undergraduate Psychiatry Education in China

OBJECTIVE

In China, a psychiatry major curriculum (PMC) has been implemented in select medical schools to improve the quality of undergraduate psychiatry education (UPE). Our aim was to describe this PMC and compare it with UPE in the standard Chinese clinical medicine curriculum (CMC). We also benchmarked PMC to UPE programs in the Hong Kong Special Administrative Region of China and the United States of America (USA) to determine how well it met standards of well-established programs and to highlight areas for improvement.

METHODS

Based on archival information, relevant literature, and communication with key informants, we described PMC and CMC in a Chinese school with both curriculums. We then compared PMC to UPE curriculums in Hong Kong and the USA.

RESULTS

PMC provides substantially more comprehensive exposure to psychiatry than CMC, with more preclinical experiences and psychiatry clerkship course hours, greater diversity of clinical sites, and exploration of subspecialties. PMC employs a variety of teaching methods and offers mentoring for students. PMC has similar UPE preclinical content and course hours as programs in Hong Kong and the USA. PMC also provides more clinical exposure than programs in Hong Kong or the USA, although there is less variety in clinical settings.

CONCLUSION

We recommend implementation of concrete measures to improve UPE in Chinese medical schools, using the PMC curriculum as a model that has been successfully implemented in China. We also recommend improvements to PMC based on comparisons with existing programs outside Mainland China.

International Medical Graduates in Psychiatry: Cultural Issues in Training and Continuing Professional Development

A position paper developed by the Canadian Psychiatric Association's Education Committee and approved by the CPA's Board of Directors on August 15, 2016.

The limitations of using randomised controlled trials as a basis for developing treatment guidelines

Randomised controlled trials (RCTs) are considered the 'gold standard' by which novel psychotropic medications and psychological interventions are evaluated and consequently adopted into widespread clinical practice. However, there are some limitations to using RCTs as the basis for developing treatment guidelines. While RCTs allow researchers to determine whether a given medication or intervention is effective in a specific patient sample, for practicing clinicians it is more important to know whether it will work for their particular patient in their particular setting. This information cannot be garnered from an RCT. These inherent limitations are exacerbated by biases in design, recruitment, sample populations and data analysis that are inevitable in real-world studies. While trial registration and CONSORT have been implemented to correct and improve these issues, it is worrying that many trials fail to achieve such standards and yet their findings are used to inform clinical decision making. This perspective piece questions the assumptions of RCTs and highlights the widespread distortion of findings that currently undermine the credibility of this powerful design. It is recommended that the clinical guidelines include advice as to what should be considered good and relevant evidence and that external bodies continue to monitor RCTs to ensure that the outcomes published indeed reflect reality.