bluuebunny/crossref_metadata_2025 huggingface dataset:
Neuroprotection by Selective Nitric Oxide Synthase Inhibition at 24 Hours After Perinatal Hypoxia-Ischemia
Authors: Peeters-Scholte Cacha , Koster Johanna , Veldhuis Wouter , van den Tweel Evelyn , Zhu Changlian , Kops Nicole , Blomgren Klas , Bär Dop , van Buul-Offers Sylvia , Hagberg Hendrik , Nicolay Klaas , van Bel Frank , Groenendaal Floris
Published: September 2002

Background and Purpose—

Perinatal hypoxia-ischemia is a major cause of neonatal morbidity and mortality. Until now no established neuroprotective intervention after perinatal hypoxia-ischemia has been available. The delay in cell death after perinatal hypoxia-ischemia creates possibilities for therapeutic intervention after the initial insult. Excessive nitric oxide and reactive oxygen species generated on hypoxia-ischemia and reperfusion play a key role in the neurotoxic cascade. The present study examines the neuroprotective properties of neuronal and inducible but not endothelial nitric oxide synthase inhibition by 2-iminobiotin in a piglet model of perinatal hypoxia-ischemia.

Methods—

Twenty-three newborn piglets were subjected to 60 minutes of hypoxia-ischemia, followed by 24 hours of reperfusion and reoxygenation. Five additional piglets served as sham-operated controls. On reperfusion, piglets were randomly treated with either vehicle (n=12) or 2-iminobiotin (n=11). At 24 hours after hypoxia-ischemia, the cerebral energy state, presence of vasogenic edema, amount of apparently normal neuronal cells, caspase-3 activity, amount of terminal deoxynucleotidyl transferase-mediated dUTP-biotin in situ nick end labeling (TUNEL)-positive cells, and degree of tyrosine nitration were assessed.

Results—

A 90% improvement in cerebral energy state, 90% reduction in vasogenic edema, and 60% to 80% reduction in apoptosis-related neuronal cell death were demonstrated in 2-iminobiotin-treated piglets at 24 hours after hypoxia- ischemia. A significant reduction in tyrosine nitration in the cerebral cortex was observed in 2-iminobiotin-treated piglets, indicating decreased formation of reactive nitrogen species.

Conclusions—

Simultaneous and selective inhibition of neuronal and inducible nitric oxide synthase by 2-iminobiotin is a promising strategy for neuroprotection after perinatal hypoxia-ischemia.
Stigma
Authors: Smith Michael
Published: August 2002

‘Medicine is a social science, and politics nothing but medicine on a grand scale.’ (Rudolph Virchov, 1848, quoted in Link & Phelan, 1996)

Discrimination and prejudice against people with mental illnesses is ubiquitous, pernicious and wrong. The overwhelming case against such stigma has been recognised by initiatives from the UK government, the Royal College of Psychiatrists, the US Surgeon General, the World Psychiatric Association and many other organisations
The pragmatic randomised controlled trial
Authors: Hotopf Matthew
Published: August 2002

In recent years there has been much debate regarding the evaluation of treatments in medicine. The evidence-based medicine (EBM) movement has formed partly out of the realisation that clinical practice is often poorly informed by the best available evidence, and that many widely used treatments are either completely untested, or tested and proven to be ineffective or even harmful. EBM has been characterised as a stick by which policy-makers and academics beat clinicians (Williams & Garner, 2002). However, another side to EBM has been the realisation that research performed to test new treatments has often been of poor quality, or has asked the wrong questions (Hotopf et al, 1997; Thornley & Adams, 1998; Barbui & Hotopf, 2001). We have previously argued that clinicians could justifiably criticise the research establishment for failing to provide answers to relevant clinical problems of everyday practice (Hotopf et al, 1999).
Teaching learning disability to undergraduate medical students
Authors: Piachaud Jack
Published: August 2002

The education of doctors shapes their professional identity: who they are and how they practise. Where does the issue of learning disability fit in? What is it and of what factors should doctors in training be aware?
Simulated patients and objective structured clinical examinations: review of their use in medical education
Authors: Wallace Jeremy , Rao Ranga , Haslam Richard
Published: August 2002

Simulated or standardised patients have been used in medical education and other medical settings for some 30 years (Box 1). Their use encompasses undergraduate and postgraduate learning, the monitoring of doctors' performance and standardisation of clinical examinations. Simulation has been used for instruction in industry and the military for much longer (Jason et al, 1971) but the first known effective use of simulated patients was by Barrows & Abrahamson (1964), who used them to appraise students' performance in clinical neurology examinations.
Physical or mental? A perspective on chronic fatigue syndrome
Authors: Sykes Richard
Published: August 2002

This paper examines the question of whether chronic fatigue syndrome (CFS), often known as myalgic encephalomyelitis (ME), should be classified as a physical or mental illness.
Identifying and challenging unhelpful thinking
Authors: Williams Chris , Garland Anne
Published: August 2002

In the first two articles of this series (Williams & Garland, 2002; Wright et al, 2002), we looked at the different areas of human experience that alter during times of mental illness. The Five Areas Assessment model (Williams, 2001; see also Fig. 1 of Williams & Garland, 2002) provides a clear summary of the range of problems and difficulties faced by the individual in each of the following domains:

1

life situation, relationships, practical problems

2

altered thinking

3

altered emotions (moods or feelings)

4

altered physical feelings/symptoms

5

altered behaviour or activity levels.
Knowledge management
Authors: Sensky Tom
Published: August 2002

Knowledge management sounds superficially like yet another of those topical expressions describing something that has been developed outside medicine and is possibly ill-suited for application within the field, but offering an excuse for yet more change. However, one of the distinguishing features of every profession is that it applies a body of specialist knowledge and skills to a defined purpose. Knowledge in medicine is growing exponentially. In a recent survey of just 22 general practices, the practice guidelines identified weighed 28 kg (Hibbleet al, 1998)! In psychiatry, about 5500 papers which potentially have clinical relevance are published annually. Keeping pace with knowledge as it grows is a major challenge for all clinicians. This is reflected in the National Health Service (NHS) information strategy, which identifies three specific needs of clinicians (NHS Executive, 1998). These are:

•

fast, reliable and accurate information about patients in their care;

•

access to knowledge to inform clinical practice;

•

access to information to underpin evaluation of clinical practice, planning and research, clinical governance and continuing professional development.
Fatal and non-fatal repetition of self-harm
Authors: Owens David , Horrocks Judith , House Allan
Published: August 2002

Background

Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions.

Aims

To estimate rates of fatal and non-fatal repetition of self-harm.

Method

A systematic review of published follow-up data, from observational and experimental studies. Four electronic databases were searched and 90 studies met the inclusion criteria.

Results

Eighty per cent of studies found were undertaken in Europe, over one-third in the UK. Median proportions for repetition 1 year later were: 16% non-fatal and 2% fatal; after more than 9 years, around 7% of patients had died by suicide. The UK studies found particularly low rates of subsequent suicide.

Conclusions

After 1 year, non-fatal repetition rates are around 15%. The strong connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is hundreds of times higher than in the general population.
Beds, budgets and burdens: Learning disability expenditure v. workload across English health authorities
Authors: Forsyth Bunny , Winterbottom Paul
Published: August 2002

Background

Following the closure of asylums and widespread changes in the population distribution of people with learning disabilities, there has been little investigation of changing expenditure requirements of health authorities in England.

Aims

To compare expenditure on learning disability health services across England with the burden of services regionally, as estimated by numbers of people with learning disabilities.

Method

A national database was set up using data from the National Audit Commission and the Department of Health. The spend/burden ratio was calculated and correlation tests for likely causes of inequality were applied.

Results

There is widespread discrepancy from the median spend/burden ratio of £10 260 per person with learning disability. There is a positive correlation between ratios and levels of net exports of people funded by their local authority social services to reside ‘out of area’. Comparative underspending occurs in rural areas.

Conclusions

There are inequalities in levels of spending on learning disability services. Comparison of regions suggests resources may not be allocated fairly. Health authorities should ensure that population increases are mirrored by appropriate adjustments in expenditure.
Duration of major depressive episodes in the general population: Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)
Authors: Spijker Jan , De Graaf Ron , Bijl Rob V , Beekman Aartjan T. F. , Ormel Johan , Nolen Willem A.
Published: August 2002

Background

Data on the duration of major depressive episodes (MDE) in the general population are sparse.

Aims

To assess the duration of MDE and its clinical and socio-demographic determinants in a study group drawn from the general population with newly originated episodes of major depression.

Method

The Netherlands Mental Health Survey and Incidence Study is a prospective epidemiological survey in the adult population (n=7076), using the Composite International Diagnostic Interview. Duration of MDE over 2 years was assessed with a Life Chart Interview.

Results

The median duration of MDE was 3.0 months; 50% of participants recovered within 3 months, 63% within 6 months, 76% within 12 months and nearly 20% had not recovered at 24 months. Determinants of persistence were severity of depression and comorbid dysthymia. A recurrent episode predicted shorter duration.

Conclusions

Although half of those affected with MDE recovered rapidly, the risk of chronicity (duration 24months or more) was considerable. This underlines the necessity of diagnosing and treating those at risk.
Residential care in Italy
Authors: De Girolamo G. , Picardi A. , Micciolo R. , Falloon I. , Fioritti A. , Morosini P.
Published: August 2002

Background

In Italy, where all mental hospitals have been gradually phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (NHRFs). However, detailed data on these facilities are sparse.

Aims

The Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs.

Method

Structured interviews were conducted with the manager of each NHRF.

Results

On 31 May 2000 there were 1370 NHRFs with 17138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time worker.

Conclusions

There is marked variability in the provision of residential places between different regions; discharge rates are generally low.
Self-help for bulimic disorders: A randomised controlled trial comparing minimal guidance with face-to-face or telephone guidance
Authors: Palmer Robert L. , Birchall Helen , Mcgrain Lesley , Sullivan Victoria
Published: August 2002

Background

There is great potential demand for treatment of bulimia nervosa and binge eating disorder. Skilled therapists are in short supply. Self-help and guided self-help based upon books have shown some promise as an economical alternative to full therapy in some cases.

Aims

To investigate the efficacy and effectiveness of self-help with and without guidance in a specialist secondary service.

Method

A randomised controlled trial comparing three forms of self-help over 4 months with a waiting-list comparison group and measurement of service consumption over the subsequent 8 months.

Results

Self-help delivered with four sessions of face-to-face guidance led to improved outcome over 4 months. There is also some evidence to support the use of telephone guidance. A minority of participants achieved lasting remission of their disorder in relation to self-help, but there was no significant difference in final outcome between the groups after they had progressed through the stepped care programme. Patients initially offered guided self-help had a lower long-term drop-out rate.

Conclusions

Guided self-help is a worthwhile initial response to bulimia nervosa and binge eating disorder. It is a treatment that could be delivered in primary care and in other non-specialist settings.
2020 Vision
Authors: Needham-Bennett Humphrey
Published: September 2002

I've been in psychiatry now for around 20 years – since the millennium in fact. I was just finishing my specialist registrar training in 2001, as the Dome was being finished off.

Things were really bad back then. I remember we had people with schizophrenia living in the community. I mean — how naive can you get. There was a reason the asylums were built in the first place. There was a run of murders, people with schizophrenia killing innocent members of the public, the same public that had been selflessly trying to help them integrate back into the community, giving them jobs and self-respect.
Learning disabilities services: primary care or mental health trust?
Authors: O'Hara Jean
Published: September 2002

In the next few months the London Region is expected to publish its strategy for learning disability services in the capital. This will inform the National Service Framework due in the autumn. At the same time, many trusts and health authorities are at various stages of reorganisation and reconfiguration. With the dawning of primary care trusts, single speciality mental health trusts and joint commissioning between health and social services, the debate over where learning disability services are best placed and their interface with mental health services has re-emerged (Barron et al, 2000).
Complaints about care in a mental health trust
Authors: Pitarka-Carcani Iris , Szmukler George , Henderson Claire
Published: September 2002

Aims and Method

A retrospective review of a random sample of written complaints made by, or on behalf of, users of psychiatric services to determine: (a) the number and nature of written complaints against clinical aspects of services in a mental health trust over a 1-year period; and (b) what information complaints provide about deficiencies in the quality of care.

Results

Out of 325 recorded complaints in 1997, 192 concerned clinical aspects of services; 89% of complainants complained once. There was a roughly equal split between complaints about technicalv. interpersonal aspects of care. Complaints were far higher from in-patient than from out-patient settings. Evidence that the complaints related to psychotic symptoms was rare. All complaints were resolved locally, but 28 responses by the team were judged unsatisfactory. In 39 cases further action was taken as a result of the complaint, but no disciplinary action was taken against medical staff.

Clinical Implications

Poor communication is likely to be at the root of many complaints. Room for improvement was found with respect to responses to complaints.
The Care Programme Approach and risk assessment of borderline personality disorder
Authors: Whewell Peter , Bonanno Daria
Published: September 2002

Aims and Methods

This paper describes the validation of self-report of risk by patients with borderline personality disorder (BPD) as compared with the judgement of experienced psychotherapists in regular contact with them. The aim was to validate the Clinical Outcomes in Routine Evaluation System (CORE) self-report in order to be able to use it to monitor risk change for patients with BPD in psychotherapy and general psychiatric settings.

Results

There was significant separation correlation between CORE risk sub-scales for self-harm, suicide and risk to others and therapists' estimation of significant risk v. no significant risk.

Clinical Implications

Using the cut-offs described, we suggest that the CORE questionnaire risk sub-scales can be used to assess significant risk for patients with BPD in psychotherapy, and in psychiatric and community health teams. The sub-scales should also prove valuable in allocating Care Programme Approach status.
Psychiatry in Slovenia
Authors: Marušic Andrej , Brecelj Marija
Published: September 2002

Although considerable changes have taken place in Slovenia since it became independent in 1991, the psychiatric services face further challenges for their future. Among these, the two main priorities are a further development of the already proposed Patients Advocacy Act and Protection of Rights of Mental Patients Law, and a development of presently almost non-existent community psychiatric services (World Health Organization, Regional Office for Europe, 1999). The developing services should become needs-oriented as Slovenia is a country with extremely high suicide rate and has high rates of alcohol misuse and alcohol-related disorders, with both problems interacting significantly throughout the country.
Management: everything I wanted to know, but was too afraid to ask …
Authors: Denny Roger
Published: September 2002

This article explores some basic questions about management and reveals that psychiatrists may already have a head start in management. The aim is not to make good psychiatrists into managers, but to enable good psychiatrists to provide good mental health care.
Consultant learning groups in psychiatry
Authors: Spurrell Mark
Published: September 2002

There is growing emphasis on the importance of continuing professional development (CPD) for consultant psychiatrists and an increasing recognition of the need for peer support. In this context the Royal College of Psychiatrists has been developing policy around CPD; a policy document has been issued by The College Council (Royal College of Psychiatrists, 1994) and there are regular updates on this topic on the website (www.rcpsych.ac.uk). All consultants are to be expected to take part in CPD and currently the annual requirement is for 20 hours of ‘external’ CPD and 30 hours of ‘internal’ CPD. ‘External’ refers to didactic or workshop events that involve input from outside a clinician's locality; ‘internal’ refers to local activities, case conferences, journal clubs, etc. CPD follows a 5-year rolling cycle, supported by the journal Advances in Psychiatric Treatment, a recommended 2 hours per week personal study and the development of personal development plans. From the outset there appear to have been issues in engaging consultants in CPD (Morgan, 1998). The problems of establishing CPD extend beyond consultants ‘finding the time’.
Consultant psychiatrists' experiences of using supervised discharge Results of a national survey
Authors: Franklin Donna , Pinfold Vanessa , Bindman Jonathan , Thornicroft Graham
Published: September 2002

Aims and Method

Supervised discharge orders (SDOs) enable a degree of compulsion to be exerted over patients in the community. We aimed to establish the level of, and reasons for, their use and consultants' perceptions of their effectiveness. All mental health provider NHS trusts in England were surveyed, and a random sample cohort of cases was identified. Community responsible medical officers (CRMOs) were surveyed using a semi-structured questionnaire.

Results

We identified 596 cases subject to SDOs in 170 mental health provider trusts (100%) in England, involving 18% of consultant psychiatrists. Responses were obtained from the CRMOs of 185 patients (84%) from a sample of 221 cases. The SDO was described as helpful or very helpful in 77% of cases in which it had been in place for over 2 months. In 58% of cases the SDO was intended to improve medication compliance, and in 46% of these cases it was perceived to be effective in doing so.

Clinical Implications

SDOs are not widely used in England. However, for those patients who are made subject to supervised discharge, the order appears to be effective and may improve medication compliance, despite the absence of the legal power to enforce treatment.
Impact of counsellors in primary care on referrals to secondary mental health services
Authors: White Mel , Bijlani Natasha , Bale Rob , Burns Tom
Published: September 2002

Aims and Method

A questionnaire survey of all general practices in one health authority plus an assessment of a random sample of referrals were used to evaluate the impact of counsellors in primary care on referrals to mental health services.

Results

A total of 91.1% of practices responded to the survey. A counsellor was present in 20.3% of these practices. A random sample of 180 referrals to community mental health teams was reviewed. There was a significantly higher referral rate from practices that employed a counsellor (P = 0.003). There was no evidence of a difference in rates of caseness of referrals between practices that employed a counsellor and those that did not.

Clinical Implications

Practices employing counsellors had significantly higher referral rates to mental health services, with no difference in the level of caseness between the two groups of referrals.
Postcode prescribing in psychiatry
Authors: Purcell Helen , Lewis Shôn
Published: September 2002

Aims and Method

We aimed to examine variations in clozapine prescribing in all 12 NHS trusts with catchment area mental health services in one English county, over a 2-year period. We tested a series of hypotheses to explain the variation in prescribing of clozapine.

Results

A 34-fold variation between trusts in rates of clozapine provision was found after adjusting for measures of local population need. This variation did not change over the 2 years examined. It was not explained by differences in resource level.

Clinical Implications

The evidence base is strong for the effectiveness and likely cost-effectiveness of clozapine in severe schizophrenia. Our data indicate that variations in evidence-based clinical practice at the provider level led to the wide variation in clozapine prescribing.
The correspondence of Archibald Campbell Clark: a 19th-century physician superintendent
Authors: Yorston Graeme , Shetty Sharat
Published: September 2002

The mythology of 19th-century asylums portrays them as dark and inhuman gothic institutions. Historical research is beginning to shed new light onto this world, however, forcing us to re-examine long-held beliefs. Case note analyses have consistently shown high levels of psychiatric morbidity in the patients admitted to these institutions (Turner, 1992; Beveridge, 1995; Doody et al, 1996). Patients' letters have been examined and confirm high levels of florid psychopathology (Beveridge, 1997), they also reveal some aspects of the rich social and cultural life available to patients at the Royal Edinburgh Asylum. Such studies add to our understanding of the culture of mental hospitals described by Jones (1991).
Clinical governance
Authors: Gralton Ernest , James Adrian , Oxborrow Sue
Published: September 2002

Aims and Method

To describe the introduction of a clinical governance programme within a regional forensic psychiatric service.

Results

The established programme meets the objectives of clinical governance. It affords regular appraisal of model practice and dissemination of information among staff. It provides a forum for continuing professional development, assessment of users' views and input of its staff to service development.

Clinical Implications

A functional clinical governance programme is possible, and likely to produce considerable benefits, but requires substantial commitment from clinical, secretarial and managerial staff. To be sustainable in the long term it may require additional funding. It is still too early to seek to evaluate any long term changes produced in patient care by the process.
Patient or client? The opinions of people attending a psychiatric clinic
Authors: Ritchie C. W. , Hayes D. , Ames D. J.
Published: September 2002

Aims and Method

The use of the term ‘client’ has become increasingly popular among non-medical staff in psychiatric practice. We sought to describe the preferences and attitudes of people attending a psychiatric clinic to the terms patient and client. A questionnaire and case note review was employed.

Results

147 people completed the questionnaire, of these 77% preferred the term patient. There was no subgroup that preferred the term client. Attitudes towards the two terms were significantly different, with a greater antipathy demonstrated towards the term client.

Clinical Implications

The majority of people attending a psychiatric clinic prefer the use of the term patient; the term client is disliked.
Clozapine – a survey of patient perceptions
Authors: Taylor D. , Shapland L. , Laverick G. , Bond J. , Munro J.
Published: September 2002

Aims and Method

We aimed to find out how patients on clozapine felt about clozapine treatment. A structured questionnaire was given to 1284 consecutive patients attending 27 clozapine clinics in the UK.

Results

The response rate was 44.4% (570 forms returned). This cohort of responders to the questionnaire consisted, for the most part, of Caucasian males who had been taking clozapine for more than 2 years. Respondents expressed largely favourable views on clozapine treatment. For example, 86.1% claimed to feel better on clozapine and 88.6% claimed to prefer to remain on clozapine than to change to another drug. Many patients stated that they disliked having to undergo blood testing, but a large majority (87.0%) felt that the advantages of clozapine outweighed disadvantages. All other responses supported this overall favourable view of clozapine therapy.

Clinical Implications

Patients stabilised on clozapine are largely content with their treatment. These results suggest that clozapine is effective as assessed by patients' own standards and that adherence to therapy is likely to be good.
Teachers' attitudes towards child mental health services
Authors: Ford Tamsin , Nikapota Anula
Published: September 2002

Aims and Method

To improve liaison between local schools and child and adolescent mental health services (CAMHS) by exploring teachers' experiences and perceptions of CAMHS. Semi-structured interviews were carried out with 25 volunteer primary school teachers.

Results

Teachers reported exhausting education-based resources before seeking external advice. Most had positive experiences of child mental health services and were keen to be more involved. They favoured a service that provided rapid advice and ongoing support. Many complained about problems in communication.

Clinical Implications

Child psychiatrists should collaborate more effectively with teachers to promote mental health and manage children with behavioural and psychological problems.
Low dose typical antipsychotics – a brief evaluation
Authors: Taylor David
Published: September 2002

Atypical antipsychotics have, according to some, revolutionised the treatment of schizophrenia. These drugs are claimed to be better tolerated than older typical drugs largely because of their lower propensity to cause acute extrapyramidal side-effects (EPSE). Some atypicals cause little or no hyperprolactinaemia. Some are suggested to cause less tardive dyskinesia than typical drugs. Many are claimed to improve, to a relatively greater extent, negative and cognitive symptoms of schizophrenia. In addition, one atypical, clozapine, is unarguably more effective than typical drugs in the treatment of refractory schizophrenia. Atypical drugs are now sometimes recommended as first choice treatment for schizophrenia (Lieberman, 1996; Tayloret al, 2000).
Newspaper coverage of psychiatric and physical illness
Authors: Lawrie Stephen M.
Published: September 2002

Aims and Method

To compare how newspapers cover psychiatric and physical illness. We conducted a survey of relevant headlines in nine daily newspapers over a one-month period and judged whether the content was essentially positive, neutral or negative.

Results

Over the one-month period, 213 article headlines about various aspects of medicine and 47 on psychiatry were identified. Ninety-nine (46%) of the former were critical intone as compared with 30 (64%) of the latter (odds ratio=4.42, 95% CI 1.64–11.94).We gained the impression that negative articles about physical medicine tended to criticise doctors whereas negative articles about psychiatry tended to criticise patients. Tabloid and broadsheet newspapers did not differ in their rates of negative coverage.

Clinical Implications

Psychiatry, psychiatrists and particularly psychiatric patients tend to be represented negatively in the newspapers. Psychiatrists should strive to influence the news agenda by proactively reporting positive messages, such as treatment advances.
Prescribing in schizophrenia
Authors: Taylor David , Mir Shameem , Kerwin Robert
Published: September 2002

Aims and Method

To develop and introduce a drug treatment protocol for schizophrenia and to evaluate its effect on prescribing. Prescribing of antipsychotics was audited in January 1998. A prescribing protocol was then developed by a collaborative process involving all medical staff, and introduced in September1998. A second prescribing audit was conducted in February 1999.

Results

The proportion of patients prescribed atypical drugs increased from 16.6% to 25.5%. Co-prescription of atypical and typical drugs was relatively uncommon compared with findings of other prescribing surveys. The use of anticholinergic medication was significantly more likely in patients receiving regular typical drugs alongside atypical agents than in those receiving atypicals alone.

Clinical Implications

Widely agreed prescribing protocols may promote improved prescribing practices. Co-prescription of atypical and typical drugs should be discouraged.
A project to develop quality improvements in the Kuwait mental health service
Authors: Bale Rod
Published: September 2002

In October, 1996, an expatriate team commenced working at the Kuwait Hospital for Psychological Medicine on a three-year government contract to develop quality improvements in the mental health service in Kuwait. The team comprised of administrative, medical and nursing staff, including nurse trainers and an occupational therapist and social worker. I was privileged to work on the contract for 17 months as Medical Director - this paper gives an account of my work from a personal perspective.
Clinical standards in psychiatry
Authors: Geddes John , Wessely Simon
Published: September 2002

It is impossible to avoid the plethora of clinical practice guidelines and other forms of practice policy and protocols that have been showered on psychiatrists and other mental health clinicians over the last decade. Several motivations lie behind this phenomenon – reducing the amount of unnecessary variation in clinical practice, improving clinician's access to research evidence and summarising available evidence to assist individual patient and clinician decision-making. With the arrival of the National Service Framework for Mental Health, it is timely to take stock of the evidence requirements for developing valid clinical standards.
Clinical standards and the wider quality agenda
Authors: Lelliott Paul
Published: September 2002

There is an unprecedented level of interest among the general public, the media and politicians in the quality of treatment and care provided by the NHS. Traditional methods for upholding the quality of medical practice, through professional self-regulation, are under attack. The General Medical Council (GMC) has responded by voting to introduce a process of revalidation for medical practitioners. If this is not seen to succeed, the Government could take this responsibility away from the GMC, and the Medical Colleges and Faculties.
Cognitive-analytical therapy – a most suitable training for psychiatrists?
Authors: Rees Harvey
Published: September 2002

Cognitive-analytical therapy (CAT) is a time-limited, integrated psychotherapy and its features have been extensively described (Ryle, 1990, 1995). It emerged as a formal psychotherapy method in 1990 and was developed with the aim of providing psychotherapy within the NHS. As the name suggests, the model integrates a wide range of theory and practice (psychoanalytical, cognitive and behavioural) yet retains a distinct method. This paper describes potential applications of CAT to general psychiatric practice and discusses the value of formal training for psychiatrists.
Outcome of clozapine treatment for patients with treatment-resistant schizophrenia in a local clinical service
Authors: Rastogi Sudhir , Mynors-Wallis Laurence
Published: September 2002

Aims and Methods

The aim of this study was to examine the impact of prescribing clozapine for a cohort of patients with treatment-resistant schizophrenia in a local clinical service. Information was collected about the use of health care resources in the six months before and the six months after starting clozapine. Information was also recorded as to the effect of clozapine on daily living skills and overall clinical improvement.

Results

The introduction of clozapine was associated with clinical befefits both in terms of overall clinical improvement and daily living skills. The introduction of clozapine was cost neutral in the first six months when taking into account both drug costs and total health care costs. The reduction in hospital bed usage did not occur untill the third and fourth year following the introduction of clozapine.

Clinical Implications

Although the drug costs of clozapine are higher than the use of traditional neuroleptics for treatments-resistant schizophrenia, the immediate overall costs of introducing colzapine were no higher than before the drug was introduced. Saving in hospital bed usage did not occur until after a period of hehabilitation. It is our impression that the clinical improvement brought about by clozapine enabled patients to benefit from the rehabilitation service to a greater extent than before the drug was started.
Chlorpromazine equivalents and percentage of British National Formulary maximum recommended dose in patients receiving high-dose antipsychotics
Authors: Yorston Graeme , Pinney Alison
Published: September 2002

Aims and Methods

The study compared two methods of identifying patients prescribed high doses of antipsychotic medication among in-patients and out-patients in Buckinghamshire. High doses were defined as those in excess of 1000 mg chlorpromazine equivalents (CPZE) per day or more than 100% of the maximum recommended dose in the British National Formulary (BNF).

Results

A total of 258 patients were identified as being prescribed antipsychotics, 30 of whom received high doses. There was 93% concordance between the two methods for identifying these patients. Nine of the 12 patients who had been prescribed high potency (> 1000 mg CPZE/day) but low toxicity (> 100% BNF maximum) therapy were receiving flupenthixol decanoate.

A group of six high-risk patients were identified who had been prescribed lower potency drugs at supra-maximal doses.

Clinical Implications

Expressing total antipsychotic dose as a percentage of the BNF maximum is easy to understand and calculate. It helps to ensure patients at risk of antipsychotic toxicity are easily identified to ensure monitoring guidelines can be followed.
Risky presentations
Authors: Subotsky Fiona , Santhouse Alistair
Published: September 2002

Aims and Methods

The aim was to review the assessment and management of the psychosocial risk (including substance misuse) of older children presenting to the accident and emergency department, with a view to making recommendations to improve services. The method used was to inspect casualty records of attendances over two weeks of 11-16-year-olds.

Results

In no cases was any note made of whether substance misuse might have occurred. Cases of apparent psychosocial risk were, however, dealt with appropriately in the main.

Clinical Implications

Brief advisory guidelines were written for accident and emergency staff to promote consideration of the misuse of substances in older children, and an information leaflet was developed for young people and their parents.
Adult psychotherapy and child and family psychiatry
Authors: Pollet Sheena , Bamforth Margaret , Collins Gloria
Published: September 2002

Aims and Methods

This paper describes a 10-year alliance between an adult psychotherapy service and a child and adolescent mental health service to bring psychotherapeutically-informed help to families in difficulties early in the lives of their children.

Results

It outlines staff training, the development of the unit into a significant training resource, the unit's underlying philosophy, its therapies and the key inter-relationships between teams and with health visitors to enable mutual teaming and the rapid access of families to assessment and treatment of the parent-child relationship.

Clinical Implications

Funding, future plans and the preventive and economic implications of such work are mentioned.
The TAPS Project
Authors: Leff Julian , Trieman Noam , Knapp Martin , Hallam Angela
Published: September 2002

The Team for the Assessment of Psychiatric Services (TAPS) was established in May 1985 with the explicit purpose of evaluating the national policy of replacing psychiatric hospitals with district based services. TAPS' remit was to mount the evaluation with respect to the closure of Friern and Claybury Hospitals in north London. Funding was provided by the Department of Health and North-East Thames Regional Health Authority (latterly North Thames Regional Health Authority) with supplements from the King's Fund and the Sainsbury Family Trusts. During 13 years of research TAPS has employed more than 50 members of staff and associated researchers. A full listing is given in Leff (1997). This summary of the research is organised by topics. However, there was very close integration of the various projects.
Prescribing and monitoring of carbamazepine and valproate – a case note review
Authors: Taylor David M. , Starkey Kate , Ginary Saira
Published: September 2002

Aims and Method

To evaluate prescribing and monitoring of carbamazepine and valproate to patients in secondary care psychiatric units. Review of prescription cards and medical case notes.

Results

Prescribing details for 433 patients were recorded. Both carbamazepine and valproate were widely prescribed for indications not listed in their product licences. Plasma level monitoring was not frequently undertaken, particularly with valproate. Where plasma levels were measured, apparently sub-therapeutic prescribing was found to be common. For the majority of samples, it could not be established that a true trough level had been taken. Monitoring of blood function was highly variable. Overall, the quality of both prescribing and monitoring was poor.

Clinical Implications

Patients may receive sub-therapeutic treatment or experience unnecessary adverse effects. Prescribing and monitoring need to be more evidence-based in line with the ideals of clinical governance.
Delay in the discharge of psychiatric in-patients with learning disabilities
Authors: Watts R.V. , Richold P. , Berney T. P.
Published: September 2002

Aims and Method

The study aimed to identify factors delaying discharge of psychiatric inpatients from a learning disability service. A census was completed, categorising in-patients as unready for discharge (n=181); discharge planned within 12 weeks (n=22); or ready for discharge but experiencing delay (n=44), the latter were followed-up 16 months later.

Results

Delayed patients were more disabled or disturbed and often awaiting adequate community provision. They were older, had been in hospital longer and were ‘informal’ admissions. At follow-up 23 remained in hospital, 21 of whom had been delayed by lack of placement.

Clinical Implications

De-institutionalisation has led to the expectation that more complex and challenging people be placed in the community. This study suggests the community to be, as yet, unready to cope with the needs of these service users.
A comparison of stimulus dosing methods for electroconvulsive therapy
Authors: Laidlaw J. , Bentham P. , Khan G. , Staples V. , Dhariwal A. , Coope B. , Day E. , Fear C. , Marley C. , Stemman J.
Published: September 2002

Aims and Methods

A prospective study comparing initial electroconvulsive therapy treatment doses determined by empirical dose titration with estimates derived from two simple dose prediction methods and a fixed-dose regimen (275 mC).

Results

Thirty-three patients had seizure thresholds between 25 mC and 403 mC. The dose titration method led to a mean initial treatment dose of 195 mC that was intermediate between those predicted by the age method (275 mC) and the half-age method (137 mC). Estimates were within acceptable limits in 33% of cases for the age method, 64% for the half-age method and 40% for the fixed-dose method.

Clinical Implications

Either dose prediction or dose titration methods may be more appropriate in different clinical situations. The half-age method appears to be a more accurate predictor of optimum initial treatment dose.
Special interest sessions in psychiatry
Authors: Stephenson Matthew , Puffett Alison
Published: September 2002

Aims and Method

While specialist registrars in psychiatry are entitled to spend one-fifth of their working week engaged in special interest sessions, little has been published on how the time is used. In order to describe what happens in practice, we conducted a semi-structured telephone survey of trainees on the South-East Thames Higher Training Scheme in psychiatry.

Results

The results indicate that while most trainees (78%) were satisfied with their use of special interest time, those using two sessions regularly for a defined training purpose were in the minority.

Clinical Implications

Use of special interest sessions is generally good in the scheme surveyed. If uptake of sessions is to be improved, there needs to be even better local support as well as existing national recognition of the educational rights of trainees. The local support should be at the level of both trust and training scheme.
Burton's Anatomy of Melancholy
Authors: Stanley W. J.
Published: September 2002

Robert Burton was an Oxford clergyman and scholar. His book was first published in 1621. He adopts the title Democritus Junior after the Greek philosopher who was also “an expert physician, a politician, and an excellent mathematician“. Hippocrates described him as “a little wearish old man, very melancholy by nature”. In the preface, the author says: “I write of melancholy by being busy to avoid melancholy.” (Burton, 1621)
Full metal jacket or the emperor's new clothes?
Authors: Deahl Martin , Douglas Brian , Turner Trevor
Published: September 2002

Launched with little more than a whimper during the Labour Party Conference the much vaunted National Service Framework for Mental Health (NSF–MH) outlines the Government's ‘ambitious agenda’ for mental health services (Department of Health, 1999a). The official driving force has been the desire to deliver a quality service throughout the whole NHS via clinical governance and underpinned by professional self-regulation. Developed following widespread consultation and with the advice of the External Reference Group (although some of this advice was clearly disregarded), the NSF–MH provides a series of seven core standards with examples of good practice. Although developed with general psychiatry and severe mental illness in mind, the NSF is not quite the ‘National Schizophrenia Framework’ that some envisaged, since it also acknowledges the needs of young people and the influence of developmental factors on adult mental health. The NSF–MH sets standards in five areas: mental health promotion, primary care and access to services, services for the severely mentally ill, caring about carers and preventing suicide. It is only the second to be published (the other being for coronary care) which is hopefully a reflection of the ‘priority’ once more being given to mental health. However, the near-simultaneous appointment of a cancer ‘tsar’ suggests that ‘priority’ is a readily used and easily diluted term.
How long can a waiting list be?
Authors: Foreman D. M. , Hanna M.
Published: September 2002

Aims and Method

Quantifying the relationship between waiting time and clinic attendance in child and adolescent psychiatry would allow better estimation of the resources needed to eliminate waiting lists in specific initiatives. All cases on a waiting list were sent a questionnaire, return of the questionnaire being necessary for an appointment to be made. Those who did not return the questionnaire or did not attend were contacted and a reason obtained whenever possible. The data were analysed using Cox regression.

Results

Most who did not return their questionnaires had been waiting less than four weeks or longer than 30 weeks. Questionnaire return seemed a good estimate of intention to attend. Other factors improving questionnaire return were younger patient age, previous experience of the service, a clear common reason for referral, and a non-general practitioner referral source.

Clinical Implications

Waiting lists in child and adolescent psychiatry may have a natural ‘endpoint’ at 30 weeks beyond which families give up, while waiting lists of less than one-month may be too short to lose transient problems. Failure to include this and other indicators of non-attendance may lead to overestimates of resources needed to remove queues for treatment. Questionnaires may be useful in identifying those intending to attend.
Lithium and pregnancy
Authors: Williams Kelwyn , Oke Sarah
Published: September 2002

The lifetime prevalence of bipolar affective disorder is approximately 1% in both men and women (Reigeret al, 1998). In women the illness is most prevalent in the child-bearing years (Robinset al, 1984). While lithium for the treatment of bipolar disorder is a cornerstone of modern psychopharmacology (Llewellynet al, 1998), there are inherent problems in treating this sizeable subgroup of patients, as lithium presents small, but significant, risks to a potential foetus. It is also becoming increasingly obvious that serious mental illness poses a risk to the unborn child. This paper reviews those risks, presents a protocol in algorithmic form for dealing with the prescription of lithium in pregnancy and discusses practical issues pertaining to dosage and lithium monitoring.