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Psychiatry: Having an abortion does not increase mental health issues

By Mike Broad - 12th December 2011 10:59 am

The world’s largest, most comprehensive and systematic review into the mental health outcomes of induced abortion has been published by the Academy of Medical Royal Colleges.

The review concludes that having an abortion does not increase the risk of mental health problems. The best current evidence suggests that it makes no difference to a woman’s mental health whether she chooses to have an abortion or to continue with the pregnancy.

The review was commissioned by the AOMRC and carried out by the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists.

The review’s Steering Group and the NCCMH carried out a systematic and comprehensive search of the literature and identified 180 potentially relevant studies published between 1990 and 2011. The Steering Group was careful to ensure only the best quality evidence was used, so all studies were subject to multiple quality assessments. In total, 44 papers were included in the review.

On the basis of the best evidence available, the Steering Group concluded that having an unwanted pregnancy is associated with an increased risk of mental health problems. However, the rates of mental health problems for women with an unwanted pregnancy are the same, whether they have an abortion or give birth.

The most reliable predictor of post-abortion mental health problems is having a history of mental health problems. In other words, women who have had mental health problems before the abortion are at greater risk of mental health problems after the abortion.

The Steering Group recommends that future practice and research should focus on supporting all women who have an unwanted pregnancy.

Dr Roch Cantwell, a consultant perinatal psychiatrist and Chair of the Steering Group, said: “Our review shows that abortion is not associated with an increase in mental health problems. Women who are carrying an unwanted pregnancy should be reassured that current evidence shows they are no more likely to experience mental health problems if they decide to have an abortion than if they decide to give birth.”

Shortage of psychiatric beds is harming care

By Mike Broad - 23rd November 2011 6:28 pm

A lack of psychiatric beds is adversely affecting patient care, a professor of psychiatry has claimed.

Peter Tyrer, Professor of Community Psychiatry at Imperial College London believes the “inane chant of ‘community good, hospital bad’ has taken over every part of national policy” and is in danger of compromising care.

The national plan is to make further bed reductions, he says on bmj.com, but believes this will lead to “harm and sub-standard care”.

Tyrer argues that “at least 30,000 beds are needed for good psychiatric care in the NHS with our present treatment options” - the total number of beds stood at 27,000 in 2008.

He believes that throughout the history of psychiatry there has been conflict between the administrative and clinical aspects of psychiatry. The former, the ‘out of sight, out of mind’ policy of the Victorian era has now been replaced by an ‘out of hospital, do not mind’ one.

Tyrer concludes that we need to get “good in-patient care back on the agenda and fight the continuing urge towards bedlessness.”

His comments are part of the forthcoming Maudsley Debate: Care in the Community? at the Institute of Psychiatry, London.

Sonia Johnson, Professor of Social and Community Psychiatry at University College London, thinks we should improve alternatives to admission rather than increasing bed numbers, and argues that “returning to a higher level of psychiatric bed provision would, in the current climate of scarcity, be both profligate and pointless”.

She says current bed use levels in the UK are unremarkable compared with other European countries, while evidence shows that “most people with significant mental illnesses live peaceful lives in the community,” despite media headlines suggesting they are a threat to others.

Read full article.

Tags: psychiatry
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Psychiatry: Cannabis use reduces thalamic volume in people at risk of schizophrenia

- 19th November 2011 6:14 pm

Using cannabis can lead to a loss of brain volume in people who are at risk of developing schizophrenia, according to a study published in the November issue of the British Journal of Psychiatry.

The finding by researchers from the University of Edinburgh could be important in understanding more fully the link between cannabis use and the development of schizophrenia.

Previous studies have found that the brains of people with schizophrenia show structural abnormalities, particularly in a part of the brain called the thalamus. We each have two thalami - the left and the right - which are responsible for processing and relaying information.

The team studied 57 people aged between 16 and 25 who were well but who had a strong family history of schizophrenia - and were therefore at high genetic risk of the disease. Each person had a full assessment including a magnetic resonance imaging (MRI) scan. Two years later, each person returned for another MRI scan. As part of this second assessment, they were asked about their use of illicit drugs (including cannabis), alcohol and tobacco in the period between scans.

Of the 57 participants, 25 had used cannabis between the two assessments. The researchers found that those people who had used cannabis experienced a reduction in their thalamic volume. This loss was significant on the left side of the thalamus and highly significant on the right. No volume loss was found in those who had remained cannabis-free during the two-year period.

Psychiatry: Anti-dementia drugs may help delay people’s admission to care homes

The Psychiatrist - 5th October 2011 10:15 am

Prescribing anti-dementia drugs to patients could help delay their admission to care homes, according to a new study published in the October issue of The Psychiatrist.

Psychiatrists Dr Emad Salib and Dr Jessica Thompson studied a total of 339 people with dementia, who were referred to psychiatric services in Peasley Cross Hospital in St Helens in 2006.

127 of the patients (24%) had been prescribed cholinesterase inhibitors. These drugs can help slow the progression of the disease by preventing an enzyme known as acetylcholinesterase from breaking down acetylcholine in the brain. Of the patients who were prescribed cholinesterase inhibitors, almost three-quarters (74%) were given donepezil (which is marketed under the trade name Aricept). A further 14% were given galantamine (trade name Reminyl), 8% rivastigmine (trade name Exelon), and 4% memantine (trade name Ebixa).

The remaining 212 patients in the study were not prescribed cholinesterase inhibitors. After four years, the researchers followed up all 339 patients to see if they had been placed in care or remained in their own home.

The researchers found that, on average, patients who did not take anti-dementia drugs moved to care homes sooner than patients who did. There was a delay in admission to care homes by a median of 12 months for patients who took anti-dementia drugs, compared to those who did not.

However, after three years, an equal proportion of patients from both treatment groups had been admitted to care homes. In other words, the delay in admission was relatively short-lived.

Tags: Elderly Medicine, psychiatry
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Mental health services in crisis over staff shortages

The Guardian - 21st June 2011 9:43 pm

Overcrowded and understaffed psychiatric wards are leaving patients fearful for their safety and unable to make proper recoveries, according to a damning assessment of Britain’s mental health service by its lead professional body.

Professor Dinesh Bhugra, the outgoing president of the Royal College of Psychiatrists, told the Guardian that widespread failures in inpatient care for mentally ill people meant many hospital wards did not meet acceptable standards and discharged back into society sick people who remained a risk to themselves and others.

Bhugra blamed the problem partly on a “dangerous vacuum” created because British doctors are not training as psychiatrists, while visa restrictions mean doctors from abroad can no longer fill the gap.

“Society will be overwhelmed by the demand of those in need if government doesn’t act now,” he said.

A survey by the royal college found that 544 consultants’ posts in the UK - 14% of the total - are either unfilled or filled by a locum. In addition, 209 consultants intend to retire or resign soon, a situation exacerbated by the government’s cap on immigration from outside the EU.

Going back to the beginning in mental health

By Dr Cerian Avent, a CT2 in psychiatry - 12:17 pm

‘Prevention is better than cure’ is a well-worn idiom and in many fields of medicine preventative measures are widely publicised and routinely practised. Any discussion with friends reveals at least an awareness of recommended limits on units of alcohol to protect our liver; that we should not smoke to reduce our risk of lung disorders; and eat less salt to prevent heart disease. But, what about our mental health?

Although understanding the causes of mental illness is improving, treatment remains focused on managing disorders once they have developed. Perhaps preventative measures within psychiatry are seen as too uncertain or expensive, or would raise concerns of more meddling by a nanny state. Maybe the complex nature of psychiatric disorders mean that few factors can reliably predict a condition will develop. There would also be challenges of whom to target, how and when.

But if we accept that the earlier preventative measures are adopted, the better the chance of success, what if we take this to its extreme - the first environment we experience - our mother’s womb? The association between certain environmental factors in pregnancy and particular physical diseases are well understood. For example, a foetus exposed to the rubella virus in its first trimester has a higher risk of developing physical complications such as eye abnormalities, hearing loss and heart defects and the prevention of this risk by vaccination is long established. Might there be similar associations for mental health disorders?

Research studies suggest there are (here, here and here). Recent work found a correlation between maternal anxiety during pregnancy and an increased susceptibility of the child to emotional and behavioural problems in later life. This is thought to result from exposure in the foetus to the maternal stress hormone, cortisol, during a critical period of brain development. So in practice, could we target preventative strategies for mental illness at the baby in the womb?

Whilst the present level of research may be too sparse to allow us to understand fully which environmental factors increase the risk of specific mental health disorders, preventative measures could be promoted to protect pregnant women and their babies’ mental health just as we do for their physical health.

Basic interventions, such as ante-natal classes and parenting programmes, can be a cost effective way of achieving positive results. They promote the emotional preparation for parenthood, teach parenting skills and foster discussion of issues such as bonding and attachment. Such programmes are known to have the potential to benefit a range of outcomes including maternal psychological well-being, parental confidence, and satisfaction within the couple and child relationships.

Provision of greater support might be targeted at women at higher risk of developing mental health disorders during pregnancy, such as victims of domestic violence, those who have suffered drug or alcohol dependence, live in poverty or have a previous mental health history. Indeed specialist perinatal teams have been developed to identify and treat maternal mental illness.

Such services do exist, but undoubtedly awareness and coordination between mental health specialities and maternity professionals could be improved. For instance, psychiatrists could offer greater specialist support to midwives who advise pregnant women on antenatal care.

The last thing I want to do is alarm pregnant women or blame mental health disorders on patients’ mothers. But I do believe we should explore any area where early intervention could help combat our nation’s mental health problems. What is clear is that more research is needed on the associations between earlier environmental influences and mental health disorders in later life, to help the vulnerable avoid these most debilitating of illnesses.

Tags: psychiatry
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Mental health experts fear incapacity benefit cuts

The Guardian - 1st June 2011 9:26 am

The government’s changes to the welfare system are having a “devastating” impact on hundreds of thousands of people with mental health problems and have driven some of the most vulnerable to try to take their own lives, according to charities and medical experts.

A letter published in The Guardian brands the government’s drive to reassess 1.5 million people receiving incapacity benefit as “deeply flawed” and warns that the rapid pace of change is having dire consequences.

“We’ve found that the prospect of incapacity benefit reassessment is causing huge amounts of distress and tragically there have already been cases where people have taken their own life following problems with changes to their benefits,” the letter, signed by leading mental health charities and a senior consultant from the Royal College of Psychiatrists, states.

“We are hugely worried that the benefits system is heading in a direction which will put people with mental health problems under even more pressure and scrutiny, at a time when they are already being hit in other areas such as cuts to services.”

In April the government began to send out 7,000 letters a week asking people to attend a “work capability assessment”. It is now sending out more than 11,000 reassessment requests and the first interviews will take place this month.

Psychiatry: mental illness linked to tobacco exposure in the womb

Evidentia - 2nd September 2010 11:20 pm

Prenatal exposure to tobacco smoke may increase the risk of psychiatric disorders later in life, a Finnish researcher said at the American Psychiatric Association meeting in New Orleans. The finding comes from analysis of medical records of 175,869 people born in Finland from 1987 through 1989, according to Mikael Ekblad, a doctoral student at Turku University in Finland.

Those whose mothers smoked had up to a 44% increased risk of using psychiatric drugs in adult life.

Psychiatry: the dos and don’ts of assessing major depression in diabetes

Evidentia - 6th August 2010 3:10 pm

It is increasingly recognised that depression constitutes a significant long-term complication of diabetes and is associated with debilitating rates of reduced quality of life, poor self care, reduced life expectancy and increased healthcare costs.

The lifetime risk of suffering major depression is up to three times higher in patients with diabetes compared with the general population. In a session dedicated to the clinical management of depressive symptoms in patients with predominantly Type 2 diabetes, Dr Jim Bolton from London discussed the means of assessing depression in this patient group and highlighted some common clues and pitfalls.

How to redesign mental health services - a summary

By Mike Broad - 2nd July 2010 9:13 am

The Royal College of Psychiatrists has made 17 new recommendations for the redesign of mental health services. The paper, Looking Ahead: Future development of UK mental health services, involved the views of more than 50 psychiatrists, psychologists and allied professionals.

Here’s a summary:

Community mental health teams

The relationship between community teams and specialist teams should be examined with a view to rebalancing their roles, and the model of an enlarged CMHT should be further explored.

A whole-system comparison of the different models of mental healthcare, for example service lines and enlarged CMHTs, should be carried out urgently, with adequate resources made available for this comparison to be made.

The comparison should aim to furnish the mental health sector with high-quality data on interventions and outcomes of the various prevailing approaches.

Consultant expertise at the beginning of the pathway

Consultants’ expertise should be used in complex assessment and management, rapid review of those in crisis, and advice to multidisciplinary teams and staff working in primary care.

Services should be organised in such a way that appropriate expertise is available to ensure that the ongoing assessment of service users’ needs is a routine aspect of the care they receive.

Research should be carried out into the clinical effectiveness and cost-effectiveness of primary care psychiatry services in the UK.

Standardised outcomes

Changes to one part of the care pathway can have unintended effects on the whole system. It is therefore imperative that whole-system comparisons of the different models of mental health service provision are carried out.

These different systems should also be evaluated, using a common system of data collection and outcome measures relevant to commissioners, clinicians, service users and carers.

The Royal College of Psychiatrists and other professional bodies should undertake this work.

Investing to save through the development of family mental healthcare

The majority of serious mental health problems among working-age adults begin early in life and cause disability when those affected would normally be at their most productive. Furthermore, some illnesses cluster in certain families.

Research should be carried out to evaluate the clinical effectiveness and cost-effectiveness of family-oriented mental healthcare jointly coordinated by adult mental health services and child and adolescent mental health services, and family-oriented mental healthcare delivered through family psychiatry services.

Out-of-area treatments

Commissioners and local authorities should - as a matter of urgency - review their systems and invest expenditure currently used to fund unnecessary out-of-area treatments into the local mental health economy (and specifically into rehabilitation services provided by the statutory and voluntary sector).

Mental health of older people

Equitable access to services across different populations (such as Black and minority ethnic groups) was identified as important throughout the enquiry.

Commissioners and providers must ensure that people over 65 also have equitable access to the full range of age-appropriate and non-discriminatory mental health services required to meet their needs. Comprehensive specialist older people’s mental health services are an essential part of meeting need across the lifespan and must be available in all commissioning areas.

In-patient care

In-patient services are a fundamental part of the whole care system. Different models of in-patient care, including assessment wards, the integration of crisis teams with wards and crisis houses, and other alternatives to admission or facilitation of discharge must be evaluated thoroughly.

Research should also be carried out to evaluate discharge procedures.

Statutory and voluntary sector partnerships

The use of partnerships or compacts between statutory and voluntary sector agencies to develop the availability and quality of step-down services from secondary and primary care should be increased.

Housing

Greater partnership working is required between health services, social services and the voluntary sector to facilitate timely and safe step-down accommodation. Services should employ suitably experienced staff to liaise with local housing departments regarding discharge, and contact should be made within days of patient admission.

Employment and mental health

Organisations with a workforce over a certain size should be required to report annually on their 13 mental health at work policy, as part of their report on health and safety at work.

This would be an inexpensive, non-prescriptive process, which is nevertheless legally required, that would encourage employers to reflect on the mental welfare of their employees.

Substance misuse

Mental health services should remove dual diagnosis/substance misuse as an exclusion criterion and ensure that staff are trained in substance misuse issues.

Given the high rates of substance misuse among people with mental health problems, denying them access to services only further excludes vulnerable members of society and deprives them of potentially beneficial treatment.

Relationship between physical and mental health

Action is required to ensure that the link between physical and mental health is addressed by all health services.

A renewed emphasis on liaison psychiatry and psychology services is required, including consultant-led services that aim to reduce acute medical and surgical bed occupancy and acute attendances of individuals with unexplained physical symptoms.

Psychological therapies

Access to evidence-based psychological interventions/therapies is required at all points along the care pathway, and should be needs-led; within five years there should be the same availability of psychological therapies as evidence-based medical interventions.

The enquiry heard that the employment of peer support workers is both a cost-effective and recovery-oriented method for providing personalised support and assistance to people using mental health services, and an approach that can reduce admissions to hospital and shorten length of hospital stay.

Piloting and evaluation of the clinical effectiveness and cost-effectiveness of the use of peer support workers in mental health services should be carried out in the UK.

Commenting on the recommendations, Prof Dinesh Bhugra, president of the Royal College of Psychiatrists, said: “We know there is growing pressure on NHS services to cut costs and do more work for less money. Although the college is opposed to disproportionate or harmful cuts to mental health services, we are aware that efficiency savings do need to be found.

“Our enquiry explored ways of creating efficiencies and improving productivity through redesigning services and care pathways, making better use of consultant expertise, the need for standardised outcome measures in mental health, and the need for more family-based mental health services.”

Read the full report.

Tags: psychiatry
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