Psychiatry (Abingdon, England)最新文献

The presence of a learning disability in an individual from an ethnic minority group raises several issues that, if not recognized and addressed, can be detrimental to the mental health of the affected individual. Affected individuals have been said to face a double disadvantage, arising from having a learning disability and being from an ethnic minority group. This disadvantage has been largely neglected both in terms of research and service provision. In order to cater effectively for people with learning disabilities from ethnic minority groups, several obstacles have to be recognized and addressed, specifically and deliberately. More research is required in this area.

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder and symptoms often persist in adult life resulting in significant impairment. ADHD is increasingly recognized as occurring in children and adults with learning disability. ADHD symptoms were found to affect everyday life performance and to increase the impairment imposed by the learning disability, suggesting a double vulnerability and indicating the need for treatment. Although treatment of ADHD in this population has not been tested widely and randomized controlled trials are sparse, there is some evidence that pharmacological treatment can be effective. Thorough assessment of ADHD and comorbid conditions, and appropriate management is warranted.

Genetic disorders account for a sizeable proportion of learning disabilities. Several disorders are associated with mental ill-health. The commonest examples of psychiatric morbidity include psychosis, depression and dementia. Here, three examples of chromosomal abnormalities that have significant research evidence are used to discuss the origins and management of mental disorders. Adults with Down syndrome may suffer from mood disorders and dementia, which has a prevalence rate of 32% by 59 years of age. Personality changes and behavioural disorders can signal the onset of dementia. Prader–Willi syndrome (PWS) has a complex genetic aetiology. A characteristic behavioural phenotype has been described for the syndrome, which includes psychiatric and psychological manifestations. PWS has been found to be associated with affective disorder. People with fragile X syndrome–the most common identifiable cause of learning disabilities–experience a wide range of developmental and psychological challenges throughout their lifespan. In all three syndromes, understanding of the endophenotypic neuropsychological difficulties facilitates the development of rational and, where possible, syndrome-specific supports and therapies.

Psychiatric medications are often used in the treatment of mental disorders as well as for problem behaviours in people with learning disabilities. However, there is little evidence directly relating to people with learning disability, and most treatment decisions and experience of medication are based on research in the general population. Good practice demands that clinicians make every effort to ascertain whether the presenting complaints are those of a diagnosable mental disorder and that there is multidisciplinary support to ameliorate problem behaviours.

‘Learning disability’ is a term used in the UK that corresponds to the internationally used ‘mental retardation’. It is determined by low IQ, impaired social adaptation and onset within the developmental period; classification is primarily by IQ. The prevalence of learning disability is rising, mainly due to improved longevity. Several psychiatric disorders are very common among people with learning disability. Promoting the social inclusion of this vulnerable group is one of the greatest challenges to any developed society.

The numbers of refugees and asylum seekers shows little sign of decreasing. An increased prevalence of stress-related common mental disorders in these populations is well documented. The causes of these conditions vary according to stresses experienced and the journeys individuals take in their migration to new countries and cultural settings. The mental health practitioner must be informed of the cultural idioms by which suffering is expressed in the refugee's community, the social stigma associated with particular traumatic experiences and with mental illness. Because of their experiences of victimization, refugees may be reluctant to disclose experiences of trauma and, as is typical of common mental disorder worldwide, the presentation of mental distress in the first instance is often in the guise of somatic complaints. The specific needs of this group will include dealing with traumatic experiences without pathologizing normal human responses.

Multiple studies performed over the past few decades using various methodologies have reported 5–10-fold incidence rates for schizophrenia in African-Caribbean communities in Europe, findings that hold across generations. Increased incidences of lesser degree have also been reported in other ethnic minority migrant groups in Europe. Various explanations of this phenomenon have been proposed – such as misdiagnosis, differing nature and course of psychotic illness in different ethnic groups, genetics, predisposition to migration, early life influences and later childhood developmental risk factors, drug use, urbanicity, racism, as well as neurobiological factors. They are reviewed here. Relevant literature from North America is also discussed.

The proportion of ethnic minority individuals over the age of 65 is increasing in the UK. This will lead to a concomitant increase in the absolute number of cases of dementia and depression among ethnic minority elders. The epidemiology of suicide in ethnic minority elders is also changing with some ethnic minority elderly groups at higher risk of suicide than previously thought. Despite the prevalence of dementia and depression being similar or higher in ethnic minority groups than the indigenous group, and ethnic minority elders having high general practice consultation rates, the prevalence of ethnic minority elders in contact with Old Age Psychiatry Services is low. Several factors may explain this discrepancy, including factors related to patients and their families, general practice and secondary care. However, there is evidence that this gloomy situation may be improving in some services. Old Age Psychiatry Services for ethnic minority elders should be integrated with existing ethnocentric services, should be flexible, have an ability to adapt to changing needs, be culturally sensitive and be available, accessible and acceptable to ethnic minority elders.

The Delivering Race Equality (DRE) in mental health action plan endorses the need for a balanced range of effective therapies including psychotherapeutic and counselling treatments that are culturally appropriate and effective. Cognitive–behavioural therapy (CBT) is a widely used and acceptable therapy for most mental health disorders, but explanations used in CBT are based on Western concepts and illness models. For reasons explained here, CBT remains the psychotherapeutic model of choice across cultures if adapted appropriately. Dissemination of cognitive therapy across widely diverse cultures is increasingly occurring. The evidence to support this is explored as are problems associated with using therapy that is not culturally adapted.

The cultivation of the body ideal and promotion of thinness values in fashion, media and the diet industry have been repeatedly shown to account for the increased prevalence of eating disorders. It is evident in women in certain sub-cultures where the demand for thinness for career advancement is endemic. There is also a correlation between eating disorders and the level of modernization and urbanization characteristic of western industrialized societies, linking it to increased social mobility, dietary changes as well as changes within family structures. Eating disorders were, therefore, thought to be unique to the ‘western culture’, an impression that was initially substantiated by the apparent absence of these disorders in non-western societies. However, the notion of the culture specificity of eating disorders began to be challenged following reports from different parts of the world when eating disorders emerged in non-western societies. This was believed at first to be a product of a simple identification with western cultural norms in this respect. However, ‘westernization’ was too simplistic and needed to be broken down to see the forces that may lie behind it. These included increased consumerism, shift from collectivist to individualist patterns, changing gender roles and increased alienation of the individual. Subsequently, the individual was forced to resort to the ‘body’ as a new medium for expressing this cultural confusion and distress. Eating disorders are an example of such socio-pathology and needs to be seen now as a marker of ‘transition’ and symptomatic of cultures caught in a process of change.