Psychiatry (Abingdon, England)最新文献

Psychiatrists working in palliative care see a wide variety of diagnoses in the setting of advanced disease and bereavement. This article describes the key features of palliative care and some of the specific presentations of psychiatric disorders in this setting, including withdrawal, requests for physician-assisted suicide or euthanasia, assessment of mental capacity, and patients with denial about their disease and its poor prognosis. The remainder of the chapter describes the problem of depression in the context of advanced disease. This includes a discussion of definitions and diagnosis, the potential adverse consequences of depression, and the assessment and management of depression.

Self-harm is a major public health problem and makes up a large proportion of the workload of many departments of liaison psychiatry. This paper focuses on self-harm from a general hospital perspective. It discusses the epidemiology of self-harm, hospital services, recent guidance, assessment, management, and prevention.

HIV affects 33.2 million people worldwide, including 2.5 million children. An estimated 77,000 people are affected in the UK, a quarter of whom are unaware of their diagnosis; each year there are more than 7000 new cases. HIV results in slowly progressive immunodeficiency and/or progressive neurodegeneration. Disease markers are CD4 count and viral load. With a CD4 count below 500 cells/ml, generalized symptoms of decreased immunological function occur including fatigue and minor cognitive decline. With a count below 200 cells/ml, opportunistic infections, neoplasms, and HIV-related dementia develop. When the count falls below 50 cells/ml, fatal HIV-related illnesses develop. HIV is treated with three main classes of antiretroviral; often three or more drugs are required. Antiretroviral treatment may cause psychological symptoms, particularly mood and sleep problems. In resource-rich countries with access to antiretrovirals, HIV has become a chronic disease, altering the profile of associated mental health problems. Organic problems such as encephalitis, meningitis and other deliriums, and dementia have declined, as have adjustment disorders and manic presentations. Depression and anxiety have increased and problems specific to survival, adherence, and risk-reduction behaviours have emerged. Psychosexual problems are also important. Certain groups are particularly vulnerable to contracting HIV; amongst them are people with pre-existing psychiatric problems and drug use. A wide range of psychological and pharmacological treatments is available, some of which are HIV specific. Caution should be exercised in prescribing psychotropic medication because of the potential difficulties that can arise from interactions with antiretrovirals, not least the reduction in efficacy of antiretroviral medication.

Up to 5% of patients attending emergency departments (EDs) present with primary psychiatric problems, and a further 20–30% have psychiatric symptoms in addition to physical disorders. This article discusses the commonest psychiatric presentations to EDs, including self-harm, acute psychosis, and alcohol and substance misuse. It also describes common clinical problems in EDs, including frequent attenders, patients who do not wait to be seen, violence and aggression, and psychological responses to trauma. Issues of service delivery and safety are also discussed. The key to a successful ED psychiatric service is a good working relationship between ED and mental health staff.

This article provides the reader with an overview of the current evidence-based concepts regarding the nature and treatment of disorders within the field of psychodermatology. Psychiatric comorbidity is high in patients with dermatological conditions and stress has a significant impact on the presentation and course of skin disease. Many of the psychophysiological disorders respond to a bio-psychosocial model of management where the reduction of stress in a key therapeutic target. In addition, psychodermatologists are often called upon to treat complex psychiatric disorders such as body dysmorphic disorder and delusional parasitosis. Managing such a patient group requires considerable clinical skill but treatment options are slowly gathering bodies of evidence to support their efficacy and effectiveness. Often overlooked, is the role of medication in the aetiology of psychodermatological disorders and clinicians should remain mindful of this when assessing their patients.

Food is a naturally occurring, nurturing and comforting substance that is also essential to survival. Over-consumption of food without compensatory increased activity in developed countries has led to epidemic proportions of obesity, with enormous healthcare implications. Often seen as resulting from emotional disturbance, obesity also carries huge stigma for sufferers, who are often disabled by the physical and psychiatric consequences of their condition. People who seek help for their obesity have high levels of depression, anxiety, binge eating disorder, and personality disorder. The neurological and psychological aspects of appetite and obesity are currently being explored in the fields of behavioural neuroscience and neuroimaging in an effort to understand the underpinnings of normal and abnormal eating behaviour. Traditional weight loss programmes, including psychologically based treatments for obesity, have proven disappointing in the long-term management of obesity, especially in the morbidly obese. Surgery for obesity has been recognized as the only treatment to bring about sustained weight loss, whilst also significantly reducing physical and psychiatric co-morbidity, and is recommended by National Institute for Health and Clinical Excellence guidelines in these patients. The alarming finding that suicide rates in post-operative patients is high raises questions as to how obese people cope with the absence of the emotionally regulating effect that food has in their lives.

Cancer is common, affecting one in three people in UK during their lifetime. Psychological factors are relevant in the prevention of cancer and also in how people respond to cancer and its treatment. This article provides an overview of the area, referred to as psycho-oncology, from a psychiatric clinician’s point of view. The most common psychiatric problem in the management of patients with cancer is that of emotional disorders. These are very common but still remain under-diagnosed and under-treated. Systematic screening using self-report measures can improve their detection, and is recommended in cancer centres. However, the effective delivery of treatments for these conditions to the large number of patients with cancer remains a challenge. Initial evaluation of a new approach in which cancer nurses deliver treatment for depression under psychiatric supervision has shown promising initial results.

This article highlights the most important principles of the Mental Capacity Act 2005 and some of the amendments to the Mental Health Act 1983 that are relevant to the general hospital setting. The article focuses on how capacity should be assessed and how best interest decisions for someone lacking capacity should be made. It also discusses the role of independent mental capacity advocates, advance decisions relating to refusal of treatment, the role of the Court of Protection, and the new deprivation of liberty safeguards that have been introduced to the Mental Capacity Act. Changes to the Mental Health Act that are likely to affect practice, such as changes to professional roles, are also discussed.

The number of transplant procedures undertaken in the UK is increasing steadily, although the number of potential recipients is rising at a faster rate. Psychiatrists in substance misuse, alcohol, and general adult services are increasingly likely to encounter patients who await or possess a solid organ transplant, often for reasons causally related to their mental disorder, such as alcoholic liver disease. They therefore need to understand the roles of the small number of highly specialized transplant psychiatrists who work alongside transplant teams. Transplant psychiatrists are often required to help select among recipients, guided in part by protocols that set out absolute and relative psychosocial contraindications to transplant listing, such as continuing substance dependence. Mental disorders are considered contraindications to the extent that they predict excess mortality, morbidity, or non-compliance leading to graft failure. Guideline development is hampered by a lack of studies linking mental disorders to post-operative outcome. Some factors, such as obesity and continued smoking, are more clearly linked to adverse outcome, and transplant psychiatrists may be asked to give opinions and offer management in these areas. Increasingly, transplant psychiatrists are also required to help in assessing potential live donors. In the case of non-directed donors, such assessment is mandated by UK law. Post-operative management has close parallels to the work of liaison psychiatry after any major surgery, particularly as regards delirium, post-traumatic stress disorder, and adjustment disorders, but when mental disorder threatens graft survival, specialist work alongside transplant teams is again required.

There is an epidemic of diabetes mellitus, mainly due to the increasing prevalence of type 2 diabetes, and, as for other chronic medical conditions, the rates of depressive disorder in patients with diabetes are increased two-fold. Depression is associated with multiple adverse biomedical, economic, and psychological outcomes. There may be other psychiatric conditions, such as eating problems, that coexist with depression in diabetes. The pathogenesis of co-morbidity is likely to be complex; there is emerging interest in shared genetic and environmental factors that contribute to both conditions. The well-known problem of poor detection and treatment of depression in the medical setting also applies to people with diabetes. There have been few well-conducted studies evaluating the treatment of depression in diabetes. Nearly all treatments, pharmacological, psychological, and combined or stepped-care models, lead to improvements in mood but there is little evidence that current treatments for depression in diabetes also lead to improvement in glycaemic control. This suggests that treatment probably needs to include diabetes-specific components to improve confidence and diabetes self-management.