BJPsych Bulletin最新文献

Aims and method: Questions often follow the suicide of someone who presented to general adult psychiatry (GAP) when expressing suicidal thoughts: 'Why were they not admitted, or managed differently, when they said they were suicidal?' Answering these questions requires knowledge of the prevalence of suicidal ideation in patients presenting to GAP. Therefore, we determined the general clinical characteristics, including suicidal ideation, of a large sample of patients presenting to a GAP emergency assessment service or referred as non-emergencies to a GAP service.

Results: Suicidal ideation was very common, being present in 76.4% of emergency presentations and 33.4% of non-emergency referrals. It was very weakly associated with suicide, varied between different diagnostic categories, and previous assessment by GAP did not appear to affect it. The suicide rate during the contingent episode of care was estimated as 66 per 100 000 episodes.

Clinical implications: This, and other evidence, shows that suicide cannot be predicted with an accuracy that is useful for clinical decision-making. This is not widely appreciated but has serious consequences for patients and healthcare resources.

Aims and method: To explore the duration of support, reach, effectiveness and equity in access to and outcome of individual placement and support (IPS) in routine clinical practice. A retrospective analysis of routine cross-sectional administrative data was performed for people using the IPS service (N = 539).

Results: A total of 46.2% gained or retained employment, or were supported in education. The median time to gaining employment was 132 days (4.3 months). Further, 84.7% did not require time-unlimited in-work support, and received in-work support for a median of 146 days (4.8 months). There was a significant overrepresentation of people from Black and minority ethnic communities accessing IPS, but no significant differences in outcomes by diagnosis, ethnicity, age or gender.

Clinical implications: Most people using IPS services do not appear to need time-unlimited in-work support. Community teams with integrated IPS employment specialists can be optimistic when addressing people's recovery goals of gaining and retaining employment.

Aims and method: Accumulating evidence suggests that early life trauma (ELT) initiates and perpetuates a cycle of depression, leading to challenges in management and achieving remission. This scoping review aimed to examine the intricate relationship between ELT and difficult-to-treat depression (DTD). An extensive literature search from 1 January 2013 to 21 October 2023 was conducted using the Cochrane Library, PubMed, Scopus, PsycINFO and OpenGrey.

Results: Our review identified scientific literature illustrating the multifaceted link between ELT and DTD, highlighting the dual impact of ELT on therapeutic resistance and clinical complexity.

Clinical implications: This complexity hampers management of patients with DTD, who are characterised by limited pharmacological responsiveness and heightened relapse risk. While exploring the ELT-DTD nexus, the review revealed a paucity of literature on the impact of ELT within DTD. Findings underscore the profound link between ELT and DTD, which is essential for comprehensive understanding and effective management. Tailoring treatments to address ELT could enhance therapeutic outcomes for patients with DTD. Future studies should use larger samples and well-defined diagnostic criteria and explore varied therapeutic approaches.

Aims and method: We explored the prevalence of autism and attention-deficit hyperactivity disorder in first-episode psychosis. Through service evaluation involving 509 individuals, detailed analyses were conducted on neurodevelopmental traits and patterns of service utilisation.

Results: Prevalence of neurodivergence in first-episode psychosis was 37.7%. Neurodivergent individuals used urgent mental health services more frequently (Mann-Whitney U = 25925, Z = -2.832, P = 0.005) and had longer hospital stays (Mann-Whitney U = 22816, Z = -4.886, P ≤ 0.001) than non-neurodivergent people. Neurodivergent people spend more than twice as long in mental health hospitals at a time than the non-neurodivergent people (Mann-Whitney U = 22 909.5, Z = -4.826, P ≤ 0.001). Mediation analysis underscored indirect impact of neurodivergence on hospital stay durations through age at onset of psychosis and use of emergency services.

Clinical implications: Prevalence of neurodevelopmental conditions in first-episode psychosis is underestimated. Neurodivergent individuals show increased utilisation of mental health services and experience psychosis earlier. Early assessment is crucial for optimising psychosis management and improving mental health outcomes.

Waiting lists for children and young people with mental health problems are at an all-time high. Almost the only policies proposed to deal with this situation involve increasing the number of mental health professionals. Little attention is given to dealing with the underlying causative stresses, of which poverty is easily the most pervasive. It is suggested that unless levels of poverty are reduced, the rates of psychiatric disorders will not change. As psychiatrists, we need to become much more active in pressing for action over child poverty.

Repetitive transcranial magnetic stimulation (rTMS) has gained regulatory approval as an adjunctive treatment for obsessive-compulsive disorder (OCD) in adults. However, its application in adolescents remains largely untested. This editorial examines the limited evidence available, focusing on choice of target, stimulation depth and methodological variation. Ethical challenges surrounding the use of rTMS in vulnerable populations, including informed consent and the unknown long-term effects on neurodevelopment, are also discussed. Although rTMS holds promise for treatment-resistant adolescent OCD, a cautious and ethically rigorous approach is essential before wider clinical adoption can be considered.

Aims and method: Functional neurological disorder (FND) most often presents in women of childbearing age, but little is known about its course and outcomes during pregnancy, labour and postpartum (the perinatal period). We searched MEDLINE, PsycInfo and Embase combining search terms for FND and the perinatal period. We extracted data on patient demographics, subtype of FND, timing of symptom onset, comorbidities, medications, type of delivery, investigations, treatment, pregnancy outcomes and FND symptoms at follow-up.

Results: We included 36 studies (34 case reports and 2 case series) describing 43 patients. Six subtypes of FND were identified: functional (dissociative) seizures, motor weakness, movement disorder, dissociative amnesia, speech disorders and visual symptoms. New onset of perinatal FND was more common in the third trimester and onwards. Some women with functional seizures were exposed to unnecessary anti-seizure prescriptions and intensive care admissions.

Clinical implications: Prospective studies are urgently needed to explore how FND interacts with women's health in the perinatal period.

Background: Young people from racialised backgrounds are overrepresented in justice services. This study explored differences in community support offered to young people from racialised groups referred to a forensic child and adolescent mental health service.

Method: We compared support offered to 427 young people, according to five ethnic groups.

Results: Over 20% of young people referred were Black (compared with 14% of the local population) and 15.8% were Dual White and Black Heritage (compared with 4% of the local population). Odds ratios showed that Black and Dual Heritage groups were more frequently involved with youth offending services (Black: 2.59, Dual Heritage: 2.88), gangs services (Black: 4.31, Dual Heritage: 7.13) and have a national referral mechanism (Black: 3.61, Dual Heritage: 4.01) than their White peers, but were less often in mainstream education compared with their Asian peers (Black: 0.26, Dual Heritage: 0.29). Black (odds ratio 0.35) and Dual Heritage (odds ratio 0.40) young people were less frequently diagnosed with a neurodevelopmental disorder than their White peers.

Conclusions: Those from Black and Dual Heritage backgrounds were disproportionately disadvantaged.

Promethazine, a sedating antihistamine, is widely and increasingly prescribed for patients reporting problems sleeping. In this Against the Stream article, the case is made that promethazine is not suitable as a sleep aid for people using mental health services, because it has no good evidence base, impedes with psychological and behavioural techniques that do improve sleep in the medium-long term, has underappreciated addictive and recreational-use potential, and an unacceptable side-effect profile. Alternatives to promethazine are described, notably the NICE first-line recommendation, cognitive-behavioural therapy for insomnia.