Cossham Hospital

The World Health Organization has described poverty as the greatest cause of suffering on earth. This article considers the direct and indirect effects of relative poverty on the development of emotional, behavioural and psychiatric problems, in the context of the growing inequality between rich and poor. The problems of children in particular are reviewed. Targets to reduce inequality have been set both nationally and internationally.

The subject of alcoholism in late life has received relatively little attention in the literature. This is despite the fact that elderly people are particularly vulnerable to the adverse effects of alcohol. Demographic data predicts that in the first half of the next century there will be an increase in the absolute number of elderly people with alcohol problems. The recognition and treatment of alcohol problems are likely therefore to become more important as this population expands. High rates of comorbidity with physical and psychiatric illness mean that elderly alcoholics are liable to be frequent users of health facilities. Concern has been expressed regarding the impact this trend will have upon health services, particularly the high costs of treatment and institutionalization. Previous researchers in this field have been disadvantaged by a lack of standardized diagnostic criteria and the absence of age-validated screening tools. This paper reviews recent publications relating to the epidemiology of alcohol problems in the elderly and focuses on comparing the prevalence rates of alcohol problems in various clinical settings. Epidemiological research is important as it improves the understanding of the scope and impact of a disease as well as being a vital component during the planning stage for new services. This review highlights some ongoing limitations in recent research.

This review summarizes the published literature on suicide by jumping, in particular focusing on the social and psychological characteristics of people who have chosen this method of suicide, and the opportunities for prevention. Suicide by jumping accounts for 5% of suicides in England and Wales, and there are marked variations in the use of this method world-wide. A number of locations have gained notoriety as popular places from which to jump. Such sites include The Golden Gate Bridge and Niagara Falls in the USA, and Beachy Head and the Clifton Suspension Bridge in the UK. There is no consistent evidence that those who commit suicide by jumping differ sociodemographically or in their psychopathology from those who use other methods of suicide, although this method is more often used for in-patient suicides, possibly due to lack of access to other means. Survivors of suicidal jumps experience higher subsequent rates of suicide and mental ill health, but the majority do not go on to kill themselves, suggesting that preventive efforts may be worthwhile. This view is supported by other evidence that restricting access to the means of suicide may prevent some would-be suicides. Such measures may also reduce the emotional trauma suffered by those who witness these acts. Health authorities and coroners should consider reviewing local patterns of suicide by jumping, and if necessary institute preventive measures.

We assessed the effect of the installation of barriers on the Clifton suspension bridge, Bristol, England, in 1998 on local suicides by jumping. Deaths from this bridge halved from 8.2 per year (1994-1998) to 4.0 per year (1999-2003; P=0.008). Although 90% of the suicides from the bridge were by males, there was no evidence of an increase in male suicide by jumping from other sites in the Bristol area after the erection of the barriers. This study provides evidence for the effectiveness of barriers on bridges in preventing site-specific suicides and suicides by jumping overall in the surrounding area.

Abstract This article details the results of a retrospective case note study on deliberate self‐harm in the elderly in the London Borough of Tower Hamlets. There were 56 females and 32 males included in the study. The ages of the patients ranged from 65 to 90. Fifty‐seven per cent of the sample had a depressive illness, most commonly found in the younger females and the older males. Over 50% of the sample had evidence of multiple health problems, particularly heart disease and arthritis. Over 90% of cases used self‐poisoning as the means of self‐harm. Sixty‐one per cent used benzodiazepines and 25% salicylates. Over 30% used multiple drug combinations. Thirty‐eight per cent of the sample had evidence of previous self‐harm, 17% had repeated self‐harm within a year and 6% were dead through suicide. Although the characteristics of the patients bore some resemblance to those identified in the literature as being risk factors for self‐harm among younger patients, they bore a much closer resemblance to known risk factors for suicide. This may have ramifications for further research into the prevention of suicide.

OBJECTIVES: To examine the epidemiology of suicide by jumping from the Clifton Suspension Bridge and its impact on local patterns of suicide. DESIGN: Case-control study of falls from the bridge (1974-93) matched by age and sex with those using other methods of suicide. Routine OPCS mortality statistics for Bristol and District Health Authority. SETTING: The County of Avon and the Bristol and District Health Authority. SUBJECTS: 1. Individuals given coroners' verdicts of suicide, "open", or misadventure after falls from the suspension bridge and 127 matched control suicides using other methods. 2. All deaths from suicide within the Bristol and District Health Authority 1982-91. MAIN OUTCOME MEASURES: Past psychiatric history, demographic characteristics of suicides, and proximity of place of residence to the bridge. RESULTS: There were 127 falls from the Clifton Suspension Bridge between 1974 and 1993. The mean age was 35.4 years for males (n = 93) and 35.5 for females (n = 34). Those who committed suicide by jumping were no more likely to have psychiatric histories than controls (95% CI of difference--1.17%, 23.2%) and were no more likely to have been psychiatric inpatients in the past (95% CI of difference--10.2%, 13.3%). Mean distance of residence from the bridge differed little between jumping suicides and controls (difference 1.7 km 95% CI 0.5, 3.9 km). Altogether 10.2% of jumpers had a past history of schizophrenia. Suicide by jumping is significantly more common in the Bristol and District Health Authority (9.3% of all suicides; 95% CI 7.6%, 11.3%) than in England and Wales (4.9% of suicides). CONCLUSIONS: Patterns of suicide in the Bristol and District Health Authority are affected by the presence of the Clifton Suspension Bridge. Those who commit suicide by jumping from the bridge do not differ significantly from those using other methods of suicide. Provision of safety measures on the bridge may lead to the prevention of some suicides.

OBJECTIVES: Overgeneral autobiographical memory (OGM) is a well-researched phenomenon in working age adults with depression. However, the relevance and importance of OGM in older adult depression is not well established. The aim of this review was to synthesise existing literature on OGM and depressive symptoms in older adults under the framework of the Capture and Rumination, Functional Avoidance and Impaired Executive Control (CaR-FA-X) model. METHOD: Literature searches were conducted using PsychINFO, PubMed and Web of Knowledge. Eighteen articles were reviewed. RESULTS: OGM is elevated in healthy older adults compared to adults of working age, and further elevated in older adults with depression. Evidence supports the role of impaired executive function as a mechanism for OGM in older adults with depression, but no studies measured other components of the CaR-FA-X model (i.e. functional avoidance and rumination). CONCLUSION: OGM is prevalent in older adults and more so for those with depression; however, there is no clear understanding of the underpinning mechanisms. It is recommended that future research looks at the role of functional avoidance and rumination, and at the use of memory specificity interventions being developed in the working age adult literature.

This paper reviews the research literature on gunshot suicide in the United Kingdom and the international literature with reference to strategies aimed at preventing gunshot suicides. Trends in gun ownership and changes in firearm legislation in the UK over the past 20 years are described. Most UK gunshot suicides are male, middle-aged and living with a partner and involve the use of shotguns. They are less likely to have current or past mental health problems, or a previous act of self-harm, than people who commit suicide by other methods, and their suicide is more likely to have been precipitated by a relationship dispute. Where alcohol is consumed the amount tends to be large. The international literature provides evidence of a strong association between rates of gun ownership and gunshot suicide, and some evidence of a reduction in firearm suicide rates following the introduction of restrictive firearm legislation. Over the past 20 years the number of gunshot suicides in the UK has declined by over 50% to a little over a hundred deaths per annum. At the same time, firearm legislation has become progressively more restrictive and rates of gun ownership have declined. Measures, which might further reduce the prevalence of gunshot suicides in the UK, are discussed.

Aims and Method Services were compared for the management of deliberate self-harm with existing national guidance. A postal survey was sent to all clinical directors of adult psychiatry at all NHS trusts assessing adult patients admitted to general hospital following deliberate self-harm in England. Results Responses were received from 129 (65%) trusts.Thirty per cent of trusts do not use secondary psychiatric services for psycho-social assessment following deliberate self-harm; 52% have designated self-harm liaison staff and 69% of general hospitals have a ward to which most cases of deliberate selfharm are admitted. However, only 18% have staff with psychiatric experience. In 82% of trusts training is provided for junior psychiatrists at induction but in only 56% are observed-assessments undertaken. Forty-two per cent of the trusts have a deliberate self-harm services planning group. Clinical Implications Standards for deliberate self-harm services fall substantially below existing national guidelines, particularly in the areas of planning and training.

A series of 14 cases of suicide by drowning in the bath in the Bristol area, England between 1974 and 1996 is presented. There were six males and eight females with a mean age of 66 years. The majority were married and lived with their spouse or another relative. Most drowned at home, face down, fully clothed. Six cases had evidence of concomitant alcohol or substance use. Seven cases had a past psychiatric history and a history of previous deliberate self-harm. Issues concerning prevention are discussed.

This case report describes a person with Prader-Willi syndrome who recently died, aged 71 years. It is suggested that her longevity was helped by being female, with a moderate degree of mental handicap and a degree of weight control which reduced the problems of diabetes and hypertension.

During the course of routine investigations it was noticed that an abnormal number of low serum cholesterol results were occurring in our laboratory, and that these results appeared to come from mentally retarded patients. An investigation was therefore carried out on over 1,400 patients in the Stoke Park Group of Hospitals. Whenever blood was taken for routine haematological examination a serum sample was also collected for cholesterol determination. A preliminary report of these findings was made (Eastham and Jancar, 1967).

A study of 51 consecutive gunshot suicides in the County of Avon, England, between 1974 and 1990 is presented. All cases were male. The majority were married and lived with their spouses. Most suicides occurred in the setting of a domestic dispute, although at least nine had a significant past psychiatric history. Possible implications of firearm legislation and psychiatric treatment on firearm suicide rates are discussed.

Management is an increasingly important issue for many doctors. If doctors wish to influence resource allocation, they must involve themselves in health service management. This article describes the results of an enquiry action learning project involving six doctors. As part of the project, clinical directors and their business managers were interviewed. In addition, the Police Force and BAA (formerly the British Airport Authority) were visited and their management structure, out-of-hours activities and planning for emergencies assessed. This article examines the reasons why many doctors do not involve themselves in management, such as increased time commitment and negative peer pressure, and suggests some solutions to these problems, including the need for a wider understanding of the role of clinical directors. It also considers how some organizations are already starting to address these issues, and how both doctors and hospitals can benefit from greater involvement of doctors in health service management.

BACKGROUND: Chronic fatigue syndrome (CFS, also known as myalgic encephalomyelitis (ME)) is defined as fatigue that is disabling, is accompanied by additional symptoms and persists for ≥ 4 months. Treatment of CFS/ME aims to help patients manage their symptoms and make lifestyle adjustments. We do not know whether intervening early in primary care (< 4 months after onset of fatigue) can prevent the development of CFS/ME. METHODS: This was a feasibility randomised controlled trial with adults (age ≥ 18 years) comparing usual care with usual care plus an early intervention (EI; a combination of psycho-education and cognitive behavioural therapy, CBT). This study took place in fourteen primary care practices in Bristol, England and aimed to identify issues around recruitment and retention for a full-scale trial. It was not powered to support statistical analysis of differences in outcomes. Integrated qualitative methodology was used to explore the feasibility and acceptability of recruitment and randomisation to the intervention. RESULTS: Forty-four patients were recruited (1 August 2012-November 28, 2013), falling short of our predicted recruitment rate of 100 patients in 8 months. Qualitative data from GPs showed recruitment was not feasible because it was difficult to identify potential participants within 4 months of symptom onset. Some referring GPs felt screening investigations recommended by NICE were unnecessary, and they had difficulty finding patients who met the eligibility criteria. Qualitative data from some participant interviews suggested that the intervention was not acceptable in its current format. Although the majority of participants found parts of the intervention acceptable, many reported one or more problems with acceptability. Participants who discontinued the intervention or found it problematic did not relate to the therapeutic model, disliked telephone consultations or found self-reflection challenging. CONCLUSIONS: A randomised controlled trial to test an early intervention for fatigue in adults in primary care is not feasible using this intervention and recruitment strategy. TRIAL REGISTRATION: International Standard Randomised Controlled Trials, ISRCTN72645894. Retrospectively registered on 17 May 2013.

Aims and Method Continuity of care is an important aspect of service provision. We retrospectively examined the number of changes over a 2-year period in care coordinator for new patients on enhanced care in a London borough. Deprivation score, length of hospital stay, and health and social needs were examined for association with continuity of care. Results Twenty-six patients met the inclusion criteria; ten patients (39%) had a change in care coordinator. Patients having one or more changes in care coordinator were found to live in significantly more deprived council wards ( P =0.004), but their needs score ( P =0.863) or length of hospital stay ( P =0.368) were not significantly different than in those who did not have changes in care coordinator. Clinical Implications Social deprivation affects relational continuity of care in community teams but the mechanism requires evaluation.

Developments in research on suicide and deliberate self-harm in the elderly are reviewed with particular reference to psychological autopsy and risk factors. The elderly suicides show high levels of treatable mental health problems, particularly of major depression. The relevance of suicidal ideation and previous suicide attempts is explored.

This paper reports the results of a postal survey conducted to ascertain the views of general practitioners on the service provided by a newly established community mental health team for the elderly. The possible implications of GP fundholding for specialist provision of mental health services are discussed.

Increase in serum gamma globulin concentration with reciprocal reduction in serum albumin concentration is commonly found in patients suffering from Down's syndrome (mongolism) (Carver et al ., 1959; Nelson, 1961; Pritham et al ., 1963). It is possible that gamma globulin of relatively less effective composition than normal is produced, and that hospitalized living increases production of this faulty protein (Pritham et al ., 1963). On the other hand, Polani (1962) suggested that in Down's syndrome there is either exaggerated or diminished response to drugs and hormones, and the raised gamma globulin levels could result from an excessive production of normal gamma globulin, possibly in response to infection.

This article deals with the resettlement of long-term mentally handicapped patients into independent living in wardened accommodation at Priory Court. The emphasis has been on ‘survival‘ and every person thought suitable for the project was given the opportunity to expand his concept of living and be discharged from a long-stay institutional environment. Motivation was the key factor, and staff and patients learnt much from the opportunity. The author gives an outline of the course taken and discusses some of the difficulties and triumphs. It was 3 years ago that long-stay institutional patients were discharged to the freedom of choosing a fuller way of life and from a distance the training team are able to see that these people are succeeding.