St Cadoc's Hospital

BACKGROUND: Psychological debriefing (PD) is widely used following major traumatic events in an attempt to reduce psychological sequelae. METHOD: One hundred and thirty-three adult burn trauma victims entered the study. After initial questionnaire completion, participants were randomly allocated to an individual/couple PD group or a control group who received no intervention; 110 (83%) were interviewed by an assessor blind to PD status three and 13 months later. RESULTS: Sixteen (26%) of the PD group had PTSD at 13-month follow-up, compared with four (9%) of the control group. The PD group had higher initial questionnaire scores and more severe dimensions of burn trauma than the control group, both of which were associated with a poorer outcome. CONCLUSION: This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives.

BACKGROUND: Experiencing life-threatening events often contributes to the onset of such psychiatric conditions as post-traumatic stress disorder (PTSD). Children can develop PTSD; however, there is controversy over whether PTSD symptoms decrease or persist over time. AIMS: To examine the long-term effects of surviving the 1966 Aberfan disaster in childhood. METHOD: Survivors (n=41) were compared with controls (n=72) matched for age and background. All were interviewed using the Composite International Diagnostic Interview, measures of current health and social satisfaction, and the General Health Questionnaire. The survivor group also completed the Impact of Event Scale to assess current levels of PTSD. RESULTS: Nineteen (46%; 95% CI 31-61) survivors had had PTSD at some point since the disaster, compared with 12 (20%; 95% CI 10-30) controls (OR=3.38 (95% CI 1.40-8.47)). Of the survivors,12 (29%; 95% CI 15-43) met diagnostic criteria for current PTSD. Survivors were not at a significantly increased risk of anxiety, depression or substance misuse. CONCLUSIONS: Trauma in childhood can lead to PTSD, and PTSD symptoms can persist for as long as 33 years into adult life. Rates of other psychopathological disorders are not necessarily raised after life-threatening childhood trauma.

Abstract Consultants in old age psychiatry were sent a questionnaire concerning their practice in informing dementia patients and their carers about the diagnosis and prognosis. The results showed a wide variation in practice. Carers almost invariably were told of the diagnosis. Patients with severe dementia were almost never told. There was more of a tendency to tell moderately affected sufferers but for patients with mild dementia practice was variable. There was a significant difference between all categories of dementia and the carer category for both diagnosis and prognosis giving. Informing patients of diagnosis differed from informing of prognosis only in the mild dementia category, with the tendency to give diagnosis more frequently than prognosis. Carers were also given diagnosis more frequently than prognosis. The article discusses some of the issues involved in giving information on diagnosis and prognosis to patients with dementia.

A computer-assisted and cross-reference literature search identified trials of therapy for alcohol withdrawal symptoms. Those with a randomized, double-blind placebo-controlled design were systematically assessed for quality of methodology. Fourteen studies were identified investigating 12 different drugs. The quality of methodological design, even among this highly selected group of published studies, was often poor. Study populations were generally under-defined, most studies excluded severely ill patients, control groups were poorly matched, and the use of additional medication may have confounded results in some studies. Twelve different rating scales were used to assess severity of symptoms. All 12 compounds investigated were reported to be superior to placebo, but this has only been replicated for benzodiazepines and chlormethiazole. Further research using better methods is required to allow comparison of different drugs in the treatment of alcohol withdrawal symptoms. On the evidence available, a long-acting benzodiazepine should be the drug of first choice.

Cognitive–behavioural therapy (CBT) is an effective treatment for a number of psychiatric disorders in adults of all ages. With the proportion of the population aged 65 or over increasing steadily, it is important to be aware of how the CBT needs of this age group can be best met. This article provides an overview of CBT and the historical context of using it with older people. Although an understanding of the individual, irrespective of age, is at the core of CBT, potential modifications to the procedure and content aimed at optimising its effectiveness for older people are discussed.

This paper reviews the literature on the use of rating scales within the treatment of the alcohol-withdrawal syndrome. A computer-assisted literature search identified trials of therapy for and rating scales used in alcohol-withdrawal states. Eighteen rating scales were identified. There is a wide variation in symptom items included in these scales. Scales also vary in their length and ease of application. We conclude that it is important to use validated and reliable assessment scales in research if proper comparisons of treatments for the alcohol-withdrawal syndrome are to be made.

PURPOSE OF REVIEW: This article draws upon articles published since 2009 to identify research evidence about the psychosocial aspects of children and young people's responses to their exposure to war, collective violence and terrorism. RECENT FINDINGS: Recent research describes children's distress and the disorders they may develop consequent on their direct and indirect exposure to war. This article covers general responses as well as those that affect refugees, displaced children, and child soldiers. Dose of exposure is the main predictor of their degree of distress. Often, loss of parental support predicts distress or disorder. Research on children who are refugees and internally displaced persons has found that they cope better with the distressing events surrounding their flight if their parents accompany them. Studies of child soldiers show that they suffer from guilt as well as experiencing many violent distressing events. Research has identified the factors that contribute to their resilience, which include their acceptance by the communities to which they return. There are personal and social sources of resilience, including emotion regulation, parenting, and social support, for children who are exposed to war. SUMMARY: Much of the recent research confirms earlier findings, which demonstrate that their exposure to war and collective violence leads to distress for many children and/or mental disorders for a smaller but substantial minority of them. The literature shows interest in identifying and measuring protective factors. The emphasis in the articles we reviewed on social as well as personal factors that confer psychosocial resilience reflects the broad interest in the two canons of literature on children's development and disasters. The findings point powerfully to people's needs for holistic and community-level interventions.

ObjectiveTo determine whether children with attention deficit hyperactivity disorder (ADHD) and mild intellectual disability (ID) are a clinically distinct ADHD subgroup.Study designThis was a cross-sectional study comparing clinical characteristics (ADHD subtypes, total number of symptoms, and rates of common comorbidities) between children with ADHD and mild ID and those with ADHD and IQ test scores >70, and also between children with ADHD and ID and a general population sample of children with ID alone. The sample comprised a clinical sample of children with ADHD with ID (n = 97) and without ID (n = 874) and a general population sample of children with ID and without ADHD (n = 58).ResultsAfter correcting for multiple statistical tests, no differences were found between the 2 ADHD groups on any measure except the presence of conduct disorder (CD) symptoms and diagnoses. Children with ADHD and ID had higher rates of both (OR, 2.38; 95% CI, 1.71-3.32 and OR, 2.69; 95% CI, 1.69-4.28, respectively). Furthermore, children with ADHD and ID had significantly higher rates of oppositional defiant disorder (OR, 5.54; 95% CI, 2.86-10.75) and CD (OR, 13.66; 95% CI, 3.25-57.42) symptoms and a higher incidence of oppositional defiant disorder diagnoses (OR, 30.99; 95% CI, 6.38-150.39) compared with children with ID without ADHD.ConclusionChildren with ADHD and mild ID appear to be clinically typical of children with ADHD except for more conduct problems. This finding has implications for clinicians treating these children in terms of acknowledging the presence and impact of ADHD symptoms above and beyond ID and dealing with a comorbid CD. To determine whether children with attention deficit hyperactivity disorder (ADHD) and mild intellectual disability (ID) are a clinically distinct ADHD subgroup. This was a cross-sectional study comparing clinical characteristics (ADHD subtypes, total number of symptoms, and rates of common comorbidities) between children with ADHD and mild ID and those with ADHD and IQ test scores >70, and also between children with ADHD and ID and a general population sample of children with ID alone. The sample comprised a clinical sample of children with ADHD with ID (n = 97) and without ID (n = 874) and a general population sample of children with ID and without ADHD (n = 58). After correcting for multiple statistical tests, no differences were found between the 2 ADHD groups on any measure except the presence of conduct disorder (CD) symptoms and diagnoses. Children with ADHD and ID had higher rates of both (OR, 2.38; 95% CI, 1.71-3.32 and OR, 2.69; 95% CI, 1.69-4.28, respectively). Furthermore, children with ADHD and ID had significantly higher rates of oppositional defiant disorder (OR, 5.54; 95% CI, 2.86-10.75) and CD (OR, 13.66; 95% CI, 3.25-57.42) symptoms and a higher incidence of oppositional defiant disorder diagnoses (OR, 30.99; 95% CI, 6.38-150.39) compared with children with ID without ADHD. Children with ADHD and mild ID appear to be clinically typical of children with ADHD except for more conduct problems. This finding has implications for clinicians treating these children in terms of acknowledging the presence and impact of ADHD symptoms above and beyond ID and dealing with a comorbid CD.

Arts for health interventions are emerging as an alternative option to medical management of mental health problems and well-being. This study investigated process and outcomes of an art intervention on patients referred by primary care professionals, including associations between patient characteristics (e.g., sex), progress through the intervention (e.g., attendance), and changes in mental well-being. Referral criteria included people with anxiety, depression, or stress; low self-esteem, confidence, or overall well-being; and chronic illness or pain. The study took place in U.K.-based general practitioner practices, with a total of 202 patients referred to a 10-week intervention. Patient sociodemographic information was recorded at baseline, and patient progress assessed throughout the intervention. Significant improvement in well-being was revealed for the 7-item (t = -6.049, d.f. = 83, P < 0.001, two-tailed) and 14-item (t = -6.961, d.f. = 83, P < 0.001, two-tailed) scales. Of referred patients, 77.7% attended and 49.5% completed. Most patients were female, and from a range of socioeconomic groups, and those who completed were significantly older (t = -2.258, d.f. = 145, P = 0.025, two-tailed). Findings reveal that this art intervention was effective in the promotion of well-being and in targeting women, older people, and people from lower socioeconomic groups.

PURPOSE OF REVIEW: The importance of ensuring robust arrangements for young people's transitions from specialist child and adolescent mental health services to specialist mental health services for adults is well documented in the international literature. Nonetheless, according to young people, there remains great variation in the quality of services in respect of their transitions. Furthermore, the problems that we report are by no means confined to single continents. This review examines recent literature and explores the themes that emerge from it with a view to finding solutions. RECENT FINDINGS: Our findings from the literature suggest a clear strategic direction to improve the quality of the care of young people who need to move from specialist child and adolescent mental health services to specialist mental health services for adults. Our examination of the literature identifies a number of themes that have been recognized by practitioners and we have used them to define a model of care and aspects of good practice. We think they should be included within all evidence-based policies, protocols and care pathways for young people. There is little literature available that documents the personal experiences of young people in transition and their families, but consistent themes emerge from what is available. SUMMARY: There are a number of topics that require active consideration when preparing young people for transition between services. Despite the limited volume of research, and particularly that which has directly involved young people and families, we know from anecdote, experience and local audit and research that improvements in service design and practice are required. These matters inform the solutions that we suggest. We see as pivotal involving young people directly in planning their own care and setting quality standards for healthcare and other services.

‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. Healthcare across the world pushes at the limits of its affordability. Driven by the development of newer and usually more expensive treatments, financial incentives that tend to reward providers for doing more, and consumerism and entitlement, and lower value care have grown alongside essential services. Market-based health systems, such as in the USA, have grown fastest while most state-funded systems have required above-inflation uplifts to keep pace with demand. The National Health System (NHS) in England has been warned that sustainability cannot be achieved through traditional methods of funding and management: services must be provided in new ways.1 Otherwise, austerity means cuts, planned or unplanned. In this context, the notion that 20%–30% of healthcare is unnecessary and/or harmful2 offers an attractive and intuitively simple solution. Stop providing low-value care and important care will be more affordable. Picking this low-hanging fruit is simple in concept and morally defensible, but it will not be easy to achieve. It will require an unprecedented level of change. The complexity of any large-scale change can be quantified in three dimensions:3 pervasiveness (how much of the system does it affect?), depth (how different is the new model to current ways of thinking and doing?) and size (how widely spread is the change across geographical boundaries, organisations or distinct groups of people). The examples below illustrate that complexity in practice. A study of low-value tests and surgical procedures among US Medicare patients4 identified low-value care for 42% of beneficiaries. However, this attractively large proportion accounted for just 2.7% of overall spending. Moreover, these estimates reflected ‘sensitive measures’ of overuse (ie, ones unlikely …

This article looks at one attempt to allow a particularly vulnerable group of men, those in contact with mental health services, to explore men's health issues in a men-only group environment. Based on an examination of current literature on men's health issues and feedback from participants in the group sessions, the authors suggest that nursing should rethink its position on the issue of men's health.

aUniversity of Glamorgan, Pontypridd, UK bGwent Healthcare NHS Trust, UK Correspondence to Richard Williams, Ty Bryn, St Cadoc's Hospital, Lodge Road, Caerleon, Near Newport, Gwent NP18 3XQ, UK Tel: +44 1633 436832; e-mail: [email protected]

The response of patients with major depressive illness to citalopram of amitriptyline was compared in a double-blind multi-centre trial. No differences in efficacy were observed, but citalopram had less hypnotic effect, and a remarkably lower profile of side-effects.

BACKGROUND: Expert clinical judgement combines technical proficiency with humanistic qualities. AIMS: To test the psychometric properties of questionnaires to assess the humanistic qualities of working with colleagues and relating to patients using multisource feedback. METHOD: Analysis of self-ratings by 347 consultant psychiatrists and ratings by 4422 colleagues and 6657 patients. RESULTS: Mean effectiveness as rated by self, colleagues and patients, was 4.6, 5.0 and 5.2 respectively (where 1=very low and 6=excellent). The instruments are internally consistent (Cronbach's alpha >0.95). Principal components analysis of the colleague questionnaire yielded seven factors that explain 70.2% of the variance and accord with the domain structure. Colleague and patient ratings correlate with one another (r=0.39, P<0.001) but not with the self-rating. Ratings from 13 colleagues and 25 patients are required to achieve a generalisability coefficient (Erho(2)) of 0.75. CONCLUSIONS: Reliable 360-degree assessment of humane judgement is feasible for psychiatrists who work in large multiprofessional teams and who have large case-loads.

People with bulimia nervosa are often ambivalent about coming for help. Motivational interviewing considers ambivalence to be a normal and appropriate state for anyone considering behavioural change. By exploring ambivalence and considering the readiness of a client to change, a structure is created that builds collaboration between therapist and client, and avoids conflict: this can help in establishing change in eating behaviour and is compatible with other therapeutic models. © 1997 John Wiley & Sons, Ltd. and Eating Disorders Association.

The Community Intensive Therapy Team (CITT) has been operating since 1998. It was developed to cater for the needs of patients with complex difficulties referred to a specialist Child and Adolescent Health Service (CAMHS) in South Wales, UK. The patients served by the CITT are comparable with patients who might be referred for admission to an inpatient unit and include patients with eating disorders, psychosis, affective disorders, adjustment disorders or repetitive self-harm. The theoretical model used is based on a biopsychosocial model which aims to empower and support family members. The philosophy of the CITT is to work with the child and family in their own environment, tailoring the therapy to the needs of all concerned. CITT makes use of the strengths within the patient, the family and extended family, the agencies already involved and the environment. Since its introduction, the CITT has been able to manage all the complex referrals made to it from the generic Tier 2/3 CAMHS teams it serves, with minimal recourse to inpatient beds.

PURPOSE OF REVIEW: We summarize and discuss recent work that highlights the role of patients and carers in educating practitioners in the light of earlier findings. RECENT FINDINGS: In today's National Health Services in the UK, a changing value base is emerging based on the participation of practitioners, patients and carers, with each group contributing to the education and training of healthcare professionals. The role of patients and carers in education is changing as the value of their experience and expertise is acknowledged. Now professionals are more actively recognizing that service users can contribute usefully to teaching in more unique ways, as 'experts' in their illness. They bring different perspectives and ways of thinking that can instill a new dimension to delivering healthcare services and training. Their expertise is defined by experience, and this different perspective gives them a unique role in teaching. They represent a potential teaching resource for medical education that is grossly underutilized. SUMMARY: Patients and carers are experts in their particular circumstances and blending their expertise with that of professionals is likely to contribute to the best outcome in a particular situation. They are a valuable resource as potential teachers at all stages of medical education.

Background 1 People with mild intellectual disability (ID) experience a higher prevalence of mental health (MH) problems in comparison to the general population, yet there is little consensus on the most appropriate type and nature of services for support and treatment for this specific group of individuals.Objective The objective of this scoping review is to explore the current evidence for the organization, structure, and delivery of mental health services for people with mild ID.Methods The PRISMA-SCr (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist was followed. Online databases were used to identify systematic reviews, meta-analyses, scoping reviews, or guidelines published between 2003 and 2020. Articles were reviewed using Roever & Zoccai criteria for critical appraisal of systematic reviews and meta-analyses.Results 130 records were identified, of which 91 were longlisted. Of these, 28 articles were shortlisted after review of abstracts prior to review of full-text papers. The review included 11 studies: one meta-analysis, eight systematic reviews, and two scoping reviews. These studies approached the provision of mental health services for individuals with mild ID from various angles – including service organization and access, therapies, and patient feedback.Conclusions According to the Roever & Zoccai criteria, there was a lack of high-quality evidence, which limited the findings and conclusions. The available evidence suggested that despite higher levels of psychopathology there is not a corresponding consideration in care for individuals with mild ID in general psychiatric services. There was no conclusive evidence on better level of services or outcomes being provided either by the general psychiatric services or specialist ID psychiatric services. Some evidence was found for intensive case management and assertive outreach for individuals with mild ID, but this was not replicated in further studies.In terms of treatment, there was no high-quality evidence found for pharmacological interventions, with some limited evidence around psychological therapy for the treatment of depression in this vulnerable population. Overall, it was found that an increase in staff training would be beneficial in terms of timely access to services and appropriate treatment.There is a need for inclusive, evidence-based guidance as regards service development for people with mild ID and MH problems.Abbreviations: ID: intellectual disability; MH: mental health; CBT: Cognitive Behavioral Therapy; RCT: randomized controlled trial; ACT: assertive community treatment; ECT: electroconvulsive therapy

This article highlights a study into the effects of witnessing violence in a psychiatric hospital setting. The results show that the majority of respondents who had witnessed violence to a colleague experienced similar emotional distress as the victims. The authors suggest measures that may help staff in these and other clinical areas. They conclude that violence to staff should not be an accepted part of the working environment.