A Devil's dictionary for mental health.

Clinical psychiatry, for all its emphasis on scientific rigour, is mediated mainly by words rather than by numbers. As with other professional areas, it has developed its own set of jargon words and phrases. Many of these are not the technical terms traditionally seen as jargon, but standard English words and phrases used in an idiosyncratic way. They therefore go unnoticed as jargon, while enfeebling our communications. I have used the template of Ambrose Bierce's The Devil's Dictionary to highlight some examples, with the aim of helping us all to talk, write and, perhaps, think more clearly.

Treatment-resistant schizophrenia: current insights on the pharmacogenomics of antipsychotics.

Up to 30% of people with schizophrenia do not respond to two (or more) trials of dopaminergic antipsychotics. They are said to have treatment-resistant schizophrenia (TRS). Clozapine is still the only effective treatment for TRS, although it is underused in clinical practice. Initial use is delayed, it can be hard for patients to tolerate, and clinicians can be uncertain as to when to use it. What if, at the start of treatment, we could identify those patients likely to respond to clozapine - and those likely to suffer adverse effects? It is likely that clinicians would feel less inhibited about using it, allowing clozapine to be used earlier and more appropriately. Genetic testing holds out the tantalizing possibility of being able to do just this, and hence the vital importance of pharmacogenomic studies. These can potentially identify genetic markers for both tolerance of and vulnerability to clozapine. We aim to summarize progress so far, possible clinical applications, limitations to the evidence, and problems in applying these findings to the management of TRS. Pharmacogenomic studies of clozapine response and tolerability have produced conflicting results. These are due, at least in part, to significant differences in the patient groups studied. The use of clinical pharmacogenomic testing - to personalize clozapine treatment and identify patients at high risk of treatment failure or of adverse events - has moved closer over the last 20 years. However, to develop such testing that could be used clinically will require larger, multicenter, prospective studies.

Sectioning on the street - futility or utility?

Aims and method A service evaluation was undertaken to examine outcomes in patients who were street homeless ('rough sleepers') and who were compulsorily admitted to hospital under the Mental Health Act 1983. The data were collected from the patients' case notes. Results At 1-year follow-up, patients had positive outcomes in areas such as accommodation status, registration with a general practitioner and engagement with the clinical team. Clinical implications The study shows that the intervention of a Mental Health Act assessment and compulsory hospital admission in homeless people on the street is associated with positive outcomes at 1 year.

Burden of mental disorders and unmet needs among street homeless people in Addis Ababa, Ethiopia.

BACKGROUND: The impact of mental disorders among homeless people is likely to be substantial in low income countries because of underdeveloped social welfare and health systems. As a first step towards advocacy and provision of care, we conducted a study to determine the burden of psychotic disorders and associated unmet needs, as well as the prevalence of mental distress, suicidality, and alcohol use disorder among homeless people in Addis Ababa, the capital of Ethiopia. METHODS: A cross-sectional survey was conducted among street homeless adults. Trained community nurses screened for potential psychosis and administered standardized measures of mental distress, alcohol use disorder and suicidality. Psychiatric nurses then carried out confirmatory diagnostic interviews of psychosis and administered a locally adapted version of the Camberwell Assessment of Needs Short Appraisal Schedule. RESULTS: We assessed 217 street homeless adults, about 90% of whom had experienced some form of mental or alcohol use disorder: 41.0% had psychosis, 60.0% had hazardous or dependent alcohol use, and 14.8% reported attempting suicide in the previous month. Homeless people with psychosis had extensive unmet needs with 80% to 100% reporting unmet needs across 26 domains. Nearly 30% had physical disability (visual and sensory impairment and impaired mobility). Only 10.0% of those with psychosis had ever received treatment for their illness. Most had lived on the streets for over 2 years, and alcohol use disorder was positively associated with chronicity of homelessness. CONCLUSION: Psychoses and other mental and behavioural disorders affect most people who are street homeless in Addis Ababa. Any programme to improve the condition of homeless people should include treatment for mental and alcohol use disorders. The findings have significant implications for advocacy and intervention programmes, particularly in similar low income settings.