Depression and anxiety in patients receiving interferon-alpha: The role of illness perceptions.

Development of psychiatric symptoms during interferon-alpha therapy may be influenced by psychological factors. We examined illness perceptions using the Revised Illness Perceptions Questionnaire in 55 patients with chronic hepatitis C virus infection, due to receive interferon-alpha. The Hospital Anxiety and Depression Scale was used to assess the development of symptoms. Negative identity, consequences and emotional representation beliefs were significantly associated with both higher depression and anxiety scores. Negative illness perceptions play a predictive role in the development of interferon-alpha-induced psychiatric symptoms.

Psychiatric aspects of acute withdrawal from gamma-hydroxybutyrate (GHB) and its analogue gamma-butyrolactone (GBL): implications for psychiatry services in the general hospital.

OBJECTIVE: The objective of this study was to describe the psychiatric symptoms, management and outcomes in a consecutive series of patients being managed medically for symptoms of withdrawal from gamma-hydroxybutyrate (GHB) and its analogue gamma-butyrolactone (GBL) in a general hospital setting. METHODS: A toxicology database was used to identify patients presenting with a history suggestive of withdrawal from GHB and analogues. Electronic and paper medical records were searched for demographic features, neuropsychiatric symptoms, psychiatric management while in hospital and overall outcome. RESULTS: There were 31 presentations with withdrawal from the drugs involving 20 patients. Of these 17 (54%) were referred to and seen by the liaison psychiatry team. Anxiety (61.3%) and agitation (48.4%) were the most common symptoms. Of the 17 cases seen by the liaison psychiatry team, 52.9% required close constant observation by a mental health nurse and 29.4% required to be detained in hospital under mental health legislation. CONCLUSIONS: The significant proportion of patients presenting with neuropsychiatric symptoms and requiring intensive input from the liaison psychiatry team during withdrawal from GHB and its analogues points to the importance of close liaison between medical and psychiatric teams in managing these patients in the general hospital.

Understanding clinical risk decision making regarding development of depression during interferon-alpha treatment for hepatitis-C: a qualitative interview study.

BACKGROUND: Hepatitis C virus (HCV) affects 170 million worldwide. Currently, around 30% of patients receiving interferon-alpha (IFN-α) treatment for HCV experience clinically significant depression. Effective and timely detection of depression is crucial to ensuring appropriate treatment and support. However, little is known about how clinical nurse specialists identify patients at risk of developing interferon-alpha-induced depression, and monitor those receiving antiviral treatment for the occurrence of depression. OBJECTIVE: This study aimed to gain an in-depth understanding of staff experience of, and attitudes towards, the identification and monitoring of interferon-alpha-induced-depression and the decision-making process concerning the use of liaison psychiatry and other clinical services. DESIGN: A qualitative interview study was conducted among clinical staff involved in the care of patients with hepatitis C, using the perspective of naturalistic decision making. SETTINGS: Outpatient liver clinics in three large teaching hospitals in South London, the United Kingdom. PARTICIPANTS: All clinical nurse specialists from the three outpatient liver clinics were included. All were involved directly in the care of patients receiving interferon-alpha treatment and had at least one year experience (mean 6.4 years, range 1-11 years) in this field. METHODS: Semi-structured face-to-face interviews were conducted between 2010 and 2011. Data collection and analysis were carried out iteratively to ensure the reliability of the analysis using the constant comparison method. RESULTS: Staff used verbal and non-verbal cues when assessing risks of patients developing depression before and during IFN-α treatment. Major sources of uncertainty were patient engagement and familiarity, referrals to psychiatrists, language barriers, and distinguishing between psychological and physical symptoms. Good rapport with patients and good communication among multidisciplinary professional groups were key strategies identified to reduce uncertainty. CONCLUSION: Current methods of identifying vulnerable patients rely on the availability of clinical experts and good communication within a multidisciplinary team. Detection and management of depression in this population is complex, however, various strategies are employed by nurses to overcome difficulties when making decisions regarding patient welfare. Current clinical practices should be taken into account when developing new tools and methods.

A survey of psychiatric services for people who attempt suicide in south India.

BACKGROUND AND AIMS: Self-harm is a major public health problem in the southern parts of India. This survey was undertaken to assess the nature of psychiatric services available in hospitals attached to medical colleges for those who have attempted suicide. MATERIALS AND METHODS: After reviewing the relevant literature, a questionnaire was prepared. We sent this questionnaire to 94 medical colleges in South India. RESULTS: The response rate of the survey was 50%. Psychiatric assessment of suicide attempters in the casualty department are done by mental health professionals in 23 (66%) hospitals. Psychotropic medications are prescribed for appropriate patients in 33 (94%) hospitals, while talking therapies are available in 31 (89%) hospitals. Six (17%) centers have training sessions for casualty staff in mental health assessment of patients who have attempted suicide. A majority of hospitals have medical students posted in the psychiatry department. CONCLUSIONS: The services available for people who have attempted suicide appear to be patchy in south Indian teaching hospitals. Training of frontline staff in the assessment and management of people who have attempted suicide is extremely important.

Quality of psychiatric care in the general hospital: referrer perceptions of an inpatient liaison psychiatry service.

AIMS: To explore the experience of senior staff on acute medical wards using an established inpatient liaison psychiatry service and obtain their views on clinically relevant performance measures. METHODS: Semistructured face-to-face interviews with consultants and senior nurses were taped, transcribed and analyzed manually using the framework method of analysis. RESULTS: Twenty-five referrers were interviewed. Four key themes were identified - benefits of the liaison service, potential areas of improvement, indices of service performance such as speed and quality of response and expanded substance misuse service. Respondents felt the liaison service benefited patients, staff and service delivery in the general hospital. Medical consultants wanted stepped management plans devised by consultant liaison psychiatrists. Senior nurses, who perceived themselves as frontline crisis managers, valued on-the-spot input on patient management. CONCLUSIONS: Consultants and senior nurses differed in their expectations of liaison psychiatry. Referrers valued speed of response and regarded time from referral to definitive management plan as a key performance indicator for benchmarking services.

Malayalam cinema and mental health.

There is a tradition of using films to teach various aspects of psychiatry and we feel that Malayalam cinema can also be used suitably to teach effectively. These films can be an invaluable resource in cultural competency training as they depict the effects of culture on psychopathology and cultural and regional influences on attitudes to mental illness and stigma. We also note that the portrayal is often far from reality but this is not a barrier for using the films as an effective alternative to traditional and didactic teaching methods. This method of teaching can stimulate interest and discussion and demystify the myths of novice students and others about mental health.

Delirium and its treatment.

Delirium occurs at rates ranging from 10% to 30% of all hospital admissions. It is a negative prognostic indicator, often leading to longer hospital stays and higher mortality. The aetiology of delirium is multifactorial and many causes have been suggested. The stress-diathesis model, which posits an interaction between the underlying vulnerability and the nature of the precipitating factor, is useful in understanding delirium. Preventing delirium is the most effective strategy for reducing its frequency and complications. Environmental strategies are valuable but are often underutilized, while remedial treatment is usually aimed at specific symptoms of delirium. Antipsychotics are the mainstay of pharmacological treatment and have been shown to be effective in treating symptoms of both hyperactive and hypoactive delirium, as well as generally improving cognition. Haloperidol is considered to be first-line treatment as it can be administered via many routes, has fewer active metabolites, limited anticholinergic effects and has a lower propensity for sedative or hypotensive effects compared with many other antipsychotics. Potential benefits of atypical compared with typical antipsychotics include the lower propensity to cause over-sedation and movement disorder. Of the second-generation antipsychotics investigated in delirium, most data support the use of risperidone and olanzapine. Other drugs (e.g. aripiprazole, quetiapine, donepezil and flumazenil) have been evaluated but data are limited. Benzodiazepines are the drugs of choice (in addition to antipsychotics) for delirium that is not controlled with an antipsychotic (and can be used alone for the treatment of alcohol and sedative hypnotic withdrawal-related delirium). Lorazepam is the benzodiazepine of choice as it has a rapid onset and shorter duration of action, a low risk of accumulation, no major active metabolites and its bioavailability is more predictable when it is administered both orally and intramuscularly.

Depression, demoralisation or adjustment disorder? Understanding emotional distress in the severely medically ill.

As emotional distress is often seen as an understandable reaction to a severe or life-threatening illness, clinicians are reluctant to make a diagnosis of depression and resort to alternative diagnoses such as adjustment disorder (AD) or demoralisation. This paper introduces these concepts and critically examines their clinical utility. It concludes that neither AD nor demoralisation can be clearly distinguished from depression on variables such as clinical symptoms, outcome or treatment response. Since AD and demoralisation are considered transient or understandable reactions, the risk of using these diagnoses as alternatives to depression in a clinical setting is that a simplistic approach of psychological therapies for the former and antidepressants for the latter will be adopted. Instead, a working diagnosis of a general distress syndrome complemented by a personalised formulation is advocated. This would lead to the generation of a problem list and a pragmatic management plan.

Gender differences in medically serious suicide attempts: a study from south India.

Studying gender differences in suicidal behaviour is important in developing specific need-based service provisions. We aimed to identify gender-specific characteristics associated with attempted suicide in a general hospital sample in south India. Two hundred and three patients admitted to medical wards following suicide attempts were assessed using a detailed clinical interview, measures of suicide intent (Suicide Intent Scale), lethality (Risk Rescue Rating), depression (Montgomery-Asberg Depression Rating Scale) and recent stress (Presumptive Stressful Life Events Scale). The majority of men attempting suicide were single. Men were more likely to use organophosphate poisons in their attempt to kill themselves and had higher rates of mental illness than women. As compared with men, women were more likely to come from rural areas, had a lower educational status, and had lower rates of employment outside the home. In women, the most common method of suicide attempt was by using plant poisons. Suicide attempt by self-immolation was significantly higher among women. Men had higher suicidal intent than women, although lethality, depression and stress were comparable between the genders. Rural women were more disadvantaged in education; however, in urban areas, men had higher psychiatric morbidity. Our results emphasise the need for a gender-specific approach among people who have attempted suicide.

Dhat syndrome as a functional somatic syndrome: developing a sociosomatic model.

Dhat syndrome is a widely recognized condition from the Indian subcontinent with fatigue and preoccupation with semen loss as the main presenting symptoms. This condition has been considered to be a culture-bound syndrome, but little is known about its illness characteristics and similarities with other conditions with medically unexplained symptoms. In this paper we review the current research on dhat syndrome, discuss its similarities and differences with other functional somatic syndromes, and propose an integrated model that incorporates both psychological and sociocultural factors. Under stress, persons predisposed to amplification of somatic symptoms and health anxiety may focus attention on physiological changes such as turbidity of urine and tiredness, and misattribute them to loss of semen in the light of widely prevalent health beliefs. This attribution may then be confirmed by traditional views as well as by local practitioners subscribing to similar beliefs. The clinical and research implications of understanding this condition as a functional somatic syndrome, the presentation of which is significantly modified by culture, are discussed.

Dhat (semen loss) syndrome: a functional somatic syndrome of the Indian subcontinent?

OBJECTIVE: To study the illness characteristics of Dhat syndrome, which has been widely regarded as a culture-bound syndrome. METHODS: The sample was selected from a general hospital and included 29 patients with Dhat syndrome and 32 medical controls. Somatization Screening Index (SSI), Illness Behaviour Questionnaire (SIBQ), Somatosensory Amplification Scale (SAS), Whitley Index (WI) and Chalder Fatigue Scale were administered to both groups. RESULTS: Patients with Dhat syndrome scored significantly higher on all the measures except the SAS. DISCUSSION: The results indicate that patients with Dhat syndrome have significantly different illness beliefs and behaviours compared to controls and have similarities with other functional somatic syndromes (FSSs).

Personality as a determinant of social functioning in depression.

BACKGROUND: The Social Adaptation Self-Evaluation Scale (SASS) is an instrument for measuring drive-based aspects of social functioning and has been used in trials of antidepressants. It has been suggested that social adaptation may be akin to a personality trait. We investigated the personality dimensions of neuroticism and extraversion as determinants of social functioning measured by SASS in patients with depression. METHODS: Patients seen at a tertiary mood disorders unit were assessed using SASS, Eysenck Personality Questionnaire (EPQ), Inventory of Depressive Symptoms-Self-Rated (IDS-SR) and Mood Disorders Questionnaire (MDQ). RESULTS: In a sample of 80 depressed outpatients, we found that extraversion made the largest unique contribution to social functioning followed by self-rated severity of depression. Neuroticism and other clinical and demographic variables were not significant predictors. CONCLUSIONS: Social functioning as measured by SASS is predicted by extraversion and severity of depression. Personality traits should be taken into account when assessing social functioning in depression.

'Refusing treatment--please see': an analysis of capacity assessments carried out by a liaison psychiatry service.

The assessment of capacity to consent to a healthcare decision is an important part of day-to-day work in general hospitals. The role of liaison psychiatric services in assessment of capacity has not been well studied in British practice. We looked at all such referrals (35) to a liaison psychiatric service in a teaching hospital in the course of one year. The commonest referrals were regarding capacity to consent to a therapeutic procedure, followed by post-discharge placement and ability to self-discharge. Organic mental disorders were the most frequent cause of incapacity. 20 (57%) of the referrals were for patients who had refused the intervention in question, and in 12 of these the contentious issue was resolved. Liaison psychiatric services can be useful not only in offering a second opinion or clarifying the influence of psychopathology on decision-making ability but also mediating between the patient and the clinical team.