Post-COVID-19: can digital solutions lead to a more equitable global healthcare workforce?

An unintended consequence of the COVID-19 pandemic has been the exponential growth of telemedicine, with automation of healthcare becoming more common. Face-to-face meetings and training events have been replaced relatively seamlessly with online versions, taking clinical or academic expertise to distant parts of the world and making them more accessible and affordable. The wide reach of digital platforms offering remote healthcare offers the opportunity of democratising access to high-quality healthcare, However, certain challenges remain: (a) clinical guidance developed in one geographical area may need adaptation for use in others; (b) regulatory mechanisms from one jurisdiction need to offer patient safety across other jurisdictions; (c) barriers created by disparity in technology infrastructure and the variation in pay for services across different economies, leading to brain drain and an inequitable workforce. The World Health Organization's Global Code of Practice on the International Recruitment of Health Personnel could offer the preliminary framework on which solutions to these challenges could be built.

Digital psychiatry and COVID-19: the Big Bang effect for the NHS?

The COVID-19 pandemic has brought untold tragedies. However, one outcome has been the dramatically rapid replacement of face-to-face consultations and other meetings, including clinical multidisciplinary team meetings, with telephone calls or videoconferencing. By and large this form of remote consultation has received a warm welcome from both patients and clinicians. To date, human, technological and institutional barriers may have held back the integration of such approaches in routine clinical practice, particularly in the UK. As we move into the post-pandemic phase, it is vital that academic, educational and clinical leadership builds on this positive legacy of the COVID crisis. Telepsychiatry may be but one component of 'digital psychiatry' but its seismic evolution in the pandemic offers a possible opportunity to embrace and develop 'digital psychiatry' as a whole.

Domiciliary and day care services: Why do people with dementia refuse?

OBJECTIVE: To explore the reasons given for refusal of day services, and to examine the relationship between willingness to accept day services and clinical variables. METHOD: Fifty people with dementia who lived alone and had refused day services were interviewed. RESULTS: The most common reasons for reluctance to attend day services were the belief that they did not need day services, that they liked being on their own, and the belief that they would not enjoy it. People who persistently refused day services tended to have additional worries about meeting new people, losing their independence and being institutionalised. Fifty-four per cent of people with dementia who lived alone and had refused day services scored six or more on the Cornell Scale for Depression in Dementia, suggesting possible presence of major depression. CONCLUSION: In patients with dementia who live alone and refuse day services, their misconceptions about day services and possibility of undiagnosed depression need further exploration.

Relationship between extrapyramidal symptoms and serum anticholinergic levels in treated chronic schizophrenics.

Serum anticholinergic levels were measured by radioreceptor assay (RRA) in schizophrenic patients treated for drug-induced Parkinsonism; 68 patients stabilized on a single neuroleptic and an anticholinergic antiparkinsonian agent (benzhexol, benztropine or procyclidine) were assessed using the extrapyramidal side effects (EPS) scale prior to each blood sampling. Serum anticholinergic levels showed a significant inverse correlation with EPS but did not appear to be dose-related in any of the three anticholinergic drug groups. Percentage binding to proteins was significantly less with benztropine than either benzhexol or procyclidine. Serum-free anticholinergic levels correlated significantly with total serum levels in the benzhexol and procyclidine groups but not in the benztropine group. At serum levels above 4.5 pmol/ml atropine equivalents, EPS was significantly less than at levels below that. We discuss the implications of this finding and suggest practical clinical applications of measurement of serum anticholinergic levels. Serum neuroleptic and serum prolactin levels did not correlate with either dose or serum level of anticholinergics.

Bipolar affective disorder following head injury.

A patient developed distinct episodes of major depressive illness, schizophreniform psychoses and mania as well as focal epilepsy following head injury. Head injury may be directly causative in the development of affective psychoses, in this case secondary bipolar (mixed) disorder.

Chronic psychosis in Turner's syndrome. Case report and a review.

A 59-year-old woman with Turner's syndrome developed epilepsy, diabetes mellitus, chronic psychosis, and subsequently pre-senile dementia. This would endorse the view that psychosis in Turner's syndrome arises through brain damage.

Epidemiology of schizophrenia in Salford, 1974-84. Changes in an urban community over ten years.

The prevalence and inception rates of treated schizophrenia in the population of inner-city Salford were compared with those from a similar survey, ten years earlier. Data were obtained from a computerised case register and a postal questionnaire sent to GPs, and case notes rated on the SCL and screened using ICD-9. The point-prevalence rate of 6.26 per 1000 adult population was higher than that previously reported (4.56), despite decreases in total inception rate and in the general population. Changes in rates are presumed to be related primarily to population movements and ageing of the schizophrenic sample. Compared with 1974, the numbers of in-patient days and long-stay in-patients had fallen substantially by 1984, although annual admissions increased over the decade; day-patient and out-patient attendances, and extramural contacts with psychiatrists, community psychiatric nurses, and social workers had also increased. Almost 62% of cases were maintained on depot injections as out-patients in 1984. Over 75% of identified schizophrenic patients were in contact with psychiatrists, but only 7 out of 557 were solely in contact with their GP. In spite of the emphasis on community care, responsibility for schizophrenic patients was still carried overwhelmingly by hospital psychiatric services.

Prodromal signs of relapse in schizophrenia.

Fifty-six patients who were hospitalised for a schizophrenic episode were followed up for nine months after discharge. The Psychiatric Assessment Scale (PAS, Krawiecka et al., 1977) was administered at monthly intervals during this period. Twenty-three patients relapsed of which data were available for sixteen. In these sixteen patients who relapsed comparisons were made of the PAS symptoms between the month prior to relapse and the month preceding this. Sixteen patients who did not relapse were randomly matched with the relapsing patients and an index point comparable in time to relapse onset in the matched relapsed patient was identified. Comparisons were made on the PAS symptoms using a repeated measures ANOVA to compare relapsers and non relapsers on the month prior to relapse and the month which preceded this. Discriminant function analysis was used to predict relapse by analysis of those PAS symptoms which showed an increase in the month before relapse. This suggested that the measures of depression and hallucinations significantly increased in the month prior to relapse compared to the preceding month in relapsers but not non-relapsers. The results of this study closely agree with previous published results even though there were some differences between studies in the patient samples.

Plasma levels of fluphenazine decanoate. Effects of site of injection, massage and muscle activity.

Depot neuroleptics are now commonly used for maintenance therapy of schizophrenia. Their physicochemical composition makes them ideal for such use because they are long-acting and show stable blood levels for prolonged periods. Their absorption from the site of injection may, however, be affected by local muscle factors. This paper describes three such factors in relation to fluphenazine decanoate: varying the site of injection; massage of the injection site; and effects of muscular exercise. Our results suggest that fluphenazine pharmacokinetics are not significantly affected by any of these factors.

Assessing the functional value of relatives' knowledge about schizophrenia: a preliminary report.

An instrument for assessing and evaluating what relatives know about schizophrenia was evaluated as both a pre- and a post-test for an educational programme. The Knowledge About Schizophrenia Interview (KASI) places emphasis on the functional value of the reported knowledge rather than on the recall of information; it is quick, easy to administer, can be rated reliably, and has face-validity for the relative. The educational programme increased scores from pre-test to a post-test one week after the programme. Relatives with high criticism ratings on the Camberwell Family Interview had lower scores at both tests. Relatives of less chronic patients showed lower scores at pre-test and acquired significantly more information from the programme, while relatives of more chronic patients were less influenced by the information sessions.

Oxypertine in tardive dyskinesia: a long-term controlled study.

A 6-month, double-blind, placebo-controlled study of oxypertine in tardive dyskinesia is described. Results suggest that any beneficial effect noticed initially is not sustained. When this effect is compared with the time course of development of supersensitivity after neuroleptics as reported in the literature, it becomes apparent that the drug, despite its different mechanism of action, behaves like any other conventional neuroleptic. On the basis of the findings, the authors feel that all proposed anti-dyskinetic drugs should be subjected to longer, controlled trials to prove their clinical efficacy.

Interactions between procyclidine and neuroleptic drugs. Some pharmacological and clinical aspects.

Procyclidine was administered to 25 chronic psychotic inpatients, stabilised on chlorpromazine, haloperidol or fluphenazine decanoate injection. We observed a significant reduction in mean serum levels of all three neuroleptic drugs which was reversed on stopping procyclidine and was inversely correlated with mean serum procyclidine levels. No significant alterations occurred on the BPRS scores or in serum prolactin levels throughout the study in any of the three groups. Possible mechanisms of this interaction and its clinical relevance are discussed.

The community management of schizophrenia. A controlled trial of a behavioural intervention with families to reduce relapse.

Schizophrenic patients were recruited into a trial of a prophylactic behavioural intervention with families. Families with at least one high Expressed Emotion (EE) relative were randomly allocated to one of four intervention groups: Behavioural Intervention Enactive; Behavioural Intervention Symbolic; Education Only; Routine Treatment. Patients from low-EE families were randomly allocated to two groups: Education Only or Routine Treatment. Relapse rates over nine months after discharge were significantly lower for patients in the two Behavioural Intervention, compared with Education Only and Routine Treatment groups. There was little difference between the two low-EE groups. Patients returning to high-EE relatives showed significantly higher relapse rates than those returning to low-EE relatives, in groups not receiving active intervention. Changes from high to low EE occurred in the Behavioural Intervention groups, and similar although less extensive changes occurred in the Education Only and Routine Treatment groups. Changes in criticism and marked emotional over-involvement (EOI) occurred generally in high-EE groups but were larger in magnitude in the Enactive and Symbolic groups. Reduction of hostility only occurred in the Behavioural Intervention groups. These results give partial support for the causal role of EE in relapse. There were no significant differences between the groups with respect to contact with the psychiatric services or medication.

Community management of schizophrenia. A two-year follow-up of a behavioural intervention with families.

The relapse and readmission rates of schizophrenic patients who participated in a controlled trial of a nine-month behavioural family intervention trial based on the EE status of their relatives are presented at two years. The patients who received the behavioural family intervention had lower rates of relapse and readmission than patients from high-EE homes who had received a short educational programme or routine treatment. The relapse rate of the behavioural family intervention group (33%) was the same as that of the low-EE group (33%), and significantly lower than that of the non-intervention high-EE group (59%).