Psychiatry is essential for now but might eventually disappear (although this is unlikely to happen any time soon).

OBJECTIVE: To provide an overview of specific aspects of historical and possible future trajectories of psychiatry. CONCLUSIONS: Psychiatric treatments alleviate suffering, promote physical health, and are associated with increased longevity. As the biological underpinnings of mental illnesses are slowly uncovered, they generally cease to be primarily part of psychiatry (e.g. epilepsy, anti-NMDA receptor encephalitis). If this process continues, the biological basis of all symptom-based 'mental illnesses' might be described, and psychiatry absorbed into neurology and other disciplines. This will be a positive development if it provides better treatment for mental illness and psychiatric symptoms in other conditions, which is psychiatry's sole concern. Psychiatry's own survival as a distinct discipline is irrelevant if other disciplines can do the job better, possibly in collaboration. Given the tiny impact of neuroscience on psychiatry to date, the disappearance of psychiatry is unlikely to occur anytime soon, if ever. It is possible that human psychological functioning and psychiatric suffering are sufficiently complex and changeable as to defy complete, fine-grained, neuroscientific explanation. This would leave a role for psychiatry indefinitely, treating the immensely disabling, biologically unexplained clusters of symptoms that we currently call 'mental illnesses', increasingly in collaboration with, or absorbed within, other disciplines in medicine.

Capacity to consent to treatment in psychiatry inpatients - a systematic review.

BACKGROUND: Mental capacity for treatment decisions in psychiatry inpatients is an important ethical and legal concern, especially in light of changes in mental capacity legislation in many jurisdictions. AIMS: To conduct a systematic review of literature examining the prevalence of mental capacity for treatment decisions among voluntary and involuntary psychiatry inpatients, and to assess any correlations between research tools used to measure mental capacity and binary judgements using criteria such as those in capacity legislation. METHOD: We searched PsycINFO, Ovid MEDLINE and EMBASE for studies assessing mental capacity for treatment decisions in people admitted voluntarily and involuntarily to psychiatric hospitals. RESULTS: Forty-five papers emanating from 33 studies were identified. There was huge variability in study methods and often selective populations, but the prevalence of decision-making capacity varied between 5% and 83.7%. These figures resulted from studies using cut-off scores or categorical criteria only. The prevalence of decision-making capacity among involuntary patients ranged from 7.7% to 42%, and among voluntary patients ranged from 29% to 97.9%. Two papers showed positive correlations between clinicians' judgement of decision-making capacity and scores on the MacArthur Competence Assessment Tool for Treatment; two papers showed no such correlation. CONCLUSIONS: Not all voluntary psychiatry inpatients possess mental capacity and many involuntary patients do. This paradox needs to be clarified and resolved in mental health legislation; supported decision-making can help with this task.Key PointsLegislative changes for mental capacity are taking place in many jurisdictions.This is an important human rights issue for many people, including psychiatry inpatients.In our review, we found the prevalence of decision-making capacity varies between 5% and 83.7% in psychiatry inpatients.Not all voluntary inpatients have decision-making capacity.Many involuntary inpatients have mental capacity to make decisions.Supported decision-making can help those with impairments in their mental capacity.

Coronavirus disease: challenges for psychiatry.

Coronavirus disease (COVID-19) presents two urgent health problems: the illness caused by the virus itself and the anxiety, panic and psychological problems associated with the pandemic. Both problems present substantial challenges for our patients, their families, our multidisciplinary teams and our psychiatrist colleagues. We need good psychiatry, now more than ever.

The right to mental healthcare: India moves forward.

In 2018, India's Mental Healthcare Act 2017 granted a legally binding right to mental healthcare to 1.3 billion people, in compliance with the Convention on the Rights of Persons with Disabilities. Many countries, including the UK, ratified the Convention but only India has stepped up to the mark so dramatically.Declaration of interestNone.

Convergence or Divergence? Comparing Mental Capacity Assessments Based on Legal and Clinical Criteria in Medical and Surgical Inpatients.

Despite the high prevalence of mental incapacity for treatment decisions in hospitals (27.7%), there is little information about the relationship, if any, between mental capacity assessments based on clinical and legal criteria. We performed a cross-sectional study of mental incapacity for treatment decisions in 300 hospital inpatients in two hospitals in Ireland, using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the legal definition of mental incapacity in Ireland's incoming Assisted Decision-Making (Capacity) Act 2015. We found that patients who lacked mental capacity according to the legal criteria scored significantly lower on all four subscales of the MacCAT-T (Understanding, Appreciation, Reasoning, and Communication) compared to those who had mental capacity according to the legal criteria. In light of the similarity between Ireland's legal definition of mental incapacity and legislative definitions in other jurisdictions (e.g. England and Wales), we conclude that legal assessments of mental incapacity in these countries accord closely with clinical assessments (as reflected in the MacCAT-T). Ireland's new mental capacity legislation should be implemented promptly in order to further operationalize Ireland's new legal definition of mental incapacity and provide patients with the supports they need to optimize their mental capacity for treatment decisions in hospitals.

Return of the asylum.

Rates of involuntary admission are increasing in England. Personality disorder should be excluded as a criterion for involuntary admission; stronger restraint reduction programmes should be instigated; and involuntary care should be based on treating illness (something we can do) and not on predicting violence (something we cannot). Declaration of interest None.

Love as delusion, delusions of love: erotomania, narcissism and shame.

Erotomania has a long, colourful history in psychiatry. It is a rare condition in which the patient ('subject') develops the belief that he or she is loved from afar by another person ('object'). The subject is generally female, though men predominate in forensic samples. The object is generally perceived to belong to a higher social class, reflecting a sociopolitical element in the construction of love. Erotomania requires active treatment and risk management as it can be associated with stalking and other offending behaviour. In addition to featuring in the psychiatry literature, erotomania features in the biography of the economist John Maynard Keynes (the apparent 'object' of a woman's erotomanic delusions in the early 1900s) and in fiction (eg, Ian McEwan's Enduring Love); this reflects, in part, the general popularity of romantic themes in broader literature and society. In psychological terms, certain cases of erotomania might be underpinned by combinations of longing, disappointment, shame and narcissism in specific social contexts. Lesser forms of delusional exaggeration of true love might also exist in some stable relationships, and might even be essential for their continued existence. Overall, the division between love and delusions of love is not as distinct as one might imagine. The potential presence of an element of delusional love in many relationships might well serve important social functions, conferring specific advantages on the parties involved and increasing social and community stability. After all, delusions persist; love dies.

Invited commentary on When unbearable suffering incites psychiatric patients to request euthanasia.

Euthanasia is available in Belgium and Luxembourg for untreatable and unbearable suffering resulting from 'physical and/or psychological suffering that cannot be alleviated and results from a serious and incurable disease, caused by accident or illness'. Verhofstadt et al's valuable analysis of testimonials from psychiatric patients requesting euthanasia demonstrates that elements of this suffering might well be alleviated. We should not kill our patients.

A fuller picture: evaluating an art therapy programme in a multidisciplinary mental health service.

Art therapy has a long history in mental healthcare, but requires an enhanced evidence base in order to better identify its precise role in contemporary services. This paper describes an evaluation of an art therapy programme in an acute adult psychiatry admission unit in Ireland. A mixed method research design was used. Quantitative data were collected through a survey of 35 staff members and 11 service users. Qualitative data included free text comments collected in the survey and individual feedback from service users. Both methods aimed to assess the role of art therapy as part of a multidisciplinary mental health service. Thematic content analysis was employed to analyse qualitative data. Staff demonstrated overwhelming support for art therapy as one element within multidisciplinary services available to patients in the acute psychiatry setting, Qualitative feedback associated art therapy with improvements in quality of life and individual support, and emphasised its role as a non-verbal intervention, especially useful for those who find talking therapy difficult. Creative self-expression is valued by staff and service users as part of the recovery process. Recommendations arising from the research include continuing the art therapy service, expanding it to include patients under rehabilitation, provision of information and education sessions to staff, and further research to identify other potential long-term effects. The low response of staff and small sample in this study, however, must be noted as limitations to these findings.

Exploring and explaining the "Santa Claus effect": cross-sectional study of jollity in 21 European countries.

BACKGROUND: Christmas "is the season to be jolly" but, despite many recent studies of happiness and wellbeing, the population distribution of jollity is unknown. AIMS: To assess levels of jollity across Europe, hypothesising the existence of a "Santa Claus effect" whereby Mr. Claus, a long-established resident of Scandinavia, increases jollity through his social network. METHODS: Cross-sectional analysis of data from 37 966 participants in the European Society Survey (Round 7, 2014/2015) across 21 European countries. RESULTS: Jollity has independent associations with satisfaction with health and income, male gender, younger age, and country of residence. Each one-point increase in satisfaction with health (on a 5-point scale) corresponds to a 0.79-point increase in jollity (23-point scale); each one-point increase in satisfaction with income (4-point scale) corresponds to a 0.76-point increase in jollity. Switzerland is the jolliest country in Europe. CONCLUSIONS: The jolliest European is likely to be a young Swiss male who is satisfied with his income and health. If there is a Santa Claus effect acting to increase jollity, it probably acts not just in Scandinavia but across Mr. Claus's broad network of contacts and admirers in many countries.

We should replace conventional mental health law with capacity-based law.

As general medicine moves away from 'paternalism' and places an increasing emphasis on patient choice and autonomy, George Szmukler and Brendan D. Kelly debate whether conventional mental health legislation should be replaced with a model that focuses on the person's decision-making capabilities.

Closing the tau loop: the missing tau mutation.

Frontotemporal lobar degeneration comprises a group of disorders characterized by behavioural, executive, language impairment and sometimes features of parkinsonism and motor neuron disease. In 1994 we described an Irish-American family with frontotemporal dementia linked to chromosome 17 associated with extensive tau pathology. We named this disinhibition-dementia-parkinsonism-amyotrophy complex. We subsequently identified mutations in the MAPT gene. Eleven MAPT gene splice site stem loop mutations were identified over time except for 5' splice site of exon 10. We recently identified another Irish family with autosomal dominant early amnesia and behavioural change or parkinsonism associated with the 'missing' +15 mutation at the intronic boundary of exon 10. We performed a clinical, neuropsychological and neuroimaging study on the proband and four siblings, including two affected siblings. We sequenced MAPT and performed segregation analysis. We looked for a biological effect of the tau variant by performing real-time polymerase chain reaction analysis of RNA extracted from human embryonic kidney cells transfected with exon trapping constructs. We found a c.915+15A>C exon 10/intron 10 stem loop mutation in all affected subjects but not in the unaffected. The c.915+15A>C variant caused a shift in tau splicing pattern to a predominantly exon 10+ pattern presumably resulting in predominant 4 repeat tau and little 3 repeat tau. This strongly suggests that the c.915+15A>C variant is a mutation and that it causes frontotemporal dementia linked to chromosome 17 in this pedigree by shifting tau transcription and translation to +4 repeat tau. Tau (MAPT) screening should be considered in families where amnesia or atypical parkinsonism coexists with behavioural disturbance early in the disease process. We describe the final missing stem loop tau mutation predicted 15 years ago. Mutations have now been identified at all predicted sites within the 'stem' when the stem-loop model was first proposed and no mutations have been found within the 'loop' region as expected. Therefore we 'close the tau loop' having 'opened the loop' 21 years ago.

Searching for the patient's voice in the Irish asylums.

The history of mental healthcare in Ireland ends to focus on the histories of institutions and development of mental health legislation. Attention has also been devoted to clinical records, with all of their interpretative and narrative complexities. In both the historiography and archives, however, patients themselves remain remarkably elusive, their voices astonishingly distant. In countries other than Ireland, there have been more extensive analyses of patients' letters, journals and first-person accounts of hospitalisation and treatment. In Ireland, there is real difficulty accessing such accounts, if they exist, especially from the 1800s. Asylum and hospital records offer some assistance in understanding patients' concerns and, arguably, the symptoms recorded in asylum records (eg, delusions) provide further windows into patients' minds. Methodological challenges abound, but while patients' voices may remain largely unknown at present, they are certainly not unknowable. This paper posits that we just need to listen harder and, perhaps, listen better.

Diagnostic Accuracy of Tests for Polyuria in Lithium-Treated Patients.

In lithium-treated patients, polyuria increases the risk of dehydration and lithium toxicity. If detected early, it is reversible. Despite its prevalence and associated morbidity in clinical practice, it remains underrecognized and therefore undertreated. The 24-hour urine collection is limited by its convenience and practicality. This study explores the diagnostic accuracy of alternative tests such as questionnaires on subjective polyuria, polydipsia, nocturia (dichotomous and ordinal responses), early morning urine sample osmolality (EMUO), and fluid intake record (FIR). This is a cross-sectional study of 179 lithium-treated patients attending a general adult and an old age psychiatry service. Participants completed the tests after completing an accurate 24-hour urine collection. The diagnostic accuracy of the individual tests was explored using the appropriate statistical techniques. Seventy-nine participants completed all of the tests. Polydipsia severity, EMUO, and FIR significantly differentiated the participants with polyuria (area under the receiver operating characteristic curve of 0.646, 0.760, and 0.846, respectively). Of the tests investigated, the FIR made the largest significant change in the probability that a patient experiences polyuria (<2000 mL/24 hours; interval likelihood ratio, 0.18 and >3500 mL/24 hours; interval likelihood ratio, 14). Symptomatic questioning, EMUO, and an FIR could be used in clinical practice to inform the prescriber of the probability that a lithium-treated patient is experiencing polyuria.

Risk factors for polyuria in a cross-section of community psychiatric lithium-treated patients.

OBJECTIVES: Polyuria increases the risk of dehydration and lithium toxicity in lithium-treated patients. Risk factors have been inconsistently described and the variance of this adverse effect remains poorly understood. This study aimed to establish independent risk factors for polyuria in a community, secondary-level lithium-treated sample of patients. METHODS: This was a cross-sectional study of the lithium-treated patients attending a general adult and an old age psychiatry service. Participants completed a 24-hour urine collection. Urine volume and the presence of polyuria were the outcomes of interest. The relationship between outcome and the participant's demographic and clinical characteristics was explored with univariable and multivariable analysis. RESULTS: A total of 122 participants were included in the analysis, with 38% being diagnosed with polyuria. Female gender and increased body weight independently predicted the presence of polyuria (standardized regression coefficient 1.01 and 0.94, respectively; p = 0.002 and p = 0.003, respectively). Female gender and increased body weight, lithium dose, and duration of lithium treatment independently predicted higher 24-hour urine volumes (standardized regression coefficients 0.693, p < 0.0005; 0.791, p < 0.0005; 0.276, p = 0.043; 0.181, p = 0.034, respectively). Of three different weight metrics, lean body weight was the most predictive. CONCLUSIONS: Female gender and increased body weight explain part of the variance of this adverse effect. Both risk factors offer fresh insights into the pathophysiology of this potentially reversible and dangerous adverse effect of lithium treatment. Future research should focus on understanding the differences between the genders and between different body compositions in terms of lithium pharmacokinetics and pharmacodynamics.

Experiences of Using Prezi in Psychiatry Teaching.

OBJECTIVE: Prezi is a presentation software allowing lecturers to develop ideas and produce mind maps as they might do on an old-style blackboard. This study examines students' experience of lectures presented using Prezi to identify the strengths and weaknesses of this new teaching medium. METHODS: Prezi was used to present mental health lectures to final-year medical and physiotherapy students. These lectures were also available online. This cross-sectional study used a questionnaire to assess students' experience of the software. RESULTS: Of students approached, 75.5 % (74/98) took part in the study. A majority, 98.6 % (73/74), found Prezi to be a more engaging experience than other styles of lecture delivery. The overview or "mind map" provided by Prezi was found to be helpful by 89.2 % (66/74). Problems arose when students used Prezi in their personal study, with 31.1 % (23/74) reporting some difficulties, mostly of a technical nature. CONCLUSION: This study highlights the potential of Prezi for providing students with an engaging and stimulating educational experience. For Prezi to be effective, however, the lecturer has to understand and be familiar with the software and its appropriate use.