Substance use in psychiatric crisis: relationship to violence.

BACKGROUND: Substance use and psychiatric illness, particularly psychotic disorders, contribute to violence in emergency healthcare settings. However, there is limited research regarding the relationship between specific substances, psychotic symptoms and violent behaviour in such settings. We investigated the interaction between recent cannabinoid and stimulant use, and acute psychotic symptoms, in relation to violent behaviour in a British emergency healthcare setting. METHODS: We used electronic medical records from detentions of 1089 individuals under Section 136 of the UK Mental Health Act (1983 amended 2007), an emergency police power used to detain people for 24-36 h for psychiatric assessment. The relationship between recent cannabinoids and/or stimulant use, psychotic symptoms, and violent behaviour, was estimated using logistic regression. FINDINGS: There was evidence of recent alcohol or drug use in 64.5% of detentions. Violent incidents occurred in 12.6% of detentions. Psychotic symptoms increased the odds of violence by 4.0 [95% confidence intervals (CI) 2.2-7.4; p < 0.0001]. Cannabinoid use combined with psychotic symptoms increased the odds of violence further [odds ratios (OR) 7.1, 95% CI 3.7-13.6; p < 0.0001]. Recent use of cannabinoids with stimulants but without psychotic symptoms was also associated with increased odds of violence (OR 3.3, 95% CI 1.4-7.9; p < 0.0001). INTERPRETATION: In the emergency setting, patients who have recently used cannabinoids and exhibit psychotic symptoms are at higher risk of violent behaviour. Those who have used both stimulants and cannabinoids without psychotic symptoms may also be at increased risk. De-escalation protocols in emergency healthcare settings should account explicitly for substance use.

Analysis and evaluation of peer group support for doctors in postgraduate training following workplace violence and aggression.

AIMS AND METHOD: Workplace violence and aggression toward healthcare staff has a significant impact on the individual, causing self-blame, isolation and burnout. Timely and appropriate support can mitigate harm, but there is little research into how this should be delivered. We conducted multi-speciality peer groups for London doctors in postgraduate training (DPT), held over a 6-week period. Pre- and post-group burnout questionnaires and semi-structured interviews were used to evaluate peer support. Thematic analysis and descriptive statistical methods were used to describe the data. RESULTS: We found four themes: (a) the experience and impact of workplace violence and aggression on DPT, (b) the experience of support following incidents of workplace violence and aggression, (c) the impact and experience of the peer groups and (d) future improvements to support. DPTs showed a reduction in burnout scores. CLINICAL IMPLICATIONS: Peer groups are effective support for DPT following workplace violence and aggression. Embedding support within postgraduate training programmes would improve access and availability.

Trends in training progression: response to the study by Silkens et al.

Recruitment and retention are of major concern to all in medicine. Improvement in recruitment to UK speciality training programmes does not directly translate into senior workforce capacity, which remains dependent on trainee progression. In 2021, Silkens et al undertook a mixed-methods study to investigate this and described a trainee-driven shift away from conventional training pathways and expectations. These findings suggest a need for a broad change in approach to careers, underpinned by commitment to reducing differential attainment, acknowledgment that trainees may have a range of unique needs, and development of a culture of equality, diversity and inclusion.

The association of acute alcohol use and dynamic suicide risk with variation in onward care after psychiatric crisis.

INTRODUCTION: Despite the association of alcohol use with recurrent suicidal acts, individuals attempting suicide after drinking alcohol face barriers accessing crisis care following emergency assessment, demonstrated by higher odds of inpatient admission for those whose suicide attempt did not feature alcohol. This disparity may be due to suicidality dissipating more rapidly after a suicide attempt involving alcohol. We investigated the effect of acute alcohol use and ongoing suicidality on onward care decisions after emergency assessment. METHODS: We analysed electronic health records of 650 suicidal adults detained under Section 136 of the Mental Health Act (1983, amended 2007) for up to 36 h at a London psychiatric emergency care centre. We used logistic regression to estimate the association of acute alcohol use and ongoing suicidality (including their interaction) with admission to psychiatric hospital. RESULTS: Fifteen percent of previously intoxicated detainees expressed suicidal intent at detention end, compared to 24% of detainees who had not used alcohol prior to detention. Compared to those who were not previously intoxicated and not suicidal at detention end, acute alcohol use was associated with reduced odds of admission amongst those no longer suicidal (AOR 0.4, 95% CI 0.2, 0.6). Where suicidality persisted, odds of admission rose; however, the magnitude of increase when in combination with prior alcohol use (AOR 3.6, 95% CI 1.9, 7.1) was under half that of when alcohol was not involved (AOR 8.2, 95% CI 3.5, 19.1). DISCUSSION AND CONCLUSIONS: Acute alcohol use is associated with transient suicidality, but this only partially accounts for disparities in care following suicide attempts.

Alcohol dependence and heavy episodic drinking are associated with different levels of risk of death or repeat emergency service attendance after a suicide attempt.

BACKGROUND: Alcohol use is a multidimensional risk factor for suicidal behaviour. However, suicide prevention strategies often take 'one-size-fits-all' approaches to alcohol use, reflecting an evidence base built on unidimensional measures. Latent Class Analysis can use a range of measures to differentiate distinct patterns of alcohol using behaviour and their associated risks. METHODS: We analysed Electronic Health Record data from 650 suicidal adults detained for up to 36 h using police powers (Section 136 of the Mental Health Act 1983, amended 2007) to facilitate psychiatric assessment at a Health-Based Place of Safety, a dedicated emergency psychiatric care centre in London, UK. We conducted a Latent Class Analysis of alcohol using behaviours at first detention, and used multivariable logistic regression to estimate the association of each identified latent class with subsequent death or recontact with emergency psychiatric care over a median follow-up of 490 days, adjusting for sex, age and past-year psychiatric diagnosis. RESULTS: Three classes of alcohol use were identified: low risk drinkers, heavy episodic drinkers and dependent drinkers. The dependent drinking class had twice the odds of death or recontact with emergency psychiatric care as the low risk drinking class (OR 2.32, 95 %CI 1.62-3.32, p < 0.001). Conversely, the heavy episodic drinking class was associated with lower odds of death or recontact than the low risk drinking class (OR 0.66, 95 %CI 0.53-0.81, p < 0.001). CONCLUSIONS: The risk of adverse outcomes after a suicide attempt are not uniform for different alcohol use classes. Clinical assessment and suicide prevention efforts should be tailored accordingly.

Switching stable patients with schizophrenia from depot and oral antipsychotics to long-acting injectable risperidone: reasons for switching and safety.

OBJECTIVE: An international, non-randomised study evaluated efficacy and safety of risperidone long-acting injectable (RLAI) compared to previous treatment. To investigate generizability of the European data set to the UK subset safety and switching data are reported here. METHODS: Patients with schizophrenia or other psychotic disorder, symptomatically stable on antipsychotic medication, received intramuscular injections of RLAI 25 mg (to a maximum of 50 mg) every 2 weeks for 6 months. RESULTS: Of 182 UK patients enrolled, 79% had schizophrenia, 21% other psychotic disorders. Insufficient efficacy (43%), side effects (45%), and non-compliance (25%) were the most common reasons for switching. Sixty-nine per cent of patients completed the trial; 8% discontinued due to adverse events (AEs). Most frequent treatment-emergent AEs were headache (8.2%), relapse (7.7%) and insomnia (7.1%); 8 (4.4%) patients reported injection-related AEs. There were significant improvements in extrapyramidal symptom rating scale total and subscale (particularly Parkinsonism) scores, regardless of previous medication (total cohort, p < or = 0.0001). There was a small but significant increase in body weight at endpoint (1.2 kg, p = 0.0023). One patient suffered a myocardial infarction and died (not treatment-related). There were no substantial differences between the full data set and the UK sub-population CONCLUSION: Switch to RLAI was well-tolerated in stable patients over 6 months. The European data set is generalizable to the UK patient population.

Increased inferior frontal activation during word generation: a marker of genetic risk for schizophrenia but not bipolar disorder?

During verbal-fluency tasks, impairments in performance and functional abnormalities in the inferior frontal cortex have been observed in both schizophrenia patients and their unaffected relatives. We sought to examine whether such functional abnormalities are a specific marker of genetic vulnerability to schizophrenia. We studied a sample of 132 subjects, comprising 39 patients with schizophrenia, 10 unaffected monozygotic (MZ) cotwins of schizophrenia probands, 28 patients with bipolar disorder, 7 unaffected MZ cotwins of bipolar disorder probands and 48 healthy controls. Blood oxygen level-dependent response was measured using functional magnetic resonance imaging during the performance of an overt verbal-fluency task with two levels of task difficulty, in a cytoarchitectonic region of interest encompassing Brodmann areas 44 and 45 bilaterally. Patients with schizophrenia and the unaffected MZ cotwins of schizophrenia probands showed increased activation in the inferior frontal cortex relative to healthy controls and bipolar patients. Increased engagement of the inferior frontal cortex during verbal-fluency may thus be a marker of genetic vulnerability to schizophrenia.

Effects of risk for bipolar disorder on brain function: A twin and family study.

Bipolar disorder (BPD) is associated with altered regional brain function during the performance of cognitive tasks. The relative contribution of genetic and environmental risk factors for BPD to these changes has not yet been quantified. We sought to address this issue in a functional neuroimaging study of people who varied in their risk for BPD. Functional magnetic resonance imaging was used to study 124 subjects (29 twin and 9 sibling pairs with at least one member with BPD, and 24 healthy twin pairs) performing a working memory task. We assessed the influence of risk for BPD on regional brain function during the task in a two stage process. Firstly, we identified areas where there were group differences in activation. Secondly, we estimated the heritability and phenotypic correlation of activation and BPD using genetic modeling. BPD was associated with increased activation in the anterior cingulate, orbitofrontal, medial prefrontal, and left precentral cortices, and in the precuneus. Within these regions, activation in the orbitofrontal cortex rendered the most significant heritability estimate (h2=0.40), and was significantly correlated with BPD phenotype (rph=0.29). A moderate proportion of the genetic influences (rg=0.69) acting on both BPD and on the degree of orbitofrontal activation were shared. These findings suggest that genetic factors that confer vulnerability to BPD alter brain function in BPD.

Schizophrenia and bipolar disorder: similarities in pathogenic mechanisms but differences in neurodevelopment.

Over the past 100 years, the Kraepelinian classification of psychoses has dominated our approach to schizophrenia and bipolar disorder. However, controversy as to the nature of the illnesses--whether they can be viewed as completely distinct, essentially the same, or occupying different points along a psychosis spectrum--has intensified in recent years. This paper reviews the evidence for these differing opinions, examining both the commonalities between the two diseases and the distinctions. A genetic propensity towards psychotic disorders is widely acknowledged; more recent studies suggest a considerable overlap in genetic susceptibility to schizophrenia and bipolar disorder. The influence of early environmental effects, such as obstetric complications, on schizophrenia is also established but little such evidence exists for bipolar disorder. Structural abnormalities of the brain of developmental origin as well as neuropsychological deficits have been clearly identified in schizophrenia but less evidence has been found in bipolar disorder. The most plausible explanation is that one or more susceptible genes are shared between schizophrenia and bipolar illness, and can be thought of as predisposing individuals to psychosis, perhaps by producing a dysregulation of the dopaminergic response to stress. Other genes and environmental factors are likely to have more specific effects and contribute to producing the patterns that psychiatrists recognize as 'classical' schizophrenia and mania. In particular, genes involved in early cortical development and early neurodevelopmental insults causing developmental impairment may put individuals on a trajectory towards schizophrenia rather than bipolar illness.

D-fenfluramine-evoked serotonergic responses in olanzapine-treated schizophrenic patients.

Antagonist activity at the 5-HT(2) receptor may contribute to the therapeutic efficacy of atypical antipsychotics in schizophrenia. This neuroendocrine study examined the in vivo functional serotonergic (5-HT) activity of the atypical antipsychotic olanzapine. We examined central 5-HT(2) responses by measuring the serum prolactin (PRL) over 5 h in response to 30 mg of D-fenfluramine (DFEN) in two groups of male schizophrenic patients. Blunted PRL responses to DFEN indicate functional 5-HT(2) receptor antagonism. Seven patients treated with olanzapine at a mean (S.D.) dose of 13.1 (4.6) for a mean of 28 weeks were compared with a matched group of eight patients who had received no antipsychotic treatment for at least 2 weeks. Baseline PRL levels did not differ significantly in the two patient groups and were within the normal range. The olanzapine-treated patients showed a significantly lower maximal DFEN-evoked PRL response and a significantly lower group x time overall PRL release compared with the untreated patient group. We have previously demonstrated a similar degree of functional in vivo 5-HT(2) antagonism with the atypical antipsychotic clozapine. This study thus suggests that this activity may not contribute to the unique clinical efficacy of clozapine.

Consensus statement on the use of intramuscular aripiprazole for the rapid control of agitation in bipolar mania and schizophrenia.

As much as the ideal treatment goal for severe mental illnesses such as bipolar disorder and schizophrenia is to prevent or delay the recurrence or relapse of acute episodes, when the patient presents with an acute episode, the goal should be to manage behavioural symptoms, and return to prior levels of symptomatic control. In a serious mental illness, the management of the acutely agitated state may require rapid tranquillisation (RT) to control violent and/or disturbed behaviour when all other methods of de-escalation have failed. Current clinical practice guidelines for emergency interventions in the case of acutely disturbed behaviours favour calming the patient by reducing agitation with mild sedation, but not sleep, to allow continued interaction with the patient, to ensure an accurate diagnosis, and to enable patients to be actively engaged in treatment decisions. Pharmacotherapy is an essential element in RT and the available agents used may be unique and separate from the patient's regular course of treatment, primarily because agents used in RT may not be suitable for long-term treatment due to an unfavourable efficacy and safety profile. Therefore, the choice of pharmacotherapy is essential to achieve an effective RT and a smooth transition to standard care and routine daily life for the patient. Of the available agents for RT, aripiprazole demonstrated a favourable efficacy and safety profile both over the short-term - including in its intramuscular form (IM) - and in the long-term treatment of bipolar I disorder and schizophrenia. The objective of this article is to assess the available clinical data on IM aripiprazole as a treatment option for the rapid control of agitation and disturbed behaviours in these conditions and to provide a consensus statement based on the expertise of UK healthcare practitioners in acute treatment units.

The nature of abnormal language processing in euthymic bipolar I disorder: evidence for a relationship between task demand and prefrontal function.

OBJECTIVES: Abnormal language processing is a consistent finding in bipolar disorder (BD). We used functional magnetic resonance imaging (fMRI) to investigate the core components of language processing as well as the impact of task demand in a group of bipolar subjects. METHODS: Twelve euthymic dextral male BD I participants receiving lithium monotherapy were matched with 12 controls. Groups were matched for age, years of education and estimated premorbid IQ. We employed a factorial design manipulating task demand (decision versus fluency) and task domain (phonetic versus semantic) to investigate differences in language processing between groups and across different task domains and requirements. Data were fitted to haemodynamic response models convolved to the experimental design. Group and task difference maps were generated. RESULTS: During the scanning session bipolar patients demonstrated significantly slower reaction times. However, groups demonstrated the same task accuracy except for one domain (phonetic decision). All participants activated regions known to be engaged by language tasks, but compared to controls the bipolar patients showed altered patterns of prefrontal activation which were related to the nature of the task, language processing, and increasing task demand. CONCLUSIONS: We have demonstrated abnormal prefrontal activation in bipolar patients across a range of language tasks with varying task demands.

Women are not the same as men: specific clinical issues for female patients with bipolar disorder.

Women are not the same as men. While this observation can be considered to subjectively manifest in many different ways, objectively a greater tendency for bipolar II disorder, depressive symptoms, a rapid cycling course, and the consequences of being of child-rearing age can all represent additional challenges for female patients. Despite much recent interest in improving the management of patients with bipolar disorder, relatively little guidance exists relating to female-biased gender-specific issues. This review article will explore how female gender can influence bipolar disorder and its treatment and will focus on epidemiologic differences, the relevance to clinical presentation of events unique to women (particularly contraception, pregnancy, and lactation), and the importance of considering gender when making decisions about the pharmacological management of mood. All female patients should receive counseling regarding family planning and sexually transmitted diseases, as well as the risks of and treatment options during pregnancy and postpartum. Wherever possible, treatment choices should be made in a partnership between patient and clinician.

Progress in understanding conversion disorder.

Conversion disorder has a history that may reach back into antiquity, and it continues to present a clinical challenge to both psychiatrists and neurologists. This article reviews the current state of knowledge surrounding the prevalence, etiology, and neurobiology of conversion disorder. There have been improvements in the accuracy of diagnosis that are possibly related to improved technologies such as neuroimaging. Once the diagnosis is made, it is important to develop a therapeutic alliance between the patient and the medical team, and where comorbid psychiatric diagnoses have been made, these need to be adequately treated. While there have been no formal trials of medication or psychoanalytic treatments in this disorder, case reports suggest that a combination of antidepressants, psychotherapy, and a multidisciplinary approach to rehabilitation may be beneficial.

The bipolar spectrum: diagnostic and pharmacologic considerations.

Bipolar disorder represents a clinically challenging, episodic, lifelong medical illness that is both disabling and dangerous to the patient and is associated with a high risk of suicide. The prognosis for bipolar patients is likely to worsen with delays in accurate diagnosis and treatment as time is allowed for more extensive complications and morbidity to accrue and for alcohol or other substance use comorbidity to complicate the course of the illness. Physicians face several challenges when diagnosing bipolar disorder, including overlapping symptomatology and comorbidity with other disorders, as well as the somewhat restrictive and categorical approach taken by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the International Statistical Classification of Diseases, 10th Revision (ICD-10) diagnostic criteria. As a result, bipolar disorder is frequently unrecognized and misdiagnosed with considerable clinical and prognostic consequences for the patient. The accuracy of diagnosis of bipolar disorder could be improved through the introduction of a refined procedure for the identification and evaluation of a broader range of symptoms, and by careful attention to the presence of subthreshold symptomatology. A conceptual shift toward acceptance of a 'spectrum' model of bipolar disorder and the development of appropriate clinical diagnostic tools should assist physicians in differentiating bipolar disorder from other Axis I, Axis II, and personality disorders, as well as ensuring early diagnosis and therapeutic intervention.

Schizophrenia and bipolar disorder are distinguished mainly by differences in neurodevelopment.

This paper examines the commonalities and the differences between schizophrenia and bipolar disorder. Recent studies suggest a possible overlap in genetic susceptibility to the two conditions. However, while the influence of early environmental effects, particularly obstetric complications, has been established for schizophrenia, no such replicable association with bipolar disorder has been found. Structural abnormalities of the brain have been identified in both schizophrenia and bipolar disorder, but while the volume of the amygdala and hippocampus appears decreased in schizophrenia, this is not the case in bipolar disorder; indeed there are some suggestions of increased volume of the amygdala. Furthermore, schizophrenia is characterised by lower IQ, executive function and verbal memory, but there is little evidence of trait neuropsychological deficits in bipolar disorder. Similarly, premanic children do not show the cognitive and neuromotor impairments characteristic of those destined to develop schizophrenia. The most plausible explanation is that the two conditions share some genetic predisposition but differ in that schizophrenia but not bipolar disorder is subject to additional genes or early environmental hazards causing neurodevelopmental impairment.

A functional MRI study of working memory task in euthymic bipolar disorder: evidence for task-specific dysfunction.

OBJECTIVES: Even when euthymic bipolar disorder patients can have persistent deficits in working memory, but the neural basis of this deficit remains unclear. We undertook an functional magnetic resonance imaging investigation of euthymic bipolar disorder patients performing two working memory paradigms; the two-back and Sternberg tasks, selected to examine the central executive and the phonological loop respectively. We hypothesized that neuronal dysfunction would be specific to the network underlying the executive rather than the phonological loop component of working memory. METHODS: Twelve right-handed euthymic bipolar I males receiving lithium carbonate monotherapy were matched with 12 controls. The two-back task comprised a single working memory load contrasted with baseline vigilance condition. The Sternberg paradigm used a parametric design incorporating variable working memory load with fixed delay between presentation of an array of items to be remembered and a target item. Functional activation data were acquired during performance of the tasks and were analysed to produce brain activation maps representing significant group differences in activation (ANOVA). Load-response curves were derived from the Sternberg task data set. RESULTS: There were no significant between-group differences (t-test) in performance of the two-back task, or in 2 x 5 group by memory load ANOVA for the performance data from Sternberg task. In the two-back task, compared with controls bipolar disorder patients showed reductions in bilateral frontal, temporal and parietal activation, and increased activations with the left precentral, right medial frontal and left supramarginal gyri. No between-group differences were observed in the Sternberg task at any working memory load. CONCLUSIONS: Our findings support the notion that, in euthymic bipolar disorder, failure to engage fronto-executive function underpins the core neuropsychological deficits.