Brain-relevant antibodies in first-episode psychosis: a matched case-control study.

BACKGROUND: There has been much recent excitement about the possibility that some cases of psychosis may be wholly due to brain-reactive antibodies, with antibodies to N-methyl-D-aspartate receptor (NMDAR) and the voltage-gated potassium channel (VGKC)-complex reported in a few patients with first-episode psychosis (FEP). METHODS: Participants were recruited from psychiatric services in South London, UK, from 2009 to 2011 as part of the Genetics and Psychosis study. We conducted a case-control study to examine NMDAR and VGKC-complex antibody levels and rates of antibody positivity in 96 patients presenting with FEP and 98 controls matched for age and sex. Leucine-rich glioma inactiviated-1 (LGI1) and contactin-associated protein (CASPR) antibodies were also measured. Notably, patients with suspicion of organic disease were excluded. RESULTS: VGKC-complex antibodies were found in both cases (n = 3) and controls (n = 2). NMDAR antibody positivity was seen in one case and one control. Either LGI1-Abs or CASPR2-Abs were found in three cases and three controls. Neuronal antibody staining, consistent with the above results or indicating potential novel antigens, was overall positive in four patients but also in six controls. Overall, antibody positivity was at low levels only and not higher in cases than in controls. CONCLUSIONS: This case-control study of the prevalence of antibodies in FEP does not provide evidence to support the hypothesis that FEP is associated with an immune-mediated process in a subgroup of patients. Nevertheless, as other bio-clinical factors may influence the effect of such antibodies in a given individual, and patients with organic neurological disease may be misdiagnosed as FEP, the field requires more research to put these findings in context.

Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study.

BACKGROUND: Gold standard protocols have yet to be established for the treatment of motor conversion disorder (MCD). There is limited evidence to support inpatient, multidisciplinary intervention in chronic, severe cases. AIMS: To evaluate the characteristics and outcomes of MCD patients admitted to a specialist neuropsychiatric inpatient unit. METHODS: All patients admitted to the Lishman Unit (years 2007-2011) with a diagnosis of MCD were included. Data relevant to characteristics and status with regard to mobility, activities of daily living (ADLs) and Modified Rankin Scale (MRS) score at admission and discharge were extracted. RESULTS: Thirty-three cases (78.8% female) were included; the median duration of illness was 48 months. In comparison with brain injury patients admitted to the same unit, more cases had histories of childhood sexual abuse (36.4%, n=12), premorbid non-dissociative mental illness (81.1%, n=27) and employment as a healthcare/social-care worker (45.5%, n=15). Cases showed significant improvements in MRS scores (p<0.001), mobility (p<0.001) and ADL (p=0.002) following inpatient treatment. CONCLUSIONS: Patients with severe, long-standing MCD can achieve significant improvements in functioning after admission to a neuropsychiatry unit.

Concepts of mental capacity for patients requesting assisted suicide: a qualitative analysis of expert evidence presented to the Commission on Assisted Dying.

BACKGROUND: In May 2013 a new Assisted Dying Bill was tabled in the House of Lords and is currently scheduled for a second reading in May 2014. The Bill was informed by the report of the Commission on Assisted Dying which itself was informed by evidence presented by invited experts.This study aims to explore how the experts presenting evidence to the Commission on Assisted Dying conceptualised mental capacity for patients requesting assisted suicide and examine these concepts particularly in relation to the principles of the Mental Capacity Act 2005. METHODS: This study was a secondary qualitative analysis of 36 transcripts of oral evidence and 12 pieces of written evidence submitted by invited experts to the Commission on Assisted Dying using a framework approach. RESULTS: There was agreement on the importance of mental capacity as a central safeguard in proposed assisted dying legislation. Concepts of mental capacity, however, were inconsistent. There was a tendency towards a conceptual and clinical shift toward a presumption of incapacity. This appeared to be based on the belief that assisted suicide should only be open to those with a high degree of mental capacity to make the decision.The 'boundaries' around the definition of mental capacity appeared to be on a continuum between a circumscribed legal 'cognitive' definition of capacity (in which most applicants would be found to have capacity unless significantly cognitively impaired) and a more inclusive definition which would take into account wider concepts such as autonomy, rationality, voluntariness and decision specific factors such as motivation for decision making. CONCLUSION: Ideas presented to the Commission on Assisted Dying about mental capacity as it relates to assisted suicide were inconsistent and in a number of cases at variance with the principles of the Mental Capacity Act 2005. Further work needs to be done to establish a consensus as to what constitutes capacity for this decision and whether current legal frameworks are able to support clinicians in determining capacity for this group.

The role of psychiatrists and mental disorder in assisted dying practices around the world: a review of the legislation and official reports.

OBJECTIVE: To establish the role of psychiatrists and mental disorder in assisted dying practices in countries and states where such practices are legal. METHODS: The authors reviewed the Assisted Dying Acts and official statistical reports from Belgium, The Netherlands, Luxembourg, and the states of Washington and Oregon in the U.S.A. The data extracted related to the role of psychiatrists in assisted dying practices, and the relevance of capacity, 'suffering', and mental disorder. RESULTS: A psychiatry referral is recommended or required by all countries and states in certain circumstances. These circumstances include mental disorder 'impairing judgement' in Oregon and Washington, and cases of exclusive mental disorder in European countries. 'Exclusive mental disorder' refers to those with a mental disorder (e.g., major depression) who apply for assisted dying in the absence of any terminal physical illness. Capacity/competence and necessary suffering must be present. On average, 5.4% (range 4.2%-6.7%) of applicants see a psychiatrist. Patients with exclusive mental disorder can apply for assisted dying in European countries but not in Oregon and Washington; actual figures are low. CONCLUSIONS: No country has a blanket policy of mandatory psychiatric review but the specialty contributes in circumstances of exclusive mental disorder or when there is doubt regarding capacity and sound judgement. The absence of a mandatory role for psychiatrists means that reversible psychopathology may be missed. As a result, the patient's decision to end his/her life may be more informed by treatable mental disorder than by his/her lifelong preferences.

Attitudes of UK doctors towards euthanasia and physician-assisted suicide: a systematic literature review.

OBJECTIVES: To review studies over a 20-year period that assess the attitudes of UK doctors concerning active, voluntary euthanasia (AVE) and physician-assisted suicide (PAS), assess efforts to minimise bias in included studies, determine the effect of subgroup variables (e.g. age, gender) on doctors' attitudes, and make recommendations for future research. DATA SOURCES: Three electronic databases, four pertinent journals, reference lists of included studies. REVIEW METHODS: Literature search of English articles between January 1990 and April 2010. Studies were excluded if they did not present independent data (e.g. commentaries) or if they related to doctors outside the UK, patients younger than 18 years old, terminal sedation, withdrawing or withholding treatment, or double-effect. Quantitative and qualitative data were extracted. RESULTS: Following study selection and data extraction, 15 studies were included. UK doctors oppose the introduction of both AVE and PAS in the majority of studies. Degree of religiosity appeared as a statistically significant factor in influencing doctors' attitudes. The top three themes in the qualitative analysis were the provision of palliative care, adequate safeguards in the event of AVE or PAS being introduced, and a profession to facilitate AVE or PAS that does not include doctors. CONCLUSIONS: UK doctors appear to oppose the introduction of AVE and PAS, even when one considers the methodological limitations of included studies. Attempts to minimise bias in included studies varied. Further studies are necessary to establish if subgroup variables other than degree of religiosity influence attitudes, and to thoroughly explore the qualitative themes that appeared.

Improving the uptake and comprehensiveness of bedside cognitive testing amongst liaison psychiatrists over an eight-month period.

The aim of this quality improvement (QI) project was to improve the uptake and comprehensiveness of bedside cognitive testing amongst liaison psychiatrists over an eight month period. The baseline measurement involved an audit of the practice of the neuropsychiatry liaison team over six months at the 840 bed St Thomas's Hospital in London, UK. Of 35 referrals, 21 patients were able, and suitable, for cognitive testing based on the referral data and clinical interview. Fourteen (66.6%) of these patients had an Addenbrooke's Cognitive Examination (ACE), while 5 (23.8%) had frontal testing. The frontal tests performed were variable and inconsistent. Two Plan-Do-Study-Act (PDSA) cycles were then conducted. Clear guidance was issued to the team on the use of the ACE or Montreal Cognitive Assessment (MoCA) in suitable patients, and how these can be supplemented by frontal testing. Given the inconsistency in the types and combination of frontal tests being conducted at baseline, a frontal lobe test sheet containing established tests was developed and implemented. In PDSA cycle 1, 100% (n=10) of able and suitable referrals had an ACE or MoCA while 100% had frontal testing (80% of these using the dedicated test sheet). In PDSA cycle 2, improvements were broadly maintained with 85.7% (n=6) of referrals having an ACE/MoCA and 85.7% having frontal testing (83.3% of these using the dedicated frontal test sheet). In conclusion, our team improved the uptake and comprehensiveness of bedside cognitive testing by changing existing practice with clear protocols regarding the use of the ACE/MoCA and the implementation of a frontal test sheet.

The usefulness of phlebotomy in the palliative care setting.

OBJECTIVES: To establish the reasons for phlebotomy and evaluate the usefulness of blood testing in the palliative setting. METHODS: The design was that of a questionnaire-based prospective study conducted in the 30-bed Specialist Palliative Care Unit at Milford Care Centre between March 23 and May 23, 2010. A questionnaire was completed by the performing clinician following each venipuncture, which included details of the admitted patient, the blood tests performed, the reason(s) for testing, and the usefulness of blood testing in diagnosing and influencing management. RESULTS: Fifty blood tests were conducted on 37 inpatients. The mean age of patients was 66.7 years and 54.1% were male. The top three diagnoses were malignancy of bowel, ovary, and prostate, respectively. The top three reasons for venipuncture were to manage medications, establish the need for blood transfusion, and guide management of sepsis. Thirty percent of phlebotomy sessions changed management, 40.7% ruled in an important diagnosis, and 86% ruled out an important diagnosis. Forty-eight percent of phlebotomy sessions had at least one type of test "added on" that in hindsight was unnecessary. CONCLUSIONS: Blood testing is a useful tool in the palliative setting to guide management and to ascertain diagnoses relevant to symptom control. For reasons of laboratory time and economic cost, unnecessary additional tests should be kept to a minimum.