COVID-19-related posttraumatic stress disorder in adults with lived experience of psychiatric disorder.

BACKGROUND: Prevalence estimates of COVID-19-related posttraumatic stress disorder (PTSD) have ranged from 1% to over 60% in the general population. Individuals with lived experience of a psychiatric disorder may be particularly vulnerable to COVID-19-related PTSD but this has received inadequate attention. METHODS: Participants were 1571 adults with lived experience of psychiatric disorder who took part in a longitudinal study of mental health during the COVID-19 pandemic. PTSD was assessed by the International Trauma Questionnaire (ITQ) anchored to the participant's most troubling COVID-19-related experiencevent. Factors hypothesised to be associated with traumatic stress symptoms were investigated by linear regression. RESULTS: 40.10% of participants perceived some aspect of the pandemic as traumatic. 5.28% reported an ICD-11 PTSD qualifying COVID-19 related traumatic exposure and 0.83% met criteria for probable ICD-11 COVID-19-related PTSD. Traumatic stress symptoms were associated with younger age, lower income, lower social support, and financial worries, and lived experience of PTSD/complex PTSD. Depression and anxiety measured in June 2020 predicted traumatic stress symptoms at follow-up approximately 20 weeks later in November 2020. CONCLUSIONS: We did not find evidence of widespread COVID-19-related PTSD among individuals with lived experience of a psychiatric disorder. There is a need for future research to derive valid prevalence estimates of COVID-19-related PTSD.

Evaluation of a framework for safe and appropriate prescribing of psychoactive medications in a UK prison.

BACKGROUND: The widespread use of drugs in prisons leads to avoidable deaths, poorer health and a poor living environment. The contribution of psychoactive prescription drugs to this problem has received little attention in prison policy or at individual prescriber level. AIMS: To determine the extent of unsafe and inappropriate prescribing of psychoactive medications in one UK prison using a newly developed medicines optimisation framework. METHOD: A medicines optimisation framework was developed based on principles of good prescribing. It was initiated on the opening of a new prison-HMP Berwyn-in February 2017. During the study period, all prisoners at HMP Berwyn were transferred from other prisons. The safety and appropriateness of psychoactive medications were evaluated de novo on reception at HMP Berwyn and during follow up, using the medicines optimisation framework. RESULTS: About 1941 sentenced men arrived at HMP Berwyn between February 2017 and November 2018. Nearly one-third (634, 33%) were on a prescribed psychoactive medication. Seventy-five percent of these (474/634) required a prescription change due to appropriateness or safety concerns. Nearly half (295, 46.5%) received changes at reception despite having already undergone medicines reconciliation at their previous prison. Forty-three percent (275/634) received changes at follow up, most commonly those who had no prior risks identified at reception. CONCLUSIONS: Inappropriate and unsafe prescribing of psychoactive medications is occurring in prisons despite mandatory medication reviews. Ongoing monitoring is required to reduce the risk from these medications. A medicines optimisation framework such as this could be adopted across other prisons, worldwide, to help contribute to risk reduction from drug use in prisons. Appropriately modified, a similar framework might help reduce inappropriate and harmful prescribing in hospitals and in the community.

Psychiatrists, spirituality and religion.

The consensus within psychiatry is that patients' religion/spirituality are legitimate topics in assessment and treatment. Religion/spirituality can help people cope with mental illness, but their use as therapeutic tools is controversial. Despite the publication of position statements by national and international psychiatric organisations, there is no clarity over therapeutic boundaries.Declaration of interestR.P. and R.H. are atheists. C.C.H.C. is an ordained Anglican and a past Chair of the Royal College of Psychiatrists Spirituality and Psychiatry Special Interest Group. He writes here in a personal capacity.

Treatment of Alcohol-Induced Psychotic Disorder (Alcoholic Hallucinosis)-A Systematic Review.

AIMS: To evaluate the effectiveness of evidence based treatments for alcohol-induced psychotic disorder (AIPD) as described by ICD-10 and DSM-5, a condition that is distinct from schizophrenia and has a close relationship with alcohol withdrawal states. METHOD: Systematic review using PRISMA guidelines. RESULTS: Of 6205 abstracts found, fifteen studies and ten case reports met criteria and were examined. Larger studies examined the use of first-generation antipsychotic drugs, reporting full or partial remission in most patients. Newer case reports report similar results using second generation antipsychotic drugs. Novel treatments, such as those acting on GABA receptors reported low numbers of patients in remission. Some large studies report the successful use of standard alcohol withdrawal treatments. CONCLUSION: The findings of our systematic review are inconclusive. There was significant heterogeneity between and within studies. Significant publication bias is likely. Randomized control trials of more carefully delineated samples would produce evidence of greater clinical utility, for example, on differential effectiveness of antipsychotics and optimal length of standard alcohol withdrawal treatments. AIPD patients who show poor treatment responses should be studied in greater depth. SHORT SUMMARY: This systematic review of alcohol-induced psychotic disorder treatment found 15 studies and 10 case reports of relevance. Older studies of first-generation antipsychotics reported full or partial remission in most patients, as did newer studies with second-generation antipsychotics. Novel drugs reported low remission rates. Standard alcohol withdrawal treatments were successful.

An assessment of need for mental health rehabilitation amongst in-patients in a Welsh region.

BACKGROUND: Rehabilitation services have received little attention in the literature compared with other types of mental health service provision over the past 15 years. However, they are an important component of whole-system functioning in mental health services. Lack of provision has a particular impact on acute in-patient services. Poor pathway management can result in delayed discharges, placement of service users far from home, and resultant loss of resource for the local mental health economy. METHODS: A cross-sectional study gathered demographic, clinical, service utilisation, and financial data on 100 participants from out of area, rehabilitation and acute mental health units. Financial data was provided by the Health Board. Other data were gathered by two clinicians from case records and staff interviews. FINDINGS: 26.0 % of people were inappropriately placed, with frequent overprovision of support. It was calculated that within an annual budget of £12.7 M, £2.5 M (19.7 % of the total expenditure on this patient group) could be saved if all placements were appropriate. INTERPRETATION: There were differences between the three cohorts. Those placed out of area had the most complex needs, although those in rehabilitation placements were similar. Most participants had been in contact with services for more than 5 years. A system better matched to their needs would benefit these patients and would also generate financial savings for reinvestment in the mental health economy.

Social prescribing: an inadequate response to the degradation of social care in mental health.

Social prescribing is poorly defined and there is little evidence for its effectiveness. It cannot address the social determinants of mental health and it is unlikely to produce enduring change for that part of the population that suffers the worst physical and mental health, namely the most deprived and marginalised. It has emerged at a time of growing health inequity. This has occurred alongside the neglect of social care and of the social aspects of mental health intervention. Social prescribing gives a false impression of addressing social factors, and as such is counterproductive. We can do better than this.

Terminology and methods used to differentiate injury intent of hospital burn patients in South Asia: Results from a systematic scoping review.

INTRODUCTION: A key component in the classification of all injury types is to differentiate whether the injury was deliberately inflicted and by whom, commonly known as "intent" in the surveillance literature. These data guide patient care and inform surveillance strategies. South Asia is believed to have the greatest number of intentional burn injuries, but national surveillance data is not disaggregated by injury intent. Scientific literature can be used for injury surveillance where national data collection does not exist. In order to synthesise research findings, it is essential to assess the potential impact of misclassification bias. We therefore conducted a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. METHODS: We followed the methods in our registered protocol (https://doi.org/10.17605/OSF.IO/DCYNQ). Studies met defined population, concept, context, and study design criteria. The databases Embase, MEDLINE, CINAHL, PsycInfo, and PakMediNet were searched. Two reviewers independently screened results. Data were extracted in a standardised manner and verified. The rigour of the method used to differentiate injury intent was appraised. RESULTS: 1435 articles were screened. Of these, 89 met our inclusion criteria. Most articles were from India and Pakistan, and used an observational study design. There were 14 stem terms used in the articles. The most common was "cause". There were 40 classifier terms. The most common were "accident", "suicide", and "homicide". Few articles defined these terms. The method used to differentiate injury intent was only described explicitly in 17% of articles and the rigour of the methods used were low. Where methods of differentiation were described, they appear to be based on patient or family report rather than multidisciplinary assessment. CONCLUSION: The heterogeneity in terms, lack of definitions, and limited investigation of injury intent means this variable is likely to be prone to misclassification bias. We strongly recommend that the global burn community unites to develop a common data element, including definitions and methods of assessment, for the concept of burn injury intent to enable more reliable data collection practices and interstudy comparisons.

Exploring misclassification of injury intent: A burn register study.

INTRODUCTION: Burn registers are an important source of surveillance data on injury intent. These data are considered essential to inform prevention activities. In South Asia, intentional burn injuries are thought to disproportionately affect women. Assessment of injury intent is difficult because it is influenced by personal, family, social, and legal sensitivities. This can introduce misclassification into data, and bias analyses. We conducted a descriptive, hypothesis generating study to explore misclassification of injury intent using data from a newly digitised single centre burn register in south India. METHODS: Data from 1st February 2016 to 28th February 2022 were analysed. All patients in the data set were included in the study (n = 1930). Demographic and clinical characteristics for patients are described for each classification of injury intent. All data cleaning and analyses were completed using RStudio. RESULTS: Injury intent data were missing for 12.6% of cases. It was the most commonly missing variable in the data set. "Accidental" injuries had a similar distribution over time, age, and total body surface area (TBSA) for males and females. "Homicidal" injuries were more common in females. Injuries reported as "Suicidal" affected men and women equally. A decrease in reporting of "Suicidal" injuries in females corresponded to an increase in high TBSA injuries classified as 'Other' or with missing data. Overwriting of injury intent was present in 1.5% of cases. The overwritten group had a greater proportion of females (62.1% vs. 48.5%) and higher median TBSA (77.5% vs. 27.5%) compared to the group where intent was not overwritten. CONCLUSION: Our findings indicate that some subgroups, such as females with high TBSA burns, appear to be more likely to be misclassified and should be the focus of future research. They also highlight that quality of surveillance data could be improved by recording of clinical impression, change in patient reported intent, and use of a common data element for intent to standardise data collection. We also recommend that injury intent is recorded as a unique variable and should not be mixed with other elements of injury causation (e.g. mechanism). Although this is a single centre study, the methods will be of interest to those who utilise routinely collected data and wish to reduce misclassification of this important variable.

Development of an electronic burns register: Digitisation of routinely collected hospital data for global burns surveillance.

INTRODUCTION: Burn registers provide important data that can track injury trends and evaluate services. Burn registers are concentrated in high-income countries, but most burn injuries occur in low- and middle-income countries where surveillance data are limited. Injury surveillance guidance recommends utilisation of existing routinely collected data where data quality is adequate, but there is a lack of guidance on how to achieve this. Our aim was to develop a rigorous and reproducible method to establish an electronic burn register from existing routinely collected data that can be implemented in low resource settings. METHODS: Data quality of handwritten routinely collected records (register books) from a tertiary government hospital burn unit in Mysore, India was assessed prior to digitisation. Process mapping was conducted for burn patient presentations. Register and casualty records were compared to assess the case ascertainment rate. Register books from February 2016 to February 2022 were scanned and anonymised. Scans were quality checked and stored securely. An online data entry form was developed. All data underwent double verification. RESULTS: Process mapping suggested data were reliable, and case ascertainment was 95%. 1930 presentations were recorded in the registers, representing 0.84% of hospital all-cause admissions. 388 pages were scanned with 4.4% requiring rescanning due to quality problems. Two-step verification estimated there to be errors remaining in 0.06% of fields following data entry. CONCLUSION: We have described, using the example of a newly established electronic register in India, methods to assess the suitability and reliability of existing routinely collected data for surveillance purposes, to digitise handwritten data, and to quantify error during the digitisation process. The methods are likely to be of particular interest to burn units in countries with no active national burns register. We strongly recommend mobilisation of resources for digitisation of existing high quality routinely collected data as an important step towards developing burn surveillance systems in low resource settings.

Social psychiatry lives!

SUMMARY: In this journal Ikkos examines the work of the American sociologist Owen Whooley, who argues that US psychiatry has gone through five paradigm shifts without defining the object of its own expertise. We look at the substance of Whooley's methods and assumptions and offer our observations on Ikkos's argument and conclusions.

Breaking out of the citadel: social theory and psychiatry.

British psychiatry has tended to hold itself aloof from social theory. Nonetheless, these ideas have influenced the development of mental health services. Alongside this, the biopsychosocial model cannot reconcile contradictions in the scientific evidence regarding mental illness. We need to develop a more constructive understanding of the implications of social theory.

Psychiatrists' attitudes to professional boundaries concerning spirituality and religion: mixed-methods study.

AIMS AND METHOD: Calls for the integration of spirituality into psychiatric practice have raised concerns about boundary violations. We sought to develop a method to capture psychiatrists' attitudes to professional boundaries and spirituality, explore consensus and understand what factors are considered. Case vignettes were developed, tested and refined. Three vignettes were presented to 80 mental health professionals (53% said they were psychiatrists; 39% did not identify their professional status). Participants recorded their reactions to the vignettes. Four researchers categorised these as identifying boundary violations or not and analysed the factors considered. RESULTS: In 90% of cases, at least three of the four researchers agreed on classification (boundary violation; possible boundary violation; no boundary violation). Participants' opinion about boundary violations was heterogeneous. There was consensus that psychiatrists should not proselytise in clinical settings. Reasoning emphasised pragmatic concerns. Few participants mentioned their religious beliefs. Equivocation was common. CLINICAL IMPLICATIONS: Mental health professionals seem unsure about professional boundaries concerning religion and spirituality in psychiatric practice.

The Goldberg-Huxley model of the pathway to psychiatric care: 21st-century systematic review.

BACKGROUND: The classification of mental disorders used to be based only on people seen by hospital psychiatrists. In fact, most people with a mental disorder were, and are, not seen by psychiatrists because of decisions made prior to psychiatric consultation. The first description of this 'pathway' to care and its levels and filters was published by Goldberg and Huxley in 1980. AIMS: To conduct a review of papers relevant to the application of the Goldberg-Huxley model in the 21st century. METHOD: Systematic review (PROSPERO registration CRD42021270603) of the pathway to psychiatric care in the 21st century. The review concentrates on community surveys and passage through the first filter (consultation in primary care or its equivalent). Ten databases were searched for papers meeting the defined inclusion criteria published between 2000 and 2019 and completed on 15 February 2020. RESULTS: In total, 1824 papers were retrieved, 137 screened fully and 31 included in this review. The results are presented in a table comparing them with previous research. Despite major social, economic and health service changes since 1980, community prevalence and consultation rates remain remarkably consistent and in line with World Health Organization findings. Passage through the first filter is largely unchanged and there is evidence that the same factors operate internationally, especially gender and social parameters. CONCLUSIONS: The Goldberg-Huxley model remains applicable internationally, but this may change owing to an increasingly mixed mental health economy and reduced access to primary care services.

Establishing Self-Harm Registers: The Role of Process Mapping to Improve Quality of Surveillance Data Globally.

Self-harm registers (SHRs) are an essential means of monitoring rates of self-harm and evaluating preventative interventions, but few SHRs exist in countries with the highest burden of suicides and self-harm. Current international guidance on establishing SHRs recommends data collection from emergency departments, but this does not adequately consider differences in the provision of emergency care globally. We aim to demonstrate that process mapping can be used prior to the implementation of an SHR to understand differing hospital systems. This information can be used to determine the method by which patients meeting the SHR inclusion criteria can be most reliably identified, and how to mitigate hospital processes that may introduce selection bias into these data. We illustrate this by sharing in detail the experiences from a government hospital and non-profit hospital in south India. We followed a five-phase process mapping approach developed for healthcare settings during 2019-2020. Emergency care provided in the government hospital was accessed through casualty department triage. The non-profit hospital had an emergency department. Both hospitals had open access outpatient departments. SHR inclusion criteria overlapped with conditions requiring Indian medicolegal registration. Medicolegal registers are the most likely single point to record patients meeting the SHR inclusion criteria from multiple emergency care areas in India (e.g., emergency department/casualty, outpatients, other hospital areas), but should be cross-checked against registers of presentations to the emergency department/casualty to capture less-sick patients and misclassified cases. Process mapping is an easily reproducible method that can be used prior to the implementation of an SHR to understand differing hospital systems. This information is pivotal to choosing which hospital record systems should be used for identifying patients and to proactively reduce bias in SHR data. The method is equally applicable in low-, middle- and high-income countries.

Terminology and methods used to differentiate injury intent of hospital burn patients in South Asia: a systematic scoping review protocol.

BACKGROUND: The greatest proportion of burn injuries globally occur in South Asia, where there are also high numbers of intentional burns. Burn injury prevention efforts are hampered by poor surveillance data on injury intent. There is a plethora of local routinely collected data in the research literature from South Asia that could be used for epidemiological purposes, but it is not known whether the definitions and methods of differentiation of injury intent are sufficiently homogenous to allow valid study comparisons. METHODS: We will conduct a systematic scoping review to understand terminology and methods used to differentiate injury intent of hospital burn patients in South Asia. The objectives of the study are to: determine the breadth of terminology and common terms used for burn injury intent; to determine if definitions are comparable across studies where the same term is used; and to appraise the rigour of methods used to differentiate burn injury intent and suitability for comparison across studies. The databases Embase, MEDLINE, CINAHL, PsycINFO, and PakMediNet will be searched. Screening and data extraction will be completed independently by two reviewers. To be included, the article must be as follows: peer reviewed, primary research, study cutaneous burns, based on hospital patients from a country in South Asia, and use intent terminology or discuss a method of differentiation of injury intent. Results will be restricted to English language studies. No date restrictions will be applied. A plain language summary and terminology section are included for non-specialist readers. DISCUSSION: Results will be used to inform stakeholder work to develop standardised terminology and methods for burn injury intent in South Asia. They will be published open access in peer-reviewed journals wherever possible. SYSTEMATIC REVIEW REGISTRATION: This review has been registered with the Open Science Framework ( https://doi.org/10.17605/OSF.IO/DCYNQ ).

Psychiatry's need for Vergangenheitsbewältigung: 'culture wars', cognitive dissonance and coming to terms with the past.

UK psychiatry's sense of self rests on being part of a socially progressive national tradition. This makes it difficult to engage with more critical narratives. The process of analysing and accepting psychiatry's past can help our profession to get closer to its real self and on a path to a better future.

Long-term, high-dose opioid prescription for chronic non-cancer pain in primary care: an observational study.

BACKGROUND: Opioid prescriptions for chronic pain have risen sharply over the last 25 years; harms associated with these drugs are related to dose and length of use. AIM: The main aim of this study was to identify patients prescribed long-term, high-dose (LTHD) opioids in the community and to assess the prevalence of such use. DESIGN & SETTING: An observational study of opioid prescribing in two demographically dissimilar GP practices in North Wales, UK. METHOD: Details of opioid prescriptions were collected for 22 841 patients, of whom 1488 (6.5%) were being prescribed opioids on the census date. Exhaustive examination of the data identified all patients who were prescribed oral morphine equivalent doses of ≥120 mg/day for ≥1 year. RESULTS: All these patients were being prescribed ≥120 mg/day, as a single drug, morphine, oxycodone, fentanyl, or buprenorphine, irrespective of opioid polypharmacy. Across both practices, 1.71/1000 patients were identified as LTHD users of opioid medication for chronic non-cancer pain (CNCP). Prevalence was similar in the two practices. Repetition of the process until January 2021 showed no change in the pattern. CONCLUSION: This study offers confirmation that a significant group of patients are prescribed long-term opioid medication for chronic pain at doses that are unlikely to be effective in reducing pain, but are likely to have harmful consequences. The findings offer a simple, reliable, and practical method of data extraction to identify these patients individually from routinely collected prescribing data, which will help in monitoring and treating individuals and establishing the problem prevalence.

A qualitative interview study of GPs' experiences of prescribing opioid medication for chronic pain.

BACKGROUND: Prescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses. AIM: To explore GPs' experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice. DESIGN & SETTING: Qualitative interviews with GPs who prescribe opioids in primary care in North East Wales. METHOD: Semi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach. RESULTS: Participating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such as lack of continuity of care, poor access to secondary care pain management support, and, most importantly, constant time pressure. They reported adverse effects on relationships with patients. Unrealistic expectations that pain could be eliminated resulted in pressure to prescribe stronger drugs and increased doses. It led to difficulties in establishing and maintaining trust and in persuading patients to agree to, and to carry out, dose reductions. CONCLUSION: Themes emerging from this study suggest that GPs lack appropriate control of opioid prescribing. There is a need to develop methods to help patients and GPs to work together to manage chronic pain safely.