Electrical and Magnetic Stimulation of the Brain; Are These Methods Used Appropriately in Treating Depression? Part 1. Where should Transcranial Magnetic Stimulation be Placed in an Algorithm for the Treatment of Resistant Depression?

Depression is a common condition which causes serious of morbidity among the population. While treatment is often provided with pharmacological antidepressants and psychotherapy, many patients do not respond to such treatment, and therefore algorithms have been proposed to develop treatments for resistant depression. Transcranial Magnetic Stimulation is a relatively new form of treatment for depression, which appear to have a good safety profile and appear to be acceptable to patients. Other forms of Brain Stimulation, such as Electro-Convulsive therapy, have a more complex safety profile, and require anaesthesia. Still other forms of electrical stimulation of the brain, such as Vagus nerve Stimulation are invasive in nature. The position of a particular modality of treatment in the Algorithm for the treatment of Resistant Depression depends on a balance between effectiveness of treatment, side effect profile, acceptability to the patients, availability of treatment, invasiveness of treatment, and the possibility of combining it with other treatments. Here we assess the position of Transcranial Magnetic Stimulation in such an Algorithm for the treatment of Resistant Depression. Given its effectiveness and its relatively good side effect profile, we suggest that it could be used early in the treatment of depression, however its use may be limited by lack of necessary equipment. On the other hand, Electro-convulsive therapy must be reserved for much more resistant cases, because of the need for anaesthesia and muscle relaxants, as well as its side effect profile, even though it might be somewhat more effective than the other modalities. Further study of Transcranial Magnetic Stimulation and are warranted.

Electrical and Magnetic Stimulation of the Brain; Are These Methods Used Appropriately in Treating Depression? Part 2. Where should Transcranial Direct Current Stimulation be Placed in an Algorithm for the Treatment of Resistant Depression?

Depression is a common condition which causes serious of morbidity among the population. While treatment is often provided with pharmacological antidepressants and psychotherapy, many patients do not respond to such treatment, and therefore algorithms have been proposed to develop treatments for resistant depression. Transcranial Direct Current Stimulation is a relatively new form of treatment for depression, which appear to have a good safety profile and appear to be acceptable to patients. Other forms of Brain Stimulation, such as Electro-Convulsive therapy, have a more complex safety profile, and require anaesthesia. Still other forms of electrical stimulation of the brain, such as Vagus nerve Stimulation are invasive in nature. The position of a particular modality of treatment in the Algorithm for the treatment of Resistant Depression depends on a balance between effectiveness of treatment, side effect profile, acceptability to the patients, availability of treatment, invasiveness of treatment, and the possibility of combining it with other treatments. Here we assess the position of Transcranial Direct Current Stimulation in such an Algorithm for the treatment of Resistant Depression. Given its effectiveness and its relatively good side effect profile, we suggest that it could be used early in the treatment of depression, however its use may be limited by lack of necessary equipment. On the other hand, Electro-convulsive therapy must be reserved for much more resistant cases, because of the need for anaesthesia and muscle relaxants, as well as its side effect profile, even though it might be somewhat more effective than the other modalities. Further study of Transcranial Direct Current Stimulation is warranted.

Since Exposure to Mental Trauma, Especially War Trauma, Causes Personality Changes, Should Deliberate Exposure to Mental Health Trauma of Civilians Be in Itself a War Crime?

Mental trauma is a consequence of war. Here we consider whether the inflicting of such trauma, which could cause personality changes, should be considered a war crime in its own right, especially when it is civilians who are exposed to mental trauma. We make the argument based on a review of the development of personality disorders in persons exposed to mental trauma caused by war, and we make the argument that it is possible to demonstrate both physiological and anatomical changes in the brain of such persons, which could account for the observed behavioural and personality changes. Therefore we argue that deliberate exposure to Mental Health Trauma, for example by deliberate targeting of civilian areas with artillery, should be considered a war crime in its own right irrespective of whether the civilians receive physical trauma or not.

The Concept of Staging in Schizophrenia; 13 Years After the 'Agius Concept of Staging' Was Published.

We review the development of clinical staging models of schizophrenia, which has developed as a logical extension of the Neuro-developmental theory of Schizophrenia. The staging approach, which involves assessing a disorder based on its severity, scope, progression, and characteristics, is gaining growing recognition in the fields of clinical psychology and psychiatry. We review the development of clinical staging models of schizophrenia, which has developed as a logical extension of the Neuro-developmental theory of Schizophrenia. The development of these clinical staging models should be based also on the neuroimaging dana, since this implies actual changes within the brain. There still are some difficulties with these models, but they are gradually providing both more logical ways of understanding the development of psychotic illness and more effective ways of treatment. The Models have contributed to research in several areas of psychiatry.

Is Edith Stein's model of the characteristics and behaviour of woman, consonant with woman's physiology and endocrinology?

In this paper we describe the physiology and endocrinology of the women's reproductive system as this refers to the function of the brain and the functioning of Oestrogen and Progesterone Receptors within the brain. We compare this to the description of woman's nature as described by the philosopher and psychologist Edith Stein, who has described the describing specific characteristics and behaviours of women, which fit woman for contributing to the professions as well as the family. We ask whether Stein's description of the characteristics of woman, is in fact consonant with the neuroscience which we have described. We conclude that these two concepts are consonant, in other words, the neuroscience of the female reproductive system and Edith Stein's characteristics of woman are not mutually exclusive and are two concepts which potentially support each other.

How Does Present Neuroscience Support Edith Stein's View on the Appropriateness of Women's Education and the Involvement of Women in the Professions?

Edith Stein has written a great deal about the nature of women and has advocated for the place of women in society and their place in the professions. We have written a series of papers describing the relationship between the findings of neuroscience and the differences between the female and male brains. Here we summarise how our knowledge of these differences underpin Edith Stein's view of the nature of women, and therefore validate Stein's particular view of feminism.

Using Opera and the Performing Arts to Educate about Mental Health Problems - Ciklu.

For several years now, the performing arts have been used to Educate about Mental Health Problems. An important aim is to eliminate stigma, which is a multifaceted concept which has several causes including shame and which is thought to act as a barrier to successful help seeking and engagement with support services by persons with mental health problems. There have been many art forms used, from One Man Shows, to films, Plays, Dance, or Singing. Recently Opera has been added to this collections of art form initiatives . We review the publications on how performing arts have been used to destigmatise mental health problems, including those in which an attempt has been made to measure the impact quantitatively. We then review Ciklu, a new Maltese Opera production which attempts to destigmatise Mental Health Problems, to show that it fits within the worldwide attempt to use performing arts to destigmatise Mental Health Issues.

Traumatic Events, Sexual Abuse and Mental Illness.

That 'Childhood Adversity', which includes many traumatic events but in particular includes sexual abuse during childhood, can cause changes in the brain, such as the finding of a smaller hippocampus is well established by the observations of such persons as Thomas Frodl (2008, 2013). That traumatic events in adulthood can also cause both clinical symptoms such as Post Traumatic Stress Disorder, with equivalent shrinkage of the hippocampus (Smith 2005), is also well known. In this article we apply these neurological findings to the particular traumatic event of sexual abuse at any age, first to demonstrate that such abuse can indeed cause a number of mental illnesses, and hence to produce a model of how different forms of mental trauma may cause different mental illnesses. Next we describe human sexuality as a form of language, whereby feelings ranging from love to indifference to exercise of power to hatred can be expressed. We suggest that the expression of these feelings can give rise to positive feelings or to the mental illnesses we have mentioned. We emphasize how free choice is central to the 'messages' that we give to our partners through our sexuality - and therefore that we are responsible for those messages and their consequences. We point out therefore that inappropriate choices by the couple may lead to the consequent neurological changes and mental health symptoms we have mentioned. We finally analyse the act of sexual intercourse into a number of component functions (or consequences) including the Generative Function - that of producing another human person, the Choice Function - that of choosing the other person, the Language Function - that of communicating that choice to the other person and the Empowering Function- that of empowering the other person. We propose a model of human sexuality in which these four functions are linked together, so that in normal circumstances they work together in complete harmony, however, numerous circumstances of modern life can cause these four functions to operate asyncronously, thus leading to the neurological changes which we have mentioned above. These neurological changes are associated with the changes in hippocampal size which we have described above. Thus in our model, we have linked the Neurological changes of Trauma with factors relating to Choice, psychological concepts, and consequent symptomatology of illness. We do this in the context of a model of the Human Person in which mind and body are linked so that the human person can be understood as an 'Embodied Spirit', rather than the Cartesian Model. This concept goes back to the model of the Human Person of Aristotle, and was re-expressed in Medieval times by Aquinas and Augustine, and is congruent with Phenominology as expressed by Husserl and Stein. We have previously argued that such an 'Embodied Spirit' model of the Human Person is more congruent with modern neuroscience than a Cartesian Model (Agius 2017).

Immune thrombocytopenia in alemtuzumab-treated MS patients: Incidence, detection, and management.

BACKGROUND: Alemtuzumab is a highly effective therapy for relapsing-remitting multiple sclerosis (RRMS), and immune thrombocytopenia (ITP) has been identified as a risk. OBJECTIVE: To examine ITP incidence, treatment, and outcomes during the clinical development of alemtuzumab for RRMS and discuss postmarketing experience outside clinical trials. METHODS: CAMMS223 and Comparison of Alemtuzumab and Rebif® Efficacy in Multiple Sclerosis (CARE-MS) I and II investigated two annual courses of alemtuzumab 12 mg (or 24 mg in CAMMS223/CARE-MS II) versus subcutaneous interferon beta-1a three times per week. Patients completing core studies could enroll in an extension. Monthly monitoring for ITP continued until 48 months after the last alemtuzumab infusion. RESULTS: Of 1485 alemtuzumab-treated MS patients in the clinical development program, 33 (2.2%) developed ITP (alemtuzumab 12 mg, 24 [2.0%]; alemtuzumab 24 mg, 9 [3.3%]) over median 6.1 years of follow-up after the first infusion; most had a sustained response to first-line ITP therapy with corticosteroids, platelets, and/or intravenous immunoglobulin. All cases occurred within 48 months of the last alemtuzumab infusion. Postmarketing surveillance data suggest that the ITP incidence is not higher in clinical practice than in clinical trials. CONCLUSION: Alemtuzumab-associated ITP occurs in approximately 2% of patients and is responsive to therapy. Careful monitoring is key for detection and favorable outcomes.

Safety and tolerability of inebilizumab (MEDI-551), an anti-CD19 monoclonal antibody, in patients with relapsing forms of multiple sclerosis: Results from a phase 1 randomised, placebo-controlled, escalating intravenous and subcutaneous dose study.

BACKGROUND: B cells may be involved in the pathophysiology of multiple sclerosis (MS). Inebilizumab (formerly MEDI-551) binds to and depletes CD19+ B cells. OBJECTIVES: To assess safety, tolerability, pharmacokinetics, pharmacodynamics and immunogenicity of inebilizumab in adults with relapsing MS. METHODS: This phase 1 trial randomised 28 patients 3:1 (21, inebilizumab; 7, placebo) to inebilizumab (2 intravenous (IV) doses, days 1 and 15: 30, 100 or 600 mg; or single subcutaneous (SC) dose on day 1: 60 or 300 mg) or matching placebo, with follow-up until at least week 24 or return of CD19+ B-cell count to ⩾80 cells/µL. RESULTS: Complete B-cell depletion was observed across all doses. Infusion/injection (grade 1/2) reactions occurred in 6/15 patients receiving inebilizumab IV, 2/5 placebo IV and 1/6 inebilizumab SC. Serious adverse events occurred in three patients receiving inebilizumab: pyrexia, mixed-drug intoxication (unrelated to inebilizumab; resulted in death) and urinary tract infection. Mean number of cumulative new gadolinium-enhancing lesions over 24 weeks was 0.1 with inebilizumab versus 1.3 with placebo; mean numbers of new/newly enlarging T2 lesions were 0.4 and 2.4, respectively. CONCLUSION: Inebilizumab had an acceptable safety profile in relapsing MS patients and showed a trend in reductions in new/newly enlarging and gadolinium-enhancing lesions.

Personality Disorders in Black People: less prevalent or the result of healthcare inequalities?

The prevalence of personality disorders (PDs) in black people has consistently been reported as significantly lower than in their white equivalents. If this result is accurate, then it may reveal important clues as to the aetiology of personality disorders, which could provide invaluable insights as to how we should support these patients. However, if this result does not reflect the truth, then important questions must be answered as to why black people with personality disorders are under- represented. There has been limited investigations into what may cause a discrepancy in the PD prevalence between ethnicities. This review aims to determine whether the lower prevalence of PDs in black people is likely to be accurate, and if it isn't, explore some of the potential causes for the difference. This is an important issue to address as may reveal pertinent inequalities in healthcare.

The wider effects of Paternal Post Natal Depression: An overview.

Paternal Post Natal Depression (PPND), although becoming more prevalent, is still poorly recognised. Unfortunately, its effects and negative outcomes have not been as widely researched as that of maternal postnatal depression. PPND can affect the fathers parenting style and lead to a negative effect on their child's behaviour and social development. Furthermore, depressed fathers may feel unsupported and this can lead to problems with the marital relationship and be associated with concurrent maternal postnatal depression. Moreover, support services and interventional therapy come at a cost to the health service and therefore treating PPND can impact the economy. Identifying the effects PPND has is important as implementing reliable screening measures and better education may prevent negative outcomes.

The Role of Care Coordinators Versus Doctors in the Management of Chronic Mental Illness in the Community.

Doctors play an important role in a multidisciplinary team, however therapeutic relationships are not limited to between a doctor and a patient. In Community Mental Health Teams, patients are allocated a care coordinator - usually a community psychiatric nurse or a social worker - and they usually become the healthcare provider the patient is most regularly in contact with. Similarly, a practice nurse in General Practice may be the healthcare professional a patient is most familiar with. In these instances, the patient-provider relationship may be stronger than the doctor-patient relationship. Non-doctor and patient relationships play an increasingly important role in improving the patient experience and contributing to information gathering, shared-decision making, and establishment and adherence to treatment plans. Care coordinators may be in a more superior position than doctors to accurately recognise the ongoing and changing needs of a person with mental illness. Patients value continuity of care, compassion, and mutual trust and respect: these qualities can potentially all be provided by any trained healthcare professional. In this paper, we will review the literature on the emerging role of the care coordinator and other healthcare professionals in the management of chronic mental illness in the community.

An audit of the reporting of depression & anxiety in COPD patients.

Anxiety and depression contribute to a substantial burden of Chronic Obstructive Pulmonary Disease-related morbidity by impairing quality of life and by reducing adherence to treatment. The identification of COPD patients with comorbid depression or anxiety symptoms is vital, as it is estimated that only a third of patients with these co-morbidities are receiving appropriate treatment. The aim of this audit was therefore to identify whether current methods of anxiety and depression screening in elderly patients (over the age of 65) with severe COPD (FEV1 <50% at most recent spirometry reading) are adequate by assessing how frequently anxiety and depression is reported as "discussed with patient" in COPD review appointments across two practices. SystmOne was used to identify a total of 83 patients, and the recording of depression and anxiety discussions in this cohort's review appointments was analysed and compared with the incidence of QOF-coded depression and anxiety in the patient notes. The results show that both the rate and the quality of depression and anxiety reporting in these review appointments is highly heterogeneous, and has led to 'missed' patients suffering from comorbid mental health issues. Additionally, this audit identified a number of patients with depression or anxiety directly related to their COPD, and it highlighted a trend among this cohort towards more frequent appointments with their General Practitioner, and towards related presentations at the Emergency Department. The results of this audit suggest there is room for amelioration of the current practice, such as the implementation of a structured screening tool into System One's COPD review appointment template.

Emotionally Unstable Personality Disorder in Primary Care: A Thematic Review and Novel Toolkit.

Emotionally Unstable Personality Disorder (EUPD) causes significantly impaired personality functioning to include feeling of emptiness, lack of identity, unstable mood and relationships, intense fear of abandonment and dangerous impulsive behaviour including severe episodes of self-harm. The vast majority of EUPD patients are managed in the community, and have less contact with specialist psychiatric services when compared to patients with other mental illnesses. Despite the burden of this condition on primary care, the academic literature focuses on EUPD in psychiatric inpatients. This paper therefore aims to redress this balance through, first, establishing the key themes present in the available body of work on EUPD in the community, and second, highlighting areas for future research. Further, in the spirit of reducing stigma surrounding mental illness, the authors present a novel and non-pejorative toolkit for the recognition of EUPD in primary care.

Pharmacological Therapies in Bipolar Disorder: a Review of Current Treatment Options.

BACKGROUND: Bipolar disorder is a mental illness characterised by periods of elevated mood alternating with periods of depression. Long-term relapse prevention in bipolar disorder is challenging, with a significant number of patients relapsing following the initial stabilisation of mood. Initial treatment of the condition is complex and usually occurs in secondary care. Whilst there is no known cure for bipolar disorder, several therapies have been found to be effective in both managing acute episodes and sustaining long-term remission. The key pharmacological therapies in bipolar disorder are lithium salts, antiepileptics and antipsychotics and these will be the focus of this review. AIM: This review seeks to outline the key common pharmacological therapies used in the treatment and relapse prevention of this condition. METHODS: A MEDLINE search was performed, and the available literature was subsequently analysed, including meta-analyses, reviews and original clinical trials. RESULTS: Management strategies can be subdivided into treating acute presentations of mania and depression and maintaining long-term remission. The extensive side effect profile of several antipsychotics means that there are certain patient groups for whom they may be intolerable or contraindicated. Lithium emerges as a highly efficacious maintenance therapy but retains the burden of therapeutic drug monitoring. Antiepileptics play a crucial role in maintaining remission but are linked to serious, albeit rare, side effects. CONCLUSION: Despite the efficacy of the medications discussed in this article, their underlying mechanisms of action remain to be fully elucidated. Nonetheless, these key therapies continue to be essential tools in the management of bipolar disorder.

Physical Health Checks in Patients on Antipsychotic Medication.

Schizophrenic patients have traditionally suffered from high rates of cardiovascular disease and early mortality. NICE guidelines suggest that several physical health measures be monitored regularly in these patients, and particularly those on antipsychotic medication, which has a wide side-effect profile that may potentiate the risk of cardiovascular disease and other comorbidities. This general practice audit aimed to determine the rates of physical health monitoring in primary care in patients on antipsychotic medication for over a year for psychotic symptoms or schizophrenia. The search was conducted in three different general practices in March 2019, yielding 19, 8 and 30 patients respectively, with a total of 57 patients. This audit aims to record and analyse rates of monitoring of a range of physical health measures recommended by NICE guidelines over the past year. The results demonstrated that physical health monitoring was poor amongst all the practices audited, especially that of prolactin and waist circumference. We recommend that these rates of monitoring be improved, through implementing templates or the delivery of targeted education to general practitioners and nurses.

The effects of eating disorders in pregnancy on mother and baby: a review.

The psychological and physiological interaction between anorexia and the pregnant state has a large intrapartum and postpartum impact on mother and baby. Current research has attempted to discern the short and long term effects of eating disorders (EDs) on pregnancy as well as mother and baby-related sequelae; however little is understood about which management strategies are likely to prove most successful in mitigating these risks. The incidence and effect of low pre-pregnancy body mass index (BMI) on obstetric outcomes, and possible health complications in the future child, has attracted widespread attention. Especially concerning is the fact that it has long been known that the incidence of EDs in women of childbearing age is not only the highest out of all age categories but also is on an increasing trajectory. This paper aims to highlight the recent evidence underpinning the management of pregnant women with EDs in the light of the discussed short and long term effects of the disorders on mother and baby. We shall focus on those women who have a previous diagnosis of an ED prior to being pregnant. Particular attention will be paid to those studies considering anorexia nervosa. We argue for the use of early intervention strategies for the management of pregnant women with eating disorders, and for the use of a multidisciplinary approach in the treatment of these patients with complex problems.

Depression and dry eye disease: a need for an interdisciplinary approach?

A recent meta-analysis including data from 22 studies including 2.9 million patients found that anxiety and depression are more prevalent in patients with dry eye disease (DED) than in controls. DED is a common disorder of the tear film which can cause ocular irritation, foreign body sensation and visual disturbance. However there is often a great discrepancy between signs and symptoms of DED, which the symptoms often being more associated with non-ocular disorders such as depression and PTSD than to tear film parameters. In this way it could be considered as more of a psychiatric than ophthalmic complaint. DED and depression feedback on one another in a synergistic manner. Severity of DED is associated with symptoms of anxiety and depression. Treatment of DED could help reduce depression symptoms, but also effective management of depression could help alleviate symptoms of DED. Complicating this however is the evidence that SSRIs can exacerbate DED. This makes the management of these comorbidities more difficult, however there are putative therapeutic targets which may be a source of future treatments for DED-associated depression. In conclusion, it is clear that DED and depression are closely linked and influence one another in ways that drastically affect patients' lives. Collaboration between psychiatrists and ophthalmologists could be beneficial in the management of those with DED.

Neuroscience and Visual Art; Moving through empathy to the Ineffable.

In this article we wish to discuss recent work on neurobiology and visual arts, with impact on human pleasure, wellbeing and improved mental health. We wish to discuss briefly our model of the Human Person and apply it to Visual Art, and we wish to discuss our view of how empathy has been suggested as an important factor in how visual art can impact the human person, with its links with neuroscience and anthropology, and thus how Visual Art can put Human Beings in touch with their deepest feelings and even with the ineffable.