Psychosocial therapy and causes of death after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching.

BACKGROUND: Psychosocial therapy after deliberate self-harm might be associated with reduced risk of specific causes of death. METHOD: In this matched cohort study, we included patients, who after an episode of deliberate self-harm received psychosocial therapy at a Suicide Prevention Clinic in Denmark between 1992 and 2010. We used propensity score matching in a 1:3 ratio to select a comparison group from 59 046 individuals who received standard care. National Danish registers supplied data on specific causes of death over a 20-year follow-up period. RESULTS: At the end of follow-up, 391 (6.9%) of 5678 patients in the psychosocial therapy group had died, compared with 1736 (10.2%) of 17 034 patients in the matched comparison group. Lower odds ratios of dying by mental or behavioural disorders [0.54, 95% confidence interval (CI) 0.37-0.79], alcohol-related causes (0.63, 95% CI 0.50-0.80) and other diseases and medical conditions (0.61, 95% CI 0.49-0.77) were noted in the psychosocial therapy group. Also, we found a reduced risk of dying by suicide as well as other external causes, however, not by neoplasms and circulatory system diseases. Numbers needed to treat were 212.9 (95% CI 139.5-448.4) for mental or behavioural disorders as a cause of death, 111.1 (95% CI 79.2-210.5) for alcohol-related causes and 96.8 (95% CI 69.1-161.8) for other diseases and medical conditions. CONCLUSIONS: Our findings indicate that psychosocial therapy after deliberate self-harm might reduce long-term risk of death from select medical conditions and external causes. These promising results should be tested in a randomized design.

Encouraging psychiatrists to work with chronic patients: opportunities and limitations of residency education.

In recent years, psychiatrists in both the public and private sectors have been insufficiently involved in the treatment of chronic psychiatric illness. Simultaneously, deinstitutionalization has made the treatment of chronic patients more complex. In this paper the authors discuss the use of medical education- specifically the psychiatric residency-to increase the number of psychiatrists involved in the treatment of chronic patients and to improve the quality of treatment. Optimally residency programs should provide intense, long-term contact with chronic patients, supervised by role models committed to the treatment of such patients. Programs should encourage appropriate attitudes, including realistic treatment expectations and understanding of the issues of patient passivity and dependence; convey specialized knowledge related to housing, ethnicity, occupational, social, and legal matters and train residents in treatment skills tailored to patient needs, including the ability to perform functional diagnostic assessments and to collaborate with other mental health professionals.

Medical students' attitudes about psychiatry. Implications for psychiatric recruitment.

A questionnaire study of 204 senior medical students at two East Coast schools revealed that most were favorable about psychiatry and psychiatrists. When queried concerning criticisms, many stated doubts about the scientific rigor, therapeutic efficacy, and appropriate roles of psychiatrists. Psychiatric clerkships strongly influences student attitudes. Students were especially pleased with opportunities to work directly with patients and to observe psychiatrists doing so. Students were negatively influenced by the antipsychiatry views of nonpsychiatric faculty, house staff, and peers. The findings are discussed with reference to various explanations for the recent decline in psychiatric recruitment and a connection with the rise of family practice is proposed. Direct confrontation of student criticisms, questions, and misconceptions about psychiatry and advocacy of the special expertise and practice opportunities may improve both students' attitudes and psychiatric recruitment.

Gestalt and psychoanalytic therapies: structural analysis and rapprochement.

This paper examines the psychoanalytic concepts of interpretation, resistance, and transference as manifest in gestalt therapy. Although these concepts are de-emphasized, criticized, and disavowed in gestalt theoretical writings, they are actually fundamental to the underlying or "deep" structure of gestalt therapy. Examples of gestalt interventions are described and indications for their use suggested.

Prevalence by Self-report questionnaire and recognition by nonpsychiatric physicians.

Previous studies of medical outpatients have documented a high prevalence of depression that is often unrecognized by primary physicians. However, the subjective methodologies of most of these studies limit their quantitative and comparative usefulness. By contrast, in the present study, 526 medical outpatients completed a self-report questionnaire, the Beck Depression Inventory (BDI). Questionnaire results were calibrated by psychiatric interviews of a subsample of 41 patients. The prevalence of depression was 12.2% when at least mild depression was used as a criterion; the rate for moderate depression was 5.5%, and the rate for severe, probably "psychotic," depression was 0.6%. A review of medical charts showed that primary physicians failed to diagnose about 50% of both depressed and otherwise impaired patients. The BDI was shown to be a sensitive screening test; its use is advocated to improve recognition of depression by primary physicians.

Choosing psychiatry: the importance of psychiatric education in medical school.

Because of the recent decline in the number of U.S. medical graduates choosing to specialize in psychiatry, it is important to reexamine the process of how a student chooses a psychiatric career. The author explores the influence of medical school psychiatric education on the subsequent choice of a psychatric career. The quality of medical school education was measured roughly by priority scores assigned during National Institutes of Mental Health peer review of grant applicatons from medical schools across the United States. Priority scores correlated positively (.17 to .29) with the percentage of each school's graduates entering psychiatric training. The author discusses the implications of these correlations.

The magnitude of declining psychiatric career choice.

Previous studies are reviewed and new data are reported which document a decline in the percentage of American medical graduates choosing psychiatric careers. Data on absolute numbers are conflicting. While 7 percent of graduates from 1945 to 1964 and 6.4 percent of graduates from 1965 to 1970 chose psychiatry, only 5.3 percent of graduates of the classes of 1975 and 1976 did so. Available data for more recent medical classes indicate that further decrements will occur. Possible explanations and strategies for research are briefly outlines.