Clinical relevance of findings in trials of CBT for depression.

Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression - Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant clinical response. The non-specific or placebo effect of being in a psychotherapy trial was a 29% reduction of HAMD.

Seclusion and enforced medication in dealing with aggression: A prospective dynamic cohort study.

BACKGROUND: In the Netherlands, seclusion is historically the measure of first choice in dealing with aggressive incidents. In 2010, the Mediant Mental Health Trust in Eastern Netherlands introduced a policy prioritising the use of enforced medication to manage aggressive incidents over seclusion. The main goal of the study was to investigate whether prioritising enforced medication over seclusion leads to a change of aggressive incidents and coercive measures. METHODS: The study was carried out with data from 2764 patients admitted between 2007 and 2013 to the hospital locations of the Mediant Mental Health Trust in Eastern Netherlands, with a catchment area of 500,000 inhabitants. Seclusion, restraint and enforced medications as well as other coercive measures were gathered systematically. Aggressive incidents were assessed with the SOAS-R. An event sequence analysis was preformed, to assess the whether seclusion, restraint or enforced medication were used or not before or after aggressive incidents. RESULTS: Enforced medication use went up by 363% from a very low baseline. There was a marked reduction of overall coercive measures by 44%. Seclusion hours went down by 62%. Aggression against staff or patients was reduced by 40%. CONCLUSIONS: When dealing with aggression, prioritising medication significantly reduces other coercive measures and aggression against staff, while within principles of subsidiarity, proportionality and expediency.

Perceived coercion in persons with mental disorder in India: A cross-sectional study.

BACKGROUND: Little is known about how patients in India perceive coercion in psychiatric care. AIMS: To assess perceived coercion in persons with mental disorder admitted involuntarily and correlate with sociodemographic factors and illness variables. MATERIALS AND METHODS: We administered the short MacArthur Admission Experience Interview Questionnaire to all consecutive involuntary psychiatric patients admitted in 2014 in Mysore, India. Multivariate linear regression was used. RESULTS: Three hundred and one patients participated. "Perceived coercion" subscale scores increased with female gender, nuclear family status, Muslim and Christian religion, lower income, and depressive disorder. It decreased with former coercion, forensic history, and longer illness duration. Drug use increased total scores; the extended family item decreased them. "Negative pressure" increased with male gender, extended family, lower income, forensic history, and longer illness duration. CONCLUSIONS: The study shows perceived coercion is a reality in India. Levels of perceived coercion and the populations affected are similar to high-income countries.

Staff and caregiver attitude to coercion in India.

OBJECTIVES: The objective of this study was to assess attitudes of Indian psychiatrists and caregivers toward coercion. MATERIALS AND: Methods: The study was conducted at the Department of Psychiatry, Krishna Rajendra Hospital, Mysore, India. Staff Attitude to Coercion Scale (SACS), a 15-item questionnaire, was administered to self-selected psychiatrists across India and caregivers from Mysore to measure attitudes on coercion. Data were analyzed using descriptive statistics and investigating differences in subgroups by means of Chi-square test, Student's t-test, and analysis of variance. Reliability of the SACS was tested in this Indian sample. RESULTS: A total of 210 psychiatrists and 210 caregivers participated in the study. Both groups agreed that coercion was related to scarce resources, security concerns, and harm reduction. Both groups agreed that coercion is necessary, but not as treatment. Older caregivers and male experienced psychiatrists considered coercion related to scarce resources to violate patient integrity. All participants considered coercion necessary for protection in dangerous situations. Professionals and caregivers significantly disagreed on most items. The reliability of the SACS was reasonable to good among the psychiatrists group, but not in the caregiver group (alpha 0.58 vs. 0.07). CONCLUSION: Caregivers and psychiatrists felt that the lack of resources is one of the reasons for coercion. Furthermore, they felt that the need on early identification of aggressive behavior, interventions to reduce aggressiveness, empowering patients, improving hospital resources, staff training in verbal de-escalation techniques is essential. There is an urgent need in the standardized operating procedure in the use of coercive measure in Indian mental health setting.

A systematic review of the clinical relevance of repetitive transcranial magnetic stimulation.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) is an approved treatment for depression. The clinical relevance of its efficacy is unclear. The clinical relevance of findings in the rTMS literature was assessed by translating Hamilton Depression Rating Scale (HAMD) data into Clinical Global Impression-Improvement scale (CGI-I) scores. METHOD: We performed electronic searches of MEDLINE, Embase, PsycINFO, PubMed and Cochrane Central Register of Controlled Trials for RCTs and non-RCT trials on rTMS using Hamilton Depression Rating Scale (HAMD). Articles were included if published in English before January 2014. We translated HAMD scores into nominal CGI-I scores for rTMS for depression and for treatment-resistant depression (TRD). RESULTS: About 960 abstracts were retrieved. Sixty-three studies were included, yielding 130 study arms. For depression, the mean percentage change in HAMD scores in all sham-controlled rTMS treatment arms was 35.63 (SD 16.35) and for sham-rTMS 23.33 (SD 16.51). For TRD, active rTMS in sham-controlled studies showed a mean HAMD percentage reduction of 45.21 (SD 10.94) versus 25.04 (SD 17.55) for sham-rTMS. When aggregated scores were translated into notional CGI-I scores, for the treatment of depression, the notional CGI-I score difference between rTMS and sham-rTMS was 0.5 in favour of rTMS; for TRD, it was 0.75 in favour of rTMS. Differences between rTMS and sham-rTMS were bigger when all study arms were combined. CONCLUSION: Whilst rTMS appears to be efficacious for both non-refractory and treatment-resistant depression, the clinical relevance of its efficacy is doubtful.

Arabic version of the Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC): a validity and feasibility study.

Mental health services are far from satisfactory in the Eastern Mediterranean Region. The Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC) is a semi-structured, computerized clinical assessment tool that was developed to assist health workers in making quick, convenient and comprehensive standardized mental health assessments. A study was carried out in the United Arab Emirates to evaluate the validity and feasibility of the Arabic version of the GMHAT/PC. Mental health nurses administered the GMHAT/PC Arabic version to 50 patients in mental health and rehabilitation settings and their GMHAT/PC diagnosis was compared with the psychiatrist's independent ICD-10 based clinical diagnosis on the same patients. The nurses found GMHAT/PC easy to administer in an average of 16 minutes. The GMHAT/PC-based diagnosis had a good agreement with the psychiatrist's diagnosis (kappa = 0.91) and a high sensitivity (97%) and specificity (94%).

Arabic version of the Global Mental Health Assessment Tool-Primary Care version [GMHAT/PC]: a validity and feasibility study

Mental health services are far from satisfactory in the Eastern Mediterranean Region. The Global Mental Health Assessment Tool-Primary Care version [GMHAT/PC] is a semi-structured, computerized clinical assessment tool that was developed to assist health workers in making quick, convenient and comprehensive standardized mental health assessments. A study was carried out in the United Arab Emirates to evaluate the validity and feasibility of the Arabic version of the GMHAT/PC. Mental health nurses administered the GMHAT/PC Arabic version to 50 patients in mental health and rehabilitation settings and their GMHAT/PC diagnosis was compared with the psychiatrist's independent ICD-10 based clinical diagnosis on the same patients. The nurses found GMHAT/PC easy to administer in an average of 16 minutes. The GMHAT/PC-based diagnosis had a good agreement with the psychiatrist's diagnosis [kappa = 0.91] and a high sensitivity [97%] and specificity [94%]

Delusional infestation and the specimen sign: a European multicentre study in 148 consecutive cases.

BACKGROUND: Systematic studies of delusional infestation (DI), also known as delusional parasitosis, are scarce. They lack either dermatological or psychiatric detail. Little is known about the specimens that patients provide to prove their infestation. There is no study on the current presentation of DI in Europe. OBJECTIVES: To determine the number of true infestations, to assess with which pathogens patients believe themselves to be infested, and to gather details about the frequency and nature of the specimens and the containers used to store them, based on European study centres. METHODS: Retrospective study of consecutive cases with suspected DI from six centres (Dermatology, Psychiatry, Tropical Medicine) in four European countries (U.K., Germany, Italy, France). RESULTS: In total, 148 consecutive cases of suspected DI were included, i.e. the largest cohort reported. None of the patients had evidence of a genuine infestation, as shown by examinations by dermatologists and/or infectious disease specialists. Only 35% believed themselves to be infested by parasites; the majority reported a large number of other living or inanimate (17%) pathogens. Seventy-one patients (48%) presented with what they believed was proof of their infestation. These specimens were mostly skin particles or hair, and rarely insects (only very few of which were human pathogenic or anthropophilic, and none of these could be correlated with the clinical presentation), and only 4% were stored in matchboxes (three of 71). CONCLUSIONS: This first multicentre study of DI in Europe confirms that the term 'delusional infestation' better reflects current and future variations of this entity than 'delusional parasitosis'. The presentation of proofs of infestation, commonly referred to as 'the matchbox sign', is typical but not obligatory in DI and might better be called 'the specimen sign'.

Delusional infestation in dermatology in the UK: prevalence, treatment strategies, and feasibility of a randomized controlled trial.

BACKGROUND: Delusional infestation (DI) is considered rare, but true epidemiological studies are only available for Germany. Patients usually contact dermatologists, and psychiatric referral is often impossible. AIM: To estimate the prevalence of DI in UK dermatology clinics, to examine the feasibility of a multicentre randomized controlled trial (RCT) in dermatology, and to evaluate the psychopharmacotherapy of DI in dermatology. METHODS: A short questionnaire survey was distributed to 231 UK dermatologists, asking how many new and ongoing patients with DI they had seen in the past 3 years, which treatments they had used, and whether they thought an RCT would be feasible. RESULTS: The return rate was good (44.6%, n=103 of 231). In total, 103 British dermatology consultants reported 182 cases seen over the past 3 years and 54 current cases. The 3-year prevalence of DI in dermatology outpatients was 4.99 per million; the point prevalence was 1.48 per million. Around a third (35%) of patients were prescribed psychotropic medication, mostly pimozide. Respondents were evenly split in their view of the feasibility of organizing an RCT of treatment of DI. CONCLUSIONS: Our survey covers more than half of the UK population, allowing the first estimate of basic epidemiological data on DI in dermatology in the UK. Our prevalence estimates indicate that DI is not as rare an illness in dermatological practice as previously assumed. There are potential difficulties in organizing an RCT of DI treatment. British dermatologists do not regularly use second-generation antipsychotics as their first choice of treatment.

Psychiatric treatments in dermatology: an update.

There is a considerable degree of connection between psychiatry and dermatology. This connection is relevant both for diagnosis and management of dermatological pathology. This article summarises common psychiatric conditions seen in patients with skin disease, both primary psychiatric disorders and psychiatric disorders secondary to dermatological pathology. Diagnosis of relevant psychiatric conditions such as anxiety, depression, obsessive-compulsive disorder, delusional parasitosis and dermatitis artefacta, and psychiatric treatments are discussed. It gives an update of psychopharmacology relevant to the dermatologist including important interactions between psychotropic and dermatological agents.

Ward safety perceived by ward managers in Britain, Germany and Switzerland: identifying factors that improve ability to deal with violence.

Little is known about how safe nurses feel on psychiatric wards across different European countries. This paper is aim to evaluate how ward safety is perceived by ward managers in Great Britain, Germany and Switzerland. We replicated a Swiss questionnaire study in Germany and Britain, which asked ward managers on adult psychiatric wards to give details about their ward including data on the management of aggression, staffing levels, staff training, standards and type of restraint used, alarm devices, treatment and management of aggression and the existence and perceived efficacy of standards (protocols, guidelines). The British sample had by far the highest staffing levels per psychiatric bed, followed by Switzerland and Germany. The British ward managers by far perceived violence and aggression least as a problem on their wards, followed by Germany and then Switzerland. British ward managers are most satisfied with risk management and current practice dealing with violence. German managers were most likely to use fixation and most likely to have specific documentation for coercive measures. Swiss wards were most likely to use non-specific bedrooms for seclusion and carry alarm devices. British wards were far more likely to have protocols and training for the treatment and management of violence, followed by Switzerland and Germany. British ward managers by far perceived violence and aggression to be a small problem on their wards compared with Swiss and German ward managers. This was associated with the availability of control and restraint teams, regular training, clear protocols and a lesser degree risk assessments, but not staffing levels.

Consent and capacity for dermatologists: an ethical review and update.

Changes in legislation and case law have brought about several changes in the way that doctors in England and Wales have to deal with consent and capacity issues. These changes affect dermatology in many ways regarding the way we gain consent and the information we have to share with the patient. This article will provide an update and overview on these changes and how they affect dermatology in particular. Legislation changes have opened up avenues to discuss difficult advance decisions with patients. It is hoped that these will reduce the number of ethical dilemmas arising from questions about the treatment of incapacitated patients. It is also necessary, following recent case law, to document and discuss any significant, unavoidable or frequently occurring side-effects of any proposed medication with patients. This means that the recent changes in legislation and case law bring opportunities to dermatologists, but also require improved documentation.

Secondary delusional parasitosis treated with paliperidone.

Second-generation antipsychotics (SGA) are increasingly used in primary and secondary delusional parasitosis (DP) because of their better overall tolerability compared with first-generation antipsychotics (FGA) such as pimozide. Controlled clinical trials with antipsychotics in DP are lacking, owing to difficulties in obtaining informed consent and in securing adherence to a study protocol by patients with DP. We present the case of an 88-year-old man with a 12-year history of DP secondary to leucoencephalopathy. After 9 days of an age-adapted dose of paliperidone, the patient no longer experienced the presence of vermin on his skin and stopped showering at night to get rid off of them. Paliperidone was well tolerated. At follow-up after 2 weeks, the DP was still remitted. Paliperidone appears to expand the therapeutic arsenal in treating DP with modern SGAs; however, this finding needs to be replicated.

Patients' attitudes towards "do not attempt resuscitation" status.

INTRODUCTION: The decision of "do not attempt resuscitation" (DNAR) in the event of cardiopulmonary arrest is usually made when the patients are critically ill and cannot make an informed choice. Although, various professional bodies have published guidelines, little is know about the patients' own views regarding DNAR discussion. AIM: The aim of this study was to determine patients' attitudes regarding discussing DNAR before they are critically ill. METHODS: A prospective study was performed in a general out patients department. A questionnaire was distributed to consecutive outpatients along with an explanatory leaflet in the adult outpatient clinic. RESULTS: 364 patients completed the questionnaire (response rate 77%). 90% of respondents wanted all patients to be asked regarding DNAR decision at some point during a hospital admission. The majority would not find a DNAR discussion distressing. Only 10% would find it upsetting, however, 48% of these still wanted a discussion. 37% of respondents wanted to discuss DNAR decisions on admission; 32% in outpatients; 17% at consent for surgery, 14% when they are critically ill. 87% of respondents would not object to their relatives being involved in making decisions about their resuscitation status. However, only 12% of the subjects in the study had been involved in discussing the resuscitation status of a relative and 21% would not be comfortable to discuss a relative's resuscitation status. Although 33% of patients preferred their resuscitation status to simply be documented within their clinical notes, 77% wanted it to be more easily accessible. CONCLUSIONS: This study suggests that contrary to current practice most patients want to discuss their DNAR status prior to becoming critically ill. This includes half of the small number that find it distressing to discuss. Although most patients are comfortable with relatives being involved in discussing DNAR, a significant proportion do not want their relatives to be asked. Furthermore, once a decision has been made, the majority of patients want it to be more accessible than current practice allows.

Delusional parasitosis: a new pathway for diagnosis and treatment.

Delusional parasitosis is an uncommon disorder that presents particular challenges to the dermatologist. Patients often resist psychiatric referral. Evidence of efficacy of treatment options is generally weak, but some studies exist. By identifying whether the disorder is primary or secondary to another illness, by attempting to involve the liaison psychiatry team if possible and by treating the patient with a modern antipsychotic, remission is achievable. A pathway for diagnostics and therapy is presented. Treatments of choice are 'atypical' or second-generation antipsychotics such as amisulpride, risperidone or olanzapine in age-appropriate doses. Pimozide is no longer the treatment of choice, owing to a higher risk of adverse drug reactions and lower concordance. In some cases, depot antipsychotics can be considered. For diagnostics and treatment, close collaboration of dermatologists and psychiatrists is recommended.

[Analysis of the ethical consequences of the new proposed mental health legislation (Mental Health Bill 2004) for England and Wales]. / Analyse der ethischen Konsequenzen des neuen Zwangseinweisungsgesetzes (Draft Mental Health Bill 2004) für England und Wales.

The article examines the ethical consequences of the new Mental Health Act for England and Wales. Particular emphasis is put on the apparent ethical shift from rights-based principles to utilitarian principles. This shift is particularly evident in the proposed provision for compulsory community treatment and with regards to patients with dangerous and severe personality disorders.

[Commitment and treatment of psychiatric patients in Great Britain and Germany. Comparison of legal principles and medical practice]. / Zwangsunterbringung und -behandlung psychisch Kranker in Grossbritannien und Deutschland. Vergleich der rechtlichen Grundlagen und der medizinischen Praxis.

PURPOSE AND METHODS: The legal provisions concerning the admission to hospital, holding powers and compulsory treatment of mentally ill persons in Great Britain and Germany are compared and the underlying medicolegal conceptions analysed. RESULTS: Whereas British law gives key powers to multiprofessional decision making and relatives, German law requests formal court decisions even in routine issues. This reflects a different understanding of individual rights and their protection. The German mental health law is motivated by the experiences of the totalitarian National Socialist regime. It tries to protect the patient's rights by restricting physicians, hospitals and family members' influence. British law, on the other hand, assumes that experts as well as family members act benevolently in the patient's interest, prefers less formal mechanisms and expresses trust in professional ethics. CONCLUSION: Further research is necessary to analyse the situations in other countries and to investigate which of these approaches is the better one from the point of view of the mentally ill. This is even more important as in the long view European integration will touch these questions and will result in convergence of medicolegal issues.