Attachment theory: survival, trauma, and war through the eyes of Bowlby.

Children are no strangers to war and conflict, and for as long as history has been documented, so too has the negative impact of war on children. Attachment theory, which has shone a light upon the ways in which early life experiences can impact individuals across the lifespan, is a helpful lens through which we can view the consequences of war. Similar to the aftermath of war leading to lifelong and transgenerational suffering due to deaths and physical health issues, attachment difficulties created during war further compound long-term damage. Yet, despite our theoretical understanding of the detrimental impact of war on children and on humankind, humanity has failed to find ways to avert, or at least minimise, this unfortunate risk. Instead in this century, we see a growing number of conflicts globally with increasing asylum seekers. In this editorial, we argue that the large-scale disruption to attachment relationships caused by conflict and war is an important consideration for global policy, and that the healthcare community must show leadership in highlighting this serious impact of war.

Response rates to sequential trials of antipsychotic medications according to algorithms or treatment guidelines in psychotic disorders. A systematic review and meta-analysis.

BACKGROUND: There is a relative lack of research evaluating the outcomes when treatment guidelines or algorithms for psychotic disorders are followed. This systematic review and meta-analysis determined the response rates to antipsychotic medications at different stages of these algorithms and whether these response rates differ in first episode cohorts. METHODS: Data sources: A systematic search strategy was conducted across four databases PubMed, EMBASE, PsycINFO (Ovid) and CINAHL. Studies that had sequential trials of different antipsychotic medications were included. A meta-analysis of proportions was performed using random effects models and sub-group analysis in first episode psychosis studies. RESULTS: Of the 4078 unique articles screened, fourteen articles, from nine unique studies, were eligible and included 2522 participants. The proportion who experienced a response to any antipsychotic in the first stage of an algorithm was 0.53 (95 % C.I.:0.38,0.68) and this decreased to 0.26 (95 % C.I.:0.15,0.39) in the second stage. When clozapine was used in the third stage, the proportion that achieved a response was 0.43 (95 % C.I. 0.19, 0.69) compared to 0.26 (95 % C.I.:0.05,0.54) if a different antipsychotic was used. Four studies included 907 participants with a first episode of psychosis and the proportions that achieved a response were: 1st stage: 0.63 (95 % C.I.: 0.45, 0.79); 2nd stage: 0.34 (95 % C.I.:0.16,0.55); clozapine 3rd stage: 0.45 (95 % C.I.:0.0,0.97), different antipsychotic 3rd stage: 0.15 (95 % C.I.,0.01,0.37). DISCUSSION: These findings support the recommendation to have a trial of clozapine after two other antipsychotic medications have been found to be ineffective.

Impact factor and future directions for the Irish Journal of Psychological Medicine.

Impact factor (IF) is a concept dating back over half a century, created to evaluate the impact of a journal within a particular scientific field. In spite of limitations, IF remains a widely used metric for journals to establish the average number of citations for articles published in a journal. The Irish Journal of Psychological Medicine (IJPM) recently received an IF of 5.1, the first IF for the journal. We believe that this is a reflection of the hard work and dedication of our authors, reviewers, publishers and editorial board. The IJPM is the official research journal of the College of Psychiatrists of Ireland, and while psychiatry is the primary discipline of the journal, the current multidisciplinary approach will continue into the future. The journal has a strong Irish and international readership; while the journal will continue to publish research with an Irish focus, the editorial team are aware of the importance of ongoing global contributions to ensure the journal maintains high-quality publications of an international standard. This is an exciting time to be involved in mental health research, and the journal will continue to publish cutting edge themes with the goal of improving mental healthcare in Ireland and beyond.

Turning the Spotlight on Apathy: Identification and Treatment in Schizophrenia Spectrum Disorders.

Among negative symptoms, apathy is central to the impairments in real-life functioning in schizophrenia spectrum disorders (SSD). Thus, optimizing treatment for apathy appears key to improve outcomes. In treatment research, however, negative symptoms are typically studied as a unifactorial construct. We, therefore, aim to shed necessary light on the status of apathy identification and treatment in SSD.

Outcomes 1 year after a first episode of psychosis in migrants to the Republic of Ireland.

BACKGROUND: Migration is a robust risk factor for developing a psychotic disorder, yet there is a paucity of research on the outcomes of migrants who develop a psychotic disorder. Identifying sub-groups within FEP cohorts who have a poorer outcome, could assist in the development and delivery of more targeted interventions. AIMS: There is a paucity of research on the outcomes of migrants who develop a psychotic disorder. This study aimed to evaluate a broad range of outcomes for those with a FEP who migrated to the Republic of Ireland, including: (i) symptomatic; (ii) functional; (iii) hospitalisation and (iv) engagement with psychosocial services. METHODS: All individuals with a FEP aged 18 to 65 who presented between 01.02.2006 and 01.07.2014 were included. Structured and validated instruments were used to measure positive, negative, depressive symptoms and insight. RESULTS: Of the 573 individuals with a FEP, 22.3% were first-generation migrants and 63.4% (n = 363) were followed up at 1 year. At this time, 72.4% of migrants were in remission of positive psychotic symptoms compared to 78.5% of the Irish born (OR = 0.84, 95% CI [0.50-1.41], p = .51). In relation to negative symptoms, 60.5% of migrants were in remission compared to 67.2% of the Irish born (OR = 0.75, 95% CI [0.44-1.27], p = .283). There was no difference in the severity of positive, negative or depressive symptoms between groups and there was a trend for the Irish born to have better insight (p = .056). The functional outcomes were similar across groups. One third of migrants were admitted to hospital compared to 28.7% of the Irish born (OR = 1.24, 95% CI [0.73-2.13], p = .426). Just over half of both groups attended CBT and 46.2% of caregivers for migrants attended the psychoeducation programme, compared to 39.7% for the Irish born (OR = 1.30, 95% CI [0.79-2.16], p = .306). CONCLUSIONS: These findings demonstrate that migrants have broadly similar outcomes to the native-born populations, however there is still considerable scope for the outcomes for all individuals affected by psychotic disorders to be improved.

Psychosocial and behavioural interventions for the negative symptoms of schizophrenia: a systematic review of efficacy meta-analyses.

BACKGROUND: Currently there is no first-line treatment recommended for the negative symptoms of schizophrenia. Psychosocial and behavioural interventions are widely used to reduce the burden of negative symptoms. Meta-analytic studies have summarised the evidence for specific approaches but not compared evidence quality and benefit. AIM: To review and evaluate the evidence from meta-analytic studies of psychosocial and behavioural interventions for the negative symptoms of schizophrenia. METHOD: A systematic literature search was undertaken to identify all meta-analyses evaluating psychosocial and behavioural interventions reporting on negative symptom outcomes in people with schizophrenia. Data on intervention, study characteristics, acceptability and outcome were extracted. Risk of bias was evaluated. Results were summarised descriptively, and evidence ranked on methodological quality. RESULTS: In total, 31 systematic reviews met the inclusion criteria evaluating the efficacy of negative symptom interventions on 33 141 participants. Exercise interventions showed effect sizes (reduction in negative symptoms) ranging from -0.59 to -0.24 and psychological interventions ranging from -0.65 to -0.04. Attrition ranged between 12% to 32%. Across the studies considered heterogeneity varied substantially (range 0-100). Most of the reviews were of very low to low methodological quality. Methodological quality ranking suggested that the effect size for cognitive remediation and exercise therapy may be more robust compared with other approaches. CONCLUSIONS: Most of the interventions considered had a small-to-moderate effect size, good acceptability levels but very few had negative symptoms as the primary intervention target. To improve the confidence of these effect sizes being replicated in clinical settings future studies should minimise risk of bias.

Risk of first-episode psychosis in migrants to the Republic of Ireland.

BACKGROUND: Migration is an established risk factor for developing a psychotic disorder in countries with a long history of migration. Less is known for countries with only a recent history of migration. This study aimed to determine the risk for developing a psychotic disorder in migrants to the Republic of Ireland. METHODS: We included all presentations of first-episode psychosis over 8.5 years to the DETECT Early Intervention for psychosis service in the Republic of Ireland (573 individuals aged 18-65, of whom 22% were first-generation migrants). Psychotic disorder diagnosis relied on SCID. The at-risk population was calculated using census data, and negative binomial regression was used to estimate incidence rate ratios. RESULTS: The annual crude incidence rate for a first-episode psychotic disorder in the total cohort was 25.62 per 100000 population at risk. Migrants from Africa had a nearly twofold increased risk for developing a psychotic disorder compared to those born in the Republic of Ireland (IRR = 1.83, 95% CI 1.11-3.02, p = 0.02). In contrast, migrants from certain Asian countries had a reduced risk, specifically those from China, India, Philippines, Pakistan, Malaysia, Bangladesh and Hong Kong (aIRR = 0.36, 95% CI 0.16-0.81, p = 0.01). CONCLUSIONS: Further research into the reasons for this inflated risk in specific migrant groups could produce insights into the aetiology of psychotic disorders. This information should also be used, alongside other data on environmental risk factors that can be determined from census data, to predict the incidence of psychotic disorders and thereby resource services appropriately.

Keyworker mediated enhancement of physical health in patients with first episode psychosis: A feasibility/acceptability study.

AIM: Early intervention for people experiencing first episode psychosis is a priority, and keyworkers are vital to such services. However, keyworkers' roles in addressing first episode psychosis patients' physical health are under researched. This study addresses this knowledge gap by evaluating a keyworker-mediated intervention promoting physical health among first episode psychosis patients. METHODS: The study was informed by the Medical Research Council's Framework for Complex Interventions to Improve Health. First episode psychosis participants were recruited from three Irish mental health services. The intervention was evaluated in terms of its feasibility/acceptability. RESULTS: Feasibility outcomes were mixed (recruitment rate = 24/68 [35.3%]; retention rate = 18/24 [75%]). The baseline sample was predominantly male (M:F ratio = 13:6; Med age = 25 y; IQR = 23-42 y). Common health issues among participants included overweightness/obesity (n = 11) and substance use (smoking/alcohol consumption [n = 19]). Participants' initial health priorities included exercising more (n = 10), improving diet (n = 6), weight loss (n = 7) and using various health/healthcare services. The intervention's acceptability was evidenced by the appreciation participants had for physical health keyworkers' support, as well as the healthy lifestyle, which the intervention promoted. Acceptability was somewhat compromised by a low-recruitment rate, variable linkages between keyworkers and general practitioners (GPs) and COVID-19 restrictions. CONCLUSIONS: Physical health-oriented keyworker interventions for first episode psychosis patients show promise and further evaluation of such initiatives is warranted. Future interventions should be mindful of participant recruitment challenges, strategies to enhance relationships between keyworkers and GPs, and if necessary, they should mitigate COVID-19 restrictions' impacts on care.

The global impact on mental health almost 2 years into the COVID-19 pandemic.

Approaching 2 years into a global pandemic, it is timely to reflect on how COVID-19 has impacted the mental health of the global population. With research continuing apace, a clearer picture should crystallise in time. COVID-19 has undoubtedly had some impact on population mental health, although the severity and duration of this impact remain less clear. The exceptional period of COVID-19 has provided a unique prism through which we can observe and consider societal mental health. This is a momentous time to be involved in mental health research as we strive to understand the mental health needs of the population and advocate for adequate resourcing to deliver quality mental healthcare in the post-pandemic period.

The role of key workers in improving physical health in first episode psychosis: A scoping review.

AIM: Studies have demonstrated that a majority of the decline in health status and functioning emerges during the first few years following the onset of psychosis. This knowledge led to the development of specialized early intervention services (EIS) targeting patients experiencing their first episode of psychosis (FEP). The central component of EIS is often assertive case management delivered by a multidisciplinary team, where an appointed key worker is responsible for coordinating treatment and delivering various psychosocial interventions to service users. The aim of this scoping review was to examine how key workers can enhance the physical health outcomes in people with FEP by addressing the factors associated with increased mortality in this population. METHODS: The scoping review framework comprised a five-stage process developed by Arksey and O'Malley. The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: A total of 27 studies conducted across 10 countries were analysed. These studies discussed the various ways in which key workers can mediate enhancements in the various factors contributing to the increased mortality rates in FEP patients. CONCLUSIONS: A broad range of key worker-mediated outcomes was identified, which were broadly classified into three themes: influences on lifestyle, influences on effects of psychosis and influences on organizational barriers. Our findings suggest that key workers primarily mediated the amelioration of psychosis-induced effects and the reduction of organizational barriers. Further trials of key worker interventions to enhance physical health outcomes in this cohort are warranted.

Visible near infrared reflectance molecular chemical imaging of human ex vivo carcinomas and murine in vivo carcinomas.

SIGNIFICANCE: A key risk faced by oncological surgeons continues to be complete removal of tumor. Currently, there is no intraoperative imaging device to detect kidney tumors during excision. AIM: We are evaluating molecular chemical imaging (MCI) as a technology for real-time tumor detection and margin assessment during tumor removal surgeries. APPROACH: In exploratory studies, we evaluate visible near infrared (Vis-NIR) MCI for differentiating tumor from adjacent tissue in ex vivo human kidney specimens, and in anaesthetized mice with breast or lung tumor xenografts. Differentiation of tumor from nontumor tissues is made possible with diffuse reflectance spectroscopic signatures and hyperspectral imaging technology. Tumor detection is achieved by score image generation to localize the tumor, followed by application of computer vision algorithms to define tumor border. RESULTS: Performance of a partial least squares discriminant analysis (PLS-DA) model for kidney tumor in a 22-patient study is 0.96 for area under the receiver operating characteristic curve. A PLS-DA model for in vivo breast and lung tumor xenografts performs with 100% sensitivity, 83% specificity, and 89% accuracy. CONCLUSION: Detection of cancer in surgically resected human kidney tissues is demonstrated ex vivo with Vis-NIR MCI, and in vivo on mice with breast or lung xenografts.

Higher rates of disengagement among young adults attending a general adult community mental health team: Time to consider a youth-specific service?

AIM: The initial onset of mental illness occurs most frequently in adolescence or early adulthood. In order to inform the development of mental health services tailored for youth, we sought to compare the characteristics of young (18-25 years old) and older (over 25 years old) adults following referral to a general adult community mental health team. METHODS: All individuals referred to a Dublin-based community mental health team and offered an appointment between January 1 and December 31, 2016 were included in the study. Information in relation to engagement patterns, demographic characteristics and clinical characteristics was collected. RESULTS: A total of 298 appointments were offered during the study period among which 94 (31.6%) were for young adults. Significant differences in demographic and clinical characteristics between the two age groups were evident. Young adults were significantly less likely to have been prescribed psychotropic medication at the point of referral (63% vs. 82% respectively, χ2 = 12.30, p < .001). Older adults were four times more likely to demonstrate a good level of early engagement in treatment than young adults (AOR 4.00, 95% CI 1.11-14.37, p = .03). CONCLUSIONS: Young adults had distinct clinical needs and a lower level of engagement in the early stage of treatment compared with their older counterparts in this community team. Further research and stakeholder consultation is needed to more clearly identify the issues in relation to patient engagement. These insights will help to inform the development of youth-specific community mental health services.

Early intervention in psychosis: health economic evaluation using the net benefit approach in a real-world setting.

BACKGROUND: Early intervention in psychosis is a complex intervention, usually delivered in a specialist stand-alone setting, which aims to improve outcomes for people with psychosis. Previous studies have been criticised because the control used did not accurately reflect actual practice. AIMS: To evaluate the cost-effectiveness of early intervention by estimating the incremental net benefit (INB) of an early-intervention programme, delivered in a real-world setting. INB measures the difference in monetary terms between alternative interventions. METHOD: Two contemporaneous incidence-based cohorts presenting with first-episode psychosis, aged 18-65 years, were compared. Costs and outcomes were measured over 1 year. The main outcome was avoidance of a relapse that required admission to hospital or home-based treatment. RESULTS: From the health sector perspective, the probability that early intervention was cost-effective was 0.77. The INB was €2465 per person (95% CI - €4418 to €9347) when society placed a value of €6000, the cost of an in-patient relapse, on preventing a relapse requiring admission or home care. Following adjustment, the probability that early intervention was cost-effective was 1, and the INB to the health sector was €3105 per person (95% CI -€8453 to €14 663). From a societal perspective, the adjusted probability that early intervention was cost-effective was 1, and the INB was €19 928 per person (95% CI - €2075 to €41 931). CONCLUSIONS: Early intervention has a modest INB from the health sector perspective and a large INB from the societal perspective. The perspective chosen is critical when presenting results of an economic evaluation of a complex intervention.

Care Pathways in a Suicide Crisis Assessment Nurse (SCAN) service.

AIM: The Suicide Crisis Assessment Nurse service has been developed as a Primary Care suicide intervention over the last decade. The current study aimed to describe the demographic details of users of this nurse led service, and to evaluate subsequent care pathways following this intervention. METHODS: This study was conducted using a retrospective file review with a cross-sectional observational design investigating demographic details of service users and care pathways in a Suicide Crisis Assessment Nurse service within a defined catchment area of Ireland between June 2015 and May 2017. RESULTS: The majority of referrals were managed in Primary Care following Suicide Crisis Assessment Nurse intervention. There was an increase in Primary Care management pathway in the second year of the service which was independent of age and gender. CONCLUSION: There was an increase in referrals to the service over time, and the majority of presentations were managed in primary care following Suicide Crisis Assessment Nurse intervention. The study suggests that primary care interventions for suicidal crises merit further research.

Key Worker-Mediated Enhancement of Physical Health in First Episode Psychosis: Protocol For a Feasibility Study in Primary Care.

BACKGROUND: Studies have demonstrated that, for patients with psychosis, a majority of the decline in health status and functioning emerges during the first few years after the onset of illness. This knowledge led to the development of specialized early intervention services (EISs) targeting patients experiencing their first episode of psychosis. The central component of EISs is often assertive case management delivered by a multidisciplinary team, where an appointed key worker is responsible for coordinating treatment and delivering various psychosocial interventions to service users. OBJECTIVE: This paper outlines the protocol for a feasibility study examining how key workers may enhance physical health by supporting integration between primary and secondary care. METHODS: Semistructured interviews were conducted with key stakeholder groups (General Practitioners and health care professionals working in mental health services). The interviews informed the development of the complex intervention involving a longitudinal pre-post intervention in 8 general practices in 2 regions in Ireland (one urban and one rural). Patients with first episode psychosis (FEP) will be identified from clinical records at general practices and mental health services. RESULTS: Baseline and follow-up data (at 6 months) will be collected, examining measures of feasibility, acceptability, and intervention effect size. CONCLUSIONS: Study findings will inform future practice by examining feasibility of key workers enhancing physical health through improved interaction between primary and secondary care. By identifying issues involved in enhancing recruitment and retention, as well as the likely effect size, the study will inform a future definitive intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13115.

Disagreement between service-users and clinicians assessment of physical health during early psychosis.

AIMS: Physical illnesses account for the majority of excess deaths following psychosis; access to care and treatment is inequitable and schizophrenia has now been dubbed the life-shortening disease. We compared service-users and clinician's perspectives of their physical health assuming that one of the fundamental issues in prompting screening and treatment is the view that health is poor. METHODS: Data comprising sample characteristics, diagnosis, symptoms, insight, antecedents to psychosis and physical health perspectives were obtained prospectively as part of a larger epidemiological study of first-episode psychosis. We compared physical health perspectives between service-users and clinicians and examined clinical correlates. RESULTS: Contrary to our expectations, we found that service-users reported poorer physical health over time than clinicians did. CONCLUSION: Reconciling service-users and clinician's views of physical health may be an important step towards collaborative care and improving access to better quality healthcare for serious mental illness.

Medline indexing success and future directions for Irish Journal of Psychological Medicine.

Irish Journal of Psychological Medicine (IJPM) was recently accepted for indexing on Medline. This reflects the high scientific quality of articles published in the journal and highlights the excellent work by publishers, authors, reviewers and the journal editorial board who have contributed to the journal's development over many years. IJPM remains committed to further progression through constant innovation and maintaining the excellent standard of publishing to date. We look forward to promoting our aims of improving knowledge and advocating for better mental health services by continuing to highlight key topics of current relevance to mental health.