Mental health plan for workers of the London Nightingale Hospital: following the evidence to support staff.

The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of 'moral injury' and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster 'post-traumatic growth', and describes the authors' implementation of this in the London Nightingale hospital, with lessons for the armed forces.

Are we failing clinical trials? A case for strong aggregate outcomes.

Clinical trials in psychiatry inherit methods for design and statistical analysis from evidence-based medicine. However, trials in other clinical disciplines benefit from a more specific relationship between instruments that measure disease state (e.g. biomarkers, clinical signs), the underlying pathology and diagnosis such that primary outcomes can be readily defined. Trials in psychiatry use diagnosis (i.e. a categorical label for a syndrome) as a proxy for the underlying disorder, and outcomes are defined, for example, as a percentage change in a univariate total score on some clinical instrument. We label this approach to defining outcomes weak aggregation of disease state. Univariate measures are necessary, because statistical methodology is both tractable and well-developed for scalar outcomes, but we show that weak aggregate approaches do not capture disease state sufficiently, potentially leading to loss of information about response to intervention. We demonstrate how multivariate disease state can be captured using geometric concepts of spaces defined over routine clinical instruments, and show how clinically meaningful disease states (e.g. representing different profiles of symptoms, recovery or remission) can be defined as prototypes (geometric locations) in these spaces. Then, we show how to derive univariate (scalar) measures, which capture patient's relationships to these prototypes and argue these represent strong aggregates of disease state that may be a better basis for outcome measures. We demonstrate our proposal using a large publically available dataset. We conclude by discussing the impact of strong aggregates for analyses in traditional and novel trial designs.

An evoked auditory response fMRI study of the effects of rTMS on putative AVH pathways in healthy volunteers.

BACKGROUND: Auditory verbal hallucinations (AVH) are the most prevalent symptom in schizophrenia. They are associated with increased activation within the temporoparietal cortices and are refractory to pharmacological and psychological treatment in approximately 25% of patients. Low frequency repetitive transcranial magnetic stimulation (rTMS) over the temporoparietal cortex has been demonstrated to be effective in reducing AVH in some patients, although results have varied. The cortical mechanism by which rTMS exerts its effects remain unknown, although data from the motor system is suggestive of a local cortical inhibitory effect. We explored neuroimaging differences in healthy volunteers between application of a clinically utilized rTMS protocol and a sham rTMS equivalent when undertaking a prosodic auditory task. METHOD: Single-blind placebo controlled fMRI study of 24 healthy volunteers undertaking an auditory temporoparietal activation task, who received either right temporoparietal rTMS or sham RTMS. RESULTS: The main effect of group was bilateral inferior parietal deactivation following real rTMS. An interaction of group and task type showed deactivation during real rTMS in the right superior temporal gyrus (STG), left thalamus, left postcentral gyrus and cerebellum. However, the left parietal lobe showed an increase in activation following right sided real rTMS, but this increase was specific to a non-linguistic, tone-sequence task. CONCLUSION: rTMS does cause local inhibitory effects, not only in the underlying region of application, but also in functionally connected cortical regions. However, there is also a related, task dependent, increase in activation within selected cortical areas in the contralateral hemisphere; these are likely to reflect compensatory mechanisms, and such cortical activation may in some cases contribute to, or retard, some of the therapeutic effects seen with rTMS.

Prosodic discrimination in patients with schizophrenia.

Fifteen patients with prominent positive symptoms of schizophrenia and 15 normal controls performed verbal prosodic and pure musical discrimination tasks, with changes in pitch and timing parameters. The patients' performance was comparable to that of controls on the discrimination of terminal pitch changes, but significantly poorer on the more difficult internal pitch discrimination. The latter deficit was positively correlated with the severity of their positive symptoms. The results suggest that patients have a deficit in processing fundamental aspects of prosody, which is associated with the presence of positive symptoms.

Timing of covert articulation: an fMRI study.

Timing is an important constituent of speech and language. Different brain regions have been associated with time management functions such as time estimation and motor timing. This study aims to identify the less well known neural networks associated with timing of internally paced covert articulation. Functional MRI was performed on subjects who either spontaneously, or in response to a visual cue, covertly generated words every 2 s. Results show the involvement of anterior cingulate gyrus, right dorsolateral and inferior frontal and right inferior parietal cortices in a putatively modality independent circuit associated with timing of covert speech. Modality specific activation in the right temporal cortex may have reflected the involvement of this region in auditory-verbal processing.

Imaging auditory hallucinations in schizophrenia.

It is increasingly recognized that there are a heterogeneous range of symptoms within the syndrome of schizophrenia and that some of these also occur frequently within other psychiatric conditions. An approach similar to that in neuropsychology, where cases are grouped based on a discrete deficit, or in this case a discrete symptom, rather than a cause or diagnosis, may be useful in exploring the neural correlates of psychotic symptomatology. Functional neuroimaging provides an excellent tool for investigating the in vivo cortical function of patients with schizophrenia. Auditory verbal hallucinations are one of the most commonly occurring psychotic symptoms in schizophrenia; and this paper examines the progress that has been made in utilizing neuroimaging techniques to investigate auditory hallucinations in schizophrenia and review potential implications for treatment and future directions for research.