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Noninvasive brain stimulation (NIBS) such a transcranial magnetic stimulation, intermittent theta burst stimulation, transcranial direct current stimulation and electroconvulsive therapy have emerged as an efficacious and well-tolerated therapy for treatment-resistant psychiatric disorders. While novel NIBS techniques are an exciting addition to the current repertoire of neuropsychiatric therapies, their success is somewhat limited by the wide range of treatment responses seen among treated patients.

In this study, the authors will review the studies on relevant genetic polymorphisms and discuss the role of RNA genotyping in personalizing NIBS.

Genome studies have revealed several genetic polymorphisms that may contribute for the heterogeneity of treatment response to NIBS where the presence of certain single nucleotide polymorphisms (SNPs) are associated with responders versus nonresponders.

Historically, mental illnesses have been arguably some of the most challenging disorders to study and to treat because of the degree of biological variability across affected individuals, the role of genetic and epigenetic modifications, the diversity of clinical symptomatology and presentations and the interplay with environmental factors. In lieu of these challenges, there has been a push for personalized medicine in psychiatry that aims to optimize treatment response based on one’s unique characteristics.

This study aims to explore medical students’ attitudes to electroconvulsive therapy (ECT). The authors sought to determine correlates of baseline attitudes to ECT and whether specific forms of ECT teaching improved attitudes to ECT during students’ psychiatry placement.

At the beginning of their placement, fourth-year medical students completed a questionnaire capturing background information and baseline attitudes. A second questionnaire, in the second half of the placement, recorded educational and clinical experience gained on ECT during placement, in addition to attitudes at this timepoint. The authors measured attitude using a five-point Likert scale and defined a positive shift in attitude as an improvement of ≥ 1 point between the two time points.

At Timepoint 1, 66% reported a positive attitude to ECT. This was associated with having attended a lecture and with having read a professional article on ECT at some time before the psychiatry placement. Attitudes significantly improved during the placement (66% vs 95% positive). Students who attended a lecture on ECT were more likely to have a positive shift in attitude, as were students who experienced three or more teaching modalities.

Personal, social and medical problems arise from treatment-resistant psychiatric disorders. ECT is a safe and effective treatment for such disorders.

It is hoped that this study will contribute to the development of medical education, so that lectures on ECT, and three or more teaching modalities, are incorporated into the undergraduate medical curriculum.

The purpose of this paper is to evaluate the effect of the planned pre-electroconvulsive therapy (ECT) family teaching on depression, anxiety and stress of caregivers of patients with mental disorders receiving ECT.

In this quasi-experimental study, 130 participants were randomized allocated into intervention or control groups. The planned family teaching program consisted of four 90 min sessions held during four weeks. Assessments occurred at pre-intervention (one week before the first session), and post-intervention (one months after the four session). Data were collected using demographic questionnaire and Depression, Anxiety and Stress Scale (DASS-21). Mean comparisons were performed using Student’s t-test while effect sizes were estimated by Cohen’s d coefficient. The significance level was considered less than 0.05.

The mean scores of the depression, anxiety and stress levels in the intervention group were significantly reduced compared to the control group (p=0.001).

The family pre-ECT teaching intervention and counseling decreased the depression, anxiety and stress level of family caregivers of patients with mental disorders receiving ECT and the maintenance of other favorable conditions at baseline. These results suggest that even a short-term educational intervention for family members of patients received ECT can improve emotional outcomes of treatment in the family.

Consideration is given to the extent to which the DSM and ICD approach to psychiatric case definition and treatment supports clinical activity. Their validity as a way of defining ‘mental illness’ is found wanting and they do not, in themselves, usefully guide treatment. These conclusions are set in a critical realist approach to ‘mental illness’, which draws attention to the legitimacy of several differing perspectives, each reflecting their own sets of interests and allegiances. DSM‐V and ICD‐11 are due to be published in 2012 and 2014 respectively, and their architects are called upon to be clear about which of these constituencies they are representing.

Medium secure units were designed to treat patients for up to three years, but some patients spend longer in acute medium secure settings which in general do not have a 'longer term focus'. The aim of this investigation was to assess and describe the needs of these patients. A survey questionnaire was designed and sent to responsible clinicians who had patients admitted at least five years previously to the Three Bridges Medium Secure Unit (males) in West London. Carer ratings using the Camberwell Assessment of Need: forensic version (CAN‐FOR) were completed by the primary nurse for each patient, complementing the survey questionnaire. Of 122 medium secure male patients 25 (21%) had been admitted at least five years before. We found high levels of co‐morbidity and treatment resistance. The CAN‐FOR revealed two groups, one with chronic challenging behaviour, treatment‐resistant mental illness and need for a high level of support, and another more able group not needing as much support but with a dependency on the hospital. It is considered here whether certain groups would benefit from a different approach or setting.

Repetitive transcranial magnetic stimulation (rTMS) is a well-established treatment with efficacy for several psychiatric disorders and has yielded promising yet mixed data showing reductions in craving for substance use. Patients with substance use disorders and comorbid depression may encounter obstacles to receiving rTMS in outpatient settings for treatment of depression. In turn, implementation of rTMS in residential substance use programs would greatly benefit those with comorbid treatment resistant depression. This paper aims to provide recommendations for implementing rTMS within residential substance use treatment centers.

Using PubMed, the authors conducted a narrative review of manuscripts using various combinations of the following search terms: rTMS, depression, substance use and substance use disorder. The authors read manuscripts for their methodology, outcomes and adverse events to synthesize their results, which correspond to their recommendations for patient selection, safely implementing rTMS in residential substance use facilities and optimal rTMS protocols to start with.

Advantages of this approach include increased compliance, monitoring and access to care. Recommendations to safely incorporate rTMS in residential substance use disorder treatment centers revolve around selection of patients eligible for rTMS, allowing for sufficient time to elapse prior to commencing rTMS, monitoring for signs of recent substance use or withdrawal and using rTMS protocols compatible with the therapeutic programming of a treatment center.

This paper details the challenges and benefits of implementing rTMS for patients with dual diagnosis and provides recommendations to safely do so. To the best of the authors’ knowledge, this is a novel and unpublished endeavor.

People with schizophrenia and related psychoses may be more likely to be ‘treatment‐resistant’ when dually diagnosed with intellectual disabilities. This case study highlights many of the difficulties which can occur in their assessment and management. Clozapine is currently the best available intervention for treatment‐resistant schizophrenia, and its use has increased in people with intellectual disabilities. However, it is not always effective, and a wide range of adjunctive strategies have been suggestive and tried. The evidence base for the specific use of these additional strategies in people with intellectual disabilities needs to be increased.

Clozapine is a well-known antipsychotic medication licensed for treatment-resistant schizophrenia, but there is limited research available to suggest its efficacy in the context of personality disorder and intellectual disabilities presenting with high-risk behaviour with or without psychotic symptoms. The purpose of this paper is to raise awareness of the benefits of using clozapine in patients with intellectual disabilities and personality disorder that present with a complex picture of serious risk of harm to both their life and the lives of others.

The authors present five patients with intellectual disabilities and serious life-threatening challenging behaviour whom were started on clozapine as part of their multidisciplinary treatment plan to manage their presentation. The authors completed baseline assessment of five main symptom domains and then repeated this assessment following treatment with clozapine.

In all five cases use of clozapine was objectively associated with an improvement in symptomatology, quality of life and a safe transfer to the community.

The findings suggest that judicious use of clozapine could be considered as one of the effective pharmacological strategies in the management of patients with intellectual disabilities and personality disorder who present with serious life-threatening challenging behaviours.

The purpose of this paper is to discuss the challenges of assessment and management of psychotic symptoms in a background of intellectual disability (ID) and treatment-resistant epilepsy caused by a genetic syndrome.

Ring chromosome 20 [r(20)] syndrome is characterised by the triad of severe refractory epilepsy, mild to severe ID and behavioural problems. This paper describes the presentation of r(20) syndrome in a young woman with moderate ID and treatment-resistant epilepsy, who experiences psychotic symptoms at times of improved seizure control.

There are several diagnostic possibilities for such a presentation, including psychotic symptoms due to adverse effects of anti-epileptic medications and forced normalisation (alternating psychosis).

This paper advocates judicious use of antipsychotic medication to manage psychotic symptoms, as well as involvement of both patient and close family members throughout all stages of care. It is essential to strike a balance between control of epileptic seizures and psychiatric symptoms, providing an optimal benefit to the patients’ quality of life by meeting their complex needs through a multidisciplinary and multi-agency team input.

The purpose of this paper is to highlight how the management of an adult with intellectual disabilities and complex medical conditions by a multi-disciplinary and multi-agency team approach across a clinical pathway (primary, secondary and tertiary care, health, social and third sector agencies) can be used to improve the person's physical and mental health outcome.

Literature review and case report in which the paper describes the presentation of the patient with multiple complex physical health conditions, mild intellectual disability and challenging behaviour and description of the management process and the observed outcome.

The patient required input from the multi-disciplinary community intellectual disabilities team and multi-agency team including social services and community support team, admission to a specialist intellectual disabilities ward to optimise her management. She improved relatively well and was discharged to the community. On discharge she continued to receive ongoing psychiatric, psychological and community psychiatric nurse input and maintains the sustained improvement in her mental health. She no longer displays risky or challenging behaviour, her mood has improved and there is no self-harm ideation. She remains anxious at times, however, her symptoms are much improved and do not affect her daily functioning.

This case highlights the profound and enduring psychiatric and behavioural sequelae following brain malignancy and treatment and how essential a multi-disciplinary and multi-agency approach is in the successful management of complex issues. Her symptoms appeared relatively treatment resistant until she had a specialist inpatient admission. This case study also demonstrates the strengths and advantages of having specialist care pathway for such complex presentations, allowing for integrated community, secondary and tertiary care, and for the care system to work together in a coordinated and managed way.