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ISSN 0790- 9667

Irish Journal of

Psychological Medicine VOL 29 No 1 April/May 2012

COVER ILLUSTRATION BY JERRY HUYSMANS


Irish Journal of Psychological Medicine Vol. 29 No 1 April/ May 2012 ISSN 0790- 9667

Editor–in-Chief: Brendan Kelly, Senior Lecturer in Psychiatry, Department of Adult Psychiatry, UCD Mater Misericordiae University Hospital, Dublin 7

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Deputy Editor: Niall Crumlish, Consultant Psychiatrist, St James’s Hospital, Dublin 8

Original Papers

Consulting Editor: Larkin Feeney, Consultant Psychiatrist, Cluain Mhuire Services, Blackrock, Co. Dublin

Editorial

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Did the Great Irish Famine increase Schizophrenia? Dermot Walsh

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Study of Presentations for Involuntary Admission to a Cork Approved Centre Elaine Dunne, Eamonn Moloney

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Mental Illness among the Homeless: Prevalence Study in a Dublin Homeless Hostel Bernice Prinsloo, Catherine Parr & Joanne Fenton

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Preferences of Dress and Address: Views of Attendees and Mental Health Professionals of the Psychiatric Services Christina Sim, Brian Hallahan & Colm McDonald

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Psychiatrists in their eyes: Children’s Drawings of what a Psychiatrist looks like... Sami Omer, Niamh O’ Connor, Gavin Sweeney, Geraldine McCarthy

Founding Editor: Mark Hartman Associate Editor: Ted Dinan (Cork) Administrator: Sibéal Farrell Editorial Board: Brian A Lawlor (Dublin), Patricia Casey (Dublin), Stephen Cooper (Belfast), Michael Fitzgerald (Dublin), Brian Leonard (Galway), Roy McClelland (Belfast), Brian O’Shea (Wicklow), Ian Pullen (Edinburgh), John Waddington (Dublin), Richard Williams (Victoria) Submissions and Correspondence to: The Editor College of Psychiatry of Ireland 5 Herbert Street Dublin 2, Ireland Telephone: 00 353 1 6618450 Fax: 00 353 1 6629677 Email: sfarrell@irishpsychiatry.ie Website: www.ijpm.ie Publisher: Irish Medical Information Fir Tree Lodge Craddockstown Road Naas Co. Kildare

The Irish Journal of Psychological Medicine and the College of Psychiatry of Ireland Brendan D. Kelly

Brief Reports 36

Selective Mutism: A Prevalence Study of Primary School Children in the Republic of Ireland Louise Sharkey & Fiona McNicholas

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Psychotherapy Training in Ireland: A Survey of College Tutors Alyson Lee & Angela Noonan

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Suicide ideation, Psychological Adjustment and Mental Health Service Support: A Screening Study in an Irish Secondary School Sample Ciara Brennan & Sinéad McGilloway

Case Report 52

Graphology and Psychiatric Diagnosis: Is the Writing on the Wall? Mary Davoren, Natalie Sherrard, Eugene Breen & Brendan D. Kelly

Opinion 55

Psychiatric Power: A Personal View Pat Bracken

Book Reviews

This paper meets the requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper)

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Coming through Depression: A Mindful Approach to Recovery by Tony Bates Stephen McWilliams

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Leadership With Consciousness by Tony Humphreys Brendan D. Kelly

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Homesickness: An American History by Susan J Matt Séamus MacSuibhne

Appreciation 63

Professor Hugh Lionel Freeman Brian O’Shea

Letters to the Editor 64

Interaction of Duloxetine with Warfarin; a Cautionary Report Mugtaba Osman, Elaine Greene

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Guidelines for Authors 2


Editorial

The Irish Journal of Psychological Medicine and the College of Psychiatry of Ireland Brendan D Kelly

Ir J Psych Med 2012; 29 (1): 3-6 his approach to both psychiatric education and clinical care.1,4 Dr Hartman was deeply involved in psychiatric training: he was appointed clinical tutor in St. Brendan’s in 1973, taught at the Royal College of Surgeons in Ireland, and was specialty tutor for the Eastern Region Postgraduate Training Programme from 1979 to 1994.3

In 2012, the Irish Journal of Psychological Medicine became the official research journal of the College of Psychiatry of Ireland. The coming together of the Journal and the College marks an important moment in the histories of both, and a significant stage in the evolution of Irish psychiatry.

Founding editor of the Irish Journal of Psychological Medicine: Dr Mark Hartman

In addition to his interests in psychiatry and psychotherapy, Dr Hartman had interests in myriad other fields. He had a particular love of Middle English and held a Masters Degree in English from Trinity College, Dublin. He was an gifted musician and accomplished pianist, and owned one of the first mobile phones in Ireland.2

The Irish Journal of Psychological Medicine was founded in 1982 by Dr Mark Hartman (1942-1994). Mark Hartman was born in Chicago in 1942, the son of an eminent forensic psychologist. After high school, Mark completed a BSc in mathematics and physics, and came to Ireland in the early 1960s.1 Mark studied medicine in Trinity College Dublin, where he qualified in 1969, following a brilliant undergraduate career which saw him elected a scholar of the university. Mark studied psychiatry under Professor Peter Beckett (1922-1974), first professor of psychiatry at Trinity,2 who described Mark as “the best student in his class”.3 Dr Hartman received his American MD in 1969.

In the midst of all of these activities and accomplishments, Dr Hartman founded the Irish Journal of Psychological Medicine, in 1982.1 At first, it was an uphill battle to attract submissions, rewrite certain papers, edit the Journal and organise publication. Dr Hartman performed all of these tasks with insight and enthusiasm, at all hours of day and night. He brought enormous vision and drive to the undertaking, travelling to Northern Ireland and England to seek out submissions, and inviting international speakers to Ireland in order to obtain more papers.

Dr Hartman served his internship in Sir Patrick Duns Hospital and then worked in St. Patrick’s Hospital, St. Ita’s, St. Brendan’s and St. Vincent’s, Fairview. He was elected a Member of the Royal College of Psychiatrists in 1973 and worked in St. Mary’s, Castlebar until permanently appointed at St. Brendan’s in 1978. In 1983, Dr Hartman took a three-year career break to the United States, where he was associate professor of psychiatry in Boston University and medical director of Lakeshore Hospital, Manchester, New Hampshire.1

In order to produce the Journal itself, Dr Hartman designed original computer software and programmes, and was determined from the outset that the Journal would embrace new technologies such as the Internet, even though the Internet was in its early infancy in Ireland when the Journal was founded in 1982. Following its foundation, Dr Hartman oversaw the establishment of a circulation base for the Journal, a remarkable growth in circulation (in terms of both numbers and geography), broad-based scientific indexing, and the stocking of the Journal in libraries around the world. This series of accomplishments built the Journal into a remarkably strong scientific and clinical voice, with impact and reach well beyond these shores.

Also in 1983, Dr Hartman attained his American Board Examinations in Psychiatry and Neurology in Boston, and was ranked in the top 2% of all candidates who had previously sat the examination. Following his career break in the United States, Dr Hartman returned to Dublin and worked at Vergemount Psychiatric Clinic. He died in 1994, following a year-long illness. Dr Hartman was posthumously elected to Fellowship of the Royal College of Psychiatrists.

Dr Hartman’s dedication to the Journal was as profound as it was pragmatic and, thanks to his unstinting work, Dr Hartman saw the Journal’s “reputation grow steadily as a quarterly specialist publication, essential to its Irish base and attracting international readers and authors”.2 From the outset, the Irish Journal of Psychological Medicine was a truly extraordinary creation, created by a truly extraordinary man.

Throughout his career, Dr Hartman demonstrated an enormous depth of knowledge and passion for psychiatry. He had a particular interest in psychoanalytical psychotherapy, a field which informed

Brendan D. Kelly, Consultant Psychiatrist and Senior Lecturer in Psychiatry,

Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7, Ireland. E-mail brendankelly35@gmail.com

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The Irish Journal of Psychological Medicine: 1994-2012

The College of Psychiatry of Ireland aims to address not only issues relevant to its Irish members but also issues for psychiatry in general, for mental health services, and ultimately for services-users. It aims to promote good mental health and high quality mental health care for all involved in mental health services. The College fully supports Ireland’s national mental health policy, “A Vision for Change”23 and has consistently urged that this policy be implemented in full, in order to give Ireland the mental health service it deserves.

In 1994, following the untimely death of Dr Hartman, Professor Brian Lawlor became editor-in-chief of the Irish Journal of Psychological Medicine. On appointment, Professor Lawlor explicitly renewed the Journal’s commitment to its central objectives: disseminating the results of original scientific research to a national and international readership; expressing the unique identity of Irish psychiatry; and underscoring the importance of cross-cultural differences in psychiatry within and beyond these islands.5

In conjunction with its representative, training and advocacy roles, the College has a growing role in promoting and encouraging research, with a view to generating an improved evidence-base for psychiatric practice. In this respect, the College is assuming at least some of the roles envisioned in long-standing calls for a research-oriented Irish Institute of Psychiatry, which has not yet materialized in Ireland.24,25

Over the following years, the Journal continued to publish national and international research papers, as well as editorials, review papers, casereports and book reviews. Format was substantially revised in conjunction with the Journal’s long-time publisher, MedMedia. As psychiatry in Ireland evolved over this period,6 the Journal appointed a trainee editor in 2004,7 a deputy editor in 2008, a new editor-in-chief in 2010, and a consulting editor in 2011.

Following the emergence of the College in 2009, it was readily apparent that the College would need a journal in order to strengthen the College’s participation in the international research community and assist the College in shaping and improving standards of mental health care. Given its unique role in expressing the “identity of Irish psychiatry”,5 long history of high-quality publishing, and growing international profile, the Irish Journal of Psychological Medicine was the obvious candidate for this role.

In 2009, the Journal published the first in a series of Continuing Professional Development (CPD) modules, to assist with learning and self-assessment for psychiatrists.8 A broad range of topics has been covered since then, including management of schizophrenia,9 alcohol use disorders,10 adherence,11 morbid jealousy,12 post-traumatic stress disorder,13 fetal alcohol spectrum disorders,14 tobacco smoking and mental illness,15 serotonin toxicity,16 improving monitoring for metabolic syndrome using audit 17 and antidepressant augmentation and combination in unipolar depression.18

In 2012, the Irish Journal of Psychological Medicine duly became the official research journal of the College of Psychiatry of Ireland.

Times of change in Irish psychiatry and medical publishing

For over two decades, the Irish Journal of Psychological Medicine has awarded the John Dunne Medal, established in honour of Professor John Dunne, president of the Royal Medico-Psychological Association in 1955 and first professor of psychiatry in Ireland.19,20 Dr Mark Hartman, founding editor of the Journal, was a strong admirer of Professor Dunne. Consistent with the emphasis that Professor Dunne placed on scientific research into mental illness,21 the John Dunne Medal is awarded annually to a trainee from Ireland or the United Kingdom. To be eligible, a trainee much have made a significant contribution (though not necessarily as first author) to an original paper published by the Journal over the previous year. Over the past two decades the John Dunne Medal has come to symbolise excellence and originality in the field of psychiatric research.22

These are challenging and exciting times for mental health care in Ireland, and beyond. In Ireland, the practice and profession of psychiatry are being gradually but definitely transformed with the implementation of the Mental Health Act 2001 (2001-2006), introduction of “A Vision for Change” (2006),23 establishment of the College of Psychiatry of Ireland (2009), development of new systems for competence assurance by the Medical Council and College of Psychiatry of Ireland (2011), and review of the Mental Health Act 2001 (2012). Looking more broadly, the ongoing expansion of the scientific evidencebase for psychiatric practice is also transforming mental health care; service user movements are helping shape better systems of care; and public services in general are seeking to become more efficient, responsive and user-focussed. Against the backdrop of the economic and social challenges facing Ireland and Europe at present,26 these developments present unique challenges and opportunities to mental health service users and providers alike.

The College of Psychiatry of Ireland The College of Psychiatry of Ireland is the professional body for psychiatrists in Ireland and the sole body recognised by the Medical Council and Health Service Executive (public health care provider in Ireland) for competence assurance and training in psychiatry. The College offers membership, for psychiatrists and trainees, of an Irish institution which aims to be the voice of psychiatry in Ireland (www.irishpsychiatry.ie).

In this medical, scientific and social context, medical journals play a vital role in the generation and dissemination of knowledge, and in shaping change.27 Medical journals have particular importance in informing evidence-based practice, developing health policy, and underpinning training programmes and continuing education for practitioners. Medical journals can also open up new areas of research, prompt critical and constructive debate, and generate interest in hitherto neglected areas of thought and practice. The Irish Journal of Psychological Medicine has a long history of filling many of these roles.

The College emerged as an organisation in 2009 when three former bodies merged: the Irish College of Psychiatrists (a division of the Royal College of Psychiatrists in the United Kingdom), the Irish Psychiatric Association, and the then training body for psychiatry, the Irish Psychiatric Training Committee. It had been apparent for many years that both the law and mental health services in the United Kingdom served different needs to those in Ireland and therefore an Irish organisation was seen by many as being long overdue. 4


mephedrone and other head shop drugs,60,61 users’ experiences of cathinones,62 “whack” induced psychosis,63 and benzlypiperazineinduced acute delirium.64 In future years, we will continue to highlight key issues in psychiatry, policy, training and research throughout the Journal.

These are, however, also times of transformation for medical journals themselves. Key changes relate to the evolution of electronic communication technologies, issues related to independent scientific peer review, and substantial changes in the broader publishing industry.28,29 Further issues relate to the complex roles of journals in the developing world30 and in the protection of human rights.31 Issues of human rights are especially important in the context of mental health policy32 and mental health law,33-35 especially following recent changes in legislation, as is the case in Ireland.36-39

In addition to these thematic and editorial priorities, we will continue to seek to expand the Journal’s indexing profile. From the outset, the Journal’s founding editor, Dr Mark Hartman, ensured broad-based indexing for the Journal. At present, the Journal is indexed in Biological Abstracts (BIOSIS Previews); Centre National de la Recherche Scientifique/Inist; Pascal; Excerpta Medica/Embase; Institute for Scientific Information; Current Contents/Social and Behavioural Sciences (Social Science Citation Index, Research Alert); Psychological Abstracts (PsycInfo/PsycLit); Cumulative Index to Nursing and Allied Health Literature; Current Aids Literature (CAB Abstracts); International Pharmaceutical Abstracts; Linguistics and Language Behaviour Abstracts; Nutrition Abstracts and Reviews (CAB Abstracts); Referativnyi Zhurnal; Social Planning/Policy and Development Abstracts; Social Work Research and Abstracts; and Sociological Abstracts.

Notwithstanding these challenges – or, more likely, because of them – medical journals are set to retain a critical role in shaping medical knowledge, informing evidence-based practice, developing health policy and underpinning training in health-care disciplines.27 While the format and structure of journals may change dramatically, the necessity for them will not.

The Journal and the College: Looking to the future As research journal of the College of Psychiatry of Ireland, the Irish Journal of Psychological Medicine will continue to publish high quality original research from around the world. These original data papers will continue to form the central focus of the Journal, supplemented by briefer reports of smaller research projects, audit cycles, and various other kinds of papers which reflect different approaches to research, practice and education in mental health care.

In coming years, we will seek actively to expand our indexing profile so as to better reflect the quality and diversity of original research published in the Journal and optimise Journal impact.

The voice of psychiatry in Ireland

The Journal has a long-standing commitment to publishing casereports, which we believe serve several important purposes, including the description of new conditions or novel effects of treatments; suggesting new indications for existing treatments; 40 quality assurance; and education.41 In addition, case-reports are often especially engaging for readers, many of whom find clinical vignettes involving, informative and pragmatic.42 Like the Lancet, the Irish Journal of Psychological Medicine still sees an important role for relevant, well-written case-reports.43

From the very beginning, the founding editor of the Irish Journal of Psychological Medicine, Dr Mark Hartman, saw the Journal becoming the voice of a national college of psychiatry in Ireland. Over subsequent decades, the Journal duly assumed a key role “in expressing the unique identity of Irish psychiatry”, and the “complex tapestry of different historical traditions and experiences that mesh together to create a system that is unique and different from any of its derivative parts”.5 The coming together of the Journal with the College of Psychiatry of Ireland in 2012 represents the realisation of Dr Hartman’s vision, and a logical and important step in the evolution of psychiatry in Ireland.

The Irish Journal of Psychological Medicine also remains committed to publishing papers presented in a range of different formats, including editorials, review papers, educational papers, letters to the editor, and book reviews. The Journal is similarly committed to publishing historical papers examining key topics in the histories of psychiatry in Ireland and elsewhere.44-46 In this issue, we are especially pleased to publish an historical paper looking at admission rates for schizophrenia and other disorders during Ireland’s Great Famine (1845-1849),47 an event which was curiously absent from the historiography of Irish psychiatry to date.19,48

As research journal of the College of Psychiatry of Ireland, the Irish Journal of Psychological Medicine will continue to fulfil its established roles in advancing the evidence-base for practice and “expressing the unique identity of Irish psychiatry”,5 but will also seek to expand and develop in new directions. As part of that process, readers who wish to make suggestions about how the Journal can develop in the future should feel free to submit their ideas to the editorial team (sfarrell@irishpsychiatry.ie). All suggestions are welcome.

The Irish Journal of Psychological Medicine has a strong tradition of highlighting and debating key issues in contemporary psychiatry, and this, too, will continue. In recent years, we have published occasional multi-author papers examining key issues,49,50 and our regular editorials have explored diverse topics including deinstitutionalisation in disability services,51 dementia care,52 mental health and the asylum process,53 psychiatric training and research,54 reflective practice in psychiatric training,55 primary care mental health 56 and perinatal psychiatry.57

Like the College of Psychiatry of Ireland, the Journal’s key aims are to inform and improve mental health services in Ireland and beyond, and, ultimately, enhance the quality of mental health care provided to those who need it. In the end, that’s what matters most.

Conflict of interest The author is editor-in-chief of the Irish Journal of Psychological Medicine.

In March 2011, we published a special supplement dedicated to head shop drugs,58,59 looking in detail at the clinical effects of

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World Health Organization, Geneva, 2001. 33. World Health Organization. WHO Resource Book on Mental Health, Human Rights and Legislation. World Health Organization, Geneva, 2005. 34. United Nations. Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care. United Nations, Secretariat Centre For Human Rights, New York, 1991. 35. United Nations. Convention on the Rights of Persons with Disabilities. United Nations, Geneva, 2006. 36. O’Donoghue B, Moran P. Consultant psychiatrists’ experiences and attitudes following the introduction of the Mental Health Act 2001: a national survey. Ir J Psychol Med 2009; 26: 23-26. 37. Jabbar F, Kelly BD, Casey P. National survey of psychiatrists' responses to implementation of the Mental Health Act 2001 in Ireland. Ir J Med Sci 2010; 179: 291-294. 38. Jabbar F, Doherty AM, Aziz M, Kelly BD. Implementing the Mental Health Act 2007 in British general practice: Lessons from Ireland. Int J Law Psychiatry 2011; 34: 414-418. 39. Kelly BD. Mental health legislation and human rights in England, Wales and the Republic of Ireland. Int J Law Psychiatry 2011; 34: 439-454. 40. Vandenbroucke JP. Case reports in an evidence-based world. J R Soc Med 1999; 92: 159-163. 41. Kelly BD. In defence of the single case report. Ir Med J 2001; 94: 37. 42. Bignall J, Horton R. Learning from stories – the Lancet’s case reports. Lancet 1995; 346: 1246. 43. Kelly BD. The Irish Journal of Psychological Medicine: looking to the future. Ir J Psychol Med 2010; 27: 170-171. 44. Kelly BD. Learning disability and forensic mental healthcare in nineteenthcentury Ireland. Ir J Psychol Med 2008; 25: 116-118. 45. Breathnach CS. Philip Crapton (1777-1858) and his description of nominal aphasia. Ir J Psychol Med 2009; 26: 41-42. 46. Walsh D. The Ennis District Lunatic Asylum and the Clare Workhouse Lunatic Asylums in 1901. Ir J Psychol Med 2009; 26: 206-211. 47. Walsh D. Did the Great Irish Famine increase schizophrenia? Ir J Psychol Med 2012; 29: 7-15 48. Finnane P. Insanity and the Insane in Post-Famine Ireland. Croon Helm, London, 1981. 49. Lawlor B, Ganter K, Daly I, Owens J. Implementing the Mental Health Act 2001: what should be done? What can be done? Ir J Psychol Med 2005; 22: 79-82. 50. Kelly BD, Bracken P, Cavendish H, Crumlish N, MacSuibhne S, Szasz T, Thornton T. The Myth of Mental Illness 50 years after publication: what does it mean today? Ir J Psychol Med 2010; 27: 35-43. 51. Carrigan N. Deinstitutionalisation – time to move on to legalisation? Ir J Psychol Med 2011; 28: 182-184. 52. O’Connell H. Dementia care in Ireland: what’s the plan? Ir J Psychol Med 2011; 28: 112-115. 53. Crumlish N, Bracken P. Mental health and the asylum process. Ir J Psychol Med 2011; 28: 57-60. 54. Nkire N, Edokpolo O. Psychiatric training and research in Ireland, the trainee’s perspective. Ir J Psychol Med 2011; 28: 3-5. 55. Omer S. McCarthy G. Reflective practice in psychiatric training: Balint groups. Ir J Psychol Med 2010; 27: 115-116. 56. Russell V, Kelly M. Primary care mental health – a new direction? Ir J Psychol Med 2010; 27: 63-65. 57. O’Keane V. Planning perinatal psychiatry services for Ireland. Ir J Psychol Med 2010; 27: 3-5. 58. Kelly BD. Head shop drugs: they haven’t gone away. Ir J Psychol Med 2011; 28: S1. 59. O’Keefe C. Medical problems caused by ‘legal highs’ continue. Irish Examiner 2011; May 12. 60. O’Domhnaill S. Mephedrone and “head/hemp” shop drugs: a clinical and biochemical “heads up”. Ir J Psychol Med 2011; 28: S2-S3. 61. Uhoegbu C, Kolshus E, Nwachukwu I, Guerandel A, Maher C. “Legal Highs”: Report on two psychiatric presentations linked with “head shop” products. Ir J Psychol Med 2011; 28: S8-S10. 62. O’Reilly F, McAuliffe R, Long J. Users’ experiences of cathinones sold in head shops and online. Ir J Psychol Med 2011; 28: S4-S7. 63. El-Higaya E, Ahmed M, Hallahan B. Whack induced psychosis: a case series. Ir J Psychol Med 2011; 28: S11-S13. 64. Tully J, Hallahan B, McDonald C. Benzlypiperazine-induced acute delirium in a patient with Schizophrenia and an incidental temporal meningioma: A case report and a review of the literature. Ir J Psychol Med 2011; 28: S14-S16.

References 1. McGennis A. Obituary: Mark Hartman. Psych Bull 1994; 18: 442. 2. Webb M. Trinity’s Psychiatrists: From Serenity of the Soul to Neuroscience. Trinity College, Dublin, 2011. 3. McClelland R. An appreciation of Dr Mark Hartman, founder and editor-inchief of the Irish Journal of Psychological Medicine. Ir J Psychol Med 1994; 11: 4. 4. Redmond L. Suicide: act of destruction or cry of despair? Irish Times 1979; January 29. 5. Lawlor BA. Quo vadis? Ir J Psychol Med 1994; 11: 107. 6. Kelly BD. Mental health policy in Ireland, 1984-2004: theory, overview and future directions. Ir J Psychol Med 2004; 21: 61-68. 7. Kelly BD. Investing in the future. Ir J Psychol Med 2004; 21: 111 8. McDonald G, Hallahan B. Recent advances in the biological treatment of mood disorders (Continuing Professional Development, Module 1). Ir J Psychol Med 2009; 26: 93-101. 9. Behan C. Current approaches to the management of schizophrenia (Continuing Professional Development, Module 2). Ir J Psychol Med 2009; 26: 157-163. 10. Feeney L. Management of alcohol use disorders (Continuing Professional Development, Module 3). Ir J Psychol Med 2009; 26: 214-220. 11. Duffy R, Kelly BD. Adherence in psychiatry (Continuing Professional Development, Module 4). Ir J Psychol Med 2010; 27: 54-60. 12. Mullins D. Morbid jealousy: the green-eyed monster (Continuing Professional Development, Module 5). Ir J Psychol Med 2010; 27: 106-112. 13. Crumlish N. Post-traumatic stress disorder: present and future (Continuing Professional Development, Module 6). Ir J Psychol Med 2010; 27: 162-167. 14. Orakwue N, McNicholas F, O’Malley K. Fetal alcohol spectrum disorders – an Irish perspective (Continuing Professional Development, Module 7). Ir J Psychol Med 2010; 27: 223-227. 15. Feeney S, Hallahan B. Tobacco smoking and mental illness: important considerations (Continuing Professional Development, Module 8). Ir J Psychol Med 2011; 28: 50-54. 16. Nassim S, Jabbar F, Afridi A, Kelly BD. Serotonin toxicity (Continuing Professional Development, Module 9). Ir J Psychol Med 2011; 28: 106-109. 17. Murtagh A, Petrovici R, Wong W, Obadan C, Solanke O, Nnabuchi E, Kilbride K. Improving monitoring for metabolic syndrome using audit (Continuing Professional Development, Module 10). Ir J Psychol Med 2011; 28: 176-179. 18. Kolshus E, Douglas L, Dunne R. Antidepressant augmentation and combination in unipolar depression : strong guidance, weak foundations (Continuing Professional Development, Module 11). Ir J Psychol Med 2011; 28: 263-271 19. Reynolds J. Grangegorman: Psychiatric Care in Dublin since 1815. Institute of Public Administration/Eastern Health Board, Dublin,1992. 20. Kelly BD. Physical sciences and psychological medicine: the legacy of Prof John Dunne. Ir J Psychol Med 2005; 22: 67-72 21. Dunne J. The Contribution of the Physical Sciences to Psychological Medicine. J Ment Sci 1956; 102: 209-220. 22. Doherty AM, Kelly BD. The social and psychological correlates of happiness in seventeen European countries: analysis of data from the European Social Survey. Ir J Psychol Med 2010; 27: 130-134. 23. Expert Group on Mental Health Policy. A Vision for Change: Report of the Expert Group on Mental Health Policy. The Stationery Office, Dublin, 2006. 24. Clare A, Daly RJ, Dinan TG, King D, Leonard BE, O’Boyle C, O’Connor J, Waddington J, Walsh N, Webb M. Advancement of psychiatric research in Ireland: proposal for a national body. Ir J Psychol Med 1990; 7: 93. 25. Daly RJ. Community psychiatry and the National Institute of Mental Health. Ir J Psychol Med 1990; 7: 5. 26. Lewis, M. Boomerang: The Meltdown Tour. Penguin/Allen Lane, London, 2011. 27. Vandenbroucke JP. Medical journals and the shaping of medical knowledge. Lancet 1998; 352; 2001-2006. 28. Fletcher RH, Fletcher SW. The future of medical journals in the western world. Lancet. 1998; 352: Suppl 2:SII30-3. 29. Horton R. 21st-century biomedical journals: failures and futures. Lancet 2003; 362: 1510-1512. 30. Lown B, Bukachi F, Xavier R. Health information in the developing world. Lancet 1998; 352: Suppl 2:SII34-38. 31. Kandela P. Medical journals and human rights. Lancet 1998; 352: Suppl 2:SII7-11. 32. World Health Organization. Mental Health: New Understanding, New Hope.

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Original Paper

Did the Great Irish Famine increase schizophrenia? Dermot Walsh Ir J Psych Med 2012; 29 (1): 7-15

Abstract

suspect relevant environmental traumas is maternal undernutrition.3

Background: Evidence from regions where there have been severe dietary restriction suggests that individuals in utero during periods of starvation may subsequently be at increased risk of schizophrenia. Because Ireland was the location of a major nineteenth century famine an attempt has been made to determine whether any such evidence for famine/schizophrenia association can be found.

The occurrence of two relatively recent famines has led to a natural experiment of their effect on neurodevelopment. The first was the Dutch Winter Hunger and the second the Great Leap Forward Chinese famine. The Dutch famine occurred at a specific time and geographical region and records were able to document the timing and extent of the resultant under-nutrition. The relevant circumstances were that towards the closing phase of World War 2 the Dutch population attempted to assist the Allied advance. In retaliation the German occupation authority imposed a ban on the importation of food supplies to occupied Holland. This began towards the end of 1944 with the west of the country most severely affected. The under-nutrition of the population was most marked between February and May 1945 when average daily food intake fell to 1,000 calories per day and eventually to as low as 500. Of the 3.3 million population of the western Netherlands at least 20,000 died as a direct result of hunger and 200,000 suffered adverse health consequences and the birth rate fell to half prefamine levels.4

Method: The data used derive mainly from the Annual Reports on the District, Criminal and Private Lunatic Asylums supplied by the Inspectors of Lunacy in Ireland for the relevant years. Nineteenth century diagnostic labels have been adjusted to conform to schizophrenia as currently understood. Evidence relating to a possible schizophrenia increase in famine-related emigrants is examined. Results: There was an increase in first admission rates for schizophrenia of 85.7% from 1860 to 1875. Admissions for other disorders, chiefly melancholia, also increased. Similar admission increases were evident in other jurisdictions over the same period. Data relating to the mental health of famine – migrating Irish are sparse and of difficult interpretation.

Researchers have followed the offspring of Dutch mothers pregnant during the famine with particular emphasis on neurodevelopmental conditions such as schizophrenia.4 In the case of schizophrenia three criteria were used to define the exposed birth cohort in the six largest Western cities of the Netherlands. The first criterion was low food intake during the first month of gestation and those born between August and December 1945 in the cities of the famine regions met this criterion. The second criterion was conception at the height of the famine as indicated by adverse health effects in the general population. Those born later among the birth cohorts of August- December 1945 (born between October 15 and December 31) met this criterion but those born earlier (between August 1 and October 14) did not. These persons were traced through the Dutch National Psychiatric Registry, followed through to ages 24-48 to determine whether they had been admitted to hospital with a diagnosis of schizophrenia between 1970 and 1992. Control cohorts from periods immediately after and prior to the famine period were also investigated. The risk of schizophrenia was found to be substantially raised in the exposed cohort as compared with the controls with a relative risk of 2.0 for males and 2.2 for females. The schizophrenia cohort also had increased perinatal mortality and increased birth complications both of which are known to be associated with schizophrenia.5

Conclusion: The evidence from available data sources attempting to link the Irish famines of the 1840s with a subsequent increase in the incidence of schizophrenia is equivocal and inconclusive. Key words: Schizophrenia, Famine, 19th Century Ireland.

Introduction The impact of famine conditions on the human embryo has been a matter of study. For example maternal under-nutrition may result in cephalopelvic disproportion resulting in increased birth complications following maternal rickets due to insufficiency of vitamin D.1 Low fertility, decreased birth weight and the survival of underweight and premature infants as a consequence of improved obstetric care may lead to substantial health consequences later in life. These include developmental retardation or abnormalities. For example there is mounting evidence that schizophrenia (as well as autism and intellectual disability) may be a developmental disorder associated with a variety of environmental/gene interactions, such as maternal pre-natal infection in genetically susceptible persons, resulting in abnormalities of synaptic formation and maintenance and of mechanisms of neurotransmission, manifesting themselves in cognitive, affective and perceptual anomalies.2 Among other Dermot Walsh, Consultant Psychiatrist Emeritus, Health Research Board, Knockmaun House, Lower Mount Street, Dublin 2. E-mail dwalsh@hrb.ie

Submitted February 4th 2011 Accepted July 29th 2011

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In explanation Hoek et al have hypothesised that prenatal micronutrient deficiencies may cause neurodevelomental schizophrenia.4 A criticism of the study is that the numbers involved, 27, was very small. A follow up study of five males and four females with schizophrenia born between October and December, these being the only traceable subjects of the original 27, was undertaken.6 Their diagnosis of schizophrenia was confirmed by standard diagnostic instruments and they participated in a magnetic resonance imaging (MRI) study. They were compared with the same number and similarly sexed healthy subjects who had also been exposed to the famine conditions. Two further groups were recruited, nine schizophrenic persons and nine non-schizophrenic individuals, both groups without famine exposure. The exposed schizophrenia group was found by comparison to the others to have decreased intracranial volume. This was interpreted to have indicated stunted early brain development. However several methodological criticisms may be made. Most obviously the numbers involved were very small and the method of recruitment of the controls far from perfect.

The Great Irish Famines In Europe the Irish famines of the 1840s are notorious for their severity and adverse health consequences resulting in an estimated one million deaths and massive emigration. There is extensive literature on the causes, characteristics and consequences of these famines such as by O’Grada.9 These famines were the consequence of successive and repeated failures of the potato crop on which much of the population, that had greatly increased during the previous half century, had come to depend as its main source of nutrition.10 The crop failure was the result of infestation of the potato by phyophtera infestans causing blight for which there was no known antidote at the time. Although there had been periodic potato crop failures and deficiencies in Ireland from at least the late eighteenth century, these were not due to blight, were of lesser intensity and more restricted in geographic range.10 The blights of 1845-50 were on a very different scale. The resultant series of famines are collectively known as The Great Famine.

The Great Leap Forward Chinese famine of 1959-61 was the consequence of collectivisation of agriculture, flawed agricultural practices and reduction of cultivated land. The famine was widespread but varied from province to province. Reports of an investigation of the effects of this famine on schizophrenia derive from an isolated province of China in the Wuhu region of Anhui. The area of Wuhu and six surrounding counties were served by a single psychiatric hospital. Hospital records from 1971 to 2001 were examined. The authors found that the risk of developing schizophrenia doubled from 1958 and 1959 and concluded that prenatal exposure to famine increased the risk of schizophrenia later in life.7 The findings from this area, much larger than that of the Netherlands, found for the most exposed cohort an effect size similar to the Dutch. The mortality adjusted relative risk for schizophrenia over the two year period was 2.3 for 1960 and 1.9 for 1961. However the study did not have month of birth for cases or controls nor was information for food intake available month by month.

Food and nutrition in Ireland from 1500 to the early 20th century have been extensively investigated by Clarkson and Crawford.11 They quote Arthur Young in stating that by the late 18th century the average person consumed 6 pounds of potatoes per day and recorded that by 1845 close to 40% of the population lived chiefly on potatoes.12 This occurred in a setting of population increase since 1700 and an exporting of meat, butter and grain. These authors estimate that between 1846 and 1851 over a million or 12% of the immediate pre-famine population died. “More than one third of Ireland’s population were potato people, competing for scarce plots on marginal soils and hard pressed for rent by farmers who were themselves under pressure from falling grain prices and impoverished landlords.”13 The question as to the specificity of the great famine in time is a relevant issue having regard to the time limits of the famine in China and the more securely identified window of time of the Dutch occurrence. The late Professor George O’Brien doubted the uniqueness of the 1845 -1850 situation when he said that the country was in a constant state of sub-famine and that the years identified by historians as “great” were but an exacerbation of a long-standing situation.14 However scholars such as Connell 10 and O’Grada 9 take a different view and Clarkson and Crawford argue that “ Ireland was not chronically a famine-stricken society and that in normal years it was well stocked with nutritious food”.15

Accordingly a second more rigorous study was undertaken.8 This was centred on Liuzhou City and surrounding counties in Guangxi region with a population of 45 million. One hospital served the area under investigation, and had good psychiatric records covering the years 1971- 2001. The famine here was less severe than in Anhui but of considerable dimensions nonetheless. As a result there was evidence of 500,000 – 800,000 deaths and fertility reductions of the same order as in Holland. All inpatient and outpatient records of the hospital were examined using ICD 10 criteria. A twofold increased risk for schizophrenia among those conceived or in early gestation at the height of the famine was found. However this result was exclusively for rural areas. The authors speculated on the possible deviant nutritional mechanisms involved such as the micronutrients involved in the folate pathway which may directly affect growth of the developing brain or indirectly by affecting DNA stability and regulation of genes.

It is therefore reasonable to accept that the years 1845 – 1851 were years of devastation and mortality in which a pre-famine population of 8.5 million was greatly reduced by mortality and by emigration. The physical effects of starvation and the accompanying exposure to the fevers and vitamin deficiencies were well documented by Wilde and others.16 Apart from the confusional states of persons dying from famine-associated fevers there is little information of the longer-run consequences for mental health. O’Grada, for example, asserted “there was little likelihood of long-lasting cohort effects in post famine Ireland” on the physical and intellectual performance of children who were born at the time.17

Thus there is evidence that famine conditions may, as one of their consequences, increase the incidence of schizophrenia. Maternal dietary deprivation or insufficiency may translate into foetal undernourishment with adverse effects on neurological and brain development during pregnancy.

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Accordingly on the assumption that what appears to be true for Holland and China might also apply in famine Ireland the current exercise has been undertaken. It operates from a basis of many deficiencies. Statistical data relating to the question are sparse and open to a myriad of interpretations; the famine was more prolonged and less incisive in time than in the other locations examined and the ability to diagnose schizophrenia hampered by rudimentary descriptions of cases, exclusively inpatients.

nourished pregnant women resulting in an excess of schizophrenic persons in these emigrant populations in the 1860s and 1870s is briefly considered.

Lunacy in 19th century Ireland The 19th century was a period of rapid growth of the recognition and institutional provision for the mentally ill or lunatic and the intellectually disabled (idiots and imbeciles). It has been reviewed in detail by Finanne18 and details of the temporal establishment of district asylums from 1830 – 1845 have been presented by Walsh.19 The main provision was in district lunatic asylums but also in the lunatic wards of workhouses established in around 1840 where residents were predominantly of idiot or imbecile type. As the years progressed a policy of transferring lunatics from workhouse to asylums was embarked upon. The following table documents the growth in the asylum population from 1824 when there was one district asylum in Armagh (although there were asylums in Dublin and Cork at this time they had not been absorbed into the district asylum system until later) to 1875 when there were 22. In addition there were smaller numbers of lunatics in goals and in workhouses.

Method The task for this study is to identify whether it is possible to adduce evidence to sustain the maternal hunger/schizophrenia hypothesis in the context of one of Europe’s severest famines of modern times. To explore this issue it is necessary to examine whether relevant health care data substantiate an increase in the disorder some 1530 years following the major famines. The relevant period is, therefore, between 1860 and 1875. The available data relevant to this enquiry include numbers of admissions to lunatic asylums in Ireland over the relevant time period. In addition the issue of whether the massive emigrations from Ireland to North America and the United Kingdom in the late 1840s and early 1850s would have included migrant under-

Table 1. Years of opening of District Lunatic Asylums with numbers of patients on opening and in 1875.

Asylum

Year Opened

Patients on Opening

Patients 1875

Armagh Ballinasloe Belfast Carlow Castlebar Clonmel Cork Down Ennis Enniscorthy Kilkenny Killarney Letterkenny Limerick Londonderry Maryborough Monaghan Mullingar Omagh Richmond Sligo Waterford

1824 1833 1829 1832 1866 1834 1852 1868 1868 1868 1852 1852 1866 1827 1829 1833 1869 1855 1853 1830 1855 1835

104 150 104 104 250 60 250 300 260 285 152 220 300 150 120 104 340 300 300 257 250 100

162 459 380 250 281 370 500 300 260 288 216 220 300 410 238 266 340 400 510 1,040 330 210

4,460

7,730

Totals

Sources: Reports on the District, Criminal and Private Lunatic Asylums in Ireland. 21st report.20 25th report.21

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There was therefore an increase of 3,270 or 73% inpatients resident between the opening of the asylums and the numbers hospitalised in 1875.

Dangerous Lunatics Act of 1867 which did not differ substantially from its processor other than requiring a medical certificate from the dispensary doctor and in allowing magistrates to commit “dangerous lunatics and idiotics” to lunatic asylums rather than to jails by legislation, the effect of which in the case of the Richmond Asylum, was to increase admissions to 401 in 1868 compared to 247 in 186.30 In effect the new legislation, far from remedying the situation, resulted in an increase in direct admissions to asylums throughout the century. This issue is examined in depth by Finnane who attributed it in part to “the widening of insanity’s boundaries”31 thus raising further nosocomial caution on the interpretation of the reasons for admission increases following the famine. And for Finnane the familial context, particularly in its socio-economic context, was at least as important in determining admission sought by relatives as the diagnostics labels appended by asylum doctors; ”it is the history of familial relations which is essential to appreciating the decision to commit”.32 As an example of commitment because of economic necessity, Malcolm, in her history of Swift’s Hospital, illustrates the dilemma encountered by a certain Mary Larkin in her deciding to apply for the re-admission of her husband Thomas.33

The reasons for the increase in these asylum populations were much debated. Broadly speaking there were two schools of commentators, those who believed that the increase reflected a genuine increase in the incidence and prevalence of lunacy such that the Times of London was moved to assert in an editorial in 1877 that “If lunacy continues to increase as at present the insane will be in the majority and, freeing themselves, will put the sane in asylums” as quoted by Scull22 and those who believed that the increase was apparent rather than real. In the former camp were those who believed that before 1800 schizophrenia, the most serious form of lunacy, was rare prior to the 19th century before increasing afterwards because of genetic mutation as did Hare 23 whereas Jablensky assigned the increase, on the basis of German evidence, to the 20th century.24 Another commentator concluded that schizophrenia became more prevalent during the 19th and early 20th century due to socioenvironmental changes associated with industrial growth and biological mediating mechanisms such as nutritional, immunological and infectious causes.1 The opposing point of view was promoted by Scull25 who, in rejecting the real increase hypothesis, invoked social conditions, such as pauperism, as contributing to the increasing influx of persons to the 19th century asylums. However he conceded that the most satisfactory means of deciding between the rival hypotheses was to sample the characteristics of 19th century admission records but conceded that “there must be serious doubt the quality of surviving records is adequate for this purpose” and that “individual case records are generally too skimpy to be useful for answering this question”.25

Incidence 1860-1875 There is no reliable information available on new cases of lunacy arising in the Irish community in the 19th century. However periodic census counts of “lunatics at large” were carried out by the Royal Irish Constabulary at the request of the Inspectors of Lunacy in the 200 constabulary areas of Ireland on a regular basis. It might have been possible to assess an increasing incidence of such cases by comparing one year with another and interpreting an increase as indicating new cases on an annual basis. However the arbitrariness of the Constabulary’s identification of lunacy, which included intellectual disability, excludes the usefulness of this information source. Accordingly it is necessary to rely on asylum admission data as a measure of the incidence of schizophrenia as returned in the Annual Reports on the District, Criminal and Private Lunatic Asylums in Ireland as provided by the Inspectors of Lunacy, the greatest proportion of which were to the district asylums.

In these debates in Ireland the Inspectors of Lunatics figured largely as did prominent asylum doctors of the time such as MacCabe26 and Drapes 27 both of whom held the increase was real. Indeed the matter was of such sufficient interest that the Inspectors devoted a Special Report to the Chief Secretary in 1884, on the “alleged increased prevalence of insanity in Ireland.28 They concluded that “the great increase in the insane under care is mainly due to ACCUMULATION (sic) and is, so far, an apparent and not a real increase”. This in fact was a compilation of the views of asylum superintendents whom the Inspectors had canvassed. Finnane, too, supported an apparent increase as explanation and cited social and administrative considerations as catalysts.29

Given that the incidence of schizophrenia is mostly concentrated in the population aged between 15 and 30 years, it is assumed that the impact of the Irish famines of 1845- 51 would be manifest mainly in an increase in hospital admissions for lunacy, and more specifically for conditions analogous to schizophrenia, in Ireland between 1860 and 1875. Admissions to the district asylums, over 80% of which were recorded as first admissions, rose from 1,313 in 1860 to 2,132 in 1875 and then increased only slightly to 1880 when they numbered 2,366.

Administrative and legal considerations may have been just as important as any perceived increase in lunacy as a disease in contributing to the increase in asylum admissions throughout the 19th century. In Ireland the Dangerous Lunatics Act of 1838 made it relatively easy for individuals who had committed what today are called “minor public order offences”, and sometimes even those whose level of misbehaviour was beneath this threshold, to be consigned to asylums, or to gaols before transfer to asylums. It was generally believed that this mechanism was abused with the result that many persons whose dangerousness and lunacy were questionable ended up in the asylums. An attempt to control the conveyance of persons to asylums in this manner resulted in the

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Table 2. Numbers of admissions to District Lunatic Asylums 1860-1875

1860 1861 1862 1863

1,313 1,262 1,171 1,420

1864 1865 1866 1867

1,242 1,291 1,782 1,527

1868 1869 1870 1871

2,113 2,692 2,333 2,253

1872 1873 1874 1875

2,165 2,277 2,154 2,132

Sources: 10 to 25th Reports on the Public, Criminal and Private Asylums of Ireland.34

was admitted under warrant to the asylum which stated that she threatened and assaulted her mother with whom she did not get on. Nevertheless she was given a diagnosis of chronic mania and the supposed cause of her insanity was identified as “family disturbances”. Confusingly the “duration of present attack” was given as 15 years. The sparse case notes indicate only that she had “from time to time maniacal symptoms”. She was still undischarged seven years later. A 33 year old female was admitted because she was alleged to have assaulted her sister and threatened to burn her father’s house. The duration of her illness prior to admission was said to be one month. Sixteen years following admission she was said to be “noisy and refractory” and she died in the asylum 41 years following admission. A 35 year old male was admitted because he threatened to kill his wife and family and was stated to have been ill for only three weeks prior to admission. He was noted in his case notes to be suffering from delusional insanity with jealous delusions concerning his wife but was noted to have taken a lot of drink prior to admission. Three weeks after admission he “escaped”, couldn’t be found and so was discharged from the asylum register a fortnight later.

There was, thus, an increase of 62% in the number of admissions between 1860 and 1875. As the population fell over these years the rate per 100,000 population rose more rapidly than the raw numbers, from 22.6 to 40.4 or by 78.7%. However, there was no decline in admissions in the years after 1880, when any famine effect would be expected to have petered out. On the contrary, admissions increased by a further 32% to 3,095 in 1890 and by 1898 had reached 3,469. First admissions constituted in and around 80% from 1861 onwards. Admissions to private hospitals increased from 165 in 1860 to 186 in 1875 and constituted 2,882 (9%) of 32,009 total private and public admissions over 1860-75. No diagnostic information was furnished on these private admissions, although it was provided on those resident each year with mania predominating. Because the numbers are small and there was little increase over the period surveyed they are discounted from further consideration. Similarly the 290 admissions to the Central Criminal Asylum over these years have been discounted.

Diagnosis in the nineteenth century Whereas in the 20th century medical practitioners were familiar with the concept of schizophrenia, introduced in the early 1900s, this was not the case in the preceding century. The term lunacy was often employed generically and administratively to include both those suffering from mental illness and those with intellectual disability (idiots and imbeciles). However although this generic usage is sometimes employed in official reports, such as the annual inspection reports employed here, these usually use lunacy in the more restricted sense of mental illness per se. Within lunacy a very restricted classificatory system was used. The most common diagnostic terms were mania, melancholia, monomania and dementia. I have examined Irish asylum casebooks of the Sligo, Mullingar and Richmond asylums from the 1850s to 1900 and attempted, from the limited clinical descriptions available, to reconcile these terms with diagnostic groupings currently in use in the International Classification of Diseases 10th edition (ICD 10). While in a minority of cases the symptoms and historical data recorded are specific enough to warrant a diagnosis in modern terms of depression with some confidence, this is not so in relation to the broader concept of schizophrenia, an entity unknown as such at that time. For example, delusional thinking and hallucinatory experiences, characteristic of this disorder, were rarely noted in the Irish nineteenth century case books quoted.

This contrasts markedly with the situation pertaining in late nineteenth century Denbigh Asylum in North West Wales where case notes were “more comprehensive than in other asylums of the period” and were sufficiently detailed to permit consultant psychiatrists to make an ICD diagnosis on each patient.36 A similar exercise was possible at the Retreat in York, dealing with patients admitted 1880-1884 where diagnostic information was sufficiently explicit to allow of ICD conversions.37 More pertinent to the Irish dilemma is the finding of researchers seeking to extract schizophrenia from admissions to the Bethlem Royal Hospital 18531862. Having reviewed the diagnostic criteria set out in contemporary psychiatric textbooks they concluded that mania comprised insanity with “confusion of ideas” and “encompassed all syndromes where thought disorder was evident”.38 Moreover, in identifying schizophrenia they excluded all persons aged over 40. This is not possible in Ireland because of lack of cross-classification by disease category and age in the Irish reports. I now turn to estimating how many of Irish asylum admissions should be classified as schizophrenia. There has been surprisingly little attempt to determine what proportion of 19th century lunacy emerges as schizophrenia as it is understood today. An outstanding exception to this general scenario is that of Hare.23 In examining the difficult issues involved Hare warned that “Before modern diagnostic criteria became generally accepted, there was much difference of opinion on what signs and outcomes were indicative of a schizophrenic illness. And what was a difficult decision in

The following cases from the Sligo Asylum casebooks, typical of the generality of admissions, illustrate the practical difficulties encountered in diagnostics of the time.35 A 45 year old woman

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clinical practice was more likely to be contentious in a historical setting even when a detailed history was available. Kraepelin, to whom we owe the concept that was later to emerge as schizophrenia, and which he had called dementia praecox, stated that many of the cases he identified as dementia praecox had previously been classed as mania or melancholia.39 Hare, speaking of the 19th century, states that “we may assume that almost all cases classified as “ordinary dementia” would have been schizophrenia”.23 Further support for this is supplied by Tuke who subdivided ordinary dementia into two forms. Primary dementia was the form that occurs most especially in young persons of feeble development and secondary was the form that “follows acute attacks of insanity, maniacal or melancholic”.40 Of course the clinical manifestations of schizophrenia may have changed over the past 100 years, and while this is more likely to be true of earlier periods, it is still a factor requiring consideration, in translating 19th century case book descriptions, even when exhaustive as they seldom were, in Irish 19th century case books, to the modern concept of schizophrenia.

53 (4%) and melancholia 220 (17%). Here one encounters the problem of assessing or best-guessing what proportion of these could be validly regarded as schizophrenic. The assumption, based on the very tenuous evidence of contemporary case- books with their admittedly poor symptomatic descriptions, is made that the following proportions of these categories were what today is called schizophrenia, mania 60%, monomania 100%, dementia 50%, and melancholia 0%. This yields an estimated total of 632 admissions for schizophrenia in 1860 (50% of all mental illness admissions) or 524 first admissions on the basis that 83% were first admissions. In 1875 there were 2,344 admissions of which 1,777 (83%) were first admissions. The equivalent estimate for 1875 was 1,006 schizophrenia admissions of which an estimated 834 were first admissions. The estimation therefore is that the first admission rate for schizophrenia rose from 8.4 per 100,000 in 1860 to 15.6 in 1875. However, as the admission rate for nonschizophrenia conditions increased to the same extent, the proportion of all admissions classified as schizophrenia remained stable. The following figures represent these data.

Mania was the predominant diagnosis of mental illness in nineteenth century Ireland, comprising 72% of admissions 186075. This clearly suggests, as pointed out above, that as well as including mania as it is known today, other categories must have been subsumed into this entity, most notably schizophrenia. This assumption gains support from the contemporary evidence, that of schizophrenia and mania first admissions combined, schizophrenia now comprises 60%. I have assumed that the relative distribution of these conditions was similar in the nineteenth century and have re-classified 60% of nineteenth century admissions, classified then as mania, to what we call schizophrenia today. I further assume that the nineteenth century category monomania connotes delusional disorder and belongs in its entirety to the schizophrenia spectrum. The term dementia was employed non-specifically in the nineteenth century admissions classification and seems often to have included those with the negative symptoms of schizophrenia, as well as dementia in the modern sense of cognitive failure of organic origin, particularly in older persons. Support for this contention is provided by the observation by Hare that the age – incidence curve or age at first admission for dementia in the 19th century was largely in the younger age groups and therefore not compatible with the modern concept of this condition and he therefore aligned much of it with schizophrenia.23 However this cannot be tested in the Irish context as no data are available for diagnosis cross- classified by age. I have therefore, somewhat arbitrarily, allocated 50% of dementia admissions to schizophrenia. As melancholia closely resembles depression as used today, this category has been regarded as not contributing to schizophrenia on the assumption that depressive syndromes were the predominant characteristic of those labelled melancholia. However as noted by Tuke40 some cases of melancholia, passing into a chronic state, might conceivably be re-labelled dementia.

Admission rates per 100,000 population.

Figure 1. Schizophrenia admission rates per 100,000 population 1860-1875 from 9th to 25th Reports on the Public Criminal and Private Asylums of Ireland.41 Percentage of all admissions that were schizophrenia

There were 1,313 admissions to district asylums in 1860, a year when one would have expected famine–related admissions to begin to appear. Excluding the 220 “relapsed” cases there were 1,093 first admissions, 83% of the total. Four categories of mental illness accounted for 96% of all admissions (the remainder comprised idiots and imbeciles). The breakdown of these four categories was: mania 892 (68%), dementia 88 (7%), monomania

Figure 2. Schizophrenia as a percentage of all admissions 1860 – 1875.

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Discussion

Given that schizophrenia is predominantly a disorder of early life with most incident cases arising in the late teens and early 20s I have attempted to determine whether there was any increase in the proportion of young persons admitted during the relevant years as a proportion of all-aged admissions. The Inspectorial reports supply age of admissions in decennial groups and not cross classified by diagnosis. The group most relevant to this enquiry is that of 20 – 30 years. The earliest years for which admission ages were provided were in the combined years 1856 and 1857. In these years 427 or 27.8% of 1,532 admissions were in this age group. This percentage rose to 34.1 in 1868 and then subsided to 28.7 in 1875 thereby giving no support to the question of whether schizophrenia increased insofar as it could be identified by age on admission.42

The plausibility of famine disrupting neurodevelopment has a sound empirical basis. Famine conditions have been shown to result in decreased fertility, increase in miscarriage, stillbirths and low birth weight. 4 Because schizophrenia is believed, in part, to reflect developmental anomalies in brain structure it is relevant to postulate that famine conditions, existing during pregnancy, may result in neurodevelopmental damage to the foetus. Accordingly the natural experiments of famine conditions in two jurisdictions have been examined to determine whether there was an increase in schizophrenia in individuals exposed to famine conditions during pregnancy. These were respectively in Holland during World War 24 and in China during the Great Leap Forward famine.8 Because of the severity of the Great Irish Famine and its resulting mortality it is reasonable to suspect that the accompanying under-nutrition of pregnant women may have similarly resulted in neurological damage leading to an increase in schizophrenia some 15 to 30 years later.

The Irish Abroad Robins contends that “the Irish who left home during the famine and post-famine decades were more susceptible to insanity than immigrants of other racial origins”.43 However he cites no quantative evidence in support of this general contention although he quotes instances where persons who had become mentally ill following emigration were returned by their families or, as in the case of the North American states, were returned by administrative decree. Nonetheless there is abundant evidence of the high prevalence of mental illness among the immigrant Irish compared to indigenous populations both in the US and UK in the mid and late 19th century. For example lunacy in Massachusetts was noted to be high among the immigrant Irish.44 However this was in 1855 less than a decade after the major famines of the 1840s and therefore too early to be related to them. Other reports of the high proportion of Irish in asylum populations came from the Canadian provinces, New Brunswick, before the famine years and Prince Edward Island, subsequent to them, where in 1864 it was claimed that as many as one third of admissions were of Irish immigrants reflecting perhaps more than anything else the very high proportion of the population that was Irish.45 Nonetheless high rates of hospital admissions among the Irish of New York City and State were still extant up to 1900.46 These were too long after the major famines to be attributed to them. Moreover these rates rose progressively throughout the latter part of the nineteenth century and showed no exceptional peak between 1865 and 1875. The rates of hospitalisation of Irish emigrants in North American asylums declined over time, in keeping with the observation that as each immigrant group becomes more assimilated and more prosperous the rate of public psychiatric hospitalisation decreases. Overall, though, these sparse and general observations shed little light on the question at issue.

The reason for the growth in the numbers of persons in Irish asylums during the 19th century led to vigorous debate. Essentially there were two points of view, those that held that it reflected a real increase in lunacy and those who claimed that it was artefactual and apparent rather than real. Explanatory reasons deriving from ecological and environmental causes or influences proliferated. However this increase was not uniquely Irish but a feature of most European and North American jurisdictions.23 The data presented here show an increase in the incidence of lunacy in Ireland as measured by asylum admissions some 15 to 30 years following the Irish famines of 1845-1850 historically referred to as The Great Famine. Admissions of lunatics, that is those suffering from mental illness, to asylums increased 1860-1875 from 1,313 to 2,132 or in rates per 100,000 population from 22.6 to 40.4, an increase of 78.7%. By assigning 60% of patients diagnosed as mania, all those designated monomania and 50% of those designated dementia to schizophrenia, estimates have been made of the numbers likely to have been schizophrenia in those first admitted in 1860 and 1875. Those first admissions identified as schizophrenia rose numerically from 524 to 834 and in rates per 100,000 population from 8.4 to 15.6 an increase of 85.7%. At first sight these increases in Ireland would seem to suggest that the Irish famines did lead to an increased level of schizophrenia in the population, but account has to be taken of the similar increases in the other “non-schizophrenia” lunacies, mainly melancholia whose first admissions rose from 31.7 to 45.5 per 100,000 from 1860-75 an increase of 43.5.41

Irrespective of nutritional status, the trauma of migration and the socio-cultural difficulties of assimilation may of themselves be sufficient to increase mental disorder in migrant populations. Classical examples of this have been identified by Odegaard among Norwegian immigrants to Minnesota 47 and by Harrison among Afro-Caribbean migrants to the United Kingdom.48 And the migrant Irish in the United Kingdom, even to the first generation UK born, appear to have poorer mental health than the indigenous London community.49 Therefore caution must be invoked in attributing mental illness rates to 19th century Irish immigrants solely to maternal nutritional deficiency.

In addition admission rates continued to increase up to the end of the century long after the Great Famine could be held to be an influence. As to the migrating Irish, other factors confound the situation such as poverty and difficulties in assimilation of the immigrant population, which are deemed to contribute to the high hospitalisation rates in many immigrant communities.47 Up to 1881 the rate of first admission to population was higher in England than it was in Ireland.50 The prevalence of persons in asylums and workhouses in England rose from 70 per 100,000 13


population in 1847 to 220 in 1877.51, 52 In Ireland the corresponding figures were 76 and 234. It can therefore be reasonably concluded that the rates of insanity (lunacy plus a small number of idiots and imbeciles) were remarkably similar in both jurisdictions and further that they increased at roughly the same rate in the second half of the nineteenth century. In consequence the record offers little support for the thesis that the increase in rates was attributable to the famines of 1845-51.

Acknowledgement I wish to thank Dr Brian Donnelly of the Irish National Archive for his help and advice and particularly for making the casebooks of the Sligo District Lunatic Asylum available to me.

Conflict of interest None.

As far as Ireland is concerned the evidence that the famines of the late 1840s led to more schizophrenia is, at best, equivocal. The apparent increase in the number of those schizophrenic was in the context of an increase in lunacy generally and the increase observed in Ireland was manifest throughout Europe and North America in jurisdictions where there were no major famines.45

References 1. Warner, R. (1995) Time trends in schizophrenia: change in obstetric risk factors with industrialization. Schizophrenia Bulletin, 21. 3, 1-30. 2. Guilmatre A, Dubourg C, Mosca A-L, Legallie S, Goldenberg A, Drouin-Garrand V, Lavet V, Rosier A, Briault S, Bonnet-Brithault F, Laumonnier F, Odent S, Le Vacon G, Joly-Helas G, David D, Bendavid C, Pinooit J- M, Henry C, Impallomenmi C, Germano E, Tortorella G, Di Rosa G, Barthelemy C, Andres C, Faivre L, Frebourg T, Saugier Veber P, Campion D (2009). Recurrent rearrangements in synaptic and neurodevelopment genes and shared biologic pathways in schizophrenia, autism and mental retardation. Archives of General Psychiatry 66. 947-936. 3. Haukka J, Suvisaari J, Hakkinen L, Lonnqvist J. (2008). Growth pattern and risk of schizophrenia Psychological Medicine 38. 63-70. 4. Hoek HW, Brown AS, Susser E. (1998). The Dutch famine and schizophrenia spectrum disorders. Social Psychiatry and Psychiatric Epidemiology. 33. 373-379. 5. Jablensky A. (1986). Epidemiology of schizophrenia: a European perspective . Schizophrenia Bulletin. 12. 52-73. 6. Hulshoff HE, Hoek HW, Susser E, Brown AS, Dingemans A, Schnack HG, Van Haren NE, Pereira Ramos LM, Gispen de Wied C,, Kahn RS. (2000). Prenatal exposure to famine schizophrenia and brain morphology. American of Psychiatry. 157. 1170-1172. 7. Song S, Wang W, Hu P. (2009). Famine, death and madness. Schizophrenia in early adulthood after prenatal exposure to the Chinese Great Leap Forward Famine. University of California eScholarship Repository. 8. St. Clair D, Xu M, Wang P, Yu Y, Fang Y, Zhang Y, Zheng X, Gu N, Feng, G, Sham P, He L (2005). Rates of adult schizophrenia following prenatal exposure to the Chinese Famine of 1959-1961. Journal of the American Medical Association. 294. 557-562. 9. O’Grada C. (1989). The Great Irish Famine, p. 76. McMillan. London. 10. Connell KH. (1950). The Population of Ireland 1750-1845, p. 146. The Clarendon Press. Oxford. 11. Clarkson LA, Crawford EM. (2001). Feast and Famine. Food and Nutrition in Ireland 1500-1920. Oxford University Press. Oxford. 12. ibid p. 59 13. ibid p. 87 14. O’Brien G. (1918). The Economic History of Ireland in the Eighteenth Century, p 102. Maunsel & Co. Dublin. 15. Clarkson LA, Crawford EM. (2001). Feast and famine. Food and Nutrition in Ireland 1500-1920, p. 112. Oxford University Press. Oxford 16. Wilde W. The census of Ireland for the year 1851, part v. Table of deaths, vol 1 11, p 1856 (2087 11) XXX, The Census of Ireland for the year 1861, part iii. Vital statistics, vol. ii. Report and table relating to deaths, PP 1863 (3204-2) LVIII. 17. O’Grada C. (1999). Black 47 and Beyond, pp 226-227. Princeton University Press. Princeton New Jersey 18. Finnane M. (1981). Insanity and the Insane in Post-Famine Ireland. Croom Helm. London 19. Walsh D. (2008). The lunatic asylums of Ireland 1825-1839. Irish Journal of Psychological Medicine. 24. 24- 28. 20. Lunatic Asylums - Ireland (1872). The Twenty-First Report of the District, Criminal, and Private Lunatic Asylums in Ireland with appendices. HC1872 (c 647) xxvii.323. p 60 Alex Thom. Dublin. 21. Lunatic Asylums – Ireland (1876). The Twenty-Fifth Report of the District, Criminal. and Private Lunatic Asylums in Ireland with appendices. HC 1876 (c 1496) xxxiii.363. p53. Alex Thom, Dublin. 22. Scull AT. (1979). Museums of Madness: the Social Organisation of Insanity in Nineteenth Century England. Allen Lane. London. 23. Hare EH. (1988). Schizophrenia as a recent disease. British Journal of Psychiatry. 153. 521-531.

It is concluded that no unequivocal evidence can be adduced to support the hypothesis that the Great Irish famine increased schizophrenia.

Limitations It may be objected that 1860 is too early a date for the consequences of the famines to be revealed in asylum admissions. Furthermore, the timing of the admissions may not have coincided exactly with the onset of the condition. Whereas the Inspectorial Reports of the 1860s tabulate the duration of disease prior to admission of those discharged as “recovered”, this information is not provided for new admissions nor is it cross-classified by type of disease. In addition, form of disease on admission was not provided in the reports after 1875 until 1890 and by then monomania no longer appeared as an entity. This is noteworthy as it might be objected that delusional disorder has a later onset than other components of the schizophrenia spectrum. A shortage of asylum beds could have caused delays in admissions in the 1860s and increased availability of beds – rather than increased incidence of mental illness – could have accounted for some of the rise in admissions in later years. By 1875, although the number of asylum places available had increased considerably, by almost 3,000 from 1860, admissions fell slightly between 1870 and 1875, as did the number of lunatics reported as at large.34 The use of a single year at either end of exploration may be questioned but there was little variation in the characteristics of the admission or residential clienteles over the years of survey. Finally, it is acknowledged that the sparseness of clinical data in nineteenth century asylum case books in Ireland does not allow translation of what little clinically descriptive material there is into meaningful diagnostic entities as applied today, a difficulty not confined to Ireland.23 The most restricting limitation, therefore, is the derivation of rates of schizophrenia based on purely personal and empirical extrapolation from 19th century diagnostics.

14


24. Jablensky A, Morgan V, Zubrick S, Bower C, Yelleachich L-A. (2005). Pregnancy, delivery and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. American Journal of Psychiatry. 162. 7981. 25. Scull AT. (1984). Was insanity increasing? A response to Edward Hare. British Journal of Psychiatry. 144. 432-436. 26. McCabe F. (1869). On the alleged increase in insanity. Journal of Mental Science. 15. 363-366. 27. Drapes T. (1894). On the alleged increase of insanity in Ireland. Journal of Mental Science. 171. 519- 548. 28. Special Report from the Inspectors of Lunatics to the Chief Secretary (1884). Alleged increasing prevalence of insanity in Ireland. Alexander Thom & Co. Dublin. 29. Finnane M. (1981). Insanity and the Insane in Post-Famine Ireland, p 169. Croom Helm. London. 30. Reynolds J. (1992). Grangegorman. Psychiatric Care in Dublin since 1815, p. 140 and quoting Statute 7 31 Vic 118. Institute of Public Administration. Dublin. 31. Finnane M. (1981). Insanity and the Insane in Post-Famine Ireland, p 223. Croom Helm. London. 32. Finnane M. (1985). Asylums, Families and the State, p. 137. History Workshop. No 20 (Autumn, 1985). 33. Malcolm E. (1989). Swift’s Hospital. A History of St Patrick’s Hospital 1746-1989, p. 144.Gill and Macmillan, Dublin. 34. Lunatic Asylums – Ireland (1861 – 1876). The 10th to the 25th Reports on the Public, Criminal and Private Asylums in Ireland. Alex Thom. Dublin. 35. Male and Female Casebooks of Sligo District Lunatic Asylum 1892-1893. National Archive of Ireland. Dublin. 36. Healy D, Savage M, Michael P, Harris M, Hirst D, Carter M, Cattell D, McMonagle T, Sohler N, Susser E. (2001). Psychiatric bed utilisation:1896 and 1996 compared. Psychological Medicine 31. 779-790. 37. Renvoize EB, Beveridge AW. (1989). Mental illness and the Victorians. A study of patients admitted to three asylums in York, 1880-1884. Psychological Medicine. 19. 19-28. 38. Klaf FS, Hamilton JG. (1961). Schizophrenia – a hundred years ago and today. Journal of Mental Science. 107. 819-827. 39. Kraepelin E. (1913). Psychiatrie (8th edn). Translated by R.M. Barclay from vol 3 part 2 as Dementia Praecox and Paraphrenia. Livingstone. Edinburgh. 40. Tuke DH. (1882). Dictionary of Psychological Medicine. Churchill. London. 41. Lunatic Asylums – Ireland (1861 – 1876). The 9th to 25th Reports on the Public, Criminal and Private Asylums of Ireland. HC 1861 (2901) xxvii. 245 and HC 1876 (c.1496) xxxiii. 363. Alex Thom. Dublin. 42. Lunatic Asylums – Ireland. (1857, 1868-1869 and 1876) The 8th, 18th and 24th Reports on the Public, Criminal and Private Asylums of Ireland. HC 1857 Session 2 (2253) xvii. 67, HC 1868-69 (4053) xxxi. 303 and HC 1876 (c.1496) xxxiii. 363. Alex Thom. Dublin. 43. Robins J. (1986). Fools & Mad. A History of the Insane in Ireland, p. 121. Institute of public Administration. Dublin. 44. Jarvis E. (1855). Report on Insanity and Idiocy in Massachusetts by the Commission on Lunacy. William White. Boston. 45. Fuller Torrey E, Miller J. (2007). The Invisible Plague. The Rise of Mental Illness from 1750 to the Present, p.163. Rutgers University Press. New Brunswick, New Jersey, and London. 46. Malzberg B, Lee ES. (1956) Migration and Mental Disease, Social Science Research Council. New York 47. Odegaard O. (1932). Emigration and insanity. A study of Norwegian-born populations of Minnesota. Acta Psychiatrica et Neurologica (Supplement 4). 1-206. 48. Harrison G, Owens D, Holton A, Neilson D, Boot D. (1988). A prospective study of severe mental illness in Afro-Caribbean patients. Psychological Medicine. 18, 3. 643-657. 49. Ryan L, Leavey G, Golden A, Blizzard M, King M. (2006). Depression n Irish emigrants living in London: case-control study. British Journal of Psychiatry. 188. 560-566. 50. Fuller Torrey E, Miller J. (2007). The Invisible Plague. The Rise of Mental Illness from 1750 to the Present, p. 109. Rutgers University Press. New Brunswick, New Jersey and London. 51. Lunatic Asylums- Ireland (1849). Report on the District, Local and Private Asylums 1847, HC 1849 (1054) xxiii. 53. 52. Lunatic Asylums – Ireland (1878), 27th report on the District, Criminal, and Private Asylums of Ireland 1877. HC 1878 (c. 2037) xxxix. 395.

15


Original Paper

Study of Presentations for Involuntary Admission to a Cork Approved Centre Elaine Dunne, Eamonn Moloney Ir J Psych Med 2012; 29 (1): 16-21

Abstract South Lee Mental Health Unit caters for a catchment area population of 179,000. The approved centre is located in Cork University Hospital and has 46 inpatient beds with approximately 500 admissions per year and had an involuntary admission rate of 54.7/100,000 in 2007.

Objectives: To describe the characteristics of patients who present to an approved centre with Mental Health Act 2001 forms, and secondly, to compare those who were subsequently detained to those who were not detained.

The objective of this study was to describe all those patients who presented to the South Lee Mental Health Unit at Cork University Hospital with an application and medical recommendation for admission under the MHA over a 22 month period in order to establish if these patients were similar to those described in national data. A comparison was also made of those patients for whom an admission order was completed and those who did not have an admission order completed. Such patients are, by definition, deprived of their liberty for up to twenty four hours and it is important that their management is reviewed.

Methods: Specific data on patients who presented to South Lee Mental Health Unit with application and recommendation forms for Involuntary Admission over a 22 month period was gathered from a retrospective case note review. Information on both groups was compared statistically using Graph Pad Prism software. Results: 71% (n=121) of patients presenting for involuntary admission did so outside of normal working hours. Those who were not subsequently detained were more likely to have had their application made by the Gardai and their recommendation made by someone other than their own General Practitioner (GP). GPs were more likely than Consultant Psychiatrists to cite risk to self or others as the reason for involuntary admission.

Methods Records were kept of all patients who presented to the South Lee Mental Health Unit with completed application and medical recommendation forms for admission under the Mental Health Act 2001 between January 2007 and October 2008. Cases of those who were subsequently detained and those who were not detained were identified from these records and included in the study. The period originally planned to be studied was a two year period from the implementation of the MHA 2001 (i.e. from November 2006 to October 2008). It was decided; however, to omit cases from the initial two month period as the high number of incorrectly completed forms due to an adjustment period during this time was likely to affect the overall results, making them less representative.

Conclusion: Although involuntary admissions most often occur in emergency situations, every effort should be made to ensure that those who are known to the patient are involved in the process of application and recommendation. In addition, there is a need for ongoing training and education of those most commonly involved, such as the Gardai and General Practitioners, as well as feedback to these groups when a patient presents who does not require involuntary admission. Key words: Mental Health Act 2001; Involuntary admission; Detention

Introduction A retrospective case note review was carried out to examine the demographic characteristics, the reasons for referral, the past psychiatric history, diagnosis and presenting symptoms of these patients. Where full medical notes were not available, all data was retrieved from copies of initial assessments, electronically recorded patient details and copies of MHA 2001 forms.

Part 2 of the Irish Mental Health Act (MHA) 2001 was implemented on November 1st 2006 and introduced new procedures for the involuntary admission of patients to approved centres. The Mental Health Commission has produced a report on the operation of the MHA1 and there have been numerous legal challenges to the legislation in the form of Article 40 challenges, judicial reviews and High Court and Supreme Court challenges.

* Elaine Dunne, South Lee Mental Health Services, Cork University Hospital, Wilton, Co. Cork, Ireland. E-mail elaine.dunne@ucc.ie

* Correspondence

Eamon Moloney, Consultant Psychiatrist/Clinical Director, South Lee Mental Health Services, Cork University Hospital, Wilton, Co. Cork, Ireland.

16

Submitted January 13th 2011 Accepted August 15th 2011


The application, medical recommendation and admission order forms were reviewed and specific details recorded. Data in relation to patients where an admission order was completed was compared to data in relation to those patients where an admission order was not completed and comparisons were also made with national data on patients admitted under the MHA 2001. Voluntary patients who were regraded and detained under the MHA during their admission were not included.

and GPs felt that both criteria were satisfied (12% (n=17) and 7% (n=10) respectively). Neither box was ticked by the GP in 3% (n=4) of cases. The Consultant and GP opinion as to the reason for admission differed in 37% (n=41) of individual cases. In relation to primary diagnosis, there was a significantly higher frequency of substance misuse related illness (38% (n=12) v 4% (n=5); Fisher’s exact test p<0.0001) and personality disorder (9% (n=3) v 0% (n=0); Fisher’s exact test p=0.0061), and a lower frequency of schizophreniform illness (19% (n=6) v 53% (n=74); x2 = 12.43; p=0.0004) in those who were not detained compared to those patients where an admission order was completed. There was no significant difference between the groups in relation to all other primary diagnoses.

All statistical calculations were performed using Graph Pad Prism version 4.0 for windows (Graph Pad Software, San Diego, CA, USA) and student t test (Mann Whitney U test for nonparametric data) or Chi square test/Fisher’s exact test were used as appropriate to identify significant differences between groups.

Results

Similar proportions of those with a primary diagnosis of substance abuse were actually reported to have a dual diagnosis (20% (n=1) of those detained v 25% (n=3) of those not detained). 60% (n=3) of those admitted as involuntary patients despite a primary diagnosis of substance abuse had a secondary psychotic illness and 20% (n=1) had a secondary depressive illness. One person (0.8%) from the group of patients with a primary diagnosis of substance abuse who were not detained had a secondary psychiatric illness (alcohol dementia). Of note, the Mental Health Act 2001 does not permit detention as an involuntary patient based on a diagnosis of substance dependence or personality disorder.

During the 22 month study period, 171 patients presented to the unit with an application and recommendation for involuntary admission completed. 81% (n=139) of these patients were detained under the MHA following the completion of an admission order. Comparison of details of those who were detained to available national statistics and secondly, to those who were not detained, is presented in Table 1 and Table 2, respectively. Almost three quarters of those patients who presented for assessment for involuntary detention did so outside of regular working hours with 29% (n=50) presenting between 9am and 5pm, Monday to Friday.

In addition, those who were detained were less likely to be using substances at the time of presentation than those who were not detained (25% (n=35) v 44% (n=14); x2 = 4.39; p=0.0362).

In 29% (n=50) of presentations, the patient was brought to the approved centre by the gardai without an assisted admission team or relatives. This occurred significantly more often in those patients where an admission order was not subsequently completed than in those patients who were subsequently detained under the MHA, 50% (n=16) and 24% (n=34) respectively (xx 2 = 8.20 ; p=0.0042)

The final part of the study examined the outcomes of the group of patients who were not detained (Table 4). 6% (n=2) of those who presented with MHA forms but who were not initially detained were admitted or regraded as involuntary patients within a week of presentation.

Discussion

For the group of patients where an admission order was not completed, there was a significantly higher number of applications made by a garda compared to the group where an admission order was completed (31% (n=10) v 12% (n=16); x2 = 7.86; p=0.0051).

This study sought to explore how Part 2 of the MHA 2001 was operating in a busy, acute psychiatric service. The importance of striking a balance between ensuring that those patients who have an acute psychiatric illness and are at risk, receive appropriate treatment, and avoiding unnecessary infringements of a person’s liberty is of critical importance in a modern mental health service. Recent research examining the attitudes of psychiatrists2,3 and service users4 with regards to involuntary admission under the MHA 2001 suggests that, though significant concerns remain among psychiatrists regarding multiple aspects of implementation of the Act, service users reflected positively on their involuntary admission.

Of all patients presenting with MHA forms during this time, 56% (n=95) had their medical recommendation made by their own General Practitioner. This includes 60% (n=84) of those who were detained and only 34% (n=11) of those who were not detained. The difference was statistically significant (xx2 = 7.15; p=0.0075). There was a significant difference between General Practitioners and Consultant Psychiatrists in relation to the criteria used for recommendation or admission (Table 3). In relation to those patients who were detained under MHA, 40% (n=56) of general practitioners considered the patient to be a risk to self or others but only 20% (n=28) of consultant psychiatrists thought so (xx 2 = 12.52; p=0.0004). Consultant Psychiatrists used criterion (b) alone (risk of serious deterioration etc.) in 68% (n=95) of completed admission orders, which was a significantly higher rate than the 50% (n=70) of cases for GPs (xx2 = 8.57; p=0.0034). There was no difference in the number of times in which consultant psychiatrists

The vast majority of patients presenting for admission under the MHA are presenting outside of normal working hours; in just over half of all cases (56%), the medical recommendation is made by the patient’s own general practitioner and in approximately one third of cases the admission order is completed by the patient’s sector consultant. This may simply reflect the emergency nature of MHA admissions but the involvement of professionals who are

17


most familiar with patients potentially requiring detention under the MHA is to be preferred. There may be scope to plan MHA assessments so that a patient’s own GP and Consultant Psychiatrist are involved in these decisions but this is obviously not always possible.

to them. These people tended not to require detention under the Act, and though these situations may be difficult to avoid, especially where the person is unknown to the service, every effort should be made by those making the application and recommendation to gain collateral from someone known to the patient so that any unnecessary referrals for involuntary admission could be avoided if possible.

Approximately four out of every five patients presenting for admission under the MHA had an admission order completed and seventy five per cent of those patients where an admission order was not completed were admitted to hospital either as a voluntary psychiatric admission or to a general hospital ward. The latter figure highlights the importance of always considering an organic cause to a psychiatric presentation. Overall, only 4% of those presenting for admission under the MHA did not require inpatient treatment, indicating that the vast majority of patients presenting in these circumstances warranted referral to hospital.

This also emphasises the importance of appropriate training of those commonly involved in the process of involuntary admission and in particular, that it is essential to provide feedback to those parties where an inappropriate application is made. This is often overlooked in a busy service and it is frequently difficult to contact those who may have been involved in the emergency situation. There may be a role for introducing standard procedures whereby feedback should be carried out automatically by the team, for example, within a week to discuss the case and why the person did not require involuntary admission, where an application and recommendation have been made but the patient is not detained. This would hopefully reduce the frequency of such instances and improve communication between parties involved.

The demographic characteristics and diagnoses of patients in this study were mainly similar to those of patients included in the Mental Health Commission’s review of the MHA, though the study group had a higher proportion of patients with a diagnosis of schizophrenia. 22% (n=332) of those in the national statistics did not have a diagnosis recorded however and it is likely that at least some of these would have had a diagnosis of a schizophreniform illness. Rates for schizophreniform and affective illnesses were similar to recent studies in other centres.5

The legal criteria for making a medical recommendation for involuntary admission by a general practitioner or an admission order by a consultant psychiatrist are detailed on the relevant forms 5 and 6 respectively. The general practitioner or consultant psychiatrist must be satisfied that the patient is suffering from a mental disorder and that criterion (a), criterion (b) or both criteria (a) and (b) are satisfied. Criterion (a) refers to “a serious likelihood of the person concerned causing immediate and serious harm” to self or others and criterion (b) refers to the person’s impaired judgement and that failure to admit the person “would be likely to lead to a serious deterioration” in their condition or “prevent the administration of appropriate treatment that could be given only by such admission” and that this “would be likely to benefit or alleviate the condition of that person to a material extent”. Of note, recommendation and admission order forms originally only permitted a choice of either (a) or (b). The forms were revised, however, midway through the study in December 2007 following a court case, to add the possibility of both (a) and (b) applying.

Those patients who were not detained were more likely to have a primary diagnosis of substance abuse related disorder or personality disorder and of course both personality disorder and alcohol or drug dependence are specifically excluded as conditions where admission under MHA 2001 is allowed. This is an interesting finding, highlighting the fact that general practitioners continue to recommend involuntary admission for those with a diagnosis of substance dependence despite the rules of the Act. It raises the issue as to whether forms which report substance dependence as the reason for admission should be automatically considered invalid if no other diagnosis is specified and rewritten if necessary. It appears that currently, the process tends to continue regardless of the reported illness mentioned on the application and recommendation forms.

In almost two thirds of cases there was agreement between the Consultant Psychiatrist and General Practitioner as to the reason for involuntary admission. However, General Practitioners seemed to have a significantly lower threshold for believing that the patient was a risk to themselves or others. This is not surprising given that Consultant Psychiatrists should be the most qualified to make an accurate assessment of risk. Also, it is much more appropriate that there is a tendency of general practitioners to over, rather than under estimate risk. Disagreements as to the reason for detention may be explained by the fact that the patient may have improved with treatment by the time they were assessed by the Consultant. Another explanation may be that General Practitioners may have a different understanding or interpretation of the term “serious and immediate risk” compared to Consultants.

One concern from the findings in relation to substance dependence might be that patients with a dual diagnosis who need admission may be prevented from being admitted as involuntary patients due to the stipulations in the Act. This however is unlikely to have been the case here as most (66%; n=8) of those with a diagnosis of substance abuse who were not detained had no other psychiatric illness recorded and none of this group has required involuntary admission since that presentation.

Patients who were not subsequently detained were more likely to have had an application made by a Garda and a medical recommendation made by a general practitioner who was not known to them. This group of patients were more likely to have been conveyed to the approved centre by the gardai and to have no past psychiatric history. These findings draw attention to the particular group of patients presenting for involuntary admission in emergency situations without the input of someone who is known

A limitation of the study is that the number of people in the group who were not detained is small relative to the group who were detained. In addition, the group examined were from one catchment area and may not be representative of other services. 18


Most figures, however, are consistent with national statistics and therefore the profile of patients in other similar services would not be expected to differ greatly. The main strength of the study is that it provides a comprehensive profile of those all those presenting to an approved centre under the MHA 2001 over a substantial period of time, identifying a number of key areas of interest.

Conflict of interest

Conclusion

None.

occurs. Involuntary admissions most frequently occur in the context of emergency situations, however, it is clear that every effort should be made to involve people known to the patient in each step of the process where possible.

This study examines every case where a patient was brought to a busy acute unit for involuntary admission over a substantial time period. Over 70% of those presenting did so outside of normal working hours highlighting the emergency nature of acute psychiatry. Application and recommendation for involuntary admission is a serious process which impacts on a patient’s freedom and should only occur in the best interests of the patient. It is particularly important to examine cases where the patient is not subsequently detained. Reassuringly, out of all of those presenting for involuntary admission, only 4% did not require any form of admission to hospital. Similar to recent research in this area,5 the findings of this study suggest a need for further education for those involved in the process of application and recommendation, in particular for the Gardai and General Practitioners, and feedback where an inappropriate presentation for involuntary admission

References 1. Mental Health Commission. Report on the operation of part 2 of the Mental Health Act 2001(April 2008) available at http://www.mhcirl.ie/Publications 2. O’Donoghue B., Moran B. Consultant psychiatrists’ experiences and attitudes following the introduction of the Mental Health Act 2001: a national survey. Ir J Psych Med 2009 Mar; 26(1): 23, 24-6 3. Jabbar F., Kelly BD., Casey P. National survey of psychiatrists’ responses to implementation of the Mental Health Act 2001 in Ireland. Ir J Med Sci 2010; 179: 291-294 4. O’ Donoghue B., Lyne J., Hill M., Larkin C., Feeney L., O’Callaghan E. Involuntary admission from the patients’ perspective. Soc Psychiat Epidemiol 2010; 45:631-638 5. Rafiq A., O’Hanlon M. An audit of incomplete involuntary admissions to an approved Irish centre. Ir J Psych Med 2010 Sep; 27(3): 143-147

Table 1: Comparison of study patients who were detained and the national statistics. Detained

X2/Fisher’s Exact Test

OR 95% CI

n

%

National Figures1 n %

Gender Male Female

80 59

58 42

831 632

55 45

0.26;p=0.61

1.10; 0.77 to 1.56

Age 18-64 65+

114 25

82 18

1251 252

83 17

0.13;p=0.71

0.92: 0.58 to 1.45

Schizophreniform illness

74

53

585

39

10.85;p=0.001*

1.79; 1.26 to 2.53

Mania

37

27

313

21

2.55;p=0.11

1.38; 0.93 to 2.05

Depression

8

6

84

6

0.0007;p=0.93

1.03; 0.49 to 2.18

Organic

13

9

84

6

3.24;p=0.07

1.74; 0.95 to 3.21

Substance related

5

4

57

4

0.01;p=0.92

0.95; 0.38 to 2.42

Personality

0

0

9

1

p=1.00

0.56; 0.03 to 9.75

Neurosis

2

1

22

1

p=1.00

0.98; 0.23 to 4.23

No Mental Illness

0

0

0

0

N/A

N/A

Relative

108

78

1034

69

4.76;p=0.03*

1.58; 1.04 to 2.39

Authorised Officer

4

1

102

7

p=0.07

0.41; 0.15 to 1.12

Member of Public

11

8

132

9

0.12;p=0.73

0.89; 0.47 to 1.70

Gardai

16

12

235

15

1.67;p=0.20

0.70; 0.41 to 1.20

Diagnosis

Applicant

Note: National figures relate to patients detained using Form 6 nationally in 2007. *statistically significant difference

19


Table 2: Comparison of study patients who were detained to those not detained

Detained (n=139)

Not detained (n=32)

t, U or Χ2;p value*

n

%

n

%

Gender Male Female

80 59

58 42

16 16

50 50

0.60; 0.44

Age 18-64 65+

114 25

82 18

26 6

81 19

2119; 0.64

Schizophreniform illness

74

53

6

19

12.43; 0.0004*

Mania

37

27

5

16

1.70; 0.19

Depression

8

6

2

6

1.00

Organic

13

9

3

9

1.00

Substance related

5

4

12

38

< 0.0001*

Personality

0

0

3

9

0.01

Neurosis

2

1

0

0

1.00

No Mental Illness

0

0

1

3

0.19

History of mental illness

122

88

17

53

Known to service

112

81

14

44

On Call Presentation

96

69

26

81

22.45; < 0.0001* 18.24; < 0.0001* 1.89; 0.17

Relative

108

78

20

63

Authorised Officer

4

1

0

0

3.19; 0.07 1.00

Member of Public

11

8

2

6

1.00

Gardai

16

12

10

31

7.86; 0.0051*

Family/Nursing home

53

38

10

31

N/A

0.53; 0.47

Gardai only

34

24

16

50

N/A

Assisted admission

37

27

4

13

N/A

8.20; 0.0042* 0.11

Ambulance

8

6

2

6

N/A

1.00

Transfer from another ward

7

5

0

0

N/A

0.35

Recommendation by own GP Assessed by sector consultant Collateral Available

84

60

11

34

N/A

52

37

11

34

N/A

7.15 0.0075* 0.10; 0.75

112

81

29

91

N/A

0.21

Current Substance Use

35

25

14

44

N/A

English speaking

137

99

30

94

N/A

4.39; 0.0362* 0.16

OR 95% CI 1.36 0.63 to 2.93

Diagnosis 4.9 1.91 to 12.74 1.96 0.70 to 5.47 0.92 0.19 to 4.54 0.99 0.27 to 3.73 0.062 0.02 to 0.20 0.03 0.0015 to 0.60 1.18 0.06 to 25.23 0.08 0.00 to 1.89 7.06 2.93 to 16.98 0.19 0.08 to 0.42 0.52 0.20 to 1.35

Applicant 2.09 0.92 to 4.75 2.09 0.11 to 39.90 1.25 0.26 to 5.93 0.29 0.12 to 0.71

Arrival

* statistically significant difference

20

1.36 0.60 to 3.09 0.32 0.15 to 0.72 2.54 0.83 to 7.73 0.92 0.19 to 4.54 3.68 0.20 to 66.14 2.92 1.30 to 6.52 1.14 0.51 to 2.56 0.43 0.12 to 1.51 0.43 0.20 to 0.96 4.57 0.62 to 33.74


Table 3. Criteria used for recommendation and admission

Criteria for admission

General Practitioner n %

Consultant Psychiatrist n %

(a) (b) (a) and (b) Neither

56 70 10 4

28 95 17 0

40 50 7 3

Statistic Χ2 =12.52;p=0.0004* Χ2 = 8.57;p=0.0034* Χ2 =2.01;p=0.1563 Fisher’s exact test; p=0.1223

20 68 12 0

(a)=Risk of immediate and serious harm to self or others. (b)=Risk of serious deterioration etc. *statistically significant difference

Table 4. Outcome where admission order was not signed

n

%

Voluntary admission

22

69

Discharge

8

25

Other admission (e.g. medical)

2

6

Involuntary admission within one week

2

6

Note: those who were admitted as involuntary patients within one week are also included in the numbers of patients admitted voluntarily, discharged or admitted medically.

21


Original Paper

Mental illness among the homeless: prevalence study in a Dublin homeless hostel Bernice Prinsloo, Catherine Parr, Joanne Fenton Ir J Psych Med 2012; 29 (1): 22-26

Objective: To determine the prevalence of mental illness among the residents of a homeless hostel in inner city Dublin.

Introduction PREVALENCE OF MENTAL ILLNESS AMONG THE HOMELESS

Method: A cross-sectional survey was carried out among hostel residents, as previous studies have indicated that homeless hosteldwelling men in Dublin constitute the largest single grouping of homeless Irish people. All agreeable residents were interviewed by the authors over an eight-week period using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) Clinical Version. For each disorder, the current (30-day) and past prevalence was determined.

Studies have consistently demonstrated high rates of mental disorders among people who are homeless.1 The rates of psychiatric morbidity among homeless adults will vary according to the type of homelessness: sleeping rough, using a night shelter, staying in special hostels, and using temporary leased accommodation.2 International comparisons also demonstrated significant cross-cultural differences in the prevalence of mental disorders among the homeless.1

Results: A total of 38 residents were interviewed, resulting in a response rate of 39.2% for the study. A total of 81.6% of residents had a current Axis I diagnosis; this number increased to 89.5% when combining current and past diagnoses. Only four residents had no diagnosis. There was considerable comorbidity between disorders, with a significant number of residents experiencing both mental illness and substance use problems. When considering lifetime diagnoses, 31.6% had a single diagnosis only; 57.9% had two/more diagnoses. Twelve residents (31.6%) had been admitted to a psychiatric hospital during their lifetime. The most prevalent disorders during the past month were Alcohol Dependence (23.7%), Opioid Dependence and Major Depressive Disorder (both 18.4%), Opioid Abuse and Alcohol-Induced Depression (both 7.9%). Only 23.7% of interviewed residents were attending psychiatric or addiction services. A significant number of residents who did not wish to participate in the study were identified by hostel staff as having a confirmed psychiatric diagnosis.

In an Australian study 73% of homeless men and 81% of homeless women in inner Sydney met criteria for at least one mental disorder in the past year and 40% of the men and 50% of the women had at least two mental disorders.1 Among the homeless population in Utrecht, The Netherlands, 32% of people had depression, 15% a schizophrenic disorder and 52% an antisocial personality disorder.3 In Madrid, Spain, 67% of homeless people had some type of mental disorder.4 In Stockholm, Sweden, 47% of the homeless suffered from mental illness.5 A survey in Belfast indicated that approximately 25% of the homeless in Belfast hostels have a diagnosed mental disorder.6 The most prominent mental disorders among the homeless are depression, affective disorders, substance abuse, psychotic disorders, schizophrenia, and personality disorders.7 Significant numbers of homeless people experience the coexistence of mental health issues and substance use problems (dual diagnosis).8

Conclusion: The survey demonstrated a very high prevalence of mental disorders among homeless hostel residents. The high prevalence of dual diagnosis highlights the need for greater collaboration between psychiatric services and addiction services. The outcome also points to the importance of providing mental health training to emergency shelter/hostel staff. Research into the mental health status of the homeless should be undertaken regularly if services are to be planned to meet the needs of this vulnerable group.

THE RELATIONSHIP BETWEEN HOMELESSNESS AND MENTAL ILLNESS The causal link between homelessness and mental ill-health is the subject of an ongoing debate. Some argue that the psychiatric problems of many of the homeless may result directly from their poverty and associated lack of accommodation. Others contend that the majority first experienced their symptoms of mental disorder before becoming homeless.2

Key words: Homeless, Hostel, Mental illness, Dual diagnosis *Bernice Prinsloo, Registrar, Child & Adolescent Psychiatry, Our Ladyâ&#x20AC;&#x2122;s Childrenâ&#x20AC;&#x2122;s Hospital, Crumlin, Dublin 12, Ireland. E-mail bernice.prinsloo@yahoo.com

* Correspondence

Catherine Parr, Registrar in Psychiatry, James Connolly Memorial Hospital, Blanchardstown, Dublin 15, Ireland. Joanne Fenton, Consultant Psychiatrist, ACCES Team, Dublin 8, Ireland.

22

Submitted December 15th 2010 Accepted March 21st 2011


According to Dr Joe Fernandez, former Director of the Programme for the Homeless in St Brendan’s Hospital in Dublin, a distinction must be drawn between “mental health problems” induced by homelessness, and “mental illness” which may be a factor in becoming or remaining homeless; both of which should be attended to by primary care agents i.e. general practitioners, or by the mental health services.9 Research suggests that the experience of being homeless may contribute to anxiety or depressive illnesses.10 On the other hand, a significant factor in precipitating homelessness is serious mental illness, and alcohol or drug addiction. It is also accepted that homelessness may exacerbate a previous existing mental condition.11

alcohol dependent, with 29% having severe alcohol dependence. More than one third of respondents reported having engaged in illicit use of at least one drug in the previous year.10 O’Neill et al conducted an audit in 2003 to determine the proportion of those attending the Mater Misericordiae Hospital’s psychiatric service that were homeless, including those presenting to accident and emergency who were homeless. Of all the A&E referrals to psychiatry, 34.8% were homeless. The homeless presented most commonly in suicidal crisis (26.6%) compared with 12.5% in the non-homeless group. Substance-abuse disorders were the primary diagnosis in 42.3% of the homeless group, accounting for 14.2% in the housed sample.18

CONSEQUENCES Considerable difficulty arises for homeless people in accessing mental health care due to the sectorisation of services into catchment areas.13 In Dublin this has resulted in increased pressure on the two assertive community mental health teams providing service to the homeless population, based in North Dublin and South Dublin respectively.

Homelessness amongst the mentally ill is associated with a range of other factors, including substance abuse, younger age at first hospitalisation, and greater severity of symptoms compared to individuals with mental illness who are not homeless.12 Many homeless people with a dual diagnosis of mental illness and drug or alcohol misuse find themselves without a service, since existing services consider themselves to be either psychiatric services or addiction services, with poorly defined collaborative functions.13

The burden resulting from the gaps in statutory service provision for homeless people with, or at risk of mental illness, falls on voluntary homeless service providers and on the wider health and social services, all of which are already under enormous strain. The consequences impact severely on the quality of life for homeless people with mental illness. The Simon Communities of Ireland, a voluntary homeless agency has said: “[we] are extremely concerned at the increase … witnessed in the numbers of people who are homeless who are presenting with mental ill health. The lack of access to assessment and treatment services by people who are homeless further exacerbates the problem – leaving individuals very vulnerable, and homeless services struggling to ensure they meet service users’ needs.”13

The homeless mentally ill also appear to encounter a range of specific, additional problems in relation to housing including, for example, difficulties accessing community care services following discharge from hospital.14 A Crisis survey performed in 2002 found that the homeless people interviewed were almost 40 times more likely not to be registered with a GP than the average person. Poor access to primary care services has a direct impact on other health care services, with an increased likelihood of people attending A&E.15 Social integration and participation, as well as employment and meaningful life activities are compromised by the presence of persistent and untreated psychiatric and physical health problems for individuals who are homeless. The ability to take steps forward may be limited due to a combination of poor life skills, ongoing mental health issues and/or substance use problems, as well as disruptive life events (lack of stable residence, lack of regular income, victimisation related to street life).15 Individuals with mental illness also tend to encounter substantial problems adapting to housing following lengthy periods of homelessness and many of these problems go on to complicate their broader re-integration into society.16

In A Vision for Change several recommendations were made in relation to mental health services for homeless individuals.19 There is however still a long way to go towards implementing this policy in the context of homelessness.

Objective The objective of the study was to determine the prevalence of mental illness among the residents of an emergency hostel located in inner city Dublin. The hostel provides direct access, emergency and short term accommodation for 74 single homeless men aged over 26. The hostel is managed in partnership by Depaul Trust and SVP.20 Previous studies have indicated that homeless hosteldwelling men in Dublin constitute the largest single grouping of homeless Irish people.10

HOMELESSNESS AND MENTAL ILLNESS IN IRELAND Holohan conducted the first study to examine the health of the adult homeless population in Dublin in 1997. Sixty six per cent of people had at least one physical or psychiatric problem. Chronic physical disease was reported by 41%. The prevalence of depression in this study was 32.5% and for anxiety disorders 27.6%.17 In 1999 Feeney et al built on this work and examined the health status and perception of health service access of homeless hostel-dwelling men in Dublin. In this study 52% of men suffered from depression, 50% from anxiety and 4% from other mental health problems. Fifty percent of hostel residents were defined as

Method A cross-sectional survey was carried out among hostel residents. Posters were placed on a public notice board at the hostel inviting residents to participate in the study; they were asked to inform their key workers should they wish to participate. All agreeable residents were then interviewed at the hostel by the authors over an eight-week period from June to August 2010. All participants

23


were given â&#x201A;Ź10 as an incentive; this was provided on completion of each interview. This procedure has been used in other studies to maximise response rates.10 Residents were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) Clinical Version. For each disorder, the 30-day (current) and past prevalence was determined. The interviewers were psychiatrically trained and familiar with the DSM-IV diagnoses. Inter-rater reliability was determined between the interviewers.

Results A total of 38 residents were interviewed. During the study period 128 men used beds at the hostel; of these 31 were emergency bed users, simply occupying rooms with no key worker input. Not taking these 31 men into account, a response rate of 39.2% was achieved for the study. Characteristics of participating residents are displayed in Table 1, with SCID-CV Diagnoses summarised in Table 2.

Table 1. Demographic profile of study participants

Table 2. Prevalence of DSM-IV Axis I Disorders among hostel residents Current* n (%) Mood Disorders Bipolar I Disorder, Most Recent Episode Mixed Bipolar II Disorder, Hypomanic Major Depressive Disorder Single Episode Recurrent, Moderate Recurrent, In Partial Remission Recurrent, In Full Remission Depressive Disorder NOS Alcohol-Induced Mood Disorder, Depressed Other Substance-Induced Mood Disorder, Depressed

Mean

Substance Use Disorders Alcohol Dependence Alcohol Abuse

9 (23.7) 2 (5.3)

Cannabis Dependence Cocaine Dependence Opioid Dependence Sedative, Hypnotic, or Anxiolytic Dependence Amphetamine Abuse Cannabis Abuse Cocaine Abuse Hallucinogen Abuse Inhalant Abuse Opioid Abuse Phencyclidine Abuse Sedative, Hypnotic, or Anxiolytic Abuse Other (or Unknown) Substance Use

45.87 years

22 (57.9) 4 (10.5) 6 (15.8) 6 (15.8)

Children Yes No

26 (68.4) 12 (31.6)

Educational status Primary level Secondary level without graduating Graduated secondary level Higher qualification

5 (13.2) 28 (73.7) 2 (5.3) 3 (7.9)

Employment Regular Casual/Volunteer work Unemployed

1 (2.6) 2 (5.3) 35 (92.1)

Ethnic origin Irish UK

35 (92.1) 3 (7.9)

1 (2.6) 4 (10.5) 1 (2.6) 1 (2.6) 1 (2.6) 3 (7.9) 2 (5.3)

2 (5.3)

12 (31.6) 18 (47.4) 8 (21.1)

Marital status Never married Married/Cohabiting Separated Divorced

1 (2.6) 1 (2.6)

Schizophrenia and Other Psychotic Disorders Schizophrenia, Paranoid Type

n (%) Age 26-39 40-54 â&#x2030;Ľ55

Anxiety Disorders Panic Disorder With Agoraphobia Posttraumatic Stress Disorder Anxiety Disorder NOS Other Substance-Induced Anxiety Disorder With Generalised Anxiety With Phobic Symptoms Adjustment Disorders Adjustment Disorder With Anxiety

7 (18.4) 1 (2.6) 2 (5.3)

1 (2.6)

1 (2.6) 1 (2.6)

11 (28.9) 3 (7.9) 2 (5.3) 1 (2.6) 1 (2.6) 2 (5.3) 2 (5.3) 4 (10.5) 2 (5.3)

1 (2.6) 3 (7.9) 1 (2.6) 2 (5.3)

1 (2.6) 3 (7.9) 1 (2.6)

1 (2.6) 2 (5.3) 2 (5.3) 1 (2.6) 1 (2.6)

1 (2.6)

*Full criteria have been met during the past month

24

Past n (%)


A total of 81.6% of residents had a current Axis I diagnosis; this number increased to 89.5% for lifetime diagnoses (when combining current and past diagnoses). Only four residents had no diagnosis. When considering lifetime diagnoses, 31.6% had a single diagnosis only; 57.9% had two/more diagnoses. Twelve residents (31.6%) had been admitted to a psychiatric hospital during their lifetime. Sixteen residents (42.1%) had a lifetime diagnosis of any depressive disorder, two residents (5.3%) of a psychotic disorder, 30 residents (78.9%) of any substance use disorder, and 7 residents (18.4%) of an anxiety/adjustment disorder.

The response rate of 39.2% in this study is low compared to other studies.17,21 A possible explanation for this could be that the interviews were conducted over a period of eight weeks, as opposed to some studies where interviews were conducted together within a few days. It is worth noting that reasons for nonparticipation in research may also be related to severe mental illness.21 There was considerable comorbidity between disorders, with a significant number of residents experiencing both mental illness and substance use problems. Both alcohol and substance use disorders were highly prevalent, as has also been found in other studies. A systematic review of the prevalence of mental disorders among the homeless found that alcohol dependence and drug dependence were the most common disorders in this group.21

The most common current and past diagnosis was Alcohol Dependence, with 52.6% of residents meeting the criteria for either current or past dependence. The most prevalent current diagnoses are displayed in Figure 1.

Combining depressive disorders (including those that are alcohol and substance-induced) results in a current prevalence of 34.2%. This is similar to the rate found in a previous study examining the health of the adult homeless population in Dublin; in that study 32.5% of homeless individuals reported depression.17 The current prevalence of anxiety disorders was 10.5%, which is much lower than the rate of 27.6% in the previous study.17 This low rate is surprising as many men have been exposed to trauma and violence. A possible explanation for this could be stricter diagnostic criteria used in this study.

! ! ! ! ! ! ! !

Of note only 5.3% of the sample were identified as having a psychotic disorder, which is lower than expected compared to some other studies.1,3,22 The prevalence would increase slightly if one were to take into account those mentioned residents who did not want to participate in the study. The systematic review previously mentioned found that the prevalence rates for psychotic illness among the homeless in western countries ranged from 2.8% to 42.3%. The review found that lower participation in surveys was associated with lower prevalence of psychosis.21

!

! !

!

!"#$%&''()''*+,-''.%&/01&2-''34",''5''6",+%7&%,''7$%"2#''-8&''.0,-''9+2-8!!

Figure 1. Most prevalent Axis I Disorders during the past month Only 23.7% of interviewed residents were attending an outpatient department (either psychiatric or addiction services); in addition one resident was attending a counsellor and one was attending AA. The majority were not linked in with any service.

The low number of residents attending services is cause for concern. There could be various reasons for this, including the differentiation between psychiatric and addiction services, sectorisation of services into catchment areas, stigma of psychiatric care, and shelter/hostel staff having limited experience in assessing for or managing mental illness or addiction. In addition both physical and psychiatric care rank low in homeless people’s list of priorities. The demands of securing immediate needs for survival – food, shelter, money – are more pressing than appointments with doctors or nurses.23

The Specialist Support Worker at the hostel was able to provide some information on the 59 hostel residents who did not wish to participate in the study. Of these men, 14 (23.7%) had evidence of mental illness. Six of these residents reportedly had a diagnosis of Schizophrenia; five of them were linked in with psychiatric services. An additional eight residents suffered from Depression (one of them having a diagnosis of Bipolar Affective Disorder); of these six were under the care of their GP, one was linked in with psychiatric services and the resident with Bipolar Affective Disorder had been refusing intervention in recent years. Another resident had no clear diagnosis but had previously been admitted to a psychiatric hospital.

A relatively small sample of residents were interviewed and the study only focused on one particular group of homeless men, thus limiting generalisability. The Specialist Mental Health Worker actively encouraged those men with mental health problems to attend for interview, possibly introducing selection bias. The study was unique though in that, to the best of the authors’ knowledge, it was the first study in Ireland assessing the complete spectrum of Axis I Disorders; previous studies focused primarily on depression and anxiety disorders.10,17 Interviews were conducted by psychiatrically trained raters using a well validated measure.

Discussion The survey demonstrated a very high prevalence of mental disorders among homeless hostel residents. Comparing prevalence rates with other cities and countries is difficult though due to different definitions used for homelessness, differing diagnostic criteria/interview techniques and different timeframes used (e.g. lifetime/12-month/30-day prevalence).

25


Conclusion

14. Melzer D, Hale AS, Malik SJ et al. Community care for patients with schizophrenia one year after hospital discharge. BMJ 1991; 303: 1023-1026. 15. Critical Condition: Vulnerable single homeless people and access to GPs. Crisis UK, London, 2002. 16. Yanos PT, Barrow SM, Tsemberis S. Community integration in the early phase of housing among homeless persons diagnosed with severe mental illness. Community Ment Health J 2004; 40: 133-15. 17. Holohan TW. Health and Homelessness in Dublin. Ir Med J 2000; 93: 41-43. 18. O’Neill A, Casey P, Minton R. The homeless mentally ill: an audit from an inner city hospital. Ir J Psychol Med 2007; 24: 62-66. 19. Expert Group on Mental Health Policy. A Vision for Change: Report of the Expert Group on Mental Health Policy. Dublin: The Stationery Office, 2006. 20. Homelessness Directory 2007/2008. Suffolk: Homeless Agency and Resource Information Centre, 2006: 10. 21. Fazel S, Khosia V, Doll H, Geddes J. The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis. PLoS Medicine 2008; 5(12): 1670-1681. 22. Shanks NJ, Priest RG, Bedford A, Garbett S. Use of the delusions-symptomsstate inventory to detect psychiatric symptoms in a sample of homeless men. British Journal of General Practice 1995; 45: 201-203. 23. Timms P, Balázs J. ABC of mental health: Mental health on the margins. British Medical Journal 1997; 315: 536-539. 24. Vamvakas A, Rowe M. Mental health training in emergency homeless shelters. Community Mental Health J 2001; 37(3): 287-95.

The study highlights the need to address mental illness in the homeless population, as it is experienced by so many and may be contributing to maintaining homelessness through sustained unemployment and social isolation. The high prevalence of dual diagnosis highlights the need for greater collaboration between psychiatric and addiction services. The outcome further points to the importance of providing mental health training to emergency shelter/hostel staff. Such training offers the potential to significantly improve staff’s ability to respond to the needs of residents with mental illness, and to the behavioural problems some of these individuals may pose for shelter/hostel operation.24 Research into the mental health status of the homeless should be undertaken regularly if services are to be planned to meet the needs of this vulnerable goup.13

Conflict of interest None.

Acknowledgement We would like to thank the following people for their assistance: • Ms Sharon Harvey, Specialist Support Worker • Ms Margaret Freeney, Administrative Assistant • Dr Some Onuoha, Locum Consultant Psychiatrist

References 1. Teesson M, Hodder T, Buhrich N. Psychiatric disorders in homeless men and women in inner Sydney. Australian and New Zealand Journal of Psychiatry 2004; 38: 162-168. 2. Meltzer H. State-of-Science Review: SR-B6 The Mental Ill-Health of Homeless People. Foresight Mental Capital and Wellbeing Project. The Government Office for Sciences, 2008: 1-8. 3. Reinking DP, Wolf JR, Kroon H. High prevalence of mental disorders and addiction problems among the homeless in Utrecht. Ned Tijdschr Geneeskd. 2001; 145(24): 1161-6. 4. Vázquez C, Muñoz M, Sanz J. Lifetime and 12-month prevalence of DSM-IIIR mental disorders among the homeless in Madrid: a European study using the CIDI. Acta Psychiatr Scand. 1997; 95(6): 523-30. 5. Halldin J, Eklöv L, Lundberg C, Åhs S. Mental health problems among homeless people in Sweden: focus on Stockholm. International Journal of Mental Health 2001; 3: 74-83. 6. McAuley A, McKenna HP. Mental disorders among a homeless population in Belfast: an exploratory survey. Journal of Psychiatric and Mental Health Nursing 2008; 2(6): 335-342. 7. Martens WH. A review of physical and mental health in homeless persons. Public Health Rev. 2001; 29(1): 13-33. 8. Holohan T. Health Status, Health Service Utilisation and Barriers to Health Service Utilisation among the Adult Homeless Population of Dublin. Dublin: Eastern Health Board, 1997. 9. Fernandez J. Caring for the Homeless Mentally Ill: Status and Directions. Seminar presentation for the Irish Psychiatric Association at St Patrick’s Hospital, April 2003. 10. Feeney A, McGee HM, Holohan T, Shannon W. Health of Hostel-dwelling Men in Dublin. ERHA & RCSI 2000. 11. Barry S. The Homeless Mentally Ill – discussion document, Apendix A, Cluain Mhuire Adult Mental Health Service Proposal: The Homeless Mentally Ill. Dublin, 2002. 12. Opler LA, White L, Caton CL et al. Gender differences in the relationship of homelessness to symptom severity, substance abuse, and neuroleptic compliance in schizophrenia. J Nerv Ment Dis 2001; 189: 449-556. 13. Crowley F. Mental Illness: The Neglected Quarter – Homelessness. Amnesty International (Irish Section), Dublin, 2003.

26


Original Paper

Preferences of dress and address: views of attendees and mental health professionals of the psychiatric services Christina Sim, Brian Hallahan, Colm McDonald

Ir J Psych Med 2012; 29 (1): 27-32

also demonstrated that attendees preferences in relation to both “dress and address” of doctors is significantly different to their preference for nurses or other allied mental health professionals; which may reflect a wish for a less familiar and more formal interaction with doctors.

Abstract Objectives: The aim of this study was to determine the views of both individuals attending the mental health services (attendees) and mental health professionals in relation to how attendees and staff should be addressed, how attendees should be described, and how staff should be attired.

Key words: Dress, Address, Mental health professionals, Psychiatric services

Methods: We surveyed 132 attendees of the West Galway Mental Health Services and 97 mental health professionals in relation to how they prefer to be addressed (first name/ title and surname/ no preference) the description of attendees (patient / client / service user / no preference) and the attire of mental health staff (casual / smart / no preference). We also ascertained how mental health professionals believed attendees would view these issues.

Introduction A positive therapeutic relationship between mental health professionals and individuals attending mental health services (attendees) is a fundamental component of care in psychiatry,1, 2 having important implications for an attendee’s clinical management and future prognosis.3-5 The interaction between attendee and mental health professional incorporates many important aspects, a number of which we analyse in this study. These include individual preferences as to how attendees are referred to by mental health staff (patient/ client/ service user); how attendees are addressed by mental health staff (first name/ title and surname); how attendees wish to address mental health staff (first name/ title and surname); and how attendees prefer mental health staff to be attired.

Results: Attendees preferred to be described as patients rather than clients or service users by all mental health professionals, with 46-54% of attendees preferring this term “patient” compared to 14-17% preferring the term “client”, 11-13% preferring the term “service user” and 20-25% having no preference (p < 0.001). They preferred to address doctors by their title and surname (61%) but other mental health professionals by their first names (60-69%) (p < 0.001). Attendees had a strong preference for being addressed by their first names by all the mental health professionals (86-91%) (p < 0.001). Doctors preferred to be attired formally (88%), compared to nurses (50%) or other mental health professionals (42%) (p = 0.002). Attendees had no preference in relation to the attire of doctors but preferred other mental health professionals to be attired informally.

In recent years, there has been pressure from some stakeholders to avoid using the term “patient” for attendees with the terms “client” and “service user” in particular often utilised to describe individuals who attend mental health services.6-10 The first of these “non-medical” terms that became utilised was “client”, which appears to have been adopted from Carl Rogers’ book in 1951, “Client-Centred Therapy”. Since the 1970s “client” became increasingly utilised to describe attendees of psychiatric services,11, 13 and appears to have arisen as “patient” had become associated with negative connotations of sickness, paternalism, authoritarianism, disability, dependence and powerlessness and considered by some as outdated, patronising and stigmatising to individuals with mental illness.12, 14 Thus the term “patient” has been disparaged as the product of a narrow reductionist medical

Conclusions: The study demonstrates that despite the increased use of several non-medical terms to describe attendees of mental health services; the preferred term of attendees of the psychiatric services in both in-patient and out-patient settings remains ‘patient’. However, this is not universally the case, and the ascertainment of the preference of the attendee at the first encounter with the health professional should be ascertained. We

Christina Sim, Registrar in Psychiatry, Department of Psychiatry, University College Hospital Galway, Ireland.

*Brian Hallahan, Consultant Psychiatrist, Department of Psychiatry, Roscommon County Hospital, Co. Roscommon, Ireland and Honorary Research Fellow, Clinical Science Institute, National University of Ireland, Galway, Co Galway, Ireland. E-mail brian.hallahan@nuigalway.ie Colm McDonald, Professor of Psychiatry, Department of Psychiatry, Clinical Science Institute, National University of Ireland, Galway, Co. Galway, Ireland.

* Correspondence

27

Submitted 15th October 2010 Accepted 15th February 2011


model of medical illness, which fails to appreciate the individual attendee’s mental health problems in the context of their personal narrative and psychosocial environment. The term “client” was viewed as de-medicalising the interaction between attendee and medical professionals. Despite this, a number of recent studies have found that the majority of individuals attending psychiatric services (67% to 83%) still prefer to be referred to as “patients”,2, 15-17 although one large multi-site study noted “client” to be the term of preference.18

in the questionnaires anonymously and handed them to a staff nurse. If they had any queries in relation to any questions, they were able to approach a staff nurse for clarification. At the end of the study period, a staff nurse at each location posted the completed anonymous questionnaires to the researcher (CS). For each attendee, we obtained data in relation to the age, gender and diagnosis, which were corroborated by their treating clinician. Data was analysed blind to attendee’s personal details. Attendees during the above time period completed a one page questionnaire detailing:

In relation to addressing attendees, a number of studies have noted that most attendees (50-79%) of the psychiatric service prefer to be addressed by their first name,2, 19, 20 although this issue has predominantly assessed attendees’ wishes only in relation to how doctors address them. It has previously been noted that attendee’s prefer to address doctors (80-95%) by their title and surname,1, 2, 20 but address allied mental health professionals (e.g. nurses, social workers, occupational therapists) by their first names.1, 2 Little information is available to date detailing how the seniority of the treating clinician may impact on how attendees wish to address their treating doctor.

1) How they preferred to be described by mental health professionals treating them (patient / client / service user / no preference). 2) How they preferred mental health professionals to address them (first name/ title and surname/ no preference). 3) What they preferred to call mental health professionals (first name/ title and surname/ no preference). 4) How they believed mental health professionals should be attired (casual/ smart/ no preference). The response rate of the attendees was 97%, with all day hospital attendees, and all individuals attending the sub-acute services completing the questionnaires, however four attendees of the acute in-patient unit refused to fill in the questionnaire.

Conflicting data has been attained to date in relation to the preference of attendees regarding doctors’ attire. A number of studies have noted that smart (formal) attire by the treating clinician is associated with increased trust and perceived competence by the attendee leading to an increased ability to discuss their social, sexual and psychological problems,2, 21 however other studies, albeit in other medical disciplines, have not corroborated these findings.22-24 Evidence also exists that the presence of nurse uniforms is associated with perceptions of professionalism,25 although there is limited evidence in relation to psychiatric nursing attire and perceptions of professionalism by attendees or their families.

A number of meetings were held with mental health professionals where the study was explained. Mental health professionals were informed that they could contact one of the researchers (CS or BH) for further clarification in relation to any of the questions. All questionnaires were filled in anonymously and were posted to the researcher (BH). Mental health professionals, including 33 doctors, 52 nurses, four social workers, four psychologists, two occupational therapists, two other mental health team members working in these centres (78 acute, and 19 sub-acute) completed the one page questionnaire detailing:

In this study, we investigated the preference of both attendees and a range of mental health professionals (consultant doctors, nonconsultant hospital doctors (NCHD), psychiatric nurses, occupational therapists, social workers and psychologists) in relation to how they prefer to be addressed (first name/ title and surname/ no preference), how they prefer to describe attendees (patient / client / service user / no preference) and how they prefer mental health staff to be attired (casual / smart / no preference). The views of attendees of both the acute services (acute in-patient and day hospital) and sub-acute services (day centres and long stay residential unit) were ascertained as were mental health professionals’ beliefs about how attendees view these issues.

1) How they wished to describe attendees of the mental health services (patient/ client/ service user/ no preference). 2) What they believed attendees preferred to be described as (patient/ client/ service user/ no preference). 3) How they preferred to be addressed by attendees (first name/ title and surname/ no preference). 4) What they believed attendees prefer to address mental health professionals by (first name/ title and surname/ no preference). 5) How they liked to address attendees (first name/ title and surname/ no preference). 6) What they believed attendees prefer to be addressed as (first name/ title and surname/ no preference). 7) How they believed they should be attired (smart/ casual/ no preference). 8) Have they believed attendees prefer them to be attired (smart (formal) / casual (smart informal)/ no preference). These terms were explained explicitly to staff and attendees.

Methods We included 56 individuals attending the acute psychiatric services, all consecutively admitted individuals in the acute in-patient unit in University College Hospital, Galway and the psychiatric day hospital in Galway, between the 17th – 30th May, 2009 and 76 individuals attending the sub-acute services, i.e. 2 day centres and a rehabilitation unit over the same time period. Each attendee was approached by a researcher (CS or BH) at the above sites and the study was explained to them, and consent was attained. They filled

28


Information on their profession, gender and age was also attained. All mental health professionals in the region were invited to complete the questionnaire; however three doctors and 20 nurses did not complete the questionnaire. All allied mental health professionals completed the questionnaire.

Discussion

We used SPSS 15.0 for Windows (SPSS 15.0 for Windows, SPSS Inc, Chicago, Illinois, USA) to analyse all data. We utilised the chi squared test to compare all group data in relation to the dress and address of attendees and mental health professionals.

In this study, we found that the term “patient” remains the predominant preference of attendees of mental health services, including those attending acute and sub-acute services. This corroborates some previous research in other countries,2, 15-17, 26 and suggests that despite the burgeoning use of a variety of other terms in recent years,7-10 attendees themselves continue to prefer the term “patient”. Previously, a UK study noted that attendees of mental health services preferred mental health professionals other than doctors to describe them as “clients” rather than “patients”,2 however we noted no such disparity in attendees views in relation to mental health professionals, and this may reflect a cultural difference in the populations studied. Nevertheless, nurses and allied mental health professionals preferred to use terms such as “client” and “service user” more than doctors, which has been interpreted as indicating a less hierarchical form of interaction and more collaborative type of relationship with attendees.2 Attendees of mental health services span a range of disorders from disabling severe enduring mental illnesses to milder forms of illness where non-medical therapies predominate. The term “client” implies that an attendee is a customer and voluntarily seeks services and is aware of their difficulties or illness.27 Our sample of attendees had a relatively severe level of mental illness with only 10% of individuals not having a significant psychosis or mood disorder, and thus one may postulate that this group with significant psychopathology may be more likely to consider themselves as suffering from a medical disorder and prefer to be regarded as “patients” rather than “clients” or “service users”. Previous research however has not noted an effect of diagnosis and preference of address.18, 26

To our knowledge, this is the first comprehensive study examining the preference of “dress and address” of both attendees and a variety of mental health professionals in the Irish psychiatric service.

Ethical approval was attained prior to the commencement of this study from the Research Ethics Committee of Galway University Hospital.

Results One hundred and thirty-two attendees of the mental health services and 97 mental health professionals participated in this study and their demographic and clinical data are described in Table 1. Attendees had a preference for all mental health professionals to refer to them as “patients” rather than “clients” or “service users”, with 46-54% of attendees preferring this term “patient” compared to 14-17% preferring the term “client”, 11-13% preferring the term “service user” and 20-25% having no preference (p < 0.001) (Table 2). Doctors, but not other mental health professionals, preferred to use the term “patient” (p < 0.00001) (Table 3). Doctors, but not other mental health professionals believed that attendees would prefer this term, however doctors over-estimated this preference (p < 0.00001) and nurses under-estimated this preference (p < 0.0001). Attendees of the mental health services had a strong preference for being addressed by their first name by all mental health professionals (86-91%) (Table 2). Nurses and allied mental health professionals preferred to address attendee’s by their first name (94%) more frequently than doctors (49%), although this was still the most common preference of doctors (p < 0.0001) (Table 3).

Our finding that attendees prefer to address doctors by their title and surname corroborates previous findings,2, 20, 22 and suggests that attendees and doctors have a preference for a more hierarchal form of interaction, in contrast to the more collaborative relationship with nurses or allied mental health professionals.

Doctors preferred to be addressed by their title and surname (61%), unlike nurses (98%) or other mental health professionals (100%) (p < 0.00001) (Table 3) and attendees preferred to address doctors by their title and surname (67%), whereas they preferred to address nurses and allied mental health professionals by their first name (60-69%) (p < 0.001) (Table 2). Attendees did not differentiate between consultants and NCHDs in how they wished to address them.

Whilst several previous studies have found that attendees prefer doctors to be dressed formally (smartly),19-22 we found that attendees were equally split in their views on doctor’s attire. Previous research in a mental health service in the UK, noted that attendees of mental health services preferred doctors to be formally attired although they viewed this as “less friendly”.19 Whilst it has previously been suggested that individuals when more acutely psychiatrically unwell prefer to emphasize boundaries between themselves and doctors including preferring doctors to be attired more formally,19 our findings did not corroborate this. The preference of attendees for other mental health professionals to be less formally attired again suggests a “more familiar” type of relationship compared to the relationship with their treating doctor.

Attendees had no preference in relation to the attire of doctors, however they expressed a preference for both nurses and allied mental health professionals to be attired in casual clothes (p < 0.05) (Table 2). Doctors (88%), but not nurses (50%) or allied mental health professionals (42%) preferred to be attired formally (p < 0.0001) (Table 3). Doctors (p < 0.00001) and nurses (p < 0.01) overestimated attendee’s wishes in relation to them being attired formally.

We noted a discrepancy between attendees preferences and doctors perception of attendees preferences. Doctors overestimated attendees’ preference for the term “patient”, and for doctors to be formally attired and under-estimated attendees’ preferences for being addressed by their first name. Therefore, we

No significant differences were noted in our findings in relation to gender (attendee / professional), age (attendee / professional), location (acute / sub-acute setting) or attendee diagnosis.

29


believe that doctors and other mental health professionals can be incorrect in relation to the preferences of attendees of the mental health services and should ascertain their preference in relation to how attendees wish to be addressed through direct enquiry during the first encounter.

The study demonstrates that despite the increased use of several terms to describe attendees of mental health services, the term ‘patient’ remains the preferred option of attendees of the psychiatric services in both in-patient and out-patient settings, with 50-55% of attendees stating a clear preference for this term compared to 14-17% preferring the term “client”, and 11-13% preferring the term “service user”. Attendees of the mental health services have different preferences in relation to how they should be addressed by mental health professionals; and we believe that it is the responsibility of the care provider to ascertain these preferences by direct enquiry during the first encounter. Despite 88% of doctors stating a preference for formal attire, only 30% of attendees stated that they preferred their treating doctor to be addressed formally. We also demonstrated that attendees preferences in relation to both “dress and address” of doctors is significantly different to their preference for nurses or other allied mental health professionals; which may reflect a wish for a less familiar and more formal interaction with doctors.

Our main limitation in this study was the limited data we were able to attain from allied mental health professionals (e.g. occupational therapists, social workers and psychologists) and thus data attained from these groups must be interpreted with caution. Whilst we attained data from both acute and sub-acute attendees from both an urban and rural setting, our findings may not be generalisable to other jurisdictions or those with less severe mental illness such as neurotic disorders. We also only utilised descriptive terms for the attire of mental health professionals, and despite the researchers explaining the three options (casual, smart or no preference), these terms are still quite subjective and the use of photographs to further explain these terms may have been useful for individuals in answering this question.

Conflict of interest Conclusion

None.

Table 1: Demographic and Clinical Data Attendees n (%)

Mental Health Professionals n (%)

56 (42.4) 28 (21.2) 28 (21.2)

78 (80.4) 65 (67.0) 13 (13.4)

76 (57.6) 58 (44.0) 18 (13.6)

19 (19.6) 12 (12.4) 7 (7.2)

Gender Male Female

64 (48.5) 68 (51.5)

31 (32.0) 66 (68.0)

Age < 40 ≥ 40

42 (31.8) 90 (68.2)

66 (68.0) 31 (32.0)

Principal Diagnosis (ICD-10 classification) Organic (F00-09) Psychoactive substance misuse (F10-19) Schizophrenia spectrum (F20-29) Mood (Affective) Disorders (F30-39) Neurotic / Stress Related Disorders (F40-49) Personality Disorders (F60-69) Mild Intellectual Disability (F70) No formal psychiatric disorder

4 (3) 10 (7.6) 64 (48.5) 39 (29.5) 3 (2.3) 9 (6.9) 1 (0.8) 2 (1.5)

Mental Health Professionals Occupation Doctor Nurse Psychologist Occupational Therapist Social Worker Other team members

33 (34.0) 52 (53.6) 4 (4.1) 2 (2.1) 4 (4.1) 2 (2.1)

Site of attendee’ treatment or mental health professional predominant workplace Acute Services (Acute Unit / Day Hospital) Acute Psychiatric Unit Day Hospital Sub-acute Services (Day Centre / Rehabilitation Unit) Day Centre Rehabilitation Unit

30


Table 2: Preferences of Attendees in relation to the dress and address of mental health professionals Consultant

NCHD

Nurse

Social Worker

Psychologist

n (%)

Occupational Therapist n (%)

n (%)

n (%)

n (%)

68 (51.5) 22 (16.7) 15 (11.4) 27 (20.5)

71 (53.8) 20 (15.2) 15 (11.4) 26 (19.7)

66 (50.0) 18 (13.6) 17 (12.9) 31 (23.5)

60 (45.5) 22 (16.7) 17 (12.9) 33 (25.0)

66 (50.0) 20 (15.2) 16 (12.1) 30 (22.7)

66 (50.0) 20 (15.2) 16 (12.1) 30 (22.7)

Preferred address by health professional First Name 115 (87.1) Title and Surname 11 (8.3) No Preference 6 (4.5)

113 (85.6) 9 (6.8) 10 (7.6)

120 (90.9) 6 (4.5) 6 (4.5)

116 (88.6) 9 (6.8) 7 (5.3)

117 (88.6) 9 (6.8) 6 (4.5)

117 (88.6) 10 (7.6) 5 (3.8)

Addressing health professionals, attendee preference* First Name Title and Surname No Preference

32 (24.2) 89 (67.4) 11 (8.3)

32 (24.2) 88 (66.7) 12 (9.1)

91 (68.9) 31 (23.5) 10 (7.6)

86 (65.2) 33 (25.0) 13 (9.8)

89 (67.4) 30 (22.7) 13 (9.8)

79(59.8) 41 (31.1) 12 (9.1)

Preferred attire of health professional Casual (Informal) 46 (34.8) Smart (Formal) 39 (29.5) No Preference 47 (35.6)

45 (34.1) 40 (30.3) 47 (35.6)

55 (41.7) 31 (23.5) 46 (34.8)

59 (44.7) 25 (18.9) 48 (36.4)

58 (43.9) 27 (20.5) 47 (35.6)

55 (41.7) 30 (22.7) 47 (35.6)

Preferred description by health professional Patient Client Service User No Preference

n (%)

* A significant difference was detected in relation to attendees preferences between the groups, with attendees preferring to address doctors by their title and surname and to address other mental health professionals by their first name (x2 = 137.66, df = 10, p = 1.3x10-24)

Table 3: Preferences of mental health professionals, and their perceptions of attendeesâ&#x20AC;&#x2122; preferences Doctor

Nurse

n (%)

n (%)

Allied Mental Health Professionals n (%)

Preferred description of attendee Patient Client Service User No Preference

30 (90.9) 0 (0) 1 (3.0) 2 (6.1)

19 (36.5) 19 (36.5) 7 (13.5) 7 (13.5)

4 (33.3) 3 (25.0) 3 (25.0) 2 (16.7)

Perceived preferred description of attendee Patient Client Service User No Preference

24 (72.7) 1 (3.0) 3 (9.1) 5 (15.2)

27 (51.9) 11 (21.2) 6 (11.5) 8 (15.4)

4 (33.3) 1 (8.3) 7 (58.3) 0 (0)

Preferred address of health professional First Name Title and Surname No Preference

5 (15.2) 20 (60.6) 8 (24.2)

51 (98.1) 0 (0) 1 (1.9)

12 (100) 0 (0) 0 (0)

Perceived preferred address of health professional First Name Title and Surname No Preference

5 (15.2) 23 (69.7) 5 (15.2)

47 (90.4) 3 (5.8) 2 (3.8)

12 (100) 0 (0) 0 (0)

Preferred address of attendee First Name Title and Surname No Preference

16 (48.5) 10 (30.3) 7 (21.2)

49 (94.2) 1 (1.9) 2 (3.8)

11 (91.7) 1 (8.3) 0 (0)

Perceived preferred address of attendee First Name Title and Surname No Preference

22 (66.7) 6 (18.2) 5 (15.2)

47 (90.4) 2 (3.8) 3 (5.8)

12 (100) 0 (0) 0 (0)

Preferred attire of health professional Casual (Informal) Smart (Formal) No Preference

4 (12.1) 29 (87.9) 0 (0)

25 (48.1) 26 (50) 1 (1.9)

6 (50.0) 5 (41.7) 1 (8.3)

Perceived preferred attire of health professional Casual (Informal) Smart (Formal) No Preference

1 (3.0) 26 (78.8) 6 (18.2)

20 (38.5) 26 (50.0) 6 (11.5)

3 (25.0) 6 (50.0) 3 (25.0)

31

x2

df

P

29.484

6

0.00005

24.512

6

0.0004

72,447

4

6.9X10-15

58.735

4

5.3x10-12

26.858

4

0.00002

11.250

4

0.024

16.528

4

0.002

14.643

4

0.006


References 1. McGuire R, McCabe R, Priebe S. Theoretical frameworks for investigating and understanding the therapeutic relationship in psychiatry. Soc Psych and Psychiatric Epidem 2001; 36: 557-64. 2. McGuire-Snieckus, R., McCabe R, Priebe S. Patient, client or service user? A survey of patient preferences of dress and address of six mental health professions. Psych Bull 2003; 27: 305-8. 3. Day JC, Bentall RP, Roberts C, et al. Attitudes toward antipsychotic medication: The impact of clinical variables and relationships with health professionals. Arch Gen Psychiatry 2005; 62: 717-24. 4. Fakhoury WK, White I, Priebe S. Be good to your patient: how the therapeutic relationship in the treatment of patients admitted to assertive outreach affects re-hospitalization. J Nerv Ment Dis 2007; 195: 789-91. 5. Gaudiano BA, Miller IW. Patients’ expectancies, the alliance in pharmacotherapy, and treatment outcomes in bipolar disorder. J Consult Clin Psychol 2006, 74: 671-76. 6. Swift G, Zachariah M, Casey PR. A rose by any other name: psychiatric outpatients’ views on dress and address. Ir J Psychol Med, 2000; 17: 132-34. 7. Nursing and Midwifery Council. The Code: Standards of conduct, Performance and Ethics for Nurses and Midwives, NMC 2008. (http://ww.nmc-uk.org/aDisplay.Document.aspx?documentID=5982). 8. British Association of Social Workers. The Code of Ethics for Social Work. BASW, 2002. (http://www.basw.co.uk/Portals/O/CODE%200F%20ETHICS.pdf). 9. British Psychological Society. Code of Ethics and Conduct. BPS, 2006. (http://www.bps.org.uk/downloadfile.cfm?File_uuid=5084A8821143-DFDO-7E6C-F1983A65C242&ext=pdf). 10. College of Occupational Therapists. Code of Ethics and Professional Conduct (Revised). College of Occupational Therapists, 2005. (http://www.cot.org.uk/MainWebsite/Resources/Documents/Code-of-Ethics.pdf). 11. Davis C, Davis J. “Nurse”: dynamic term for a dynamic relationship. Nurse Manager 1992; 23: 42-3. 12. Herzberg SR. Client or patient: which term is more approprioate for use in occupational therapy? Am J Occup Ther 1990 44: 561-4. 13. Keaney F, Strang J, Raga-JM, Spektor D, Manning V, Kelleher M, et al. Does anyone care about names? How attendees at substance misuse services like to be addressed by health professionals. Eur Addict Res 2004; 10: 75-9.

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14. Neuberger J. Do we need a new word for patients? Let’s do away with “patients”. BMJ 1999; 318: 1756-8. 15. Ritchie CW, Hayes D, Ames DJ. Patient or client? The opinions of people attending a psychiatric clinic. Psych Bull 2000; 24: 447-50. 16. Upton MWM, Boer GH, Neale AJ. Patients or clients? - a hospital survey. Psych Bull 1994; 18, 142-3. 17. Simmons P, Hawley CJ, Gale TM, Sivakumaran T. Service user, patient, client, user or survivor: describing recipients of mental health services. The Psychiatrist 2010; 34: 20-3. 18. Covell NH, McCorkle BH, Weissman EM, Summerfelt T, Essock SM. What’s in a name? Preferred by service recipients. Adm Policy Ment Health 2007; 34: 443-7. 19. Gledhill JA, Warner JP, King M. Psychiatrists and their patients: views on forms of dress and address. BJPsych 1997; 171: 228-32. 20. Gallagher J, Waldron Lynch F, Stack J, Barragry J. Dress and address: Patient preferences regarding doctor’s style of dress and patient interaction. IMJ 2008; 101: 211-3. 21. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med 2005; 118: 1279-86. 22. Lill MM, Wilkinson TJ. Judging a book by its cover: descriptivesurvey of patients’ preferences from doctors’ appearance and mode of address. BMJ 2005; 331:1524-7. 23. Hennessy N, Harrison DA, Aitkenhead AR. The effect of the anaesthetist’s attire on patient attitudes. The influence of dress on patient perception of the anaesthetist’s prestige. Anaesthesia 1993; 48: 219-2. 24. Baevsky RH, Fisher AL, Smithline HA, Salzberg MR. The influence of physician attire on patient satisfaction. Acad Emerg Med 1998; 5: 82-4. 25. Albert NM, Wocial L, Meyer KH, et al. Impact of nurses’ uniforms on patient and family perceptions of nurse professionalism. Appl Nurs Res 2008; 21: 181-90. 26. Sharma V, Whitney D, Kazarian SS, Manchanda R. Preferred terms for users of mental health services among service provides and recipients. Psychiatric Services 2000; 51: 203-9. 27. Torrey EF. Patients, clients, consumers, survivors’ et al: What is in a name? Schiz Bull 2010, in press.


Original Paper

Psychiatrists in their eyes: Children’s drawings of what a psychiatrist looks like Sami Omer, Niamh O’Connor, Gavin Sweeney, Geraldine McCarthy Ir J Psych Med 2012; 29 (1): 33-35

Few studies have addressed the question of how doctors are perceived in children’s drawings. Marshall studied drawings of 40 children aged six to nine years in New Zealand and found that 92% of doctors were depicted as happy or normal and only one child drew a doctor with an ‘unfavourable facial attitude’.14 Another study of 50 school children aged seven to eleven years in the UK found that in 50% of the drawings the doctor was portrayed as a benign or a kindly figure, in 44% as gruesome or threatening, and in six percent as neutral.15 In the present study we set out to explore children’s perception of psychiatrists by inviting a group of primary school children to draw what they thought a psychiatrist looks like.

Abstract Drawings can be used as an important tool to measure children’s perception and emotions. Using a qualitative design, we asked a group of 24 school children (10 boys and 14 girls) aged 11-12 to draw their impressions of psychiatrists. In the majority of drawings, psychiatrists were portrayed as a friendly or kind figure. The art work was analysed by the coordinator of the Arts Initiative in Mental Health, Niamh O’Connor. Psychiatrists were portrayed positively by this group of young people. This reflects a strong influence of the media on children’s perception.

Introduction

Methodology As part of the intergenerational art project, six school children aged 11-12 years, from Carraroe Primary School in Sligo, attended Liscarney house, a day hospital for the old age psychiatry service in Sligo, once a week for a period of seven weeks. The children formed pairs with patients and participated in artwork with the emphasis being on exchanging ideas and skills to promote understanding. At the end of the period we asked the school principal if the whole class, including those who did not participate in the project, could visually represent an image of a psychiatrist. This was a qualitative study combined with quantitative methods; The art work was analysed by the coordinator of the Arts Initiative in Mental Health (Niamh O’Connor). When studying the children's drawings a comparative analysis of the themes and approaches of the creators' was determined.

Public perception of psychiatry is influenced by several factors such as personal experience, the media and the experience of family members and friends.1 A positive attitude towards the profession will help reduce the stigma of mental illness. Several studies have examined the public attitude towards mental illness,2, 3 patients with mental health problems,2, 4 and psychiatric treatments.5-7 Less is known about how psychiatrists are perceived by the general public. A telephone survey in New Zealand found that psychiatrists were perceived negatively compared with dentists, family doctors and lawyers. Forty eight percent of the study population did not know that psychiatrists are medical doctors, and 60% did not know the difference between psychiatrists and psychologists.8 In the UK , 412 adults were given a list of 26 professions and were asked to rank according to which they most respected, psychiatrists came 8th above jobs such as bank managers, accountants and MPs. However, psychiatrists had the lowest ranking compared to other medical professions such as GPs, pathologists and nurses.9

The primary concern was to ascertain the relative friendliness of each psychiatrist and to then categorise and quantify all the other information. Drawings were categorised under the following headings - friendliness, sex, dress, setting, doctor with patient, doctor's couch, other paraphernalia etc.

Drawings could provide useful information about children’s feelings and emotions. In health settings, children’s drawings have been used for various purposes including as diagnostic aides for headaches,10, 11 as an index of self-esteem and anxiety in children undergoing plastic surgery,12 and to describe the quality of care children receive in hospitals.13

A formal analysis of the images - the creator's use of line, shape, colour, texture, and composition was considered; particularly in relation to any unusual characteristics and to the categories listed above. Given the small size of our sample it was not possible to conduct any meaningful statistical analysis.

*Sami Omer, Consultant Psychiatrist, Department of Old Age Psychiatry, Sligo, Ireland. E-mail Omersami@hotmail.com

Gavin Sweeney, Clinical Nurse Manager, Department of Old Age Psychiatry, Liscarney House, Pearse Road, Sligo, Ireland.

Niamh O’Connor, Coordinator of the Arts Initiative in Mental Health, Sligo/Leitrim Mental Health Services, Clarion Road, Sligo, Ireland.

Geraldine McCarthy, Department of Old Age Psychiatry, Liscarney House, Pearse Road, Sligo, Ireland.

* Correspondence

33

Submitted August 11th 2009 Accepted February 13th 2012


Results Twenty four school children (10 boys and 14 girls) took part in the study. One child submitted two drawings making the total number of drawings 25.

The context While many children took great care to detail the surrounding environment a full 56% did not represent any context or included only one piece of furniture with no floor, walls, ceiling or other reference to place.

Their artwork was made on A4 photocopier paper using coloring pencils and was an immediate response to the question posed, with no prior sketching or preparatory work. The main features of the drawings are summarized in Table 1. Feature

In seven (28%) drawings the psychiatrist was portrayed alone, without any other reference to context. A further 17 (68%) showed interior furniture of one kind or another (desks, chairs, couches) with one drawing locating the psychiatrist in a garden. In one drawing (4%) the psychiatrist was shown in a home environment with a row of shoes, a kitchen and a rug etc. The doctor’s couch was an overwhelming feature, apparent in 14 (56%) of the drawings. While the drawings were colourful, almost all showed sparse and anonymous surroundings with limited or no decorative features. The exception is two (8%) pictures where much decorative detail was evident (cupboards, rugs, a fish tank, a plant) both drawn by girls.

Frequency of representation Number (%)

Female psychiatrist Friendly psychiatrist Psychiatrist with patient Doctor’s Couch Psychiatrist offers help No context and/or sparse context Psychiatrist with paraphernalia

18 21 12 14 5 14

(72) (84) (48) (56) (20) (56)

(Pen, file, book, bag/briefcase, stethoscope)

12 (48)

Doctor-patient relationship Of the 12 drawings, which also incorporate the person receiving treatment, 11 out of 12 (92%) showed an engagement between doctor and patient. The doctor either stands nearby, sits facing the patient or is speaking with the patient. Only one drawing showed little relationship between the two subjects-the psychiatrist disproportionately bigger than and facing away from the patient. eleven of the drawings depicted the patient on a couch, with the doctor standing nearby in seven of the pictures. Four images showed the doctor sitting beside the patient who is always, with the exception of one drawing, lying down.

Table 1: Main features of the drawings There was no difference in the quality of the drawings between the six children who attended the day hospital and the 18 children who did not attend. Gender Most children depicted the psychiatrist as female 18 (72%), while in seven (28%) drawings the psychiatrist was portrayed as male. Only one girl depicted the psychiatrist as male while four boys drew a female doctor.

Interestingly, a number of children added text to the drawing in the form of speech, giving us a more layered understanding of the relationship between doctor and patient. Questions like “how are you feeling?”, “tell me your thoughts?” and statements like “of course (I’ll help)”, “it’s ok I’ll help” and “I will help you” are evident. A psychiatrist possibly using hypnosis to relax the patient - “stare into this as you fall asleep” is shown in Figure 1. Discussion about medication did not feature in any of the drawings.

Facial expression The majority of the drawings showed the psychiatrist as friendly, with 16 (64%) of them smiling broadly. Five (20%) drawings showed a less openly smiling face but a kind expression nonetheless, while three (12%) showed the psychiatrist’s facial expression as worried, shocked and unhappy. Of the 12 (48%) drawings, which showed the person receiving treatment, six out of 12 (50%) were smiling, three out of 12 (25%) were unhappy and a further three (25%) were not apparent or hidden. Clothing and accessories In the majority of pictures the psychiatrist was dressed in normal attire, while three children (12%) had them wearing a type of uniform. Many of the doctors wore colorful clothing of stripes and florals with careful detailing of buttons, collars and hair accessories. The female psychiatrists wore stylish colour-coordinated outfits with an emphasis on fashion, while the male doctors were dressed more soberly. A small number showed the doctor with a handbag, one(4%) carrying a book and seven (28%) wore spectacles, perhaps denoting studiousness and maturity. One drawing depicted the psychiatrist as a very mature, perhaps elderly woman. Two (8%) psychiatrists wore a doctor’s headband. One child (4%) depicted a female psychiatrist in an apparently religious scheme, wearing robes similar in colour to the Virgin Mary, hovering above the ground with an arc of stars encircling the woman.

Figure 1. Drawing by Sophie

34


Conclusion Psychiatrists were portrayed positively by this group of young people. They were all primary school children and although six had attended a mental health setting over a seven week period, the majority projected a positive/friendly image of psychiatrists in their artwork. This reflects a strong influence of the media on children’s perception. It also suggests that health promotion helping to diminish or avoid stigma about mental health should be addressed at an early stage. Further work looking at perceptions of teenagers could help to elucidate this further.

Conflict of interest None.

Figure 2. Drawing by Laura.

Acknowledgement In Figure 2 there is an ominous black cloud or speech bubble over the patient’s head.

We wish to thank Dr. Maria Morgan, Dr. Caroline Ang, Dr. Kate Johnson and Professor John Waddington from the Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland. As part of an outreach programme, they asked a group of school children to draw their impressions of scientists before and after they took part in an interactive hands-on science workshop. Their work inspired us to undertake this project. The authors are immensely grateful to the principal of Carraroe National School and to the children who took part in the study.

Discussion To the best of our knowledge this is the first study that describes children’s perception of psychiatrists. In the majority of drawings the psychiatrist was portrayed as a friendly or kind figure. Television had inevitably played a significant role in forming children’s opinions about ‘What a psychiatrist looks like’. The doctor’s couch, a familiar scene from the private clinics of hundreds of television and film ‘shrinks’, was a recurring feature. The role of television in influencing children’s perception and imagination is wellrecognised in the literature.16-18 Furthermore, it had been suggested that while children can make the distinction between reality and fictional TV when they have the real-world information about an occupation, for unfamiliar occupations children may perceive what they see on TV as real ‘perceived reality’.18

References 1. Philo G (ed.). Media and mental distress. London; Longman, 1996. 2. Wolff G, Pathare S, Craig T, Leff J. Community knowledge of mental illness and reaction to mentally ill people. Br J Psychiatry 1996; 168(2):191-8. 3. Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illness. Br J Psychiatry. 2000; 177:4-7. 4. Mehta N, Kassam A, Leese M, Butler G, Thornicroft G. Public attitudes towards people with mental illness in England and Scotland 1994-2003. Br J Psychiatry 2009; 194(3):278-84. 5. Angermeyer MC, Breier P, Dietrich S, Kenzine D, Matschinger H. Public attitudes toward psychiatric treatment. An international comparison. Soc Psychiatry Psychiatr Epidemiol. 2005; 40(11): 855-64. 6. Burke S, Kerr R, McKeon P. Male secondary school students’ attitudes towards using mental health services. Ir J Psychol Med 2008; 25(2):52-56. 7. Mojtabai R. Americans’ attitudes toward mental health treatment seeking: 1990-2003. Psychiatr Serv. 2007; 58(5):642-651. 8. Sellman D, Pearson G. The public perception of psychiatrists: a telephone survey. N Z Med J. 1985; 98(785):699-703. 9. Luty J, Fekadu D, Gallagher J. Umoh O. The professional status of psychiatrists: good but not great. Psychiatric Bulletin (2006) 30: 314. 10. Wojaczyńska-Stanek K, Koprowski R, Wróbel Z, Gola M. Headache in children’s drawings. J Child Neurol. 2008; 23(2):184-91. 11. Stafstrom CE, Rostasy K, Minster A. The Usefulness of children’s drawings in the diagnosis of headache. Pediatrics 2002; 109(3):460-472. 12. Lukash F. Children’s art as a helpful index of anxiety and self-esteem with plastic surgery. Plast Reconstr Surg. 2002; 109(6):1777-86. 13. Pelander T, Lehtonen K, Leino-Kilpi H. Children in the Hospital: Elements of quality in drawings. J Pediatr Nurs. 2007; 22(4):333-41. 14. Marshall CS. Looking at the doctor through the eyes of a child. N Z Fam Phys. 1985; 12:17-19. 15. Philipp R, Philipp E, Pendered L, Barnard C, Hall M. Can Children’s paintings of their doctors be interpreted? J R Coll Gen Pract. 1986; 36(288):325-7. 16. Gash H, Domínguez Rodríguez P. Young people’s heroes in France and Spain. Span J Psychol. 200; 12(1):246-57. 17. Comer JS, Furr JM, Beidas RS, Babyar HM, Kendall PC. Media use and children’s perception of societal threat and personal vulnerability. J Clin Child Adolesc Psychol. 2008; 37(3):622-30. 18. Pecora N, Murray JP, Wartella EA (eds.). Children and television. Fifty years of research. Laurence Erlbaum Associates, Inc. New Jersey, 2007. 19. O’Connor A, Casey P. What it says in the papers: an audit. Ir J Psychol Med. 2001; 18:68-71. 20. Kelly B. Psychiatry in contemporary Irish cinema. Ir J Psychol Med. 2006; 23(2): 74-79.

In Ireland a limited number of studies examined how psychiatry is portrayed in the media. An audit of print media found that mental health issues were generally portrayed in either a neutral or positive way.19 A study of a small number of Irish films found that psychiatrists were portrayed as humane, caring and occasionally conflicted individuals.20 The colorful and fashionable attire may be attributed to the children’s personal preferences and practiced modes of visual representation rather than their knowledge of the dress sense of psychiatrists. The psychiatrist in most drawings was depicted as being female. This is probably a mere reflection of the gender difference in our study sample. Bearing in mind that the task was to make a drawing to illustrate ‘What I think a psychiatrist looks like’ and not ‘What I think a psychiatrist does’, significantly, almost 50% of the children, of their own initiative, determined to expand upon this, to show the psychiatrist in a supportive relationship with patients. The six children who attended the day hospital had mainly worked with patients. They were only briefly introduced to a psychiatrist at the end of their art project. This would probably explain the lack of difference in their impressions of psychiatrists compared to those who did not attend the day hospital. 35


Brief Report

Selective Mutism: A prevalence study of primary school children in the Republic of Ireland Louise Sharkey, Fiona McNicholas

Ir J Psych Med 2012; 29 (1): 36-40

Abstract

persistent, lasting longer than one month, and causes impairment in communication, educational and occupational achievement.1

Objective: This study was carried out to determine the prevalence of selective mutism (SM) in an urban school population and to assess comorbidity and family characteristics.

Reported prevalence rates for selective mutism range between 0.033-2% of primary school children.2,3,4,5 Comparison between different studies is difficult due to different populations sampled and criteria for diagnosis used. For example, studies examining a narrow age band looking at children between the ages of 4-6 years27 (when SM is more likely to present), yield higher prevalence rates than those examining a wider age band4 (7-15 years). In addition studies using DSM IV criteria yield smaller prevalence rates than those using ICD 10 or DSM III R1 due to the inclusion of impairment as a criterion for diagnosis in DSM IV.5 School and community based studies typically yield consistently higher rates than those cited in clinical samples, reflecting the fact that many children with SM do not come to clinical attention.

Method: Teachers of primary schools, teaching children between the ages of four and 12, were sent a description of SM and asked to complete the selective mutism questionnaire (SMQ) if they believed a child in their class met criteria. Thirty-nine schools were sampled, covering a catchment area of 10,927 children. Children who screened positive on the SMQ were offered a full psychiatric assessment. Parent, child and clinicians completed various rating scales. Results: A response rate of 100% from schools was obtained. The prevalence rate of SM was 0.18% (20/10927). fourteen (70%) attended for further evaluation. All children scored within the clinical range on the Clinical Global Assessment Scale (CGAS), indicating moderate to severe impairment. fifty percent (7) reported a family history of social anxiety disorder, and 43% (6) autistic spectrum disorders.

The conceptualisation of SM has undergone a number of changes in recent years. A wide variety of child characteristics have been reported, including oppositional behaviour, developmental delay, speech disorder, anxiety and shyness.6,7,8,9,10 Recent research describes SM as closely related or an early developmental expression of social phobia.11,12,13 Other authors have reported a high frequency of neurodevelopmental delay, affecting motor, linguistic and cognitive functioning. 9,14,15,16

Conclusion: This is the first Irish based prevalence study of SM. Results indicate that SM is not as rare as previously believed. Children with SM were found to have significant functional impairment along with a strong family history of anxiety and autism.

A high frequency of family psychopathology has also been reported in SM families.17,12,18,19 Previous studies have suggested an association between SM and parental social anxiety.12,19 Two studies suggest a family link with Asperger Disorder. 20,21

Key words: Comorbidity, Family psychopathology, Prevalence, Selective mutism.

This study aimed to carry out a community study and follow cases up with a clinical evaluation to try and establish an accurate prevalence rate in a defined geographical catchment area in Ireland. It also aimed to document any comorbidity or family pathology.

Introduction Selective mutism is considered a rare disorder of communication, characterised by an emotionally determined consistent failure to speak in select social situations, where speaking is expected, for example school, despite demonstrating language competence in more familiar situations, for example, home. The disorder is

* Louise Sharkey, Consultant Child and Adolescent Psychiatrist, Mater Child and Adolescent Mental Health Service, Mater Misericordiae University Hospital, Dublin 7, Ireland. E-mail lsharkey@mater.ie

* Correspondence

Fiona McNicholas, Consultant Child Psychiatrist and Professor of Child Psychiatry, Lucena Clinic, Rathgar, Dublin 6, Ireland. Our Ladyâ&#x20AC;&#x2122;s Childrenâ&#x20AC;&#x2122;s Hospital, Crumlin University College Dublin, Ireland.

36

Submitted September 2010 Accepted August 2011


Clinical presentation: All children assessed met diagnostic criteria for Selective Mutism.22 The onset of their symptoms dated back to school entry (average age 4.6 years). One child was previously assessed by the psychiatric services and three received therapy for dyspraxia. Nine children (64%) had a history of speech and language delay. One child had a diagnosis of Tourette’s Syndrome. All children were considered by their school to be functioning within the average range of cognitive ability. All children with SM presented with moderate to severe impairment in functioning (CGAS = 32-61) (Figure 1), as rated by clinicians. (Table 2)

Method Participants: The study group consisted of children aged 4-12 years attending primary school in a defined geographical urban child and adolescent mental health service catchment area in the Republic of Ireland. The catchment area covers a population of 350 000, primarily belonging to the lower socio-economic group.24 There are 39 primary schools in this area and all were sampled, covering a total population of 10,927 students. The study was approved by the ethical review board of St John of God’s Hospital. Full informed written consent was obtained from parents or guardians of all participants before the study.

Only 21%, one fifth of the sample, scored within the clinical range on the SCAS25 as rated by the children or parents (>42.48) (Figure 2). The most frequent items scored by these children related to social phobia and separation anxiety disorder. None of the children met criteria for obsessive compulsive disorder, generalized anxiety disorder or panic disorder, as rated by the SCAS. (Table 2)

Procedure: The study was conducted late in the academic year (April/ May), in order to ensure a six month duration and to eliminate transient mutism, common in the first term post school entry. A description of selective mutism according to DSM-IV criteria22 was sent to the principal and teachers of each school. If the principal or teacher suspected that a pupil met criteria, they completed and returned the Selective Mutism Questionnaire,2 in the stamped addressed envelope enclosed. In addition, the principal was asked to indicate on a separate form if there were no children in the school with symptoms suggestive of SM. Children who met DSM-IV criteria for SM were invited to participate in a clinical assessment with a consultant child psychiatrist, to confirm the diagnosis and to assess for additional comorbidity. The child and parent filled out some additional questionnaires and the clinician completed the Children’s Global Assessment Scale (CGAS) 23 (see Table 1).

Although only four children (29%) received a total score within the abnormal range on the SDQ,26 eight (57%) presented with emotional difficulties and five (36%) with problems with peer interaction and 2 (14%) with behaviour difficulties (Table 4). Family psychopathology: Family psychopathology and neuro-developmental delay were assessed by a child psychiatrist according to detailed information about family history obtained during clinical interview. Results were included only if a formal diagnosis had been given by a qualified professional, for example a psychiatrist, psychologist or speech and language therapist. According to parental report, there was a positive family history in nine children (64.3%) of speech and language delay or articulation difficulties in a first degree relative which required clinical intervention. Similarly, there was a high frequency of social anxiety disorders among family members with two siblings from two families and seven (50%) parents who reported receiving treatment for either selective mutism or social phobia. All children had at least one parent who was portrayed as ‘very shy’. Surprisingly, almost half the sample, six (43%) reported a diagnosis of autistic spectrum disorder in a first degree relative. (Table 3)

Results A total of 39 schools (100%) responded to the study questionnaires. Schools who did not return data within a specified time frame were followed up via telephone contact. Up to three telephone calls were required before all data was returned for analysis. Twenty children were identified by 19 teachers of 12 schools as having symptoms suggestive of SM. Twenty seven schools returned forms or indicated through telephone contact that there were no children in the school with symptoms suggestive of the disorder. All parents of children who met criteria on the SMQ were contacted by a clinician and offered a clinical assessment. Parents of 14 children (70%), consented to an assessment.

Discussion To the authors’ knowledge, this is the first prevalence study of selective mutism in Ireland, and suggests a prevalence rate of 0.18% in a sample of primary school children aged 4-12 years. This is a two stage study, using questionnaire screening and diagnostic interview to achieve a diagnosis of SM using DSM IV criteria. As such the prevalence rate found (0.18%) may be lower than that found in other studies with less stringent diagnostic criteria. In addition, this study included children aged 4-12 years, as compared to other studies sampling a narrower age band (4-6 years) when SM is most likely to present. For example, Kopp & Gillberg4 who used criteria that are stricter than DSM-IV, found a rate of 0.18% comparable to our results, in their study of Swedish school children (7-15 years), while the relatively high rate of 1.9% reported by Kumpulainen et al,5 was based on DSM III R criteria1 that do not include impairment.

The ages of children with SM ranged from 5.2-10.6 years (average age 6.9 years). There was a preponderance of female subjects (female to male ratio was 4:1). The spoken language in 11 of the families was English. Three of the pupils were of ethnic minority origin, but had been living in the country and attending school for more than two years. All three pupils were reported to be bilingual and demonstrated SM symptoms in both native and non-native languages. Eleven children (79%) lived with both biological parents. All children had regular contact with both parents. Ten (71%) were the eldest in their family. All families belonged to the lower socio-economic group.24

37


More recently Bergman et al11 reported a prevalence rate of 0.76% among their sample of kindergarten, first and second grade pupils using DSM-IV22 criteria. Their relatively higher prevalence rate is comparable to the rate reported in the United Kingdom by Brown & Lloyd,27 and probably reflects the narrow age band studied, when SM is more likely to present.

Although an association between SM and autistic spectrum disorder has been queried in previous studies,20 almost half of our sample had a first degree relative with a diagnosis of ASD. Our findings extend previous reports and describe the important role family psychopathology plays in the aetiology of SM. Limitations: This current study suffers from a number of methodological limitations. Information from teachers was limited to a screening questionnaire, and as children with SM are more likely to manifest symptoms within the school environment, additional information from teachers, in particular in relation to anxiety symptoms, would have contributed significantly to this study. Second, our largely working class sample, while representative of our geographically defined catchment area, is probably not representative of the population as a whole, and while attendance at school is mandatory, it is possible that children with SM who are not attending school were missed by this methodology. However principals were reminded to consider all children enrolled in the school. Thirdly, as there is no direct control group, comorbidity and family characteristics of this SM sample can only be compared to those found in other published studies. Whilst the structure of the family interview method would have led to increased reliability and could have been done by an independent researcher, the expertise of the clinician in taking family histories must not be underestimated.

Although SM is generally considered to be a rare disorder, most of the recent evidence does not support this. The figure of 0.06% cited by Fundudis et al28 is based on the use of very vague criteria for diagnosing SM, that are not comparable to the current conceptualization of SM in DSM-IV. This figure however is similar to a more recent publication by Karakaya et al,3 in their study of kindergarten to 3rd grade pupils using DSM-IV criteria. Their initial prevalence rate following screening by teachers of 0.83% was reduced to 0.033% following clinical evaluation by a child psychiatrist. Gender differences have been noted in past studies of SM and a suggestion that gender differences in prevalence increase with age.16 In our study, we found a male: female prevalence ratio of 1:4, with more females than typically reported (ratio of 1:1.2),6 which may reflect the older age range sampled. Comorbidity: Comorbid conditions were highly prevalent in our sample of children with selective mutism. Similar to previous studies,11,12,13 all children in the study were rated by clinicians as moderately to severely impaired in social, academic and overall functioning. Speech and language delay was the most common comorbid problem, reported in 64% of the sample studied. This association is in line with findings of 30-60% language disorder/delay recorded in previous studies of SM. 9,16,29,30

Despite these shortcomings the study has a number of methodological qualities. The study of a non-referred population of school children aged 4-12 years provides a more representative sample than that obtained in clinical studies, and identifies the population of ‘hidden SM’, children who do not come to clinical attention as they do not cause a disturbance in the classroom, and the disorder is not perceived as problematic in the home environment. In addition, our study included a relatively large population of school-aged children. All children whose parents consented received a psychiatric evaluation, by a senior clinician, confirming the diagnosis and identifying comorbidity. The use of validated rating scales completed by multiple informants, emphasized the situational nature of the disorder and the degree of impairment experienced by children who have not yet come to clinical attention.

Twenty one percent of the children with SM met criteria for dyspraxia, a rate slightly lower than that reported by Kristensen15 for DCD. Only one fifth of the sample met criteria for an anxiety disorder on a self-rating scale. This finding is inconsistent with previous studies,12,13, 16 that suggest that SM is an anxiety disorder, closely related to social phobia, but consistent with other studies using self-rating scales to measure anxiety symptoms in children, who manage anxiety symptoms and the self-consciousness associated with speaking by avoiding speech.30 A teacher rating scale would probably yield a much higher rate of anxiety disorder in this population. The finding that only four children (29%) received a total score in the abnormal range on the SDQ26 as rated by parents, reflects the contextual nature of the disorder, where SM may not be perceived as a problem in the home environment, and the family’s tolerance and acceptance of mute behaviour (Table 4).

Conclusion This study provides data that concur with other studies in suggesting that SM is not as rare as previously reported, and that a significant number of children with considerable impairment do not come to clinical attention until later years, requiring more intensive intervention. This suggests that efforts to identify and treat SM in the early school year need to be increased, so that an increased awareness of the disorder and early intervention treatment programmes can be delivered in the school environment. Following this study the authors developed a SM manual which has been sent to all primary schools in the catchment area.37

Family characteristics: There was a high loading for speech and language delay and anxiety symptoms in the families of selectively mute children. Fifty percent of the sample reported a family history of social anxiety disorders and at least one parent of all children described themselves as ‘excessively’ shy. This is consistent with earlier results.32,33,34 Sixty-four percent of our sample reported a history of speech and language delay in first degree relatives, comparable to results from previous studies (21% - 78%).16,35,36.

Our findings suggest an association between SM and a family history of social anxiety disorder, speech and language delay and autistic spectrum disorder. It is significant that seven (50%) parents reported receiving treatment for either selective mutism or social phobia. While these results should be viewed as preliminary, further studies of the etiological nature of the disorder and more specific evidence based treatment interventions are clearly warranted. 38


Conflict of interest None.

References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – Third Edition Revised. Washington. American Psychiatric Association, 1987. 2. Bergman RL, Keller M, Wood J, Piacentini J, McCracken J. Selective Mutism Questionaire (SMQ): development and findings. Poster session presented at the American Academy of Child and Adolescent Psychiatry, Honolulu, USA. 2001 3. Karakaya I, Sismanlar SG, Oc OY, Memik NC, Coskun A, Agaoglu B, Yavuz CI. (2007). Selective Mutism: A school- based cross-sectional study from Turkey. Euro Child Adolesc Psychiatry 2007; 17:114- 117. 4. Kopp S, Gillberg C. Selective mutism: a population-based study: a research note. J Child Psychol and Psychiatry 1997; 38:257-262. 5. Kumpulainen K, Rasanen R, Raaska H, Sompii V. Selective Mutism among second- graders in an elementary school. Euro Child Adolesc Psychiatry 1998; 7: 24-29. 6. Tancer N. Elective Mutism: A Review of the Literature. Advances in Clin Child Psychol 1992; 14:265-288. 7. Bradley S, Sloman L. Elective mutism in immigrant families. J Am Acad Child Psychiatry 1975; 14: 510-514. 8. Hayden TL. The Classification of elective mutism. J Am Acad Child Psychiatry 1980;19: 118-133. 9. Kolvin I, Fundudis T. (1981). Electively mute children: Psychological Development and background factors. J Clin Psychol Psychiatry 1981; 22:219-232. 10. Leonard HL. Selective Mutism. In Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (Vol 1, 7th Ed) Sadock BJ, Sadock VA. 11. Bergman RL, Piacentini J, Mc Cracken J. Prevalence and Description of Selective Mutism in a school-based sample. J Am Acad Child Psychiatry 2002; 41: 238-246. 12. Black B, Uhde TW. Psychiatric characteristics of children with selective mutism: A pilot study. J Am Acad of Child Psychiatry 1995; 34:847-855. 13. Dummit ES, Klein RG, Tancer NK, Asche B, Martin J, Fairbanks JA. Systematic assessment of 50 children with selective mutism. J Am Acad Child Psychiatry 1997; 36:653-660. 14. Kristensen H. Elective mutism associated with developmental disorder/ delay:two case studies. Euro Child Adolesc Psychiatry 1997; 6:234-239. 15. Kristensen, H. Selective mutism and comorbidity with developmental disorder/delay, anxiety disorder and elimination disorder. J Am Acad Child Adolesc Psychiatry 2000; 39: 249-256. 16. Steinhausen HC & Juzi C. Elective Mutism: An analysis of 100 cases. J Am Acad Child Psychiatry 1996; 35:606-614.

Figure 1: CGAS Scores

17. Brown BJ, Lloyd H. A controlled study of children not speaking at school. J Ass Workers with Maladjusted Children 1975; 3: 49- 63. 18. Browne E, Wilson V, Laybourne P. Diagnosis and treatment of elective mutism in children. J Am Acad Child Adolesc Psychiatry 1963; 2:605-617. 19. Kristensen H & Torgersen S. MCMI-II personality traits and symptom traits in parents of children with selective mutism: A case-controlstudy. J Abn Psychol 2001; 110:648-652. 20. Gillberg IC & Gillberg C. Asperger syndrome – some epidemiological considerations: a research note. J Child Psychol and Psychiatry 1989; 30:631- 638. 21. Brix Andersson C, Hove Thomsen P. Electively mute children: an analysis of 37 Danish cases. Nordic J Psychiatry 1998;52:231-238. 22. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition. Washington. American Psychiatric Association 1994. 23. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, & Aluwahlia S. Childrens Global Assessment Scale. Archives of General Psychiatry 1983; 40:1228-1231. 24. National Statistics Socio-economic Classification: users manual NS-SEC. 2005: Office for National Statistics. 25. Spence S. The Spence children’s Anxiety Scale. The Child Psychology Portfolio1997: NFER-NELSON. 26. Goodman, R. The Strengths and Difficulties Questionnaire: a research note. J Child Psychol and Psychiatry 1997; 38:581-586. 27. Brown BJ, Lloyd H. A controlled study of children not speaking at school. Journal of Association of Workers with Maladjusted Children, 1975; 3, 49- 63. 28. Fundudis T, Kolvin I, Gariside RF. Speech Retarded and Deaf Children their Psychological Development. 1979; London:Academic Press. 29. Rosler M.Befunde beim neurotischen Mutismus der Kinder cine Untersuchungan 32 mutistischen Kindern. Praisx der Kinderpsychologie und Kinderpsychiatier 1981; 30, 187- 194. 30. Wilkens, R. A comparison of elective mutism and emotional disorders in children. British Journal of Psychiatry, 1985;146, 198-203. 31. DiBartolo PM, Albano AM, Barlow DH, Heimberg RG. Cross-informant agreement in the assessment of social phobia in youth. Journal of Abnormal Psychology 1998; 26, 213-20. 32. Lorand B. Katamnese elektiv mutistischer Kinder. Acta Paedopsychiatrica 1960; 27, 273-289. 33. Popella, E. Psychogener Mutismus bei Kindern. Nervenarzt, 1960;31, 257-263. 34. Steinhausen HC, Adamek R. The family history of children with elective mutism. European Journal of Child and Adolescent Psychiatry, 1997; 6, 107-111. 35. Carmody L. The Power of Silence: Selective Mutism in Ireland – a speech and language perspective. Journal of Clinical Speech and Language Studies, 2000;1, 41-60. 36. Remschmidt H., Poller M, Herpertz-Dahlmann B, Hennighausen K., Gutenbrunner, C.A follow-up study of 45 patients with elective mutism. European Archives of Psychiatry and Clinical Neuroscience, 2001; 251, 284-296. 37. Sharkey L, McNicholas F, Begley M. Elective Mutism Manual. Dublin. Mac Communications, 2004.

Figure 1: CGAS Scores

39


Table 1: Measures: Name of questionnaire

Rater

Description

Children’s Global Assessment Scale (CGAS)

Clinician

A measure of psychosocial and psychiatric functioning for children aged 4-16 years. A score less than 61 is used to identify subjects with definite disorders and a score between 61 and 71 to identify subjects with probable disorders.

Selective Mutism Questionaire (SMQ)

Parent/Teacher

A 36-item multiple-choice scale. Parental or teacher report of child’s speaking behaviours and interference associated with failure to speak.

Strengths and Difficulties Questionaire (SDQ)

Parent

A 24-item questionnaire of children aged 4-16 years. It identifies children with conduct, hyperactivity, depressive and anxiety disorders.

Spence Children’s Anxiety Scale (SCAS)

Child (age 8-12 years)

A self-report measure of anxiety. Thirty-eight anxiety items, six filler items and one open-ended non-scored item assessing social desirability. Scores on six sub-scales relating to separation anxiety, social phobia, panic/agoraphobia, generalized anxiety, obsessions/compulsions and fear of physical injury. The child is asked to rate on a four point scale – ‘never’= 0, ‘sometimes’ = 1, ‘often’ = 2, or ‘always’ = 3 – how often each item happens to them. This yields a maximum score of 114.

Parental report completed for children age 4-8 years Table 2: Clinical Descriptives N=14 Age Females Primary language

6.9 (5.2-10.6) 11 11 english (78.5%) 3 bilingual Average 4.6 years (range 2.9 – 5.2 years) 1=assessed 1=Tourette’s Syndrome (same child as above) 3 (21%) 9 (64%) 14 (100%) >moderate impairment Range 36-61 3 (21%) clinical range for anxiety

Onset symptoms Past child psychiatry history Treatment Dyspraxia Speech & Language delay CGAS SCAS

Table 3: Family History

SM SP Shy SL delay ASD Depression Hearing Imp’d Dyslexia

Mother

Father

3 3 11 1

1 3 1

Siblings

1st relative 2 1

3 1

4 5(6)

1 1 1

Table 4: SDQ (abnormal range)

Average score

Normal

Borderline

Abnormal

Emotional* (5-10 abN) HA/Imp (7-10 abN) CD (4-10 abN) Prosocial (0-4 abN) Peer* (4-10 abN) Total* (17-40 abN)

5 4 2 6.7 2 12.6

5 11 10 11 9 8

1 0 2 2 0 2

8 (57%) 3 (21%) 2 (14%) 1 (7%) 5 (36%) 4 (29%)

40


Brief Report

Psychotherapy training in Ireland: A survey of college tutors Alyson Lee, Angela Noonan

Ir J Psych Med 2012; 29 (1): 41-45

Abstract

Introduction

Objectives: Psychotherapeutic skills are essential to practice psychiatry effectively, but previous surveys of trainees in Ireland show that they have not been getting adequate training in psychotherapy. This survey of college tutors was carried out to coincide with the establishment of the College of Psychiatry of Ireland which is introducing new psychotherapy training requirements. The survey aims to ascertain if trainees had fulfilled the Royal College of Psychiatrists’ psychotherapy training requirements, models of psychotherapy available and the availability of psychotherapy qualifications amongst consultants and senior registrars.

Psychotherapeutic skills are an important component of general psychiatric practice: to enhance awareness of one’s emotional responses to situations, to improve communication skills and in understanding group dynamics.1 The biopsychosocial model is widely accepted and endorsed by A Vision for Change 2 and yet evidence from surveys of trainees in Ireland shows that trainees are not getting adequate experience or training in the psychological components of this model of psychiatric practice.3,4,5 This has been largely attributed to supply of trainers and supervisors rather than low demand from trainee psychiatrists.4 The new College of Psychiatry of Ireland was established in 2009 and a new training curriculum for basic specialist training has been published, though this will be reviewed. This could be viewed as an opportunity to have a fresh look at psychotherapy training and how it could realistically be implemented given the ever increasing workload of psychiatrists.

Methods: A questionnaire was posted to all registered tutors in the Republic of Ireland. Results: The postal questionnaire was sent to the 62 registered college tutors in the 13 training schemes. There is one tutor in each training hospital. The response rate was 79%. Our survey reveals that no psychotherapy training was available according to 16.3% of tutors. Only 22.5% of tutors were aware of trainees who had met college training requirements in the previous two years. 79.8% of tutors reported that there were consultants and senior registrars with qualifications in psychotherapy who could offer training if time and resources permitted.

The Royal College of Psychiatrists has consistently emphasised the importance of psychotherapy training by making it mandatory as part of basic psychiatric training. The practice of psychotherapy is considered a key aspect of psychiatric practice.1, 6 In 1993 the Royal College of Psychiatrists published guidelines for psychotherapy training as part of general professional training in psychiatry.7 In 2001 the College published requirements that were more specific and were intended to be mandatory for eligibility for the MRCPsych examinations.8 Psychotherapeutic knowledge and skills feature prominently in the Royal College of Psychiatrists’ 2009 Core Module of a Competency Based Curriculum for Specialist Training in Psychiatry.9 Trainees are expected to have delivered “basic psychological treatment in at least two modalities of therapy and over longer and shorter durations.”

Conclusions: Current training requirements are not being fulfilled. There are consultants and senior registrars who have psychotherapy qualifications to provide psychotherapy training but there are inadequate resources and time to formalise training. It is unlikely that the implementation of training requirements by the new college will be realisable without a review of training delivery. Key words: Psychotherapy; Training; Resources

Guidelines and the mandatory requirements of the Royal College of Psychiatrists have proved difficult to implement with repeated

* Angela Noonan, Consultant Psychiatrist, St. Vincent’s Hospital, Richmond Road, Dublin 3, Ireland. E-mail angelanoonan@svhf.ie

* Correspondence

Alyson Lee, Consultant Psychiatrist, Lakeview Unit, Naas General Hospital, Naas, Co. Kildare, Ireland.

Submitted July 20th 2010 Accepted August 31st 2011

41


studies showing that trainees have often been unable to meet them.10,11,12 A survey on psychotherapy conducted on trainees in the Eastern region of Ireland in 1997 also showed failure to meet requirements.4 In this study the authors found that 31.4% of trainees surveyed received formal training in psychotherapy and 47% delivered psychotherapy. Only 4% of trainees met the College requirements which were in place at the time.7 Trainees rate psychotherapy training as relevant to their overall training but have highlighted the lack of training opportunities and supervision as a problem.3,4,5

36.7% of training centres only psychiatrists were involved in delivering psychotherapy training. Table 3 shows how some centres have a limited range of modalities of psychotherapy training, where it exists at all. A noteworthy finding is that 79.8% of tutors reported that there were senior clinicians with training in psychotherapy who could be involved in the delivery of training if time and resources permitted. 67.3% of tutors stated that trainees had not met the training requirements and 10.2% did not know if trainees had met the requirements. Table 1: Provision of Psychotherapy Training

Tutors were surveyed for several reasons: knowledge of availability and access to training at a local level; knowledge of trainees who are fulfilling training requirements; identification of psychotherapy skills among trainers and supervisors.

Provider

Number of sites

None Psychiatry only Psychology only Family therapy only Psychiatry and psychology Psychiatry and social work Psychiatry and family therapist Psychiatry and nurse specialist Psychiatry and CBT therapist Psychiatry, psychology and nurse therapist Psychiatry, psychology, nurse therapist and occupational therapist Psychology and nurse therapist

The Royal College of Psychiatrists’ psychotherapy training requirements8 published in 2001 which were in place at the time of the survey were: • Development of interview skills • Psychotherapeutic formulation of psychiatric disorder • A minimum of three short term cases (12-16 sessions), each using a different psychotherapeutic model • One long-term individual case (12-18 months)-any model • Some experience of either group psychotherapy or couple, family or systemic therapy

8 (16.3%) 18 (36.7%) 6 (12.2%) 1 (2%) 5 (10.2%) 1 (2%) 2 (4.1%) 2 (4.1%) 1 (2%) 3 (6.1%) 1 (2%) 1 (2%)

Method A list of registered college tutors was obtained from the College of Psychiatry of Ireland. An anonymous questionnaire was posted to the 62 registered college tutors in the 13 training schemes. The tutors were asked to complete and return the questionnaire to the College of Psychiatry of Ireland in an envelope provided. The respondents were asked the following questions: 1. Is there psychotherapy training available on your scheme? 2. If there is training available who provides this? (Respondents were asked to identify disciplines that provided training.) 3. If there is training available what models of psychotherapy can the trainees access? 4. Within the last two years (2006-2008) did any trainees meet the Royal College of Psychiatrists’ training requirements? 5. Are there consultants and senior registrars trained in psychotherapy who, if time and resources permitted, could provide training?

Table 2: Modalities of Training Available Modality CBT Supportive Psychoanalytic Systemic/Family Therapy CAT IPT DBT Other

Number of sites where available 31 (63.3%) 21 (42.9%) 19 (38.8%) 15 (30.6%) 6 (12.2%) 4 (8.2%) 3 (6.1%) 2 (4.1%)

Table 3: Number of Psychotherapy Modalities Available Number of modalities

There was a free text section for comments. (A copy of the questionnaire is available from the authors on request).

None 1 modality 2 modalities 3 modalities 4 modalities 5 modalities

Results The results were recorded and collated by the authors and are presented in tables 1-5. The response rate was 79% with 49 tutors out of a possible 62 responding to the questionnaire. Some psychotherapy training was available to trainees according to 83.7% of tutors, with 16.3% reporting no training available. CBT was the most commonly available modality of psychotherapy. In

42

Number of tutors who reported availability 8 (16.3%) 9 (18.4%) 16 (32.7%) 9 (18.4%) 3 (6.1%) 4 (8.2%)


Table 4: Trainees meeting Royal College of Psychiatrists guidelines Yes No Don’t know

The clinical cases should be in at least two different psychotherapy modalities. It also states that training must include both theoretical and practical training and must be effectively supervised. Since the establishment of the College of Psychiatry of Ireland, a Basic Specialist Training Blueprint based on achievement of competencies has been published.6 This includes yet another set of psychotherapeutic goals. The requirement of the Handbook regarding four cases is suggested as desirable. It is stated that training schemes must provide Balint-style groups. Additionally the Blueprint states that each trainee must complete a minimum of 18 sessions of brief psychological intervention and demonstrate competence in psychotherapeutic aspects of advanced history taking and formulation. As one of the competencies for child psychiatry, it is stated that the trainee must be able to utilise play therapy. The basic principles of the new curriculum are to be welcomed, as indeed is the introduction of a training portfolio, but in our view what a trainee is expected to know and to be able to demonstrate at the end of training remains onerous and the obstacles to training delivery remain the same.

11 (22.5%) 33 (67.3%) 5 (10.2%)

Table 5: Consultants and Senior Registrars trained in psychotherapy who could provide training if time and resources permitted Yes No

39 (79.6%) 10 (20.4%)

Discussion To our knowledge this is the first survey of college tutors about psychotherapy training in Ireland. However, the small percentage of trainees meeting college training requirements is in keeping with a previous survey of trainees in the Eastern region of Ireland.4 As the larger training schemes have several tutors they may be over represented and the finding that 16.3% of tutors report no psychotherapy training could be an underestimate as it is likely that in smaller schemes there are fewer resources.

There are other challenges. Many training schemes cover wide geographical areas so seeing a patient over a long period of time is impractical. One solution would be for trainees to remain in the same hospital for one year. Many trainees do spend their first year in one hospital but as they advance in their training when undertaking psychotherapy may be more appropriate, they rotate through subspecialty posts every six months and lack of continuity in terms of patient and trainee tutor contact are further obstacles. Some tutors were not aware of how many, if any, trainees were meeting training requirements. One tutor responded that psychotherapy training was “virtually non-existent leaving a massive chasm in service provision.” Another respondent said that the training arrangements were “very piecework.” The establishment of a national training programme with designated psychotherapy tutors in each training scheme would create greater structure and continuity to training. This was suggested as a possible solution by a previous survey of trainees and consultants.3

Our survey shows that 79.6% of respondents affirmed that training could be provided if there were sufficient time and resources available. In Ireland there are approximately 400 trainees in basic training and approximately 100 in higher training. There are only two approved consultant psychiatrist posts with a special interest in psychotherapy in the public health service.19 In contrast to the UK there are no subspecialty placements in psychotherapy at basic specialist training or higher training level. This survey highlights the fact that psychiatrists are obtaining psychotherapy training but are not using these skills to train junior colleagues. Furthermore, whilst consultants may update their theoretical knowledge through attendance at courses and workshops, they possibly are not utilising their formal psychotherapy skills due to other commitments which can lead to their attrition.18

The European Working Time Directive means that trainees have less time than before to fulfil training requirements. The high court settlement on 22nd of January 2010, between the Irish Medical Organisation and the Health Service Executive decreed that time rostered for training would not constitute working time under the EWTD but would qualify for payment.14 This may be a solution; however, it would depend on the motivation of trainees and the willingness of employers to pay.

In June 2008 the Irish Psychiatric Training Committee produced a Handbook for Basic Specialist Training in Psychiatry13 which was valid at the time of our survey (and a slightly updated version is still valid for all but the foundation year basic specialist trainees who commenced training in July 2011). The handbook includes the following psychotherapy training guidelines: • Understanding of psychodynamics and team work • Development of good communication and interview skills • Participation in an experiential reflective group (e.g. Balint group) minimum 30 sessions • One long term case (minimum 24 sessions) • Three short term cases (8-16 sessions)

Even where training is available, feedback from some tutors indicates that interest and take up of psychotherapy cases can be poor. This may be because of fear and apprehension about feeling de-skilled12 and of psychotherapy not being immediately pertinent to training and career progression as the focus of trainees may be on passing examinations.13 UK based trainees are expected to have been assessed formally in having achieved competencies in psychotherapy and the trainee must have received structured, documented feedback on their performance to be eligible to undertake the CASC exam, the final component of the membership exam.16 Tutors based in Ireland are completing sponsorship forms for the CASC examination without these competencies being demonstrated. 43


Another challenge is bringing about a shift in the culture of training so that more emphasis is placed on psychotherapy experience in becoming a good psychiatrist. One respondent stated that we require psychotherapy role models. The majority of trainees aspire to do their higher training in Ireland and in order to be considered for interview for higher training, candidates will be awarded marks for research or audit that has been published or presented. According to the College of Psychiatry of Ireland, qualifications in psychotherapy will be rated for shortlisting for higher training in psychiatry.17 However, obtaining a qualification in psychotherapy is a time consuming undertaking and is unlikely to be attained during basic training. Perhaps the College could consider rewarding trainees who have documentary evidence of cases undertaken for psychotherapy as part of basic specialist training so that trainees selected for higher training have a range of both academic and psychotherapeutic skills.

References 1. Mitchison S. Next year in Jerusalem: Psychotherapy training for tomorrowâ&#x20AC;&#x2122;s consultants. Advances in Psychiatric Treatment 2007;13:276-283 2. A Vision for Change. Report of the expert group on mental health policy. The Stationery Office.2006. http://www.hse.ie/eng/services/Publications/services/ Mentalhealth/Mental_Health_-_A_Vision_for_Change.pdf 3. Rooney S, Kelly G. Psychotherapy experience in Ireland. Psychiatr Bull 1999; 23:89-94. 4. Byrne P, Meagher D. Psychotherapy and trainees. Psychiatr Bull 1997; 21:707-710. 5. Oâ&#x20AC;&#x2122; Mahoney E, Corvin A. The attitudes of Irish trainees to their training and its supervision: a five year follow up study. Ir J Psych Med 2001; 18(4): 120125. 6. http://www.irishpsychiatry.ie/Libraries/Postgraduate_ Training_Documents/BST_Blueprint_Final.sflb.ashx (accessed 25th July 2011) 7. Royal College of Psychiatrists. Guidelines for psychotherapy training as part of general professional training. Psychiatr Bull 1993;17:695-698. 8. Royal College of Psychiatrists. Requirements for psychotherapy training as part of basic specialist psychiatric training. Royal College of Psychiatrists. 2001. 9. http://www.rcpsych.ac.uk/pdf/CORE%20CURRICULUM %20October%202010.pdf (accessed 26th July 2011) 10. McCrindle D, Wildgoose J, Tillett R. Survey of psychotherapy training for psychiatric trainees in south west England. Psychiatr Bull 2001; 25:140-143. 11. Pretorius W, Goldbeck R. Survey of psychotherapy experience and interest among psychiatric specialist registrars. Psychiatr Bull 2006; 30:223-225. 12. Agarwal S, Singh Y, Palanisamy V, Basker R, Van der Speck R. Psychotherapy requirements as recommended by the college: awareness and achievement by senior house officers. Psychiatr Bull 2007; 31:394-396. 13. http://www.irishpsychiatry.ie/Libraries/2010_Press_Releases /CPsychi_BST_handbook_sept_2010.sflb.ashx (accessed 26th July 2011) 14. http://www.hse.ie/eng/about/Who/Board_Members/ceorpts /feb10ceorpt.pdf (accessed 25th July 2011) 15. Malcolm M. Reflections in psychotherapy: a personal view. Pscyhiatr Bull 1977; 1:8-10. 16. http://www.rcpsych.ac.uk/pdf/Information%20Pack%20 for%20the%20Psychotherapy%20section%20of%20the %20C&G%20curriculum.pdf (accessed 26th July 2011) 17. http://www.irishpsychiatry.ie/Libraries/Postgraduate_ Training_Documents/Psy868_Shortlisting_Criteria.sflb.ashx (accessed 26th July 2011) 18. Denman C. The place of psychotherapy in modern psychiatric practice. Advances in psych treatment 2011;17:243-249. 19. Consultant Appointment Unit, Health Service Executive

Conclusion Limited psychotherapy training is available in most training schemes but 16.3% of respondents reported that no psychotherapy training of any kind was available in their training scheme. Although only 22.5% of respondents stated that their training scheme met the Royal College of Psychiatrists training requirements, almost 80% of tutors said that there were a sufficient number of senior trainees and consultants who could provide training if they had enough time to do so. Increased resources are needed so that consultants have protected time to provide psychotherapy supervision. Provision of training by our psychology colleagues needs to be considered further although their resources are also very limited. The establishment of a national training programme would allow for greater structure and coordination in delivery of training. We have suggested other changes to improve delivery of psychotherapy training which include one year hospital placements in the latter part of basic training and shifting the training culture by placing a greater value on psychotherapy experience in the shortlisting process for higher specialist training. The formation of the College of Psychiatry of Ireland and the development of a new curriculum provides a wonderful opportunity to enshrine the central importance of psychotherapy in psychiatric training, but given the many competing demands on consultants, our view is that unless there are increased resources, the proposed requirements will merely represent unrealisable ideals.

Conflict of interest None.

Acknowledgements Thanks to Grace Smyth of the College of Psychiatry of Ireland for her invaluable assistance.

45


Original Paper

Suicide ideation, psychological adjustment and mental health service support: A screening study in an Irish secondary school sample Ciara Brennan, Sinéad McGilloway

Ir J Psych Med 2012; 29 (1): 46-51

Abstract

Introduction

Objective: The aim of this exploratory study was to investigate the extent of suicide ideation, psychological maladjustment and views of mental health service support in a sample of secondary school pupils.

The increasing levels of suicide in Ireland, particularly amongst young people, have attracted much attention in recent years. Ireland has the fifth highest rate of youth suicide in the European Union1 and suicide is the principal cause of death amongst young men in this country.2 In 2006, 409 people in the Republic of Ireland (9.6 per 100,000) reportedly completed suicide.3 Crucially, these figures do not include parasuicide or deliberate self harm, for which the National Parasuicide Registry (NPR) recorded 11,000 hospital attendances in 2004. Recent data released by the Institute of Public Health (IPH) (Barron et al 2008)4 indicate an overall suicide rate for the Republic of Ireland of 11.2/100,000 (2001-2004), although this figure conceals considerable regional variations.

Method: A cross-sectional survey was conducted on a purposive sample of participants (n=93) recruited from a secondary school located in the south east of Ireland. Participants completed a Background Information Questionnaire (BIQ); the Suicide Ideation Questionnaire (SIQ); and the Reynolds Adolescence Adjustment Screening Inventory (RAASI). Results: Approximately ten percent of participants displayed high levels of suicide ideation whilst one third reported having previously had suicidal thoughts; one quarter reported psychological adjustment difficulties, although these varied by age and sex. Participants’ drug use and their levels of parental closeness were both individual factors that significantly predicted both suicide ideation and psychological adjustment. Females reported higher levels of parental closeness than males. Forty percent of respondents rated mental health support services as insufficient to meet their needs.

A number of factors have been identified as antecedents in suicidal behaviour and suicide attempts,5, 6, 7 whilst a stable progression has also been found between suicide ideation and suicidal behaviour. 8, 9 However, relatively little research on suicide ideation has been conducted amongst young people in non-clinical settings in Ireland, particularly within school-based populations. O’Sullivan10 and Lynch2 have conducted research among young school-going adolescents (13-15 years old), whilst other studies have based their research on older adolescents.11, 12 Suicide ideation is evident in both age groups.

Conclusion: The findings raise serious concerns about the extent of suicidal thoughts amongst young people in Ireland; they also highlight a potentially important role for parents in this regard. Further research should ascertain national prevalence rates whilst appropriate school-based mental health education/promotion and support services should also be implemented.

The principal aim of this exploratory study was to investigate the extent of suicide ideation in a sample of secondary school pupils and to assess their overall psychological adjustment. The specific study objectives were to: (1) ascertain overall levels of suicide ideation; (2) assess the prevalence of common psychological adjustment problems; (3) explore the relationship between suicide ideation, psychological adjustment and a number of key background variables including parental closeness; and (4) assess overall views of mental health service provision.

Key words: Suicide ideation, Young people, Adolescents, Schools, Mental health.

* Sinéad McGilloway, Senior Lecturer and Director Mental Health and Social Research Unit, Department of Psychology, NUI Maynooth, Maynooth, Co. Kildare, Ireland. E-mail Sinead.McGilloway@nuim.ie

* Correspondence

Ciara Brennan, HDip Student and Classroom Assistant, Sandford Parish National School, Ranelagh, Dublin 6, Ireland.

46

Submitted August 22nd 2008 Accepted August 4th 2010


pupil and parents were asked to provide their written informed consent on an ‘opt-out’ basis. Participants were also given the opportunity not to take part in the study, although all agreed to take part. Whilst participants were of an age that did not require the questions to be read aloud, the researcher was on hand to answer any questions and address any concerns. No literacy problems were reported. All participants also received a self-help information booklet (e.g. on local mental health services) following questionnaire completion, and were reminded of the counselling service provided by the school. In addition, the school principal and the school counsellor were identified to the pupils as appropriate support persons. Thes two individuals were alerted to the findings (in writing) as soon as they became available and indicated their commitment to provide support to the relevant classes in whom ‘at risk’ pupils were identified.

Method Participants and Settings A purposive sample of 93 participants (46 males and 47 females) aged 15 to 18 years (Mn=16.73; SD=0.75), was recruited from a large, co-educational secondary school located in an urban area of Wexford in the south east of Ireland. Both younger (15-16 years) and older (17-18 years) age groups were targeted in order that agerelated comparisons could be made. The school principal identified four classes in which there were prospective participants of a suitable age and which were deemed to be broadly representative of the different age groups within the school; each class included approximately 25 pupils. All of those present at the time of the study agreed to take part. Whilst we were unable to gauge the exact number of pupils who were absent at the time of questionnaire administration, we would estimate, from the final sample size and the average class size, that the proportion missing was approximately 5%-7%.

Results Participant profile Most participants were living in rural settings (65%), had parents who were married (79%) and came from families with three or fewer siblings (63%). Three quarters consumed alcohol and 48% of males and 21% of females respectively were classified as ‘binge drinkers’ (i.e. those who consume more than 5 drinks in one setting) (World Health Organisation, 2004).15 One third confirmed using drugs such as cannabis, ecstasy, cocaine and ‘speed’, 42% of whom stated that they did so to relieve stress. Seventy per cent indicated that they had no trouble in acquiring drugs. Whilst females tended to report higher levels (M=6.94, SD=2.9) of parental closeness than their male counterparts (M=5.59, SD=2.5) (t(91)=2.4, p=0.18; η2= .06), this failed to reach statistical significance.

Measures Participants completed (anonymously) a questionnaire booklet containing three self-report questionnaires including: 1) A Background Information Questionnaire (BIQ); 2) the Reynolds Adolescents Adjustment Screening Inventory (RAASI); and 3) the Suicide Ideation Questionnaire (SIQ). The BIQ was designed specifically for purposes of this study to obtain key sociodemographic and background information, such as experience of suicidal thoughts (direct questions), parental closeness (Likert scale) and views of mental health provision (open-ended questions). A number of questions on the use and abuse of alcohol and drugs were also included.

Suicide Ideation and Experiences with Suicide Approximately one third of participants (32%, 30/93) reported that they had, at some stage, experienced suicidal thoughts (Figure 1) (defined as thoughts of death and wanting to die), more than one quarter of whom (27%, 8/30) met the ‘at risk’ criteria (i.e. scores above 31) on the SIQ; 67% (20/30) of this group were in the older age group (17-18 years). We were particularly interested in exploring any age and sex differences due to previous research that suggests that these are important concerns in this area.10,16 Participants experienced suicidal thoughts as young as 10 years, although these most commonly occurred between the ages of 14 and 16 years (78%). More young (15-16 year olds) females (44%) than males (8%) reported being bothered by suicidal thoughts, although this had levelled off in the older age groups. A series of independent t-tests showed no significant gender or age group (younger versus older) differences in SIQ scores (p>0.05).

The RASSI13 is a 32-item, easy-to-administer and psychometrically robust measure that is commonly used to screen for psychological adjustment problems (e.g. antisocial behaviour; anger control problems; emotional distress) in adolescents aged 12-19 years. Participants are asked to rate the extent to which they have experienced a particular thought in the last six months. All items use a three-point response format ranging from ‘never’ through ‘almost never’ to ‘nearly all the time’. The frequency of symptoms of adjusted problems is recorded for each sub-scale. A ‘Total Adjustment’ score may also be calculated, based on the scores for all four sub-scales together. The SIQ-JR,14 (Reynolds, 1987) is a brief, 15-item screening measure (with good psychometric status) designed to assess thoughts about suicide amongst adolescents aged 12 to 15 years. Item content ranges from general thoughts of death and wishes to die, to serious and more specific thoughts and ideas. Each item is rated on a 7-point scale (0-6) in order to assess the frequency of occurrence during the previous month (maximum score 90); higher scores indicate more numerous, regular suicidal thoughts. Respondents are considered to be ‘at risk’ if they obtain scores above 31.

All students identified as ‘high risk’ (8/93) (as measured by the SIQ) were currently using drugs and more commonly reported binge drinking (43%, 13/30) than those without suicidal thoughts (29%, 18/63). Similarly, over half of this group (57%, 17/30) reported consuming drugs in the past, compared to only 14% (9/63) of those who reported no suicidal thoughts. Furthermore, 70% of all participants (64/93) knew someone who had either attempted, or completed suicide and this group was significantly more likely to experience suicide ideation than those without such knowledge (χ2= 5.4, df= 93 p=0.02).

Ethical considerations This study was conducted in accordance with the Codes of Conduct of the British Psychological Society and Psychological Society of Ireland. It was also reviewed internally and discussed in detail with relevant school staff prior to commencement. Parental consent forms, devised for purposes of the study, were distributed to each 47


perceived parental closeness, were more likely to experience suicide ideation. Neither binge drinking, nor knowing a suicide victim, contributed significantly to this model. The second regression model (Table 1) explained 36% (adjusted R2 =.32) of the variability in adjustment scores and again, drug use, followed closely by parental closeness were the most influential variables and were of a similar size and direction to those indicated above. As in the case of SIQ scores, neither of the other two independent variables made a significant unique contribution to the model.

% of participants

50 40 30

Males

20

Females

10 0 15-16YRS

15-16YRS Age Group

Figure 1: Proportion of participants (n=93) who had, at some stage, experienced suicidal thoughts Psychological adjustment Clinically relevant levels of adjustment problems were reported in one quarter (23/93) of participants and most commonly included negative self-esteem and emotional distress respectively (Figure 2). Unsurprisingly, moderate to strong positive correlations were found between the SIQ and all sub-scales of the RAASI. One third of those experiencing maladjustment (i.e. high total adjustment scores) also reported ‘high-risk’ levels of suicide ideation. Parental closeness was negatively and strongly correlated with both suicide ideation [r = -.466, n = 92, p<0.000] and total adjustment [r=-.437, n=92, p<0.000]. None of the male participants showed signs of emotional distress, although one-quarter (6/24) of the 17-18 year old females reported clinically significant emotional problems. Poor anger control and antisocial behaviour respectively were seen in 9%-12% of older males and 5%-9% of younger females. None of the younger males or older females reported these problems. No significant age or gender differences were found with respect to the RAASI total adjustment scores, or each of the sub-scales, with the exception of emotional distress scores, which were significantly higher for females (M=9.66, SD=5.1) than for males (M=6.11, SD=3.8) (t(91)=4.12, p=0.000, eta squared= 0.6).

Table 1: Summary of findings from two standard multiple regression analyses of key variables on suicide ideation (SIQ) and total adjustment (RAASI) scores respectively B RAASI

SIQ

RAASI

SIQ

RAASI

4.5

2.9

3.7

9.63

.442

.378***

Parent closeness 1.77

.43

.54

1.28

.379

.309**

Binge drinking

.45

1.3

1.7

.008

.034

.001ns

Know suicide Victim

2.69

2.6

3.3

3.07

.102

.125ns

Drug Use

Note: SIQ: R2=.41, Adj R2 = .376; RAASI: R2 = .363, Adj R2 = .324 ***p<0.001; **p<0.01; ns = non-significant

Service provision Almost one third of participants reported that they had received professional help, primarily for anger management, stress and family problems. Forty per cent of those who had experienced suicide ideation (12/30) reported that they had never received any professional help whilst only one quarter of the ‘high risk’ group (2/8) were receiving counselling. Forty per cent of the total sample reported that they would like to receive additional information and education on mental health and that they needed more support services to help them during times of stress. Some suggestions included: the provision of younger counsellors to whom pupils could more easily relate; stress management classes; advice on supporting others with mental health difficulties; problem solving; and regular counselling sessions available to everyone.

45 40 35 30 25 20

% of participants

10 5 0

Antisocial behaviour

Anger Control

Emotional Distress

Negative Self-esteem

Beta

SIQ

50

15

S.E.

Total Adjustment

Discussion Figure 2: Levels of clinically significant adjustment problems in the sample (n=93)

The principal aim of this study was to obtain a ‘snapshot’ of suicide ideation in an opportune sample of secondary school students. However, overall levels of psychological adjustment and participants’ views of mental health service provision were also assessed. The findings suggest that a significant proportion of teenagers struggle with suicide ideation at some point in their lives and yet, most of those deemed to be currently at risk, do not appear to be seeking or receiving appropriate professional support. Nonetheless, it is interesting to note the relatively high proportion of the total sample overall, who reported that they had received professional help, primarily for anger management, stress and family problems. No information was sought on precisely the type of services used, although it is likely that a proportion of this group

A number of predictor variables were regressed upon suicide ideation and overall adjustment problems in two standard multiple regression analyses (Table 1). These variables included drug use, binge drinking, parental closeness and knowledge of someone who had completed suicide (age and sex were not included as these were only weakly correlated with SIQ and total RAASI scores). In the first analysis, 41% of the variance in SIQ scores (adjusted R2 =.38) was predicted by the model and both drug use and parental closeness respectively, emerged as significant predictors of suicide ideation. Thus, the size and direction of the relationships suggested that those who engage in drug use and have low levels of

48


the Irish Mental Health Initiative of 200320 highlights the importance of education and positive mental health promotion in suicide prevention. One of its aims is to educate adults and young people on the prevention and recognition of mental illness, to teach them how to deal with stressful situations and create their own support network. For instance, the National University of Ireland, Galway (one of the seven universities in Ireland), introduced a ‘mind body and soul programme’ in 2002 to promote general well-being amongst its student population. This approach has since been used in several other third level institutions and may offer a useful model for secondary level schools. Similarly, Eckert and colleagues21 found that implementing curriculum-based programmes to educate students about mental illness and suicide was viewed (by American students) as less invasive than school screening procedures. The Finnish government22 (which is well known for its innovative mental health service provision), has also implemented a national strategy which has effectively reduced suicide deaths across all age groups, by involving local communities in regional decision making strategies and procedures.

sought help from the school counsellor, given the relative dearth of youth mental health services. Similarly, Sullivan and colleagues17 report that almost one in five teenagers who were experiencing problems, had received professional help. Previous research conducted in Ireland suggests that the proportion of young people with suicide ideation has not changed substantially during the last ten years, despite greater suicide awareness and ongoing attempts to improve both formal and informal service provision.2,11,18 For example, an early study by O’Sullivan and Fitzgerald11 found that suicide ideation and self harm rates within a sample of 13-14 year-old Dublin schoolchildren (n=88-101) ranged from 29% to 44% respectively. Another Irish study,18 conducted with younger adolescents (13-15, n=195) in a school setting, found that 15% reported suicidal thoughts – much lower than the one third seen in the current study, which also included older adolescents. In 2004, Lynch and colleagues2 identified almost 20% of a sample of Irish 12-15 year-olds (n=723) to be at risk of possible suicide ideation and mental ill health. This is consistent with Sullivan et al17 who reported that 20% of pupils showed signs of possible depression. They also found that just over 30% of girls had serious thoughts of harming themselves. Thus, it is clear that there is considerable variation in suicide ideation/self harm rates amongst adolescents in Ireland. It is also difficult, on the basis of available data, to make comparisons with other countries. For instance, rates in Poland amongst adolescents appear to compare favourably to Ireland,7 although Italy has lower levels than reported in either country.10 It is likely, of course, that such disparity may be due to methodological differences across studies, as well as variations in sample size and overall quality.

Research has shown that negative family environments contribute to emotional distress which, in turn, can affect suicide ideation.23, 24 Thus, those who have a supportive family environment are less likely to report suicidal behaviour.25 Irish society, particularly in rural areas of the country, is characterised by strong family ties, and parental closeness was one factor that was examined in this study; this has not previously been reported in Irish studies. The findings outlined here suggest, in line with previous cross-cultural research, 26, 27, 28 that parental closeness is a strong negative correlate of suicide ideation, and second only to substance abuse. This, coupled with drug use, predicted a sizeable proportion of the variance in both suicide ideation and psychological adjustment scores, although other factors are clearly at play. This highlights the potentially critical role of parenting and of strong parent-child relationships in preventing suicide, but this merits further research, both nationally and internationally, in order to tease apart the precise mechanisms involved in this relationship.

Whilst the above studies focus on younger adolescents, the current research also included older adolescents, but more large-scale research with this group is needed, particularly as these young people are moving into an important transition phase in their lives. Furthermore, the current study was based in county Wexford, an area in which there has been a recent spate of family suicides and which has a suicide rate (13-15/100, 00) that is higher than the national average;4 consequently, the researchers were interested in establishing (albeit in an exploratory manner) any possible effects of this on young people living in the area. The findings reported here confirm that most of the young people surveyed knew someone who had attempted, or completed suicide and, in line with work from elsewhere, this group was more likely to experience suicidal thoughts and ideas.6, 12, 19 Therefore, it would appear that the young people living in this area represent a particularly important target group for mental health professionals and schools, in terms of developing effective suicide prevention strategies and appropriate support services, including school-based initiatives.

The current sample reported high levels of alcohol and drug abuse similar to those seen in other larger samples,29 particularly in young people deemed to be at risk. Substance abuse has been identified as an important risk factor in suicide ideation30, 31 and research would suggest that the provision of mental health education and promotion in schools, should incorporate some information on substance abuse as well as depression, anxiety and some of the other more common adjustment problems seen in this study. Interestingly, the one quarter of participants in the current study who experienced some form of adjustment problem, is marginally higher than the 20 percent prevalence of mental ill health typically found amongst young people elsewhere,1,32 although no clinical diagnoses were used in this study.

However, young people must also be prepared to seek and receive help and recent qualitative research has shown that young student males, in particular, may not be willing to seek help for a mental health problem due to a lack of understanding, stigma and confidentiality issues.12 This may explain, at least in part, the lower levels of emotional distress reported in the young males in this study. It is also possible that there is a lack of openness among young males to recognise or admit to these feelings. Reassuringly,

Conclusion This exploratory screening study was limited by a relatively small sample drawn from a single large, urban-based school and the results do not include clinical/diagnostic interviews. While the sample was one of convenience, there is no reason to expect that the 5th and 6th year classes included in this study were in any way

49


atypical of young people generally in this age group and indeed the findings would tend to support this; for instance, the results are consistent with those found elsewhere with both similar-sized and larger samples.

health promoting initiatives and support services for our young people.

Acknowledgements We would like to thank the school principal and all of the pupils for participating in this study.

Overall, the findings raise some serious concerns about the extent of suicidal thoughts and ideas in young people whilst also highlighting, amongst other things, the importance of the parentchild relationship into the teenage years. The latter is something about which very little is known. However, it would be useful to assess regional variations within a larger national longitudinal study in order to describe and track the overall prevalence of, and changes in, suicide ideation amongst young people over time and the extent to which these relate to actual suicide rates.

Conflict of interest None.

References 1. WHO. World Health Organisation, European Ministerial Conference 2005. Mental health: facing the challenges, building solutions (2005). 2. Lynch F, Mills C, Daly I, Fitzpatrick C. Challenging times: a study to detect Irish adolescents at risk of psychiatric disorders and suicidal ideation. J Adolesc 2004; 27(4): 441-451. 3. Central Statistics Office. Vital Statistics Fourth Quarter & Yearly Summary 2006. Released 31 July 2007. http://www.cso.ie/newsevents/pr_vitalstatsq4andyear2006.htm 4. Barron S, Balanda K, Graham A, Fahy L. Irish Health Poverty Index (interim release). INIsPHO Data Briefing No.2008:1. Dublin: Institute of Public Health, 2008. 5. Friedman AC. Prevalence and correlates of suicidal ideation and selfreported attempts in an adolescent community population. Dissertation Abstracts International Section A: Humanities and Social Sciences 1998; 59 (1): 0322. 6. Leo DD, Cerin E, Spathonis K, Burgis S. Lifetime risk of suicide ideation and attempts in an Australian community: Prevalence, suicidal process,and helpseeking behaviour. J Affective Disorders 2005; 86: 215–224. 7. Gmitrowicz A, Szymczak W, Kotlicka-Antczak M, Rabe-Joblonska J. Suicidal ideation and suicide attempts in Polish adolescents: Is it a suicidal process? Int J Adolesc and Med Health 2003; 15 (2): 113-124. 8. Miros NJ. Depression, anger, and coping skills as predictors of suicidal ideation in young adults: Examination of the diathesis-stress-hopelessness theory. Dissertation Abstracts International: Section B: The Sciences and Engineering 2000; 61(6): 3286. 9. Wong JPS, Stewart SM, Ho SY, Rao U, Lam TH. Exposure to suicide and suicidal behaviors among Hong Kong adolescents. Soc Sci & Med 2005; 61: 591–599. 10. O’Sullivan M, Fitzgerald M. Suicidal ideation and acts of self-harm among Dublin school children. J Adolesc 1998; 21: 427-433. 11. Miotto, P., De Coppi, M., Frezza, M., Petretto, D., Masala, C., & Preti, A. (Suicidal ideation and aggressiveness in school-aged youths. Psychiatry Research 2003, 120, 247-255. 12. Burke S, Kerr R, McKeon P. Male secondary school students’ attitudes towards using mental health services. Ir J Psych Med 2008; 25(2): 52-56. 13. Reynolds WM. Reynolds Adolescent Adjustment Screening Inventory. Professional Manual Psychological Assessment Resources. Odessa FL: Psychological Assessment Resources, 2001. 14. Reynolds WM. Suicide Ideation Questionnaire. Odessa, FL: Psychological Assessment Resources, 1987. 15. World Health Organisation. Global Status on Alcohol – Binge drinking defined. Geneva: World Health Organisation, 2004. 16. Bensley, L S, Van Eenwyk, J, Spieker, S J, Schoder, J. Selfreported abuse history and adolescent problem behaviours I: Antisocial and suicidal behaviours, Journal of Adolescent Health, 1999, 24, 163-172. 17. Sullivan C, Arensman E, Keeley HS, Corcoran P, Perry IP. Young People’s Mental Health: a report of the Lifestyle and Coping Survey. National Suicide Research Foundation, 2004. 18. Rowley J, Ganter K, Fitzpatrick C. Suicidal thoughts and acts in Irish adolescents. Ir J Psych Med 2001; 18(3): 82-86. 19. Fergusson DM, Beaturais AL, Horwood LJ. Vulnerability and resiliency to suicidal behaviour in young people. Psych Med 2003; 33: 61-73.

It is widely acknowledged that young people on the island of Ireland lack specialist mental health service provision33 whilst mental health services spending is also well below what is required.34 Nonetheless, it is imperative that vulnerable, at risk young people can be identified as early as possible and appropriate prevention strategies put in place in order that potential deaths can be avoided into the future. The Irish National Strategy for Action on Suicide Prevention 2005-201435 advocates the development of counselling services and crisis response protocols in all primary and secondary schools throughout Ireland. Likewise, one of the aims enshrined in the recent Programme for Government document in Northern Ireland,36 is to establish a suicide prevention helpline, as well as initiatives aimed at improving the life and coping skills of all those at risk of suicide. Importantly, a significant proportion of the young people in the current study were not satisfied with mental health support and indicated a high level of unmet need. While some of their suggestions for improvement in this regard have significant resource implications (e.g. regular counselling), others could be more easily implemented in schools (e.g. younger counsellors). It is also important to note that the Irish school curriculum includes a Social Personal Health Education (SPHE) module aimed at: developing self-awareness and personal skills; emotional health; relationship skills; stress management; and promoting a greater awareness/knowledge of mental illness. Other elements of the programme are aimed at helping students to develop the confidence to protect their mental health and well being, and to examine the factors that might impact on these. It is difficult to know to what extent this programme has been effective, but at the very least, it is providing a forum to discuss the many issues that affect young people. The prevention of suicide amongst young people continues to be controversial due, in large part, to the paucity of population-based studies and a failure to take account of the multiple risk factors involved.37 The results of the research were conveyed to the school that was the focus of this study and in this way, research findings such as those reported here, may help to develop mental health promotion initiatives in schools, thereby potentially preventing deaths from suicide in ‘at risk’ young people into the future. However, it remains to be seen to what extent the current downturn in the Irish economy will impact upon the much needed implementation of school and other community-based mental

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20. Kracen, A. The Mental Health Initiative: a resource manual for mental health promotion and suicide prevention in third level institutions. A partnership initiative between Trinity College Dublin and the Northern Area Health Board. Supported by the National Suicide Review Group, the Department of Health and Children, and the Department of Education and Science, 2003. 21. Eckert TL, Miller DN, Riley-Tillman TC, DuPaul GJ. Adolescent suicide prevention: Gender differences in students’ perceptions of the acceptability and intrusiveness of school-based screening programs. J School Psychol 2006; 44: 271–285. 22. Jenkins R, Singh B. Suicide prevention strategies – an international perspective. Int Rev Psychiatr 2000; 12(1): 7-14. 23. Connor JJ, Rueter MA. Parent–Child Relationships as Systems of Support or Risk for Adolescent Suicidality. J Family Psych 2006; 20(1): 143–155. 24. Stanley H. Family characteristics that influence and differentiate adolescent non-single, and multiple suicide attempts. Dissertation Abstracts International: Section B: The Sciences and Engineering 2004; 65(5-B), 2008. 25. Evan DL, Foa EB, Gur RE, Hendin H, O’Brien CP, Seligman MEP, Walsh BT. Treating and Preventing Adolescent Mental Health Disorders: What we know and what we don’t know. London: Oxford University Press, 2005. 26. Borowsky IW, Ireland M, Resnick MD. Adolescent suicide attempts: Risks and protectors. Pediatrics 2001; 107: 485-493. 27. Séguin M, Lynch J, Labelle R, Gagnon A. Personal and family risk factors for adolescent suicidal ideation and attempts. Arch Suicide Res 2004; 8(3): 227238. 28. Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behaviour. J Child Psych and Psychiatry 2006; 47(3): 372–394. 29. McCrystal P, Percy A, Higgins K. Drug use patterns and behaviours of young people at an increased risk of drug use during adolescence. Int J Drug Policy 2006; 17(5): 393-401. 30. Fombonne E. Suicidal behaviours in vulnerable adolescents. Time trends and their correlates. Br J Psychiatry 1998; 173: 556–7. 31. Cleary A, Nixon E, Fitzgerald M. Psychological health and well-being among young Irish adults. Ir J Psych Med 2007; 24(4): 139-144. 32. Department of Health and Children. A Vision for Change. Dublin: Department of Health and Children, 2006. 33. McGilloway S, Donnelly M, Scott D. Teenagers in adult psychiatric inpatient care in Northern Ireland. Ir J Psych Med 2000; 17(2): 54-58. 34. O’Shea E, Gannon B, Kennelly B. Eliciting preferences for resource allocation in mental health care in Ireland, Health Policy 2008; doi:10.1016/j.healthpol.2008.03.018. 35. Health Service Executive. Reach Out: National Strategy for Action on Suicide Prevention 2005-2014. Dublin: The Health Service Executive, 2005. 36. Northern Ireland Executive. Building a Better Future – Programme for Government 2008-2011. Belfast: Northern Ireland Executive, 2008. 37. Donnelly M, McGilloway S. Mental Disorders. In: Yarnell J, Ed. Epidemiology and Prevention: A Systems-Based Approach. London: Oxford University Press, 2007.

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Case Report

Graphology and psychiatric diagnosis: Is the writing on the wall? Mary Davoren, Natalie Sherrard, Eugene Breen, Brendan D. Kelly

Ir J Psych Med 2012; 29 (1): 52-54

Abstract

Case Report

Objective: To review the role of handwriting analysis in psychiatry.

M was a 27-year-old man who was brought to the Emergency Department by the police, having been found setting fires outside his home. He presented in a confused, dishevelled and unkempt state. On admission, M’s speech was incoherent and demonstrated palilalia (repetition of a word with increasing frequency) and logoclonia (repetition of the last syllable of the last spoken word). His affect was incongruent with his situation (i.e. in police custody).

Method: Case-report and review of key papers. Results: M, a 27-year-old man, presented with incoherent speech, palilalia, logoclonia, incongruous affect, paranoid delusions and auditory hallucinations. M was diagnosed with schizophrenia and cannabis misuse, complicated by speech and language difficulties. M spent long periods writing on pieces of paper; towards the start of his admission, his writing was unintelligible but became more intelligible as his psychosis resolved. M’s handwriting demonstrates clinical features of psychosis (e.g. clang associations) and graphological abnormalities associated with schizophrenia in the literature (rigidity in letter-formation, mechanical expressions, and tendency toward over-use of straight lines).

M had multiple delusions that famous actors were involved in his daily life (e.g. making him cups of tea) and that he was being pursued by unknown, threatening forces. M described auditory hallucinations in a “deep, deep voice” but was unable to detail what the voice said. While he was oriented in time, place and person, M’s insight was limited: he did not agree that he was ill and was legally detained in hospital as an involuntary patient.

Conclusion: Analysis of handwriting is likely to play a limited role in psychiatric diagnosis but may prove useful in monitoring clinical improvement in certain patients.

Background history from M’s brother revealed that M and his brother, who lived together, were frequent users of large amounts of cannabis and that M had been in this mental state for many months or possibly years. M’s brother confirmed that M’s delusions persisted even when M was abstinent from cannabis and had preceded M’s use of cannabis in the first instance.

Key words: Psychoses; Cannabis; Psychomotor dysfunction; Review of the literature

Introduction

M was diagnosed with schizophrenia, according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision)5 criteria, and substance misuse, complicated by significant difficulties with speech and language. Following admission to hospital, M was prescribed olanzapine orodispersible tablet (10 miligrams per day, administered orally) and as he became less agitated it became apparent that he had significant difficulties with speech and language. Formal assessment by a speech and language therapist revealed that M had minimal verbal output which was generally unintelligible; this caused him considerable frustration. M appeared able to understand the words of others but was poorly cooperative with more detailed speech and language assessments.

The study of handwriting as a diagnostic tool has a lengthy history in psychiatry.1-4 Sulner reflected the position of many in the psychiatric and legal professions when she wrote that handwriting was closely related to brain function and was, thus, likely to reflect disordered psychological functioning and mental illness.2 Consistent with this idea, authors such as Lewinson1 and Privat4 provide detailed analyses of samples of handwriting from individuals with mental illness. While this field was the subject of considerable research and clinical interest in the 1940s, 1950s and 1960s, it has not commanded similar attention in recent decades. We aimed to review key papers in this field in light of a specific clinical case in which disturbances of handwriting were a central feature.

* Brendan D. Kelly, Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Ireland. E-mail brendankelly35@gmail.com

* Correspondence

M’s brother revealed that, prior to admission, M had spent long periods writing letters and words on small pieces of paper. Throughout his one-month hospital stay, M continued to write

Mary Davoran, Senior Registrar and Lecturer in Forensic Psychiatry, Central Mental Hospital, Dundrum, Dublin 14, Ireland.

Natalie Sherrard, Liaison Psychiatry Clinical Nurse Specialist, Department of Psychiatry, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.

Eugene Breen, Consultant Psychiatrist, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.

Submitted October 3rd 2008 Accepted August 11th 2011

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intensively on sheets of note-paper, the back of cigarette cartons, etc. Towards the start of his admission, M’s writings were fragmented and difficult to understand (Figure 1, during first week of admission) but they became more intelligible as his psychosis resolved (Figures 2 and 3, during third and fourth weeks of admission, respectively).

“manic-depressive condition”, and concluded that the handwriting of individuals with psychosis was especially characterised by disturbances in all three dimensions of handwriting: height, breadth and depth.1 Lewinson’s handwriting samples included twenty individuals with schizophrenia and these tended to demonstrate “narrowness of letters” (not present in M’s handwriting), slant “toward the right” (not present in M’s handwriting), “rigid school-copy forms” (present in Figures 1 to 3), an “empty-mechanical” expression (present in Figures 1 to 3) and a “tendency for straight line” (see the letter ‘O’ in Figure 3, which resembles a square more than a circle).1

Three weeks after admission, M’s psychotic symptoms had decreased significantly and, one week later, he was discharged from hospital. At ten-month follow-up, M remained well in the community on continued antipsychotic medication, although he continued to abuse cannabis.

Consistent with the presence of schizophrenia and “paranoid condition” on a single diagnostic continuum, Lewinson described considerable overlap between the handwriting features of these two conditions.1 Lewinson reported that handwriting in the “paranoid condition” was characterised by “lack of connection in printed writing” (present in Figures 1 to 3), “inhibited, constricted” character (present in Figures 1 to 3), “alteration between wide and narrow letters” (not present in M’s handwriting), “wide writing” (present in Figures 1 to 3) and “irregular slant toward the right” (not present in M’s handwriting).1

Discussion M’s diagnoses were schizophrenia and substance misuse, complicated by significant difficulties with speech and language. It is not possible to determine if the difficulties with communication predated his psychotic illness, but it was readily apparent that improvement in psychotic symptoms was associated with improvement in communication behaviours, including handwriting. Samples of M’s handwriting reproduced in this paper demonstrate both clinical features of psychosis (e.g. clang association, in Figure 2) and some of the more specific graphological abnormalities described in the literature on mental illness and disturbances of handwriting.

Handwriting of individuals in the “depressive phase” of manicdepression was characterised by “smallness of the writing” (not present in M’s handwriting), “lack of rhythm” (not present in M’s handwriting), “narrowness in letters” (not present in M’s handwriting) and “vertical to right slanting” (present in Figure 3).1 Handwriting in individuals with “mania” was characterised by “irregular and increasing” size (not present in M’s handwriting), “lack of rhythm” (not present in M’s handwriting) and “school copy forms with additions and ornamentations” (see drawings of hands in Figure 2, especially at the end of the fifth last line, where the word “handsome” is presented as a picture of a hand followed by the letters “sume”).1

Sulner, for example, listed a range of “abnormalities” which she suggested “indicate mental disease or mental or emotional disturbance”, including repetition of letters or words, omission of letters or words (or parts of letters or words), transposition of letters, incorrect spelling, scribbling in the midst of an otherwise readable text, lack of control of writing, meaningless marks, or interruptions between letters.2 Many of these “abnormalities” are, however, common, and Sulner’s list does not appear aimed at assisting in reaching a clinical diagnosis, but rather achieving a legal aim: i.e. determining, in a general sense, if an individual was suffering from any “mental disease or mental or emotional disturbance”.2

Overall, M’s handwriting was most consistent with the graphological features that Lewinson1 associated with schizophrenia and the “paranoid condition”, although M’s handwriting also demonstrated selected features of both the depressive and elated phases of manic-depression. Notwithstanding these similarities to Lewinson’s typologies, analysis of M’s handwriting did not make a significant contribution to the diagnostic process. The increased intelligibility of his writing as his psychotic symptoms resolved, however, suggests that changes in the content and/or form of handwriting may, in certain patients, assist in monitoring clinical improvement over time. The longitudinal course and predictive usefulness of this approach has not yet been studied.

Hilton was somewhat more circumspect about the proposed relationship between handwriting and mental disorders, questioning both the sensitivity and specificity of handwriting abnormalities by posing two key questions: Are such abnormalities always present in the writing of individuals with mental disorder? And are such abnormalities specific to mental disorders? 3 It is exceedingly unlikely that any of the anomalies outlined by Sulner2 are only found in the handwriting of persons with mental disorder. For example, logoclonus/logoclonia is also found in Parkinson’s disease and here represents a spastic repetitive phenomenon, e.g. “I went to the cinema...maa...maaa...maa...” Against this background, Lewinson1 drew on the work of the German philosopher and graphologist Ludwig Klages (1872-1956) to develop a more detailed approach based on the presence of different constellations of features in the writing of individuals with psychosis.1,6

As a result, it remains the case that graphology can, at best, provide only “supplementary assistance to accepted psychiatric determinations”.3 This position may change in future years if and when novel graphological approaches and analytic technologies improve the sensitivity and specificity of handwriting analysis in the context of psychiatric diagnosis and practice.

Conflict of interest Lewinson studied and reproduced handwriting samples from individuals with schizophrenia, the “paranoid condition” and the

None. 53


Figure 1 First sample of handwriting (first week of M’s admission), showing “rigid school-copy forms” and “empty-mechanical” expression, consistent with schizophrenia; “lack of connection in printed writing”, “inhibited, constricted” character and “wide writing”, consistent with Lewison’s “paranoid condition”.1

Figure 3 Third sample of handwriting (fourth week of M’s admission), showing “rigid school-copy forms”, an “empty-mechanical” expression and a “tendency for straight line” (see the letter ‘O’, which resembles a square more than a circle), consistent with schizophrenia; “lack of connection in printed writing”, “inhibited, constricted” character and “wide writing”, consistent with “paranoid condition”; and “vertical to right slanting”, consistent with the “depressive phase” of manic-depression.1

References 1. Lewinson TS. Dynamic disturbances in the handwriting of psychotics. Am J Psychiatry 1940; 97: 102-135. 2. Sulner HF. Mental disorders: their effects upon handwriting. Am Bar Assoc J 1959; 45: 931-934. 3. Hilton O. Handwriting and the mentally ill. J Forensic Sci 1962; 7: 131-139. Figure 2 Second sample of M’s handwriting (third week of M’s admission), showing “rigid school-copy forms” and an “empty-mechanical” expression, consistent with schizophrenia; “lack of connection in printed writing”, “inhibited, constricted” character and “wide writing”, consistent with “paranoid condition”; “school copy forms with additions and ornamentations” consistent with mania (see the end of the fifth last line, where the word “handsome” is presented as a picture of a hand followed by the letters “sume”).1

4. Privat S. Contribution de la graphologie au diagnostic et au pronostic des psychoses. Gaz Med Fr 1965; 72: 2501-2523. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision). Washington, DC: American Psychiatric Association, 2000. 6. Lewinson TS. An introduction to the graphology of Ludwig Klages. Character and Personality 1938; 6: 163-176.

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Opinion

Psychiatric power: A personal view Pat Bracken

Ir J Psych Med 2012; 29 (1): 55-58

Introduction

admission, but this is also carried out by a psychiatrist. The threeperson tribunal team that reviews the admission order always includes a psychiatrist.

One of the most important questions facing psychiatry today concerns its relationship to the emerging international service user movement. I believe that this movement presents not only the greatest challenge to psychiatry, but also the greatest opportunity. As it becomes more organised and influential this movement is starting to play a major role in shaping the sort of questions that are being asked about mental health services and their priorities. Yet there is limited reflection in our profession about how we, as doctors, might engage positively with it. It seems that while we are comfortable working with individuals and organisations who accept the medical framing of mental problems, we are less willing to contemplate working with critical service users. These are people who reject the medical model because they feel harmed by a system that describes their problems using the language of psychopathology. If we are serious about having an inclusive debate on mental health we will have to overcome this impasse. We need to entertain the idea that people who reject the medical framing of their problems are nevertheless legitimate stakeholders. It is time that we learned how to talk to them and to listen to their ideas. The user movement, with its substantial critical component, is not going to go away.

There is evidence that many people who have undergone involuntary admission and treatment continue to feel hurt and even violated by this process.1 Stefan Priebe and his colleagues reported on a study in which they were able to follow up more than half of a cohort of patients who were detained under the Mental Health Act in England.2 After one year they asked these patients if their involuntary detention was justified. Only 40% said that it was. The authors comment that ‘this percentage might have been even smaller if all patients had been re-interviewed’. This would indicate that a majority of patients are currently unhappy with the process of involuntary detention. A review of the 2001 Irish Mental Health Act will be taking place shortly. In my opinion, this presents us with an opportunity to engage creatively with the user movement in all its diversity, something that many psychiatrists genuinely welcome. However, in order to do so we will have to reflect critically on the ‘micro-politics’ of our current clinical encounters. In this paper I will argue that the decision-making powers that are currently given to psychiatry cannot be justified on either scientific or moral grounds. I will go on to argue that shedding these powers (and subsequent responsibilities) would be a positive move for our profession.

One of the most important elements of the relationship between psychiatric services and the people who use them is the reality of psychiatric power. Many critical service users accept that legally sanctioned interventions may be necessary when individuals lose capacity to care for themselves and perhaps put themselves or others at risk. However they do not accept the fact that the Mental Health Act in Ireland gives sole authority to doctors to take decisions on such interventions without any obligation to consult other interested parties.

Justifying Psychiatric Power It is usual to justify psychiatric power by asserting that we have an expertise about mental illness that allows us to diagnose accurately, classify logically and treat efficiently. The assumption is that no other group in society has such knowledge and therefore can be trusted to make decisions about people who are mentally deranged for one reason or another. The logic for psychiatric power would appear to be:

Under the terms of the 2001 Act in Ireland, while an application for involuntary detention may be made by a relative or other named individual and a GP is required to support this with a recommendation order, once a patient is detained all power is put into the hands of the consultant psychiatrist. As a result the Act effectively privileges the voice of psychiatry. When an individual is detained, the psychiatrist is endowed with the authority to determine the nature of his or her problems and the vocabulary that will be used to describe them. Moreover, the psychiatrist has the power to determine what treatment will be used, how it will be used and for how long. It is also within the power of the psychiatrist to decide what side-effects of medication will be taken into account and what risks to the patient’s health will be tolerated and to order ECT for a patient even if the patient and his/her family refuse it. The patient is seen for a second opinion shortly after

• States of madness and distress are the result of episodes of mental illness. • Mental illness can be fully grasped in the logic of medicine and thus doctors are uniquely positioned to explain and to predict the outcome of such episodes. • Psychiatry possesses a range of treatments that are uncontroversially of benefit to its patients. • It is therefore justified to give psychiatrists the power to both detain and to treat patients without their consent. The assertion here is that psychiatric science leads to psychiatric power.

Pat Bracken, Consultant Psychiatrist and Clinical Director, Centre for Mental Health Care and Recovery, Bantry General Hospital, Bantry, Co Cork, Ireland. E-Mail Pat.Bracken@hse.ie

Submitted October 20th 2010 Accepted January 13th 2012

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Thomas Szasz has challenged this position for over half a century.3 He argues that it is actually the other way round. In his opinion the history of psychiatry is very different from the history of medicine. Western medicine traces its origins back to the Greeks, and has always been primarily concerned with the suffering caused by diseased organs, and the various interventions that can be made to ease or cure this suffering. Until the 19th century most mental and emotional problems were not treated by physicians. Disturbances of thinking and emotion were understood mainly as spiritual or moral problems. When people were detained on account of such disturbances, this was the domain of clerics rather than doctors.

Psychiatry did not have any answers. In fact, the one regime that genuinely seemed to possess therapeutic efficacy, the moral treatment practiced at the Quaker York Retreat, was devised by the Tuke family who were tea merchants, not doctors. Yet, psychiatry was invested with the power to detain, to explain and to treat. In our own era, the powers of psychiatry have been refined but not lessened. The question still faces us: is the science of psychiatric treatment robust enough to justify psychiatric power? In their defense of involuntary commitment, in The Reality of Mental Illness, Martin Roth and Jerome Kroll make an important point:

In the 19th century a new sort of physician was born: the ‘maddoctor’, the ‘alienist’, and in the end, the psychiatrist. What characterised all these doctors was not their knowledge but the location of their work. Psychiatrists were simply doctors who worked in asylums. There is general agreement amongst historians that the enormous asylums were not the creation of the medical profession, less still of psychiatry.

‘Since most people agree that civil commitment, i.e. involuntary incarceration of a person who has not committed a crime, and involuntary treatment (based upon what others believe is best for a person) represent massive [their emphasis] infringements of that person’s civil liberties and personal integrity, it follows that the factual basis and the ethico-legal justification for such a course must be suitably strong and unambiguous’.6

As Roy Porter says: ‘It would be wrong to regard this drive over the last three centuries towards institutionalizing insanity fundamentally as the brainchild of “psychiatry”. In the first instance the sequestration of ‘lunatics’ was primarily an expression of civil policy: rather an initiative from magistrates, philanthropists and families than the achievement (for good or ill) of the doctors. Indeed, the rise of psychological medicine was more the consequence than the cause of the rise of the insane asylum. Psychiatry could flourish once, but not before, large numbers of inmates were crowded into asylums’.4

According to Roth and Kroll, if psychiatrists are ever going to be able to justify their role in such ‘massive infringements’ of civil liberty we will need to be very confident that our science is disinterested and robust and that our treatments are transparently effective. We will need to be confident that we can predict outcomes, and happy that we understand how our treatments work and for whom. Furthermore, we will need to be very clear that the benefit of these treatments completely outweighs their negative effects. Remember, no other branch of medicine has the power that psychiatry possesses. We will need to be at least as confident as the rest of medicine about the veracity of our science if we are to justify this power. Do we have such a science? Let us briefly look at a couple of issues.

Szasz argues that ‘as the clergyman’s power diminished, the maddoctor’s increased, and theological coercion was replaced by psychiatric coercion’.3 Furthermore, according to Porter, the emergence of a psychiatric science only took place once individuals had already been separated from society and brought together in the asylums of the early 19th century. In other words, according to Szasz and historians like Roy Porter, psychiatric power led to psychiatric science.

Is the science of psychiatric treatment ‘strong and unambiguous’? While mainstream psychiatry still holds to the idea that antidepressants work through their pharmacological effects on specific neurotransmitters in the CNS, critical psychiatrists like Joanna Moncrieff and David Healy have been pointing out for many years that most of the therapeutic effect of anti-depressants can be explained by the placebo effect. In the past two years the evidence for this has become indisputable. Two major metaanalyses of US Federal Drug Administration (FDA) data by Turner et al7 and Kirsch et al8 concluded that over 80% of the improvement seen in the drug groups was duplicated in the placebo groups. Irving Kirsch published a book based upon this research in 2009. He concludes:

This analysis has major implications for the situation in which we find ourselves today. Historically, there was no real science of psychiatry that could justify the power that was given to the profession. In the early 19th century, there were disparate, contradictory theories of madness; there were no clear classification systems and the treatments used were often akin to torture. Porter gives us an account of Johann Christian Reil’s approach to treatment (Reil is credited with being the first person to coin the term ‘psychiatry’). Reil, says Porter: ‘proposed an idiosyncratic variant on moral treatment: the charismatic alienist would master the delinquent mind; a staff trained in play-acting would further the alienist’s efforts to break the patient’s fixed ideas – and all would be combined with salutary doses of therapeutic terror (sealing-wax dropped onto the palms, immersion in a tub of eels, etc.)’.5

‘The belief that antidepressants can cure depression chemically is simply wrong’.9 The placebo phenomenon is not peculiar to psychiatry.10 However, a great deal of theoretical reflection in psychiatry, such as the monoamine theory of affective disorders, has been based upon the

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supposed biological effects of these drugs. Thus these recent metaanalyses represent not only a challenge to our prescribing but also question the foundations of contemporary psychiatric science itself. Rather than embrace the therapeutic reality and the theoretical implications of the placebo phenomenon and explore ways of incorporating these positively and transparently, a number of prominent psychiatrists have sought to justify current prescribing practices by dismissing the results of these meta-analyses. Some of them have done so by arguing that we should abandon the evidence-based medicine (EBM) approach. They say something like: ‘actually science isn’t that important in debates about psychopharmacology, what is really important is the experience of the doctor’. So we hear one prominent psychopharmacologist, MacAllister Williams, insisting that:

Conclusion As in most other countries, the Mental Health Act in Ireland puts a great deal of power and responsibility into the hands of psychiatrists. Advance directives, advocates, carers, other professionals and other interested parties play little if any part in the decision-making process regarding detention and treatment. In other words, the current legal framework governing these interventions endorses the singular authority of psychiatric science. In this paper, I have argued that psychiatric power did not develop logically from the explanatory and therapeutic abilities of psychiatric science in the 19th century. Indeed, historians suggest that this science was given energy and direction from the prior incarceration of thousands of patients across the western world. Furthermore, I have argued that, in our own time, we simply do not possess the sort of medical science with explanatory, predictive and therapeutic powers that might justify the legal authority invested in us. Our knowledge does not pass the test set by Roth and Kroll. Indeed, I believe that because psychiatry is tasked to deal specifically with problems of beliefs, feelings, behaviours and relationships, its knowledge has to be qualitatively different to that upon which a medicine of the tissues is built.14

‘it matters little whether the patient responds due to the placebo effect or the specific pharmacological actions of the drug, as long as they get better’.11 But the whole logic of EBM, of double blind controlled trials, is to identify what part of therapeutic improvement is due to the placebo response. MacAllister Williams is telling us that this is not important: we know how to get our patients better with antidepressants and that is all that matters.

But even if we did have such a knowledge, the current privileged position given to psychiatry in the Mental Health Act directly contradicts the fundamental ethic of the ‘recovery approach’ to mental health which is promoted by ‘A Vision for Change’ and by the Mental Health Commission. One of the Commission’s most recent documents contains the statement: ‘the recovery approach challenges the privileging of one theoretical perspective as the primary explanation for and the treatment of mental distress and the privileging of professional interpretations and expertise over expertise by experience and personal meaning. The biomedical model and medical treatments may have an important place for some people in the recovery process, but as an invited guest, rather than the overarching paradigm’.15 A key element of the recovery approach is the promotion of ‘empowerment’.16 This includes the power to define the nature of one’s problems and to be involved in decisions about treatment.

The psychiatric discourse around antidepressants is far from the ‘strong and unambiguous science’ demanded by Roth and Kroll. Is the science of anti-psychotics any more robust? The development of second generation antipsychotics was heralded as one of the great achievements of modern psychopharmacology. For many years after their introduction, psychiatrists told patients and relatives how safe and effective these drugs were. There was talk about a ‘breakthrough’ in the treatment of schizophrenia. Several years on, and the picture does not look so rosy. We now know that these drugs are possibly more toxic than the earlier ones and there is no evidence that they are more effective. Furthermore, in a major paper in the Lancet last year, evidence was presented to show that even the notion that these drugs represented a significantly different grouping was false.12 In an editorial comment on this paper, Peter Tyrer and Tim Kendall wrote:

Some psychiatrists have yet to embrace the ‘recovery approach’ and continue to think and act as though the psychopathological framework was the only legitimate and valid way of understanding states of madness and distress.17 But many are now responding to the calls of service users to create a different sort of psychiatry. A key element of any mental health service involves the management of risk. But there is clearly room to rethink how we do this. The EUNOMIA study has demonstrated ‘huge variation’ in the rates of involuntary admissions across Europe.18 Differences in ‘sociocultural contexts’ appear to be responsible for this variation rather than rates of mental illness. I am not arguing that there should be no mechanisms in place to intervene when individuals are mentally disturbed. I am not denying that medical practitioners have an important role to play. However, I am suggesting that the current powers and responsibilities of psychiatry are not warranted on either empirical or philosophical grounds.

‘The spurious invention of the atypicals can now be regarded as invention only, cleverly manipulated by the drug industry for marketing purposes and only now being exposed. But how is it that for nearly two decades we have, as some have put it, “been beguiled” into thinking they were superior?’.13 Antidepressants and antipsychotics are cornerstones of psychopharmacology. These are the drugs that are administered to patients when they are detained. Psychopharmacology is the usual form of treatment given to patients on an involuntary basis. My argument is that the science we have available to us now, with its explanations and treatments, is simply not of the standard set by Roth and Kroll to justify the power that psychiatrists have been given.

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References

In their recent qualitative study of the impact of coercive interventions, Sibitz et al19 found that while some service users, who had received such interventions in the past, felt that involuntary treatment was sometimes needed; many felt that their crises could have been managed differently. They found that ‘the ways that problems were formulated by mental health staff as psychiatric issues were sometimes contrary to the ways patients saw their problems and what was needed to solve them’. As a result, participants in this study reported that the experience of involuntary treatment had left them with a ‘general distrust of others, particularly of medical professionals’. They reported living their lives as if ‘on probation’ in the aftermath.

1. Katsakou C, Priebe S. Patients’ experiences of involuntary hospital admission and treatment: a review of qualitative studies. Epidemiol Psichiatr Soc 2007; 16: 172-8. 2. Priebe S, Amos T, Leese M et al. Patients’ views and readmissions 1 year after involuntary hospitalisation. Br J Psychiatry 2009; 94: 49-54. 3. Szasz T. The medicalization of everyday life. New York: Syracuse University Press; 2007. 4. Porter R. A social history of madness: Stories of the insane. London: Weidenfeld and Nicolson, 1987. 5. Porter R. Madness: A brief history. Oxford: Oxford University Press; 2002. 6. Roth M, Kroll J. The reality of mental illness. Cambridge: Cambridge University Press; 1986 7. Turner EH, Matthews AM, Linardatos E et al. Selective publication of antidepressant trials and its influence on apparent efficacy. NEJM 2008; 358: 252-60. 8. Kirsch I, Deacon BJ, Huedo-Medina TB et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008; 5: e45. 9. Kirsch I. The Emperor’s new drugs. Exploding the antidepressant myth. London: The Bodley Head; 2009. 10. Moerman D. Meaning, medicine and the ‘placebo effect’. Cambridge: Cambridge University Press; 2002. 11. McAllister-Williams RH. Do antidepressants work? A commentary on “Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration” by Kirsch et al. Evidence Based Mental Health 2008; 11: 66-68. 12. Leucht S, Corves C, Arbter D et al. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet, 2009; 373: 31-34. 13. Tyrer P, Kendall T. The spurious advance of antipsychotic drug therapy. Lancet 2009; 373: 4-5. 14. Bracken P. Thomas, P. Postpsychiatry: mental health in the postmodern world. Oxford: Oxford University Press; 2005. 15. Mental Health Commission. A recovery approach within the Irish mental health services. A framework for development. Dublin: MHC; 2008. 16. Warner R. Does the scientific evidence support the recovery model? The Psychiatrist 2010; 34: 3-5. 17.Goss C, Moretti F, Mazzi MA, Del Piccolo L, Rimondini M, Zimmermann C. Involving patients in decisions during psychiatric consultations. Br J Psych 2008; 193: 416-421. 18. Fiorillo A, De Rosa C, Del Vecchio V et al. How to improve clinical practice on involuntary hospital admissions of psychiatric patients: suggestions from the EUNOMIA study. Eur Psychiatry 2011; 26(4): 201-207. 19. Sibitz I, Scheutz A, Lakeman R, Schrank B, Schaffer M, Amering M. Impact of coercive measures on life stories: qualitative study. Br J Psych 2011; 199: 239-244.

This has implications for the personal relationships between individual psychiatrists and their patients but also for the profession and the society it serves. At present, psychiatry continues to be feared. In spite of all the anti-stigma campaigns, as long as the profession is bestowed with powers to incarcerate and to treat on an involuntary basis, this fear will continue. The forthcoming review of the Mental Health Act provides an opportunity for psychiatrists to shed some of these powers and to engage with service-users in a positive debate about how and when force should be used in mental health crises.

Conflict of interest None.

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Book review

Coming through Depression: A Mindful Approach to Recovery Tony Bates

Gill & Macmillan: 2011 (160pp). ISBN: 978-071714780-9

If the shelves of my local bookshop are anything to go by, the selfhelp genre has never been more popular. Everything from career, to love life, to weight, to self esteem is seemingly malleable with the help of a little paperback tome filled with wisdom. But there is a catch – not all self help is of the same quality and faithful readers do not always know the difference. For clinicians, it can be equally difficult to know what reading materials to recommend to patients and relatives with the aim of expediting recovery.

In Part Two, Dr Bates examines approaches that can aid recovery, including daily structure, mood tracking, lifestyle changes and appropriate help-seeking. The author explains in detail how to set up a mood diary, an activity log and a recovery journal, while this section also includes both a chapter on building self-esteem, and a chapter dedicated to carers. Finally, in Part Three, Dr Bates explores the concept and practice of mindfulness. Much of what he writes is based on the work of three pioneers of the area, Thich Nhat Hanh, Jon Kabat-Zinn and Mark Williams, all of whom were one-time teachers of Dr Bates. According to the author, “Mindfulness means resting in the present moment, with full awareness. When we are mindful, we bring attention back to whatever is happening in our lives”. This, he suggests, allows us to enjoy the simple things in daily life we might otherwise overlook such as “the smile on a child’s face” or “the sensation of the breeze against our skin”. Mindfulness, Dr Bates says, “gives us a gentle way to respond to distress” in which we “learn to notice and to accept difficulties as they emerge, rather than trying to push them away and suppress them”. The book benefits in particular from the inclusion of a mindfulness CD, allowing the theory explained in the book to be practiced with relative ease.

Consequently, it is always a relief when a reputable professional with a proven track record decides to update material that has already proved enormously successful. One such example is Dr Tony Bates, the founding Director of Headstrong (the National Centre for Youth Mental Health in Ireland), who has many years additional experience as a Principal Clinical Psychologist at St James’s Hospital, Dublin. His original self-help book, entitled Depression: A Common Sense Approach (1999), was so well received it sold some thirty thousand copies. His updated version could leap off the shelves just as quickly, particularly as it incorporates mindfulness, a technique that has become increasingly popular over the past decade. Coming through Depression: A Mindful Approach to Recovery is written in clear and concise English. This is worth mentioning first, lest we forget that, in the context of mental illness, not all of its potential readers will have optimum concentration levels. This book is practical, however. Dr Bates utilises vignettes and case histories to which the reader can easily relate, while diagrams and tables illustrate concepts such as the manner in which thoughts, feelings, physical symptoms and behaviours interact. The book is divided into three parts, with Part One providing a simple explanation of what it might feel like to experience depression, along with common signs and symptoms of the illness and a differentiation between mild and severe depression. There are sections on childhood and postnatal depression, and a checklist that the reader can use to assess their own depressive symptoms. Dr Bates also explores the causes of depression, from childhood experiences through to genetic theories.

Coming through Depression: A Mindful Approach to Recovery is an articulate, sensitive and practical guide to recovery from depression that at no point encroaches upon other components of the multidisciplinary recovery plan. Perhaps, indeed, it provides the ray of hope individuals need when finding themselves trapped in the dark chamber of depression. Well worth recommending to patients and relatives alike.

Stephen McWilliams, Consultant Psychiatrist, St John of God Hospital, Stillorgan, Co. Dublin, Ireland. E-mail stephen.mcwilliams@sjog.ie

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Book review

Leadership With Consciousness Tony Humphreys

Atrium/Attic Press/Cork University Press: Cork, 2011 (202pp). ISBN 978-1-85594-218-9

Leadership is a complicated concept. Leadership can be difficult to define in words, yet most people can agree when it is present and virtually all can agree when it is absent. While many books have been written about leadership, there are few that stand out as providing the in-depth insight necessary truly to understand the qualities of a good leader.

essential element in health services, but I would have liked to see greater exploration of the some of the less-discussed complexities of compassion: How, for example, does a health-planner incorporate compassion into the decision-making process when there are difficult choices to be made about the distribution of scarce resources? Evaluating legitimate but competing claims on one’s compassion is difficult but necessary: sometimes, hard-nosed decision-making may be needed in order to be compassionate.

In “Leadership With Consciousness”, Tony Humphreys strides fearlessly into many of the great debates about leadership today, and comes up with an admirably clear-sighted set of recommendations about “training for raising consciousness”, amongst other measures. Dr Humphreys is well-placed to undertake such an endeavour: he a consultant clinical psychologist, national and international speaker, and accomplished author. To date, Dr Humphreys has written fourteen best-selling books on a range of themes, including the intriguing “Power of Negative Thinking” (Newleaf, 2004).

“Leadership With Consciousness” is good but not perfect. The book would, for example, have benefitted from more extensive referencing: there are many points at which the author makes quite specific statements or provides quotations, and it would be helpful if there were more pointers to sources. In terms of navigating the volume itself, it would have been helpful if the contents page included page numbers for the chapter sub-sections listed, and not just for the start of each chapter.

“Leadership With Consciousness” will undoubtedly join the ranks of Dr Humphrey’s other successful books: it is clear, incisive and timely. Dr Humphreys argues that various economic processes, such as those which contributed to the economic crisis of 2008 onward, are enmeshed with defensive emotional processes at individual level. At least some of these processes are unconscious but powerful, and their potential effects on leadership, decisionmaking and other matters are explored throughout the book.

To counter-balance these deficits, this book’s index is truly a rare joy: extensive, accurate and sensibly arranged. A book like this is not only to be read through from start to finish, but will also be consulted from time to time for reference and study. A good index assists greatly with these tasks. Overall, this is a good, if imperfect, book. Dr. Humphrey’s emphasis on the effects of individual psychological processes on leadership and decision-making is greatly to be welcomed. His suggestions on “training for consciousness” are also likely to prove thoughtprovoking for at least some readers.

Placing these arguments in a strongly contemporary framework, Dr Humphreys draws much-needed attention to individual psychological processes which underpin society in general and the financial “system” in particular – a system which is so often blamed for recent economic and social turmoil. This system does not, of course, appear out of a vacuum, and Dr Humphreys examines the role of undetected individual emotional processes in producing and shaping it. In essence, Dr Humphreys argues that consciousness of the need to resolve unconscious defences is critical for effective leadership. The final chapter, “Training for Consciousness”, focuses on specific steps necessary for this task, and provides a list of qualities for “leadership with consciousness”.

This book might, perhaps, be best approached in conjunction with two other volumes both of which provide additional, if contrasting, perspectives on leadership. Readers with interests in psychiatric and psychological perspectives on political leadership will undoubtedly enjoy the classic “Psychological Assessment of Political Leaders” (University of Michigan Press, 2005) by Jerrold M. Post, Professor of Psychiatry, Political Psychology, and International Affairs at George Washington University, and founder of the CIA's intriguing Center for the Analysis of Personality and Political Behavior. Professor Post’s penetrating volume is both a joy to read and a fascinating window into the analysis of political leaders from a psychiatric perspective.

Quite apart from these conclusions, there is much else that is of interest along the way. There is, for example, an involving passage about “the place of dignity and compassion in the medical care of people”. This discussion provides a useful focus on compassion at individual level in the delivery of patient care. This is clearly an

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This reading would be well complemented by another classic of the leadership literature: “The Prince” (1532), by Niccolò Machiavelli (1469-1527). Despite the ubiquitous use of the term “Machiavellian” in a rather pejorative fashion, there is much in “The Prince” that is informative and interesting, and the work as a whole is more subtle that it is often given credit for, especially in its recommendations for leaders. The literature on leadership is full of such books: intelligent, insightful and very often misunderstood. Tony Humphrey’s “Leadership With Consciousness” is a useful addition to the leadership literature. It is clearly written, admirably focussed, and provides welcome insight into the role of individual psychological processes in producing the social and economic predicaments in which much of Europe finds itself. The solutions to these predicaments may be complex, but more “leadership with consciousness”, as suggested by Dr Humphreys, would certainly be a good start.

Brendan D. Kelly, Consultant Psychiatrist and Senior Lecturer in Psychiatry, Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7, Ireland. E-mail brendankelly35@gmail.com

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Book review

Homesickness: An American History Susan J Matt.

Oxford University Press 2011, (344 pp). ISBN 978-0-19-537185-7

The wonderfully named French physician Louis-AlexandreHippolyte Leroy-Dupré wrote that acute homesickness “becomes more rare each day thanks to rapid communications which modern industry is beginning to establish among people who will soon be nothing more than one big happy family.” One might imagine that this observation was written for the age of Facebook, Skype and Twitter, but it is fact over one hundred and fifty years old, dating from 1846.

of a tender sensibility. How homesickness was addressed by the military in the various wars in the era Matt’s history covers is revealing. Armies have to balance the motivating power of attachment to country with the demotivating power of separation from that same country. In the American Civil War, homesickness among soldiers was seen as evidence of a nobility of nature. This attitude persisted through the century. The sole nostalgia fatality of the Spanish-American War of 1898 was treated with great sympathy bordering on glorification by the contemporary media. The inter-war years saw the cultural shift gain momentum. This was the era where the child rearing “expert” began to opine in the popular press; no less a figure than the seminal behaviourist John Watson weighs in on the importance of avoiding excessive affection with one’s children. The following fifty years saw the denigration of homesickness gain pace. Where the home-loving children of previous eras were celebrated, now over attachment to parents and to home was seen as “sissifying” and a manifestation of “Momism.” An ethic of universal cheerfulness which celebrated the “can-do” spirit further cast homesickness into disrepute. The interests of corporate America were in creating a mobile workforce, ready to cross the continent at short notice. While this is not a matter that Matt discusses, this aspect did get me thinking how the anti-family jeremiads of R D Laing and David Cooper ironically dovetailed neatly with this corporate imperative. Perhaps, as the Marxists say, there are no accidents.

Susan J Matt is a historian at Weber State University in Utah; her specialty is the history of the emotions (a previous book is entitled “Keeping Up With The Joneses: Envy in American Consumer Society 1890-1930”) This admirably lucid book, based on primary sources such as diaries, letters and personal interviews, is an overview of the history of a particular emotion, homesickness. American society is famously built on the archetype of the pioneer, the rugged individualist, cheerfully moving on from place to place without demur. This archetype finds different forms; the immigrant, the cowboy, the “Organisation Man”, the pilgrim settler, but all have in common a sense of perpetual motion and freedom from ties. As with all archetypes and grand narratives, the details of reality were very different. Very many pioneers and immigrants returned, despite the social pressures to remain. Matt places centre stage the men and women who actually lived these experiences, and who were often beset by overwhelming homesickness. This was especially so for women, less in control of their destiny than men. From the first settlers on, thoughts of home contended with the various religious, political and economic motives for perpetual motion. While official rhetoric emphasised the importance of forging on with the pioneer spirit, diaries and letters allow Matt to reconstruct the emotional lives often lost to history.

Anti-homesickness rhetoric persists today, although the picture is complicated by the rise of technologies which allow instantaneous communication, and the global availability of familiar brands. Yet these developments are palliatives for homesickness, not cures. Skype, Facebook and similar technologies allow a certain abolition of distance, and Matt shows how they have perhaps helped in the rehabilitation of homesickness as a valid public emotion. Indeed, one of her themes is “the surprising persistence of the extended family” and how emotions and their expression can be moulded and shaped by social forces, but are also strangely resistant to them Indeed, this is a history of the resilience of homesickness, despite everything. So many approaches in contemporary humanities emphasise the contingent and socially constructed nature of things; what Matt manages to do is to acknowledge the role of social and economic pressures while making a strong case that emotions are less fungible than theorists, pundits and social engineers of all political hues would believe. There is also very little of the jargon and theoretical ballast which many contemporary historians freight their work

In 1865, twenty –four Union soldiers officially died of nostalgia. Among the American forces in World War 1, only one casualty had a cause of death listed as nostalgia. Matt records the varying opinions of psychiatrists, alienists on physicians on the causes and management of nostalgia-as-an-illness. Contemporary concerns such as racial and ethnic purity (“weaker” ethnicities such as the Irish and Southern Europeans were often held to be more susceptible) and venereal disease were implicated as risk factors for nostalgia cases. Over the later nineteenth century and into the twentieth, public attitudes to homesickness hardened. Once, children who crossed thousands of miles to return from boarding schools to families were celebrated. Their attachment to home was seen as evidence

Matt’s title clearly indicates that this is an American history of homesickness, but the book is of great interest to an Irish

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readership too. The Irish immigrant experience abroad is of course familiar to most of us; a sizable chunk of Irish popular music is eloquent testimony to the force of homesickness. More fundamentally, homesickness is a universal emotion; all readers will find someone to identify with among the lives Matt describes. We may not always go through the same social transformations as America at the same time, but we always seem to get round to them sooner or later. In our age of ghost estates and resurgent emigration, many of the concerns of the book seem all too relevant.

lived in six different states and travelled many places, but no matter where we are, when I am with him, I am home.” It is a poignant note, and one which sets the tone for a humane and thoughtprovoking work.

Séamus MacSuibhne, Consultant Psychiatrist, St Lukes Hospital, Co. Kilkenny, Ireland. Visiting Fellow, School of Medicine, University College Cork, Co. Cork, Ireland. E-mail seamus.macsuibhne@ucd.ie

Academic careers rival medical careers in demanding frequent moves (and in requiring a certain insouciance as the proper response.) In her acknowledgements, Matt salutes her husband and observes “since we met in Ithaca, New York, in 1990, we have

Appreciation

Professor Hugh Lionel Freeman (1930-2011) Brian O’ Shea

Submitted November 8th 2011 Accepted February 2nd 2012

Hugh Freeman, editor of the British Journal of Psychiatry from 1983 to 1993, died recently at the age of 81. A native of Salford in Greater Manchester, Hugh attended Oxford University on a scholarship and subsequently joined the Royal Army Medical Corps. He went on to train in psychiatry at the Maudsley and became a consultant psychiatrist in Salford. He was an early advocate of community psychiatry, with retention of inpatient facilities in general hospitals.

was so calm and polite that you carried out his wishes unhesitatingly despite not having a computer! Over the years I received appreciative letters from Hugh for anything I sent him. When he was ill some years ago his wife Joan Casket, a professor of psychology, handled his correspondence until Hugh was fit again. My abiding memory of Professor Freeman is one of unruffled determination. Hugh had three sons and a daughter. His family, and psychiatry, has lost an enormous presence in their, and our, lives.

Hugh may best be remembered as an historian of his specialty. He co-edited 150 Years of British Psychiatry, published in 1991 to commemorate a century and a half of the Royal College of Psychiatrists, and edited 1999’s A Century of Psychiatry. As well as his decade at the helm of the British Journal, he was an editor of History of Psychiatry and founding editor of Current Opinion in Psychiatry.

Brian O’ Shea, Editor, Psychiatry Professional, Editor, A Textbook of Psychological Medicine, Tribunal Consultant Psychiatrist with the Mental Health Commission. E-mail drbosheas@eircom.net

I got to know Hugh when I wrote, with Jane Falvey, a chapter on the Richmond Asylum (St. Brendan’s Hospital) for the second volume of 150 Years of Psychiatry. In those days Hugh wrote to you in a small but legible hand asking you to cut and paste. He

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Letter to the Editor Mugtaba Osman, Elaine Greene

Interaction of duloxetine with warfarin; a cautionary report Dear Editor,

In light of the temporal relationship between the increase in duloxetine and the rise of INR, the most likely explanation lies at the cytochrome P450 level. It is likely that duloxetine may potentiate the anticoagulant effect of warfarin through displacing warfarin from CYP 1A2 isoenzymes.6 This would result in a net increase in bioactive warfarin and a consequent increase in INR.

Drug-drug interactions are common in older adults. Four out of five people aged over 75 years take at least one medicine and thirtysix percent of this age group take four medicines or more. 1 Warfarin is primarily cleared by the liver through the cytochrome P450 system. Many of the isoenzymes involved are also involved in the metabolism of psychotropic agents.2 Drug interactions with Warfarin are generally well described. Data regarding the interaction of warfarin with duloxetine are limited. There are only two case reports in the literature which report conflicting findings.3,4 Additionally, a small open-label study reported no significant interaction between the two agents. 5

Discussion A higher number of people enter old age nowadays thanks for recent advances in health measures.7 Therefore, more people over the age of 65 are expected to be on combination of warfarin plus another one or more medications, especially psychiatric medications. This report adds to the scarce evidence that currently exists for possibility of drug-drug interactions between duloxetine and warfarin. It is the first report, we know of, to describe a potentiating effect for duloxetine upon the action of warfarin in older adults. It stresses the need to closely monitor INR levels for elderly patients on warfarin, especially if it is combined with duloxetine for treatment of depressive illness or other psychiatric or non-psychiatric disorder. It appears that duloxetine can synergistically potentiate the effect of warfarin, thereby, leading to a bleeding hazard. Further research is urgently needed in this area.

Warfarin is normally indicated for serious vascular conditions. So an elderly patient who is attending the psychiatric service and is on warfarin will have higher risk for serious interactions. This is exactly the subject of this case report.

Case Report An eighty seven year old gentleman was admitted for treatment of a severe depressive episode with prominent anxiety symptoms. Relevant medical co-morbidities included paroxysmal atrial fibrillation, for which he was on lifelong warfarin prophylaxis. Notably, his warfarin dose had been stable for several months prior to admission. He presented with a treatment resistant depression and failed to respond to trials of antidepressant medications (including venlafaxine, bupropion, SSRI’s, mirtazapine and agomelatine) and to augmentation with several different agents (including risperidone, lithium, olanzapine, amisulpride and aripiprazole). He refused the option of ECT. A trial of duloxetine was moderately successful. The dose was increased cautiously to 90 mg with good effect. At this point it was noted that his INR had increased significantly. This was temporally related to an increase in duloxetine from 60 to 90 mg daily. There had been no other significant changes in his management or his medical condition that would explain the increased INR. Review of his INR readings and comparison with his duloxetine treatment revealed a stepwise increase in INR which coincided with the increase in duloxetine.

References 1. Department of Health (2001) National Service Framework for Older People. London: Stationery Office. 2. Limke KK, Shelton AR, Elliott ES. Fluvoxamine interaction with warfarin. Ann Pharmacother. 2002;36:1890-1892 3. Glueck C J, Khalil Q, Wang P. Interaction of Duloxetine and Warfarin Causing Severe Elevation of International Normalized Ratio. JAMA, April 2006; 13: 1517-1518. 4. Monastero R. Potential drug-drug interaction between duloxetine and acenocoumarol in a patient with Alzheimer's disease, Clinical Therapeutics, December 2007; 29: 2706-2709 5. Frincu-Mallos C. Duloxetine Does Not Modify Anticoagulant Effects of Warfarin: Presented at American College of Clinical Pharmacology (ACCP) 37th Annual Meeting, September 2008. 6. Glueck C J, Khalil Q, Wang P. Interaction of Duloxetine and Warfarin Causing Severe Elevation of International Normalized Ratio. JAMA, April 2006; 13: 1517-1518. 7. Kapplan B J, Sadock’s V A, Psynopsis of Psychiatry Behavioural Sciences/ Clinical Psychiatry, 10th edition. In Geriatric Psychiatry, chapter 56, page 1348, Lippincott W&W, 2007.

As this patient’s treatment resistant depression had responded to duloxetine, a decision was made to continue duloxetine treatment at this higher dose. This necessitated a forty percent dose reduction in warfarin to stabilise the INR at a safe therapeutic level.

* Mugtaba Osman, Psychiatric Registrar, St Patrick’s University Hospital, Dublin 8, Ireland. E-mail mugtabasulman@yahoo.co.uk

Elaine Greene, Consultant Old Age Psychiatrist, Jonathan Swift Clinic, St James’s Hospital, Dublin 8, Ireland.

*Correspondence

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Irish Journal of Psychological Medicine Guidelines for Authors

Aim and Scope of the Journal The aim of the Irish Journal of Psychological Medicine is to publish original scientific contributions in psychiatry, psychological medicine (including surgery and obstetrics), and related basic sciences (neurosciences, biological, psychological, and social sciences).

The scope of the Journal includes any subspecialties of the above, including, but not limited to, behavioural pharmacology, biological psychiatry, child and adolescent psychiatry, intellectual disability, forensic psychiatry, psychotherapies, psychiatry of old age, epidemiology, rehabilitation, psychometrics, substance misuse, sexual studies, linguistics, and the history, philosophy and economics of psychiatry.

• • • • • • • •

The Journal is dedicated to providing reliable, valid clinical and scientific information to inform mental health care decisions and improve the quality of mental health care.

automated referencing software, or any mechanism to track changes to various drafts of a manuscript. Numbers one to ten should be written as words in the text, unless used as a unit of measurement; all numbers should be written in digits in tables and figures. All numbers which start sentences should be written in words, not digits. Bold type-face should be used for headings of sections and subsections within the paper. Do not use tabs or indents within the text of the paper. SI units are required for all measurements. Means should be accompanied by standard deviations. Exact p values should be provided, unless p<0.0001. Recommended non-proprietary drug names should be used. Writing should be clear, simple and direct. Short sentences are preferred.

Abstract and Key-Words

Editorial Standards

The page following the title page should carry an abstract followed by a list of three to ten key-words drawn, if possible, from the medical subject headings (MeSH) list of the United States National Library of Medicine and National Institutes of Health (www.ncbi.nlm.nih.gov/mesh). The title and key-words should be chosen to help future literature searchers.

The Irish Journal of Psychological Medicine complies with the “Code of Conduct and Best Practice Guidelines for Journal Editors” of the Committee on Publication Ethics (2011) and the “Editorial Policy Statements” of the Council of Science Editors (2009). http://publicationethics.org/files/Code_of_conduct_for_journal_edit ors_Mar11.pdf http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid= 3286

The abstract, up to 150 words for an unstructured or 250 words for a structured abstract (Haynes et al, 1991), should state specifically the main purposes, procedures, findings and conclusions of the study, emphasising what is new or important. For original papers, brief research reports, audits and review articles, a structured abstract is required, using the headings: Objectives, Methods, Results and Conclusions.

Submission Guidelines The Journal will accept for consideration original papers, brief research reports, audits, clinical case reports, review articles, historical papers, perspective articles, editorials, letters to the editor and book reviews. Original data papers receive top priority for speedy publication.

Under the Abstract heading of Method, include, wherever applicable the study design, setting, patients/participants (selection criteria, description), interventions, observational and analytical methods and main outcome measures. (For review articles specify the methods of literature search and selection). Under the Abstract heading of Results, give the most important specific data together with their statistical significance.

Manuscripts should be prepared in accordance with the “Uniform Requirements for Manuscripts (URM) Submitted to Biomedical Journals” of the International Committee of Medical Journal Editors (2010). www.icmje.org

Title Page

Original Papers

The title page should include the paper title, author name(s), author qualifications, author job title(s), author affiliation(s) and full address (es). The name, address, email address and telephone number of the corresponding author should be clearly and separately indicted.

Text • The manuscript should be typed, double-spaced, in 12-point Times New Roman font. • Pages should be numbered but do not use any other automated features (such as endnotes, headers or footers), any form of

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Original papers should be divided into sections as follows: Introduction, Methods, Results and Discussion. A Conclusions section is not mandatory but may be included in the original submission if the author wishes, or may be requested at a later stage by peer-reviewers or editors. The Results section should present a summary of main results and should not simply refer to tables. Reports of randomised trials must conform to CONSORT 2010 guidelines. http://www.consort-statement.org/consort-statement/overview0/


Audit Papers

“Public trust in the peer review process and the credibility of published articles depend in part on how well conflict of interest is handled during writing, peer review, and editorial decision making. Conflict of interest exists when an author (or the author's institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties). These relationships vary from those with negligible potential to those with great potential to influence judgment, and not all relationships represent true conflict of interest. The potential for conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment. Financial relationships (such as employment, consultancies, stock ownership, honoraria, paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion.”

It is preferable that audit papers present the full cycle of clinical audit, including audit, intervention and re-audit. In exceptional circumstances, papers presenting one element of the audit cycle may be published, but priority will be given to papers presenting full audit cycles. The format for audit papers may differ from that outlined for original papers, and may include, for example, Introduction, Audit, Intervention, Re-Audit, Discussion and Conclusions.

Clinical Case Reports All clinical case reports must have the patient’s written, informed consent before the paper is submitted.

References Timely references should highlight the paper’s relevance to current research or clinical practice. For references to journal articles (International Committee of Medical Journal Editors, 2006; 2010; Haynes et al, 1991; Bailar & Mosteller, 1998) and to books (Daly et al, 1991; Gardner & Altman, 1989; American Psychiatric Association, 1987) use the ‘Vancouver’ style, i.e. number references in the order they appear in the text, do not alphabetise. Journal titles should be abbreviated as outlined on PubMed by the United States National Library of Medicine and National Institutes of Health (www.ncbi.nlm.nih.gov/nlmcatalog/journals). Please see the sample paper on the website of the College of Psychiatry of Ireland for further details http://www.irishpsychiatry.ie/Members/MembersInformationTools/ irishjournalofpsychologicalmedicine.aspx

Statement of Informed Consent Where relevant, papers must include a statement regarding informed consent, in accordance with the guidance of the International Committee of Medical Journal Editors (2006): “Patients have a right to privacy that should not be infringed without informed consent. Identifying information, including patients' names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Complete anonymity is difficult to achieve, however, and informed consent should be obtained if there is any doubt. For example, masking the eye region in photographs of patients is inadequate protection of anonymity. If identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note. The requirement for informed consent should be included in the journal's instructions for authors. When informed consent has been obtained it should be indicated in the published article.”

Tables and Figures Figures and graphs should be clear and of good quality, and should be accompanied by relevant data to facilitate redrawing where necessary. Clear and informative headings and captions should be provided.

Submission Process Manuscripts may be submitted electronically via email to journal@irishpsychiatry.ie or sfarrell@irishpsychiatry.ie Full postal address, telephone and fax numbers should be included. Where possible, tables, figures and text should be included in the same document. There is no need to also submit by post or fax.

Statement of Human and Animal Rights

All submitted material will become the property of the Journal until, and if, publication is refused. Material so referred should not be sent elsewhere for publication.

Where relevant, papers must include a statement regarding human and animal rights, in accordance with the guidance of the International Committee of Medical Journal Editors (2006):

Conflict of Interest

“When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach, and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should be asked to

In the interest of accountability all financial and material support for the research and the work should be clearly stated (DeAngelis et al, 2001). Authors of original data must take responsibility for the integrity of the data and accuracy of the data analysis. All authors must have full access to all the data in the study (Davidoff et al, 1986). Authors must declare any conflict of interest clearly, in accordance with the guidance of the International Committee of Medical Journal Editors (2006):

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Plagiarism and Duplicate Publication

indicate whether the institutional and national guide for the care and use of laboratory animals was followed.”

Manuscripts are considered with the understanding that they have not been published previously, either in print or electronic format. In the event that plagiarism or duplicate publication is suspected, the author will be invited to comment on the matter and a decision will be taken by the editors.

Acknowledgements Authors should obtain permission to acknowledge individuals named in any Acknowledgments section, since readers may infer endorsement.

Appeals Suggested Peer-Reviewers

IIn the event that an author wishes to appeal an editorial decision, the author can send a letter of appeal to the Editor-In-Chief. The Editor-In-Chief will pass the relevant materials to the Consulting Editor who may seek external opinion. The Consulting Editor will advise the Editor-In-Chief in relation to the appeal but the final decision on the matter rests with the Editor-In-Chief.

Each submission must be accompanied by the names, professional titles, professional addresses and email addresses of three suggested peer-reviewers. Authors should select these suggested peerreviewers to include individuals, in any part of the world, who are recognized experts in the area to which the submission refers, and whom the authors believe would provide useful, objective peerreviews of the manuscript. The editors will give consideration to sending the manuscript to some or all of these peer-reviewers, but are not under any obligation to do so.

References

Description of the Peer-Review Process

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington DC: American Psychiatric Association, 1987.

All submissions are acknowledged by email. Submissions are initially considered by the Editor-In-Chief or Deputy Editor for suitability for peer-review. Submissions selected for peer-review are sent to three anonymous outside peer-reviewers. Where one or more peer-reviewers recommend acceptance or acceptance after revision, all peer-reviews are sent to the corresponding author, with an invitation to revise the paper.

Bailar JC, Mosteller F. Guidelines for statistical reporting in articles for medical journals. Ann Intern Med 1988; 108: 266-273. Committee on Publication Ethics. Code of Conduct and Best Practice Guidelines for Journal Editors. London: Committee on Publication Ethics, 2011. http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf Council of Science Editors. Promoting Integrity in Scientific Journal Publications. Wheat Ridge, CO: Council of Science Editors, 2009. http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid=3286.

If the author chooses to revise the paper, the revised paper should be accompanied by a detailed cover letter responding to each comment made by each peer-reviewer, indicating precisely how the revision deals with each comment, or why the author disagrees with or cannot incorporate specific comments.

Daly LE, Bourke GJ, McGilvray J. Interpretation and Uses of Medical Statistics (4th Edition). Oxford: Blackwell Scientific Publications, 1991. DeAngelis CD, Fontanarosa PB, Flanagin A. Reporting financial conflicts of interest and relationships between investigators and research sponsors. JAMA 2001; 286: 89-91.

Each peer-reviewer will then receive the revised paper, cover letter and comments of the other peer-reviewers. After the peerreviewers’ further comments have been received, a final decision about publication will be made.

Davidoff F, DeAngelis CD, Drazen JM, Hoey J, Højgaard L, Horton R, Kotzin S, Nicholls MG, Nylenna M, Overbeke AJ, Sox HC, Van Der Weyden MB, Wilkes MS. Sponsorship, authorship, and accountability. JAMA 2001; 286: 1232-1234.

The editorial process may vary from the above under certain circumstances, at the discretion of the Editor-In-Chief or Deputy Editor.

Gardner MJ, Altman DG (editors). Statistics with Confidence: Confidence Intervals and Statistical Guidelines. London: British Medical Journal, 1989.

Other Modes of Review

Haynes RB, Mulrow CD, Huth EJ, Altman DG, Gardner MJ. More information abstracts revisited. Ann Intern Med 1990; 113: 69-76.

Some guidance on statistical matters for authors is provided by International Committee of Medical Journal Editors (2006; 2010) and Bailar & Mosteller (1998). Notwithstanding this guidance, statistical review may be required for certain papers, and this will be arranged by the Journal editors where indicated. Other, more specialist forms of peer-review may also be required on occasion, and these, too, will be arranged by the Journal editors where indicated.

International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Vancouver: International Committee of Medical Journal Editors, 2006. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Vancouver: International Committee of Medical Journal Editors, 2010. www.icmje.org

Fast-Track Publication Papers which the editors feel warrant fast-track publication will be expedited through the publication process. The decision to “fasttrack” papers lies with the editors.

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Irish Journal of Psychological Medicine  

Official journal of the Irish College of Psychiatry

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