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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Letters to the Editor

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New online family intervention model

Lars Hansen, Consultant Psychiatrist (Southern Health NHS) and Chief Medical Officer (Healios), University of Southampton
David Kingdon, Professor of Mental Health Delivery and Clinical Director of Adult Mental Health (Southern Health NHS), University of Southampton
Colin Pritchard, Professor of Social Work, Emeritus, University of Southampton, University of Bournemouth
19 June 2017

Family interventions (FI) of various denominations have for the last 50 years been known to have a positive impact on both the individual with psychosis and their carers - patient outcome include reductions in risk of relapse, severity of symptoms in addition to an increase in social functioning (NICE, 2014). In spite of this knowledge, very few current service users, around 1% or carers receive any FI at all (Haddock et al., 2014) in spite of it being a NICE requirement in the treatment of psychosis. Serious questions have been raised about the consistency in quality of the family interventions currently provided due to lack of training, structure and supervision.

The reasons for the poor provision of FI are thought to be due to a lack of resources, poor attendance rates for face-to-face FI and cultural barriers within the NHS. A considerable level of evidence exists for phone and online delivery of a range of interventions for both physical and psychological conditions (e.g. Hedman et al. 2013). Several meta analyses have shown that the effect size of online interventions match that of face-to-face interventions (Anderson & Cuipers, 2010).

On that background Healios was founded 2013 with the purpose of delivering family interventions for a wide range of psychological disorders as well as increasing the accessibility of an evidence based, but underused treatment tool. The service is based on an integration of technology and manualised interventions delivered in 40 minute sessions online by specifically trained clinicians. All sessions are recorded and randomly evaluated weekly by a supervising psychologist and the clinician to ensure quality. In May of 2016 Healios received NICE endorsement for the family intervention manual in schizophrenia and psychosis. A number of NHS trusts in England have engaged Healios in addition to existing services to comply with guideline requirements.

The results following eight sessions have demonstrated a 25% reduction in burden on the Involvement Evaluation Questionnaire (N=128), 29% reduction in anxiety levels and 35% reduction in depression levels on the Hospital Anxiety and Depression Scales (N=128) in carers looking after a mixed group of patients suffering from psychosis, depression and PTSD. In a smaller sample of 24 families impact on work and social functioning reduced 41% measured on the Work and Social adjustment Scale over 12 sessions. Satisfactions rates with the intervention were high, 98% of service users are very satisfied or satisfied with the service.

FI is currently underused in spite of being recommended by NICE and having a solid evidence base for effectiveness dating back 50 years. To bridge that gap a service dedicated to online FI was established in 2013. The digitalised FI appeared to be effective and acceptable though further trials will be needed to continue to build the evidence behind this new model.

1.Psychosis and schizophrenia in adults: prevention and management, Clinical guideline [CG178], NICE, 2014

2.Haddock, G., Eisner, E., Boone, C., Davies, G., Coogan, C., & Barrowclough, C. An investigation of the implementation of NICE-recommended CBT interventions for people with schizophrenia. Journal of Mental Health 2014; 23(4), 162–165.

3.Hedman E, Ljótsson B, Rück C, Bergström J, Andersson G, Kaldo V, Jansson L, Andersson E, Andersson E, Blom K, El Alaoui S, Falk L, Ivarsson J, Nasri B, Rydh S, Lindefors N. Effectiveness of Internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Scandinavica Psychiatrica 2013;128 (6) , 457–467

4.Gerhard Andersson1 and Pim Cuijpers Internet-Based and Other Computerized Psychological Treatments for Adult Depression: A Meta-Analysis Cogn Behav Ther. 2009;38(4):196-205.

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Conflict of interest: Dr Lars Hansen is Chief Medical Officer at Healios

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Adolescent suicide and media: an epidemic of romanticizing suicide and celebrity idealism

Ahmed Waqas, Research Assistant, CMH Lahore Medical College & Institute of Dentistry, Lahore Cantt, Pakistan
Sadiq Naveed, Child & Adolescent Psychiatrist, KVC Prairie Ridge Psychiatric Hospital, Kansas City, KS, USA
Muhammad Hassan Majeed, Child & Adolescent Psychiatrist, Natchaug Hospital, Mansfield Center, CT, USA
13 June 2017

Recently, entertainment industry has attracted strong criticism from the medical community especially the mental health professionals; for glorifying suicide among the adolescents, in the Netflix series 13 reasons why. The peaceful, romantic and provocative portrayal of suicidality in the entertainment industry and the news media may have detrimental effects on social and psychological wellbeing of individuals. It may also legitimize suicide especially among teens suffering from intrapersonal and interpersonal predicaments. In our clinical experience, we have noticed negative effects of this negligent media coverage of suicide and deaths on adolescent mental health.

The glorified portrayal of suicide is also evident in the, historical narratives and the romantic literature, classic music and paintings among other forms of art. For instance, Goethe’s novel The sorrows of young Werther, portraying the suicide of the protagonist after the death of his beloved. This had led to an epidemic of suicide among the European youngsters, imitating the behavior of Werther.

Much later, this phenomenon led to coining of the term “Werther effect” by Phillips (1974), who described the relationship between portrayal of suicide in the media and subsequent risk of suicidal behavior among the readers, in his landmark study (1). Fortunately, the increasing trend in suicide among the American adolescents is matched by an explosive rise in research output on related research studies. As of May 31st, 2017, our analysis of related research output in pubmed, using search terms “suicid* AND adolescent*”, revealed a staggering number of 21,432 articles, ranging from 127 articles in 1971 to 1,166 articles in 2015.

Although the evidence regarding risks associated with reckless and glorified portrayal of suicides is clear, media personnel have seldom paid heed to it. Moreover, media content is seldom assessed for its psychological consequences among the general population. The World Health Organization, for instance, implores the news media to consider the importance of role models and aftermath of their suicides among the general public. According to it, news reporters should avoid “sensationalizing suicide, giving specific details, take the opportunity to educate the public and provide help/support to vulnerable readers/viewers” [2]. Niederkrotenthaler & Sonnek estimated a reduction in rates of suicides in Austria, after the implementation of such guidelines [3]. This phenomenon of positive impact of informed reporting among the general public is termed as the Papageno effect [3].

However, unfortunately, the situation seems bleak in the United States among many other countries where the media personnel are not much aware of these guidelines [4]. For instance, many journalists reporting incidents on suicide among the highest circulating newspapers in the US were not familiar with reporting guidelines [4].

Suicide is traditionally covered in media as a matter of extreme sensitivity but with 24 hours running new channels, demands for more innovative television shows and social media frenzy has sensationalized these deaths with irresponsible coverage [5]. Hence, it is pertinent that the training of journalists and media personnel be psychologically informed, to understand and report that every death is tragic and there is no glory in suicide.


1.Phillips, DP. The influence of suggestion on suicide: Substantive and theoretical implications of the Werther effect. Am. Sociol. Rev. 1974;39:340–54.

2.World Health Organization. Preventing Suicide: A Resource for Media Professionals, developed by the World Health Organization. 2000. Available at

3.Niederkrotenthaler T, Sonneck G. Assessing the impact of media guidelines for reporting on suicides in Austria: interrupted time series analysis. Aust. N. Z. J. Psychiatry. 2007;41:419-28.

4.Pirkis J, Blood RW, Beautrais A, Burgess P, Skehan J. Media guidelines on the reporting of suicide. Crisis. 2006;27:82-7.

5.Harshe D, Karia S, Harshe S, Shah N, Harshe G, De Sousa A. Celebrity suicide and its effect on further media reporting and portrayal of suicide: An exploratory study. ‎Indian J. Psychiatry. 2016;58:443.

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Conflict of interest: None Declared

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Should psychiatrists be prescribing exercise for depression?

David Burke, Consultant Psychiatrist, St. Patrick's University Hospital, Dublin
Laura M Bond, Psychiatry Registrar, St. Patrick's University Hospital, Dublin
13 June 2017

Depression remains one of the world’s leading physical and mental health issues, currently affecting over 350 million people globally; but a significant proportion of depressed patients do not access or receive effective treatment.1 Antidepressants and psychotherapy are well recognised as the treatments of choice for depression; but what if a there was another treatment psychiatrists could prescribe that was comparably effective, economical, and easily accessible?

Depression is a mental illness in which the mind-body relationship is highly prominent. The illness develops in response to the negative effects of allostatic overload on neural circuitry, through neuroendocrine, autonomic, immune, and metabolic mechanisms; and evidence suggests that exercise can help treat depression through its epigenetic effects on cellular and molecular level brain function. In particular, exercise reduces depressive symptoms through stimulating endorphin release, increasing neurogenesis via brain derived neurotrophic factor (BDNF), and buffering the damaging effects of stress (or allostatic overload) via the hypothalamic-pituitary adrenal axis (HPA).2 Exercise also encourages social interaction and engagement, improves physical co-morbidities such as diabetes mellitus and cardiovascular disease, and significantly improves a patient’s sense of well-being, and quality of life.

Furthermore, exercise has been shown to be moderately more effective than control interventions in treating depression, and to be comparable to both psychological and pharmacological interventions;3 and exercise may play a role in enhancing the positive benefits of antidepressants and psychotherapy, as well as in the prevention of relapse. However, only a minority of patients are counselled by their general practitioners about the benefits of exercise in overcoming depression;1 and we found no information on the rate at which psychiatrists counsel their patients about exercise for the treatment and prevention of depression, but we suspect it to be similarly low.

An ‘exercise prescription’ involves recommending an evidence-based, structured, personalised, exercise programme to patients, taking into account their baseline physical activity levels, personal preferences, and goals for the future. The recommendations of most exercise guidelines for an exercise prescription involve at least 150 minutes of moderate exercise per week;4 and it appears the best types of exercise for the treatment of depression are aerobic exercise, and strength training.5 ‘Moderate exercise’ is generally defined as exercise at a level of intensity that increases heart rate, increases perspiration, and makes the person out of breath to the point where it is difficult to maintain a conversation. Additionally, guidelines suggest an exercise prescription should be combined with education and discussion about the current scientific basis for prescribing exercise, and the provision of appropriate motivation and support to promote adherence.

Exercise is a highly effective, affordable, and readily accessible intervention in the treatment and prevention of depression; but currently, patients are mostly not advised by their treating doctors about the benefits of exercise. An effective exercise prescription can improve mood, enhance self-esteem, promote social interaction, reduce cardiovascular and cerebrovascular risk, and enhance the benefits of pharmacotherapy and psychotherapy. So, yes – we would suggest psychiatrists should always be prescribing exercise as part of their biopsychosocial management plan for patients with depression.


1. World Health Organisation. Depression is a common illness and people suffering from depression need support and treatment. WHO, 2012. Accessed May 2017 at:

2. McEwen B. Neurobiological and systemic effects of chronic stress. Chronic Stress. 2017; 1(1): 1-11.

3. Cooney G, Dwan K, Greig C, et al. Exercise for depression. Cochrane Database of Systematic Reviews. 2013.

4. Garber C, Blissmer B, Deschenes M, et al. Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults. Medicine & Science in Sports & Exercise. 2011; 43(7): 1334-1359.

5. Silveira H, Moraes H, Oliveira N, et al. Physical exercise and clinically depressed patients: a systematic review and meta-analysis. Neuropsychobiology. 2013; 67: 61-68.

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Conflict of interest: None Declared

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why form over content ?

Saad F Ghalib, Consultant Old Age Psychiatrist, Behavioral Sciences Pavilion, SKMC, Abu Dhabi,UAE
10 June 2017

“Establishing a relationship between particular biochemical processes and the clinical data of illness requires a scientifically rational approach to behavioral and psychosocial data, for these are the terms in which most clinical phenomena are reported by patients “ G. Engel(1).

Many scientists across different disciplines do find the need of physical explanations (cells, atoms) to some form of an understanding (meaning) that can potentially be communicated, very intriguing indeed. So eloquently put by Niels Bohr, the father of atomic theory: “Any account of experience even in atomic physics must ultimately rest on the use of concepts indispensable for a conscious recording of sense impressions” (2). In quantum theory an act of measurement entails the integration of observer’s choice into the micro-world (collapse of wave function) and the registration of results via the classical language of the macro-world (space, time).

Karl Jaspers and out of many contributions to psychiatry, he too advocated a distinction between understanding and causal explanations. According to Jaspers, while the former operates within the phenomenological sphere of consciousness, the latter belongs to the realm of natural sciences and uses measurement (3). Moreover, he emphasized form over content as a core feature for a proper understanding of patient’s experiences. In Jaspers’ view, a delusional belief may not necessarily be false or out of keep with the patient’s cultural or religious background. However, by asking specific sets of questions, a clinician can nevertheless determine if a belief is delusional in nature. Therefore, the presence of an observer (clinician) is an essential component of the arduous process of finding a narrative for patient’s symptoms. Not unlike the process of measurement in quantum physics, in psychopathology too, understanding is weaved into the process of delineating the form of an experience by an observer. Unfortunately, literature in psychopathology repeatedly attributes meaning to content rather than the form of an experience! The latter position cannot be justified, considering that content on its own will not go very far in elucidating the phenomenological meaning of an experience. For example: a hypochondiacal belief as content cannot provide a meaningful clinical description unless the form of the belief is stated, i,e., depressive, obsessive, or psychotic in nature. Often though, the “content’ of delusions is non-understandable; it nevertheless is still possible for an attentive clinician to reach an understanding of the” form” of the belief by the art of empathy and the creation of narratives for patient’s symptoms. However, it is rather unrealistic to expect all different professionals to follow the same operational principle in the process of identifying the meaning (form) of patient’s experience.

Information theory, another cornerstone of modern science, seems to agree with Jasperian psychopathology as well as quantum theory, whereby form is emphasized over content. Furthermore, the role of observers is cemented in the actual process of elucidating the context of information. For example: a system looks more disordered to an observer that knows little about it. By the same token, a statement is measurably more informative to a listener that has little familiarity with the topic stated. According to information theory, different listeners would end up reaching different conclusions as to how informative a statement is despite the fact that statement content remains the same! So for example, a statement that infers a delusional belief may represent projection as a defense mechanism to one listener and at the same time to another a sign of self-isolation and poor self-esteem.

In conclusion: although it is easy for different clinicians to agree on the content of a patient’s experience, it nevertheless remains impossible to agree on the form with high precision as this would entail that all observers have the same involvement and background knowledge, which is a logical impossibility. However, the form of experience remains the core feature of understanding of patients’ concerns.


1. Engel G . The Need for a New Medical Model: A Challenge for Biomedicine. Psychodynamic Psychiatry, 40(3)377-396, 2012. Reprinted with permission. 1977 American Association for the Advancement of Science.

2.Bohr N. Atomic Physics and Human Knowledge. P21. 2010. Dover Publication.

3. Jablensky A. Karl Jaspers: Psychiatrist, Philosopher, Humanist. Schizophr Bull.2013 Mar, 39(2):239-241.

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Conflict of interest: None Declared

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the hippocampus

David H Yates, retired psychiatrist, FRC Psych Carer
05 June 2017

It is a long time since schizophrenia was the core subject for clinical Psychiatry, if it ever was, or will be again, delivery of services lapsing under competing mental health conditions with prior political imperatives. Luckily academic studies have maintained interest, subsequent to HM's surgical hippocampal disaster, many corroborating the crucial importance of brain hippocampal neurogenesis status in managing experience into memory, although clinical practice interest lags.

Importantly, hippocampal neurogenesis in continuing schizophrenia is half only of what is required normally.

It is a disaster for those with schizophrenia. for , they do not, cannot reliably, call on updated experience to get through their daily living, nor prime themslves for their more immediate future,without much more time, and by restricting the flow of incoming stimuli

/information . They are overloaded.

This situation is worse if the illness arrives in adolescence.Those whose illness arrives later will have had the chance to accumulate some settled relationships, work and domestic skills.

Less reliable hippocapal memory management needs to be emphasised when providing a clinical service.

Insufficiently informed community workers need more instruction, when they visit, on the imperfect memory and reduced capacity, that will likely be present in conversational interviews.

More time is needed to accommodate changes in daily living happenings, conversation.

Protected repetition in a simplified personal environment, is an unfulfilled treatment requirement at home and in community settings.

David Yates FRCPsych.

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Conflict of interest: None Declared

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