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In September 2014, as part of a national initiative to increase access to liaison psychiatry services, the liaison psychiatry services at Bristol Royal Infirmary received new investment of £250 000 per annum, expanding its availability from 40 to 98 h per week. The long-term impact on patient outcomes and costs, of patients presenting to the emergency department with self-harm, is unknown.
To assess the long-term impact of the investment on patient care outcomes and costs, of patients presenting to the emergency department with self-harm.
Monthly data for all self-harm emergency department attendances between 1 September 2011 and 30 September 2017 was modelled using Bayesian structural time series to estimate expected outcomes in the absence of expanded operating hours (the counterfactual). The difference between the observed and expected trends for each outcome were interpreted as the effects of the investment.
Over the 3 years after service expansion, the mean number of self-harm attendances increased 13%. Median waiting time from arrival to psychosocial assessment was 2 h shorter (18.6% decrease, 95% Bayesian credible interval (BCI) −30.2% to −2.8%), there were 45 more referrals to other agencies (86.1% increase, 95% BCI 60.6% to 110.9%) and a small increase in the number of psychosocial assessments (11.7% increase, 95% BCI −3.4% to 28.5%) per month. Monthly mean net hospital costs were £34 more per episode (5.3% increase, 95% BCI −11.6% to 25.5%).
Despite annual increases in emergency department attendances, investment was associated with reduced waiting times for psychosocial assessment and more referrals to other agencies, with only a small increase in cost per episode.
National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.
To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.
Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.
A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (−6.3, 95% CI −12.0 to −0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.
SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.
Self-harm in young people is associated with later problems in social and emotional development. However, it is unknown whether self-harm in young women continues to be a marker of vulnerability on becoming a parent. This study prospectively describes the associations between pre-conception self-harm, maternal depressive symptoms and mother–infant bonding problems.
The Victorian Intergenerational Health Cohort Study (VIHCS) is a follow-up to the Victorian Adolescent Health Cohort Study (VAHCS) in Australia. Socio-demographic and health variables were assessed at 10 time-points (waves) from ages 14 to 35, including self-reported self-harm at waves 3–9. VIHCS enrolment began in 2006 (when participants were aged 28–29 years), by contacting VAHCS women every 6 months to identify pregnancies over a 7-year period. Perinatal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale during the third trimester, and 2 and 12 months postpartum. Mother–infant bonding problems were assessed with the Postpartum Bonding Questionnaire at 2 and 12 months postpartum.
Five hundred sixty-four pregnancies from 384 women were included. One in 10 women (9.7%) reported pre-conception self-harm. Women who reported self-harming in young adulthood (ages 20–29) reported higher levels of perinatal depressive symptoms and mother–infant bonding problems at all perinatal time points [perinatal depressive symptoms adjusted β = 5.40, 95% confidence interval (CI) 3.42–7.39; mother–infant bonding problems adjusted β = 7.51, 95% CI 3.09–11.92]. There was no evidence that self-harm in adolescence (ages 15–17) was associated with either perinatal outcome.
Self-harm during young adulthood may be an indicator of future vulnerability to perinatal mental health and mother–infant bonding problems.
The mental health of university students, especially medical students, is of growing concern in the UK.
To estimate the prevalence of mental disorder in health sciences students and investigate help-seeking behaviour.
An online survey from one English university (n = 1139; 53% response rate) collected data on depression (using the nine-item Patient Health Questionnaire), anxiety (seven-item Generalised Anxiety Disorder Assessment), alcohol use (Alcohol Use Disorders Identification Test), self-harm and well-being, as well as help seeking.
A quarter of the students reported symptoms of moderate/severe depression and 27% reported symptoms of moderate/severe anxiety. Only 21% of students with symptoms of severe depression had sought professional help; the main reason for not seeking help was fear of documentation on academic records.
The study highlights the extent of mental health problems faced by health science students. Barriers to help seeking due to concerns about fitness-to-practise procedures urgently need to be addressed to ensure that this population of students can access help in a timely fashion.
Illegal wildlife trade is one of the major threats to Neotropical psittacids, with nearly 28% of species targeted for the illegal pet trade. We analysed the most comprehensive data set on illegal wildlife trade currently available for Venezuela, from various sources, to provide a quantitative assessment of the magnitude, scope and detectability of the trade in psittacids at the national level. We calculated a specific offer index (SO) based on the frequency of which each species was offered for sale. Forty-seven species of psittacids were traded in Venezuela during 1981–2015, of which 17 were non-native. At least 641,675 individuals were traded, with an overall extraction rate of 18,334 individuals per year (35 years of accumulated reports). Amazona ochrocephala was the most frequently detected species (SO = 3.603), with the highest extraction rate (10,544 individuals per year), followed by Eupsittula pertinax (SO = 1.357) and Amazona amazonica (SO = 1.073). Amazona barbadensis, Ara ararauna and Ara chloropterus were the fourth most frequently detected species (SO = 0.564–0.615). Eleven species were involved principally in domestic trade (> 60% of records). Our approach could be the first step in developing a national monitoring programme to inform national policy on the trade in psittacids. Patterns and numbers provided may be used to update the official list of threatened species, and could also be used in planning conservation actions.
Imagine asking yourself the question, “How would I describe a typical pregnant woman who uses drugs?” You might reply that she comes from a different social class, cannot think beyond the pregnancy, uses jargon, and doesn’t listen or care about the welfare of the child. However, my experience when asking drug-using women what they thought about the typical obstetrician is that they say the doctor was from a different social class, could not think beyond the pregnancy, used jargon, and didn’t listen or care about the welfare of the child.
We aimed to evaluate the availability and nature of services for people affected by personality disorder in England by conducting a survey of English National Health Service (NHS) mental health trusts and independent organisations.
In England, 84% of organisations reported having at least one dedicated personality disorder service. This represents a fivefold increase compared with a 2002 survey. However, only 55% of organisations reported that patients had equal access across localities to these dedicated services. Dedicated services commonly had good levels of service use and carer involvement, and engagement in education, research and training. However, a wider multidisciplinary team and a greater number of biopsychosocial interventions were available through generic services.
There has been a substantial increase in service provision for people affected by personality disorder, but continued variability in the availability of services is apparent and it remains unclear whether quality of care has improved.
The use of the Mental Capacity Act 2005 in assessing decision-making capacity in patients with borderline personality disorder (BPD) is inconsistent. We believe this may stem from persisting confusion regarding the nosological status of personality disorder and also a failure to recognise the fact that emotional dysregulation and characteristic psychodynamic abnormalities may cause substantial difficulties in using and weighing information. Clearer consensus on these issues is required in order to provide consistent patient care and reduce uncertainty for clinicians in what are often emergency and high-stakes clinical scenarios.
The relationship between ethnic density and psychiatric disorder in
postnatal women in the UK is unclear.
To examine the effect of own and overall ethnic density on postnatal
depression (PND) and personality dysfunction.
Multilevel analysis of ethnically mixed community-level data gathered
from a sample of 2262 mothers screened at 6 weeks postpartum for PND and
Living in areas of higher own ethnic density was protective against
screening positive for PND in White women (z =–3.18,
P = 0.001), even after adjusting for area level
deprivation, maternal age, relationship status, screening positive for
personality dysfunction, parity and geographical clustering (odds ratio
(OR) 0.98 (95% CI 0.96–0.99); P = 0.002), whereas the
effect on personality dysfunction (z =–2.42,
P = 0.016) was no longer present once the effect of
PND was taken into account (OR = 0.99 (95% CI 0.90–1.0);
P = 0.13). No overall ethnic density effect was found
for women screening positive for PND or personality dysfunction.
In White women, living in areas of higher own ethnic density was
protective against developing PND.
The pandemic of carbapenem-resistant Enterobacteriaceae (CRE) was primarily due to clonal spread of blaKPC producing Klebsiella pneumoniae. Thus, thoroughly studied CRE cohorts have consisted mostly of K. pneumoniae.
To conduct an extensive epidemiologic analysis of carbapenem-resistant Enterobacter spp. (CREn) from 2 endemic and geographically distinct centers.
CREn were investigated at an Israeli center (Assaf Harofeh Medical Center, January 2007 to July 2012) and at a US center (Detroit Medical Center, September 2008 to September 2009). blaKPC genes were queried by polymerase chain reaction. Repetitive extragenic palindromic polymerase chain reaction and pulsed-field gel electrophoresis were used to determine genetic relatedness.
In this analysis, 68 unique patients with CREn were enrolled. Sixteen isolates (24%) were from wounds, and 33 (48%) represented colonization only. All isolates exhibited a positive Modified Hodge Test, but only 93% (27 of 29) contained blaKPC. Forty-three isolates (63%) were from elderly adults, and 5 (7.4%) were from neonates. Twenty-seven patients died in hospital (40.3% of infected patients). Enterobacter strains consisted of 4 separate clones from Assaf Harofeh Medical Center and of 4 distinct clones from Detroit Medical Center.
In this study conducted at 2 distinct CRE endemic regions, there were unique epidemiologic features to CREn: (i) polyclonality, (ii) neonates accounting for more than 7% of cohort, and (iii) high rate of colonization (almost one-half of all cases represented colonization). Since false-positive Modified Hodge Tests in Enterobacter spp. are common, close monitoring of carbapenem resistance mechanisms (particularly carbapenemase production) among Enterobacter spp. is important.
Infect. Control Hosp. Epidemiol. 2015;36(11):1283–1291
The evidence base for rapid tranquillisation is small in higher-income countries but is even smaller in sub-Saharan Africa. We initiated the first ever survey on the use of rapid tranquillisation in Zambia in 2009; a further survey was then done in 2010, after a programme of teaching and training. It demonstrated an overall improvement in clinical practice, safety, awareness and use of medications within therapeutic doses. It also led to a reduction in inappropriate use of medications. These improvements in practice occurred within a short time span and with minimal effort. Further international collaborative partnerships are required to build stronger mental health infrastructure in Zambia.
The identification of a reliable and valid severity index for borderline personality disorder has vexed researchers for decades. A simple, clinically intuitive severity index for borderline personality disorder with predictive validity has now been identified. This index could usefully guide treatment planning, but other contextual factors should also determine the need for specialist treatment.
People with borderline personality disorder frequently experience crises.
To date, no randomised controlled trials (RCTs) of crisis interventions
for this population have been published.
To examine the feasibility of recruiting and retaining adults with
borderline personality disorder to a pilot RCT investigating the
potential efficacy and cost-effectiveness of using a joint crisis
An RCT of joint crisis plans for community-dwelling adults with
borderline personality disorder (trial registration: ISRCTN12440268). The
primary outcome measure was the occurrence of self-harming behaviour over
the 6-month period following randomisation. Secondary outcomes included
depression, anxiety, engagement and satisfaction with services, quality
of life, well-being and cost-effectiveness.
In total, 88 adults out of the 133 referred were eligible and were
randomised to receive a joint crisis plan in addition to treatment as
usual (TAU; n=46) or TAU alone (n=42).
This represented approximately 75% of our target sample size and
follow-up data were collected on 73 (83.0%) participants.
Intention-to-treat analysis revealed no significant differences in the
proportion of participants who reported self-harming (odds ratio (OR)
=1.9, 95% CI 0.53-6.5,P = 0.33) or the frequency of
self-harming behaviour (rate ratio (RR)=0.74, 95% CI 0.34-1.63,
P=0.46) between the two groups at follow-up. No
significant differences were observed between the two groups on any of
the secondary outcome measures or costs.
It is feasible to recruit and retain people with borderline personality
disorder to a trial of joint crisis plans and the intervention appears to
have high face validity with this population. However, we found no
evidence of clinical efficacy in this feasibility study.