Showing papers in "The Psychiatrist in 1992"

The Hospital Anxiety and Depression Scale

Abstract: Sir, As one of the authors of the hospital anxiety and depression scale I wish to comment on the study presented by Dowell and Biran (January Journal, p.27). Their study misinterpreted the purpose of the hospital anxiety and depression scale. It was devised as a clinical guide as to whether depression and/or anxiety may be contributing to the distress of patients attending non-psychiatric departments of general hospital clinics. Its purpose was not to rival the general health questionnaire' as a screening instrument for otherwise undefined 'cases' of psychiatric disorder. The two sub-scales of the hospital anxiety and depression scale must therefore be considered separately and it is unfortunate that their study has reproduced the error of an earlier study2 which presented data in terms of the summation of the scores on the two subscales, using an arbitrary score for definition of the supposed 'cases'. The statement by Dowell and Biran concerning the detection of 50%o of cases in their sample is therefore invalid. As regards the data in their Table 1, the finding that 10% of the 394 consulting sample (11+29) may be suffering from an associated, or primary, depressive state and 26% (25 + 76) from an anxiety state are not unrealistic estimates. It is important to bring to attention some further characteristics of the hospital anxiety and depression scale. Previous self-assessment instruments were either too long for convenient clinical use, presented concepts of 'depression' and 'anxiety' partly in terms of somatic symptoms thus rendering them less useful in physically ill patients, failed to differentiate the concepts of anxiety and depression or lacked instructions for interpretation of scores. The hospital anxiety and depression scale has attempted to overcome these defects. The general concept of 'depression' is overinclusive since the term is used to cover a wide variety of states of misery or unhappiness and, in devising the hospital anxiety and depression subscale we concentrated on the construct of anhedonia since this provides the clinician with the nearest clinical marker for the biogenic (antidepressant responsive) depressive state.3 Finally, may I take the opportunity to advise readers on the availability of the scale? To date it has been made available to users in the UK and Eire by the Medical Liaison Service of Upjohn. This good service must now unfortunately end but users may obtain a copy for subsequent photocopy by stamped addressed envelope from myself.

DSM–IV and culture: is the classification internationally valid?

Abstract: Although relatively neglected in Britain, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has been widely adopted in both Western and non-Western countries (Spitzer, Williams & Skrodol, 1983). The descriptive and multiaxial approach used in DSM-III (1980) and in its revised edition DSM-III-R (1987), together with the introduction of specific criteria for allocating each diagnosis, would seem particularly useful when comparing psychopathologies across societies. In addition to Axes I, II and III (Clinical Syndromes, Developmental and Personality Disorders, Physical Disorders and Conditions), the Manual has two more obviously ‘social’ axes – (IV) Severity of Psychosocial Stressors and (V) Global Assessment of Functioning.

Communication between general practitioners and psychiatrists

Abstract: The quality of care which patients receive within the NHS is dependent upon the communication between general practitioners (GPs) and specialists and the letter is the most widely used instrument in this process (Freeling & Kessel, 1984). There are only a few studies which have evaluated the efficiency of communication between the GP and the hospital specialist. For example, de Alarcon et al( 1960)showed that 96% of specialists' reports to GPs were found to

Are psychiatric case-notes offensive?

Abstract: During the last decade there have been a number of legislative changes establishing and extending the rights of patients to have access to their own medical and social service records. The Data Protection Act 1984, as modified by the Subject Access Modification Order 1987, gave patients access to computerised medical records with certain restrictions, in particular for information thought to be harmful to patients. The Access to Personal Files Act of 1987 granted access to Social Services Records. Again there were restrictions, e.g. to protect clients from serious harm or to protect confidential staff judgements. Finally, the Access to Health Records Act of 1990, which took effect on 1 November 1991 gives patients access to their own medical records and enables them to correct inaccuracies which they may find. Information likely to cause serious harm to the physical or mental health of the patient or of any other individual who could be identified can be withheld.

The Criminal Procedure (Insanity and Unfitness to Plead) Act 1991

Abstract: This short Act, which amends some parts of the Criminal Procedure (Insanity) Act 1964, came into force on 1 January 1992. It applies only to cases where arraignment was after that date (start of trial when charge[s] is read to the defendant), and only in the Crown and higher Courts. It enables Courts to try the facts of a case even when the defendant is “Under Disability” (= Unfit to Plead) and, when finding a person “Under Disability” or “Not Guilty by Reason of Insanity”, to order other disposals than indefinite detention in hospital. The legal definitions remain unchanged.

Mental Health Review Tribunals

Abstract: Following the 1983 Mental Health Act, Mental Health Review Tribunals (MHRT) now provide the opportunity for patients to have their detention reviewed and give a right of appeal against compulsory hospital detention or guardianship (Bluglass, 1983).

‘Mentally Incapacitated Adults and Decision Making’: implications of the Law Commission consultation paper for old age psychiatrists

Abstract: Old age psychiatrists' main concern with regard to incapacity is with patients with dementia. Dementia is predominantly a disorder of old age, probably affecting over half a million people in the UK, and it inevitably affects decision-making capacity. The 1983 Mental Health Act does not appear to have been framed with particular consideration for this group and it is vital that any new laws pay special attention to people with dementia.

Audit in psychotherapy: the concept of Kaizen

Abstract: When any organisation is exposed to pressure to change, this not only mobilises considerable anxieties within the organisation but calls a variety of defensive operations into play. The work of Jaques (1955) and Menzies Lyth (1959, 1988) has demonstrated that this can result in the central problem ceasing to be the focus of attention, with primitive defensive mechanisms (often of an obssesional or paranoid kind) being mobilised. This process may either lead to energy being devoted to isolated elements of the situation, or staff withdrawing into a state of passivity and hopelessness. Indeed, Jaques has observed that when changes are imposed on an institution in a way which fails to take account of the functions that existing structures serve in relation to the deeper needs and anxieties of those working within the institution, such changes are likely to be resisted, and may even fail.

Needs for continuing care of demented people: a model for estimating needs

Abstract: The way in which residential and other forms of continuing care have developed in the United Kingdom has been reviewed (Lewis & Wattis, 1988). It has been a story of unclear policy and confusion, especially in respect of people with dementia. At present there is a lack of clarity about who is responsible for providing continuing care for demented people. Traditionally, their care was shared between social services Part III (including EMI for the 'elderly mentally infirm') homes and

Patients repeatedly admitted to psychiatric wards

Abstract: Many admissions to general adult psychiatric beds occur as emergencies, either due to social crisis or relapse of psychiatric illness Other admissions are planned to arrest or reverse deterioration in mental state Length of stay varies from days to months depending on reason for admission and adequacy of support in the community Rapid readmission or failed discharge, defined as readmission within three months, has been linked with multiple previous admissions and personality factors (Jones, 1991)

Generic services for people with a mental handicap

Abstract: There has been much discussion on the most suitable services for mentally handicapped people with special needs such as additional mental illness or marked behavioural disorders. A number of policy documents have advocated the use of generic services as a matter of course, such as the All Wales Strategy (1983). while others have acknowledged a possible need for specialist input when such services are used e.g. Needs and Responses (Department of Health, 1989). In 1986 the Royal College of Psychiatrists stated that the psychiatric needs of this group required a specialised service and suggested that ideally this would be integrated with other psychiatric specialities as part of a comprehensive service. In 1989 a service was developed for mentally handicapped adults based at the University Hospital of Wales (UHW) in Cardiff. It gave the Academic United of Mental Handicap admitting rights to four bedson the acute general psychiatric unit in this teach ing hospital. Before this, admissions were to the local mental handicap hospital (Ely Hospital). In view of the discussions regarding services for this group we felt that a review of this new facility would be helpful.

Establishing psychiatric attachments to general practice: a six stage plan

Abstract: Since the 1970s there has been a growing trend for psychiatrists to establish formal attachments to primary care and these now form an important component of community psychiatry (Strathdee & Williams, 1984). In this paper a six stage plan for the establishment of a psychiatric attachment is pro posed. The framework outlined may be modified in the light of local service, training and research needs.

Psychopathology and violent behaviour in psychiatric intensive care

Abstract: This study considered the use of staff observation and patient's self-ratings of subjective psychopathology on admission to a psychiatric intensive care unit. The aim was to evaluate these measures as a means of predicting subsequent assaults and self-injury during the patients' stay on the ward. Few studies have shown a relationship between subjective experience and observable violent behaviour although some have found a correlation with ‘violence potential’. Eichelman & Hartwig (1990) have suggested the use of the SCL-90 hostility subscale, although doubts have been expressed about the ability of psychotic patients to complete such questionnaires reliably. The usefulness of both patients' self-ratings and staff observation would lie in their ability to help staff predict violence and self-injury and to take appropriate action.

The problem with registrar research

Abstract: In recent years registrars on psychiatric training rotations have been encouraged to begin their research careers early. Most of them are in such (training posts) for three and a half years. A few with extensive previous experience in other areas of medicine will be in post for less than this. The usual pattern of work with such schemes is to change both posts and accompanying routine every six months. At no point during this time will they have time allocated for research per se unless they are a fortunate member of some of the training rotations which include this in the weekly timetable. Such time has to be begged, stolen or borrowed from the hapless consultant who is all too aware of the service shortfall in his or her own area. If the registrar is fortunate enough to find an accommodating senior, this may not be the situation in his or her next post, which renders long term research well nigh impossible.

Community mental health services in Malaysia

Abstract: The need to confine and restrain psychotic patients at the turn of the last century saw the building of a few large asylums which soon became overcrowded with the growth of the population. These asylums were the only service available to the mentally ill until 1959 when the trend to decentralise began with the building of general hospital psychiatric units.