Prolonged-Release Buprenorphine Therapy in Opioid Use Disorder Can Address Stigma and Improve Patient Quality of Life

Treatment for opioid use disorder (OUD) including opioid agonist therapy (OAT) is effective. Medication with the oral administration of methadone and buprenorphine has well-known limitations (establishing consistent optimal dosing levels, misuse, diversion, and accidental exposure). Treatment may require attendance at treatment services for collection and consumption of medication; this is associated with stigma and discrimination. Novel therapeutic options include approved, injectable, prolonged-release buprenorphine (PRB) products providing consistently optimal drug levels and less frequent dosing. This work assesses the lived experience of persons currently engaged in OUD therapy to define the potential value of novel therapeutic options in order to inform treatment decisions.

One hundred and twenty-two people engaged with treatment services participated in this assessment. Seventy-two percent of participants believed that novel therapeutic options would improve quality of life and 67% stated it would reduce stigma and discrimination. Participants were neither concerned about the efficacy of (net score negative 30%), or lack of control over (net score negative 36%) treatment, nor about reduced contact with treatment services (net score negative 11%). Results from this assessment indicate that the provision of choice including novel therapeutic options is likely to improve quality of life and reduce the stigma of persons with OUD.

Patient-Reported Outcomes, Experiences and Satisfaction with Weekly and Monthly Injectable Prolonged-Release Buprenorphine

Introduction

Prolonged-release buprenorphine (PRB), administered by weekly or monthly injection, for opioid dependence (OD) treatment offers the potential to address some limitations of oral therapy including stigma, difficulty in achieving consistent appropriate dosing, risk of diversion of medications, risk of overdose, and continuing use of other drugs. Patient-reported outcomes (PRO) and experiences are important in the evaluation of OD therapy success. This work aimed to document PRO during PRB therapy to guide future treatment decision-making.

Methods

Qualitative interviews were completed with people on PRB OD treatment. Twenty individuals from four treatment services in England and Wales were asked to participate. A structured interview was developed guided by a person with OD lived experience. Interviews were transcribed, coded and analyzed using iterative categorization.

Results

Fifteen of 20 individuals approached agreed to participate, and 14 completed interviews. The average age of participants was 42 (range 33–54) years, 13 males and 1 woman, the history of problematic opioid use was 14 years (3–25 years), time in treatment was 7 years (1–20 years), and duration on treatment with PRB was 4 months (range 1–8 months). Participants reported treatment experiences leading to coding of 277 unique comments: therapy effectiveness (77% indicated a benefit of, or satisfaction with, PRB therapy, 7% neutral/general, 16% indicated concern or questions about PRB therapy), convenience (81% benefit, 7% neutral/general, 12% concern), and overall satisfaction (81% benefit, 3% neutral/general, 16% concern). Reported benefits include cravings reduction of 10 (71%), self-care improvement of 10 (71%), relationships improvement of 9 (64%), resources management of 6 (43%), positive outlook on life of 12 (86%). Participants reported a range of positive personal experiences; challenges reported included temporary injection discomfort at treatment initiation.

Discussion

In this small, focused population, there was generally a positive level of treatment satisfaction with PRB. These experiences provide insights to explain potential treatment benefit to others and are useful in guiding therapy choices for others in the future.

OUD Care Service Improvement with Prolonged-release Buprenorphine in Prisons: Cost Estimation Analysis

Background

In prisons in England, integrated treatment for opioid use disorder (OUD) is accessible and effective, commonly based on daily supervised consumption of methadone. Treatment limitations (inadequate dosing, nonengagement with care, stigma, diversion and bullying) are noted. Flexible dose, injectable prolonged-release buprenorphine (PRB) which removes the need for daily dispensing and supervision is suggested for prisoner care. This work aimed to predict the difference in costs of current standard of care vs partial introduction of PRB.

Methods

A predictive model of compared costs for the provision of OUD care in the prison setting in England evaluated current standard of care (all receive methadone) with a future situation of 30% of prisoners electing to use a monthly dose of PRB. Evidence describing costs to deliver OUD care for 150 prisoners (pharmacotherapy, direct service, indirect health care, indirect security costs) were collected, including assumptions describing how care would be delivered. Evidence sources include national data sources, scientific literature and from experience in the prison health care setting.

Results

For a representative standard prison population requiring OUD care of 150 prisoners in England PRB introduction is associated with a predicted reduction in direct and indirect costs of OUD care. Annual OUD care costs for current standard of care were £0.6M; with 30% PRB costs reduced by £8665, more than 3000 hours of staff time is saved. Sensitivity analyses showed greater adoption of PRB resulted in further cost reduction.

Conclusion

PRB can address limitations of OUD care in prisons and improve outcomes. Introduction does not increase cost of care in this predictive analysis. PRB may lead the transformation of prisoner OUD care.

Standards for opioid use disorder care: An assessment of Nordic approaches

Aims:

Outcomes in opioid use disorder (OUD) in Nordic countries have improved with integrated treatment and harm-reduction programmes. Approaches and the standard of care are different across the region. Evidence of treatment needs and current approaches are defined from evidence to inform development of a common standard.

Method:

Evidence of population sizes and treatment approach collected. Common standards for care (harm reduction, pharmacotherapy, psychology/social therapy) defined for each country.

Results:

Evidence defines number in treatment; potential population needing treatment not defined for all countries. Populations sizes, treatment access (ratio in treatment programme compared to total country population) defined: Sweden 4,000 in OUD care (access ratio 40); Finland 3,000 (55); Norway 8,000 (154); Denmark 7,500 (132). Approach to treatment similar: integrated treatment programmes standard. Care provided by specialists in outpatient clinics/primary care; secondary care/inpatient services are available. Harm reduction is limited in Sweden but available and more accessible elsewhere. Treatment entry criteria: access relatively unlimited in Norway and Denmark, more limited in Finland and Sweden. Standards of care defined: easy access to high-quality services, individual planning, care not limited by time, management of relapse, education for patients, continuous engagement, holistic approach including management of comorbidities, needle equipment programmes without limit, treatment in prisons as community.

Conclusion:

There are opportunities to improve OUD care in the Nordics. Policy makers and clinicians can advance OUD care and share common success factors. Collaborative work across the Nordic countries is valuable. Further research in clinical practice development can yield important results for the benefit of patients with OUD.

Offering HCV treatment to prisoners is an important opportunity: key principles based on policy and practice assessment in Europe

Background

Prisoners have a high prevalence of hepatitis C virus (HCV) infection but may find it difficult to access healthcare services. This may be related to risk behaviour including history of injecting drugs and marginalisation related to problem drug use/ opioid use disorder (OUD). Direct-acting antiviral products with superior efficacy and safety compared to interferon-based regimens offer HCV cure. Many citizens in Europe have been treated, although few received therapy in prisons.

Methods

Analysis of prisoner HCV treatment need and policy determinants of clinical practice was completed for 5 EU countries. Evidence was collected from national statistical sources and peer-reviewed publications to describe prison populations and HCV prevalence, to map national prison/ HCV health policy or guidance. A consensus of important principles for prisoner HCV care was developed.

Results

Data from published sources describing prisoner HCV prevalence is limited. Prisoner population requiring HCV treatment is not known; estimated numbers based on analysis of evidence: England and Wales, 9000, France, 8000, Spain, 6000, Italy, 6000, Germany, 6000. Treatment access: national law defines right to equivalent care in all countries implying access to HCV therapy in prison similar to community; useful prisoner HCV guidance facilitating treatment decisions present in: 4 of 5 national/ regional HCV policy documents, 4 of 5 national prison healthcare policies. Four of five had practical prison HCV clinical guidelines. Despite existence of policy, implementation of guidance, and so HCV treatment, is suboptimal in many locations.

Conclusions

Prison is an important location to detect, address and treat HCV infection in people who may be underserved for healthcare and find it difficult to navigate community treatment pathways. This is often related to problems with OUD and resulting social inequity. HCV management in prisons must be improved. Policy and clinical practice guidance must be set to promote treatment, and practical steps to make treatment easy should be followed including education to promote engagement, set-up of optimal screening and work up processes with modern tools to reduce time needed/ achieve efficiency; programs to make it easier to get specialists’ input include remote working and nurse-led services.

Practical steps to improve chronic hepatitis C treatment in people with opioid use disorder

OBJECTIVES

People with a history of injecting drugs have high prevalence of hepatitis C virus (HCV) infection, and many have opioid use disorder (OUD). Modern HCV therapies with improved efficacy and tolerability are available, but access is often limited for this group, who may be underserved for health care and face social inequity. This work develops practical steps to improve HCV care in this population.

METHODS

Practical steps to improve HCV care in OUD populations were developed based on clinical experience from Spain, structured assessment of published evidence.

RESULTS

Options for improving care at engagement/screening stages include patient education programs, strong provider-patient relationship, peer support, and adoption of rapid effective screening tools. To facilitate work up/treatment, start options include simplified work up process, integration of HCV and OUD care, and continuous psychosocial support prior, during, and after HCV treatment.

CONCLUSION

It is important to plan on local basis to set up a joint integrated approach between specific drug treatment services and local points of HCV care. The elements for a specific integrated program should be chosen from options identified, including education services, peer input, organization to make HCV screening and treatment easier by co-location of services, and wider access to prescribing direct-acting antiviral (DAA) therapy.

Principles for managing OUD related to chronic pain in the Nordic countries based on a structured assessment of current practice

BACKGROUND

Long-term use of opioid analgesics (OA) for chronic pain may result in opioid use disorder (OUD). This is associated with adverse outcomes for individuals, families and society. Treatment needs of people with OUD related to chronic pain are different compared to dependence related to use, and also injection, of illicit opioids. In Nordic countries, day-to-day practical advice to assist clinical decision-making is insufficient.

AIM

To develop principles based on expert clinical insights for treatment of OUD related to the long-term use of OA in the context of chronic pain.

METHODS

Current status including an assessment of barriers to effective treatment in Finland, Denmark, Iceland, Norway, Sweden was defined using a patient pathway model. Evidence to describe best practice was identified from published literature, clinical guidelines and expert recommendations from practice experience.

RESULTS

Availability of national treatment guidelines for OUD related to chronic pain is limited across the Nordics. Important barriers to effective care identified: patients unlikely to present for help, healthcare system set up limits success, diagnosis tools not used, referral pathways unclear and treatment choices not elucidated. Principles include the development of a specific treatment pathway, awareness/ education programs for teams in primary care, guidance on use of diagnostic tools and a flexible treatment plan to encourage best practice in referral, treatment assessment, choice and ongoing management via an integrated care pathway. Healthcare systems and registries in Nordic countries offer an opportunity to further research and identify population risks and solutions.

CONCLUSIONS

There is an opportunity to improve outcomes for patients with OUD related to chronic pain by developing and introducing care pathways tailored to specific needs of the population.

Current and future options for opioid use disorder: a survey assessing real-world opinion of service users on novel therapies including depot formulations of buprenorphine

PURPOSE

Integrated treatment for opioid use disorder (OUD) includes opioid agonist therapy (OAT) such as methadone and buprenorphine with well-evidenced benefits. Treatment with typical existing oral medications is associated with burdens and limits to successful outcomes (frequent dosing, attendance for collection/consumption, difficulty in achieving optimal dosing, misuse, diversion, accidental exposure, and stigma from the treatment process). Novel medications include injected depot formulations with less frequent administration, providing consistent drug levels after dosing. This survey assesses the opinion of those with OUD treatment services lived experience to inform future medication choices.

PATIENTS AND METHODS

A survey of people with experience of OUD pharmacotherapy - the treatment system - was completed. Participants reviewed statements describing elements of OUD care using 7-point Likert scales to indicate their level of agreement or disagreement. Data were assessed using descriptive analysis.

RESULTS

In total, 35 people (16 in treatment; 19 with previous history of treatment) completed the survey. Average drug-use duration, 20 years, commonly included injected opioids. The majority agreed treatment was effective, but not tailored to their individual needs and limited normal day-to-day activities. Opinions on novel depot medications included the following: agreement on its potential to make life easier, reduce stigma, free-up time for preferred activities. Participants did not report concerns over the effectiveness and safety of depot medications, nor about reduced contact with treatment services that could be associated with less frequent dosing.

CONCLUSION

This survey provides a useful initial record of the opinions of people experienced in OUD treatment services on novel depot medications, which may result in important benefits. Care providers and policy makers should continue to work with those with lived experience to understand the specific opportunity provided by such innovation.

Buprenorphine dosing choices in specific populations: review of expert opinion

INTRODUCTION

Treatment of opioid dependence with buprenorphine improves outcomes. Typical dosing ranges for all patients from clinical evidence and as defined in the product information are wide. For specific groups with complex clinical scenarios, there is no clear consensus on dosing choices to achieve best possible outcomes.

AREAS COVERED

The doses of buprenorphine used in 6 European countries was reviewed. A review of published evidence supported rapid induction with buprenorphine and the benefits of higher doses but did not identify clearly useful guidance on dosing choices for groups with complex clinical scenarios. An expert group of physicians with experience in addiction care participated in a discussion meeting to share clinical practice experience and develop a consensus on dosing choices.

EXPERT OPINION

There was general agreement that treatment outcomes can be improved by optimising buprenorphine doses in specific subgroups. Specific groups in whom buprenorphine doses may be too low and who could have better outcomes with optimised dosing were identified on the basis of clinical practice experience. These groups include people with severe addiction, high tolerance to opioids, and psychiatric comorbidities. In these groups it is recommended to review dosing choices to ensure buprenorphine dosing is sufficient.

The Impact of Misuse and Diversion of Opioid Substitution Treatment Medicines: Evidence Review and Expert Consensus

BACKGROUND/AIMS

Opioid substitution treatment (OST) improves outcomes in opioid dependence. However, controlled drugs used in treatment may be misused or diverted, resulting in negative treatment outcomes. This review defines a framework to assess the impact of misuse and diversion.

METHODS

A systematic review of published studies of misuse and diversion of OST medicines was completed; this evidence was paired with expert real-world experience to better understand the impact of misuse and diversion on the individual and on society.

RESULTS

Direct impact to the individual includes failure to progress in recovery and negative effects on health (overdose, health risks associated with injecting behaviour). Diversion of OST has impacts on a community that is beyond the intended OST recipient. The direct impact includes risk to others (unsupervised use; unintended exposure of children to diverted medication) and drug-related criminal behavior. The indirect impact includes the economic costs of untreated opioid dependence, crime and loss of productivity.

CONCLUSION

While treatment for opioid dependence is essential and must be supported, it is vital to reduce misuse and diversion while ensuring the best possible care. Understanding the impact of OST misuse and diversion is key to defining strategies to address these issues.

Spontaneous spinal epidural haematoma mimicking meningitis in a 2-year-old child--a case report and literature review

INTRODUCTION

We report the case of a 2-year-old boy with suspected meningitis who presented with acute onset neck pain and stiffness associated with right-sided weakness and ataxia.

MANAGEMENT

Despite intravenous antibiotics and antiviral treatment, his condition deteriorated. Magnetic resonance imaging demonstrated spontaneous cervical epidural haematoma (C4-C7) extending down to thoracic (T7) level with associated compression of the spinal cord. He was treated successfully by neurosurgical decompression and made a complete recovery.

DISCUSSION

Spinal epidural haematoma is a neurosurgical emergency characterised by extravasation of blood in the spinal epidural space. The clinical presentation particularly in young children can masquerade other conditions such as meningitis. In this article, we discuss our case and review the literature on spontaneous spinal epidural hematoma with an aim to improve awareness of this condition which if not recognised and treated early can lead to significant lifelong morbidity.

Mental health and intellectual disability: culture and diversity

BACKGROUND

Compared with that in mental illness, cultural variation in popular conceptualisations of intellectual disability has been rarely addressed.

METHODS

A survey of the relevant literature was conducted.

RESULTS AND CONCLUSION

Preliminous conclusions are that local conceptualisation does not lead to invariant social response, but that intellectual disability is generally distinguished from mental illness.

A postmarketing surveillance study of the safety and efficacy of ReFactoR (St Louis-derived active substance) in patients with haemophilia A

This clinical trial evaluated the safety and efficacy of ReFacto (St Louis-derived active substance) in patients with severe or moderately severe haemophilia A over a period of 6 months or 50 exposure days (EDs), whichever occurred first. Sixty patients, 58 previously treated and two previously untreated, were enrolled into this study. This was an open-label, multicentre, postmarketing surveillance study in which patients received prophylaxis or on-demand treatment as determined by their doctor. Surgical prophylaxis was evaluated in seven patients requiring elective surgery. Thirty-two patients aged <1 to 66 years (median 19.5) received prophylaxis and 28 patients, aged 1-71 years (median 33.5), received on-demand treatment. The majority of patients had severe haemophilia A (FVIII:C < 2%): 84.4% in the prophylaxis group and 85.7% in the on-demand group. Prophylaxis with ReFacto was associated with a median of 6.7 bleeds per year (range: 0-37). The investigator's assessment of final outcome for prophylactic treatment was excellent or effective for 93.1% of patients. ReFacto resolved 92.8% of bleeds with one or two infusions. The investigator's assessment was excellent or good for 98.2% of bleeds treated with ReFacto. Haemostasis was achieved for all seven surgical cases and ReFacto gave an excellent or good response for each. The nature and incidence of adverse events was as expected and no new safety concerns emerged. One previously treated patient (PTP) developed a high-titre inhibitor (maximum 75 BU) and one minimally treated patient (MTP) developed a low-titre inhibitor while on the study but eventually achieved high titres (maximum 30 BU) after immune tolerance therapy was initiated with a plasma-derived FVIII product. One previously untreated patient (PUP) developed a transient low-titre inhibitor (0.4 BU). Other serious adverse events (SAEs) were unrelated to study treatment. There were no allergic events. The results of this study are consistent with the previously published ReFacto pivotal studies.

Psychotherapy in cultural contexts

This article examines gender politics, culture, and race, as well as therapy and social transition, as they relate to psychotherapy in cultural contexts. Examples of gender politics in Kenya and Somalia are discussed. Rites of passage as they relate to psychiatric illness also are discussed. "Therapeutic cure" as defined in various cultures also is reviewed.

Social institutions and psychological explanations: Druze reincarnation as a therapeutic resource

For Emile Durkheim, to explain our social institutions through individual psychology was generally regarded as illegitimate. It has, however, often been assumed by psychologists and psychiatrists, particularly in the case of religious doctrine and institutions. However, the people actually concerned, our religious informants, might sometimes themselves volunteer interpretations which are psychologically functional for the origin and maintenance of certain cultural facts. This is particularly so when they are faced with a 'modern' worldview. The instance of the Druze belief in bodily reincarnation after death is considered in the context of the recent civil war in the Lebanon.

Against over-interpretation: the understanding of pain amongst Turkish and Kurdish speakers in London

The understanding of experienced pain has recently moved from the biological to the metaphorical. Detailed interviews with twelve Turkish and Kurdish patients in London who had been unsuccessfully investigated medically for chronic pain showed that their understanding reflected local, typically humoural, conceptions of self and body. However there was little to suggest interpretation of the illness as a more specific and grounded idiom for social or political experience. It is suggested that the current vogue for 'interpretation' in medical anthropology and social psychiatry may occasionally be, as Umberto Eco puts it, 'over-interpretation'.

Perceptions about mental illness among pre-clinical medical students in Trinidad & Tobago

Perceptions about mental illness among medical practitioners are likely to determine their capacity to recognise, treat appropriately and refer patients who have mental health problems. It is therefore important that training of medical students in psychiatry is undertaken with knowledge of their attitudes to mental health disorders. We determined the perceptions of 108 pre-clinical medical students (69 males, 39 females; mean age 22 years) toward mental illness in Trinidad & Tobago by analysing their responses to a questionnaire based on a case vignette of a young man with a paranoid psychotic illness. 88% felt that medical treatment in hospital was the best means of treating the illness and 86% suggested that discharge should be conditional on regular visits to a doctor. 89% however opposed the patient's marrying into their families and 85% to his teaching their children. This was associated significantly with having a personal relationship with someone having a mental illness (p < 0.03). Surprisingly, 25% believed that mental illness could be caused by supernatural forces, particularly females who were almost twice as likely as males to express this belief.

Patient satisfaction: ethnic origin or explanatory model?

Despite concern over their psychiatric treatment, little is known about black and ethnic minority patient satisfaction with psychiatric services and whether perceived 'ethnicity' or discrepant understanding of illness experience is most relevant. Twenty-one white British and 63 ethnic minority patients were interviewed for their opinions on psychiatric in-patient care, their treatment preferences and their explanatory models of their illness. The most significant association with satisfaction was not ethnic origin but the patient's explanatory model of their illness which showed little association with ethnicity whether patients were voluntary or involuntary. Satisfaction is most likely when there is concordance between the patient's and psychiatrist's explanatory model.

The effects of two doses of replacement growth hormone on the biochemical, body composition and psychological profiles of growth hormone-deficient adults

This study examined the effects of growth hormone (GH) replacement on the insulin-like growth factor-I (IGF-I), body composition and psychological profiles of GH-deficient adults. We assessed whether two doses of GH produced different effects on these variables and whether patients who, at the end of the study chose to remain on long-term GH replacement responded differently to those who chose to abandon therapy. Forty-two adults (aged 42.9 +/- 1.9 years (mean +/- S.E.M.)) with documented GH deficiency entered two studies (24 in study 1, 18 in study 2). Biochemical, body composition and psychological profiles were assessed at baseline, and after 6 months and 1 year. Psychological assessments were performed using well-established, independent, validated 'Quality of Life' questionnaires (Nottingham Health Profile (NHP) and the Psychological General Well-Being Schedule (PGWB)). The study protocols differed only in the doses of growth hormone (0.024 mg/kg per day and 0.012 mg/kg per day respectively). Comparison between studies and between patients eventually continuing and abandoning GH therapy was performed. GH replacement was associated with significant changes in IGF-I levels (P < 0.001), body composition (P < 0.01) and self-perceived well-being (NHP, P < 0.01; PGWB, P < 0.01). The higher dose of GH produced a greater IGF-I response than the lower dosage (44.6 +/- 7.3 vs 26.2 +/- 3.6 nmol/l, P < 0.05), but no better psychological response (NHP, P = 0.22; PGWB, P = 0.23). Those deciding to continue replacement therapy did not respond differently to those choosing to abandon therapy with respect to IGF-I (P = 0.72), body composition (P = 0.38) and psychological assessment (NHP, P = 0.29; PGWB, P = 0.24). GH replacement in GH-deficient adults was associated with significant improvements in self-perceived well-being as well as changes in body composition and other variables. This improvement was similar at two different doses of replacement GH. Those patients electing to continue on long-term replacement did not achieve a demonstrably different psychological, body composition or biochemical benefit to those patients deciding to discontinue replacement.

Vision testing in atrophic macular degeneration

PURPOSE

To determine the correlation between a group of vision tests in atrophic macular degeneration (AMD) in an office setting.

METHODS

Patients with documented vision loss from atrophic macular degeneration in one eye were invited to attend an eye clinic every three months for a series of six vision tests for their good eye followed by fundus photography. Modified contrast sensitivity, blue/yellow anomaloscopy, flicker fusion frequency, Amsler grid, and photostress recovery time were correlated with Snellen acuity using the Pearson correlation coefficient. The regression of the Snellen acuity on sex, age and the presence of disciform macular degeneration in the other eye was obtained using a general linear model.

RESULTS

The correlation with Snellen acuity result was low for all tests. It was highest for Amsler grid abnormality (r = -0.33345) and blue/yellow anomaloscopy matching range (r = -0.20742), where r denotes the correlation coefficient. Patient age was strongly correlated with Snellen results (P = 0.0001), but it was not significantly related to sex (P = 0.1187) or the presence of disciform macular degeneration in the other eye (P = 0.9989). The photostress recovery time showed enormous inter-visit variations and poor correlation with Snellen acuity (P = 0.0526).

CONCLUSIONS

The course of AMD is routinely assessed by Snellen acuity and any of several additional tests. When employing a test battery in an office setting, a clinician needs to know the relative utility and correlation between the tests at his disposal. Of the tests used in this study, the Amsler grid was the most useful addition to the Snellen acuity at all stages of atrophic macular degeneration, and blue/yellow anomaloscopy was useful only in mild macular degeneration where Snellen acuity was 6/12 or better.

Psychiatry's culture

Culture remains an ambiguous concept for psychiatry: deprecated by the assumption that it is secondary to biomedical reality, yet at the same time some notion of 'culture' has served to represent the modern against the primitive. Contemporary clinical understandings of culture derive from imperial medicine which had applied the accepted distinction between the biological form and the cultural content of psychopathology to local illnesses which could not easily be fitted into the European nosology. The later concept of culture-bound pathology, like the psychoanalysts' 'modal personality', only imperfectly escaped from evaluative assumptions of 'development', but it is difficult to argue that psychiatry provided British colonial administrations with any significant ideological justification.

The effectiveness of words: religion and healing among the Lubavitch of Stamford Hill

Testimonials of miraculous healing offered by Lubavitch Hasidim evoke images of exile and restitution which derive from Kabbalistic texts. Mediated practically through the person of the Rebbe, these testimonials articulate both immediate affliction and ultimate meaning, physical embodiment as well as symbolic representation, each constituting the other. Both Kabbalah and medical anthropology attempt to transcend not dissimilar epistemological dualisms: those characteristic of monotheism and contemporary science. Yet the 'lower root' of Kabbalah affirms a material reality known through immediate sensory experience which recalls the rationale of biomedicine.

Post-adoption incest and phenotypic matching: experience, personal meanings and biosocial implications

Recent changes in British law have enabled adults who were adopted when young to trace their biological relatives. The reported frequency of incestuous sentiments and relationships in these reunions, together with the individual experiences and the meanings which are attached to them, challenge fundamental assumptions of both Westermarck's and Freud's theories. Post-adoption incest is characterized experientially by a romantic search for attachment followed by a recognition of oneself in the other. The question of incest has been fundamental to biosocial theories of individual and cultural development. Some revisions are proposed, principally that adult sexual interests remain constrained both by early attachments and later phenotypic matching, reinforced by personal contingencies and cultural rules.

Psychopathology and personal agency: modernity, culture change and eating disorders in south Asian societies

The cultural contribution to psychopathology may become more salient in situations of social change, but it remains difficult to distinguish individual agency among wider social and economic transitions, such as 'modernization' or simply 'culture change', which carry the potential for recourse to new patterns. Eating disorders, a biosocial pattern once identified exclusively with European societies, do occur among South Asian women including those living in the West. This seems not just a simple appropriation of contemporary Western ideals of female morphology--the 'fear of fatness'-but a reassertion of an instrumental strategy of self-renunciation in situations of experienced constraint.

Screening for congenital colour vision defects. A comparison between the Ohkuma and Ishihara plates

A prospective comparison between the Ohkuma and Ishihara pseudoisochromatic (PIC) plates was carried out in a group of 400 patients attending a general ophthalmology practice. The sensitivity of the Ohkuma test was compared to the Ishihara test, and the specificity of both was determined by reference to anomaloscopy as a gold standard. Both tests correctly identified the same group of 24 patients as having a red/green confusion axis, and the Ohkuma test was equally as sensitive as the Ishihara. The grading plates in both tests are unreliable, but the Ohkuma test is quicker, easier to administer, gives less ambiguous responses and has a clearer cut-off score for abnormality. On the basis of this experience the Ohkuma test is recommended as more appropriate for routine colour vision screening than either the 24 or 38 plate Ishihara tests.

Psychiatric diagnosis and racial bias: empirical and interpretative approaches

Understanding of psychiatric illness among Britain's Black and ethnic minority population has shifted from an emphasis on cultural difference to one on racism within psychiatric theory and practice. In spite of this apparent turn, the explanations put forward remain within an empirical framework of methodological individualism, reflecting the background and training of British psychiatrists themselves. How racism may be actually demonstrated in individual clinical practice remains elusive. The standard hypotheses are examined here through a conventional clinical vignette study: this suggests medical education does not in itself now involve any specific racist psychiatric assumptions. Fuller understanding of the exercise of social power within this particular domain requires not only more complex interactive studies, preferably derived from a variety of clinical and social contexts, but a more developed interpretation of psychiatric practice and ideology within the social system.

Against pathology. The new psychiatry and its critics

The notion of 'pathology' presumes an experiential and socially embedded frame of reference which is at variance with some recent attempts to understand the procedures and subject matter of psychiatry. Psychiatric theories remain bound by individual and historical contingencies whose compelling urgency obfuscates the inter-relationship of phenomenon, social context, response, and explanatory model.

From categories to contexts: a decade of the 'new cross-cultural psychiatry'

Over the last ten years a new approach to psychiatric knowledge has developed under the influence of social anthropology. Its origins, assumptions, methods, achievements, and limitations are reviewed.