Suicidal ideation in people with tinnitus: a systematic review and meta-analysis

OBJECTIVE

Tinnitus is associated with a variety of cognitive, psychosocial and psychiatric disorders, and may contribute to suicidality. However, the prevalence of suicidal ideation (SI) in tinnitus populations has not previously been systematically reviewed.

METHOD

Medline, Embase and PsychInfo were searched in August 2020 to identify studies that assessed suicidal ideation in people aged 16 years and above with subjective tinnitus.

RESULTS

Six cross-sectional studies were included, representing 7192 tinnitus sufferers across 4 countries. The pooled prevalence of suicidal ideation in tinnitus populations was 20.6 per cent (95 per cent confidence interval, 10.8-30.3 per cent; I2 = 88 per cent). Two studies included a control population, in which the prevalence of suicidal ideation was significantly lower. The quality of included studies was variable.

CONCLUSION

It is not possible to arrive at any reasonable conclusion given the lack of quality studies, meaning the pooled prevalence should be interpreted very cautiously. Suicidal ideation may be more prevalent in tinnitus populations. Further large-scale epidemiological research investigating this relationship is needed, which may help psychiatric risk stratification.

Trends in involuntary admissions for observation in malta

Introduction

Schedule II of the 2013 Mental Health Act is part of the legal framework for involuntary admission to a licensed mental healthcare facility in Malta (Mount Carmel Hospital) for observation.

Objectives

To identify trends in presenting features cited by registered specialists in psychiatry in Schedule II applications as well as impact of time of day on involuntary admission.

Methods

Schedule II forms relating to all involuntary admissions to Mount Carmel Hospital between 01 June 2018 and 01 June 2019 were retrieved from paper files (n=364). Details relating to reason for using this legal framework were recorded and processed through custom linguistic analysis. Timings of application were also assessed. Data Protection permissions to retrospectively access patient files were obtained. All data collected was de-identified at source.

Results

The commonest reason for use of Schedule II was psychosis (n=139). Substance abuse was recorded in 68 cases, with alcohol and cannabinoids the commonest substances cited. 155 instances relate to situations of increased risk, the commonest being aggressive behaviour (n=74). 61 cases recorded suicidal intent. Peak use of this schedule occurs between 17:00 and 18:00, which is outside normal working hours.

Conclusions

Predominance of psychosis as a reason for involuntary admission concurs with trends reported internationally, including recent German, Irish and Dutch reports, as does increased use of involuntary admission with out-of-hours presentations. Practices relating to involuntary admission to a mental healthcare facility in Malta appear to reflect general trends in other European cohorts, despite differing legal frameworks.

Do bipolar II and bipolar I disorder have different genotypes and why do we observe unipolar depression converting to bipolar II and then bipolar I?

We review the recent literature in order to establish the importance of a spectrum for bipolar affective disorder, and that unipolar depression, bipolar II and bipolar I are discrete entities that may however evolve in sequence. We discuss clinical, genetic and neurobiological data which illustrate the differences between bipolar I and bipolar II. To fit the data we suggest a series of multiple mood disorder genotypes, some of which evolve into other conditions on the bipolar spectrum. Thence, we discuss the nature of the bipolar spectrum and demonstrate how this concept can be used as the basis of a staging model for bipolar disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

‘Dar Kenn Ghal Sahhtek’ – An Effective Therapeutic Intervention

Introduction

‘Dar Kenn Ghal Sahhtek’ is a residential service for patients suffering from eating disorders, namely Bulimia Nervosa, Anorexia Nervosa and Obesity (Binge Eating and Non Binge Eating type). The focus will be made on the obesity services.

Objectives

1. To show that Dar Kenn Ghal Sahhtek has proved to be an effective therapeutic intervention towards obesity (with or without binge eating). 2. To show that from a recruitment of 30 obese subjects a substantial proportion met the DSM-5 criteria for Binge Eating Disorder.

Aims

1. To show that by means of questionnaires and physical testing a marked improvement was made following the therapeutic interventions offered at DKGS. 2. To highlight the high incidence of binge eating disorder in a sample of 30 obese subjects recruited via DKGS.

Methods

1. Interviewing the patient for the DSM-5 criteria of binge eating. 2. Comparing scores of questionnaires before admission and prior to discharge. 3. Evaluating the response to various treatment modalities.

Results

On interviewing the group of 30 patients, 47.6% of the patients were found to be the diagnostic criteria of Binge Eating Disorder according to DSM-5 (Table 1).

Conclusion

Firstly, a considerable proportions of obese subjects proved to meet the DSM-5 criteria for binge eating while Dar Kenn Ghall Sahhtek has proved to be an effective therapeutic intervention towards obesity (with and without binge eating).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Long-term trajectories of cognitive deficits in schizophrenia: A critical overview

BACKGROUND

Cognitive disturbances are widely pronounced in schizophrenia and schizophrenia spectrum disorders. Whilst cognitive deficits are well established in the prodromal phase and are known to deteriorate at the onset of schizophrenia, there is a certain discrepancy of findings regarding the cognitive alterations over the course of the illness.

METHODS

We bring together the results of the longitudinal studies identified through PubMed which have covered more than 3 years follow-up and to reflect on the potential factors, such as sample characteristics and stage of the illness which may contribute to the various trajectories of cognitive changes.

RESULTS

A summary of recent findings comprising the changes of the cognitive functioning in schizophrenia patients along the longitudinal course of the illness is provided. The potential approaches for addressing cognition in the course of schizophrenia are discussed.

CONCLUSIONS

Given the existing controversies on the course of cognitive changes in schizophrenia, differentiated approaches specifically focusing on the peculiarities of the clinical features and changes in specific cognitive domains could shed light on the trajectories of cognitive deficits in schizophrenia and spectrum disorders.

A User and Their Family's Perspective of The Use of a Low-Tech Vs A High-Tech AAC System

This qualitative case study describes a 9-year-old child, diagnosed with homonymous hemianopia, left side weakness and seizures that has been followed by Access to Communication and Technology Unit in Malta for 5 years. The child previously used a communication book and now uses an iPad as a speech generating device. A semi-structured interview was utilised with the parent to explore preference for each AAC system and the reasons for it. The impact of each AAC system on the family and on the child's communication skills, and perceived barriers in the implementation of the AACs were also explored. The child's own experience using the AAC systems was also investigated using a structured interview format. Talking Mats was used to support the child's understanding of the questions and to explore her perspectives on the two AAC systems using Yes-No responses. The parent interview was analysed thematically and represented visually using a thematic network. This was compared with child responses. Four organising themes emerged including barriers, benefits, facilitators, and expectations. Specific barriers included self-funding in order to provide the child with the best fit high-tech AAC. Perceived benefits for both AAC systems were that it increased her communicative intent. The child's mother perceived access to increased vocabulary and capacity for sentence building, operational autonomy as well as voice output as a benefit of the SGD. The child's results indicated a preference for the high-tech AAC because she found it easier to navigate than the low-tech AAC.

An audit to identify factors that are more commonly associated with depressed patients on augmentation therapy under the befordshire east community mental health team (BECMHT)

Background

Whilst it is important that we treat patients with depression in primary care if possible there are many patients with depression who will need the more expert support provided in secondary care.

Aims and methods

An Anonymised Database held by the Bedford East Community Mental Health Team was studied to assess what factors were related to the use of Augmentation Strategies to treat resistant depression.

Results

Of the total 282 patients 109 (38.7%) were on augmentation therapy. In the F32 and F33 group just over a third of the patients (35.8% and 37.1%) were on augmentation therapy and in the F41.2 group over a half of patients (56.7%) were on augmentation therapy.

Discussion

There does seem to be a relationship between the number of risk factors a patient has and the likelihood that they are on augmentation. Particularly strong factors are another psychiatric diagnosis and ‘other suicide risk factors’.

Conclusion

Generally the patients coming to secondary care with more of the specified risk factors are more likely to need augmentation.

Mixed affective states; a study within a community mental health team with treatment recommendations

Introduction

Agitated Unipolar Depression and Bipolar mixed states combine depressive and manic symptoms, reflecting severe forms of affective disorders with an increased suicide risk. These states have not been defined with adequate consensus and hence present a diagnostic and therapeutic challenge.

Method

We searched the records of patients with Affective Mixed States in a community Mental Health Team to identify patients with affective mixed states.

We assessed the treatments prescribed and the time it took to treat the Mixed states so that they then suffered from depression or were euthymic.

Results

Ten out of 17 patients were suicidal when experiencing a mixed state. Of the 6 patients that were agitated, 5 were suicidal. Best results were achieved with a combination of -Reducing antidepressant -Increasing mood stabilisers (Depakote, Lithium) -Increasing/adding atypical antipsychotics. With such treatment, the average duration to resolution was 2.5 weeks. The worse results were achieved by adding antidepressants to a patient experiencing low mood with a mixed state such treatment led to resolution in 10 weeks

Discussion

Agitation is a strong predictor of suicide risk. Reducing antidepressants is important thus Increasing/adding antipsychotics and mood stabilisers without changing antidepressants led to an 8.5 weeks duration of treatment.

Conclusion

Patients with mixed states should be reviewed regularly and risk-assessed -We suggest weekly due to increased suicide risk. With very high-risk patients, referral should be made to the Crisis Team. Care coordinators should be involved for regular contact with services.

The krapellenian dicotomy in terms of employment outcomes

Background

We decided to examine the employment status of all patients with Schizophrenia actively treated by the Bedford East CMHT and compare this to the employment status of all those in the team who suffered from Bipolar Affective Disorder.

Methods

Cases of Schizophrenia and Bipolar Disorder were anonymously identified from a database held by the team and their employment status was established.

Results

124 patients were identified with schizophrenia, 24 with Schizoaffective disorder, and 60 with Bipolar Disorder.

Of the Schizophrenia patients, 91 (73.38%) were unemployed, 15(12%) were employed, 10 (8%) were in voluntary employment and 8 (6.45%) were labelled ‘other’ [housewife, student etc].

Of the Bipolar patients, 32 (53.33%) were unemployed, 14(23%) were employed, 5 (8.3%) were in voluntary employment and 9 (15%) were labelled ‘other’

Of the Schizoaffective patients, 15 (62.5%) were unemployed, 4 (16.66%) were employed, 2 (8.33%) were in voluntary employment and 3 (12.5%) were labelled ‘other’.

Discussion

Employment Outcomes for serious mental illness were poor, however Schizophrenia patients had a lower chance of returning to employment, partly due to the heterogeneity of the condition. Bipolar patients had twice the chance of gainful employment as Schizophrenic ones.

Conclusion

It is particularly difficult to achieve employment for patients with serious mental illness. This adds to the recently made argument for a more assertive approach by the creation of ad hoc chronic psychosis teams who could give ongoing support to aid patients to return to social inclusion and possibly work.

The mental health assessment unit; A novel method for assessing new inpatients

Introduction

The Mental Health Assessment Unit (MHAU) isa gateway between community services and in-patient services. It aims to provide an acute setting in which to assess patients within 72 hours, with the view to reducing in-patient hospital admissions. We aimed to ascertain the number of referrals made to the MHAU and admissions over a one month period. The presentation and length of stay was investigated and the diagnosis and follow up plans made were explored.

Method

Data was collated from a one month period. Crisis and home treatment team (CRHT) notes were reviewed.

Results

100 referrals were made to the MHAU; 48 patients were admitted. 25 patients had care coordinators. In the majority of cases the source of referral was through the Emergency Department. There was a range of presenting complaints.Diagnoses included a wide variety of nature and severity. Average length of stay was 2 nights. Patients deemed to require in-patient management had shorter length of stay with swift transfer to treatment units. Shorter stays were also associated with milder degrees of illness. Longer length of stay was associated with more complex illness.

37 patients were discharged home, 11 were transferred to in-patient treatment units. Most patients discharged home were followed up by the CRHT.

5 patients were admitted to the MHAU more than once. This may represent a subgroup of more complex patients.

Conclusion

We recommend study into patients’ experiences with care coordinators at times of need. We also plan to re-audit for a longer time frame.

The effects of the economic crisis on mental health

The events that unfolded towards the end of 2008 led to the worst global economic crisis since the Great Depression of the 1930s. While the economic and political implications have been studied in detail, the impact on health - especially that of mental health - has received much less attention. This poster aims to achieve a critical evaluation of causality (or lack thereof) between an economic crisis and mental health, using a combination of psychological theories, statistical review and common logic.

From a theoretical perspective, establishing the value-laden concept of mental health is core to this evaluation. We reflect on Professor Warr's component-based model of mental health and how/whether the economic downturn relates to these ‘components’ individually. On the statistical front, an analysis of data from previous global economic crises reveals a close association between job-related insecurities and psychological morbidities.

Integrating the analyses, both psychological theory and epidemiological data support causation between a recession and conditions like depression, anxiety and substance abuse. Further, we also explore the effects of the crisis on the family unit, society and international relations. This will highlight issues like child abuse, the psychological impacts on the socially deprived, and effects of the crisis on the developing world.

We also review the effectiveness of efforts of different nature and magnitude to mitigate the effects of this downturn. All this will hopefully impact on our understanding of the causes of mental health problems in times of economic insecurity and assist in developing strategies to ameliorate them.

An audit to identify factors affecting response to treatment among depressed patients who have documented suicidal ideation/attempts in a bedfordshire community mental health team

Introduction

In recent years there has been a move towards treating depressed patients in the community.One factor that may reduce the likelihood of discharge from secondary care is suicidality. The aim of this audit was to identify factors associated with continued suicidality among Community patients.

Subjects and methods

We searched an anonymised database of patients and identified all those with previously documented suicidal thoughts or attempts. We also noted the presence of factors such as alcohol problems, drug problems, augmentation therapy and ‘other risk’ factors (e.g. financial problems or homelessness). We assessed the latest clinic letter, to see if patients were still reporting suicidality. We compared the aforementioned factors between the group of patients in which suicidality was still present (group N) and the group of patients in which suicidality was no longer a feature (group Y).

Results

Of the 56 patients with suicidal thoughts or attempts there were 44 in group N (79%) and 12 in group Y (21%). Alcohol problems, drug problems and ‘other’ risk factors were more common among group Y than group N. Conversely, the percentage of patients on augmentation therapy was greater in group N than group Y.

Discussion

The audit provides an insight into the factors that might influence outcomes among depressed patients.

Conclusions

Although the results are suggestive, it is difficult to make firm conclusions about patient outcomes on the present data. The audit provides a useful starting point, especially in considering the treatment of patients within the CMHT.

Effect of the worldwide crises on mental health

The events that unfolded towards the end of 2008 led to the worst global economic crisis since the Great Depression of the 1930s. While the economic and political implications have been studied in detail, the impact on health – especially that of mental health – has received much less attention. This essay aims to achieve a critical evaluation of causality (or lack thereof) between an economic crisis and mental health, using a combination of psychological theories, statistical review and common logic.

From a theoretical perspective, establishing the value-laden concept of mental health is core to this evaluation. We reflect on Professor Warr's component-based model of mental health and how/whether the economic downturn relates to these ‘components’ individually. On the statistical front, an analysis of data from previous global economic crises reveals a close association between job-related insecurities and psychological morbidities.

We found that both psychological theory and epidemiological data support causation between a recession and conditions like depression, anxiety and substance abuse. Further, we also explore the effects of the crisis on the family unit, society and international relations. This will highlight issues like child abuse, the psychological impacts on the socially deprived, and effects of the crisis on the developing world.

We also review the effectiveness of efforts of different nature and magnitude to mitigate the effects of this downturn. All this will hopefully impact on our understanding of the causes of mental health problems in times of economic insecurity and assist in developing strategies to ameliorate them.

Audit and re-audit of patients with PTSD in a community team in bedfordshire UK

Introduction

Post-traumatic stress disorder (PTSD) is a disorder which can develop following exposure to one or more severely traumatic events. Symptoms experienced by PTSD suffers include re-experiencing the trauma through intrusive ‘flashbacks’ and recurrent dreams or nightmares, distress when exposed to reminders of the trauma, hyperarousal and emotional blunting. These symptoms can cause significant impairment of function and reduction in quality of life for suffers. Both psychotherapies, including cognitive behavioural therapies (CBTs) and eye movement desensitisation and reprocessing (EMDR), and pharmacotherapy are used in the treatment of PTSD.

Method

We audited patients with PTSD in Bedford East performed in November 2008. A re-audit was performed using data from August 2010 patient database. Demographic information, risk factors, co-morbidities, psychological therapy and pharmacotherapy were compared between these audit and re-audit.

Results

There is increased use of antidepressant augmentation between 2008 and 2010. While no patients in 2008 were on antidepressant augmentations, by 2010, 9 patients were. All 25 patients on anti-psychotics have important identified risk factors. There is no evidence of Psychosis in our PTSD patients except in two cases. There is an increase in Anti-psychotic use in our PTSD Patients. There is an increased use of Mood Stabilisers in our patients with PTSD.

Discussion

PTSD is being identified more frequently in our patients, probably because of greater awareness and more accurate identification.

Conclusion

New patients being identified represent a group of more difficult to treat patients who represent severe risks. Present psychotherapies offered are not all recommended in present guidelines.

Manic-depressive illness and the artistic temperament

Introduction

A notion exists of a special kind of relationship between poets and being “crazy”. A possible correlation between madness and genius is one of the oldest and most persistent and controvertialof cultural concepts. We decided to investigate the relationship between manic-depressive illness and the artistic temperament.

Method

A review was conducted on Professor Kay Redfield Jamison's treatise Touched with Fire, Manic-depressive Illness and the Artistic Temperament.

Results

Research strongly suggests that, compared with the general population, writers and artists show a vastly disproportionate rate of the affective disorders manic-depressive and depressive illness. Research employing systematic biographical methodology has also given strong support to a much higher rate of mood disorders in artistic populations than could be expected from chance alone. A British study revealed many overlapping mood, cognitive, and behavioral changes between hypomania and intense creative states. Many of the changes in mood, thinking, and perception that characterize the mildly manic states are highly characteristic of creative thought as well. Although it seems counterintuitive at first, melancholy has also been reported to be associated with artistic inspiration and productivity.

Discussion

Not all (not even most) writers and artists suffer from major mood disorders. Likewise, most of those who have a major mood disorder are not writers or artists. However despite this, research does strongly suggest that there is a correlation between manic-depressive illness and the artistic temperament. The major resistance to an association between psychopathology, or mental illness, and creativity seems to revolve around a few central points.

Is there a biological basis to the Bipolar spectrum?

Background

The Bipolar Spectrum is usually presented as a Clinical Spectrum. We attempt to demonstrate that there is a neurobiological basis to this spectrum.

Method

We carried out a review of the literature.

Results

There is evidence, at a neuroimaging level, at a genetic level, and also at an intracellular level for a biological basis to the bipolar spectrum.

Discussion

What arises from this review is that the bipolar spectrum may be wider than previously thought. It is of interest that similar neuroimaging findings may be found in PTSD, Unipolar Depression, Bipolar Illness, and Borderline Personality Disorder.

Conclusion

The key biological issue regarding the bipolar spectrum is the mechanism by which unipolar depression evolves over time into bipolar illness. At present we can only speculate about this mechanism, but its elucidation will clarify how these illnesses are related in the bipolar spectrum.

An unusual cause of chest pain in a young man: bronchogenic cysts and their cardiac manifestations

We report a case of a 24-year-old man who presented with chest pain and electrocardiographic evidence of myocardial ischaemia. An abnormal structure located behind the heart on the urgent transthoracic echocardiogram and a computed tomography scan of the mediastinum led to prompt surgery with eventual resection of the lesion. The histology revealed fragments of connective tissue covered by squamous epithelium and ciliated epithelium, consistent with a bronchogenic cyst. The case study is accompanied by a literature review of the pathogenesis, diagnosis and management of bronchogenic cysts and their association with cardiac symptoms.

How to Involve Undergraduate Medical Students in Psychiatric Research

The poster will address the important issue of how we can use opportunities in teaching our medical students how to take a wider view of psychiatry and learn to ‘think outside the box’ thus broadening their vision, enabling them to challenge presently held concepts, while at the same time learning the basic tenets of our profession.

Clearly, this is done by involving our students in clinical research based and audit based activities. However not all schools or teachers are comfortable with doing this, while the medical curriculum is broad, and there is a risk that students ‘only study for exams’.

Research based activities, including simple things such as using basic it skills to do a literature search for a review article or carrying out a useful clinical audit, using a unit held database, are however things which students can easily do, and these can lead to publishable case reports, posters, or ever articles in peer reviewed journals.

The poster will illustrate how we developed research activities with students at Cambridge University Clinical School. It shall discuss the advantages, difficulties, and indeed enjoyment of carrying out such activities.

Correlation of Diagnosis, Risk Assessment and Involvement of a Care Co-Ordinator [CPA Status] in an English Community Mental Health Team

Introduction:

The Care Program Approach [CPA] envisages that patients with serious mental illness who are deemed to be at risk [of self harm, harm to others, or serious deterioration of their condition] should have an appropriate assessment of needs, an appropriate care plan and should have an allocated care co-ordinator to implement the plan.

We investigated whether patients with Bipolar Disorder, Schizophrenia and Depression, who had recorded risk factors did indeed have an allocated care co-ordinator in a typical English Community Mental Health Team [CMHT]. This issue is of importance in describing ‘Treatment as Usual’ in a CMHT when comparing it to newer forms of management, such as assertive outreach teams.

Method:

We used a database held by a CMHT in order to assess whether all patients with the above diagnoses did indeed have an appointed care coordinator.

Results:

The results show poor correlation between diagnosis, presence of risk factors, and the appointment of a care coordinator. Interestingly, patients with bipolar disorder appeared more likely to have a care coordinator appointed than patients with schizophrenia. Patients with depression were least likely to have a care coordinator appointed.

Conclusion:

Lack of resources in the CMHT may account for the results. Another issue may be that, with treatment, patients may become less risk prone, but the work of the care coordinator may not be completed, and so the care coordinator may continue to be involved, thus being unable to move to other more needy patients in the team.

Developing Services for Schizophrenia in Croatia, Slovenia, and Bosnia

Along the coast of the Adriatic, several small projects have developed to improve treatment of patients with Schizophrenia. All these projects have benefited from links with the Department of Psychiatry in Cambridge.

In Ljubljana, The Ljubljana Prodrome Project has developed a system of early intervention and treatment which has a strong research arm. It has contributed knowledge about how psychosis develops, and shown that treatment in the prodromal phase of illness gives patients significant advantages.

The Assertive Outreach Team in Ljubljana Psychiatric Hospital has reduced readmissions for the chronic patients it deals with. Case Management in the Community has also been established at Vrapce Hospital Zagreb, where there has also been established a ward for first episodes of Psychosis. Non Governmental Organisations have been working with patients and their families in Central Croatia, using group interventions for carers.

In Sarajevo, one doctor is working with identifying psychosis early.

All of these projects are successful and amount to a major contribution in improving treatment for schizophrenia for patients in these countries.

Staff from Croatia and Slovenia have visited the UK to learn Early Detection and Intervention techniques and case management.

Further development nationally of these techniques for delivery of Mental Health Care in the Community is now awaited.