Psychiatrists In UK Research Articles

Antipsychotic Use: Cross-Sectional Opinion Survey of Psychiatrists in India and United Kingdom.

The aim of this survey of psychiatrists from the UK and India was to compare their opinions on antipsychotic medication choice and their experiences of such medications' effectiveness and tolerability in patients who were newly diagnosed with acute schizophrenia. Following ethical approval, a cross-sectional online survey of psychiatrists from the UK and India was conducted. Ninety-five responses were received from each country. The most selected first-line APDs in both countries were olanzapine (47.5%), risperidone (42.8%) and aripiprazole (25.3%). A total of 60% of psychiatrists from India (60%) and 48% from the UK (48%) selected 'medication efficacy' as the main factor in their choice. Reassessment and consideration to switch most often took place within 4-6 weeks (53.7%) and 3-6 months (11.6%). The major reasons for switching antipsychotic medications were poor clinical efficacy (69%) and lack of tolerability (45%). Nonadherence was the most common reason for relapse (90% of UK psychiatrists and 70% of Indian psychiatrists), followed by illicit drug use (27.6%). The most commonly reported side effects that led to nonadherence were weight gain (10.8%), drowsiness (10.4%), erectile dysfunction and movement disorders (equally 8.7%). It was concluded that olanzapine, risperidone and aripiprazole are the most commonly selected as the initial treatment choice by psychiatrists from India and the UK. They are perceived as widely effective and well tolerated.

The UK psychiatrists' experience of rationalising antipsychotics in adults with intellectual disabilities: A qualitative data analysis of free-text questionnaire responses.

Overprescribing of off-licence psychotropic medications, particularly antipsychotics, for challenging behaviours in people with intellectual disabilities without a psychiatric disorder is a significant public health concern. In the United Kingdom, the National Health Service England launched an initiative in 2016, 'STopping Over-Medication of People with learning disabilities, autism or both (STOMP)', to address this concern. STOMP is supposed to encourage psychiatrists in the United Kingdom and elsewhere to rationalise psychotropic medication use in people with intellectual disabilities. The current study aims to gather UK psychiatrists' views and experience of implementing the STOMP initiative. An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disabilities (estimated 225). Two open-ended questions allowed participants to write comments in response to these questions in the free text boxes. One question asked about the challenges psychiatrists faced locally to implement STOMP, and the other asked for examples of successes and positive experiences from the process. The free text data were analysed using a qualitative method with the help of the NVivo 12 plus software. Eighty-eight (estimated 39%) psychiatrists returned the completed questionnaire. The qualitative analysis of free-text data has shown variation within services in the experience and views of the psychiatrists. In areas with good support for STOMP implementation provided through adequate resources, psychiatrists reported satisfaction in the process with successful antipsychotic rationalisation, betterlocal multi-disciplinary and multi-agency working, and increased awareness of STOMP issues among the stakeholders such as people with intellectual disabilities and their caregivers and multidisciplinary teams, and improved quality of life caused by reduced medication-related adverse events in people with intellectual disabilities. However, where resource utilisation is not optimum, psychiatrists seemed dissatisfied with the process with little success in medication rationalisation. Whereas some psychiatrists are successful and enthusiastic about rationalising antipsychotics, others still face barriers and challenges. Much work is needed to achieve a uniformly positive outcome throughout the United Kingdom.

Diagnosis of Alzheimer's disease before dementia: A study of UK psychiatrists

AbstractBackgroundAlzheimer’s disease (AD) is increasingly conceptualised as a continuum spanning presymptomatic, symptomatic pre‐dementia and dementia stages. With potential disease modifying treatments emerging, this study explored the views of clinicians working in Old Age Psychiatry in the UK regarding the diagnosis of symptomatic AD before dementia, including the role of biomarkers, and the preparedness of services to deliver future disease modifying treatments.MethodThis study, conducted by the Royal College of Psychiatrists and Alzheimer's Research UK, used a two‐stage quantitative and qualitative approach consisting of an online survey (n=493) followed by focus groups (n=42) of clinicians.ResultConceptualising AD as a continuum was considered a helpful framework for thinking about disease pathology, progression and treatment. However, translating this framework into clinical practice generated a number of challenges including uncertainties about diagnostic nomenclature and criteria with at least seven diagnostic terms possible. Overall, terms referencing “mild cognitive impairment” were considered more helpful than those explicitly stating AD. Hesitancy to reference AD at this stage was influenced by concerns about the accuracy of diagnostic criteria, limitations linked to biomarkers and potential negative impacts on individuals, especially in the absence of disease modifying treatments. Access to biomarkers other than CT was sub‐optimal, 96% of responders reported insufficient or no access to CSF and 93% to PET Aβ, limited access negatively impacted on the clinician’s confidence in their utility (P<0.001).Psychiatrists indicated that it was important their services offer disease modifying treatments if licensed but recognised that services faced significant challenges to be prepared, including capacity, resources and staff expertise.ConclusionDiagnosing AD before the onset of dementia is likely to become increasingly relevant if new treatments are licensed, but this study highlights a number of important challenges to achieve this including concerns about the reliability and validity of the diagnostic criteria and access to key biomarkers. There was a clear view that Old Age Psychiatry services should be able to provide any future treatments alongside their usual care but recognition that this would require better access to biomarkers, clearer diagnostic criteria, up‐skilling of staff and changes to training as well as changes to care pathways.

Recognition and management of depression in early psychosis.

Depression in first-episode psychosis (FEP) is highly prevalent and associated with poor outcomes; it has become increasingly recognised and adopted in national and international guidelines for psychosis. Using a 26-item questionnaire, this study aimed to explore if this shift has led to greater recognition among UK psychiatrists, and more effective management of depression in FEP. Of the 297 respondents, 54.4% observed depression occurring in chronic psychosis, with the least number of respondents (17.7%) identifying depression occurring frequently during FEP. Although there was reasonable agreement in the use of antidepressants as a first-line treatment for depression (70% prescribing antidepressants), there was uncertainty around assessing depression and delineating from psychosis symptoms, and particularly negative symptoms. Evidence-based treatments for comorbid depression in psychosis will lead to clearer national guidelines, allowing for optimal management of depression in early psychosis, potentially leading to improved outcomes for these individuals.

UK psychiatrists' experience of withdrawal of antipsychotics prescribed for challenging behaviours in adults with intellectual disabilities and/or autism.

A high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, 'Stopping over-medication of people with a learning disability [intellectual disability], autism or both' (STOMP), to address this major public health concern. To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours. An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225). Half of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers' concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt. There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.

Psychiatrists’ knowledge of novel psychoactive substances

PurposeThe purpose of this paper is to measure the level of experience and knowledge of novel psychoactive substances (NPS) amongst psychiatrists, asking them to rank NPS against other psychoactive substances in terms of concern and the role they believe NPS play in the diagnosis and management of psychiatric disorders.Design/methodology/approachAn online survey was created and emailed to all 217 psychiatrists working for a large city Mental Health Trust.FindingsIn total, 108 of 217 psychiatrists responded to the survey. A majority of the respondents believed that their level of knowledge of NPS was inadequate and stated that they would like to receive more training. Half of them either named only one or no NPS that they had encountered within the last five years. There was a correlation between the experience of the respondent and the number of NPS that they could name.Practical implicationsMost of the respondents assessed their own knowledge of NPS as either poor or basic. Psychiatrists’ knowledge of NPS could be improved by having regular NPS-related training, by being sent regular updates on NPS and by including lectures in the Membership of the Royal College of Psychiatrists courses. Psychiatrists should also be encouraged to access online resources such as NEPTUNE and the European Monitoring Centre for Drugs and Drug Addiction.Originality/valueThis is the first survey of the UK psychiatrists of their knowledge and experience of NPS.

Improving recruitment in psychiatry: The impact of a psychiatry summer school on attitudes towards psychiatry in medical students and foundation doctors

IntroductionIn 2011, the Royal College of Psychiatrists in UK published a five-year plan to boost recruitment to a 95% fill rate for core training posts. Psychiatric summer schools were one of the methods outlined to improve recruitment. These are 3-day courses allowing attendees to explore different subspecialties and showcase inspiring psychiatrists who are leaders in their field.AimsTo evaluate whether attending a Psychiatry Summer School improves scores on the attitudes towards Psychiatry Scale (ATP-30) in Medical Students (MS) and Junior Doctors (JD).MethodsTwo free courses were held; one for MS in August 2016 and one for JD in November 2015. These involved interactive talks from consultant psychiatrists in various sub-specialties and a day in a forensic setting. All attendees were asked to complete ATP-30 before and immediately after attendance. A higher ATP-30 score indicates a more positive the attitude the minimum score is 30 and the maximum is 50. Paired scores were analysed using a paired t-test.ResultsThirty-three out of 45 attendees completed ATP-30 MS (n = 20/24) and JD (n = 13/21) before and after the course. The mean ATP30 score was 116 before attendance and 128 after the course, the mean difference was +12. When the two samples were compared using a paired t-test, there was a significant positive difference P < 0.0005.ConclusionsPsychiatry summer schools can improve attitudes towards psychiatry in medical students and junior doctors.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice

BackgroundDiagnosing mental illness is a central role for psychiatrists. Correct diagnosis informs both treatment and prognosis, and facilitates accurate communication. We sought to explore how psychiatrists distinguished two common psychiatric diagnoses: bipolar disorder (BD) and borderline personality disorder (BPD). MethodsWe conducted a qualitative study of psychiatrists to explore their practical experience. We then sought to validate these results by conducting a questionnaire study testing the theoretical knowledge and practical experience of a large number of UK psychiatrists. Finally we studied the assessment process in NHS psychiatric teams by analysing GP letters, assessments by psychiatrists, and assessment letters. ResultsThere was broad agreement in both the qualitative and questionnaire studies that the two diagnoses can be difficult to distinguish. The majority of psychiatrists demonstrated in survey responses a comprehensive understanding DSM-IV-TR criteria although many felt that these criteria did not necessarily assist diagnostic differentiation. This scepticism about diagnostic criteria appeared to strongly influence clinical practice in the sample of clinicians we observed. In only a minority of assessments were symptoms of mania or BPD sufficiently assessed to establish the presence or absence of each diagnosis. ConclusionClinical diagnostic practice was not adequate to differentiate reliably BD and BPD. The absence of reliable diagnostic practice has widespread implications for patient care, service provision and the reliability of clinical case registries.

Exit examination: a survey of UK psychiatrists' views.

Aims and method The Royal College of Psychiatrists is considering how best to introduce a post-MRCPsych-examination assessment (‘exit examination’) in anticipation of external pressures to ensure patient safety through the use of such assessments. The Psychiatric Trainees' Committee conducted an online survey to gather the views of psychiatrists regarding the possible format and content of this examination in the hope that this information can be used to design a satisfactory assessment.Results Of the 2082 individuals who started the survey, 1735 completed all sections (83.3%). Participants included consultants and trainees from a range of subspecialties. There was general agreement that the content and structure of the exit examination should include assessment of clinical and communication skills.Clinical implications UK psychiatrists believe that an exit assessment should focus on clinical and communication skills. It should assess both generic and subspecialty-specific competencies and incorporate a mixture of assessment techniques.

Attitudes of UK psychiatrists to the diagnosis of MCI in clinical practice

Mild cognitive impairment (MCI) may represent a transitional stage between normal functioning and dementia. Following the initial criteria developed by Petersen et al. in 1999, which focused on memory deficit in the context of otherwise normal cognition and general functioning, the concept has evolved with the introduction of subtypes of MCI and improved understanding of etiology. Our aim was to investigate current practice as well as familiarity with and attitudes toward the concept of MCI amongst UK old age psychiatrists. We sent an anonymized postal survey to all clinicians on the Royal College of Psychiatrists Old Age Psychiatry register. Questions covered attitudes toward the concept of MCI in addition to diagnostic criteria and assessment tools used. The response rate was 39% (453 of 1,154 questionnaires returned completed). The majority of respondents were consultants (83%) and 91% diagnosed MCI. Only 4.4% of the respondents thought that the concept of MCI was not useful and 79% of them required a memory complaint from either the patient or an informant for a diagnosis, but the majority did not have a specific cut-off on cognitive testing. Eighty-two percent reported that they required no or minimal impairment in activities of daily living for a diagnosis of MCI. The two most frequently used tools for assessment were the Mini-Mental State Examination and the Addenbrooke's Cognitive Examination-Revised. Our survey shows that in the United Kingdom, the term MCI has become part of everyday clinical practice in psychiatry, suggesting that clinicians find it a useful term to conceptualize the transitional stage between normal aging and dementia. However, there is variability in diagnostic practice.

The Stalking of Psychiatrists

Healthcare professionals are known from previous studies to be at risk from stalkers, and mental healthcare professionals, particularly psychiatrists, are thought to be at higher risk. However, no previous large-scale study has investigated this among psychiatrists. This questionnaire-based survey of 10,429 UK psychiatrists aimed to investigate the prevalence, nature and impact of stalking of UK psychiatrists. Of the 2,585 psychiatrists who submitted valid responses, 21% thought they had been stalked; the experiences of 33% met current legal criteria and 10% met strict research criteria. Three percent of respondents were currently being stalked; 2% reported that their stalking had begun in the past year. Of those who had been stalked, 64% were stalked by patients. The most commonly reported motives were intimacy seeking and resentment. Stalking persisted for over a year for 52% of victims. The stalking was intrusive, disruptive, and had significant impact. Organizational and individual responses varied in scope and effectiveness. Stalking of psychiatrists is therefore an important professional hazard with a serious impact. Improvements in organizational responses to stalking are needed.

UK psychiatrists' opinions and experiences of Community Treatment Orders

UK psychiatrists' opinions and experiences of Community Treatment Orders

Economic evaluation of duloxetine versus serotonin selective reuptake inhibitors and venlafaxine XR in treating major depressive disorder in Scotland

Background Major depressive disorders (MDD) are responsible for substantial direct and indirect health care costs. Despite the availability of numerous treatments, the need for effective pharmacotherapy remains. Duloxetine is a relatively balanced serotonin norepinephrine reuptake inhibitor (SNRI) with favourable clinical and tolerability profile. The cost-effectiveness of duloxetine versus established SSRIs, venlafaxine XR and mirtazapine was estimated in the UK. Methods A decision analysis simulating clinical management of MDD was developed to estimate health and economic impacts of alternative treatments over one year. Patients on treatment experience remission, response without remission, no response, relapse or discontinue the initial regimen. Model outcomes were total treatment costs and quality-adjusted life years. Resource utilization data were derived from literature and practising UK psychiatrists and GPs. The robustness of findings with respect to modelling assumptions was assessed in extensive sensitivity analyses. Results With similar efficacy to venlafaxine XR but lower drug costs, duloxetine is less costly and marginally more effective than venlafaxine XR both in the overall MDD population and in a more severe subgroup. Duloxetine has a low cost-effectiveness ratio in primary care against SSRIs and mirtazapine, and was found cost-saving against mirtazapine in more severe patients. Limitations Cost-effectiveness results are sensitive to changes in efficacy parameters and resource use data were collected from physician panel. Conclusions Duloxetine represents an important option in the treatment of MDD in the UK that can be recommended on economic grounds. With similar efficacy and different side-effect profile to venlafaxine XR it represents a valuable choice to MDD patients.

Taking the path less trodden: UK psychiatrists working in low- and middle-income countries

The project run in Ghana by the South West London and St George’s Mental Health National Health Service (NHS) Trust, Royal College of Psychiatrists and Challenges Worldwide, is a good model for developing opportunities for UK psychiatrists to practise in low- and middle-income countries (

Taking the path less trodden: UK psychiatrists working in low- and middle-income countries

SummaryUK-based psychiatrists have the opportunity to work in low- and middle-income countries. the political climate is supportive, as evidenced by the recent Crisp report on ‘Global Health Partnerships: the UK Contribution to Health in Developing Countries’, and the Royal College of Psychiatrists volunteer scheme. However, many psychiatrists are unaware of ways in which they might contribute. In this article, we give examples of the diverse ways in which UK-based psychiatrists are already engaged in collaborative work overseas. We discuss some of the mutual benefits that such partnerships can bring and highlight the under-recognised benefits to the UK, both to the individual and to the National Health Service.

Bypassing bureaucracy to answer important questions quickly

Sometimes there is a need to answer important clinical questions quickly. Bureaucracy can erect an insurmountable barrier. The Research Governance Framework (RGF) for Health and Social Care was introduced in England in 2005 aiming to improve the efficiency and quality of research in the NHS, but has unwittingly introduced a new layer of bureaucracy which is preventing some important questions being answered. We attempted to survey prescribing practices among UK psychiatrists in response to an urgent need for this information. There was huge variation between the responses of Research and Development (R and D) offices and our capacity to address the requirements of each office was overwhelmed. R and D approval can now be impossible to obtain. This implies the need for a radical rethink of the system. Scotland is now leading the way in the development of the first UK Multicentre R and D committee which aims to create a standardised and more simple system.

Assessment of an undergraduate psychiatry course in an African setting

BackgroundInternational reports recommend the improvement in the amount and quality of training for mental health workers in low and middle income countries. The Scotland-Malawi Mental Health Education Project (SMMHEP) has been established to support the teaching of psychiatry to medical students in the University of Malawi. While anecdotally supportive medical educational initiatives appear of value, little quantitative evidence exists to demonstrate whether such initiatives can deliver comparable educational standards. This study aimed to assess the effectiveness of an undergraduate psychiatry course given by UK psychiatrists in Malawi by studying University of Malawi and Edinburgh University medical students' performance on an MCQ examination paper.MethodsAn undergraduate psychiatry course followed by an MCQ exam was delivered by the SMMHEP to 57 Malawi medical students. This same MCQ exam was given to 71 Edinburgh University medical students who subsequently sat their own Edinburgh University examination.ResultsThere were no significant differences between Edinburgh students' performance on the Malawi exam and their own Edinburgh University exam. (p = 0.65). This would suggest that the Malawi exam is a comparable standard to the Edinburgh exam. Malawi students marks ranged from 52.4%–84.6%. Importantly 84.4% of Malawi students scored above 60% on their exam which would equate to a hypothetical pass by UK university standards.ConclusionThe support of an undergraduate course in an African setting by high income country specialists can attain a high percentage pass rate by UK standards. Although didactic teaching has been surpassed by more novel educational methods, in resource poor countries it remains an effective and cost effective method of gaining an important educational standard.

Digest

Digest

Enabling Recovery: The Principles and Practice of Rehabilitation Psychiatry

The key aim of this book’s editorial team of four UK psychiatrists was to summarize the current state of psychiatric rehabilitation services. It primarily targets psychiatrists and immediately associated specialties. It concentrates on those with greatest psychiatric need, i.e. for whom avoidance of hospital re-admission is the main priority, with return to work ranking lower in importance. Of course these two are not mutually exclusive, but occupational considerations are understandably constrained. However, to the editors’ credit, occupational aspects are accorded one of the 26 chapters. Unfortunately, this chapter gives an account which mainly focuses on theoretical and historical aspects, which terminate at The Disability Discrimination Act. The latter is covered by just one sentence; an earlier chapter gives a more insightful single paragraph treatment of the DDA, but I could find no other mention of it in the book. But nevertheless it does provide thought provoking, and very informative chapters on many topics in which occupational health practitioners are naturally interested. These include occupationally ‘hot’ topics such as CBT, and cognitive rehabilitation, plus several other chapters on therapeutic aspects of rehabilitation. Specific chapters on acquired head injury and learning disability are also of high relevance to us. Hence, it is not a book that will provide day-to-day succour to the jobbing occupational health practitioner. But clearly it was never intended to, and if accepted for what it is, it does provide some very useful insights (and a lot of information, using boxed summaries) about how psychiatrists currently regard their rehabilitative role. Perhaps then, its greatest value to OH practitioners is in showing what is going on and what may be coming from psychiatric rehabilitative services in future. Overall, I found that the book covers many areas of importance for occupational health practitioners, but it is not primarily aimed at us. Nevertheless, it is stimulating and informative to read.

Robert William Kerwin

When Rob Kerwin arrived at the Maudsley to begin his psychiatric training his bosses were secretly in awe of him. For he was in the vanguard of a new breed...