European Journal of Obstetrics & Gynecology and Reproductive Biology: X
Impaired decision making ability is common on general medical wards. Audit evidence suggests that... more Impaired decision making ability is common on general medical wards. Audit evidence suggests that the prevalence of incapacity may be higher than previously assumed in Obstetric Emergency Procedures (OEP) during childbirth. We investigated the prevalence of incapacity in OEP and factors associated with this. Design: Capacity to consent to treatment was assessed retrospectively in 93 women undergoing OEP. All women were interviewed using a semi-structured questionnaire aided interview within 24 h of the emergency. Five assessors (3 obstetricians and 2 psychiatrists) were asked to determine capacity to consent from audio recordings of the interviews. Results: All 5 assessors determined 59 % of women to have capacity to consent to treatment and 2 % of women to lack capacity. In 39 % of women there was some disagreement between assessors. Using a majority decision (3 assessors in agreement), 14 % of women lacked capacity. High pain scores, young age and no previous history of theatre deliveries were associated with more incapacity judgments, whilst parity and history of mental illness were not. Using a 7point Likert scale only marginally improved agreement between assessors, compared to their binary decision. Conclusion: It is often assumed that it is rare to lack capacity in an obstetric emergency procedure during childbirth, but these data suggest that incapacity may be relatively common. In particular, severe pain is a demonstrable risk factor for impaired capacity. Wide variation between assessors questions the validity of current commonly employed (informal) methods used in clinical practice to assess capacity to consent during OEP.
Background: Nonattendance is common among patients suffering from delusional infestation (DI) wit... more Background: Nonattendance is common among patients suffering from delusional infestation (DI) with a risk factor for poorer patient outcomes. Objective: The aim of this study was to determine the incidence rate and predictors of nonattendance among patients presenting to a psychodermatology department with DI and the subsequent effect on the success of prescribing new antipsychotics. Methods: Data of 265 patients were reviewed of the Amsterdam UMC, the Erasmus University Medical Center, the Royal London Hospital, and the Liverpool School of Tropical Medicine between January 2008 and October 2019. Results: We observed that among the patients who attended the first consultation, 57% (n = 144) did not attend their second visit. Recreational drug use was significantly higher in the nonattendance group compared to the attendance group (25% against 18%). Patients who had a history of previously prescribed antipsychotics at the time of the first consultation were less likely to get prescri...
Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. First... more Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. First described by Conrad, a delusional mood is characterised by a period of increasingly oppressive tension, a feeling that “something is in the air”, which can last for days or months. It is sometimes described as “impending doom”, although the tension can be positive excitation as well. It usually develops into full blown psychotic symptoms within days or weeks. In this case, the patient reports experiencing this sensation persistently since early childhood. Whilst he may yet develop psychotic illness, this seemingly unique case suggests that Wahnstimmung may persist for years without developing into full psychosis. Mr X is a white British, 50 year old retired concrete manufacturer from North Wales. He presented to clinic with a feeling of excitement. Despite being referred for suicidal ideation, he described himself as “the happiest guy that I know. I wake up every morning feeling excited...
Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. In th... more Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. In this case, the patient reports experiencing this sensation persistently since early childhood. This case suggests that Wahnstimmung may persist for years without developing into full psychosis. This is the first reported case of prolonged and persistent delusional mood in literature. It should be of interest to psychiatry professionals looking to investigate the prodromal phase of psychosis. This case is regarding a 50-year-old, Caucasian male. He presented to clinic with a feeling of excitement. Despite being referred for suicidal ideation, he described himself as “the happiest guy that I know. I wake up every morning feeling excited.” This original case should highlight the possibility of this phenomenon in other patients. Ultimately, an understanding of why patients may not progress to full psychotic illness may improve our understanding of protective factors in psychotic illnesses.
Aims: To evaluate the effectiveness of evidence based treatments for alcohol-induced psychotic di... more Aims: To evaluate the effectiveness of evidence based treatments for alcohol-induced psychotic disorder (AIPD) as described by ICD-10 and DSM-5, a condition that is distinct from schizophrenia and has a close relationship with alcohol withdrawal states. Method: Systematic review using PRISMA guidelines. Results: Of 6205 abstracts found, fifteen studies and ten case reports met criteria and were examined. Larger studies examined the use of first-generation antipsychotic drugs, reporting full or partial remission in most patients. Newer case reports report similar results using second generation antipsychotic drugs. Novel treatments, such as those acting on GABA receptors reported low numbers of patients in remission. Some large studies report the successful use of standard alcohol withdrawal treatments. Conclusion: The findings of our systematic review are inconclusive. There was significant heterogeneity between and within studies. Significant publication bias is likely. Randomized control trials of more carefully delineated samples would produce evidence of greater clinical utility, for example, on differential effectiveness of antipsychotics and optimal length of standard alcohol withdrawal treatments. AIPD patients who show poor treatment responses should be studied in greater depth. Short Summary: This systematic review of alcohol-induced psychotic disorder treatment found 15 studies and 10 case reports of relevance. Older studies of first-generation antipsychotics reported full or partial remission in most patients, as did newer studies with second-generation antipsychotics. Novel drugs reported low remission rates. Standard alcohol withdrawal treatments were successful. BACKGROUND Excess alcohol consumption results in medical and social problems around the world. It accounts for 3% of global deaths (Rehm et al., 2009). Neuropsychiatric consequences to alcohol dependence syndrome include delirium tremens, alcohol-related brain damage, Korsakoff's syndrome and alcoholic hallucinosis. The terms 'alcoholic hallucinosis' and 'alcohol-induced psychotic' disorder (AIPD) are often used interchangeably, although they may be better
Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated... more Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression – Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant...
Transactions of the Royal Society of Tropical Medicine and Hygiene, Jan 20, 2018
Delusional infestation (DI) is a well-recognised delusional disorder presenting as the persisting... more Delusional infestation (DI) is a well-recognised delusional disorder presenting as the persisting belief in the presence of parasitic or other infestations. Combined clinics have been run by dermatology and psychiatry in a small number of centres. Here we report the first few years of a unique combined clinic run with experts in infectious diseases/tropical medicine and psychiatric management of DI. We reviewed all patients seen at the combined assessment clinics run at the Liverpool School of Tropical Medicine between 19 December 2011 and 31 October 2016. Data were collected prospectively as part of clinical assessment. Descriptive analysis of these data was performed to examine clinical features at assessment, investigations performed and treatment outcomes. A total of 75 patients were assessed and 52 (69%) were given the formal diagnosis of DI. A history of travel was given by 64% of individuals but no significant tropical or infectious diagnosis was made. Of those who returned f...
Progress in neuro-psychopharmacology & biological psychiatry, Jan 24, 2017
Monothematic delusional disorders are characterized by a single tenacious belief. They provide a ... more Monothematic delusional disorders are characterized by a single tenacious belief. They provide a great opportunity to study underlying brain structures in the absence of confounding symptoms that accompany delusions in schizophrenia. Delusional beliefs include persecution, jealousy or somatic delusions including infestation. It is unclear whether specific delusional content is associated with distinct neural substrates. We used magnetic resonance imaging in patients presenting with somatic vs. non-somatic delusional disorders. Patients with delusional infestation (DI, n=18), and individuals with non-somatic delusional disorders (n=19) were included, together with healthy volunteers (n=20). Uni- and multivariate techniques for structural data analysis were applied to provide a comprehensive characterization of abnormal brain volume at both the regional and neural network level. Patients with DI showed lower gray matter volume in thalamic, striatal (putamen), insular and medial prefro...
Conversion (functional) limb weakness or paralysis (FW) can be a debilitating condition, and ofte... more Conversion (functional) limb weakness or paralysis (FW) can be a debilitating condition, and often causes significant distress or impairment in social, occupational, or other important areas of functioning. Most treatment concepts are multi-disciplinary, containing a behavioral approach combined with a motor learning program. Non-invasive brain stimulation (NIBS) methods, such as electroconvulsive therapy (ECT), and transcranial magnetic stimulation (TMS) have been used in the past few decades to treat FW. In order to identify all published studies that used NIBS methods such as ECT, TMS and transcranial direct current stimulation (tDCS) for treating FW patients a systematic review of the literature was conducted in PubMed and Web of Science. In a second step, narratives were used to retrospectively determine nominal CGI-I (Clinical Global Impression scale-Improvement) scores to describe approximate changes of FW symptoms. We identified two articles (case reports) with ECT used for ...
Recent court cases in England and Wales have refocused attention on patients' decision-making... more Recent court cases in England and Wales have refocused attention on patients' decision-making capacity to consent. Little is known about the prevalence of incapacity across specialities but decision-making capacity is likely to be overestimated by clinicians. The aim of this systematic review is to estimate the prevalence of incapacity to consent to treatment or admission in different medical and psychiatric settings, and compare the two. We conducted an electronic search following PRISMA principles and included 35 studies in psychiatric and 23 studies in medical settings. The 58 included studies revealed 70 data sets across all settings. For psychiatric settings the weighted average proportion of patients with incapacity was 45% (95% confidence interval (CI) 39-51%). For medical settings, the weighted average proportion of patients with incapacity was 34% (95% CI 25-44%). The two groups are not significantly different from each other in terms of the proportion of incapacity (p=...
Aims and method Community treatment orders (CTOs) have been used more than anticipated. We report... more Aims and method Community treatment orders (CTOs) have been used more than anticipated. We report data from the North Wales audit about their current use and explain how a SMART framework can be used to potentially improve their effectiveness. Results Findings from this audit confirm those from other studies, with the reasons for use of CTOs extending beyond that of medication adherence to risk management. The combined recall and voluntary admission rate was 40%, which raises questions about the effectiveness of CTOs. Clinical implications More research is needed as it remains to be seen whether CTOs are able to achieve their intended aims. The SMART framework can be used to aid clinicians in ensuring that conditions placed on patients have a specific purpose and are clinically meaningful.
Philosophy, Ethics, and Humanities in Medicine, 2009
Psychiatric practice is often faced with complex situations that seem to pose serious moral dilem... more Psychiatric practice is often faced with complex situations that seem to pose serious moral dilemmas for practitioners. Methods for solving these dilemmas have included the development of more objective rules to guide the practitioner such as utilitarianism and deontology. A more modern variant on this objective model has been 'Principlism' where 4 mid level rules are used to help solve these complex problems. In opposition to this, there has recently been a focus on more subjective criteria for resolving complex moral dilemmas. In particular, virtue ethics has been posited as a more sensitive method for helping doctors to reason their way through difficult ethical issues. Here the focus is on the character traits of the practitioner. Bloch and Green advocated another way whereby more objective methods such as Principlism and virtue ethics are combined to produce what they considered sound moral reasoning in psychiatrists. This paper points out some difficulties with this approach and instead suggests that a better model of ethical judgment could be developed through the use of narratives or stories. This idea puts equal prima facie value on the patient's and the psychiatrist's version of the dilemma they are faced with. It has the potential to lead to a more genuine empathy and reflective decision-making.
Paliperidone (9-hydroxy-risperidone), the active metabolite of risperidone, was approved for trea... more Paliperidone (9-hydroxy-risperidone), the active metabolite of risperidone, was approved for treating schizophrenia worldwide in 2006 as paliperidone extended-release (PER), and became the first second-generation antipsychotic specifically licensed for treating schizoaffective disorder in 2009. However, at the same time, its comparatively high cost gave rise to concerns about the cost-effectiveness of PER as compared with its precursor, risperidone. This paper reviews the existing knowledge of the pharmacology, kinetics, efficacy, tolerability, and fields of application of PER, and compares PER with risperidone in order to determine whether it has a place in antipsychotic therapy. An independent assessment of all relevant publications on PER published until July 2010 was undertaken. PER has a unique pharmacological profile, including single dosing, predominantly renal excretion, low drug-drug interaction risk, and differs from risperidone in terms of mode of action and pharmacokinetics. High-level evidence suggests that PER is efficacious and safe in schizophrenia, schizoaffective disorder, and acute manic episodes. There is a striking lack of published head-to-head comparisons between PER and risperidone, irrespective of indication. Low-level evidence shows a lower risk for hyperprolactinemia and higher patient satisfaction with PER than with risperidone. PER adds to the still limited arsenal of second-generation antipsychotics. In the absence of direct comparisons with risperidone, it remains difficult to come to a final verdict on the potential additional therapeutic benefits of PER which would justify its substantially higher costs as compared with risperidone. However, in terms of pharmacology, the available evidence cautiously suggests a place for PER in modern antipsychotic therapy.
SUMMARY This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional ... more SUMMARY This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional infestation (DI), also known as delusional parasitosis. It is characterized by the fixed belief of being infested with pathogens against all medical evidence. DI is no single disorder but can occur as a delusional disorder of the somatic type (primary DI) or secondary to numerous other conditions. A set of minimal diagnostic criteria and a classification are provided. Patients with DI pose a truly interdisciplinary problem to the medical system. They avoid psychiatrists and consult dermatologists, microbiologists, or general practitioners but often lose faith in professional medicine. Epidemiology and history suggest that the imaginary pathogens change constantly, while the delusional theme “infestation” is stable and ubiquitous. Patients with self-diagnosed “Morgellons disease” can be seen as a variation of this delusional theme. For clinicians, clinical pathways for efficient diagnosti...
SummaryCurrent capacity-based legislation and practice overvalues autonomy to the detriment of ot... more SummaryCurrent capacity-based legislation and practice overvalues autonomy to the detriment of other ethical principles. A balanced ethical approach would consider the patient's right to treatment, their relationships and interactions with society and not solely the patient's right to liberty and autonomous decision-making.
European Journal of Obstetrics & Gynecology and Reproductive Biology: X
Impaired decision making ability is common on general medical wards. Audit evidence suggests that... more Impaired decision making ability is common on general medical wards. Audit evidence suggests that the prevalence of incapacity may be higher than previously assumed in Obstetric Emergency Procedures (OEP) during childbirth. We investigated the prevalence of incapacity in OEP and factors associated with this. Design: Capacity to consent to treatment was assessed retrospectively in 93 women undergoing OEP. All women were interviewed using a semi-structured questionnaire aided interview within 24 h of the emergency. Five assessors (3 obstetricians and 2 psychiatrists) were asked to determine capacity to consent from audio recordings of the interviews. Results: All 5 assessors determined 59 % of women to have capacity to consent to treatment and 2 % of women to lack capacity. In 39 % of women there was some disagreement between assessors. Using a majority decision (3 assessors in agreement), 14 % of women lacked capacity. High pain scores, young age and no previous history of theatre deliveries were associated with more incapacity judgments, whilst parity and history of mental illness were not. Using a 7point Likert scale only marginally improved agreement between assessors, compared to their binary decision. Conclusion: It is often assumed that it is rare to lack capacity in an obstetric emergency procedure during childbirth, but these data suggest that incapacity may be relatively common. In particular, severe pain is a demonstrable risk factor for impaired capacity. Wide variation between assessors questions the validity of current commonly employed (informal) methods used in clinical practice to assess capacity to consent during OEP.
Background: Nonattendance is common among patients suffering from delusional infestation (DI) wit... more Background: Nonattendance is common among patients suffering from delusional infestation (DI) with a risk factor for poorer patient outcomes. Objective: The aim of this study was to determine the incidence rate and predictors of nonattendance among patients presenting to a psychodermatology department with DI and the subsequent effect on the success of prescribing new antipsychotics. Methods: Data of 265 patients were reviewed of the Amsterdam UMC, the Erasmus University Medical Center, the Royal London Hospital, and the Liverpool School of Tropical Medicine between January 2008 and October 2019. Results: We observed that among the patients who attended the first consultation, 57% (n = 144) did not attend their second visit. Recreational drug use was significantly higher in the nonattendance group compared to the attendance group (25% against 18%). Patients who had a history of previously prescribed antipsychotics at the time of the first consultation were less likely to get prescri...
Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. First... more Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. First described by Conrad, a delusional mood is characterised by a period of increasingly oppressive tension, a feeling that “something is in the air”, which can last for days or months. It is sometimes described as “impending doom”, although the tension can be positive excitation as well. It usually develops into full blown psychotic symptoms within days or weeks. In this case, the patient reports experiencing this sensation persistently since early childhood. Whilst he may yet develop psychotic illness, this seemingly unique case suggests that Wahnstimmung may persist for years without developing into full psychosis. Mr X is a white British, 50 year old retired concrete manufacturer from North Wales. He presented to clinic with a feeling of excitement. Despite being referred for suicidal ideation, he described himself as “the happiest guy that I know. I wake up every morning feeling excited...
Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. In th... more Delusional mood, or Wahnstimmung, is a prodromal feature of an impending psychotic illness. In this case, the patient reports experiencing this sensation persistently since early childhood. This case suggests that Wahnstimmung may persist for years without developing into full psychosis. This is the first reported case of prolonged and persistent delusional mood in literature. It should be of interest to psychiatry professionals looking to investigate the prodromal phase of psychosis. This case is regarding a 50-year-old, Caucasian male. He presented to clinic with a feeling of excitement. Despite being referred for suicidal ideation, he described himself as “the happiest guy that I know. I wake up every morning feeling excited.” This original case should highlight the possibility of this phenomenon in other patients. Ultimately, an understanding of why patients may not progress to full psychotic illness may improve our understanding of protective factors in psychotic illnesses.
Aims: To evaluate the effectiveness of evidence based treatments for alcohol-induced psychotic di... more Aims: To evaluate the effectiveness of evidence based treatments for alcohol-induced psychotic disorder (AIPD) as described by ICD-10 and DSM-5, a condition that is distinct from schizophrenia and has a close relationship with alcohol withdrawal states. Method: Systematic review using PRISMA guidelines. Results: Of 6205 abstracts found, fifteen studies and ten case reports met criteria and were examined. Larger studies examined the use of first-generation antipsychotic drugs, reporting full or partial remission in most patients. Newer case reports report similar results using second generation antipsychotic drugs. Novel treatments, such as those acting on GABA receptors reported low numbers of patients in remission. Some large studies report the successful use of standard alcohol withdrawal treatments. Conclusion: The findings of our systematic review are inconclusive. There was significant heterogeneity between and within studies. Significant publication bias is likely. Randomized control trials of more carefully delineated samples would produce evidence of greater clinical utility, for example, on differential effectiveness of antipsychotics and optimal length of standard alcohol withdrawal treatments. AIPD patients who show poor treatment responses should be studied in greater depth. Short Summary: This systematic review of alcohol-induced psychotic disorder treatment found 15 studies and 10 case reports of relevance. Older studies of first-generation antipsychotics reported full or partial remission in most patients, as did newer studies with second-generation antipsychotics. Novel drugs reported low remission rates. Standard alcohol withdrawal treatments were successful. BACKGROUND Excess alcohol consumption results in medical and social problems around the world. It accounts for 3% of global deaths (Rehm et al., 2009). Neuropsychiatric consequences to alcohol dependence syndrome include delirium tremens, alcohol-related brain damage, Korsakoff's syndrome and alcoholic hallucinosis. The terms 'alcoholic hallucinosis' and 'alcohol-induced psychotic' disorder (AIPD) are often used interchangeably, although they may be better
Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated... more Cognitive behavioural therapy (CBT) is beneficial in depression. Symptom scores can be translated into Clinical Global Impression (CGI) scale scores to indicate clinical relevance. We aimed to assess the clinical relevance of findings of randomised controlled trials (RCTs) of CBT in depression. We identified RCTs of CBT that used the Hamilton Rating Scale for Depression (HAMD). HAMD scores were translated into Clinical Global Impression – Change scale (CGI-I) scores to measure clinical relevance. One hundred and seventy datasets from 82 studies were included. The mean percentage HAMD change for treatment arms was 53.66%, and 29.81% for control arms, a statistically significant difference. Combined active therapies showed the biggest improvement on CGI-I score, followed by CBT alone. All active treatments had better than expected HAMD percentage reduction and CGI-I scores. CBT has a clinically relevant effect in depression, with a notional CGI-I score of 2.2, indicating a significant...
Transactions of the Royal Society of Tropical Medicine and Hygiene, Jan 20, 2018
Delusional infestation (DI) is a well-recognised delusional disorder presenting as the persisting... more Delusional infestation (DI) is a well-recognised delusional disorder presenting as the persisting belief in the presence of parasitic or other infestations. Combined clinics have been run by dermatology and psychiatry in a small number of centres. Here we report the first few years of a unique combined clinic run with experts in infectious diseases/tropical medicine and psychiatric management of DI. We reviewed all patients seen at the combined assessment clinics run at the Liverpool School of Tropical Medicine between 19 December 2011 and 31 October 2016. Data were collected prospectively as part of clinical assessment. Descriptive analysis of these data was performed to examine clinical features at assessment, investigations performed and treatment outcomes. A total of 75 patients were assessed and 52 (69%) were given the formal diagnosis of DI. A history of travel was given by 64% of individuals but no significant tropical or infectious diagnosis was made. Of those who returned f...
Progress in neuro-psychopharmacology & biological psychiatry, Jan 24, 2017
Monothematic delusional disorders are characterized by a single tenacious belief. They provide a ... more Monothematic delusional disorders are characterized by a single tenacious belief. They provide a great opportunity to study underlying brain structures in the absence of confounding symptoms that accompany delusions in schizophrenia. Delusional beliefs include persecution, jealousy or somatic delusions including infestation. It is unclear whether specific delusional content is associated with distinct neural substrates. We used magnetic resonance imaging in patients presenting with somatic vs. non-somatic delusional disorders. Patients with delusional infestation (DI, n=18), and individuals with non-somatic delusional disorders (n=19) were included, together with healthy volunteers (n=20). Uni- and multivariate techniques for structural data analysis were applied to provide a comprehensive characterization of abnormal brain volume at both the regional and neural network level. Patients with DI showed lower gray matter volume in thalamic, striatal (putamen), insular and medial prefro...
Conversion (functional) limb weakness or paralysis (FW) can be a debilitating condition, and ofte... more Conversion (functional) limb weakness or paralysis (FW) can be a debilitating condition, and often causes significant distress or impairment in social, occupational, or other important areas of functioning. Most treatment concepts are multi-disciplinary, containing a behavioral approach combined with a motor learning program. Non-invasive brain stimulation (NIBS) methods, such as electroconvulsive therapy (ECT), and transcranial magnetic stimulation (TMS) have been used in the past few decades to treat FW. In order to identify all published studies that used NIBS methods such as ECT, TMS and transcranial direct current stimulation (tDCS) for treating FW patients a systematic review of the literature was conducted in PubMed and Web of Science. In a second step, narratives were used to retrospectively determine nominal CGI-I (Clinical Global Impression scale-Improvement) scores to describe approximate changes of FW symptoms. We identified two articles (case reports) with ECT used for ...
Recent court cases in England and Wales have refocused attention on patients' decision-making... more Recent court cases in England and Wales have refocused attention on patients' decision-making capacity to consent. Little is known about the prevalence of incapacity across specialities but decision-making capacity is likely to be overestimated by clinicians. The aim of this systematic review is to estimate the prevalence of incapacity to consent to treatment or admission in different medical and psychiatric settings, and compare the two. We conducted an electronic search following PRISMA principles and included 35 studies in psychiatric and 23 studies in medical settings. The 58 included studies revealed 70 data sets across all settings. For psychiatric settings the weighted average proportion of patients with incapacity was 45% (95% confidence interval (CI) 39-51%). For medical settings, the weighted average proportion of patients with incapacity was 34% (95% CI 25-44%). The two groups are not significantly different from each other in terms of the proportion of incapacity (p=...
Aims and method Community treatment orders (CTOs) have been used more than anticipated. We report... more Aims and method Community treatment orders (CTOs) have been used more than anticipated. We report data from the North Wales audit about their current use and explain how a SMART framework can be used to potentially improve their effectiveness. Results Findings from this audit confirm those from other studies, with the reasons for use of CTOs extending beyond that of medication adherence to risk management. The combined recall and voluntary admission rate was 40%, which raises questions about the effectiveness of CTOs. Clinical implications More research is needed as it remains to be seen whether CTOs are able to achieve their intended aims. The SMART framework can be used to aid clinicians in ensuring that conditions placed on patients have a specific purpose and are clinically meaningful.
Philosophy, Ethics, and Humanities in Medicine, 2009
Psychiatric practice is often faced with complex situations that seem to pose serious moral dilem... more Psychiatric practice is often faced with complex situations that seem to pose serious moral dilemmas for practitioners. Methods for solving these dilemmas have included the development of more objective rules to guide the practitioner such as utilitarianism and deontology. A more modern variant on this objective model has been 'Principlism' where 4 mid level rules are used to help solve these complex problems. In opposition to this, there has recently been a focus on more subjective criteria for resolving complex moral dilemmas. In particular, virtue ethics has been posited as a more sensitive method for helping doctors to reason their way through difficult ethical issues. Here the focus is on the character traits of the practitioner. Bloch and Green advocated another way whereby more objective methods such as Principlism and virtue ethics are combined to produce what they considered sound moral reasoning in psychiatrists. This paper points out some difficulties with this approach and instead suggests that a better model of ethical judgment could be developed through the use of narratives or stories. This idea puts equal prima facie value on the patient's and the psychiatrist's version of the dilemma they are faced with. It has the potential to lead to a more genuine empathy and reflective decision-making.
Paliperidone (9-hydroxy-risperidone), the active metabolite of risperidone, was approved for trea... more Paliperidone (9-hydroxy-risperidone), the active metabolite of risperidone, was approved for treating schizophrenia worldwide in 2006 as paliperidone extended-release (PER), and became the first second-generation antipsychotic specifically licensed for treating schizoaffective disorder in 2009. However, at the same time, its comparatively high cost gave rise to concerns about the cost-effectiveness of PER as compared with its precursor, risperidone. This paper reviews the existing knowledge of the pharmacology, kinetics, efficacy, tolerability, and fields of application of PER, and compares PER with risperidone in order to determine whether it has a place in antipsychotic therapy. An independent assessment of all relevant publications on PER published until July 2010 was undertaken. PER has a unique pharmacological profile, including single dosing, predominantly renal excretion, low drug-drug interaction risk, and differs from risperidone in terms of mode of action and pharmacokinetics. High-level evidence suggests that PER is efficacious and safe in schizophrenia, schizoaffective disorder, and acute manic episodes. There is a striking lack of published head-to-head comparisons between PER and risperidone, irrespective of indication. Low-level evidence shows a lower risk for hyperprolactinemia and higher patient satisfaction with PER than with risperidone. PER adds to the still limited arsenal of second-generation antipsychotics. In the absence of direct comparisons with risperidone, it remains difficult to come to a final verdict on the potential additional therapeutic benefits of PER which would justify its substantially higher costs as compared with risperidone. However, in terms of pharmacology, the available evidence cautiously suggests a place for PER in modern antipsychotic therapy.
SUMMARY This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional ... more SUMMARY This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional infestation (DI), also known as delusional parasitosis. It is characterized by the fixed belief of being infested with pathogens against all medical evidence. DI is no single disorder but can occur as a delusional disorder of the somatic type (primary DI) or secondary to numerous other conditions. A set of minimal diagnostic criteria and a classification are provided. Patients with DI pose a truly interdisciplinary problem to the medical system. They avoid psychiatrists and consult dermatologists, microbiologists, or general practitioners but often lose faith in professional medicine. Epidemiology and history suggest that the imaginary pathogens change constantly, while the delusional theme “infestation” is stable and ubiquitous. Patients with self-diagnosed “Morgellons disease” can be seen as a variation of this delusional theme. For clinicians, clinical pathways for efficient diagnosti...
SummaryCurrent capacity-based legislation and practice overvalues autonomy to the detriment of ot... more SummaryCurrent capacity-based legislation and practice overvalues autonomy to the detriment of other ethical principles. A balanced ethical approach would consider the patient's right to treatment, their relationships and interactions with society and not solely the patient's right to liberty and autonomous decision-making.
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Papers by Peter Lepping