Coming at the tail end of the era of the asylum, the Penrose (or hydraulic) hypothesis posited that deinstitutionalisation of long-term residential patients would lead to a rise in prison incarceration, and others have argued about further adverse sequelae such as greater rates of homelessness. The topic has a contemporary flavour: while we no longer have asylums, we live in a time of financial constraint and ever-tighter in-patient bed numbers. Winkler and colleagues (pp. 421–428) systematically review the issue and refute the core hypothesis, with no correlation identified between discharge after long-term care and subsequent homelessness and/or imprisonment. They note that the arguments that had supported the concept were often subjective editorials or ecological studies that could not disentangle concomitant confounders such as changes in globalisation, alterations to traditional support networks, and operational differences in mental health services. Efficacious public investment is the proposed ‘hydraulic’, not deinstitutionalisation; Salisbury & Thornicroft's editorial (pp. 412–413) advocates that the debate now needs to move to looking at the optimal in-patient/community ratio in differing settings.
Murray et al (pp. 414–415) note how much work in eating disorders focuses on female patients, meaning that professionals can be less sighted on men exhibiting such difficulties, not least as their distinct presentation can elude classification systems. It is a concern, especially as there is evidence of a growth in prevalence (in both genders), and the finding that men are often less likely to seek treatment for such behaviours. Some body dissatisfaction may fit with wider cultural trends of male ‘action figures’ with muscularity greater than that seen in the biggest of bodybuilders. Protein ‘bulking’, fat/carbohydrate ‘cutting’, and anabolic steroid use are argued to parallel the more typically female purging behaviour. Murray and colleagues propose that the transdiagnostic core is overvaluation of shape and weight, with various control behaviours secondary to these; further, they call for future diagnostic criteria to recognise this.
Dementia: causes, detection, and living with illness
Dementia with Lewy bodies (DLB) accounts for 10–15% of degenerative dementias in older people. It is notable for its visual hallucinations, but it has proven difficult to elucidate their aetiology. Taylor and colleagues (pp. 497–498) compared transcranial magnetic stimulation (TMS) and functional magnetic resonance imaging (fMRI) data, finding a loss of inhibitory drive in the visual cortex in DLB that they suggest may drive the pathophysiology. Neuroimaging is used to diagnose dementia, with computed tomography (CT) detected medial temporal lobe atrophy a cardinal sign of Alzheimer's disease, delineating it from DLB. Temporoparietal hypometabolism, as measured by fluorodeoxyglucose positron emission tomography (FDG-PET), has also been proposed as a differentiator of these conditions but it is unclear how much value this test adds to the more standard (and cheaper and quicker) repertoire. Firbank et al (pp. 491–496) compared CT and FDG-PET across a sample that included individuals with Alzheimer's disease and DLB; they found that the novel investigation did add clinical utility, but only in those with less (or no) atrophy, and was of limited use when losses in the medial temporal lobe were more severe.
Living with dementia is a profound burden for individuals and those around them. Their behaviour and psychological symptoms (BPSD), which afflict about 90%, are commonly a particular distress to family carers. Feast et al (pp. 429–434) review the BPSD factors that impact most upon the individual–carer dyad. Changes in communication and relationships led to family carers feeling bereft, while transgressions against social norms was the other factor identified as fundamental to their belief that their loved one had lost their identity to illness. Carers' acceptance of, and responses to, BPSD can vary considerably, and such factors have the power to alter the trajectory of these symptoms. The authors conclude that there is a significant unmet psychological need in family carers, who have lost an emotional bond, and have their own requirements for nurture, care and emotional security.
Training and intervention in suicide
The incidence of suicide in the year following giving birth is lower than in women who have not delivered, but it is nevertheless an area of importance, and one of the commonest causes of death in women in high-income countries during this period. Esscher and colleagues (pp. 462–469) analysed almost 30 years of Swedish national register data, and determined a suicide ratio of 3.7/100 000 live births, but with an odds ratio over three times greater in women born in low-income countries. Violent methods of death were considerably more common than normal, occurring in 87% of those who died before the end of the 6-month postpartum period. Of concern, antenatal documentation was inconsistent, and a considerable number had no psychiatric care plan.
The complex issue of assisted suicide is addressed by Steck et al (pp. 484–490); the study was undertaken in Switzerland, one of the few countries to allow this act (provided there is no self-interest in such assistance, and euthanasia is banned). The overall suicide rate in Switzerland is higher than most European countries; most choosing assisted acts are terminally ill, but it is also legal in capacitous healthy individuals. Over 1300 assisted and 5700 unassisted suicides were analysed. The results showed that rates of assisted suicide were similar in men and women (bucking the typical gender differences seen in unassisted acts). There were no differences based upon religious affiliation, having children or living alone; however, tertiary education was positively associated with assisted, and negatively associated with unassisted, suicide.
This month's Kaleidoscope (pp. 503–504) has fascinating data that the opioid partial agonist buprenorphine can acutely reduce suicidal thinking – the hypothesis being the anaesthetising of mental pain – but what about psychosocial inputs? There are some conflicting data from two papers: de Beurs et al (pp. 477–483) found no benefit from training professionals, via eLearning, in adhering to suicide prevention guidelines, while Armitage et al (pp. 470–476) showed that an ‘implementation intentions’ programme produced significant benefit. Suicide prevention training has been shown to improve the knowledge, skills and attitudes of practitioners. It is therefore a challenge understanding why training in the application of professional practice guidelines (and putatively therein the delivery of optimal evidence-based care) did not improve 3-month outcomes – in terms of suicide ideation, non-fatal attempts or treatment satisfaction – in this first randomised controlled trial on the topic. Notably, the control group also showed improvement, and the authors considered their sample size was insufficient to detect additional training benefits. The positive outcomes of the ‘implementation intentions’ programme, which links triggers for self-harm with coping skills, may suggest more focused interventions are necessary.
- © The Royal College of Psychiatrists 2016.