Anne M. Doherty

Adjustment disorder: implications for ICD-11 and DSM-5

Adjustment disorder has been a recognised disorder for decades but has been the subject of little epidemiological research. Now researchers have identified the prevalence of adjustment disorder in primary care, and found general practitioner recognition very low but with high rates of antidepressant prescribing. Possible reasons for the seemingly low prevalence, recognition rate and inappropriate management include its recognition as a residual category in diagnostic instruments and poor delineation from other disorders or from normal stress responses. These problems could be rectified in ICD-11 and DSM-5 if changes according it full syndromal status, among others, were made. This would have an impact on future research.

Implementing the Mental Health Act 2007 in British general practice: Lessons from Ireland.

Changes in mental health legislation (e.g. Mental Health Act 2007 in England and Wales, Mental Health Act 2001 in Ireland) have generally improved adherence to international human rights standards, but also present challenges to primary care providers. When mental health legislation was substantially reformed in Ireland, 62.9% of general practitioners (GPs) felt the new legislation was not user-friendly. Majorities of GPs who felt the legislation affected their practice reported increased workloads (85%) and various other difficulties (53%). GPs who had received training about the legislation were more likely to find it user-friendly (43% versus 30.9%), and informal training (e.g. from colleagues) was just as likely as formal training to be associated with a GP finding it user-friendly. With similar changes to mental health legislation being introduced in England and Wales, it is significant that informal training is just as good as formal training in helping GPs work with new mental health legislation.

Suicidal behaviours in adjustment disorder and depressive episode

BACKGROUND Little is known about suicidal ideation and behaviours in adjustment disorder (AD). In this paper we sought to examine the variables independently associated with suicidal ideation and behaviour in patients diagnosed with AD or depressive (DE) episode among psychiatric outpatients and in liaison psychiatry. METHODS 370 patients who were referred to the liaison psychiatry services (including those seen in the Emergency Department) at 3 Dublin hospitals, and were clinically diagnosed with either DE or AD, based on the ICD 10 diagnostic criteria, were recruited to the study. We examined their demographic and clinical characteristics, and the associations between these and suicidal ideation and behaviour on multivariate analysis. RESULTS Younger age, single marital status, and greater severity of depressive symptoms were significantly associated with suicidality across both diagnoses. On multivariate analysis, greater severity of depressive symptoms was associated with suicidality in those with AD (p=0.012) and DE (p=0.009). Those with AD exhibited suicidality at lower symptom scores than did those with DE but in both groups it still occurred at the highest level of severity. There were differences in the objective circumstances measure of suicide intent. LIMITATIONS We used clinical diagnosis rather as the main diagnostic classification. The generalisability of this paper may be limited to consultation-liaison psychiatry settings, where suicidal ideation and behaviours are common. CONCLUSIONS Suicidality in AD and DE has broadly similar risk factors but differ in aspects of suicide intent. Different mechanisms may underpin suicidality in those with AD compared to DE.

Distinguishing between adjustment disorder and depressive episode in clinical practice: The role of personality disorder

BACKGROUND There is significant symptomatic overlap between diagnostic criteria for adjustment disorder and depressive episode, commonly leading to diagnostic difficulty. Our aim was to clarify the role of personality in making this distinction. METHODS We performed detailed assessments of features of personality disorder, depressive symptoms, social function, social support, life-threatening experiences and diagnosis in individuals with clinical diagnoses of adjustment disorder (n=173) or depressive episode (n=175) presenting at consultation-liaison psychiatry services across 3 sites in Dublin, Ireland. RESULTS Fifty six per cent of participants with adjustment disorder had likely personality disorder compared with 65% of participants with depressive episode. Compared to participants with depressive episode, those with adjustment disorder had fewer depressive symptoms; fewer problems with social contacts or stress with spare time; and more life events. On multi-variable testing, a clinical diagnosis of adjustment disorder (as opposed to depressive episode) was associated with lower scores for personality disorder and depressive symptoms, and higher scores for life-threatening experiences. LIMITATIONS We used clinical diagnosis as the main diagnostic classification and generalisability may be limited to consultation-liaison psychiatry settings. CONCLUSIONS Despite a substantial rate of likely personality disorder in adjustment disorder, the rate was even higher in depressive episode. Moreover, features of likely personality disorder are more strongly associated with depressive episode than adjustment disorder, even when other distinguishing features (severity of depressive symptoms, life-threatening experiences) are taken into account.

Improving quality of diabetes care by integrating psychological and social care for poorly controlled diabetes: 3 Dimensions of Care for Diabetes.

Objective Many people with persistent suboptimal diabetes control also have psychiatric morbidity and social problems which interfere with their ability to self-manage their diabetes. Current models of care in the UK do not integrate these different dimensions of care or address inequalities between physical and mental health. 3DFD (3 Dimensions of Care For Diabetes) integrated medical, psychological, and social care in diabetes for patients with persistent suboptimal glycemic control (HbA1c > 75 mmol/mol) despite guideline-based routine diabetes care, to improve glycemic control, reduce psychological distress, and improve social functioning. Methods The service delivered interventions including brief psychological therapies, mental health assessments, psychotropic medications, and social support, enhanced by patient-led case conferences aiming to optimize diabetes care. 3DFD measured changes in HbA1c, psychological functioning, quality of life, rates of unscheduled care, and levels of engagement with routine diabetes care at baseline and at 12 months. Conclusion At 12-month follow-up, 3DFD patients achieved significant reductions in HbA1c of 15 mmol/mol, International Federation of Clinical Chemistry (1.4% Diabetes Control and Complications Trial) and improvements in depression scores and patient satisfaction. This model of care demonstrates that integrated care can improve diabetes outcomes in people with psychological and social comorbidities.

Social and psychological correlates of happiness in 17 European countries

OBJECTIVES Happiness has been associated with a number of individual and societal factors, but much of the individual-to-individual variation in happiness remains unexplained. The purpose of this paper is to examine a broad range of social and psychological correlates of self-rated happiness in Europe. METHODS We used data from the European Social Survey to determine levels of happiness in individuals (n = 30,816) from 17 European countries and to identify associations between happiness and age, gender, family relationships, satisfaction with income, employment status, community trust, satisfaction with health, satisfaction with democracy, religious belief and country of residence. RESULTS Self-rated happiness varies significantly between European countries, with individuals in Denmark reporting the highest levels of happiness and individuals in Bulgaria reporting the lowest levels. On multi-variable analysis, happiness is positively correlated with younger age, satisfaction with household income, being employed, high community trust and religious belief. Overall, these factors account for 22.5% of the individual-to-individual variation in happiness in Europe. CONCLUSIONS For the individual, this study highlights possible associations between happiness and the individuals attitudes towards various aspects of their personal, household and societal circumstances. For social policy-makers, this study suggests the potential usefulness of civic measures to increase community trust and social capital. Further studies of the inter-relationships between individual and community-level variables would assist in further explaining the variance in happiness between individuals and countries.

3 Dimensions of Care for Diabetes: integrating diabetes care into an individual's world

3DFD (3 Dimensions of Care for Diabetes) is an award winning gold‐standard model of integrated care, which was developed and evaluated as a sustainable service for improving glycaemic control and reducing diabetes complications in South Londons multi‐ethnic, socio‐economically disadvantaged and growing diabetes population. This service is fully integrated into the diabetes services across Lambeth and Southwark boroughs. It consists of a liaison psychiatrist who provides clinical leadership and psychiatric interventions, psychologists and two third‐sector social support workers who provide social care in the community, working directly with the diabetes teams across the sectors.

Attitudes and experiences of nursing staff to the Mental Health Act 2001: lessons for future mental health legislation

OBJECTIVES The Mental Health Act 2001 was implemented in 2006 to bring Ireland into line with international practice and United Nations Conventions on Human Rights. Previous studies have reported some practical difficulties for the professionals involved. We wished to examine the experiences of nursing staff and the impact of the Act on clinical nursing practice since its implementation. METHOD This cross-sectional survey was conducted by questionnaire. It contained questions examining training in and attitudes to the Act, and any resultant changes in nursing practise. RESULTS A total of 317 questionnaires were returned. Of the nurses, 92% reported having received training in the Act, and 56% of nursing staff believed that their workload had increased as a result of the change in legislation. Of those who made a comment, 76.5% were negative, with increased paper work, lack of clarity and an excessive focus on legalities being the most common difficulties reported. CONCLUSIONS Nursing staff have shown mixed attitudes to the Mental Health Act 2001, but many of the difficulties encountered are similar to those experienced by other professionals.

P02-159 - Attitudes and experiences to the implementation of the Mental Health Act 2001

Introduction The Mental Health Act 2001 was implemented in November 2006 and its introduction has heralded many important changes in the provision of mental health care in Ireland. Objectives To examine the impact of the Act on the time and patterns of attention given to patients since its implementation, and to look at some of the difficulties encountered. Aims To propose amendments to the legislation, based on the experiences elicited. Methods This cross-sectional survey was conducted by questionnaire which we distributed along the chain of command in nursing management. They contained questions looking at attitudes to the Act and the resultant changes in nursing practise. The questionnaire also examined the levels of training with regard to the Act received by members of nursing staff. There was a space given for comments not encompassed by the questions. Results 317 questionnaires were returned. 56% of nursing staff believed that their workload had increased as a result of the change in legislation. Of those who made a comment, 76.5% were negative in relation to the new legislation, with increased paper work, lack of clarity and an excessive focus on legal technicalities being the most common difficulties reported. Conclusion Nursing staff have shown mixed attitudes to the Mental Health Act 2001. However, as a majority have reported a need for increased training, this is an important need which needs to be met.

The Role of a Neuropsychiatry Clinic in a Tertiary Referral Teaching Hospital: A Two-Year Study

OBJECTIVES Mental disorder is common among individuals with neurological illness. We aimed to characterise the patient population referred for psychiatry assessment at a tertiary neurology service in terms of neurological and psychiatric diagnoses and interventions provided. METHODS We studied all individuals referred for psychiatry assessment at a tertiary neurology service over a 2-year period (n= 82). RESULTS The most common neurological diagnoses among those referred were epilepsy (16%), Parkinsons disease (15%) and multiple sclerosis (8%). The most common reasons for psychiatric assessment were low mood or anxiety (48%) and medically unexplained symptoms or apparent functional or psychogenic disease (21%). The most common diagnoses among those with mental disorder were mood disorders (62%), and neurotic, stress-related and somatoform disorders, including dissociative (conversion) disorders (28%). Psychiatric diagnosis was not related to gender, neurological diagnosis or psychiatric history. CONCLUSION Individuals with neurological illness demonstrate significant symptoms of a range of mental disorders. There is a need for further research into the characteristics and distribution of mental disorder in individuals with neurological illness, and for the enhancement of integrated psychiatric and neurological services to address the comorbidities demonstrated in this population.