Richard M. Duffy

Custody, care and country of origin: demographic and diagnostic admission statistics at an inner-city adult psychiatry unit

Involuntary detention is a feature of psychiatric care in many countries. We previously reported an involuntary admission rate of 67.7 per 100,000 population per year in inner-city Dublin (January 2008-December 2010), which was higher than Irelands national rate (38.5). We also found that the proportion of admissions that was involuntary was higher among individuals born outside Ireland (33.9%) compared to those from Ireland (12.0%), apparently owing to increased diagnoses of schizophrenia in the former group. In the present study (January 2011-June 2013) we again found that the proportion of admissions that was involuntary was higher among individuals from outside Ireland (32.5%) compared to individuals from Ireland (9.9%) (p<0.001), but this is primarily attributable to a lower rate of voluntary admission among individuals born outside Ireland (206.1 voluntary admissions per 100,000 population per year; deprivation-adjusted rate: 158.5) compared to individuals from Ireland (775.1; deprivation-adjusted rate: 596.2). Overall, admission rates in our deprived, inner-city catchment area remain higher than national rates and this may be attributable to differential effects of Irelands recent economic problems on different areas within Ireland. The relatively low rate of voluntary admission among individuals born outside Ireland may be attributable to different patterns of help-seeking which mental health services in Ireland need to take into account in future service-planning. Other jurisdictions could also usefully focus attention not just on rates on involuntary admission among individuals born elsewhere, but also rates of voluntary admission which may provide useful insights for service-planning and delivery.

Screening for metabolic syndrome in long-term psychiatric illness: Audit of patients receiving depot antipsychotic medication at a psychiatry clinic

Background and Objectives: Metabolic syndrome (visceral obesity, dys- lipidaemia, hyperglycaemia, hypertension) is a substantial public health problem, espe- cially amongst individuals receiving antipsychotic medication. Methods: We studied routine screening practices for metabolic syndrome amongst psy- chiatry outpatients receiving injected depot anti-psychotic medication at a clinic in Dublin, Ireland. Results: Our initial audit (n = 64) demonstrated variable levels of documentation of crite- ria for metabolic syndrome in outpatient files; e.g. weight was recorded in 1.6% of files, serum high density lipoprotein in 12.5%. As our intervention, we introduced a screening check-list comprising risk factors and criteria for metabolic syndrome, based on the defini- tion of the International Diabetes Federation. Re-audit (n = 54) demonstrated significantly improved levels of documentation; e.g. weight was recorded in 61.1% of files. Notwith- standing these improvements, only 11 (20.4%) of 54 patient files examined in the re-audit, contained sufficient information to determine whether or not the patient fulfilled criteria for metabolic syndrome; of these, 3 patients (27.3%) fulfilled criteria for metabolic syndrome. There was, however, significant additional morbidity in relation to individual criteria (waist circumference, serum triglyceride level, systolic blood pressure and serum fasting glucose). Conclusions: We recommend enhanced attention be paid to metabolic morbidity in this patient group.

Which involuntary admissions are revoked by mental health tribunals? A report from the Dublin Involuntary Admission Study (DIAS)

Little is known about which involuntary psychiatry patients are likely to have their involuntary admission orders revoked by mental health tribunals or review boards and which are not. We studied 2940 admissions, of which 423 (14.4%) were involuntary, at three adult psychiatry units covering a population of 552,019 people in Dublin. A majority of involuntary admission orders were revoked by psychiatrists (94.6%) rather than tribunals (3.0%). Revocation by tribunal was associated with older age and a diagnosis of schizophrenia. More detailed information about the conduct and outcome of tribunals is needed to better protect the rights of the mentally ill.

Who can decide? Prevalence of mental incapacity for treatment decisions in medical and surgical hospital inpatients in Ireland

Background The prevalence of mental incapacity for treatment decisions among medical and surgical hospital inpatients is poorly understood or not known in many countries, including Ireland. Aim To assess the prevalence of mental incapacity in hospital inpatients in Ireland. Design Cross-sectional observational study of mental incapacity for treatment decisions. Methods We assessed mental capacity in 300 randomly selected hospital inpatients in 2 general hospitals in Dublin (urban) and Portlaoise (rural), in Ireland, using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Results Mean MacCAT-T score was 14.80 (SD: 8.40) out of a possible maximum of 20 (with a higher score indicating greater mental capacity). Over one quarter of participants (27.7%; n = 83) lacked the mental capacity for treatment decisions; 1.7% (n = 5) had partial capacity and 70.7% (n = 212) had full capacity. Scores for each of the four sub-scales of the MacCAT-T were generally consistent across the four key areas of understanding, appreciation, reasoning and expressing a choice. Conclusions Mental incapacity for treatment decisions is common in medical and surgical hospital inpatients in Ireland. This issue both merits and requires greater attention in clinical practice, research and legislation.

Variations in involuntary admission rates at three psychiatry centres in the Dublin Involuntary Admission Study (DIAS): Can the differences be explained?

Involuntary psychiatric admission is an established practice for patients who are acutely or severely mentally ill but the factors contributing to involuntary (as opposed to voluntary) admission are not fully clear. Nor is it clear why rates of involuntary admission often vary between hospitals within the same jurisdiction. We studied all admissions, voluntary and involuntary, in three inpatient psychiatry units in Dublin, Ireland, which cover a population of 552,019 people, over a one-year period (1 July 2014 until 30 June 2015, inclusive), as part of the Dublin Involuntary Admission Study (DIAS). During the study period, there was a total of 1136 admissions to these three units, of which 17% were involuntary for all or part of their admission. The overall admission rate (205.8 admissions per 100,000 population per year) was lower than the national rate (387.9) but this varied substantially across the three units studied. On multi-variable analysis, involuntary admission status was associated with male gender, being unmarried, and a diagnosis of schizophrenia, and was not significantly associated with age, occupation or which inpatient unit the person was admitted to. We conclude that variations in involuntary admission rates between different psychiatry admission units in Dublin are significantly explained by patient-level variables (such as gender, marital status and diagnosis) rather than centre-level variables, but that much of the variation in admission status between patients remains unexplained. Future, multi-level research could usefully focus on other patient-level factors of possible relevance (e.g. symptom severity), centre-level factors (e.g. local mental health service resourcing) and community-level factors (e.g. socio-economic circumstances in different areas) in order to further elucidate unexplained variance in admission status between patients.

Demographic characteristics of survivors of torture presenting for treatment to a national centre for survivors of torture in Ireland (2001–2012)

OBJECTIVES The asylum process has received a lot of recent media attention but little has been said about the psychological needs of those seeking or granted asylum. Many asylum seekers have experienced trauma and torture, which is associated with substantial psychiatric and psychological morbidity. The Spiritan Asylum Services Initiative (Spirasi) is Irelands national treatment centre for survivors of torture. The aim of this study was to examine the demographic profile of those attending Spirasi and to consider potential clinical implications of this. METHODS We retrospectively analysed demographic data relating to the 2590 individuals who attended Spirasi over a 12-year period (2001-2012 inclusive). RESULTS The majority of attenders were asylum seekers (88%), male (71%) and from African countries. The mean age was 31.9 years. The rate of new referrals, as a percentage of Irelands asylum-seeking population, has stabilised at ~6% since 2008. Women are underrepresented among those who attend. CONCLUSIONS The number of new referrals to Spirasi is lower than expected given international estimates of torture prevalence and the impact this has on mental health. Clinicians working with populations of asylum seekers and refugees should sensitively enquire about such events and be aware of the available services. Female refugees and asylum seekers are underrepresented, especially from Asian and Middle Eastern regions. Psychiatric, psychological and general practice services need to respond flexibly to evolving patterns of migration and address potential barriers to access, especially among female refugees and asylum seekers.

Concordance of the Indian Mental Healthcare Act 2017 with the World Health Organization’s Checklist on Mental Health Legislation

BackgroundIndia is revising its mental health legislation with the Indian Mental Healthcare Act 2017 (IMHA). When implemented, this legislation will apply to over 1.25 billion people. In 2005, the World Health Organization (WHO) published a Resource Book (WHO-RB) on mental health, human rights and legislation, including a checklist of 175 specific items to be addressed in mental health legislation or policy in individual countries. Even following the publication of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) (2006), the WHO-RB remains the most comprehensive checklist for mental health legislation available, rooted in UN and WHO documents and providing the most systematic, detailed framework for human rights analysis of mental health legislation. We sought to determine the extent to which the IMHA will bring Indian legislation in line with the WHO-RB.MethodsThe IMHA and other relevant pieces of Indian legislation are compared to each of the items in the WHO-RB. We classify each item in a binary manner, as either concordant or not, and provide more nuanced detail in the text.ResultsThe IMHA addresses 96/175 (55.4%) of the WHO-RB standards examined. When other relevant Indian legislation is taken into account, 118/175 (68.0%) of the standards are addressed in Indian law. Important areas of low concordance include the rights of families and carers, competence and guardianship, non-protesting patients and involuntary community treatment. The important legal constructs of advance directives, supported decision-making and nominated representatives are articulated in the Indian legislation and explored in this paper.ConclusionsIn theory, the IMHA is a highly progressive piece of legislation, especially when compared to legislation in other jurisdictions subject to similar analysis. Along with the Indian Rights of Persons with Disabilities Act 2016, it will bring Indian law closely in line with the WHO-RB. Vague, opaque language is however, used in certain contentious areas; this may represent arrangement-focused rather than realisation-focused legislation, and lead to inadvertent limitation of certain rights. Finally, the WHO-RB checklist is an extremely useful tool for this kind of analysis; we recommend it is updated to reflect the CRPD and other relevant developments.

Steroids, psychosis and poly-substance abuse

OBJECTIVE To review consequences of the changing demographic profile of anabolic-androgenic steroid (AAS) use. METHOD Case report and review of key papers. RESULTS We report here a case of a 19-year-old Irish male presenting with both medical and psychiatric side effects of methandrostenolone use. The man had a long-standing history of harmful cannabis use, but had not experienced previous psychotic symptoms. Following use of methandrostenolone, he developed rhabdomyolysis and a psychotic episode with homicidal ideation. Discussion Non-medical AAS use is a growing problem associated with medical, psychiatric and forensic risks. The population using these drugs has changed with the result of more frequent poly-substance misuse, potentially exacerbating these risks. CONCLUSION A higher index of suspicion is needed for AAS use. Medical personnel need to be aware of the potential side effects of their use, including the risk of violence. Research is needed to establish the magnitude of the problem in Ireland.

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.