Psychiatry beyond the current paradigm.

A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially 'applied neuroscience'. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.

Estimating the prevalence of adult ADHD in the psychiatric clinic: a cross-sectional study using the adult ADHD self-report scale (ASRS).

OBJECTIVES: We sought to determine the point prevalence of adult attention deficit/hyperactivity disorder (ADHD) in an out-patient psychiatric population. METHODS: Patients (n=243) attending five different outpatient clinics in a largely urban adult psychiatric service completed the Adult ADHD Self-Report Scale, a recently developed instrument by the World Health Organisation. Clinical and demographic data were recorded. RESULTS: There was a high apparent rate of adult ADHD detected (23.9%). Such patients were significantly more likely to have lower educational attainment, ADHD as children, a forensic history and the diagnosis of personality disorder as well as a higher rate of benzodiazepine use. They were no more likely to be dissatisfied with the service, nor to be heavier users of the service. CONCLUSIONS: We report a high apparent rate of adult ADHD. Correlates of this high rate indicate individuals with less positive lifestyles than other patients. Screening for this disorder appears warranted, particularly in the light of the emergence of new non-amphetamine-based therapies.

Psychiatric aftercare and suicide risk: a case-control study using blind rating.

Blindly abstracted records of last episode of care together with aftercare records of 39 psychiatric patient suicides and their matched controls were rated blind for suicidal talk during aftercare, reduction of aftercare at last appointment and high-low suicide risk. Neither suicidal talk nor reduction of aftercare was confirmed as a predictor of suicide, although trends in the predicted directions were observed. Blind estimates of high-low risk correctly identified a significant minority (40%) of suicides but at the cost of misclassifying 60% as controls. Evidence is still lacking that clinicians blind to case identity may, from records, reliably distinguish a majority of suicides from their matched controls. Some implications for practice and research are discussed.

Lipids and essential fatty acids in patients presenting with self-harm.

BACKGROUND: Low cholesterol has been reliably demonstrated in people who self-harm. AIMS: To determine whether people who self-harm also have low levels of essential fatty acids (EFAs) and to examine associations between the EFAs and serotonergic function. METHOD: Depression, impulsivity and suicidal intent were measured in patients with self-harm (n=40) and matched controls, together with plasma lipids and EFAs. Platelet serotonergic studies were carried out in a subgroup (n=27). RESULTS: Patients with self-harm had significantly more pathology on all psychometric measures, lower mean total cholesterol levels (4.18 (s.d.=0.93) v. 4.87 (s.d.=0.83) mmol/l, P=0.003) and lower mean total EFA levels (89. 5 (15.6) v.103.7 (17.1) microg/ml, P=0.0001) than controls after adjustment for confounding variables. Total n-3 and n-6 EFA levels were also significantly lower. Impulsivity and depression scores were significantly inversely correlated with both n-6 EFAs and n-3 EFAs, but were not associated with total or low-density lipoprotein cholesterol levels. Platelet serotonergic measures did not differ between groups, and were not related to psychobiological measures. CONCLUSIONS: Lower plasma EFA levels combined with low cholesterol concentrations were associated with self-harm as well as impulsivity and affect. This was not related to platelet serotonergic measures.

Omega-3 fatty acid supplementation in patients with recurrent self-harm. Single-centre double-blind randomised controlled trial.

BACKGROUND: Trials have demonstrated benefits of long-chain omega-3 essential fatty acid (n-3 EFA) supplementation in a variety of psychiatric disorders. AIMS: To assess the efficacy of n-3 EFAs in improving psychological well-being in patients with recurrent self-harm. METHOD: Patients (n=49) presenting after an act of repeated self-harm were randomised to receive 1.2 g eicosapentaenoic acid plus 0.9 g decosahexaenoic acid (n=22) or placebo (n=27) for 12 weeks in addition to standard psychiatric care. Six psychological domains were measured at baseline and end point. RESULTS: At 12 weeks, the n-3 EFA group had significantly greater improvements in scores for depression, suicidality and daily stresses. Scores for impulsivity, aggression and hostility did not differ. CONCLUSIONS: Supplementation achieved substantial reductions in surrogate markers of suicidal behaviour and improvements in well-being. Larger studies are warranted to determine if insufficient dietary intake of n-3 EFAs is a reversible risk factor for self-harm.

Essential fatty acids and their role in conditions characterised by impulsivity.

There is a biological basis for anticipating a role for the essential fatty acids (EFAs) in the therapeutics of the large number of conditions characterized by impulsivity, hostility and aggression. Abnormalities in these constructs have been linked to dysfunction of several monoaminergic systems, 5-hydroxytryptamine (5-HT) in particular. The EFAs ameliorate the function of these systems and also act through a number of other mechanisms. While limited in volume, a number of EFA supplementation studies support their role in the treatment of such conditions. This paper summarises the literature in terms of epidemiology, clinical science and therapeutics in clinical and non-clinical populations.

The effects of vagus nerve stimulation on pro- and anti-inflammatory cytokines in humans: a preliminary report.

OBJECTIVE: Vagus nerve stimulation (VNS) is a novel therapy in resistant epilepsy, and is undergoing clinical trials in resistant depression. The mechanism of action of VNS is assumed to be due to modulation of deep brain structures via its afferent connections. As the vagus nerve has potentially important immunological actions that may have relevance to its therapeutic effects, we hypothesised that an additional mechanism may occur via vagally mediated actions on cytokine synthesis. METHODS: Patients (n=10) with resistant depression were studied in the weeks prior to, and 3 months following, implantation of a vagus nerve stimulator. No medication changes were made during the course of the study. High-sensitivity ELISA kits were used to measure plasma IL-1 beta, IL-6, TNF-alpha, IL-10 and TGF-beta concentrations. C-reactive protein (CRP) was measured using a high sensitivity immunonephelometry assay. RESULTS: There were highly significant increases in the plasma levels of IL-6, TNF-alpha and TGF-beta. Increases seen with IL-10 and IL-1 beta were not significant. Plasma CRP levels were unchanged. CONCLUSION: VNS is associated with marked peripheral increases in pro- and anti-inflammatory circulating cytokines. Such changes are unlikely to be non-specific inflammatory reactions, reflected by CRP levels. In view of gathering evidence supporting a role for the immune system in modulating affect, as well as seizure activity, these effects of VNS may be therapeutically relevant.

Essential fatty acids and their role in the treatment of impulsivity disorders.

Essential fatty acids (EFAs) have been shown to benefit patients with depression, schizophrenia and dementia. More recently, their role in disorders characterised by impulsivity has attracted some attention. The psychiatric conditions of attention-deficit hyperactivity disorder and borderline personality disorder as well as the phenomena of deliberate self-harm and violence have been ameliorated by the supplementation of EFAs in a number of recent clinical trials. This paper summarises the burgeoning clinical and basic research indicating the existence of significant deficits of EFAs in impulsivity disorders and the supplementation studies of EFAs in these diverse conditions, all of which remain a major therapeutic challenge.

Cortisol does not mediate the suppressive effects of psychiatric morbidity on natural killer cell activity: a cross-sectional study of patients with early breast cancer.

BACKGROUND: There is evidence that depression impairs natural killer cell activity (NKA); this could have implications for anti-tumour immunity. Our aim was to examine the role of the hypothalamic-pituitary-adrenal (HPA) axis in suppressing NKA in a population of patients with early breast cancer, screened for depression. Secondary aims were to study the relationship between psychological, endocrine and immune variables and baseline tumour characteristics. METHOD: A cross-sectional population of female patients (n=55) with early breast cancer was sampled prior to primary surgery. Structured interview and psychometric instruments measured psychological distress. Flow cytometry was used to enumerate NK cells and lymphocytes were cryopreserved for use in a 51Cr-release assay, to estimate NKA. Midnight and three early morning saliva samples were collected to measure free cortisol levels. Tumour characteristics were obtained from hospital laboratory data. RESULTS: A high rate of psychological morbidity (40%) was observed in the population. NKA was reduced in those with past or current psychiatric illness compared to those without (344 v. 553 LU20 and 455 v. 569 LU20 respectively, p < 0.05 for both). Cortisol was not related to psychological status but was modestly positively correlated to NKA. A positive correlation was observed between the Fighting Spirit subscale of the Mental Adjustment to Cancer Scale and tumour size (r=0.383, p=0.012). CONCLUSIONS: Our data support the evidence that psychological morbidity is associated with immune dysfunction; however, the most obvious candidate mediator of this effect, the HPA axis, does not appear responsible for this effect. Possible reasons for this are discussed.

A one-year audit of specialist psycho-oncology services in an Irish tertiary referral centre.

OBJECTIVES: Psychological services to patients with cancer are very limited in Ireland. A dedicated psycho-oncology service was established at our Institution 18 months ago. The aim of this study was to examine referral rates, psychiatric diagnoses and treatment interventions in this patient group. METHODS: The clinical and psychiatric characteristics of consecutive patients (n = 63) referred to a recently established specialist psycho-oncology service in an Irish university teaching hospital over a one-year period were examined prospectively. International diagnostic criteria were applied. Forms of treatment instituted and clinical response to same were also audited. RESULTS: Over half (54%) of patients presented with affective disorder spectrum illnesses. The remaining referrals represented a diverse group of psychiatric diagnoses, but included a large proportion of patients with delirium. Approximately 20% of patients did not meet criteria for a psychiatric diagnosis. There was an over-representation of breast cancer and lymphoma. Thirty-eight per cent of patients were on prescribed corticosteroids at the time of referral. Eighty-two per cent of patients required some form of psychiatric intervention, and 86% of these benefited clinically from our intervention. CONCLUSIONS: The data suggest that even in oncology services with good existing support networks, such as this one, the role of an additional input from liaison psychiatry is considerable.

Stress-related hormonal suppression of natural killer activity does not show menstrual cycle variations: implications for timing of surgery for breast cancer.

BACKGROUND: Evidence exists that prognosis in breast cancer may be related to the timing of primary surgery. Fluctuations in natural killer (NK) cells and/or their sensitivity to surgical stress hormones could mediate this phenomenon. We sought to establish, firstly, if there are any numerical or functional changes in NK cells during the course of the menstrual cycle and, secondly, if their prior in vitro incubation with cortisol and adrenaline produced functional change that was more pronounced at a particular point in the cycle. SUBJECTS AND METHODS: Normally menstruating females (n = 10) were sampled at two points (mid-follicular and mid-luteal) during two cycles. NK cell numbers were determined by flow cytometry. Natural killer cell activity (NKA) (unstimulated and following a 2-hour pre-incubation with cortisol and adrenaline) was determined using chromium-51 release assays from peripheral blood mononuclear cells (PBMCs) prepared from cryopreserved samples from the second cycle. RESULTS: NK cell numbers (expressed as a percentage of a standard lymphgate) were significantly higher at the mid-luteal point compared to the mid-follicular point (8.45 +/- 3.71 vs. 6.85 +/- 2.80, p < 0.05, data pooled from both cycles). Corresponding changes in NKA were observed, although these did not reach statistical significance. The mean inhibitory effects of cortisol (67%) and adrenaline (12%) on NKA were significant, but this phenomenon was uninfluenced by cycle point. CONCLUSION: This study supports the role of menstrual cycle-induced alterations in NK cells as a putative mediator of improved survival when surgery for breast cancer is carried out in the follicular phase. However there is no evidence of the cyclical sensitivity of NK cells to the principal surgical stress hormones.