A public health perspective on mental health: lessons for population health in the 21st century.

In December 2019, clinicians and academics from the disciplines of public health and psychiatry met in Dublin at the Royal College of Surgeons in Ireland (RCSI), to restate their shared commitment to population health. The purpose of this review is to bring our discussion to a wider audience. The meeting could not have been more timely. Six weeks later, the COVID-19 emergency emerged in China and within 12 months it had swept the world. This paper, the contents of which were presented at that meeting in December recommended that future healthcare would be guided more by public health perspectives and informed by an understanding of health economics, population health and the lessons learned by psychiatry in the 20th century. Ultimately two issues are at stake in 21st century healthcare: the sustainability of our healthcare systems and the maintenance of public support for population health. We must plan for the next generation of healthcare. We need to do this now since it is clear that COVID-19 marks the beginning of 21st century medicine.

Bringing Lived Lives to Swift's Asylum: a psychiatric hospital perspective.

Background: Few "interventions" around suicide and stigma have reached into psychiatric institutions. Lived Lives is a science-arts approach to addressing suicide and stigma, informed by a psychobiographical and visual arts autopsy. The resulting artworks and mediated exhibition ( Lived Lives), has facilitated dialogue, response and public action around stigma-reduction, consistent with a community intervention. Recent evidence from Lived Lives moved us to consider how it may situate within a psychiatric hospital. Methods: Lived Lives manifested in St. Patrick's University Hospital (Ireland's oldest and largest psychiatric hospital) in November 2017.   A mixed-methods approach was used to evaluate the exhibition as a potential intervention to address stigma around suicide, with quantitative and qualitative data collected via written questionnaire and oral data collected via video documentation.  Bereavement support was available. A Clinician and an artist also provided independent evaluation. Results:  86 participants engaged with the exhibition, with 68 completing questionnaire data. Audiences included service users, policy makers, health professionals, senior hospital administrators and members of the public. 62% of participants who completed questionnaires were suicide-bereaved; 46% had experienced a mental health difficulty, and 35% had been suicidal in the past. 91% thought Lived Lives could be of benefit in the aftermath of a suicide death. Half of participants thought Lived Lives could help reduce suicidal feelings, whereas 88% thought it could benefit those with Mental Health difficulties. The emotional response was of a visceral nature, including fear, anger, sadness, disgust and anxiety. Conclusions: Lived Lives sits comfortably in discomfort, unafraid to call out the home-truths about stigma and its pervasive and pernicious impact, and with restoring identity at its core. Lived Lives can operate within a psychiatric hospital, as well as in community. The challenge is to move it forward for greater exposure and impacts in at-risk communities.

Prospective study of provided smoking cessation care in an inpatient psychiatric setting.

OBJECTIVE: People with mental health difficulties (MHD) are more likely to smoke and to have smoking-related diseases, yet little research has investigated the provision of smoking cessation care in psychiatric inpatient settings. This study aimed to evaluate current levels of cessation care provided, and 3-month quit-rates, in one such setting in Ireland. METHODS: From January to October 2016, inpatients across all 8 adult wards of St Patrick's University Hospital were recruited to participate in a baseline face-to-face survey (N = 246), assessing demographic information, smoking history and quit attempts, motivation to quit, nicotine dependence, attitudes towards cessation advice and actual care received. For baseline current smokers (n = 84) who consented, casenotes were also audited for documentation of smoking status and cessation care (n = 77/84) while quit rates were assessed at three months (n = 72/84), including a carbon monoxide test for those who reported quitting. RESULTS: Current smoking prevalence was 34% (n = 84/246). At baseline 75% of smokers wanted to quit and 48% reported they would like cessation advice while in hospital. Few reported receiving cessation advice from any healthcare professional in the past year (13%), while just 6% had smoking cessation care clearly documented in their casenotes. The 3-month quit-rate was 17%, with a 100% pass rate for those completing an objective CO validation test. CONCLUSION: Despite a high current smoking prevalence among psychiatric inpatients, and similar motivation and quit rates to other populations, current cessation care rates are low. Smoking cessation care needs to be prioritised in psychiatric settings.

Alteration of immune markers in a group of melancholic depressed patients and their response to electroconvulsive therapy.

BACKGROUND: Immune system dysfunction is implicated in the pathophysiology of major depression, and is hypothesized to normalize with successful treatment. We aimed to investigate immune dysfunction in melancholic depression and its response to ECT. METHODS: 55 melancholic depressed patients and 26 controls participated. 33 patients (60%) were referred for ECT. Blood samples were taken at baseline, one hour after the first ECT session, and 48h after ECT series completion. RESULTS: At baseline, melancholic depressed patients had significantly higher levels of the pro-inflammatory cytokine IL-6, and lower levels of the regulatory cytokine TGF-ß than controls. A significant surge in IL-6 levels was observed one hour after the first ECT session, but neither IL-6 nor TGF-ß levels normalized after completion of ECT series. Seventy per cent (n=23) of ECT recipients showed clinical response and 42% (n=10) reached remission. Neither IL-6 nor TGF-ß changes correlated with clinical improvement following ECT. No significant changes in IL-10, TNF-α and CRP levels were found in relation to melancholia or response to ECT. LIMITATIONS: As a naturalistic study, some potential confounders could not be eliminated or controlled, including medication use. CONCLUSIONS: Melancholic depressed patients demonstrated a peripheral increase in IL-6 and reduction in TGF-ß, which did not normalize despite clinical response to ECT. These findings may be consistent with emerging hypotheses of the role of inflammation in mediating neurotrophin expression. The implications of chronic inflammation in the melancholic depressed population for future medical health, particularly cardiovascular risk, are largely unknown and warrant further investigation.

ECT: An investigation of lay attitudes and experiences in an Irish sample.

OBJECTIVES: Electroconvulsive therapy (ECT) is one of the most controversial psychiatric treatments of the modern era. Few studies have used validated scales to examine attitudes and knowledge regarding ECT in lay people. We examined attitudes, knowledge and experience of ECT using standardised questionnaires in Irish lay people, and compared the present results with the findings from a similar study reported over 25 years previously. METHODS: A total of 103 lay people were recruited from a variety of settings and completed a questionnaire. Data were analysed using independent samples t-tests, χ2 tests and Pearson correlations. RESULTS: Attitudes to ECT among Irish lay people are negative and knowledge of the treatment is poor. A significant correlation (r = 0.32) was found between knowledge and attitudes, with higher levels of knowledge associated with more positive attitudes. People with relatives who experienced ECT had a significantly higher ECT knowledge than the people without such relatives (p < 0.05). CONCLUSION: Results confirmed previous findings and revealed novel statistically significant factors that contributed to attitudes towards ECT. Further replications are required to examine the findings' robustness and the relationship between attitudes, knowledge and experience. Such research can help increase the understanding of ECT and remove the stigmatisation associated with ECT. Mental health education programmes should consider the relation between knowledge and attitudes to better inform programme focus and content.

Electroconvulsive therapy: International guidelines, clinical governance and patient selection.

Recent reports from the Inspector of Mental Health Services have highlighted marked variations in electroconvulsive therapy (ECT) prescriptions nationally. This article reviews six international guidelines in order to assess the question of which patients should be referred for ECT treatment and at what stage in their illness. The guidelines display a general consensus in terms of the acutely and severely ill, but differ dramatically in terms of access to ECT outside this category, such as the moderately depressed patient who is treatment resistant but non-psychotic and non-suicidal and who requests ECT due to a previous good response. The American Psychiatric Association guidelines strongly support the early consideration and use of ECT, highlighting the dangers associated with increased length of illness for individual prognosis. The National Institute of Clinical Excellence (UK) guidelines are the strictest, reserving ECT for the severely ill exclusively and only in cases with a demonstrable failure of alternative treatments. This confusion may ultimately need to be addressed by the Mental Health Commission as data relating to variations in practice may result in inappropriate reductions in access to an established treatment.

D-fenfluramine-evoked serotonergic responses in olanzapine-treated schizophrenic patients.

Antagonist activity at the 5-HT(2) receptor may contribute to the therapeutic efficacy of atypical antipsychotics in schizophrenia. This neuroendocrine study examined the in vivo functional serotonergic (5-HT) activity of the atypical antipsychotic olanzapine. We examined central 5-HT(2) responses by measuring the serum prolactin (PRL) over 5 h in response to 30 mg of D-fenfluramine (DFEN) in two groups of male schizophrenic patients. Blunted PRL responses to DFEN indicate functional 5-HT(2) receptor antagonism. Seven patients treated with olanzapine at a mean (S.D.) dose of 13.1 (4.6) for a mean of 28 weeks were compared with a matched group of eight patients who had received no antipsychotic treatment for at least 2 weeks. Baseline PRL levels did not differ significantly in the two patient groups and were within the normal range. The olanzapine-treated patients showed a significantly lower maximal DFEN-evoked PRL response and a significantly lower group x time overall PRL release compared with the untreated patient group. We have previously demonstrated a similar degree of functional in vivo 5-HT(2) antagonism with the atypical antipsychotic clozapine. This study thus suggests that this activity may not contribute to the unique clinical efficacy of clozapine.