International Review of Psychiatry

Published by Informa Healthcare
Online ISSN: 1369-1627
Print ISSN: 0954-0261
Publications
Gender dysphoria in the DSM. 
Abstract The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.
 
Descriptive demographic information on study participants.
Clinicians ’ organization of disorders by dimensions 1 and 3. See Table 2 for abbreviations of disorders depicted. 
Clinicians ' organization of disorders by dimensions 2 and 3. See Table 2 for abbreviations of disorders depicted.
Abstract Enhancing clinical utility is an emphasis of the World Health Organization's development of the mental and behavioural disorders chapter of the next International Classification of Diseases (ICD-11). Understanding how clinicians conceptualize the structure of mental disorders can enable a more clinically intuitive classification architecture that will help professionals find the categories they need more efficiently. This study examined clinicians' conceptualizations of the relationships among mental disorders and the dimensions they use in making these judgements. Psychiatrists and psychologists from 64 countries (n = 1,371), participating in English or Spanish, rated the similarity of mental and behavioural disorders presented as paired comparisons. Data were analysed by multidimensional scaling procedures (INDSCAL) and by analyses of consistency. Participants used three distinctive dimensions to evaluate the similarity among disorders: internalizing versus externalizing, developmental versus adult onset, and functional versus organic. Clinicians' conceptual map of mental disorders was rational and highly stable across profession, language, and country income level. The proposed ICD-11 structure is a moderately better fit with clinicians' conceptual model than either ICD-10 or DSM-IV. Clinician judgements can be used to improve clinical utility of the ICD-11 without sacrificing validity based on a scientific approach to enhancing a logically organized classification meta-structure.
 
Abstract Psychiatry recruitment continues to be a problem in the UK and large-scale studies are required to understand the factors surrounding this. A quantitative, cross-sectional online survey, incorporating demographics, career choices, teaching exposure, attitudes to psychiatry and personality factors, was administered to final-year UK medical students. A total of 484 students from 18 medical schools responded (66% women). Sixteen (16%) had chosen psychiatry at medical school entry. By final year, 15 respondents (3%) had decided to pursue a career in psychiatry, while another 78 (17%) were seriously considering it. There was little difference in the quality ratings of lectures and small group teaching between those interested in psychiatry and those not. Experience of 'enrichment activities' (psychiatry special study modules or components, psychiatric research, university psychiatry clubs, and psychiatry electives) were significantly more likely to take up psychiatry. Causality cannot, however, be determined in this study. The study identified several distinct groups of UK students: those deciding on psychiatry before medical school and maintaining that career choice, those deciding on psychiatry during medical school, and those interested in other fields. Addressing psychiatry teaching and exposure may improve recruitment into the speciality.
 
Somatic symptoms have been conceptualized in many different ways in literature. Current classifications mainly focus on the numbers of symptoms, with relative neglect of the underlying psychopathology. Researchers have emphasized the importance of a number of experiential, perceptual and cognitive-behavioural aspects of somatization. This review focuses on existing literature on the role of somatosensory amplification, attribution styles, and illness behaviour in somatization. Evidence suggests that somatosensory amplification is neither sensitive nor specific to somatizing states, and that other factors like anxiety, depression, neuroticism, alexithymia may also have an influence. Attribution research supports the existence of multiple causal attributions, which are related to the numbers of somatic symptoms. While somatizing patients have more organic attributions, depressed patients have more psychological attributions. A global somatic attribution style is associated with the number of obscure somatic symptoms, while a psychological attribution style is associated with both--psychological and somatic-- symptoms of depression and anxiety. There are conflicting findings with respect to the role of normalizing attributions in reducing physician recognition of anxiety and depression. Specific symptom attributions appear to explain physician recognition of psychological distress, but global attribution styles do not appear to explain any further variance in physician recognition beyond that explained by specific causal attributions. Illness behaviour has been studied in two distinct ways in literature. Research focusing on attendance rates as a form of illness behaviour suggests that somatization is associated with high levels of health care utilization. There is also some evidence that health care utilization, amplification and attributions styles may be interrelated among somatizing patients. More structured ways to assess illness behaviour have found high levels of abnormal illness behaviour in this population. Overall, research appears to suggest a complex (and as yet unclear) relationship between somatic symptoms and underlying cognitions/illness behaviours. While it is clear that somatization is closely related to a number of perceptual and cognitive-behavioural factors, the precise nature of these relationships are yet to be elucidated.
 
Four broad phases can be traced in the development of modern psychiatry in India. After briefly considering the outline of each of these phases this article will focus its attention on the second and third. It will be argued through tracing the trends in patient admission, treatment regimes and the organisation of the asylum system in these years that the foundations of modern psychiatry were laid in India in the period 1858 to 1947 and that the modern psychiatric system in India as it is today, although it has evolved since Independence in 1947, continues in significant ways to be shaped by the colonial period.
 
This paper presents prevalence data from the 1994 OPCS survey of psychiatric morbidity among adults permanently resident in institutions catering for people with mental health problems in Great Britain. It describes briefly the survey methods used, and how diagnoses of psychiatric morbidity were derived. Its main aim is to show the prevalence of psychiatric morbidity in different types of institutional settings. Residents were eligible for the survey if they were aged 16 to 64 at the date of sampling and were permanently resident at the establishment. Residents were defined as permanently resident if they had been living in the sampled establishment for six months or more, or had no other permanent address, or were likely to stay in the establishment for the foreseeable future. In 1994, about 33,200 adults aged 16 to 64 were permanently resident in accommodation for people with mental health problems. About a third of residents were in NHS hospitals, while about two-thirds were in residential care facilities. About two-thirds of adults interviewed suffered from schizophrenia, delusional and schizoaffective disorders. About 8% suffered from neurotic disorders and 8% suffered from affective psychoses (mainly bipolar affective disorder). The prevalence of schizophrenia, delusional, and schizoaffective disorders was higher in hospitals than in residential care, while the prevalence of neurotic and related disorders was higher in residential accommodation. The prevalence of schizophrenia, delusional, and schizoaffective disorders was higher in NHS psychiatric hospitals and general hospital units than in private hospitals, clinics or nursing homes.
 
The findings described in this report and summarized here focus on the prevalence of mental disorders among 5-15 year olds and on the associations between the presence of a mental disorder and biographic, sociodemographic, socio-economic, and social functioning characteristics of the child and the family. Causal relationships should not be assumed for any of the results presented in this report.
 
Abstract Healthcare in Germany is characterized by a dichotomy of a private and a public healthcare sector, which also pertains to mental healthcare. While the prevalence figures of mental disorders in Germany remained fairly constant over the last 15 years, utilization rates of healthcare services due to mental disorders increased by 70-80% including inpatient and outpatient services, sick leave cases and cases of early retirement due to mental disorders. Several challenges are currently evident for mental healthcare in Germany, ranging from interesting a sufficient number of medical students for this field of medicine, dealing with the yet unforeseeable consequences of a novel mental hospital remuneration system, better integration of services and remuneration providers, to elucidating the causes of the increasing utilization rates. Mental healthcare research will take centre stage in addressing these challenges.
 
Major depression is one of the most prevalent mental disorders and the number one cause of disability worldwide. Once a person experiences a major depressive episode (MDE), the likelihood of recurrence is very high. The prevention of first onset, as well as the protection against recurrence after recovery, are therefore essential goals for the mental health field. By the end of the 20th century, however, most depression research efforts had focused on either acute or prophylactic treatment. In this article, we review USA and international studies that have attempted to reduce incidence of MDE, either 1) to prevent onset in populations of children and adults (including women during the postpartum period) not currently meeting diagnostic criteria for depression, or 2) to prevent a new episode in individuals who have recovered after treatment through protective, but not prophylactic interventions. We identified twelve randomized controlled trials focused on preventing the onset of major depression (both MDE and postpartum depression (PPD)), five randomized controlled trials focusing on preventing relapse, and no randomized controlled trials focused exclusively on preventing recurrent episodes through protective interventions. The review is limited in scope given that depression prevention trials focused on infants, young children, and older adults were not included in the review. The research to date suggests that the prevention of major depression is a feasible goal for the 21st century. If depression prevention interventions become a standard part of mental health services, unnecessary suffering due to depression will be greatly reduced. This review concludes with suggestions for the future direction of depression prevention research.
 
The World Health Organization estimates that approximately one in five young people under the age of 18 experiences some form of developmental, emotional or behavioural problem, and one in eight experiences a mental disorder. Because research shows that half of adult mental disorders begin before the age of 14 and that early intervention can prevent and reduce more serious consequences later in life, it is critical to expand the role of mental health professionals with schools worldwide. Schools have the potential to affect the mental health of millions of young people, as well as those who work in schools. Research indicates that programmes promoting mental health are among the most effective of health promoting school efforts. This paper discusses the health promoting schools framework, reviews effective strategies for promoting mental health in schools, and provides examples from Zhejiang Province, China. This article also discusses the key roles that mental health professionals can play in promoting mental health through schools. As advocates, policy makers, researchers and teachers, mental health professionals can bridge the sectors of education, mental health and public health. Developing common frameworks and interdisciplinary training will create a foundation of shared understanding to achieve this goal.
 
Major depression is twice as common in women as men and depressive episodes appear to be more common in women with bipolar disorder. There is accumulating evidence that, in at least some women, reproductive-related hormonal changes may play a role in increasing the risk of depressive symptoms premenstrually, postpartum and in the perimenopausal period. In this review, the evidence for the role of hormonal fluctuations, specifically estrogen, in triggering depressive symptoms in a subgroup of women is summarized. In addition, the potential role of estrogen in triggering depressive symptoms via its effects on the serotonergic system, brain-derived neurotrophic factor and Protein Kinase C is reviewed.
 
Neurospectroscopy allows biochemical processes in the brain to be studied non-invasively. At magnetic field strengths of 1.5 T or higher, cerebral proton neurospectroscopy allows the ascertainment of values of myo-inositol, choline-containing compounds, creatine, glutamate, glutamine, and N-acetyl aspartate. At similar field strengths, cerebral 31-phosphorus neurospectroscopy allows the ascertainment of values of phosphomonoesters, inorganic phosphate, phosphodiesters, phosphocreatine, and the gamma, alpha and beta nucleotide triphosphate (mainly adenosine triphosphate) resonances. Since choline is a common polar head group at the Sn3 position of membrane phospholipid molecules, a raised level of free choline, as indexed by proton neurospectroscopy, can indicate relatively low anabolism of membrane phospholipid molecules. Furthermore, the choline peak includes phosphorylcholine and glycerophosphorylcholine and even ethanolamine. The phosphomonoesters peak measured using 31-phosphorus spectroscopy includes major contributions from phosphocholine, phosphoethanolamine and L-phosphoserine, which are important precursors of membrane phospholipids, while the phosphodiesters peak includes contributions from glycerophosphocholine and glycerophosphoethanolamine, which are important products of membrane phospholipid catabolism. Hence proton neurospectroscopy and 31-phosphorus neurospectroscopy can yield important information relating to the metabolism of cerebral membrane phospholipids. The application of these techniques to the investigation of membrane phospholipid metabolism in schizophrenia, depression, chronic fatigue syndrome (myalgic encephalomyelitis or M.E.) and dyslexia is described.
 
Abstract Thirty-four years have elapsed since the passing of the Italian Law 180, the reform law that marked the transition from a hospital-based system of care to a model of community psychiatry that was designed to be an alternative to, rather than to complement, the old hospital-centred services. The main principle of Law 180 is that psychiatric patients have the right to be treated the same way as patients with other diseases and only voluntary treatments are allowed, with a few exceptions that are strictly regulated. The main features and consequences of the Italian reform are initially reviewed; national and local level experiences and epidemiological data are then analysed in order to highlight and disentangle the 'active ingredients' of the Italian experience. A public health attitude with the capacity to network good practice in service organization by giving voice to successful experiences and promoting health service research, apart from some local services, is still generally lacking. Furthermore, it is still difficult to provide an evidence-based reply to the question: can à l'Italienne community-care be exported elsewhere?
 
With DSM-V and ICD-11 on the horizon, now is an excellent time to consider options for improving their utility in clinical practice. A prerequisite for determining what can be done to improve their clinical utility is to establish a baseline from which to work. Surprisingly, there is virtually no information available that illuminates how clinicians actually use the DSM-IV and ICD-10 in clinical practice settings. Our first recommendation is for studies to be conducted that examine how the DSM-IV and ICD-10 is being used in the field and then to identify areas in need of improvement. We then propose two new diagnostic approaches to be considered that might significantly improve the system's clinical utility: (1) the addition of clinically useful dimensions (i.e., dimensions for indicating disorder severity, dimensions that cut across various disorders that would quantify symptoms of particular treatment-relevance such as psychosis, and dimensions to measure functioning) and (2) the augmentation of the DSM and ICD operationalized diagnostic criteria with the addition of a prototype-matching system that is likely to more closely conform to the way clinicians think about psychiatric diagnoses.
 
Somatization and abnormal illness behaviour (AIB) often co-exist, and their inter-relationship appears to be complex. Patients with somatization are often observed to demonstrate abnormal illness behaviour. On the other hand, somatization has been explained in terms of abnormal illness behaviour. The exact cause-effect or any other relationship is not fully understood. This review examines the available evidence to understand these two clinically important, common and interrelated phenomena, their measurements and management. Many studies have confirmed that occurrence of multiple somatic symptoms as the chief or presenting complaints are highly suggestive of abnormal illness behaviour. Recognition of AIB in somatoform disorders is important in order to avoid unnecessary tests, inappropriate treatment, and to prevent encouragement and reinforcement of abnormal behaviours.
 
White matter deficits have been demonstrated in people with bipolar disorder, schizophrenia and their unaffected relatives. These deficits are supported by evidence from post-mortem studies, including microarray investigations which have repeatedly implicated abnormal myelin-associated gene expression. Furthermore, several risk-associated genes have now been identified that encode for proteins which have effects on white matter integrity. These genes include neuregulin-1 (NRG1) polymorphisms of which have been associated with risk to bipolar disorder. NRG1 has been shown to have effects on axonal migration, myelination and oligodendrocyte function. We and others have also shown that 5' risk-associated genetic variants in NRG1 are associated with reductions in both white matter density and integrity in regions associated with prefrontal connectivity. These findings are discussed in the context of the current literature, along with possible future research directions.
 
Obesity and binge-eating disorder (BED) frequently arise in adolescence, which is a critical developmental time period where self-regulatory processes are formed. Indeed, both obesity and BED are thought to arise partly due to deficits in self-regulatory processes (i.e. lack of inhibitory control to overeat or binge). Recent neuroimaging studies have implicated the frontal cortex, a brain region involved in regulating inhibitory-control, and the striatum, which is thought to be involved in food reward, satiety and pleasure, in mediating responses to food cues and feeding in normal-weight individuals as well as obese and BED subjects. Intriguingly, frontostriatal circuits have been observed to be preferentially modulated in obese adults and similar associations have been observed in obese/overweight adolescents. Furthermore, brain dopamine (DA) is selectively altered in striatum in obese relative to normal-weight individuals, and frontostriatal regions constitute a major component of DA circuitry. The aim of this review will be to present the main findings from neuroimaging studies in obese and BED adults and adolescents, as these relate to frontostriatal circuitry, and to emphasize the potential for using functional neuroimaging in both humans and animals with the scope of obtaining information on developmental and molecular contributions to obesity and BED.
 
Endophenotypes, which represent intermediate phenotypes on the causal pathway from the genotype to the phenotype, can help unravel the molecular etiopathology of complex psychiatric disorders such as schizophrenia. Several candidate endophenotypic markers have been proposed in schizophrenia, including neurocognitive and neurophysiological impairments. Over the past three decades, there has been an impressive body of literature in support of brain structural alterations in schizophrenia, but few studies have critically examined whether these abnormalities can be considered useful endophenotypic markers. We critically reviewed the extant literature on the neuroanatomy of schizophrenia in this paper to evaluate their candidacy as endophenotypes. Structural brain changes are robustly associated with schizophrenia, are state independent and may cut across the diagnostic boundaries of major psychotic illnesses. Brain morphometric measures are heritable, co-segregate with the broadly defined neurocognitive and behavioural phenotypes within the first degree relatives of schizophrenia patients and are present in unaffected family members more frequently than in the general population. Taken together, brain morphometric alterations appear largely to meet the criteria for endophenotypes in psychotic disorders. Further work is needed to examine how specific genes and their interactions with the environment may produce alterations in brain structure and function that accompany psychotic disorders.
 
Reward pathways in rat brain. The schematic illustrates the primary brain regions implicated in appetitive behaviours and reinforcement. Green lines represent excitatory glutamatergic neurons, red lines represent inhibitory GABAergic neurons, orange lines represent orexin neurons, and black lines represent dopaminergic neurons. The insert shows an autoradiograph of 15 nM [ 3 H]CP-55,940 binding to a 30-nm sagittal section 
Since the discovery of the cannabinoid CB1 receptor (CB1R) in 1988, and subsequently of the CB2 receptor (CB2R) in 1993, there has been an exponential growth of research investigating the functions of the endocannabinoid system. The roles of CB1Rs have been of particular interest to psychiatry because of their selective presence within the CNS and because of their association with brain-reward circuits involving mesocorticolimbic dopamine systems. One potential role that has become of considerable focus is the ability of CB1Rs to modulate the effects of the drugs of abuse. Many drugs of abuse elevate dopamine levels, and the ability of CB1R antagonists or inverse agonists to modulate these elevations has suggested their potential application as pharmacotherapies for treating drug abuse disorders. With the identification of the selective CB1R antagonist, rimonabant, in 1994, and subsequently of other CB1R antagonists, there has been a rapid expansion of research investigating their ability to modulate the effects of the drugs of abuse. This review highlights some of the preclinical and clinical studies that have examined the effects of CB1R antagonists under conditions potentially predictive of their therapeutic efficacy as treatments for drug abuse disorders.
 
Proportion of subjects with neuropsychological impairment increases with increasing number of risk factors (HIV AE HCV AE Methamphetamine dependence). Data from Cherner et al., Neurology, 2005, reproduced by permission. 
Interaction between age group and viral burden showing that levels of CSF HIV RNA differ according to NP impairment in older subjects but not in younger subjects. Data from Cherner et al., AIDS, 2004, reproduced by permission. 
Neurocognitive disturbances associated with HIV infection may be modulated or confounded by coexisting and comorbid conditions that reflect the changing populations affected by the disease. HIV infection is often accompanied by substance dependence and/or hepatitis C co-infection. Both of these cofactors that may lead to brain dysfunction on their own, and therefore can affect the nature and course neurocognitive functioning in HIV. Improvements in antiretroviral therapies translate into greater longevity for people infected with HIV, many of whom are now entering their 6th and 7th decade of life and beyond. The increasing proportion of older persons with HIV is also the result of new infections in this age group. As aging confers additional metabolic, neurologic, and neuropsychiatric vulnerability, it is important to understand how this constellation of changes affects neurocognitive functioning in the context of HIV.
 
Cannabis use disorders have been recently identified as a relevant clinical issue: a subset of cannabis smokers seeks treatment for their cannabis use, yet few succeed in maintaining long-term abstinence. The rewarding and positive reinforcing effects of the primary psychoactive component of smoked cannabis, delta-9-tetrahydrocannabinol (THC) are mediated by the cannabinoid CB1 receptor. The CB1 receptor has also been shown to mediate cannabinoid dependence and expression of withdrawal upon cessation of drug administration, a phenomenon verified across species. This paper will review findings implicating the CB1 receptor in the behavioural effects of exogenous cannabinoids with a focus on cannabinoid dependence and reinforcement, factors that contribute to the maintenance of chronic cannabis smoking despite negative consequences. Opioidergic modulation of these effects is also discussed.
 
Alcohol problems are a global issue, and the nature of alcohol abuse is very complicated. The susceptibility to alcohol abuse varies greatly from one individual to another and also from one nation to another, depending on the availability of alcohol, a country's regulation related to alcohol, a country's cultural background, religious tradition and its economics. Alcohol dependence is also a complicated disease process. The prevalence of alcohol dependence also varies greatly from one ethnic group to another. Asia is the world's largest and most populous continent. The natural disasters, religious conflicts as well as political disputes cause people lack of opportunity in many countries. People in this region do not consume more alcohol than the people in the rest of the world. The prevalence of alcohol dependence is not as high as is seen in other regions. In Asia, not only socio-economic factors, but also biological factors influence drinking behaviour. Findings of functional genetic polymorphism of the major alcohol metabolizing enzymes, alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) have led to the suggestion that this enzyme system may possibly play a diverse but critical role in alcohol dependence and in the alcohol-related disease process in the different ethnic groups. This paper reviews alcohol problems and related factors. Their management and prevention strategy are discussed.
 
Childhood maltreatment of various types has been associated with onset of depression in adults. Previous epidemiological studies in Asian countries have confirmed a high level of childhood maltreatment, especially physical maltreatment. Yet, depression appears to be less prevalent in Asian countries than in western cultures. This study aimed to investigate the protective effect of a Chinese cultural factor, namely filial piety, against clinical depression. The study also aimed to examine the relation between filial piety, childhood maltreatment-specific inferences and adult inferential styles, so as to understand the mechanism of how filial piety protects against depression in Chinese population. Depressed outpatients (n = 80) and community controls (n = 80) were recruited from a psychiatric out-patient clinic and from community centres respectively. The two groups were compared on levels of filial piety, adult inferential styles and levels of childhood maltreatment. Depressed participants, compared to community controls, had higher levels of reported experiences of childhood maltreatment and lower levels of filial piety. Filial piety moderates adult negative inferential style and global belief of maltreatment through interacting with reported experiences of childhood maltreatment. Such moderation effect was found only in physical and emotional child maltreatment experiences, but not in sexual child maltreatment. Filial piety might be a protective factor against depression through its moderating effect on explanations and global belief of childhood maltreatment experiences.
 
Abstract For several years the demand regarding psychiatrists in Switzerland can only be satisfied by recruiting colleagues from other countries. Given the global increase of mental disorders, initiatives encouraging young academics to choose psychiatry as their speciality, and enhancing the attractiveness of our field, are urgently needed. Two projects for the promotion of young academics are presented in this paper, one working with medical students, the other with residents in psychiatry. The Zurich 'Study Focus on Psychiatry' provides medical students with knowledge and key competencies in psychiatry at an early stage of their undergraduate training. This way, students are offered an opportunity to have a thorough look into psychiatry as a clinical specialism and as a science. The three-year psychotherapy training curriculum in medical psychotherapy provides residents in psychiatry and psychotherapy with specific training in either cognitive behavioural, or psychodynamic, or systemic psychotherapy. Additionally, and independent of the psychotherapeutic orientation they have chosen, all trainees attend joint sessions focusing on generic elements of psychotherapy and facilitating a hands-on transfer of psychotherapeutic principles into their clinical routine. These two projects aim at enhancing the attractiveness of psychiatry and psychotherapy as a speciality, and thus contributing to the promotion of young academics.
 
Hierarchy of functional disorders used to establish single primary diagnosis 
In this paper we use data from the National Survey of Psychiatric Morbidity to examine how many people with neurotic disorders receive professional evaluation, and how this is affected by clinical and sociodemographic differences. We hypothesized that psychiatric symptoms and attendant dysfunctions would both have an effect on contacting, and that key demographic variables would not. The household component of the British National Surveys of Psychiatric Morbidity was based on a random sample of >10,000 subjects. Lay interviewers using the CIS-R established psychiatric symptoms and ICD-10 diagnosis. Social dysfunction was tapped by asking about difficulties in performing seven types of everyday activity. We examined symptom score, ADL deficit score, and demographic variables in relation to contact with primary care physicians for psychiatric symptoms. The major determinant of contacting a primary care physician was severity, mainly due to the level of psychiatric symptoms, but with an independent contribution from social dysfunction. There were also significant contributions from sex, marital status, age, employment status, and whether the subject had a physical condition as well. The major influence on whether people seek the help of their family doctors for mental health problems is the severity of disorder. Although there are some social inequalities in access to family doctors, these are less important. The most salient finding from our study is that even people suffering from high levels of psychiatric symptoms very often do not have contact with professionals who might help them.
 
Actions performed in a state of automatism are not subject to moral evaluation, while automatic actions often are. Is the asymmetry between automatistic and automatic actions justified? In order to answer this question we need a model of moral accountability that does justice to our intuitions about a range of modes of agency, both pathological and non-pathological. Our aim in this paper is to lay the groundwork for the development of such a model.In all of us, even in good men, there is a lawlesswild-beast nature, which peers out in sleep.Plato, The Republic
 
During the last two decades, the number of international migrants worldwide has constantly risen. In this context, cross-cultural dimensions of psychological disorders receive increased attention, especially depression, anxiety and post-traumatic stress disorders among the migrant population. In this paper we propose a theoretical framework for the understanding of migrant mental health. This framework combines elements from Berry's acculturation model and Antonovsky's salutogenic theory. The former illustrates the main factors that affect an individual's adaptation in a new cultural context. The term acculturative stress denotes unresolved problems resulting from intercultural contact that cannot be overcome easily by simply adjusting or assimilating. The latter specifies the relationship between culturally associated stress and mental health more distinctive, introducing the concepts of generalized resistance resources and sense of coherence that determine mental health outcomes of migrants during acculturative stress periods. Specifically, we provide an integrative framework of acculturation and salutogenesis that helps to integrate inconsistent findings in the migrant mental health literature. The current paper focuses on the effect of resource factors for positive mental health outcomes in the migrant population and summarises some implications for future research activities.
 
This study explores acculturative stress as a risk factor for depressive and anxiety disorders as well as their symptomatology. It is hypothesized that perceived discrimination and general psychosocial stress will show the greatest association with psychopathology. The sample consists of 414 Latin American immigrant primary care patients in Barcelona. The instruments used are: the Barcelona Immigration Stress Scale (BISS) to evaluate acculturative stress, the Goldberg Anxiety and Depression Scale (GADS) for anxiety and depression symptoms, the Mini International Neurological Interview (MINI), a semi-structured interview, to detect psychiatric pathology, and a questionnaire for sociodemographic and attitudinal characteristics. The most elevated levels of acculturative stress were observed in the factors homesickness and general psychosocial stress. Acculturative stress is associated with depression and anxiety. With the covariants controlled, intercultural contact stress and general psychosocial stress maintain the relationship. Acculturative stress constitutes a risk factor for both depression and anxiety. General psychosocial stress and intercultural contact stress are related to psychopathology. Perceived discrimination and homesickness are not associated with psychopathology in the Spanish context, suggesting that cultural congruity plays a key role in the relationship between immigration and mental health.
 
Before the tsunami, there was no systematic training provided for General Practitioners (GPs) and nurses in issues related to mental health and psychosocial support in times of disasters. After the tsunami, the Department of Psychiatry, Faculty of Medicine, University of Indonesia in Jakarta was contracted to organize a special two-week intensive training programme on basic psychiatry for 13 GPs from Banda Aceh Mental Hospital. To improve the nursing practice, a Professional Nursing Practice Model (MPKP) has been piloted in two wards in Banda Aceh Mental Hospital. This is a model of best practice for nursing care and management in an open ward system developed by the School of Nursing group and implemented in several mental hospitals in Indonesia. Basic training of GPs located at the primary healthcare level is being carried out based on the existing Ministry of Health curriculum for GPs. It covers 14 conditions listed in the International Classification of Diseases (ICD) Primary Care classification and has been conducted in 11 tsunami-affected districts. Currently, a total of 169 GPs have been trained. In general, there is an increasing interest among primary care doctors in mental health. Currently, community mental healthcare is provided in 11 districts in Aceh and two districts in North Sumatra by 277 Community Mental Health Nurses (CMHN) who have received basic training. Two thousand six hundred and two cases of serious mental disorders (mostly chronic psychosis) have been detected and treated by the CMHN and the doctors in Primary Health Centres (PHC). CMHN can provide a vital link between patients in the community and doctors in PHC. Two years after the earthquake and tsunami in Aceh, psychosocial intervention should continue and mental healthcare should be made available not only at Banda Aceh Mental Hospital, but also general health services, including PHC services.
 
Within two months of the Asian tsunami, a team of four individuals conducted an assessment on the post-disaster needs of young people in Aceh Province. In addition to assessing current needs, the team examined the extent to which young people (aged 14-24) were involved in the planning and implementation of ongoing rebuilding and relief efforts. Finally, the team assessed the degree to which young people could be involved in such efforts as the recovery process moves forward. The team: reviewed all existing documents developed and/or compiled by the UN Office for Coordination of Humanitarian Assistance (UNOCHA) from the inception of the disaster relief response to the present; met with approximately 20 organizations including UN agencies as well as international and local programs presently working in Banda Aceh and Maulaboh; and conducted direct discussions with young people in a variety of settings.
 
Schizophrenia is associated with a broad range of neurodevelopmental, structural and behavioral abnormalities that often progress with or without treatment. Evidence indicates that such neurodevelopmental abnormalities may result from defective genes and/or non-genetic factors such as pre-natal and neonatal infections, birth complications, famines, maternal malnutrition, drug and alcohol abuse, season of birth, sex, birth order and life style. Experimentally, these factors have been found to cause the cellular metabolic stress that often results in oxidative stress, such as increased cellular levels of reactive oxygen species (ROS) over the antioxidant capacity. This can trigger the oxidative cell damage (i.e., DNA breaks, protein inactivation, altered gene expression, loss of membrane lipid-bound essential polyunsaturated fatty acids [EPUFAs] and often apoptosis) contributing to abnormal neural growth and differentiation. The brain is preferentially susceptible to oxidative damage since it is under very high oxygen tension and highly enriched in ROS susceptible proteins, lipids and poor DNA repair. Evidence is increasing for increased oxidative stress and cell damage in schizophrenia. Furthermore, treatments with some anti-psychotics together with the lifestyle and dietary patterns, that are pro-oxidant, can exacerbate the oxidative cell damage and trigger progression of neuropathology. Therefore, adjunctive use of dietary antioxidants and EPUFAs, which are known to regulate the growth factors and neuroplasticity, can effectively improve the clinical outcome. The dietary supplementation of either antioxidants or EPUFAs, particularly omega-3 has already been found to improve some psychopathologies. However, a combination of antioxidants and omega-3 EPUFAs, particularly in the early stages of illness, when brain has high degree of neuroplasticity, potentially may be even more effective for long-term improved clinical outcome of schizophrenia.
 
Tardive dyskinesia (TD) is a movement disorder described in individuals who have been treated with anti-dopaminergic agents. The pathophysiology of this condition remains to be fully elucidated. Several mechanisms like dopaminergic supersensitivity, dysfunction of striatonigral, GABAergic neurons and disturbed balance between dopaminergic and cholinergic systems have been described. Essential fatty acids (EFAs) are important components of neuronal membrane and the EFA content of these membranes can significantly influence neuronal functioning. Lower levels of EFAs have been reported in red blood cells (RBC) and plasma of individuals with moderate to severe TD. Supplementation with EFAs (omega-3 and omega-6 and ethyl-EPA) have been tried to alleviate TD in open and double-blind clinical trials and in some animal models of TD. In addition, antioxidants (Vitamin E) and melatonin have been tried. However, smaller numbers of patients and shortened length of clinical studies make it difficult to draw any definitive conclusions. Large multi-centre studies with sound methodology of both EFAs and antioxidants are needed.
 
Omega-3 fatty acids are dietary essentials, and are critical to brain development and function. Increasing evidence suggests that a relative lack of omega-3 may contribute to many psychiatric and neurodevelopmental disorders. This review focuses on the possible role of omega-3 in attention-deficit/hyperactivity disorder (ADHD) and related childhood developmental disorders, evaluating the existing evidence from both research and clinical perspectives. Theory and experimental evidence support a role for omega-3 in ADHD, dyslexia, developmental coordination disorder (DCD) and autism. Results from controlled treatment trials are mixed, but the few studies in this area have involved different populations and treatment formulations. Dietary supplementation with fish oils (providing EPA and DHA) appears to alleviate ADHD-related symptoms in at least some children, and one study of DCD children also found benefits for academic achievement. Larger trials are now needed to confirm these findings, and to establish the specificity and durability of any treatment effects as well as optimal formulations and dosages. Omega-3 is not supported by current evidence as a primary treatment for ADHD or related conditions, but further research in this area is clearly warranted. Given their relative safety and general health benefits, omega-3 fatty acids offer a promising complementary approach to standard treatments.
 
The treatment of psychiatric illness requires novel pharmacological strategies. There is a growing body of evidence examining the role of neuronal phospholipid abnormalities in the pathogenesis of psychiatric illness, particularly in schizophrenia. However, work in other conditions like mood disorders are also showing interesting outcomes with EPA supplementation. Diseases that are considered to have a genetic basis may be significantly influenced by environmental factors including dietary supplementation. The suggestion that EFA supplementation may prevent the onset of symptoms of a psychiatric disease or aberrant behaviour needs longitudinal randomized controlled research. In recent years the focus has shifted from omega-6 to omega-3. It is true that western diets have far more omega-6 than omega-3. In the 1980s, there were positive outcomes in research studies using GLA in schizophrenia (Vaddadi et al., 1989). Future research needs to incorporate studies using pure GLA. Research should not be restricted to parent fatty acid (omega-3) supplementation alone but be expanded to include bioactive down-the-chain metabolites. The recent identification of novel omega-3 derived mediators such as resolvins and neuroprotectins, which are a highly bioactive (1-10 nMol range), may well have some role to play in psychiatric disorders; however this remains highly speculative at this stage.
 
Top-cited authors
Kathryn M Abel
  • The University of Manchester
Richard James Drake
  • The University of Manchester
David M Clark
  • University of Oxford
Hyunjung Lim
  • Kyung Hee University
Theresa S Betancourt
  • Boston College