irish journal of psychological medicine
DESCRIPTION
Official journal of the Irish College of PsychiatryTRANSCRIPT
Irish Journal of
VOL 29 No 1 April/May 2012
COVER ILLUSTRATION BY JERRY HUYSMANS
Psychological Medicine
ISSN 0790- 9667
Irish Journal of Psychological MedicineVol. 29 No 1 April/ May 2012 ISSN 0790- 9667
Editorial3 The Irish Journal of Psychological Medicine and the College of Psychiatry of Ireland
Brendan D. Kelly
Original Papers7 Did the Great Irish Famine increase Schizophrenia?
Dermot Walsh
16 Study of Presentations for Involuntary Admission to a Cork Approved CentreElaine Dunne, Eamonn Moloney
22 Mental Illness among the Homeless: Prevalence Study in a Dublin Homeless HostelBernice Prinsloo, Catherine Parr & Joanne Fenton
27 Preferences of Dress and Address: Views of Attendees and Mental HealthProfessionals of the Psychiatric ServicesChristina Sim, Brian Hallahan & Colm McDonald
33 Psychiatrists in their eyes: Children’s Drawings of what a Psychiatrist looks like...Sami Omer, Niamh O’ Connor, Gavin Sweeney, Geraldine McCarthy
Brief Reports36 Selective Mutism: A Prevalence Study of Primary School Children in the Republic
of IrelandLouise Sharkey & Fiona McNicholas
41 Psychotherapy Training in Ireland: A Survey of College TutorsAlyson Lee & Angela Noonan
46 Suicide ideation, Psychological Adjustment and Mental Health Service Support: AScreening Study in an Irish Secondary School SampleCiara Brennan & Sinéad McGilloway
Case Report52 Graphology and Psychiatric Diagnosis: Is the Writing on the Wall?
Mary Davoren, Natalie Sherrard, Eugene Breen & Brendan D. Kelly
Opinion55 Psychiatric Power: A Personal View
Pat Bracken
Book Reviews59 Coming through Depression: A Mindful Approach to Recovery by Tony Bates
Stephen McWilliams
60 Leadership With Consciousness by Tony HumphreysBrendan D. Kelly
62 Homesickness: An American History by Susan J MattSéamus MacSuibhne
Appreciation63 Professor Hugh Lionel Freeman
Brian O’Shea
Letters to the Editor64 Interaction of Duloxetine with Warfarin; a Cautionary Report
Mugtaba Osman, Elaine Greene
65 Guidelines for Authors
2
Editor–in-Chief: Brendan Kelly, SeniorLecturer in Psychiatry, Department of AdultPsychiatry, UCD Mater MisericordiaeUniversity Hospital, Dublin 7
Deputy Editor: Niall Crumlish, ConsultantPsychiatrist, St James’s Hospital, Dublin 8
Consulting Editor: Larkin Feeney,Consultant Psychiatrist, Cluain MhuireServices, Blackrock, Co. Dublin
Founding Editor: Mark Hartman
Associate Editor: Ted Dinan (Cork)
Administrator: Sibéal Farrell
Editorial Board: Brian A Lawlor (Dublin),Patricia Casey (Dublin), Stephen Cooper(Belfast), Michael Fitzgerald (Dublin), BrianLeonard (Galway), Roy McClelland(Belfast), Brian O’Shea (Wicklow), IanPullen (Edinburgh), John Waddington(Dublin), Richard Williams (Victoria)
Submissions and Correspondence to:The EditorCollege of Psychiatry of Ireland5 Herbert StreetDublin 2, Ireland
Telephone: 00 353 1 6618450Fax: 00 353 1 6629677Email: [email protected]: www.ijpm.ie
Publisher: Irish Medical InformationFir Tree LodgeCraddockstown RoadNaasCo. Kildare
This paper meets the requirements ofANSI/NISOZ39.48-1992 (Permanence of Paper)
In 2012, the Irish Journal of Psychological Medicine became theofficial research journal of the College of Psychiatry of Ireland. The
coming together of the Journal and the College marks animportant moment in the histories of both, and a significant stage
in the evolution of Irish psychiatry.
Founding editor of the Irish Journal of PsychologicalMedicine: Dr Mark Hartman
The Irish Journal of Psychological Medicinewas founded in 1982 byDr Mark Hartman (1942-1994). Mark Hartman was born in
Chicago in 1942, the son of an eminent forensic psychologist.
After high school, Mark completed a BSc in mathematics and
physics, and came to Ireland in the early 1960s.1 Mark studied
medicine in Trinity College Dublin, where he qualified in 1969,
following a brilliant undergraduate career which saw him elected
a scholar of the university. Mark studied psychiatry under Professor
Peter Beckett (1922-1974), first professor of psychiatry at Trinity,2
who described Mark as “the best student in his class”.3 Dr
Hartman received his American MD in 1969.
Dr Hartman served his internship in Sir Patrick Duns Hospital and
then worked in St. Patrick’s Hospital, St. Ita’s, St. Brendan’s and St.
Vincent’s, Fairview. He was elected a Member of the Royal College
of Psychiatrists in 1973 and worked in St. Mary’s, Castlebar until
permanently appointed at St. Brendan’s in 1978. In 1983, Dr
Hartman took a three-year career break to the United States, where
he was associate professor of psychiatry in Boston University and
medical director of Lakeshore Hospital, Manchester, New
Hampshire.1
Also in 1983, Dr Hartman attained his American Board
Examinations in Psychiatry and Neurology in Boston, and was
ranked in the top 2% of all candidates who had previously sat the
examination. Following his career break in the United States, Dr
Hartman returned to Dublin and worked at Vergemount Psychiatric
Clinic. He died in 1994, following a year-long illness. Dr Hartman
was posthumously elected to Fellowship of the Royal College of
Psychiatrists.
Throughout his career, Dr Hartman demonstrated an enormous
depth of knowledge and passion for psychiatry. He had a particular
interest in psychoanalytical psychotherapy, a field which informed
his approach to both psychiatric education and clinical care.1,4 Dr
Hartman was deeply involved in psychiatric training: he was
appointed clinical tutor in St. Brendan’s in 1973, taught at the Royal
College of Surgeons in Ireland, and was specialty tutor for the
Eastern Region Postgraduate Training Programme from 1979 to
1994.3
In addition to his interests in psychiatry and psychotherapy, Dr
Hartman had interests in myriad other fields. He had a particular
love of Middle English and held a Masters Degree in English from
Trinity College, Dublin. He was an gifted musician and
accomplished pianist, and owned one of the first mobile phones in
Ireland.2
In the midst of all of these activities and accomplishments, Dr
Hartman founded the Irish Journal of Psychological Medicine, in1982.1 At first, it was an uphill battle to attract submissions, re-
write certain papers, edit the Journal and organise publication. Dr
Hartman performed all of these tasks with insight and enthusiasm,
at all hours of day and night. He brought enormous vision and
drive to the undertaking, travelling to Northern Ireland and England
to seek out submissions, and inviting international speakers to
Ireland in order to obtain more papers.
In order to produce the Journal itself, Dr Hartman designed original
computer software and programmes, and was determined from
the outset that the Journal would embrace new technologies such
as the Internet, even though the Internet was in its early infancy in
Ireland when the Journal was founded in 1982. Following its
foundation, Dr Hartman oversaw the establishment of a circulation
base for the Journal, a remarkable growth in circulation (in terms
of both numbers and geography), broad-based scientific indexing,
and the stocking of the Journal in libraries around the world. This
series of accomplishments built the Journal into a remarkably
strong scientific and clinical voice, with impact and reach well
beyond these shores.
Dr Hartman’s dedication to the Journal was as profound as it was
pragmatic and, thanks to his unstinting work, Dr Hartman saw the
Journal’s “reputation grow steadily as a quarterly specialist
publication, essential to its Irish base and attracting international
readers and authors”.2 From the outset, the Irish Journal of
Psychological Medicine was a truly extraordinary creation, created
by a truly extraordinary man.
3
Brendan D. Kelly,Consultant Psychiatrist and Senior Lecturer in Psychiatry,
Department of Adult Psychiatry,University College Dublin,Mater Misericordiae University Hospital,62/63 Eccles Street, Dublin 7, Ireland.
E-mail [email protected]
Ir J Psych Med 2012; 29 (1): 3-6
Editorial
The Irish Journal of Psychological Medicine and theCollege of Psychiatry of IrelandBrendan D Kelly
The Irish Journal of Psychological Medicine: 1994-2012
In 1994, following the untimely death of Dr Hartman, Professor Brian
Lawlor became editor-in-chief of the Irish Journal of PsychologicalMedicine. On appointment, Professor Lawlor explicitly renewed theJournal’s commitment to its central objectives: disseminating theresults of original scientific research to a national and international
readership; expressing the unique identity of Irish psychiatry; and
underscoring the importance of cross-cultural differences in psychiatry
within and beyond these islands.5
Over the following years, the Journal continued to publish national andinternational research papers, as well as editorials, review papers, case-
reports and book reviews. Format was substantially revised in
conjunction with the Journal’s long-time publisher, MedMedia. Aspsychiatry in Ireland evolved over this period,6 the Journal appointed atrainee editor in 2004,7 a deputy editor in 2008, a new editor-in-chief
in 2010, and a consulting editor in 2011.
In 2009, the Journal published the first in a series of ContinuingProfessional Development (CPD) modules, to assist with learning and
self-assessment for psychiatrists.8 A broad range of topics has been
covered since then, including management of schizophrenia,9 alcohol
use disorders,10 adherence,11 morbid jealousy,12 post-traumatic stress
disorder,13 fetal alcohol spectrum disorders,14 tobacco smoking and
mental illness,15 serotonin toxicity,16 improving monitoring for
metabolic syndrome using audit 17 and antidepressant augmentation
and combination in unipolar depression.18
For over two decades, the Irish Journal of Psychological Medicine hasawarded the John Dunne Medal, established in honour of Professor
John Dunne, president of the Royal Medico-Psychological Association in
1955 and first professor of psychiatry in Ireland.19,20 Dr Mark Hartman,
founding editor of the Journal, was a strong admirer of Professor
Dunne. Consistent with the emphasis that Professor Dunne placed on
scientific research into mental illness,21 the John Dunne Medal is
awarded annually to a trainee from Ireland or the United Kingdom. To
be eligible, a trainee much have made a significant contribution (though
not necessarily as first author) to an original paper published by the
Journal over the previous year. Over the past two decades the JohnDunne Medal has come to symbolise excellence and originality in the
field of psychiatric research.22
The College of Psychiatry of Ireland
The College of Psychiatry of Ireland is the professional body for
psychiatrists in Ireland and the sole body recognised by the Medical
Council and Health Service Executive (public health care provider in
Ireland) for competence assurance and training in psychiatry. The
College offers membership, for psychiatrists and trainees, of an Irish
institution which aims to be the voice of psychiatry in Ireland
(www.irishpsychiatry.ie).
The College emerged as an organisation in 2009 when three former
bodies merged: the Irish College of Psychiatrists (a division of the
Royal College of Psychiatrists in the United Kingdom), the Irish
Psychiatric Association, and the then training body for psychiatry, the
Irish Psychiatric Training Committee. It had been apparent for many
years that both the law and mental health services in the United
Kingdom served different needs to those in Ireland and therefore an
Irish organisation was seen by many as being long overdue.
The College of Psychiatry of Ireland aims to address not only issues
relevant to its Irish members but also issues for psychiatry in general,
for mental health services, and ultimately for services-users. It aims to
promote good mental health and high quality mental health care for all
involved in mental health services. The College fully supports Ireland’s
national mental health policy, “A Vision for Change”23 and has
consistently urged that this policy be implemented in full, in order to
give Ireland the mental health service it deserves.
In conjunction with its representative, training and advocacy roles, the
College has a growing role in promoting and encouraging research, with
a view to generating an improved evidence-base for psychiatric practice.
In this respect, the College is assuming at least some of the roles
envisioned in long-standing calls for a research-oriented Irish Institute of
Psychiatry, which has not yet materialized in Ireland.24,25
Following the emergence of the College in 2009, it was readily
apparent that the College would need a journal in order to strengthen
the College’s participation in the international research community
and assist the College in shaping and improving standards of mental
health care. Given its unique role in expressing the “identity of Irish
psychiatry”,5 long history of high-quality publishing, and growing
international profile, the Irish Journal of Psychological Medicine wasthe obvious candidate for this role.
In 2012, the Irish Journal of Psychological Medicine duly became theofficial research journal of the College of Psychiatry of Ireland.
Times of change in Irish psychiatry and medicalpublishing
These are challenging and exciting times for mental health care in
Ireland, and beyond. In Ireland, the practice and profession of
psychiatry are being gradually but definitely transformed with the
implementation of the Mental Health Act 2001 (2001-2006),
introduction of “A Vision for Change” (2006),23 establishment of the
College of Psychiatry of Ireland (2009), development of new systems
for competence assurance by the Medical Council and College of
Psychiatry of Ireland (2011), and review of the Mental Health Act
2001 (2012).
Looking more broadly, the ongoing expansion of the scientific evidence-
base for psychiatric practice is also transforming mental health care;
service user movements are helping shape better systems of care; and
public services in general are seeking to become more efficient,
responsive and user-focussed. Against the backdrop of the economic
and social challenges facing Ireland and Europe at present,26 these
developments present unique challenges and opportunities to mental
health service users and providers alike.
In this medical, scientific and social context, medical journals play a
vital role in the generation and dissemination of knowledge, and in
shaping change.27 Medical journals have particular importance in
informing evidence-based practice, developing health policy, and
underpinning training programmes and continuing education for
practitioners. Medical journals can also open up new areas of
research, prompt critical and constructive debate, and generate
interest in hitherto neglected areas of thought and practice. The IrishJournal of Psychological Medicine has a long history of filling many ofthese roles.
4
These are, however, also times of transformation for medical
journals themselves. Key changes relate to the evolution of
electronic communication technologies, issues related to
independent scientific peer review, and substantial changes in the
broader publishing industry.28,29 Further issues relate to the complex
roles of journals in the developing world30 and in the protection of
human rights.31 Issues of human rights are especially important in
the context of mental health policy32 and mental health law,33-35
especially following recent changes in legislation, as is the case in
Ireland.36-39
Notwithstanding these challenges – or, more likely, because of
them – medical journals are set to retain a critical role in shaping
medical knowledge, informing evidence-based practice, developing
health policy and underpinning training in health-care disciplines.27
While the format and structure of journals may change
dramatically, the necessity for them will not.
The Journal and the College: Looking to the future
As research journal of the College of Psychiatry of Ireland, the IrishJournal of Psychological Medicine will continue to publish highquality original research from around the world. These original data
papers will continue to form the central focus of the Journal,supplemented by briefer reports of smaller research projects, audit
cycles, and various other kinds of papers which reflect different
approaches to research, practice and education in mental health care.
The Journal has a long-standing commitment to publishing case-reports, which we believe serve several important purposes,
including the description of new conditions or novel effects of
treatments; suggesting new indications for existing treatments; 40
quality assurance; and education.41 In addition, case-reports are
often especially engaging for readers, many of whom find clinical
vignettes involving, informative and pragmatic.42 Like the Lancet,the Irish Journal of Psychological Medicine still sees an importantrole for relevant, well-written case-reports.43
The Irish Journal of Psychological Medicine also remains committedto publishing papers presented in a range of different formats,
including editorials, review papers, educational papers, letters to
the editor, and book reviews. The Journal is similarly committed topublishing historical papers examining key topics in the histories
of psychiatry in Ireland and elsewhere.44-46 In this issue, we are
especially pleased to publish an historical paper looking at
admission rates for schizophrenia and other disorders during
Ireland’s Great Famine (1845-1849),47 an event which was curiously
absent from the historiography of Irish psychiatry to date.19,48
The Irish Journal of Psychological Medicine has a strong tradition ofhighlighting and debating key issues in contemporary psychiatry,
and this, too, will continue. In recent years, we have published
occasional multi-author papers examining key issues,49,50 and our
regular editorials have explored diverse topics including
deinstitutionalisation in disability services,51 dementia care,52mental
health and the asylum process,53 psychiatric training and research,54
reflective practice in psychiatric training,55 primary care mental
health 56 and perinatal psychiatry.57
In March 2011, we published a special supplement dedicated to
head shop drugs,58,59 looking in detail at the clinical effects of
mephedrone and other head shop drugs,60,61 users’ experiences of
cathinones,62 “whack” induced psychosis,63 and benzlypiperazine-
induced acute delirium.64 In future years, we will continue to
highlight key issues in psychiatry, policy, training and research
throughout the Journal.
In addition to these thematic and editorial priorities, we will
continue to seek to expand the Journal’s indexing profile. From
the outset, the Journal’s founding editor, Dr Mark Hartman,ensured broad-based indexing for the Journal. At present, the
Journal is indexed in Biological Abstracts (BIOSIS Previews); CentreNational de la Recherche Scientifique/Inist; Pascal; Excerpta
Medica/Embase; Institute for Scientific Information; Current
Contents/Social and Behavioural Sciences (Social Science Citation
Index, Research Alert); Psychological Abstracts (PsycInfo/PsycLit);
Cumulative Index to Nursing and Allied Health Literature; Current
Aids Literature (CAB Abstracts); International Pharmaceutical
Abstracts; Linguistics and Language Behaviour Abstracts; Nutrition
Abstracts and Reviews (CAB Abstracts); Referativnyi Zhurnal; Social
Planning/Policy and Development Abstracts; Social Work Research
and Abstracts; and Sociological Abstracts.
In coming years, we will seek actively to expand our indexing
profile so as to better reflect the quality and diversity of original
research published in the Journal and optimise Journal impact.
The voice of psychiatry in Ireland
From the very beginning, the founding editor of the Irish Journal ofPsychological Medicine, Dr Mark Hartman, saw the Journal becomingthe voice of a national college of psychiatry in Ireland. Over
subsequent decades, the Journal duly assumed a key role “inexpressing the unique identity of Irish psychiatry”, and the “complex
tapestry of different historical traditions and experiences that mesh
together to create a system that is unique and different from any of
its derivative parts”.5 The coming together of the Journal with theCollege of Psychiatry of Ireland in 2012 represents the realisation of
Dr Hartman’s vision, and a logical and important step in the evolution
of psychiatry in Ireland.
As research journal of the College of Psychiatry of Ireland, the IrishJournal of Psychological Medicinewill continue to fulfil its establishedroles in advancing the evidence-base for practice and “expressing the
unique identity of Irish psychiatry”,5 but will also seek to expand and
develop in new directions. As part of that process, readers who wish
to make suggestions about how the Journal can develop in the futureshould feel free to submit their ideas to the editorial team
([email protected]). All suggestions are welcome.
Like the College of Psychiatry of Ireland, the Journal’s key aims areto inform and improve mental health services in Ireland and
beyond, and, ultimately, enhance the quality of mental health care
provided to those who need it.
In the end, that’s what matters most.
Conflict of interest
The author is editor-in-chief of the Irish Journal of PsychologicalMedicine.
5
References
1. McGennis A. Obituary: Mark Hartman. Psych Bull 1994; 18: 442.
2. Webb M. Trinity’s Psychiatrists: From Serenity of the Soul to Neuroscience.
Trinity College, Dublin, 2011.
3. McClelland R. An appreciation of Dr Mark Hartman, founder and editor-in-
chief of the Irish Journal of Psychological Medicine. Ir J Psychol Med 1994; 11: 4.
4. Redmond L. Suicide: act of destruction or cry of despair? Irish Times 1979;
January 29.
5. Lawlor BA. Quo vadis? Ir J Psychol Med 1994; 11: 107.
6. Kelly BD. Mental health policy in Ireland, 1984-2004: theory, overview and
future directions. Ir J Psychol Med 2004; 21: 61-68.
7. Kelly BD. Investing in the future. Ir J Psychol Med 2004; 21: 111
8. McDonald G, Hallahan B. Recent advances in the biological treatment of
mood disorders (Continuing Professional Development, Module 1). Ir J Psychol
Med 2009; 26: 93-101.
9. Behan C. Current approaches to the management of schizophrenia
(Continuing Professional Development, Module 2). Ir J Psychol Med 2009;
26: 157-163.
10. Feeney L. Management of alcohol use disorders (Continuing Professional
Development, Module 3). Ir J Psychol Med 2009; 26: 214-220.
11. Duffy R, Kelly BD. Adherence in psychiatry (Continuing Professional
Development, Module 4). Ir J Psychol Med 2010; 27: 54-60.
12. Mullins D. Morbid jealousy: the green-eyed monster
(Continuing Professional Development, Module 5). Ir J Psychol Med 2010;
27: 106-112.
13. Crumlish N. Post-traumatic stress disorder: present and future
(Continuing Professional Development, Module 6). Ir J Psychol Med
2010; 27: 162-167.
14. Orakwue N, McNicholas F, O’Malley K. Fetal alcohol spectrum disorders – an
Irish perspective (Continuing Professional Development, Module 7). Ir J
Psychol Med 2010; 27: 223-227.
15. Feeney S, Hallahan B. Tobacco smoking and mental illness: important
considerations (Continuing Professional Development, Module 8). Ir J Psychol
Med 2011; 28: 50-54.
16. Nassim S, Jabbar F, Afridi A, Kelly BD. Serotonin toxicity (Continuing
Professional Development, Module 9). Ir J Psychol Med 2011; 28: 106-109.
17. Murtagh A, Petrovici R, Wong W, Obadan C, Solanke O, Nnabuchi E, Kilbride
K. Improving monitoring for metabolic syndrome using audit (Continuing
Professional Development, Module 10). Ir J Psychol Med 2011; 28: 176-179.
18. Kolshus E, Douglas L, Dunne R. Antidepressant augmentation and
combination in unipolar depression : strong guidance, weak foundations
(Continuing Professional Development, Module 11). Ir J Psychol Med 2011;
28: 263-271
19. Reynolds J. Grangegorman: Psychiatric Care in Dublin since 1815. Institute of
Public Administration/Eastern Health Board, Dublin,1992.
20. Kelly BD. Physical sciences and psychological medicine: the legacy of Prof
John Dunne. Ir J Psychol Med 2005; 22: 67-72
21. Dunne J. The Contribution of the Physical Sciences to Psychological Medicine.
J Ment Sci 1956; 102: 209-220.
22. Doherty AM, Kelly BD. The social and psychological correlates of
happiness in seventeen European countries: analysis of data from the
European Social Survey. Ir J Psychol Med 2010; 27: 130-134.
23. Expert Group on Mental Health Policy. A Vision for Change: Report of the
Expert Group on Mental Health Policy. The Stationery Office, Dublin, 2006.
24. Clare A, Daly RJ, Dinan TG, King D, Leonard BE, O’Boyle C, O’Connor J,
Waddington J, Walsh N, Webb M. Advancement of psychiatric research in
Ireland: proposal for a national body. Ir J Psychol Med 1990; 7: 93.
25. Daly RJ. Community psychiatry and the National Institute of Mental Health.
Ir J Psychol Med 1990; 7: 5.
26. Lewis, M. Boomerang: The Meltdown Tour. Penguin/Allen Lane, London, 2011.
27. Vandenbroucke JP. Medical journals and the shaping of medical knowledge.
Lancet 1998; 352; 2001-2006.
28. Fletcher RH, Fletcher SW. The future of medical journals in the western
world. Lancet. 1998; 352: Suppl 2:SII30-3.
29. Horton R. 21st-century biomedical journals: failures and futures. Lancet
2003; 362: 1510-1512.
30. Lown B, Bukachi F, Xavier R. Health information in the developing world.
Lancet 1998; 352: Suppl 2:SII34-38.
31. Kandela P. Medical journals and human rights. Lancet 1998; 352: Suppl 2:SII7-11.
32. World Health Organization. Mental Health: New Understanding, New Hope.
World Health Organization, Geneva, 2001.
33. World Health Organization. WHO Resource Book on Mental Health, Human
Rights and Legislation. World Health Organization, Geneva, 2005.
34. United Nations. Principles for the Protection of Persons with Mental Illness
and the Improvement of Mental Health Care. United Nations, Secretariat
Centre For Human Rights, New York, 1991.
35. United Nations. Convention on the Rights of Persons with Disabilities. United
Nations, Geneva, 2006.
36. O’Donoghue B, Moran P. Consultant psychiatrists’ experiences and attitudes
following the introduction of the Mental Health Act 2001: a national survey.
Ir J Psychol Med 2009; 26: 23-26.
37. Jabbar F, Kelly BD, Casey P. National survey of psychiatrists' responses to
implementation of the Mental Health Act 2001 in Ireland. Ir J Med Sci 2010;
179: 291-294.
38. Jabbar F, Doherty AM, Aziz M, Kelly BD. Implementing the Mental Health Act
2007 in British general practice: Lessons from Ireland. Int J Law Psychiatry
2011; 34: 414-418.
39. Kelly BD. Mental health legislation and human rights in England, Wales and
the Republic of Ireland. Int J Law Psychiatry 2011; 34: 439-454.
40. Vandenbroucke JP. Case reports in an evidence-based world. J R Soc Med
1999; 92: 159-163.
41. Kelly BD. In defence of the single case report. Ir Med J 2001; 94: 37.
42. Bignall J, Horton R. Learning from stories – the Lancet’s case reports. Lancet
1995; 346: 1246.
43. Kelly BD. The Irish Journal of Psychological Medicine: looking to the future.
Ir J Psychol Med 2010; 27: 170-171.
44. Kelly BD. Learning disability and forensic mental healthcare in nineteenth-
century Ireland. Ir J Psychol Med 2008; 25: 116-118.
45. Breathnach CS. Philip Crapton (1777-1858) and his description of
nominal aphasia. Ir J Psychol Med 2009; 26: 41-42.
46. Walsh D. The Ennis District Lunatic Asylum and the Clare Workhouse Lunatic
Asylums in 1901. Ir J Psychol Med 2009; 26: 206-211.
47. Walsh D. Did the Great Irish Famine increase schizophrenia? Ir J Psychol Med
2012; 29: 7-15
48. Finnane P. Insanity and the Insane in Post-Famine Ireland. Croon Helm,
London, 1981.
49. Lawlor B, Ganter K, Daly I, Owens J. Implementing the Mental Health Act
2001: what should be done? What can be done? Ir J Psychol Med 2005; 22:
79-82.
50. Kelly BD, Bracken P, Cavendish H, Crumlish N, MacSuibhne S, Szasz T,
Thornton T. The Myth of Mental Illness 50 years after publication: what does
it mean today? Ir J Psychol Med 2010; 27: 35-43.
51. Carrigan N. Deinstitutionalisation – time to move on to legalisation? Ir J
Psychol Med 2011; 28: 182-184.
52. O’Connell H. Dementia care in Ireland: what’s the plan? Ir J Psychol Med
2011; 28: 112-115.
53. Crumlish N, Bracken P. Mental health and the asylum process. Ir J Psychol
Med 2011; 28: 57-60.
54. Nkire N, Edokpolo O. Psychiatric training and research in Ireland, the trainee’s
perspective. Ir J Psychol Med 2011; 28: 3-5.
55. Omer S. McCarthy G. Reflective practice in psychiatric training: Balint groups.
Ir J Psychol Med 2010; 27: 115-116.
56. Russell V, Kelly M. Primary care mental health – a new direction? Ir J Psychol
Med 2010; 27: 63-65.
57. O’Keane V. Planning perinatal psychiatry services for Ireland. Ir J Psychol Med
2010; 27: 3-5.
58. Kelly BD. Head shop drugs: they haven’t gone away. Ir J Psychol Med
2011; 28: S1.
59. O’Keefe C. Medical problems caused by ‘legal highs’ continue. Irish Examiner
2011; May 12.
60. O’Domhnaill S. Mephedrone and “head/hemp” shop drugs: a clinical and
biochemical “heads up”. Ir J Psychol Med 2011; 28: S2-S3.
61. Uhoegbu C, Kolshus E, Nwachukwu I, Guerandel A, Maher C. “Legal
Highs”: Report on two psychiatric presentations linked with “head shop”
products. Ir J Psychol Med 2011; 28: S8-S10.
62. O’Reilly F, McAuliffe R, Long J. Users’ experiences of cathinones sold in head
shops and online. Ir J Psychol Med 2011; 28: S4-S7.
63. El-Higaya E, Ahmed M, Hallahan B. Whack induced psychosis: a case series.
Ir J Psychol Med 2011; 28: S11-S13.
64. Tully J, Hallahan B, McDonald C. Benzlypiperazine-induced acute delirium in
a patient with Schizophrenia and an incidental temporal meningioma: A
case report and a review of the literature. Ir J Psychol Med 2011; 28: S14-S16.
6
Abstract
Background: Evidence from regions where there have been severedietary restriction suggests that individuals in utero during periodsof starvation may subsequently be at increased risk of
schizophrenia. Because Ireland was the location of a major
nineteenth century famine an attempt has been made to
determine whether any such evidence for famine/schizophrenia
association can be found.
Method: The data used derive mainly from the Annual Reports onthe District, Criminal and Private Lunatic Asylums supplied by the
Inspectors of Lunacy in Ireland for the relevant years. Nineteenth
century diagnostic labels have been adjusted to conform to
schizophrenia as currently understood. Evidence relating to a
possible schizophrenia increase in famine-related emigrants is
examined.
Results: There was an increase in first admission rates forschizophrenia of 85.7% from 1860 to 1875. Admissions for other
disorders, chiefly melancholia, also increased. Similar admission
increases were evident in other jurisdictions over the same period.
Data relating to the mental health of famine – migrating Irish are
sparse and of difficult interpretation.
Conclusion: The evidence from available data sources attemptingto link the Irish famines of the 1840s with a subsequent increase
in the incidence of schizophrenia is equivocal and inconclusive.
Key words: Schizophrenia, Famine, 19th Century Ireland.
Introduction
The impact of famine conditions on the human embryo has been
a matter of study. For example maternal under-nutrition may result
in cephalopelvic disproportion resulting in increased birth
complications following maternal rickets due to insufficiency of
vitamin D.1 Low fertility, decreased birth weight and the survival of
underweight and premature infants as a consequence of improved
obstetric care may lead to substantial health consequences later in
life. These include developmental retardation or abnormalities. For
example there is mounting evidence that schizophrenia (as well as
autism and intellectual disability) may be a developmental disorder
associated with a variety of environmental/gene interactions, such
as maternal pre-natal infection in genetically susceptible persons,
resulting in abnormalities of synaptic formation and maintenance
and of mechanisms of neurotransmission, manifesting themselves
in cognitive, affective and perceptual anomalies.2 Among other
suspect relevant environmental traumas is maternal under-
nutrition.3
The occurrence of two relatively recent famines has led to a natural
experiment of their effect on neurodevelopment. The first was the
Dutch Winter Hunger and the second the Great Leap Forward
Chinese famine.
The Dutch famine occurred at a specific time and geographical
region and records were able to document the timing and extent
of the resultant under-nutrition. The relevant circumstances were
that towards the closing phase of World War 2 the Dutch
population attempted to assist the Allied advance. In retaliation
the German occupation authority imposed a ban on the
importation of food supplies to occupied Holland. This began
towards the end of 1944 with the west of the country most
severely affected. The under-nutrition of the population was most
marked between February and May 1945 when average daily food
intake fell to 1,000 calories per day and eventually to as low as
500. Of the 3.3 million population of the western Netherlands at
least 20,000 died as a direct result of hunger and 200,000 suffered
adverse health consequences and the birth rate fell to half pre-
famine levels.4
Researchers have followed the offspring of Dutch mothers
pregnant during the famine with particular emphasis on
neurodevelopmental conditions such as schizophrenia.4 In the case
of schizophrenia three criteria were used to define the exposed
birth cohort in the six largest Western cities of the Netherlands.
The first criterion was low food intake during the first month of
gestation and those born between August and December 1945 in
the cities of the famine regions met this criterion. The second
criterion was conception at the height of the famine as indicated
by adverse health effects in the general population. Those born
later among the birth cohorts of August- December 1945 (born
between October 15 and December 31) met this criterion but those
born earlier (between August 1 and October 14) did not. These
persons were traced through the Dutch National Psychiatric
Registry, followed through to ages 24-48 to determine whether
they had been admitted to hospital with a diagnosis of
schizophrenia between 1970 and 1992. Control cohorts from
periods immediately after and prior to the famine period were also
investigated. The risk of schizophrenia was found to be
substantially raised in the exposed cohort as compared with the
controls with a relative risk of 2.0 for males and 2.2 for females.
The schizophrenia cohort also had increased perinatal mortality and
increased birth complications both of which are known to be
associated with schizophrenia.5
7
Dermot Walsh, Submitted February 4th 2011Consultant Psychiatrist Emeritus, Health Research Board, Accepted July 29th 2011Knockmaun House, Lower Mount Street, Dublin 2.E-mail [email protected]
Ir J Psych Med 2012; 29 (1): 7-15
Original Paper
Did the Great Irish Famine increase schizophrenia?Dermot Walsh
In explanation Hoek et al have hypothesised that prenatal
micronutrient deficiencies may cause neurodevelomental
schizophrenia.4 A criticism of the study is that the numbers involved,
27, was very small. A follow up study of five males and four females
with schizophrenia born between October and December, these
being the only traceable subjects of the original 27, was undertaken.6
Their diagnosis of schizophrenia was confirmed by standard
diagnostic instruments and they participated in a magnetic resonance
imaging (MRI) study. They were compared with the same number
and similarly sexed healthy subjects who had also been exposed to
the famine conditions. Two further groups were recruited, nine
schizophrenic persons and nine non-schizophrenic individuals, both
groups without famine exposure. The exposed schizophrenia group
was found by comparison to the others to have decreased
intracranial volume. This was interpreted to have indicated stunted
early brain development. However several methodological criticisms
may be made. Most obviously the numbers involved were very small
and the method of recruitment of the controls far from perfect.
The Great Leap Forward Chinese famine of 1959-61 was the
consequence of collectivisation of agriculture, flawed agricultural
practices and reduction of cultivated land. The famine was
widespread but varied from province to province. Reports of an
investigation of the effects of this famine on schizophrenia derive
from an isolated province of China in the Wuhu region of Anhui. The
area of Wuhu and six surrounding counties were served by a single
psychiatric hospital. Hospital records from 1971 to 2001 were
examined. The authors found that the risk of developing
schizophrenia doubled from 1958 and 1959 and concluded that
prenatal exposure to famine increased the risk of schizophrenia later
in life.7 The findings from this area, much larger than that of the
Netherlands, found for the most exposed cohort an effect size similar
to the Dutch. The mortality adjusted relative risk for schizophrenia
over the two year period was 2.3 for 1960 and 1.9 for 1961.
However the study did not have month of birth for cases or controls
nor was information for food intake available month by month.
Accordingly a second more rigorous study was undertaken.8 This was
centred on Liuzhou City and surrounding counties in Guangxi region
with a population of 45 million. One hospital served the area under
investigation, and had good psychiatric records covering the years
1971- 2001. The famine here was less severe than in Anhui but of
considerable dimensions nonetheless. As a result there was evidence
of 500,000 – 800,000 deaths and fertility reductions of the same
order as in Holland. All inpatient and outpatient records of the
hospital were examined using ICD 10 criteria. A twofold increased
risk for schizophrenia among those conceived or in early gestation at
the height of the famine was found. However this result was
exclusively for rural areas. The authors speculated on the possible
deviant nutritional mechanisms involved such as the micronutrients
involved in the folate pathway which may directly affect growth of
the developing brain or indirectly by affecting DNA stability and
regulation of genes.
Thus there is evidence that famine conditions may, as one of their
consequences, increase the incidence of schizophrenia. Maternal
dietary deprivation or insufficiency may translate into foetal
undernourishment with adverse effects on neurological and brain
development during pregnancy.
The Great Irish Famines
In Europe the Irish famines of the 1840s are notorious for their
severity and adverse health consequences resulting in an estimated
one million deaths and massive emigration. There is extensive
literature on the causes, characteristics and consequences of these
famines such as by O’Grada.9 These famines were the consequence
of successive and repeated failures of the potato crop on which
much of the population, that had greatly increased during the
previous half century, had come to depend as its main source of
nutrition.10 The crop failure was the result of infestation of the
potato by phyophtera infestans causing blight for which there wasno known antidote at the time. Although there had been periodic
potato crop failures and deficiencies in Ireland from at least the
late eighteenth century, these were not due to blight, were of
lesser intensity and more restricted in geographic range.10 The
blights of 1845-50 were on a very different scale. The resultant
series of famines are collectively known as The Great Famine.
Food and nutrition in Ireland from 1500 to the early 20th century
have been extensively investigated by Clarkson and Crawford.11
They quote Arthur Young in stating that by the late 18th century
the average person consumed 6 pounds of potatoes per day and
recorded that by 1845 close to 40% of the population lived chiefly
on potatoes.12 This occurred in a setting of population increase
since 1700 and an exporting of meat, butter and grain. These
authors estimate that between 1846 and 1851 over a million or
12% of the immediate pre-famine population died. “More than
one third of Ireland’s population were potato people, competing
for scarce plots on marginal soils and hard pressed for rent by
farmers who were themselves under pressure from falling grain
prices and impoverished landlords.”13
The question as to the specificity of the great famine in time is a
relevant issue having regard to the time limits of the famine in
China and the more securely identified window of time of the
Dutch occurrence. The late Professor George O’Brien doubted the
uniqueness of the 1845 -1850 situation when he said that the
country was in a constant state of sub-famine and that the years
identified by historians as “great” were but an exacerbation of a
long-standing situation.14 However scholars such as Connell 10 and
O’Grada 9 take a different view and Clarkson and Crawford argue
that “ Ireland was not chronically a famine-stricken society and that
in normal years it was well stocked with nutritious food”.15
It is therefore reasonable to accept that the years 1845 – 1851
were years of devastation and mortality in which a pre-famine
population of 8.5 million was greatly reduced by mortality and by
emigration. The physical effects of starvation and the
accompanying exposure to the fevers and vitamin deficiencies were
well documented by Wilde and others.16 Apart from the
confusional states of persons dying from famine-associated fevers
there is little information of the longer-run consequences for
mental health. O’Grada, for example, asserted “there was little
likelihood of long-lasting cohort effects in post famine Ireland” on
the physical and intellectual performance of children who were
born at the time.17
8
Accordingly on the assumption that what appears to be true for
Holland and China might also apply in famine Ireland the current
exercise has been undertaken. It operates from a basis of many
deficiencies. Statistical data relating to the question are sparse and
open to a myriad of interpretations; the famine was more
prolonged and less incisive in time than in the other locations
examined and the ability to diagnose schizophrenia hampered by
rudimentary descriptions of cases, exclusively inpatients.
Method
The task for this study is to identify whether it is possible to adduce
evidence to sustain the maternal hunger/schizophrenia hypothesis
in the context of one of Europe’s severest famines of modern times.
To explore this issue it is necessary to examine whether relevant
health care data substantiate an increase in the disorder some 15-
30 years following the major famines. The relevant period is,
therefore, between 1860 and 1875.
The available data relevant to this enquiry include numbers of
admissions to lunatic asylums in Ireland over the relevant time
period. In addition the issue of whether the massive emigrations
from Ireland to North America and the United Kingdom in the late
1840s and early 1850s would have included migrant under-
nourished pregnant women resulting in an excess of schizophrenic
persons in these emigrant populations in the 1860s and 1870s is
briefly considered.
Lunacy in 19th century Ireland
The 19th century was a period of rapid growth of the recognition
and institutional provision for the mentally ill or lunatic and the
intellectually disabled (idiots and imbeciles). It has been reviewed in
detail by Finanne18 and details of the temporal establishment of
district asylums from 1830 – 1845 have been presented by Walsh.19
The main provision was in district lunatic asylums but also in the
lunatic wards of workhouses established in around 1840 where
residents were predominantly of idiot or imbecile type. As the years
progressed a policy of transferring lunatics from workhouse to
asylums was embarked upon. The following table documents the
growth in the asylum population from 1824 when there was one
district asylum in Armagh (although there were asylums in Dublin
and Cork at this time they had not been absorbed into the district
asylum system until later) to 1875 when there were 22. In addition
there were smaller numbers of lunatics in goals and in workhouses.
Table 1. Years of opening of District Lunatic Asylums withnumbers of patients on opening and in 1875.
9
Asylum Year Opened Patients on Opening Patients 1875
Armagh 1824 104 162
Ballinasloe 1833 150 459
Belfast 1829 104 380
Carlow 1832 104 250
Castlebar 1866 250 281
Clonmel 1834 60 370
Cork 1852 250 500
Down 1868 300 300
Ennis 1868 260 260
Enniscorthy 1868 285 288
Kilkenny 1852 152 216
Killarney 1852 220 220
Letterkenny 1866 300 300
Limerick 1827 150 410
Londonderry 1829 120 238
Maryborough 1833 104 266
Monaghan 1869 340 340
Mullingar 1855 300 400
Omagh 1853 300 510
Richmond 1830 257 1,040
Sligo 1855 250 330
Waterford 1835 100 210
Totals 4,460 7,730
Sources: Reports on the District, Criminal and Private Lunatic Asylums in Ireland. 21st report.20 25th report.21
There was therefore an increase of 3,270 or 73% inpatients
resident between the opening of the asylums and the numbers
hospitalised in 1875.
The reasons for the increase in these asylum populations were
much debated. Broadly speaking there were two schools of
commentators, those who believed that the increase reflected a
genuine increase in the incidence and prevalence of lunacy such
that the Times of London was moved to assert in an editorial in
1877 that “If lunacy continues to increase as at present the insane
will be in the majority and, freeing themselves, will put the sane in
asylums” as quoted by Scull22 and those who believed that the
increase was apparent rather than real.
In the former camp were those who believed that before 1800
schizophrenia, the most serious form of lunacy, was rare prior to
the 19th century before increasing afterwards because of genetic
mutation as did Hare 23 whereas Jablensky assigned the increase,
on the basis of German evidence, to the 20th century.24 Another
commentator concluded that schizophrenia became more
prevalent during the 19th and early 20th century due to socio-
environmental changes associated with industrial growth and
biological mediating mechanisms such as nutritional,
immunological and infectious causes.1 The opposing point of view
was promoted by Scull25 who, in rejecting the real increase
hypothesis, invoked social conditions, such as pauperism, as
contributing to the increasing influx of persons to the 19th century
asylums. However he conceded that the most satisfactory means
of deciding between the rival hypotheses was to sample the
characteristics of 19th century admission records but conceded that
“there must be serious doubt the quality of surviving records is
adequate for this purpose” and that “individual case records are
generally too skimpy to be useful for answering this question”.25
In these debates in Ireland the Inspectors of Lunatics figured largely
as did prominent asylum doctors of the time such as MacCabe26
and Drapes 27 both of whom held the increase was real. Indeed the
matter was of such sufficient interest that the Inspectors devoted
a Special Report to the Chief Secretary in 1884, on the “alleged
increased prevalence of insanity in Ireland.28 They concluded that
“the great increase in the insane under care is mainly due to
ACCUMULATION (sic) and is, so far, an apparent and not a real
increase”. This in fact was a compilation of the views of asylum
superintendents whom the Inspectors had canvassed. Finnane,
too, supported an apparent increase as explanation and cited social
and administrative considerations as catalysts.29
Administrative and legal considerations may have been just as
important as any perceived increase in lunacy as a disease in
contributing to the increase in asylum admissions throughout the
19th century. In Ireland the Dangerous Lunatics Act of 1838 made
it relatively easy for individuals who had committed what today are
called “minor public order offences”, and sometimes even those
whose level of misbehaviour was beneath this threshold, to be
consigned to asylums, or to gaols before transfer to asylums. It was
generally believed that this mechanism was abused with the result
that many persons whose dangerousness and lunacy were
questionable ended up in the asylums. An attempt to control the
conveyance of persons to asylums in this manner resulted in the
Dangerous Lunatics Act of 1867 which did not differ substantially
from its processor other than requiring a medical certificate from
the dispensary doctor and in allowing magistrates to commit
“dangerous lunatics and idiotics” to lunatic asylums rather than to
jails by legislation, the effect of which in the case of the Richmond
Asylum, was to increase admissions to 401 in 1868 compared to
247 in 186.30 In effect the new legislation, far from remedying the
situation, resulted in an increase in direct admissions to asylums
throughout the century. This issue is examined in depth by Finnane
who attributed it in part to “the widening of insanity’s
boundaries”31 thus raising further nosocomial caution on the
interpretation of the reasons for admission increases following the
famine. And for Finnane the familial context, particularly in its
socio-economic context, was at least as important in determining
admission sought by relatives as the diagnostics labels appended by
asylum doctors; ”it is the history of familial relations which is
essential to appreciating the decision to commit”.32 As an example
of commitment because of economic necessity, Malcolm, in her
history of Swift’s Hospital, illustrates the dilemma encountered by
a certain Mary Larkin in her deciding to apply for the re-admission
of her husband Thomas.33
Incidence 1860-1875
There is no reliable information available on new cases of lunacy
arising in the Irish community in the 19th century. However
periodic census counts of “lunatics at large” were carried out by
the Royal Irish Constabulary at the request of the Inspectors of
Lunacy in the 200 constabulary areas of Ireland on a regular basis.
It might have been possible to assess an increasing incidence of
such cases by comparing one year with another and interpreting an
increase as indicating new cases on an annual basis. However the
arbitrariness of the Constabulary’s identification of lunacy, which
included intellectual disability, excludes the usefulness of this
information source. Accordingly it is necessary to rely on asylum
admission data as a measure of the incidence of schizophrenia as
returned in the Annual Reports on the District, Criminal and Private
Lunatic Asylums in Ireland as provided by the Inspectors of Lunacy,
the greatest proportion of which were to the district asylums.
Given that the incidence of schizophrenia is mostly concentrated in
the population aged between 15 and 30 years, it is assumed that
the impact of the Irish famines of 1845- 51 would be manifest
mainly in an increase in hospital admissions for lunacy, and more
specifically for conditions analogous to schizophrenia, in Ireland
between 1860 and 1875. Admissions to the district asylums, over
80% of which were recorded as first admissions, rose from 1,313
in 1860 to 2,132 in 1875 and then increased only slightly to 1880
when they numbered 2,366.
10
There was, thus, an increase of 62% in the number of admissions
between 1860 and 1875. As the population fell over these years
the rate per 100,000 population rose more rapidly than the raw
numbers, from 22.6 to 40.4 or by 78.7%. However, there was no
decline in admissions in the years after 1880, when any famine
effect would be expected to have petered out. On the contrary,
admissions increased by a further 32% to 3,095 in 1890 and by
1898 had reached 3,469. First admissions constituted in and
around 80% from 1861 onwards. Admissions to private hospitals
increased from 165 in 1860 to 186 in 1875 and constituted 2,882
(9%) of 32,009 total private and public admissions over 1860-75.
No diagnostic information was furnished on these private
admissions, although it was provided on those resident each year
with mania predominating. Because the numbers are small and
there was little increase over the period surveyed they are
discounted from further consideration. Similarly the 290 admissions
to the Central Criminal Asylum over these years have been
discounted.
Diagnosis in the nineteenth century
Whereas in the 20th century medical practitioners were familiar
with the concept of schizophrenia, introduced in the early 1900s,
this was not the case in the preceding century. The term lunacy
was often employed generically and administratively to include
both those suffering from mental illness and those with intellectual
disability (idiots and imbeciles). However although this generic
usage is sometimes employed in official reports, such as the annual
inspection reports employed here, these usually use lunacy in the
more restricted sense of mental illness per se. Within lunacy a very
restricted classificatory system was used. The most common
diagnostic terms were mania, melancholia, monomania and
dementia. I have examined Irish asylum casebooks of the Sligo,
Mullingar and Richmond asylums from the 1850s to 1900 and
attempted, from the limited clinical descriptions available, to
reconcile these terms with diagnostic groupings currently in use in
the International Classification of Diseases 10th edition (ICD 10).
While in a minority of cases the symptoms and historical data
recorded are specific enough to warrant a diagnosis in modern
terms of depression with some confidence, this is not so in relation
to the broader concept of schizophrenia, an entity unknown as
such at that time. For example, delusional thinking and
hallucinatory experiences, characteristic of this disorder, were rarely
noted in the Irish nineteenth century case books quoted.
The following cases from the Sligo Asylum casebooks, typical of
the generality of admissions, illustrate the practical difficulties
encountered in diagnostics of the time.35 A 45 year old woman
was admitted under warrant to the asylum which stated that she
threatened and assaulted her mother with whom she did not get
on. Nevertheless she was given a diagnosis of chronic mania and
the supposed cause of her insanity was identified as “family
disturbances”. Confusingly the “duration of present attack” was
given as 15 years. The sparse case notes indicate only that she had
“from time to time maniacal symptoms”. She was still
undischarged seven years later. A 33 year old female was admitted
because she was alleged to have assaulted her sister and
threatened to burn her father’s house. The duration of her illness
prior to admission was said to be one month. Sixteen years
following admission she was said to be “noisy and refractory” and
she died in the asylum 41 years following admission. A 35 year old
male was admitted because he threatened to kill his wife and
family and was stated to have been ill for only three weeks prior to
admission. He was noted in his case notes to be suffering from
delusional insanity with jealous delusions concerning his wife but
was noted to have taken a lot of drink prior to admission. Three
weeks after admission he “escaped”, couldn’t be found and so
was discharged from the asylum register a fortnight later.
This contrasts markedly with the situation pertaining in late
nineteenth century Denbigh Asylum in North West Wales where
case notes were “more comprehensive than in other asylums of
the period” and were sufficiently detailed to permit consultant
psychiatrists to make an ICD diagnosis on each patient.36 A similar
exercise was possible at the Retreat in York, dealing with patients
admitted 1880-1884 where diagnostic information was sufficiently
explicit to allow of ICD conversions.37 More pertinent to the Irish
dilemma is the finding of researchers seeking to extract
schizophrenia from admissions to the Bethlem Royal Hospital 1853-
1862. Having reviewed the diagnostic criteria set out in
contemporary psychiatric textbooks they concluded that mania
comprised insanity with “confusion of ideas” and “encompassed
all syndromes where thought disorder was evident”.38 Moreover, in
identifying schizophrenia they excluded all persons aged over 40.
This is not possible in Ireland because of lack of cross-classification
by disease category and age in the Irish reports.
I now turn to estimating how many of Irish asylum admissions
should be classified as schizophrenia. There has been surprisingly
little attempt to determine what proportion of 19th century lunacy
emerges as schizophrenia as it is understood today. An outstanding
exception to this general scenario is that of Hare.23 In examining the
difficult issues involved Hare warned that “Before modern
diagnostic criteria became generally accepted, there was much
difference of opinion on what signs and outcomes were indicative
of a schizophrenic illness. And what was a difficult decision in
11
Table 2. Numbers of admissions to District Lunatic Asylums 1860-1875
1860 1,313 1864 1,242 1868 2,113 1872 2,165
1861 1,262 1865 1,291 1869 2,692 1873 2,277
1862 1,171 1866 1,782 1870 2,333 1874 2,154
1863 1,420 1867 1,527 1871 2,253 1875 2,132
Sources: 10 to 25th Reports on the Public, Criminal and Private Asylums of Ireland.34
clinical practice was more likely to be contentious in a historical
setting even when a detailed history was available. Kraepelin, to
whom we owe the concept that was later to emerge as
schizophrenia, and which he had called dementia praecox, stated
that many of the cases he identified as dementia praecox had
previously been classed as mania or melancholia.39 Hare, speaking
of the 19th century, states that “we may assume that almost all
cases classified as “ordinary dementia” would have been
schizophrenia”.23 Further support for this is supplied by Tuke who
subdivided ordinary dementia into two forms. Primary dementia
was the form that occurs most especially in young persons of
feeble development and secondary was the form that “follows
acute attacks of insanity, maniacal or melancholic”.40 Of course the
clinical manifestations of schizophrenia may have changed over the
past 100 years, and while this is more likely to be true of earlier
periods, it is still a factor requiring consideration, in translating 19th
century case book descriptions, even when exhaustive as they
seldom were, in Irish 19th century case books, to the modern
concept of schizophrenia.
Mania was the predominant diagnosis of mental illness in
nineteenth century Ireland, comprising 72% of admissions 1860-
75. This clearly suggests, as pointed out above, that as well as
including mania as it is known today, other categories must have
been subsumed into this entity, most notably schizophrenia. This
assumption gains support from the contemporary evidence, that of
schizophrenia and mania first admissions combined, schizophrenia
now comprises 60%. I have assumed that the relative distribution
of these conditions was similar in the nineteenth century and have
re-classified 60% of nineteenth century admissions, classified then
as mania, to what we call schizophrenia today. I further assume
that the nineteenth century category monomania connotes
delusional disorder and belongs in its entirety to the schizophrenia
spectrum. The term dementia was employed non-specifically in the
nineteenth century admissions classification and seems often to
have included those with the negative symptoms of schizophrenia,
as well as dementia in the modern sense of cognitive failure of
organic origin, particularly in older persons. Support for this
contention is provided by the observation by Hare that the age –
incidence curve or age at first admission for dementia in the 19th
century was largely in the younger age groups and therefore not
compatible with the modern concept of this condition and he
therefore aligned much of it with schizophrenia.23 However this
cannot be tested in the Irish context as no data are available for
diagnosis cross- classified by age. I have therefore, somewhat
arbitrarily, allocated 50% of dementia admissions to schizophrenia.
As melancholia closely resembles depression as used today, this
category has been regarded as not contributing to schizophrenia
on the assumption that depressive syndromes were the
predominant characteristic of those labelled melancholia. However
as noted by Tuke40 some cases of melancholia, passing into a
chronic state, might conceivably be re-labelled dementia.
There were 1,313 admissions to district asylums in 1860, a year
when one would have expected famine–related admissions to
begin to appear. Excluding the 220 “relapsed” cases there were
1,093 first admissions, 83% of the total. Four categories of mental
illness accounted for 96% of all admissions (the remainder
comprised idiots and imbeciles). The breakdown of these four
categories was: mania 892 (68%), dementia 88 (7%), monomania
53 (4%) and melancholia 220 (17%). Here one encounters the
problem of assessing or best-guessing what proportion of these
could be validly regarded as schizophrenic. The assumption, based
on the very tenuous evidence of contemporary case- books with
their admittedly poor symptomatic descriptions, is made that the
following proportions of these categories were what today is called
schizophrenia, mania 60%, monomania 100%, dementia 50%,
and melancholia 0%. This yields an estimated total of 632
admissions for schizophrenia in 1860 (50% of all mental illness
admissions) or 524 first admissions on the basis that 83% were
first admissions. In 1875 there were 2,344 admissions of which
1,777 (83%) were first admissions. The equivalent estimate for
1875 was 1,006 schizophrenia admissions of which an estimated
834 were first admissions. The estimation therefore is that the first
admission rate for schizophrenia rose from 8.4 per 100,000 in
1860 to 15.6 in 1875. However, as the admission rate for non-
schizophrenia conditions increased to the same extent, the
proportion of all admissions classified as schizophrenia remained
stable. The following figures represent these data.
Admission rates per 100,000 population.
Figure 1. Schizophrenia admission rates per 100,000population 1860-1875 from 9th to 25th Reports on thePublic Criminal and Private Asylums of Ireland.41
Percentage of all admissions that were schizophrenia
Figure 2. Schizophrenia as a percentage of all admissions1860 – 1875.
12
Given that schizophrenia is predominantly a disorder of early life
with most incident cases arising in the late teens and early 20s I
have attempted to determine whether there was any increase in
the proportion of young persons admitted during the relevant years
as a proportion of all-aged admissions. The Inspectorial reports
supply age of admissions in decennial groups and not cross
classified by diagnosis. The group most relevant to this enquiry is
that of 20 – 30 years. The earliest years for which admission ages
were provided were in the combined years 1856 and 1857. In
these years 427 or 27.8% of 1,532 admissions were in this age
group. This percentage rose to 34.1 in 1868 and then subsided to
28.7 in 1875 thereby giving no support to the question of whether
schizophrenia increased insofar as it could be identified by age on
admission.42
The Irish Abroad
Robins contends that “the Irish who left home during the famine
and post-famine decades were more susceptible to insanity than
immigrants of other racial origins”.43 However he cites no
quantative evidence in support of this general contention although
he quotes instances where persons who had become mentally ill
following emigration were returned by their families or, as in the
case of the North American states, were returned by administrative
decree. Nonetheless there is abundant evidence of the high
prevalence of mental illness among the immigrant Irish compared
to indigenous populations both in the US and UK in the mid and
late 19th century. For example lunacy in Massachusetts was noted
to be high among the immigrant Irish.44 However this was in 1855
less than a decade after the major famines of the 1840s and
therefore too early to be related to them. Other reports of the high
proportion of Irish in asylum populations came from the Canadian
provinces, New Brunswick, before the famine years and Prince
Edward Island, subsequent to them, where in 1864 it was claimed
that as many as one third of admissions were of Irish immigrants
reflecting perhaps more than anything else the very high
proportion of the population that was Irish.45 Nonetheless high
rates of hospital admissions among the Irish of New York City and
State were still extant up to 1900.46 These were too long after the
major famines to be attributed to them. Moreover these rates rose
progressively throughout the latter part of the nineteenth century
and showed no exceptional peak between 1865 and 1875. The
rates of hospitalisation of Irish emigrants in North American
asylums declined over time, in keeping with the observation that as
each immigrant group becomes more assimilated and more
prosperous the rate of public psychiatric hospitalisation decreases.
Overall, though, these sparse and general observations shed little
light on the question at issue.
Irrespective of nutritional status, the trauma of migration and the
socio-cultural difficulties of assimilation may of themselves be
sufficient to increase mental disorder in migrant populations.
Classical examples of this have been identified by Odegaard among
Norwegian immigrants to Minnesota 47 and by Harrison among
Afro-Caribbean migrants to the United Kingdom.48 And the
migrant Irish in the United Kingdom, even to the first generation
UK born, appear to have poorer mental health than the indigenous
London community.49 Therefore caution must be invoked in
attributing mental illness rates to 19th century Irish immigrants
solely to maternal nutritional deficiency.
Discussion
The plausibility of famine disrupting neurodevelopment has a
sound empirical basis. Famine conditions have been shown to
result in decreased fertility, increase in miscarriage, stillbirths and
low birth weight. 4 Because schizophrenia is believed, in part, to
reflect developmental anomalies in brain structure it is relevant to
postulate that famine conditions, existing during pregnancy, may
result in neurodevelopmental damage to the foetus. Accordingly
the natural experiments of famine conditions in two jurisdictions
have been examined to determine whether there was an increase
in schizophrenia in individuals exposed to famine conditions during
pregnancy. These were respectively in Holland during World War 24
and in China during the Great Leap Forward famine.8 Because of
the severity of the Great Irish Famine and its resulting mortality it
is reasonable to suspect that the accompanying under-nutrition of
pregnant women may have similarly resulted in neurological
damage leading to an increase in schizophrenia some 15 to 30
years later.
The reason for the growth in the numbers of persons in Irish
asylums during the 19th century led to vigorous debate. Essentially
there were two points of view, those that held that it reflected a
real increase in lunacy and those who claimed that it was
artefactual and apparent rather than real. Explanatory reasons
deriving from ecological and environmental causes or influences
proliferated. However this increase was not uniquely Irish but a
feature of most European and North American jurisdictions.23
The data presented here show an increase in the incidence of
lunacy in Ireland as measured by asylum admissions some 15 to 30
years following the Irish famines of 1845-1850 historically referred
to as The Great Famine. Admissions of lunatics, that is those
suffering from mental illness, to asylums increased 1860-1875 from
1,313 to 2,132 or in rates per 100,000 population from 22.6 to
40.4, an increase of 78.7%. By assigning 60% of patients
diagnosed as mania, all those designated monomania and 50% of
those designated dementia to schizophrenia, estimates have been
made of the numbers likely to have been schizophrenia in those
first admitted in 1860 and 1875. Those first admissions identified
as schizophrenia rose numerically from 524 to 834 and in rates per
100,000 population from 8.4 to 15.6 an increase of 85.7%.
At first sight these increases in Ireland would seem to suggest that
the Irish famines did lead to an increased level of schizophrenia in
the population, but account has to be taken of the similar increases
in the other “non-schizophrenia” lunacies, mainly melancholia
whose first admissions rose from 31.7 to 45.5 per 100,000 from
1860-75 an increase of 43.5.41
In addition admission rates continued to increase up to the end of
the century long after the Great Famine could be held to be an
influence. As to the migrating Irish, other factors confound the
situation such as poverty and difficulties in assimilation of the
immigrant population, which are deemed to contribute to the high
hospitalisation rates in many immigrant communities.47
Up to 1881 the rate of first admission to population was higher in
England than it was in Ireland.50 The prevalence of persons in
asylums and workhouses in England rose from 70 per 100,000
13
population in 1847 to 220 in 1877.51, 52 In Ireland the
corresponding figures were 76 and 234. It can therefore be
reasonably concluded that the rates of insanity (lunacy plus a small
number of idiots and imbeciles) were remarkably similar in both
jurisdictions and further that they increased at roughly the same
rate in the second half of the nineteenth century. In consequence
the record offers little support for the thesis that the increase in
rates was attributable to the famines of 1845-51.
As far as Ireland is concerned the evidence that the famines of the
late 1840s led to more schizophrenia is, at best, equivocal. The
apparent increase in the number of those schizophrenic was in the
context of an increase in lunacy generally and the increase
observed in Ireland was manifest throughout Europe and North
America in jurisdictions where there were no major famines.45
It is concluded that no unequivocal evidence can be adduced to
support the hypothesis that the Great Irish famine increased
schizophrenia.
Limitations
It may be objected that 1860 is too early a date for the
consequences of the famines to be revealed in asylum admissions.
Furthermore, the timing of the admissions may not have coincided
exactly with the onset of the condition. Whereas the Inspectorial
Reports of the 1860s tabulate the duration of disease prior to
admission of those discharged as “recovered”, this information is
not provided for new admissions nor is it cross-classified by type of
disease. In addition, form of disease on admission was not provided
in the reports after 1875 until 1890 and by then monomania no
longer appeared as an entity. This is noteworthy as it might be
objected that delusional disorder has a later onset than other
components of the schizophrenia spectrum.
A shortage of asylum beds could have caused delays in admissions
in the 1860s and increased availability of beds – rather than
increased incidence of mental illness – could have accounted for
some of the rise in admissions in later years. By 1875, although the
number of asylum places available had increased considerably, by
almost 3,000 from 1860, admissions fell slightly between 1870
and 1875, as did the number of lunatics reported as at large.34
The use of a single year at either end of exploration may be
questioned but there was little variation in the characteristics of
the admission or residential clienteles over the years of survey.
Finally, it is acknowledged that the sparseness of clinical data in
nineteenth century asylum case books in Ireland does not allow
translation of what little clinically descriptive material there is into
meaningful diagnostic entities as applied today, a difficulty not
confined to Ireland.23 The most restricting limitation, therefore, is
the derivation of rates of schizophrenia based on purely personal
and empirical extrapolation from 19th century diagnostics.
Acknowledgement
I wish to thank Dr Brian Donnelly of the Irish National Archive for
his help and advice and particularly for making the casebooks of
the Sligo District Lunatic Asylum available to me.
Conflict of interest
None.
References
1. Warner, R. (1995) Time trends in schizophrenia: change in obstetric risk factors with
industrialization. Schizophrenia Bulletin, 21. 3, 1-30.
2. Guilmatre A, Dubourg C, Mosca A-L, Legallie S, Goldenberg A, Drouin-Garrand V,
Lavet V, Rosier A, Briault S, Bonnet-Brithault F, Laumonnier F, Odent S, Le Vacon G,
Joly-Helas G, David D, Bendavid C, Pinooit J- M, Henry C, Impallomenmi C, Germano
E, Tortorella G, Di Rosa G, Barthelemy C, Andres C, Faivre L, Frebourg T, Saugier Veber
P, Campion D (2009). Recurrent rearrangements in synaptic and neurodevelopment
genes and shared biologic pathways in schizophrenia, autism and mental retardation.
Archives of General Psychiatry 66. 947-936.
3. Haukka J, Suvisaari J, Hakkinen L, Lonnqvist J. (2008). Growth pattern and risk of
schizophrenia Psychological Medicine 38. 63-70.
4. Hoek HW, Brown AS, Susser E. (1998). The Dutch famine and schizophrenia spectrum
disorders. Social Psychiatry and Psychiatric Epidemiology. 33. 373-379.
5. Jablensky A. (1986). Epidemiology of schizophrenia: a European perspective .
Schizophrenia Bulletin. 12. 52-73.
6. Hulshoff HE, Hoek HW, Susser E, Brown AS, Dingemans A, Schnack HG, Van Haren
NE, Pereira Ramos LM, Gispen de Wied C,, Kahn RS. (2000). Prenatal exposure to
famine schizophrenia and brain morphology. American of Psychiatry. 157. 1170-1172.
7. Song S, Wang W, Hu P. (2009). Famine, death and madness. Schizophrenia in early
adulthood after prenatal exposure to the Chinese Great Leap Forward Famine.
University of California eScholarship Repository.
8. St. Clair D, Xu M, Wang P, Yu Y, Fang Y, Zhang Y, Zheng X, Gu N, Feng, G, Sham P,
He L (2005). Rates of adult schizophrenia following prenatal exposure to the Chinese
Famine of 1959-1961. Journal of the American Medical Association. 294. 557-562.
9. O’Grada C. (1989). The Great Irish Famine, p. 76. McMillan. London.
10. Connell KH. (1950). The Population of Ireland 1750-1845, p. 146. The Clarendon
Press. Oxford.
11. Clarkson LA, Crawford EM. (2001). Feast and Famine. Food and Nutrition in Ireland
1500-1920. Oxford University Press. Oxford.
12. ibid p. 59
13. ibid p. 87
14. O’Brien G. (1918). The Economic History of Ireland in the Eighteenth Century, p 102.
Maunsel & Co. Dublin.
15. Clarkson LA, Crawford EM. (2001). Feast and famine. Food and Nutrition in Ireland
1500-1920, p. 112. Oxford University Press. Oxford
16. Wilde W. The census of Ireland for the year 1851, part v. Table of deaths, vol 1 11, p
1856 (2087 11) XXX, The Census of Ireland for the year 1861, part iii. Vital statistics,
vol. ii. Report and table relating to deaths, PP 1863 (3204-2) LVIII.
17. O’Grada C. (1999). Black 47 and Beyond, pp 226-227. Princeton University Press.
Princeton New Jersey
18. Finnane M. (1981). Insanity and the Insane in Post-Famine Ireland. Croom Helm.
London
19. Walsh D. (2008). The lunatic asylums of Ireland 1825-1839. Irish Journal of
Psychological Medicine. 24. 24- 28.
20. Lunatic Asylums - Ireland (1872). The Twenty-First Report of the District, Criminal, and
Private Lunatic Asylums in Ireland with appendices. HC1872 (c 647) xxvii.323. p 60
Alex Thom. Dublin.
21. Lunatic Asylums – Ireland (1876). The Twenty-Fifth Report of the District, Criminal.
and Private Lunatic Asylums in Ireland with appendices. HC 1876 (c 1496) xxxiii.363.
p53. Alex Thom, Dublin.
22. Scull AT. (1979). Museums of Madness: the Social Organisation of Insanity in
Nineteenth Century England. Allen Lane. London.
23. Hare EH. (1988). Schizophrenia as a recent disease. British Journal of Psychiatry. 153.
521-531.
14
24. Jablensky A, Morgan V, Zubrick S, Bower C, Yelleachich L-A. (2005). Pregnancy,
delivery and neonatal complications in a population cohort of women with
schizophrenia and major affective disorders. American Journal of Psychiatry. 162. 79-
81.
25. Scull AT. (1984). Was insanity increasing? A response to Edward Hare. British Journal
of Psychiatry. 144. 432-436.
26. McCabe F. (1869). On the alleged increase in insanity. Journal of Mental Science. 15.
363-366.
27. Drapes T. (1894). On the alleged increase of insanity in Ireland. Journal of Mental
Science. 171. 519- 548.
28. Special Report from the Inspectors of Lunatics to the Chief Secretary (1884). Alleged
increasing prevalence of insanity in Ireland. Alexander Thom & Co. Dublin.
29. Finnane M. (1981). Insanity and the Insane in Post-Famine Ireland, p 169. Croom
Helm. London.
30. Reynolds J. (1992). Grangegorman. Psychiatric Care in Dublin since 1815, p. 140 and
quoting Statute 7 31 Vic 118. Institute of Public Administration. Dublin.
31. Finnane M. (1981). Insanity and the Insane in Post-Famine Ireland, p 223. Croom
Helm. London.
32. Finnane M. (1985). Asylums, Families and the State, p. 137. History Workshop. No 20
(Autumn, 1985).
33. Malcolm E. (1989). Swift’s Hospital. A History of St Patrick’s Hospital 1746-1989, p.
144.Gill and Macmillan, Dublin.
34. Lunatic Asylums – Ireland (1861 – 1876). The 10th to the 25th Reports on the Public,
Criminal and Private Asylums in Ireland. Alex Thom. Dublin.
35. Male and Female Casebooks of Sligo District Lunatic Asylum 1892-1893. National
Archive of Ireland. Dublin.
36. Healy D, Savage M, Michael P, Harris M, Hirst D, Carter M, Cattell D, McMonagle T,
Sohler N, Susser E. (2001). Psychiatric bed utilisation:1896 and 1996 compared.
Psychological Medicine 31. 779-790.
37. Renvoize EB, Beveridge AW. (1989). Mental illness and the Victorians. A study of
patients admitted to three asylums in York, 1880-1884. Psychological Medicine. 19.
19-28.
38. Klaf FS, Hamilton JG. (1961). Schizophrenia – a hundred years ago and today. Journal
of Mental Science. 107. 819-827.
39. Kraepelin E. (1913). Psychiatrie (8th edn). Translated by R.M. Barclay from vol 3 part
2 as Dementia Praecox and Paraphrenia. Livingstone. Edinburgh.
40. Tuke DH. (1882). Dictionary of Psychological Medicine. Churchill. London.
41. Lunatic Asylums – Ireland (1861 – 1876). The 9th to 25th Reports on the Public,
Criminal and Private Asylums of Ireland. HC 1861 (2901) xxvii. 245 and HC 1876
(c.1496) xxxiii. 363. Alex Thom. Dublin.
42. Lunatic Asylums – Ireland. (1857, 1868-1869 and 1876) The 8th, 18th and 24th
Reports on the Public, Criminal and Private Asylums of Ireland. HC 1857 Session 2
(2253) xvii. 67, HC 1868-69 (4053) xxxi. 303 and HC 1876 (c.1496) xxxiii. 363. Alex
Thom. Dublin.
43. Robins J. (1986). Fools & Mad. A History of the Insane in Ireland, p. 121. Institute of
public Administration. Dublin.
44. Jarvis E. (1855). Report on Insanity and Idiocy in Massachusetts by the Commission on
Lunacy. William White. Boston.
45. Fuller Torrey E, Miller J. (2007). The Invisible Plague. The Rise of Mental Illness from
1750 to the Present, p.163. Rutgers University Press. New Brunswick, New Jersey, and
London.46. Malzberg B, Lee ES. (1956) Migration and Mental Disease, Social Science
Research Council. New York
47. Odegaard O. (1932). Emigration and insanity. A study of Norwegian-born
populations of Minnesota. Acta Psychiatrica et Neurologica (Supplement 4).
1-206.
48. Harrison G, Owens D, Holton A, Neilson D, Boot D. (1988). A prospective
study of severe mental illness in Afro-Caribbean patients. Psychological
Medicine. 18, 3. 643-657.
49. Ryan L, Leavey G, Golden A, Blizzard M, King M. (2006). Depression n Irish
emigrants living in London: case-control study. British Journal of Psychiatry.
188. 560-566.
50. Fuller Torrey E, Miller J. (2007). The Invisible Plague. The Rise of Mental Illness
from 1750 to the Present, p. 109. Rutgers University Press. New Brunswick,
New Jersey and London.
51. Lunatic Asylums- Ireland (1849). Report on the District, Local and Private
Asylums 1847, HC 1849 (1054) xxiii. 53.
52. Lunatic Asylums – Ireland (1878), 27th report on the District, Criminal, and
Private Asylums of Ireland 1877. HC 1878 (c. 2037) xxxix. 395.
15
Original Paper
Study of Presentationsfor Involuntary Admission to a Cork Approved CentreElaine Dunne, Eamonn Moloney
Abstract
Objectives: To describe the characteristics of patients who presentto an approved centre with Mental Health Act 2001 forms, and
secondly, to compare those who were subsequently detained to
those who were not detained.
Methods: Specific data on patients who presented to South LeeMental Health Unit with application and recommendation forms
for Involuntary Admission over a 22 month period was gathered
from a retrospective case note review. Information on both groups
was compared statistically using Graph Pad Prism software.
Results: 71% (n=121) of patients presenting for involuntary
admission did so outside of normal working hours. Those who
were not subsequently detained were more likely to have had their
application made by the Gardai and their recommendation made
by someone other than their own General Practitioner (GP). GPs
were more likely than Consultant Psychiatrists to cite risk to self or
others as the reason for involuntary admission.
Conclusion: Although involuntary admissions most often occur inemergency situations, every effort should be made to ensure that
those who are known to the patient are involved in the process of
application and recommendation. In addition, there is a need for
ongoing training and education of those most commonly involved,
such as the Gardai and General Practitioners, as well as feedback
to these groups when a patient presents who does not require
involuntary admission.
Key words: Mental Health Act 2001; Involuntary admission;Detention
Introduction
Part 2 of the Irish Mental Health Act (MHA) 2001 was implemented
on November 1st 2006 and introduced new procedures for the
involuntary admission of patients to approved centres. The Mental
Health Commission has produced a report on the operation of the
MHA1 and there have been numerous legal challenges to the
legislation in the form of Article 40 challenges, judicial reviews and
High Court and Supreme Court challenges.
South Lee Mental Health Unit caters for a catchment area
population of 179,000. The approved centre is located in Cork
University Hospital and has 46 inpatient beds with approximately
500 admissions per year and had an involuntary admission rate of
54.7/100,000 in 2007.
The objective of this study was to describe all those patients who
presented to the South Lee Mental Health Unit at Cork University
Hospital with an application and medical recommendation for
admission under the MHA over a 22 month period in order to
establish if these patients were similar to those described in
national data. A comparison was also made of those patients for
whom an admission order was completed and those who did not
have an admission order completed. Such patients are, by
definition, deprived of their liberty for up to twenty four hours and
it is important that their management is reviewed.
Methods
Records were kept of all patients who presented to the South Lee
Mental Health Unit with completed application and medical
recommendation forms for admission under the Mental Health Act
2001 between January 2007 and October 2008. Cases of those
who were subsequently detained and those who were not
detained were identified from these records and included in the
study. The period originally planned to be studied was a two year
period from the implementation of the MHA 2001 (i.e. from
November 2006 to October 2008). It was decided; however, to
omit cases from the initial two month period as the high number
of incorrectly completed forms due to an adjustment period during
this time was likely to affect the overall results, making them less
representative.
A retrospective case note review was carried out to examine the
demographic characteristics, the reasons for referral, the past
psychiatric history, diagnosis and presenting symptoms of these
patients. Where full medical notes were not available, all data was
retrieved from copies of initial assessments, electronically recorded
patient details and copies of MHA 2001 forms.
16
* Elaine Dunne,South Lee Mental Health Services,Cork University Hospital, Wilton, Co. Cork, Ireland.E-mail [email protected]
Eamon Moloney,Consultant Psychiatrist/Clinical Director,South Lee Mental Health Services,Cork University Hospital, Wilton, Co. Cork, Ireland.
Submitted January 13th 2011Accepted August 15th 2011
Ir J Psych Med 2012; 29 (1): 16-21
* Correspondence
The application, medical recommendation and admission order
forms were reviewed and specific details recorded. Data in relation
to patients where an admission order was completed was
compared to data in relation to those patients where an admission
order was not completed and comparisons were also made with
national data on patients admitted under the MHA 2001.
Voluntary patients who were regraded and detained under the
MHA during their admission were not included.
All statistical calculations were performed using Graph Pad Prism
version 4.0 for windows (Graph Pad Software, San Diego, CA,
USA) and student t test (Mann Whitney U test for nonparametric
data) or Chi square test/Fisher’s exact test were used as appropriate
to identify significant differences between groups.
Results
During the 22 month study period, 171 patients presented to the
unit with an application and recommendation for involuntary
admission completed. 81% (n=139) of these patients were
detained under the MHA following the completion of an admission
order. Comparison of details of those who were detained to
available national statistics and secondly, to those who were not
detained, is presented in Table 1 and Table 2, respectively.
Almost three quarters of those patients who presented for
assessment for involuntary detention did so outside of regular
working hours with 29% (n=50) presenting between 9am and
5pm, Monday to Friday.
In 29% (n=50) of presentations, the patient was brought to the
approved centre by the gardai without an assisted admission team
or relatives. This occurred significantly more often in those patients
where an admission order was not subsequently completed than in
those patients who were subsequently detained under the MHA,
50% (n=16) and 24% (n=34) respectively (xx2 = 8.20 ; p=0.0042)
For the group of patients where an admission order was not
completed, there was a significantly higher number of applications
made by a garda compared to the group where an admission order
was completed (31% (n=10) v 12% (n=16); xx2 = 7.86; p=0.0051).
Of all patients presenting with MHA forms during this time, 56%
(n=95) had their medical recommendation made by their own
General Practitioner. This includes 60% (n=84) of those who were
detained and only 34% (n=11) of those who were not detained.
The difference was statistically significant (xx2 = 7.15; p=0.0075).
There was a significant difference between General Practitioners
and Consultant Psychiatrists in relation to the criteria used for
recommendation or admission (Table 3). In relation to those
patients who were detained under MHA, 40% (n=56) of general
practitioners considered the patient to be a risk to self or others
but only 20% (n=28) of consultant psychiatrists thought so (xx2 =
12.52; p=0.0004). Consultant Psychiatrists used criterion (b) alone
(risk of serious deterioration etc.) in 68% (n=95) of completed
admission orders, which was a significantly higher rate than the
50% (n=70) of cases for GPs (xx2 = 8.57; p=0.0034). There was no
difference in the number of times in which consultant psychiatrists
and GPs felt that both criteria were satisfied (12% (n=17) and 7%
(n=10) respectively). Neither box was ticked by the GP in 3% (n=4)
of cases. The Consultant and GP opinion as to the reason for
admission differed in 37% (n=41) of individual cases.
In relation to primary diagnosis, there was a significantly higher
frequency of substance misuse related illness (38% (n=12) v 4%
(n=5); Fisher’s exact test p<0.0001) and personality disorder (9%
(n=3) v 0% (n=0); Fisher’s exact test p=0.0061), and a lower
frequency of schizophreniform illness (19% (n=6) v 53% (n=74); xx2
= 12.43; p=0.0004) in those who were not detained compared to
those patients where an admission order was completed. There
was no significant difference between the groups in relation to all
other primary diagnoses.
Similar proportions of those with a primary diagnosis of substance
abuse were actually reported to have a dual diagnosis (20% (n=1)
of those detained v 25% (n=3) of those not detained). 60% (n=3)
of those admitted as involuntary patients despite a primary
diagnosis of substance abuse had a secondary psychotic illness and
20% (n=1) had a secondary depressive illness. One person (0.8%)
from the group of patients with a primary diagnosis of substance
abuse who were not detained had a secondary psychiatric illness
(alcohol dementia). Of note, the Mental Health Act 2001 does not
permit detention as an involuntary patient based on a diagnosis of
substance dependence or personality disorder.
In addition, those who were detained were less likely to be using
substances at the time of presentation than those who were not
detained (25% (n=35) v 44% (n=14); xx2 = 4.39; p=0.0362).
The final part of the study examined the outcomes of the group of
patients who were not detained (Table 4). 6% (n=2) of those who
presented with MHA forms but who were not initially detained
were admitted or regraded as involuntary patients within a week
of presentation.
Discussion
This study sought to explore how Part 2 of the MHA 2001 was
operating in a busy, acute psychiatric service. The importance of
striking a balance between ensuring that those patients who have
an acute psychiatric illness and are at risk, receive appropriate
treatment, and avoiding unnecessary infringements of a person’s
liberty is of critical importance in a modern mental health service.
Recent research examining the attitudes of psychiatrists2,3 and
service users4 with regards to involuntary admission under the MHA
2001 suggests that, though significant concerns remain among
psychiatrists regarding multiple aspects of implementation of the
Act, service users reflected positively on their involuntary admission.
The vast majority of patients presenting for admission under the
MHA are presenting outside of normal working hours; in just over
half of all cases (56%), the medical recommendation is made by
the patient’s own general practitioner and in approximately one
third of cases the admission order is completed by the patient’s
sector consultant. This may simply reflect the emergency nature of
MHA admissions but the involvement of professionals who are
17
most familiar with patients potentially requiring detention under
the MHA is to be preferred. There may be scope to plan MHA
assessments so that a patient’s own GP and Consultant Psychiatrist
are involved in these decisions but this is obviously not always
possible.
Approximately four out of every five patients presenting for
admission under the MHA had an admission order completed and
seventy five per cent of those patients where an admission order
was not completed were admitted to hospital either as a voluntary
psychiatric admission or to a general hospital ward. The latter
figure highlights the importance of always considering an organic
cause to a psychiatric presentation. Overall, only 4% of those
presenting for admission under the MHA did not require inpatient
treatment, indicating that the vast majority of patients presenting
in these circumstances warranted referral to hospital.
The demographic characteristics and diagnoses of patients in this
study were mainly similar to those of patients included in the
Mental Health Commission’s review of the MHA, though the study
group had a higher proportion of patients with a diagnosis of
schizophrenia. 22% (n=332) of those in the national statistics did
not have a diagnosis recorded however and it is likely that at least
some of these would have had a diagnosis of a schizophreniform
illness. Rates for schizophreniform and affective illnesses were
similar to recent studies in other centres.5
Those patients who were not detained were more likely to have a
primary diagnosis of substance abuse related disorder or
personality disorder and of course both personality disorder and
alcohol or drug dependence are specifically excluded as conditions
where admission under MHA 2001 is allowed. This is an
interesting finding, highlighting the fact that general practitioners
continue to recommend involuntary admission for those with a
diagnosis of substance dependence despite the rules of the Act. It
raises the issue as to whether forms which report substance
dependence as the reason for admission should be automatically
considered invalid if no other diagnosis is specified and rewritten
if necessary. It appears that currently, the process tends to continue
regardless of the reported illness mentioned on the application and
recommendation forms.
One concern from the findings in relation to substance
dependence might be that patients with a dual diagnosis who
need admission may be prevented from being admitted as
involuntary patients due to the stipulations in the Act. This however
is unlikely to have been the case here as most (66%; n=8) of those
with a diagnosis of substance abuse who were not detained had
no other psychiatric illness recorded and none of this group has
required involuntary admission since that presentation.
Patients who were not subsequently detained were more likely to
have had an application made by a Garda and a medical
recommendation made by a general practitioner who was not
known to them. This group of patients were more likely to have
been conveyed to the approved centre by the gardai and to have
no past psychiatric history. These findings draw attention to the
particular group of patients presenting for involuntary admission in
emergency situations without the input of someone who is known
to them. These people tended not to require detention under the
Act, and though these situations may be difficult to avoid,
especially where the person is unknown to the service, every effort
should be made by those making the application and
recommendation to gain collateral from someone known to the
patient so that any unnecessary referrals for involuntary admission
could be avoided if possible.
This also emphasises the importance of appropriate training of
those commonly involved in the process of involuntary admission
and in particular, that it is essential to provide feedback to those
parties where an inappropriate application is made. This is often
overlooked in a busy service and it is frequently difficult to contact
those who may have been involved in the emergency situation.
There may be a role for introducing standard procedures whereby
feedback should be carried out automatically by the team, for
example, within a week to discuss the case and why the person
did not require involuntary admission, where an application and
recommendation have been made but the patient is not detained.
This would hopefully reduce the frequency of such instances and
improve communication between parties involved.
The legal criteria for making a medical recommendation for
involuntary admission by a general practitioner or an admission
order by a consultant psychiatrist are detailed on the relevant forms
5 and 6 respectively. The general practitioner or consultant
psychiatrist must be satisfied that the patient is suffering from a
mental disorder and that criterion (a), criterion (b) or both criteria
(a) and (b) are satisfied. Criterion (a) refers to “a serious likelihood
of the person concerned causing immediate and serious harm” to
self or others and criterion (b) refers to the person’s impaired
judgement and that failure to admit the person “would be likely to
lead to a serious deterioration” in their condition or “prevent the
administration of appropriate treatment that could be given only by
such admission” and that this “would be likely to benefit or
alleviate the condition of that person to a material extent”. Of
note, recommendation and admission order forms originally only
permitted a choice of either (a) or (b). The forms were revised,
however, midway through the study in December 2007 following
a court case, to add the possibility of both (a) and (b) applying.
In almost two thirds of cases there was agreement between the
Consultant Psychiatrist and General Practitioner as to the reason
for involuntary admission. However, General Practitioners seemed
to have a significantly lower threshold for believing that the patient
was a risk to themselves or others. This is not surprising given that
Consultant Psychiatrists should be the most qualified to make an
accurate assessment of risk. Also, it is much more appropriate that
there is a tendency of general practitioners to over, rather than
under estimate risk. Disagreements as to the reason for detention
may be explained by the fact that the patient may have improved
with treatment by the time they were assessed by the Consultant.
Another explanation may be that General Practitioners may have
a different understanding or interpretation of the term “serious
and immediate risk” compared to Consultants.
A limitation of the study is that the number of people in the group
who were not detained is small relative to the group who were
detained. In addition, the group examined were from one
catchment area and may not be representative of other services.
18
Most figures, however, are consistent with national statistics and
therefore the profile of patients in other similar services would not
be expected to differ greatly. The main strength of the study is that
it provides a comprehensive profile of those all those presenting to
an approved centre under the MHA 2001 over a substantial period
of time, identifying a number of key areas of interest.
Conclusion
This study examines every case where a patient was brought to a
busy acute unit for involuntary admission over a substantial time
period. Over 70% of those presenting did so outside of normal
working hours highlighting the emergency nature of acute
psychiatry. Application and recommendation for involuntary
admission is a serious process which impacts on a patient’s freedom
and should only occur in the best interests of the patient. It is
particularly important to examine cases where the patient is not
subsequently detained. Reassuringly, out of all of those presenting
for involuntary admission, only 4% did not require any form of
admission to hospital. Similar to recent research in this area,5 the
findings of this study suggest a need for further education for
those involved in the process of application and recommendation,
in particular for the Gardai and General Practitioners, and feedback
where an inappropriate presentation for involuntary admission
occurs. Involuntary admissions most frequently occur in the context
of emergency situations, however, it is clear that every effort should
be made to involve people known to the patient in each step of the
process where possible.
Conflict of interest
None.
References
1. Mental Health Commission. Report on the operation of part 2 of the Mental
Health Act 2001(April 2008) available at http://www.mhcirl.ie/Publications
2. O’Donoghue B., Moran B. Consultant psychiatrists’ experiences and attitudes
following the introduction of the Mental Health Act 2001: a national survey.
Ir J Psych Med 2009 Mar; 26(1): 23, 24-6
3. Jabbar F., Kelly BD., Casey P. National survey of psychiatrists’ responses to
implementation of the Mental Health Act 2001 in Ireland. Ir J Med Sci 2010;
179: 291-294
4. O’ Donoghue B., Lyne J., Hill M., Larkin C., Feeney L., O’Callaghan E.
Involuntary admission from the patients’ perspective. Soc Psychiat Epidemiol
2010; 45:631-638
5. Rafiq A., O’Hanlon M. An audit of incomplete involuntary admissions to an
approved Irish centre. Ir J Psych Med 2010 Sep; 27(3): 143-147
19
Table 1: Comparison of study patients who were detained and the national statistics.
Detained National �X2/Fisher’s ORFigures1 Exact Test 95% CI
n % n %
GenderMale 80 58 831 55 1.10;
Female 59 42 632 45 0.26;p=0.61 0.77 to 1.56
Age18-64 114 82 1251 83 0.92:
65+ 25 18 252 17 0.13;p=0.71 0.58 to 1.45
Diagnosis
Schizophreniform illness 74 53 585 39 10.85;p=0.001* 1.79; 1.26 to 2.53
Mania 37 27 313 21 2.55;p=0.11 1.38; 0.93 to 2.05
Depression 8 6 84 6 0.0007;p=0.93 1.03; 0.49 to 2.18
Organic 13 9 84 6 3.24;p=0.07 1.74; 0.95 to 3.21
Substance related 5 4 57 4 0.01;p=0.92 0.95; 0.38 to 2.42
Personality 0 0 9 1 p=1.00 0.56; 0.03 to 9.75
Neurosis 2 1 22 1 p=1.00 0.98; 0.23 to 4.23
No Mental Illness 0 0 0 0 N/A N/A
Applicant
Relative 108 78 1034 69 4.76;p=0.03* 1.58; 1.04 to 2.39
Authorised Officer 4 1 102 7 p=0.07 0.41; 0.15 to 1.12
Member of Public 11 8 132 9 0.12;p=0.73 0.89; 0.47 to 1.70
Gardai 16 12 235 15 1.67;p=0.20 0.70; 0.41 to 1.20
Note: National figures relate to patients detained using Form 6 nationally in 2007.*statistically significant difference
20
Detained (n=139) Not detained (n=32) t, U or Χ2;p value* OR95% CI
n % n %GenderMale 80 58 16 50 0.60; 0.44 1.36Female 59 42 16 50 0.63 to 2.93
Age18-64 114 82 26 81 2119;65+ 25 18 6 19 0.64
Diagnosis
Schizophreniform illness 74 53 6 19 12.43; 0.0004* 4.91.91 to 12.74
Mania 37 27 5 16 1.70; 0.19 1.960.70 to 5.47
Depression 8 6 2 6 1.00 0.920.19 to 4.54
Organic 13 9 3 9 1.00 0.990.27 to 3.73
Substance related 5 4 12 38 < 0.0001* 0.0620.02 to 0.20
Personality 0 0 3 9 0.01 0.030.0015 to 0.60
Neurosis 2 1 0 0 1.00 1.180.06 to 25.23
No Mental Illness 0 0 1 3 0.19 0.080.00 to 1.89
History of mental illness 122 88 17 53 22.45; 7.06< 0.0001* 2.93 to 16.98
Known to service 112 81 14 44 18.24; 0.19< 0.0001* 0.08 to 0.42
On Call Presentation 96 69 26 81 1.89; 0.17 0.520.20 to 1.35
Applicant
Relative 108 78 20 63 3.19; 2.090.07 0.92 to 4.75
Authorised Officer 4 1 0 0 1.00 2.090.11 to 39.90
Member of Public 11 8 2 6 1.00 1.250.26 to 5.93
Gardai 16 12 10 31 7.86; 0.290.0051* 0.12 to 0.71
Arrival
Family/Nursing home 53 38 10 31 N/A 0.53; 0.47 1.360.60 to 3.09
Gardai only 34 24 16 50 N/A 8.20; 0.320.0042* 0.15 to 0.72
Assisted admission 37 27 4 13 N/A 0.11 2.540.83 to 7.73
Ambulance 8 6 2 6 N/A 1.00 0.920.19 to 4.54
Transfer from another ward 7 5 0 0 N/A 0.35 3.680.20 to 66.14
Recommendation 84 60 11 34 N/A 7.15 2.92by own GP 0.0075* 1.30 to 6.52Assessed by 52 37 11 34 N/A 0.10; 0.75 1.14sector consultant 0.51 to 2.56Collateral Available 112 81 29 91 N/A 0.21 0.43
0.12 to 1.51Current Substance Use 35 25 14 44 N/A 4.39; 0.43
0.0362* 0.20 to 0.96English speaking 137 99 30 94 N/A 0.16 4.57
0.62 to 33.74
* statistically significant difference
Table 2: Comparison of study patients who were detained to those not detained
21
Table 3. Criteria used for recommendation and admission
Criteria for admission General Practitioner Consultant Psychiatrist Statistic
n % n %
(a) 56 40 28 20 Χ2 =12.52;p=0.0004*(b) 70 50 95 68 Χ2 = 8.57;p=0.0034*(a) and (b) 10 7 17 12 Χ2 =2.01;p=0.1563Neither 4 3 0 0 Fisher’s exact test; p=0.1223
(a)=Risk of immediate and serious harm to self or others.
(b)=Risk of serious deterioration etc.
*statistically significant difference
Table 4. Outcome where admission order was not signed
n %
Voluntary admission 22 69
Discharge 8 25
Other admission (e.g. medical) 2 6
Involuntary admission within one week 2 6
Note: those who were admitted as involuntary patients within one week are also included in the numbers of patients admitted voluntarily,
discharged or admitted medically.
Objective: To determine the prevalence of mental illness amongthe residents of a homeless hostel in inner city Dublin.
Method: A cross-sectional survey was carried out among hostelresidents, as previous studies have indicated that homeless hostel-
dwelling men in Dublin constitute the largest single grouping of
homeless Irish people. All agreeable residents were interviewed by
the authors over an eight-week period using the Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID-I) Clinical Version. For
each disorder, the current (30-day) and past prevalence was
determined.
Results: A total of 38 residents were interviewed, resulting in aresponse rate of 39.2% for the study. A total of 81.6% of residents
had a current Axis I diagnosis; this number increased to 89.5%
when combining current and past diagnoses. Only four residents
had no diagnosis. There was considerable comorbidity between
disorders, with a significant number of residents experiencing both
mental illness and substance use problems. When considering
lifetime diagnoses, 31.6% had a single diagnosis only; 57.9% had
two/more diagnoses. Twelve residents (31.6%) had been admitted
to a psychiatric hospital during their lifetime. The most prevalent
disorders during the past month were Alcohol Dependence
(23.7%), Opioid Dependence and Major Depressive Disorder (both
18.4%), Opioid Abuse and Alcohol-Induced Depression (both
7.9%). Only 23.7% of interviewed residents were attending
psychiatric or addiction services. A significant number of residents
who did not wish to participate in the study were identified by
hostel staff as having a confirmed psychiatric diagnosis.
Conclusion: The survey demonstrated a very high prevalence ofmental disorders among homeless hostel residents. The high
prevalence of dual diagnosis highlights the need for greater
collaboration between psychiatric services and addiction services.
The outcome also points to the importance of providing mental
health training to emergency shelter/hostel staff. Research into the
mental health status of the homeless should be undertaken
regularly if services are to be planned to meet the needs of this
vulnerable group.
Key words: Homeless, Hostel, Mental illness, Dual diagnosis
Introduction
PREVALENCE OF MENTAL ILLNESS AMONG THE HOMELESS
Studies have consistently demonstrated high rates of mental
disorders among people who are homeless.1 The rates of
psychiatric morbidity among homeless adults will vary according
to the type of homelessness: sleeping rough, using a night shelter,
staying in special hostels, and using temporary leased
accommodation.2 International comparisons also demonstrated
significant cross-cultural differences in the prevalence of mental
disorders among the homeless.1
In an Australian study 73% of homeless men and 81% of homeless
women in inner Sydney met criteria for at least one mental disorder
in the past year and 40% of the men and 50% of the women had
at least two mental disorders.1 Among the homeless population in
Utrecht, The Netherlands, 32% of people had depression, 15% a
schizophrenic disorder and 52% an antisocial personality disorder.3
In Madrid, Spain, 67% of homeless people had some type of
mental disorder.4 In Stockholm, Sweden, 47% of the homeless
suffered from mental illness.5 A survey in Belfast indicated that
approximately 25% of the homeless in Belfast hostels have a
diagnosed mental disorder.6
The most prominent mental disorders among the homeless are
depression, affective disorders, substance abuse, psychotic
disorders, schizophrenia, and personality disorders.7 Significant
numbers of homeless people experience the coexistence of mental
health issues and substance use problems (dual diagnosis).8
THE RELATIONSHIP BETWEEN HOMELESSNESS AND MENTAL
ILLNESS
The causal link between homelessness and mental ill-health is the
subject of an ongoing debate. Some argue that the psychiatric
problems of many of the homeless may result directly from their
poverty and associated lack of accommodation. Others contend
that the majority first experienced their symptoms of mental
disorder before becoming homeless.2
22
*Bernice Prinsloo,Registrar,Child & Adolescent Psychiatry, Our Lady’s Children’s Hospital,Crumlin, Dublin 12, Ireland.E-mail [email protected]
Catherine Parr,Registrar in Psychiatry,James Connolly Memorial Hospital,Blanchardstown, Dublin 15, Ireland.
Joanne Fenton,Consultant Psychiatrist,ACCES Team,Dublin 8, Ireland.
Submitted December 15th 2010Accepted March 21st 2011
Ir J Psych Med 2012; 29 (1): 22-26
Original Paper
Mental illness among the homeless: prevalence studyin a Dublin homeless hostelBernice Prinsloo, Catherine Parr, Joanne Fenton
* Correspondence
According to Dr Joe Fernandez, former Director of the Programme
for the Homeless in St Brendan’s Hospital in Dublin, a distinction
must be drawn between “mental health problems” induced byhomelessness, and “mental illness” which may be a factor inbecoming or remaining homeless; both of which should be
attended to by primary care agents i.e. general practitioners, or by
the mental health services.9 Research suggests that the experience
of being homeless may contribute to anxiety or depressive
illnesses.10 On the other hand, a significant factor in precipitating
homelessness is serious mental illness, and alcohol or drug
addiction. It is also accepted that homelessness may exacerbate a
previous existing mental condition.11
CONSEQUENCES
Homelessness amongst the mentally ill is associated with a range
of other factors, including substance abuse, younger age at first
hospitalisation, and greater severity of symptoms compared to
individuals with mental illness who are not homeless.12 Many
homeless people with a dual diagnosis of mental illness and drug
or alcohol misuse find themselves without a service, since existing
services consider themselves to be either psychiatric services or
addiction services, with poorly defined collaborative functions.13
The homeless mentally ill also appear to encounter a range of
specific, additional problems in relation to housing including, for
example, difficulties accessing community care services following
discharge from hospital.14 A Crisis survey performed in 2002 found
that the homeless people interviewed were almost 40 times more
likely not to be registered with a GP than the average person. Poor
access to primary care services has a direct impact on other health
care services, with an increased likelihood of people attending
A&E.15
Social integration and participation, as well as employment and
meaningful life activities are compromised by the presence of
persistent and untreated psychiatric and physical health problems
for individuals who are homeless. The ability to take steps forward
may be limited due to a combination of poor life skills, ongoing
mental health issues and/or substance use problems, as well as
disruptive life events (lack of stable residence, lack of regular
income, victimisation related to street life).15 Individuals with mental
illness also tend to encounter substantial problems adapting to
housing following lengthy periods of homelessness and many of
these problems go on to complicate their broader re-integration
into society.16
HOMELESSNESS AND MENTAL ILLNESS IN IRELAND
Holohan conducted the first study to examine the health of the
adult homeless population in Dublin in 1997. Sixty six per cent of
people had at least one physical or psychiatric problem. Chronic
physical disease was reported by 41%. The prevalence of
depression in this study was 32.5% and for anxiety disorders
27.6%.17 In 1999 Feeney et al built on this work and examined the
health status and perception of health service access of homeless
hostel-dwelling men in Dublin. In this study 52% of men suffered
from depression, 50% from anxiety and 4% from other mental
health problems. Fifty percent of hostel residents were defined as
alcohol dependent, with 29% having severe alcohol dependence.
More than one third of respondents reported having engaged in
illicit use of at least one drug in the previous year.10
O’Neill et al conducted an audit in 2003 to determine the
proportion of those attending the Mater Misericordiae Hospital’s
psychiatric service that were homeless, including those presenting
to accident and emergency who were homeless. Of all the A&E
referrals to psychiatry, 34.8% were homeless. The homeless
presented most commonly in suicidal crisis (26.6%) compared with
12.5% in the non-homeless group. Substance-abuse disorders
were the primary diagnosis in 42.3% of the homeless group,
accounting for 14.2% in the housed sample.18
Considerable difficulty arises for homeless people in accessing
mental health care due to the sectorisation of services into
catchment areas.13 In Dublin this has resulted in increased pressure
on the two assertive community mental health teams providing
service to the homeless population, based in North Dublin and
South Dublin respectively.
The burden resulting from the gaps in statutory service provision for
homeless people with, or at risk of mental illness, falls on voluntary
homeless service providers and on the wider health and social
services, all of which are already under enormous strain. The
consequences impact severely on the quality of life for homeless
people with mental illness. The Simon Communities of Ireland, a
voluntary homeless agency has said: “[we] are extremely concerned
at the increase … witnessed in the numbers of people who are
homeless who are presenting with mental ill health. The lack of
access to assessment and treatment services by people who are
homeless further exacerbates the problem – leaving individuals very
vulnerable, and homeless services struggling to ensure they meet
service users’ needs.”13
In A Vision for Change several recommendations were made inrelation to mental health services for homeless individuals.19 There
is however still a long way to go towards implementing this policy
in the context of homelessness.
Objective
The objective of the study was to determine the prevalence of
mental illness among the residents of an emergency hostel located
in inner city Dublin. The hostel provides direct access, emergency
and short term accommodation for 74 single homeless men aged
over 26. The hostel is managed in partnership by Depaul Trust and
SVP.20 Previous studies have indicated that homeless hostel-
dwelling men in Dublin constitute the largest single grouping of
homeless Irish people.10
Method
A cross-sectional survey was carried out among hostel residents.
Posters were placed on a public notice board at the hostel inviting
residents to participate in the study; they were asked to inform
their key workers should they wish to participate. All agreeable
residents were then interviewed at the hostel by the authors over
an eight-week period from June to August 2010. All participants
23
24
were given €10 as an incentive; this was provided on completion
of each interview. This procedure has been used in other studies to
maximise response rates.10
Residents were interviewed using the Structured Clinical Interview
for DSM-IV Axis I Disorders (SCID-I) Clinical Version. For each
disorder, the 30-day (current) and past prevalence was determined.
The interviewers were psychiatrically trained and familiar with the
DSM-IV diagnoses. Inter-rater reliability was determined between
the interviewers.
Results
A total of 38 residents were interviewed. During the study period
128 men used beds at the hostel; of these 31 were emergency bed
users, simply occupying rooms with no key worker input. Not
taking these 31 men into account, a response rate of 39.2% was
achieved for the study. Characteristics of participating residents are
displayed in Table 1, with SCID-CV Diagnoses summarised in Table 2.
Table 1. Demographic profile of study participants
n (%)Age26-39 12 (31.6)
40-54 18 (47.4)
≥55 8 (21.1)
Mean 45.87 years
Marital statusNever married 22 (57.9)
Married/Cohabiting 4 (10.5)
Separated 6 (15.8)
Divorced 6 (15.8)
ChildrenYes 26 (68.4)
No 12 (31.6)
Educational statusPrimary level 5 (13.2)
Secondary level without graduating 28 (73.7)
Graduated secondary level 2 (5.3)
Higher qualification 3 (7.9)
EmploymentRegular 1 (2.6)
Casual/Volunteer work 2 (5.3)
Unemployed 35 (92.1)
Ethnic originIrish 35 (92.1)
UK 3 (7.9)
Table 2. Prevalence of DSM-IV Axis I Disorders among hostelresidents
*Full criteria have been met during the past month
Mood DisordersBipolar I Disorder, Most Recent Episode Mixed
Bipolar II Disorder, Hypomanic
Major Depressive Disorder
Single Episode
Recurrent, Moderate
Recurrent, In Partial Remission
Recurrent, In Full Remission
Depressive Disorder NOS
Alcohol-Induced Mood Disorder, Depressed
Other Substance-Induced Mood Disorder, Depressed
Schizophrenia and Other Psychotic DisordersSchizophrenia, Paranoid Type
Substance Use DisordersAlcohol Dependence
Alcohol Abuse
Cannabis Dependence
Cocaine Dependence
Opioid Dependence
Sedative, Hypnotic, or Anxiolytic Dependence
Amphetamine Abuse
Cannabis Abuse
Cocaine Abuse
Hallucinogen Abuse
Inhalant Abuse
Opioid Abuse
Phencyclidine Abuse
Sedative, Hypnotic, or Anxiolytic Abuse
Other (or Unknown) Substance Use
Anxiety DisordersPanic Disorder With Agoraphobia
Posttraumatic Stress Disorder
Anxiety Disorder NOS
Other Substance-Induced Anxiety Disorder
With Generalised Anxiety
With Phobic Symptoms
Adjustment DisordersAdjustment Disorder With Anxiety
Current*n (%)
1 (2.6)
1 (2.6)
1 (2.6)
4 (10.5)
1 (2.6)
1 (2.6)
1 (2.6)
3 (7.9)
2 (5.3)
2 (5.3)
9 (23.7)
2 (5.3)
7 (18.4)
1 (2.6)
2 (5.3)
1 (2.6)
3 (7.9)
1 (2.6)
2 (5.3)
2 (5.3)
1 (2.6)
1 (2.6)
1 (2.6)
Pastn (%)
1 (2.6)
1 (2.6)
1 (2.6)
11 (28.9)
3 (7.9)
2 (5.3)
1 (2.6)
1 (2.6)
2 (5.3)
2 (5.3)
4 (10.5)
2 (5.3)
1 (2.6)
3 (7.9)
1 (2.6)
1 (2.6)
2 (5.3)
A total of 81.6% of residents had a current Axis I diagnosis; this
number increased to 89.5% for lifetime diagnoses (when
combining current and past diagnoses). Only four residents had no
diagnosis. When considering lifetime diagnoses, 31.6% had a
single diagnosis only; 57.9% had two/more diagnoses. Twelve
residents (31.6%) had been admitted to a psychiatric hospital
during their lifetime. Sixteen residents (42.1%) had a lifetime
diagnosis of any depressive disorder, two residents (5.3%) of a
psychotic disorder, 30 residents (78.9%) of any substance use
disorder, and 7 residents (18.4%) of an anxiety/adjustment
disorder.
The most common current and past diagnosis was Alcohol
Dependence, with 52.6% of residents meeting the criteria for
either current or past dependence. The most prevalent current
diagnoses are displayed in Figure 1.
Figure 1. Most prevalent Axis I Disorders during the pastmonth
Only 23.7% of interviewed residents were attending an outpatient
department (either psychiatric or addiction services); in addition
one resident was attending a counsellor and one was attending
AA. The majority were not linked in with any service.
The Specialist Support Worker at the hostel was able to provide
some information on the 59 hostel residents who did not wish to
participate in the study. Of these men, 14 (23.7%) had evidence of
mental illness. Six of these residents reportedly had a diagnosis of
Schizophrenia; five of them were linked in with psychiatric services.
An additional eight residents suffered from Depression (one of
them having a diagnosis of Bipolar Affective Disorder); of these six
were under the care of their GP, one was linked in with psychiatric
services and the resident with Bipolar Affective Disorder had been
refusing intervention in recent years. Another resident had no clear
diagnosis but had previously been admitted to a psychiatric
hospital.
Discussion
The survey demonstrated a very high prevalence of mental
disorders among homeless hostel residents. Comparing prevalence
rates with other cities and countries is difficult though due to
different definitions used for homelessness, differing diagnostic
criteria/interview techniques and different timeframes used (e.g.
lifetime/12-month/30-day prevalence).
The response rate of 39.2% in this study is low compared to other
studies.17,21 A possible explanation for this could be that the
interviews were conducted over a period of eight weeks, as
opposed to some studies where interviews were conducted
together within a few days. It is worth noting that reasons for
nonparticipation in research may also be related to severe mental
illness.21
There was considerable comorbidity between disorders, with a
significant number of residents experiencing both mental illness
and substance use problems. Both alcohol and substance use
disorders were highly prevalent, as has also been found in other
studies. A systematic review of the prevalence of mental disorders
among the homeless found that alcohol dependence and drug
dependence were the most common disorders in this group.21
Combining depressive disorders (including those that are alcohol
and substance-induced) results in a current prevalence of 34.2%.
This is similar to the rate found in a previous study examining the
health of the adult homeless population in Dublin; in that study
32.5% of homeless individuals reported depression.17 The current
prevalence of anxiety disorders was 10.5%, which is much lower
than the rate of 27.6% in the previous study.17 This low rate is
surprising as many men have been exposed to trauma and
violence. A possible explanation for this could be stricter diagnostic
criteria used in this study.
Of note only 5.3% of the sample were identified as having a
psychotic disorder, which is lower than expected compared to
some other studies.1,3,22 The prevalence would increase slightly if
one were to take into account those mentioned residents who did
not want to participate in the study. The systematic review
previously mentioned found that the prevalence rates for psychotic
illness among the homeless in western countries ranged from
2.8% to 42.3%. The review found that lower participation in
surveys was associated with lower prevalence of psychosis.21
The low number of residents attending services is cause for
concern. There could be various reasons for this, including the
differentiation between psychiatric and addiction services,
sectorisation of services into catchment areas, stigma of psychiatric
care, and shelter/hostel staff having limited experience in assessing
for or managing mental illness or addiction. In addition both
physical and psychiatric care rank low in homeless people’s list of
priorities. The demands of securing immediate needs for survival –
food, shelter, money – are more pressing than appointments with
doctors or nurses.23
A relatively small sample of residents were interviewed and the
study only focused on one particular group of homeless men, thus
limiting generalisability. The Specialist Mental Health Worker
actively encouraged those men with mental health problems to
attend for interview, possibly introducing selection bias. The study
was unique though in that, to the best of the authors’ knowledge,
it was the first study in Ireland assessing the complete spectrum of
Axis I Disorders; previous studies focused primarily on depression
and anxiety disorders.10,17 Interviews were conducted by
psychiatrically trained raters using a well validated measure.
25
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! !"#$%&'''()'''*+,-'''.%&/01&2-'''34",'''5'''6",+%7&%,'''7$%"2#'''-8&'''.0,-'''9+2-8!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!!
!!! ''' ''' ''' ''' ''' ''' ''' ''' ''' ''' !!!
!!!
!!!
Conclusion
The study highlights the need to address mental illness in the
homeless population, as it is experienced by so many and may be
contributing to maintaining homelessness through sustained
unemployment and social isolation. The high prevalence of dual
diagnosis highlights the need for greater collaboration between
psychiatric and addiction services. The outcome further points to
the importance of providing mental health training to emergency
shelter/hostel staff. Such training offers the potential to significantly
improve staff’s ability to respond to the needs of residents with
mental illness, and to the behavioural problems some of these
individuals may pose for shelter/hostel operation.24 Research into
the mental health status of the homeless should be undertaken
regularly if services are to be planned to meet the needs of this
vulnerable goup.13
Conflict of interest
None.
Acknowledgement
We would like to thank the following people for their assistance:
• Ms Sharon Harvey, Specialist Support Worker
• Ms Margaret Freeney, Administrative Assistant
• Dr Some Onuoha, Locum Consultant Psychiatrist
References
1. Teesson M, Hodder T, Buhrich N. Psychiatric disorders in homeless men andwomen in inner Sydney. Australian and New Zealand Journal of Psychiatry 2004; 38: 162-168.
2. Meltzer H. State-of-Science Review: SR-B6 The Mental Ill-Health of HomelessPeople. Foresight Mental Capital and Wellbeing Project. The Government Office for Sciences, 2008: 1-8.
3. Reinking DP, Wolf JR, Kroon H. High prevalence of mental disorders and addiction problems among the homeless in Utrecht. Ned Tijdschr Geneeskd. 2001; 145(24): 1161-6.
4. Vázquez C, Muñoz M, Sanz J. Lifetime and 12-month prevalence of DSM-III-R mental disorders among the homeless in Madrid: a European study using the CIDI. Acta Psychiatr Scand. 1997; 95(6): 523-30.
5. Halldin J, Eklöv L, Lundberg C, Åhs S. Mental health problems among homeless people in Sweden: focus on Stockholm. International Journal of Mental Health 2001; 3: 74-83.
6. McAuley A, McKenna HP. Mental disorders among a homeless population inBelfast: an exploratory survey. Journal of Psychiatric and Mental Health Nursing 2008; 2(6): 335-342.
7. Martens WH. A review of physical and mental health in homeless persons. Public Health Rev. 2001; 29(1): 13-33.
8. Holohan T. Health Status, Health Service Utilisation and Barriers to Health Service Utilisation among the Adult Homeless Population of Dublin. Dublin:Eastern Health Board, 1997.
9. Fernandez J. Caring for the Homeless Mentally Ill: Status and Directions. Seminar presentation for the Irish Psychiatric Association at St Patrick’s Hospital, April 2003.
10. Feeney A, McGee HM, Holohan T, Shannon W. Health of Hostel-dwelling Men in Dublin. ERHA & RCSI 2000.
11. Barry S. The Homeless Mentally Ill – discussion document, Apendix A, CluainMhuire Adult Mental Health Service Proposal: The Homeless Mentally Ill. Dublin, 2002.
12. Opler LA, White L, Caton CL et al. Gender differences in the relationship of homelessness to symptom severity, substance abuse, and neuroleptic compliance in schizophrenia. J Nerv Ment Dis 2001; 189: 449-556.
13. Crowley F. Mental Illness: The Neglected Quarter – Homelessness. Amnesty International (Irish Section), Dublin, 2003.
14. Melzer D, Hale AS, Malik SJ et al. Community care for patients with schizophrenia one year after hospital discharge. BMJ 1991; 303: 1023-1026.
15. Critical Condition: Vulnerable single homeless people and access to GPs. Crisis UK, London, 2002.
16. Yanos PT, Barrow SM, Tsemberis S. Community integration in the early phaseof housing among homeless persons diagnosed with severe mental illness. Community Ment Health J 2004; 40: 133-15.
17. Holohan TW. Health and Homelessness in Dublin. Ir Med J 2000; 93: 41-43.18. O’Neill A, Casey P, Minton R. The homeless mentally ill: an audit from an inner
city hospital. Ir J Psychol Med 2007; 24: 62-66.19. Expert Group on Mental Health Policy. A Vision for Change: Report of the
Expert Group on Mental Health Policy. Dublin: The Stationery Office, 2006.20. Homelessness Directory 2007/2008. Suffolk: Homeless Agency and Resource
Information Centre, 2006: 10.21. Fazel S, Khosia V, Doll H, Geddes J. The Prevalence of Mental Disorders among
the Homeless in Western Countries: Systematic Review and Meta-RegressionAnalysis. PLoS Medicine 2008; 5(12): 1670-1681.
22. Shanks NJ, Priest RG, Bedford A, Garbett S. Use of the delusions-symptoms-state inventory to detect psychiatric symptoms in a sample of homeless men.British Journal of General Practice 1995; 45: 201-203.
23. Timms P, Balázs J. ABC of mental health: Mental health on the margins. BritishMedical Journal 1997; 315: 536-539.
24. Vamvakas A, Rowe M. Mental health training in emergency homeless shelters. Community Mental Health J 2001; 37(3): 287-95.
26
Abstract
Objectives: The aim of this study was to determine the views ofboth individuals attending the mental health services (attendees)
and mental health professionals in relation to how attendees and
staff should be addressed, how attendees should be described, and
how staff should be attired.
Methods: We surveyed 132 attendees of the West Galway MentalHealth Services and 97 mental health professionals in relation to
how they prefer to be addressed (first name/ title and surname/ no
preference) the description of attendees (patient / client / service
user / no preference) and the attire of mental health staff (casual /
smart / no preference). We also ascertained how mental health
professionals believed attendees would view these issues.
Results: Attendees preferred to be described as patients ratherthan clients or service users by all mental health professionals, with
46-54% of attendees preferring this term “patient” compared to
14-17% preferring the term “client”, 11-13% preferring the term
“service user” and 20-25% having no preference (p < 0.001).
They preferred to address doctors by their title and surname (61%)
but other mental health professionals by their first names (60-69%)
(p < 0.001). Attendees had a strong preference for being
addressed by their first names by all the mental health professionals
(86-91%) (p < 0.001). Doctors preferred to be attired formally
(88%), compared to nurses (50%) or other mental health
professionals (42%) (p = 0.002). Attendees had no preference in
relation to the attire of doctors but preferred other mental health
professionals to be attired informally.
Conclusions: The study demonstrates that despite the increaseduse of several non-medical terms to describe attendees of mental
health services; the preferred term of attendees of the psychiatric
services in both in-patient and out-patient settings remains
‘patient’. However, this is not universally the case, and the
ascertainment of the preference of the attendee at the first
encounter with the health professional should be ascertained. We
also demonstrated that attendees preferences in relation to both
“dress and address” of doctors is significantly different to their
preference for nurses or other allied mental health professionals;
which may reflect a wish for a less familiar and more formal
interaction with doctors.
Key words:Dress, Address, Mental health professionals, Psychiatricservices
Introduction
A positive therapeutic relationship between mental health
professionals and individuals attending mental health services
(attendees) is a fundamental component of care in psychiatry,1, 2
having important implications for an attendee’s clinical
management and future prognosis.3-5 The interaction between
attendee and mental health professional incorporates many
important aspects, a number of which we analyse in this study.
These include individual preferences as to how attendees are
referred to by mental health staff (patient/ client/ service user); how
attendees are addressed by mental health staff (first name/ title
and surname); how attendees wish to address mental health staff
(first name/ title and surname); and how attendees prefer mental
health staff to be attired.
In recent years, there has been pressure from some stakeholders to
avoid using the term “patient” for attendees with the terms
“client” and “service user” in particular often utilised to describe
individuals who attend mental health services.6-10 The first of these
“non-medical” terms that became utilised was “client”, which
appears to have been adopted from Carl Rogers’ book in 1951,
“Client-Centred Therapy”. Since the 1970s “client” became
increasingly utilised to describe attendees of psychiatric services,11, 13
and appears to have arisen as “patient” had become associated
with negative connotations of sickness, paternalism, autho-
ritarianism, disability, dependence and powerlessness and
considered by some as outdated, patronising and stigmatising to
individuals with mental illness.12, 14 Thus the term “patient” has
been disparaged as the product of a narrow reductionist medical
27
Christina Sim, Registrar in Psychiatry, Departmentof Psychiatry, University College Hospital Galway,Ireland.
*Brian Hallahan,Consultant Psychiatrist, Department of Psychiatry,Roscommon County Hospital, Co. Roscommon,Ireland and Honorary Research Fellow, ClinicalScience Institute, National University of Ireland,Galway, Co Galway, Ireland.E-mail [email protected]
Colm McDonald, Professor of Psychiatry,Department of Psychiatry, Clinical Science Institute,National University of Ireland, Galway, Co. Galway, Ireland.
Submitted 15th October 2010Accepted 15th February 2011
Ir J Psych Med 2012; 29 (1): 27-32
Original Paper
Preferences of dress and address: views of attendees and mentalhealth professionals of the psychiatric services Christina Sim, Brian Hallahan, Colm McDonald
* Correspondence
model of medical illness, which fails to appreciate the individual
attendee’s mental health problems in the context of their personal
narrative and psychosocial environment. The term “client” was
viewed as de-medicalising the interaction between attendee and
medical professionals. Despite this, a number of recent studies
have found that the majority of individuals attending psychiatric
services (67% to 83%) still prefer to be referred to as “patients”,2,
15-17 although one large multi-site study noted “client” to be the
term of preference.18
In relation to addressing attendees, a number of studies have noted
that most attendees (50-79%) of the psychiatric service prefer to
be addressed by their first name,2, 19, 20 although this issue has
predominantly assessed attendees’ wishes only in relation to how
doctors address them. It has previously been noted that attendee’s
prefer to address doctors (80-95%) by their title and surname,1, 2,
20 but address allied mental health professionals (e.g. nurses, social
workers, occupational therapists) by their first names.1, 2 Little
information is available to date detailing how the seniority of the
treating clinician may impact on how attendees wish to address
their treating doctor.
Conflicting data has been attained to date in relation to the
preference of attendees regarding doctors’ attire. A number of
studies have noted that smart (formal) attire by the treating
clinician is associated with increased trust and perceived
competence by the attendee leading to an increased ability to
discuss their social, sexual and psychological problems,2, 21 however
other studies, albeit in other medical disciplines, have not
corroborated these findings.22-24 Evidence also exists that the
presence of nurse uniforms is associated with perceptions of
professionalism,25 although there is limited evidence in relation to
psychiatric nursing attire and perceptions of professionalism by
attendees or their families.
In this study, we investigated the preference of both attendees and
a range of mental health professionals (consultant doctors, non-
consultant hospital doctors (NCHD), psychiatric nurses,
occupational therapists, social workers and psychologists) in
relation to how they prefer to be addressed (first name/ title and
surname/ no preference), how they prefer to describe attendees
(patient / client / service user / no preference) and how they prefer
mental health staff to be attired (casual / smart / no preference).
The views of attendees of both the acute services (acute in-patient
and day hospital) and sub-acute services (day centres and long stay
residential unit) were ascertained as were mental health
professionals’ beliefs about how attendees view these issues.
Methods
We included 56 individuals attending the acute psychiatric services,
all consecutively admitted individuals in the acute in-patient unit
in University College Hospital, Galway and the psychiatric day
hospital in Galway, between the 17th – 30th May, 2009 and 76
individuals attending the sub-acute services, i.e. 2 day centres and
a rehabilitation unit over the same time period. Each attendee was
approached by a researcher (CS or BH) at the above sites and the
study was explained to them, and consent was attained. They filled
in the questionnaires anonymously and handed them to a staff
nurse. If they had any queries in relation to any questions, they
were able to approach a staff nurse for clarification. At the end of
the study period, a staff nurse at each location posted the
completed anonymous questionnaires to the researcher (CS). For
each attendee, we obtained data in relation to the age, gender
and diagnosis, which were corroborated by their treating clinician.
Data was analysed blind to attendee’s personal details. Attendees
during the above time period completed a one page questionnaire
detailing:
1) How they preferred to be described by mental health
professionals treating them (patient / client / service user / no
preference).
2) How they preferred mental health professionals to address them
(first name/ title and surname/ no preference).
3) What they preferred to call mental health professionals (first
name/ title and surname/ no preference).
4) How they believed mental health professionals should be attired
(casual/ smart/ no preference).
The response rate of the attendees was 97%, with all day hospital
attendees, and all individuals attending the sub-acute services
completing the questionnaires, however four attendees of the
acute in-patient unit refused to fill in the questionnaire.
A number of meetings were held with mental health professionals
where the study was explained. Mental health professionals were
informed that they could contact one of the researchers (CS or BH)
for further clarification in relation to any of the questions. All
questionnaires were filled in anonymously and were posted to the
researcher (BH). Mental health professionals, including 33 doctors,
52 nurses, four social workers, four psychologists, two
occupational therapists, two other mental health team members
working in these centres (78 acute, and 19 sub-acute) completed
the one page questionnaire detailing:
1) How they wished to describe attendees of the mental health
services (patient/ client/ service user/ no preference).
2) What they believed attendees preferred to be described as
(patient/ client/ service user/ no preference).
3) How they preferred to be addressed by attendees (first name/
title and surname/ no preference).
4) What they believed attendees prefer to address mental health
professionals by (first name/ title and surname/ no preference).
5) How they liked to address attendees (first name/ title and
surname/ no preference).
6) What they believed attendees prefer to be addressed as (first
name/ title and surname/ no preference).
7) How they believed they should be attired (smart/ casual/ no
preference).
8) Have they believed attendees prefer them to be attired (smart
(formal) / casual (smart informal)/ no preference). These terms
were explained explicitly to staff and attendees.
28
Information on their profession, gender and age was also attained.
All mental health professionals in the region were invited to
complete the questionnaire; however three doctors and 20 nurses
did not complete the questionnaire. All allied mental health
professionals completed the questionnaire.
We used SPSS 15.0 for Windows (SPSS 15.0 for Windows, SPSS
Inc, Chicago, Illinois, USA) to analyse all data. We utilised the chi
squared test to compare all group data in relation to the dress and
address of attendees and mental health professionals.
Ethical approval was attained prior to the commencement of this
study from the Research Ethics Committee of Galway University
Hospital.
Results
One hundred and thirty-two attendees of the mental health services
and 97 mental health professionals participated in this study and
their demographic and clinical data are described in Table 1.
Attendees had a preference for all mental health professionals to
refer to them as “patients” rather than “clients” or “service users”,
with 46-54% of attendees preferring this term “patient”
compared to 14-17% preferring the term “client”, 11-13%
preferring the term “service user” and 20-25% having no
preference (p < 0.001) (Table 2). Doctors, but not other mental
health professionals, preferred to use the term “patient” (p <
0.00001) (Table 3). Doctors, but not other mental health
professionals believed that attendees would prefer this term,
however doctors over-estimated this preference (p < 0.00001) and
nurses under-estimated this preference (p < 0.0001).
Attendees of the mental health services had a strong preference for
being addressed by their first name by all mental health
professionals (86-91%) (Table 2). Nurses and allied mental health
professionals preferred to address attendee’s by their first name
(94%) more frequently than doctors (49%), although this was still
the most common preference of doctors (p < 0.0001) (Table 3).
Doctors preferred to be addressed by their title and surname
(61%), unlike nurses (98%) or other mental health professionals
(100%) (p < 0.00001) (Table 3) and attendees preferred to address
doctors by their title and surname (67%), whereas they preferred
to address nurses and allied mental health professionals by their
first name (60-69%) (p < 0.001) (Table 2). Attendees did not
differentiate between consultants and NCHDs in how they wished
to address them.
Attendees had no preference in relation to the attire of doctors,
however they expressed a preference for both nurses and allied
mental health professionals to be attired in casual clothes (p < 0.05)
(Table 2). Doctors (88%), but not nurses (50%) or allied mental
health professionals (42%) preferred to be attired formally (p <
0.0001) (Table 3). Doctors (p < 0.00001) and nurses (p < 0.01) over-
estimated attendee’s wishes in relation to them being attired formally.
No significant differences were noted in our findings in relation to
gender (attendee / professional), age (attendee / professional),
location (acute / sub-acute setting) or attendee diagnosis.
Discussion
To our knowledge, this is the first comprehensive study examining
the preference of “dress and address” of both attendees and a
variety of mental health professionals in the Irish psychiatric service.
In this study, we found that the term “patient” remains the
predominant preference of attendees of mental health services,
including those attending acute and sub-acute services. This
corroborates some previous research in other countries,2, 15-17, 26 and
suggests that despite the burgeoning use of a variety of other
terms in recent years,7-10 attendees themselves continue to prefer
the term “patient”. Previously, a UK study noted that attendees of
mental health services preferred mental health professionals other
than doctors to describe them as “clients” rather than “patients”,2
however we noted no such disparity in attendees views in relation
to mental health professionals, and this may reflect a cultural
difference in the populations studied. Nevertheless, nurses and
allied mental health professionals preferred to use terms such as
“client” and “service user” more than doctors, which has been
interpreted as indicating a less hierarchical form of interaction and
more collaborative type of relationship with attendees.2 Attendees
of mental health services span a range of disorders from disabling
severe enduring mental illnesses to milder forms of illness where
non-medical therapies predominate. The term “client” implies that
an attendee is a customer and voluntarily seeks services and is
aware of their difficulties or illness.27 Our sample of attendees had
a relatively severe level of mental illness with only 10% of
individuals not having a significant psychosis or mood disorder, and
thus one may postulate that this group with significant psycho-
pathology may be more likely to consider themselves as suffering
from a medical disorder and prefer to be regarded as “patients”
rather than “clients” or “service users”. Previous research however
has not noted an effect of diagnosis and preference of address.18, 26
Our finding that attendees prefer to address doctors by their title
and surname corroborates previous findings,2, 20, 22 and suggests
that attendees and doctors have a preference for a more hierarchal
form of interaction, in contrast to the more collaborative
relationship with nurses or allied mental health professionals.
Whilst several previous studies have found that attendees prefer
doctors to be dressed formally (smartly),19-22 we found that
attendees were equally split in their views on doctor’s attire.
Previous research in a mental health service in the UK, noted that
attendees of mental health services preferred doctors to be
formally attired although they viewed this as “less friendly”.19
Whilst it has previously been suggested that individuals when more
acutely psychiatrically unwell prefer to emphasize boundaries
between themselves and doctors including preferring doctors to
be attired more formally,19 our findings did not corroborate this.
The preference of attendees for other mental health professionals
to be less formally attired again suggests a “more familiar” type of
relationship compared to the relationship with their treating doctor.
We noted a discrepancy between attendees preferences and
doctors perception of attendees preferences. Doctors over-
estimated attendees’ preference for the term “patient”, and for
doctors to be formally attired and under-estimated attendees’
preferences for being addressed by their first name. Therefore, we
29
believe that doctors and other mental health professionals can be
incorrect in relation to the preferences of attendees of the mental
health services and should ascertain their preference in relation to
how attendees wish to be addressed through direct enquiry during
the first encounter.
Our main limitation in this study was the limited data we were able
to attain from allied mental health professionals (e.g. occupational
therapists, social workers and psychologists) and thus data attained
from these groups must be interpreted with caution. Whilst we
attained data from both acute and sub-acute attendees from both
an urban and rural setting, our findings may not be generalisable
to other jurisdictions or those with less severe mental illness such as
neurotic disorders. We also only utilised descriptive terms for the
attire of mental health professionals, and despite the researchers
explaining the three options (casual, smart or no preference), these
terms are still quite subjective and the use of photographs to further
explain these terms may have been useful for individuals in
answering this question.
Conclusion
The study demonstrates that despite the increased use of several
terms to describe attendees of mental health services, the term
‘patient’ remains the preferred option of attendees of the
psychiatric services in both in-patient and out-patient settings, with
50-55% of attendees stating a clear preference for this term
compared to 14-17% preferring the term “client”, and 11-13%
preferring the term “service user”. Attendees of the mental health
services have different preferences in relation to how they should be
addressed by mental health professionals; and we believe that it is
the responsibility of the care provider to ascertain these preferences
by direct enquiry during the first encounter. Despite 88% of doctors
stating a preference for formal attire, only 30% of attendees stated
that they preferred their treating doctor to be addressed formally.
We also demonstrated that attendees preferences in relation to
both “dress and address” of doctors is significantly different to their
preference for nurses or other allied mental health professionals;
which may reflect a wish for a less familiar and more formal
interaction with doctors.
Conflict of interest
None.
30
Table 1: Demographic and Clinical Data
Attendees Mental HealthProfessionals
n (%) n (%)
Site of attendee’ treatment or mental health professional predominant workplaceAcute Services (Acute Unit / Day Hospital) 56 (42.4) 78 (80.4)Acute Psychiatric Unit 28 (21.2) 65 (67.0)Day Hospital 28 (21.2) 13 (13.4)
Sub-acute Services (Day Centre / Rehabilitation Unit) 76 (57.6) 19 (19.6) Day Centre 58 (44.0) 12 (12.4) Rehabilitation Unit 18 (13.6) 7 (7.2)
GenderMale 64 (48.5) 31 (32.0)Female 68 (51.5) 66 (68.0)
Age < 40 42 (31.8) 66 (68.0)≥ 40 90 (68.2) 31 (32.0)
Principal Diagnosis (ICD-10 classification)Organic (F00-09) 4 (3)Psychoactive substance misuse (F10-19) 10 (7.6) Schizophrenia spectrum (F20-29) 64 (48.5)Mood (Affective) Disorders (F30-39) 39 (29.5)Neurotic / Stress Related Disorders (F40-49) 3 (2.3)Personality Disorders (F60-69) 9 (6.9)Mild Intellectual Disability (F70) 1 (0.8)No formal psychiatric disorder 2 (1.5)
Mental Health Professionals OccupationDoctor 33 (34.0)Nurse 52 (53.6)Psychologist 4 (4.1)Occupational Therapist 2 (2.1)Social Worker 4 (4.1)Other team members 2 (2.1)
31
Consultant NCHD Nurse Social Worker Occupational PsychologistTherapist
n (%) n (%) n (%) n (%) n (%) n (%)
Preferred description by health professionalPatient 68 (51.5) 71 (53.8) 66 (50.0) 60 (45.5) 66 (50.0) 66 (50.0)Client 22 (16.7) 20 (15.2) 18 (13.6) 22 (16.7) 20 (15.2) 20 (15.2)Service User 15 (11.4) 15 (11.4) 17 (12.9) 17 (12.9) 16 (12.1) 16 (12.1)No Preference 27 (20.5) 26 (19.7) 31 (23.5) 33 (25.0) 30 (22.7) 30 (22.7)
Preferred address by health professionalFirst Name 115 (87.1) 113 (85.6) 120 (90.9) 116 (88.6) 117 (88.6) 117 (88.6)Title and Surname 11 (8.3) 9 (6.8) 6 (4.5) 9 (6.8) 9 (6.8) 10 (7.6)No Preference 6 (4.5) 10 (7.6) 6 (4.5) 7 (5.3) 6 (4.5) 5 (3.8)
Addressing health professionals, attendee preference*First Name 32 (24.2) 32 (24.2) 91 (68.9) 86 (65.2) 89 (67.4) 79(59.8)Title and Surname 89 (67.4) 88 (66.7) 31 (23.5) 33 (25.0) 30 (22.7) 41 (31.1)No Preference 11 (8.3) 12 (9.1) 10 (7.6) 13 (9.8) 13 (9.8) 12 (9.1)
Preferred attire of health professionalCasual (Informal) 46 (34.8) 45 (34.1) 55 (41.7) 59 (44.7) 58 (43.9) 55 (41.7)Smart (Formal) 39 (29.5) 40 (30.3) 31 (23.5) 25 (18.9) 27 (20.5) 30 (22.7)No Preference 47 (35.6) 47 (35.6) 46 (34.8) 48 (36.4) 47 (35.6) 47 (35.6)
* A significant difference was detected in relation to attendees preferences between the groups, with attendees preferring to address doctors by their title and surname and to address other mental health professionals by their first name (x2 = 137.66, df = 10, p = 1.3x10-24)
Table 2: Preferences of Attendees in relation to the dress and address of mental health professionals
Doctor Nurse Allied Mental x2 df PHealth Professionals
n (%) n (%) n (%)Preferred description of attendee 29.484 6 0.00005Patient 30 (90.9) 19 (36.5) 4 (33.3)Client 0 (0) 19 (36.5) 3 (25.0)Service User 1 (3.0) 7 (13.5) 3 (25.0)No Preference 2 (6.1) 7 (13.5) 2 (16.7)
Perceived preferred description of attendee 24.512 6 0.0004Patient 24 (72.7) 27 (51.9) 4 (33.3)Client 1 (3.0) 11 (21.2) 1 (8.3)Service User 3 (9.1) 6 (11.5) 7 (58.3)No Preference 5 (15.2) 8 (15.4) 0 (0)
Preferred address of health professional 72,447 4 6.9X10-15
First Name 5 (15.2) 51 (98.1) 12 (100)Title and Surname 20 (60.6) 0 (0) 0 (0)No Preference 8 (24.2) 1 (1.9) 0 (0)
Perceived preferred address of health professional 58.735 4 5.3x10-12
First Name 5 (15.2) 47 (90.4) 12 (100)Title and Surname 23 (69.7) 3 (5.8) 0 (0)No Preference 5 (15.2) 2 (3.8) 0 (0)
Preferred address of attendee 26.858 4 0.00002First Name 16 (48.5) 49 (94.2) 11 (91.7)Title and Surname 10 (30.3) 1 (1.9) 1 (8.3)No Preference 7 (21.2) 2 (3.8) 0 (0)
Perceived preferred address of attendee 11.250 4 0.024First Name 22 (66.7) 47 (90.4) 12 (100)Title and Surname 6 (18.2) 2 (3.8) 0 (0)No Preference 5 (15.2) 3 (5.8) 0 (0)
Preferred attire of health professional 16.528 4 0.002Casual (Informal) 4 (12.1) 25 (48.1) 6 (50.0)Smart (Formal) 29 (87.9) 26 (50) 5 (41.7)No Preference 0 (0) 1 (1.9) 1 (8.3)
Perceived preferred attire of health professional 14.643 4 0.006Casual (Informal) 1 (3.0) 20 (38.5) 3 (25.0)Smart (Formal) 26 (78.8) 26 (50.0) 6 (50.0)No Preference 6 (18.2) 6 (11.5) 3 (25.0)
Table 3: Preferences of mental health professionals, and their perceptions of attendees’ preferences
References
1. McGuire R, McCabe R, Priebe S. Theoretical frameworks for investigating and
understanding the therapeutic relationship in psychiatry. Soc Psych and
Psychiatric Epidem 2001; 36: 557-64.
2. McGuire-Snieckus, R., McCabe R, Priebe S. Patient, client or service user? A
survey of patient preferences of dress and address of six mental health
professions. Psych Bull 2003; 27: 305-8.
3. Day JC, Bentall RP, Roberts C, et al. Attitudes toward antipsychotic
medication: The impact of clinical variables and relationships with health
professionals. Arch Gen Psychiatry 2005; 62: 717-24.
4. Fakhoury WK, White I, Priebe S. Be good to your patient: how the therapeutic
relationship in the treatment of patients admitted to assertive outreach affects
re-hospitalization. J Nerv Ment Dis 2007; 195: 789-91.
5. Gaudiano BA, Miller IW. Patients’ expectancies, the alliance in
pharmacotherapy, and treatment outcomes in bipolar disorder. J Consult Clin
Psychol 2006, 74: 671-76.
6. Swift G, Zachariah M, Casey PR. A rose by any other name: psychiatric
outpatients’ views on dress and address. Ir J Psychol Med, 2000; 17: 132-34.
7. Nursing and Midwifery Council. The Code: Standards of conduct,
Performance and Ethics for Nurses and Midwives, NMC 2008.
(http://ww.nmc-uk.org/aDisplay.Document.aspx?documentID=5982).
8. British Association of Social Workers. The Code of Ethics for Social Work.
BASW, 2002. (http://www.basw.co.uk/Portals/O/CODE%200F%20ETHICS.pdf).
9. British Psychological Society. Code of Ethics and Conduct. BPS, 2006.
(http://www.bps.org.uk/downloadfile.cfm?File_uuid=5084A882-
1143-DFDO-7E6C-F1983A65C242&ext=pdf).
10. College of Occupational Therapists. Code of Ethics and Professional Conduct
(Revised). College of Occupational Therapists, 2005.
(http://www.cot.org.uk/MainWebsite/Resources/Documents/Code-of-Ethics.pdf).
11. Davis C, Davis J. “Nurse”: dynamic term for a dynamic relationship. Nurse
Manager 1992; 23: 42-3.
12. Herzberg SR. Client or patient: which term is more approprioate for use in
occupational therapy? Am J Occup Ther 1990 44: 561-4.
13. Keaney F, Strang J, Raga-JM, Spektor D, Manning V, Kelleher M, et al. Does
anyone care about names? How attendees at substance misuse services like
to be addressed by health professionals. Eur Addict Res 2004; 10: 75-9.
14. Neuberger J. Do we need a new word for patients? Let’s do away with
“patients”. BMJ 1999; 318: 1756-8.
15. Ritchie CW, Hayes D, Ames DJ. Patient or client? The opinions of people
attending a psychiatric clinic. Psych Bull 2000; 24: 447-50.
16. Upton MWM, Boer GH, Neale AJ. Patients or clients? - a hospital survey. Psych
Bull 1994; 18, 142-3.
17. Simmons P, Hawley CJ, Gale TM, Sivakumaran T. Service user, patient, client,
user or survivor: describing recipients of mental health services. The
Psychiatrist 2010; 34: 20-3.
18. Covell NH, McCorkle BH, Weissman EM, Summerfelt T, Essock SM. What’s in
a name? Preferred by service recipients. Adm Policy Ment Health 2007; 34:
443-7.
19. Gledhill JA, Warner JP, King M. Psychiatrists and their patients: views on forms
of dress and address. BJPsych 1997; 171: 228-32.
20. Gallagher J, Waldron Lynch F, Stack J, Barragry J. Dress and address: Patient
preferences regarding doctor’s style of dress and patient interaction. IMJ
2008; 101: 211-3.
21. Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect
of doctor’s attire on the trust and confidence of patients. Am J Med 2005;
118: 1279-86.
22. Lill MM, Wilkinson TJ. Judging a book by its cover: descriptivesurvey of
patients’ preferences from doctors’ appearance and mode of address. BMJ
2005; 331:1524-7.
23. Hennessy N, Harrison DA, Aitkenhead AR. The effect of the anaesthetist’s
attire on patient attitudes. The influence of dress on patient perception of
the anaesthetist’s prestige. Anaesthesia 1993; 48: 219-2.
24. Baevsky RH, Fisher AL, Smithline HA, Salzberg MR. The influence of physician
attire on patient satisfaction. Acad Emerg Med 1998; 5: 82-4.
25. Albert NM, Wocial L, Meyer KH, et al. Impact of nurses’ uniforms on
patient and family perceptions of nurse professionalism. Appl Nurs Res 2008;
21: 181-90.
26. Sharma V, Whitney D, Kazarian SS, Manchanda R. Preferred terms for users
of mental health services among service provides and recipients. Psychiatric
Services 2000; 51: 203-9.
27. Torrey EF. Patients, clients, consumers, survivors’ et al: What is in a name?
Schiz Bull 2010, in press.
32
Abstract
Drawings can be used as an important tool to measure children’s
perception and emotions. Using a qualitative design, we asked a
group of 24 school children (10 boys and 14 girls) aged 11-12 to
draw their impressions of psychiatrists. In the majority of drawings,
psychiatrists were portrayed as a friendly or kind figure. The art
work was analysed by the coordinator of the Arts Initiative in
Mental Health, Niamh O’Connor. Psychiatrists were portrayed
positively by this group of young people. This reflects a strong
influence of the media on children’s perception.
Introduction
Public perception of psychiatry is influenced by several factors such
as personal experience, the media and the experience of family
members and friends.1 A positive attitude towards the profession
will help reduce the stigma of mental illness. Several studies have
examined the public attitude towards mental illness,2, 3 patients
with mental health problems,2, 4 and psychiatric treatments.5-7 Less
is known about how psychiatrists are perceived by the general
public. A telephone survey in New Zealand found that psychiatrists
were perceived negatively compared with dentists, family doctors
and lawyers. Forty eight percent of the study population did not
know that psychiatrists are medical doctors, and 60% did not
know the difference between psychiatrists and psychologists.8 In
the UK , 412 adults were given a list of 26 professions and were
asked to rank according to which they most respected, psychiatrists
came 8th above jobs such as bank managers, accountants and
MPs. However, psychiatrists had the lowest ranking compared to
other medical professions such as GPs, pathologists and nurses.9
Drawings could provide useful information about children’s feelings
and emotions. In health settings, children’s drawings have been
used for various purposes including as diagnostic aides for
headaches,10, 11 as an index of self-esteem and anxiety in children
undergoing plastic surgery,12 and to describe the quality of care
children receive in hospitals.13
Few studies have addressed the question of how doctors are
perceived in children’s drawings. Marshall studied drawings of 40
children aged six to nine years in New Zealand and found that 92%
of doctors were depicted as happy or normal and only one child
drew a doctor with an ‘unfavourable facial attitude’.14 Another
study of 50 school children aged seven to eleven years in the UK
found that in 50% of the drawings the doctor was portrayed as a
benign or a kindly figure, in 44% as gruesome or threatening, and
in six percent as neutral.15 In the present study we set out to explore
children’s perception of psychiatrists by inviting a group of primary
school children to draw what they thought a psychiatrist looks like.
MethodologyAs part of the intergenerational art project, six school children aged
11-12 years, from Carraroe Primary School in Sligo, attended
Liscarney house, a day hospital for the old age psychiatry service in
Sligo, once a week for a period of seven weeks. The children
formed pairs with patients and participated in artwork with the
emphasis being on exchanging ideas and skills to promote
understanding. At the end of the period we asked the school
principal if the whole class, including those who did not participate
in the project, could visually represent an image of a psychiatrist.
This was a qualitative study combined with quantitative methods;
The art work was analysed by the coordinator of the Arts Initiative
in Mental Health (Niamh O’Connor). When studying the children's
drawings a comparative analysis of the themes and approaches of
the creators' was determined.
The primary concern was to ascertain the relative friendliness of
each psychiatrist and to then categorise and quantify all the other
information. Drawings were categorised under the following
headings - friendliness, sex, dress, setting, doctor with patient,
doctor's couch, other paraphernalia etc.
A formal analysis of the images - the creator's use of line, shape,
colour, texture, and composition was considered; particularly in
relation to any unusual characteristics and to the categories listed
above. Given the small size of our sample it was not possible to
conduct any meaningful statistical analysis.
33
*Sami Omer,Consultant Psychiatrist,Department of Old Age Psychiatry, Sligo, Ireland.E-mail [email protected]
Niamh O’Connor, Coordinator of the Arts Initiative in Mental Health,Sligo/Leitrim Mental Health Services, Clarion Road,Sligo, Ireland.
Gavin Sweeney,Clinical Nurse Manager,Department of Old Age Psychiatry,Liscarney House, Pearse Road, Sligo, Ireland.
Geraldine McCarthy,Department of Old Age Psychiatry,Liscarney House, Pearse Road, Sligo, Ireland.
Submitted August 11th 2009Accepted February 13th 2012
Ir J Psych Med 2012; 29 (1): 33-35
Original Paper
Psychiatrists in their eyes: Children’s drawings ofwhat a psychiatrist looks likeSami Omer, Niamh O’Connor, Gavin Sweeney, Geraldine McCarthy
* Correspondence
34
ResultsTwenty four school children (10 boys and 14 girls) took part in the
study. One child submitted two drawings making the total number
of drawings 25.
Their artwork was made on A4 photocopier paper using coloring
pencils and was an immediate response to the question posed,
with no prior sketching or preparatory work. The main features of
the drawings are summarized in Table 1.
Feature Frequency of representation Number (%)
Female psychiatrist 18 (72)
Friendly psychiatrist 21 (84)
Psychiatrist with patient 12 (48)
Doctor’s Couch 14 (56)
Psychiatrist offers help 5 (20)
No context and/or sparse context 14 (56)
Psychiatrist with paraphernalia(Pen, file, book, bag/briefcase, stethoscope) 12 (48)
Table 1: Main features of the drawings
There was no difference in the quality of the drawings between
the six children who attended the day hospital and the 18 children
who did not attend.
GenderMost children depicted the psychiatrist as female 18 (72%), while
in seven (28%) drawings the psychiatrist was portrayed as male.
Only one girl depicted the psychiatrist as male while four boys drew
a female doctor.
Facial expressionThe majority of the drawings showed the psychiatrist as friendly,
with 16 (64%) of them smiling broadly. Five (20%) drawings
showed a less openly smiling face but a kind expression
nonetheless, while three (12%) showed the psychiatrist’s facial
expression as worried, shocked and unhappy. Of the 12 (48%)
drawings, which showed the person receiving treatment, six out
of 12 (50%) were smiling, three out of 12 (25%) were unhappy
and a further three (25%) were not apparent or hidden.
Clothing and accessoriesIn the majority of pictures the psychiatrist was dressed in normal
attire, while three children (12%) had them wearing a type of
uniform. Many of the doctors wore colorful clothing of stripes and
florals with careful detailing of buttons, collars and hair accessories.
The female psychiatrists wore stylish colour-coordinated outfits
with an emphasis on fashion, while the male doctors were dressed
more soberly. A small number showed the doctor with a handbag,
one(4%) carrying a book and seven (28%) wore spectacles,
perhaps denoting studiousness and maturity. One drawing
depicted the psychiatrist as a very mature, perhaps elderly woman.
Two (8%) psychiatrists wore a doctor’s headband. One child (4%)
depicted a female psychiatrist in an apparently religious scheme,
wearing robes similar in colour to the Virgin Mary, hovering above
the ground with an arc of stars encircling the woman.
The contextWhile many children took great care to detail the surrounding
environment a full 56% did not represent any context or included
only one piece of furniture with no floor, walls, ceiling or other
reference to place.
In seven (28%) drawings the psychiatrist was portrayed alone,
without any other reference to context. A further 17 (68%)
showed interior furniture of one kind or another (desks, chairs,
couches) with one drawing locating the psychiatrist in a garden.
In one drawing (4%) the psychiatrist was shown in a home
environment with a row of shoes, a kitchen and a rug etc. The
doctor’s couch was an overwhelming feature, apparent in 14
(56%) of the drawings. While the drawings were colourful, almost
all showed sparse and anonymous surroundings with limited or no
decorative features. The exception is two (8%) pictures where
much decorative detail was evident (cupboards, rugs, a fish tank,
a plant) both drawn by girls.
Doctor-patient relationshipOf the 12 drawings, which also incorporate the person receiving
treatment, 11 out of 12 (92%) showed an engagement between
doctor and patient. The doctor either stands nearby, sits facing the
patient or is speaking with the patient. Only one drawing showed
little relationship between the two subjects-the psychiatrist
disproportionately bigger than and facing away from the patient.
eleven of the drawings depicted the patient on a couch, with the
doctor standing nearby in seven of the pictures. Four images
showed the doctor sitting beside the patient who is always, with
the exception of one drawing, lying down.
Interestingly, a number of children added text to the drawing in
the form of speech, giving us a more layered understanding of the
relationship between doctor and patient. Questions like “how are
you feeling?”, “tell me your thoughts?” and statements like “of
course (I’ll help)”, “it’s ok I’ll help” and “I will help you” are
evident. A psychiatrist possibly using hypnosis to relax the patient
- “stare into this as you fall asleep” is shown in Figure 1. Discussion
about medication did not feature in any of the drawings.
Figure 1. Drawing by Sophie
Figure 2. Drawing by Laura.
In Figure 2 there is an ominous black cloud or speech bubble over
the patient’s head.
Discussion
To the best of our knowledge this is the first study that describes
children’s perception of psychiatrists. In the majority of drawings
the psychiatrist was portrayed as a friendly or kind figure. Television
had inevitably played a significant role in forming children’s
opinions about ‘What a psychiatrist looks like’. The doctor’s couch,
a familiar scene from the private clinics of hundreds of television
and film ‘shrinks’, was a recurring feature. The role of television in
influencing children’s perception and imagination is well-
recognised in the literature.16-18 Furthermore, it had been suggested
that while children can make the distinction between reality and
fictional TV when they have the real-world information about an
occupation, for unfamiliar occupations children may perceive what
they see on TV as real ‘perceived reality’.18
In Ireland a limited number of studies examined how psychiatry is
portrayed in the media. An audit of print media found that mental
health issues were generally portrayed in either a neutral or positive
way.19 A study of a small number of Irish films found that
psychiatrists were portrayed as humane, caring and occasionally
conflicted individuals.20
The colorful and fashionable attire may be attributed to the
children’s personal preferences and practiced modes of visual
representation rather than their knowledge of the dress sense of
psychiatrists.
The psychiatrist in most drawings was depicted as being female.
This is probably a mere reflection of the gender difference in our
study sample.
Bearing in mind that the task was to make a drawing to illustrate
‘What I think a psychiatrist looks like’ and not ‘What I think a
psychiatrist does’, significantly, almost 50% of the children, of their
own initiative, determined to expand upon this, to show the
psychiatrist in a supportive relationship with patients.
The six children who attended the day hospital had mainly worked
with patients. They were only briefly introduced to a psychiatrist
at the end of their art project. This would probably explain the lack
of difference in their impressions of psychiatrists compared to those
who did not attend the day hospital.
ConclusionPsychiatrists were portrayed positively by this group of young
people. They were all primary school children and although six had
attended a mental health setting over a seven week period, the
majority projected a positive/friendly image of psychiatrists in their
artwork. This reflects a strong influence of the media on children’s
perception. It also suggests that health promotion helping to
diminish or avoid stigma about mental health should be addressed
at an early stage. Further work looking at perceptions of teenagers
could help to elucidate this further.
Conflict of interest
None.
Acknowledgement
We wish to thank Dr. Maria Morgan, Dr. Caroline Ang, Dr. Kate
Johnson and Professor John Waddington from the Department of
Molecular and Cellular Therapeutics, Royal College of Surgeons in
Ireland. As part of an outreach programme, they asked a group of
school children to draw their impressions of scientists before and
after they took part in an interactive hands-on science workshop.
Their work inspired us to undertake this project. The authors are
immensely grateful to the principal of Carraroe National School
and to the children who took part in the study.
References
1. Philo G (ed.). Media and mental distress. London; Longman, 1996.
2. Wolff G, Pathare S, Craig T, Leff J. Community knowledge of mental illness
and reaction to mentally ill people. Br J Psychiatry 1996; 168(2):191-8.
3. Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of
people with mental illness. Br J Psychiatry. 2000; 177:4-7.
4. Mehta N, Kassam A, Leese M, Butler G, Thornicroft G. Public attitudes
towards people with mental illness in England and Scotland 1994-2003. Br
J Psychiatry 2009; 194(3):278-84.
5. Angermeyer MC, Breier P, Dietrich S, Kenzine D, Matschinger H. Public
attitudes toward psychiatric treatment. An international comparison. Soc
Psychiatry Psychiatr Epidemiol. 2005; 40(11): 855-64.
6. Burke S, Kerr R, McKeon P. Male secondary school students’ attitudes towards
using mental health services. Ir J Psychol Med 2008; 25(2):52-56.
7. Mojtabai R. Americans’ attitudes toward mental health treatment seeking:
1990-2003. Psychiatr Serv. 2007; 58(5):642-651.
8. Sellman D, Pearson G. The public perception of psychiatrists: a telephone
survey. N Z Med J. 1985; 98(785):699-703.
9. Luty J, Fekadu D, Gallagher J. Umoh O. The professional status of
psychiatrists: good but not great. Psychiatric Bulletin (2006) 30: 314.
10. Wojaczyńska-Stanek K, Koprowski R, Wróbel Z, Gola M. Headache in children’s drawings. J Child Neurol. 2008; 23(2):184-91.
11. Stafstrom CE, Rostasy K, Minster A. The Usefulness of children’s drawings in
the diagnosis of headache. Pediatrics 2002; 109(3):460-472.
12. Lukash F. Children’s art as a helpful index of anxiety and self-esteem with
plastic surgery. Plast Reconstr Surg. 2002; 109(6):1777-86.
13. Pelander T, Lehtonen K, Leino-Kilpi H. Children in the Hospital: Elements of
quality in drawings. J Pediatr Nurs. 2007; 22(4):333-41.
14. Marshall CS. Looking at the doctor through the eyes of a child. N Z Fam Phys.
1985; 12:17-19.
15. Philipp R, Philipp E, Pendered L, Barnard C, Hall M. Can Children’s paintings
of their doctors be interpreted? J R Coll Gen Pract. 1986; 36(288):325-7.
16. Gash H, Domínguez Rodríguez P. Young people’s heroes in France and Spain.
Span J Psychol. 200; 12(1):246-57.
17. Comer JS, Furr JM, Beidas RS, Babyar HM, Kendall PC. Media use and
children’s perception of societal threat and personal vulnerability. J Clin Child
Adolesc Psychol. 2008; 37(3):622-30.
18. Pecora N, Murray JP, Wartella EA (eds.). Children and television. Fifty years of
research. Laurence Erlbaum Associates, Inc. New Jersey, 2007.
19. O’Connor A, Casey P. What it says in the papers: an audit. Ir J Psychol Med.
2001; 18:68-71.
20. Kelly B. Psychiatry in contemporary Irish cinema. Ir J Psychol
Med. 2006; 23(2): 74-79.
35
Abstract
Objective: This study was carried out to determine the prevalenceof selective mutism (SM) in an urban school population and to
assess comorbidity and family characteristics.
Method: Teachers of primary schools, teaching children betweenthe ages of four and 12, were sent a description of SM and asked
to complete the selective mutism questionnaire (SMQ) if they
believed a child in their class met criteria. Thirty-nine schools were
sampled, covering a catchment area of 10,927 children. Children
who screened positive on the SMQ were offered a full psychiatric
assessment. Parent, child and clinicians completed various rating
scales.
Results: A response rate of 100% from schools was obtained. Theprevalence rate of SM was 0.18% (20/10927). fourteen (70%)
attended for further evaluation. All children scored within the
clinical range on the Clinical Global Assessment Scale (CGAS),
indicating moderate to severe impairment. fifty percent (7)
reported a family history of social anxiety disorder, and 43% (6)
autistic spectrum disorders.
Conclusion: This is the first Irish based prevalence study of SM.Results indicate that SM is not as rare as previously believed.
Children with SM were found to have significant functional
impairment along with a strong family history of anxiety and
autism.
Key words: Comorbidity, Family psychopathology, Prevalence,Selective mutism.
Introduction
Selective mutism is considered a rare disorder of communication,
characterised by an emotionally determined consistent failure to
speak in select social situations, where speaking is expected, for
example school, despite demonstrating language competence in
more familiar situations, for example, home. The disorder is
persistent, lasting longer than one month, and causes impairment
in communication, educational and occupational achievement.1
Reported prevalence rates for selective mutism range between
0.033-2% of primary school children.2,3,4,5 Comparison between
different studies is difficult due to different populations sampled
and criteria for diagnosis used. For example, studies examining a
narrow age band looking at children between the ages of 4-6
years27 (when SM is more likely to present), yield higher prevalence
rates than those examining a wider age band4 (7-15 years). In
addition studies using DSM IV criteria yield smaller prevalence rates
than those using ICD 10 or DSM III R1 due to the inclusion of
impairment as a criterion for diagnosis in DSM IV.5 School and
community based studies typically yield consistently higher rates
than those cited in clinical samples, reflecting the fact that many
children with SM do not come to clinical attention.
The conceptualisation of SM has undergone a number of changes
in recent years. A wide variety of child characteristics have been
reported, including oppositional behaviour, developmental delay,
speech disorder, anxiety and shyness.6,7,8,9,10 Recent research
describes SM as closely related or an early developmental
expression of social phobia.11,12,13 Other authors have reported a
high frequency of neurodevelopmental delay, affecting motor,
linguistic and cognitive functioning. 9,14,15,16
A high frequency of family psychopathology has also been reported
in SM families.17,12,18,19 Previous studies have suggested an
association between SM and parental social anxiety.12,19 Two studies
suggest a family link with Asperger Disorder. 20,21
This study aimed to carry out a community study and follow cases
up with a clinical evaluation to try and establish an accurate
prevalence rate in a defined geographical catchment area in
Ireland. It also aimed to document any comorbidity or family
pathology.
36
* Louise Sharkey, Consultant Child and Adolescent Psychiatrist,Mater Child and Adolescent Mental Health Service,Mater Misericordiae University Hospital,Dublin 7, Ireland.E-mail [email protected]
Fiona McNicholas,Consultant Child Psychiatrist and Professor of ChildPsychiatry, Lucena Clinic, Rathgar, Dublin 6, Ireland.Our Lady’s Children’s Hospital, CrumlinUniversity College Dublin, Ireland.
Submitted September 2010Accepted August 2011
Ir J Psych Med 2012; 29 (1): 36-40
Brief Report
Selective Mutism: A prevalence study of primary school children in the Republic of Ireland
Louise Sharkey, Fiona McNicholas
* Correspondence
Method
Participants:The study group consisted of children aged 4-12 years attending
primary school in a defined geographical urban child and
adolescent mental health service catchment area in the Republic
of Ireland. The catchment area covers a population of 350 000,
primarily belonging to the lower socio-economic group.24 There are
39 primary schools in this area and all were sampled, covering a
total population of 10,927 students.
The study was approved by the ethical review board of St John of
God’s Hospital. Full informed written consent was obtained from
parents or guardians of all participants before the study.
Procedure:The study was conducted late in the academic year (April/ May), in
order to ensure a six month duration and to eliminate transient
mutism, common in the first term post school entry. A description
of selective mutism according to DSM-IV criteria22 was sent to the
principal and teachers of each school. If the principal or teacher
suspected that a pupil met criteria, they completed and returned
the Selective Mutism Questionnaire,2 in the stamped addressed
envelope enclosed. In addition, the principal was asked to indicate
on a separate form if there were no children in the school with
symptoms suggestive of SM. Children who met DSM-IV criteria for
SM were invited to participate in a clinical assessment with a
consultant child psychiatrist, to confirm the diagnosis and to assess
for additional comorbidity. The child and parent filled out some
additional questionnaires and the clinician completed the Children’s
Global Assessment Scale (CGAS) 23 (see Table 1).
Results
A total of 39 schools (100%) responded to the study
questionnaires. Schools who did not return data within a specified
time frame were followed up via telephone contact. Up to three
telephone calls were required before all data was returned for
analysis. Twenty children were identified by 19 teachers of 12
schools as having symptoms suggestive of SM. Twenty seven
schools returned forms or indicated through telephone contact
that there were no children in the school with symptoms suggestive
of the disorder. All parents of children who met criteria on the SMQ
were contacted by a clinician and offered a clinical assessment.
Parents of 14 children (70%), consented to an assessment.
The ages of children with SM ranged from 5.2-10.6 years (average
age 6.9 years). There was a preponderance of female subjects
(female to male ratio was 4:1). The spoken language in 11 of the
families was English. Three of the pupils were of ethnic minority
origin, but had been living in the country and attending school for
more than two years. All three pupils were reported to be bilingual
and demonstrated SM symptoms in both native and non-native
languages. Eleven children (79%) lived with both biological
parents. All children had regular contact with both parents. Ten
(71%) were the eldest in their family. All families belonged to the
lower socio-economic group.24
Clinical presentation:All children assessed met diagnostic criteria for Selective Mutism.22
The onset of their symptoms dated back to school entry (average
age 4.6 years). One child was previously assessed by the psychiatric
services and three received therapy for dyspraxia. Nine children
(64%) had a history of speech and language delay. One child had
a diagnosis of Tourette’s Syndrome. All children were considered
by their school to be functioning within the average range of
cognitive ability. All children with SM presented with moderate to
severe impairment in functioning (CGAS = 32-61) (Figure 1), as
rated by clinicians. (Table 2)
Only 21%, one fifth of the sample, scored within the clinical range
on the SCAS25 as rated by the children or parents (>42.48) (Figure
2). The most frequent items scored by these children related to
social phobia and separation anxiety disorder. None of the children
met criteria for obsessive compulsive disorder, generalized anxiety
disorder or panic disorder, as rated by the SCAS. (Table 2)
Although only four children (29%) received a total score within the
abnormal range on the SDQ,26 eight (57%) presented with
emotional difficulties and five (36%) with problems with peer
interaction and 2 (14%) with behaviour difficulties (Table 4).
Family psychopathology:Family psychopathology and neuro-developmental delay were
assessed by a child psychiatrist according to detailed information
about family history obtained during clinical interview. Results were
included only if a formal diagnosis had been given by a qualified
professional, for example a psychiatrist, psychologist or speech and
language therapist. According to parental report, there was a
positive family history in nine children (64.3%) of speech and
language delay or articulation difficulties in a first degree relative
which required clinical intervention. Similarly, there was a high
frequency of social anxiety disorders among family members with
two siblings from two families and seven (50%) parents who
reported receiving treatment for either selective mutism or social
phobia. All children had at least one parent who was portrayed as
‘very shy’. Surprisingly, almost half the sample, six (43%) reported
a diagnosis of autistic spectrum disorder in a first degree relative.
(Table 3)
Discussion
To the authors’ knowledge, this is the first prevalence study of
selective mutism in Ireland, and suggests a prevalence rate of
0.18% in a sample of primary school children aged 4-12 years. This
is a two stage study, using questionnaire screening and diagnostic
interview to achieve a diagnosis of SM using DSM IV criteria. As
such the prevalence rate found (0.18%) may be lower than that
found in other studies with less stringent diagnostic criteria. In
addition, this study included children aged 4-12 years, as compared
to other studies sampling a narrower age band (4-6 years) when
SM is most likely to present. For example, Kopp & Gillberg4 who
used criteria that are stricter than DSM-IV, found a rate of 0.18%
comparable to our results, in their study of Swedish school children
(7-15 years), while the relatively high rate of 1.9% reported by
Kumpulainen et al,5 was based on DSM III R criteria1 that do not
include impairment.
37
More recently Bergman et al11 reported a prevalence rate of 0.76%
among their sample of kindergarten, first and second grade pupils
using DSM-IV22 criteria. Their relatively higher prevalence rate is
comparable to the rate reported in the United Kingdom by Brown
& Lloyd,27 and probably reflects the narrow age band studied,
when SM is more likely to present.
Although SM is generally considered to be a rare disorder, most of
the recent evidence does not support this. The figure of 0.06% cited
by Fundudis et al28 is based on the use of very vague criteria for
diagnosing SM, that are not comparable to the current
conceptualization of SM in DSM-IV. This figure however is similar to
a more recent publication by Karakaya et al,3 in their study of
kindergarten to 3rd grade pupils using DSM-IV criteria. Their initial
prevalence rate following screening by teachers of 0.83% was
reduced to 0.033% following clinical evaluation by a child psychiatrist.
Gender differences have been noted in past studies of SM and a
suggestion that gender differences in prevalence increase with
age.16 In our study, we found a male: female prevalence ratio of
1:4, with more females than typically reported (ratio of 1:1.2),6
which may reflect the older age range sampled.
Comorbidity:Comorbid conditions were highly prevalent in our sample of
children with selective mutism. Similar to previous studies,11,12,13 all
children in the study were rated by clinicians as moderately to
severely impaired in social, academic and overall functioning.
Speech and language delay was the most common comorbid
problem, reported in 64% of the sample studied. This association
is in line with findings of 30-60% language disorder/delay recorded
in previous studies of SM. 9,16,29,30
Twenty one percent of the children with SM met criteria for
dyspraxia, a rate slightly lower than that reported by Kristensen15
for DCD. Only one fifth of the sample met criteria for an anxiety
disorder on a self-rating scale. This finding is inconsistent with
previous studies,12,13, 16 that suggest that SM is an anxiety disorder,
closely related to social phobia, but consistent with other studies
using self-rating scales to measure anxiety symptoms in children,
who manage anxiety symptoms and the self-consciousness
associated with speaking by avoiding speech.30 A teacher rating
scale would probably yield a much higher rate of anxiety disorder
in this population. The finding that only four children (29%)
received a total score in the abnormal range on the SDQ26 as rated
by parents, reflects the contextual nature of the disorder, where
SM may not be perceived as a problem in the home environment,
and the family’s tolerance and acceptance of mute behaviour (Table 4).
Family characteristics:There was a high loading for speech and language delay and
anxiety symptoms in the families of selectively mute children. Fifty
percent of the sample reported a family history of social anxiety
disorders and at least one parent of all children described
themselves as ‘excessively’ shy. This is consistent with earlier
results.32,33,34 Sixty-four percent of our sample reported a history of
speech and language delay in first degree relatives, comparable to
results from previous studies (21% - 78%).16,35,36.
Although an association between SM and autistic spectrum
disorder has been queried in previous studies,20 almost half of our
sample had a first degree relative with a diagnosis of ASD. Our
findings extend previous reports and describe the important role
family psychopathology plays in the aetiology of SM.
Limitations:This current study suffers from a number of methodological
limitations. Information from teachers was limited to a screening
questionnaire, and as children with SM are more likely to manifest
symptoms within the school environment, additional information
from teachers, in particular in relation to anxiety symptoms, would
have contributed significantly to this study. Second, our largely
working class sample, while representative of our geographically
defined catchment area, is probably not representative of the
population as a whole, and while attendance at school is mandatory,
it is possible that children with SM who are not attending school
were missed by this methodology. However principals were reminded
to consider all children enrolled in the school. Thirdly, as there is no
direct control group, comorbidity and family characteristics of this
SM sample can only be compared to those found in other published
studies. Whilst the structure of the family interview method would
have led to increased reliability and could have been done by an
independent researcher, the expertise of the clinician in taking family
histories must not be underestimated.
Despite these shortcomings the study has a number of
methodological qualities. The study of a non-referred population of
school children aged 4-12 years provides a more representative
sample than that obtained in clinical studies, and identifies the
population of ‘hidden SM’, children who do not come to clinical
attention as they do not cause a disturbance in the classroom, and
the disorder is not perceived as problematic in the home
environment. In addition, our study included a relatively large
population of school-aged children. All children whose parents
consented received a psychiatric evaluation, by a senior clinician,
confirming the diagnosis and identifying comorbidity. The use of
validated rating scales completed by multiple informants, emphasized
the situational nature of the disorder and the degree of impairment
experienced by children who have not yet come to clinical attention.
Conclusion
This study provides data that concur with other studies in
suggesting that SM is not as rare as previously reported, and that
a significant number of children with considerable impairment do
not come to clinical attention until later years, requiring more
intensive intervention. This suggests that efforts to identify and
treat SM in the early school year need to be increased, so that an
increased awareness of the disorder and early intervention
treatment programmes can be delivered in the school environment.
Following this study the authors developed a SM manual which
has been sent to all primary schools in the catchment area.37
Our findings suggest an association between SM and a family
history of social anxiety disorder, speech and language delay and
autistic spectrum disorder. It is significant that seven (50%) parents
reported receiving treatment for either selective mutism or social
phobia. While these results should be viewed as preliminary, further
studies of the etiological nature of the disorder and more specific
evidence based treatment interventions are clearly warranted.
38
Conflict of interest
None.
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders – Third Edition Revised. Washington. American Psychiatric
Association, 1987.
2. Bergman RL, Keller M, Wood J, Piacentini J, McCracken J. Selective Mutism
Questionaire (SMQ): development and findings. Poster session presented at
the American Academy of Child and Adolescent Psychiatry, Honolulu, USA.
2001
3. Karakaya I, Sismanlar SG, Oc OY, Memik NC, Coskun A, Agaoglu B, Yavuz
CI. (2007). Selective Mutism: A school- based cross-sectional study from
Turkey. Euro Child Adolesc Psychiatry 2007; 17:114- 117.
4. Kopp S, Gillberg C. Selective mutism: a population-based study: a research
note. J Child Psychol and Psychiatry 1997; 38:257-262.
5. Kumpulainen K, Rasanen R, Raaska H, Sompii V. Selective Mutism among
second- graders in an elementary school. Euro Child Adolesc Psychiatry 1998;
7: 24-29.
6. Tancer N. Elective Mutism: A Review of the Literature. Advances in Clin Child
Psychol 1992; 14:265-288.
7. Bradley S, Sloman L. Elective mutism in immigrant families. J Am Acad Child
Psychiatry 1975; 14: 510-514.
8. Hayden TL. The Classification of elective mutism. J Am Acad Child Psychiatry
1980;19: 118-133.
9. Kolvin I, Fundudis T. (1981). Electively mute children: Psychological
Development and background factors. J Clin Psychol Psychiatry 1981;
22:219-232.
10. Leonard HL. Selective Mutism. In Kaplan & Sadock’s Comprehensive Textbook
of Psychiatry (Vol 1, 7th Ed) Sadock BJ, Sadock VA.
11. Bergman RL, Piacentini J, Mc Cracken J. Prevalence and Description of
Selective Mutism in a school-based sample. J Am Acad Child Psychiatry 2002;
41: 238-246.
12. Black B, Uhde TW. Psychiatric characteristics of children with selective mutism:
A pilot study. J Am Acad of Child Psychiatry 1995; 34:847-855.
13. Dummit ES, Klein RG, Tancer NK, Asche B, Martin J, Fairbanks JA. Systematic
assessment of 50 children with selective mutism. J Am Acad Child Psychiatry
1997; 36:653-660.
14. Kristensen H. Elective mutism associated with developmental disorder/
delay:two case studies. Euro Child Adolesc Psychiatry 1997; 6:234-239.
15. Kristensen, H. Selective mutism and comorbidity with developmental
disorder/delay, anxiety disorder and elimination disorder. J Am Acad Child
Adolesc Psychiatry 2000; 39: 249-256.
16. Steinhausen HC & Juzi C. Elective Mutism: An analysis of 100 cases. J Am
Acad Child Psychiatry 1996; 35:606-614.
17. Brown BJ, Lloyd H. A controlled study of children not speaking at school. J Ass
Workers with Maladjusted Children 1975; 3: 49- 63.
18. Browne E, Wilson V, Laybourne P. Diagnosis and treatment of elective mutism
in children. J Am Acad Child Adolesc Psychiatry 1963; 2:605-617.
19. Kristensen H & Torgersen S. MCMI-II personality traits and symptom traits in
parents of children with selective mutism: A case-controlstudy. J Abn Psychol
2001; 110:648-652.20. Gillberg IC & Gillberg C. Asperger syndrome – some epidemiological
considerations: a research note. J Child Psychol and Psychiatry 1989; 30:631- 638.
21. Brix Andersson C, Hove Thomsen P. Electively mute children: an analysis of 37
Danish cases. Nordic J Psychiatry 1998;52:231-238.
22. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders – Fourth Edition. Washington. American Psychiatric Association 1994.
23. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, & Aluwahlia S.
Childrens Global Assessment Scale. Archives of General Psychiatry
1983; 40:1228-1231.
24. National Statistics Socio-economic Classification: users manual
NS-SEC. 2005: Office for National Statistics.
25. Spence S. The Spence children’s Anxiety Scale. The Child Psychology
Portfolio1997: NFER-NELSON.
26. Goodman, R. The Strengths and Difficulties Questionnaire: a research note.
J Child Psychol and Psychiatry 1997; 38:581-586.
27. Brown BJ, Lloyd H. A controlled study of children not speaking at school.
Journal of Association of Workers with Maladjusted Children, 1975; 3, 49- 63.
28. Fundudis T, Kolvin I, Gariside RF. Speech Retarded and Deaf Children their
Psychological Development. 1979; London:Academic Press.
29. Rosler M.Befunde beim neurotischen Mutismus der Kinder cine
Untersuchungan 32 mutistischen Kindern. Praisx der Kinderpsychologie und
Kinderpsychiatier 1981; 30, 187- 194.
30. Wilkens, R. A comparison of elective mutism and emotional disorders in
children. British Journal of Psychiatry, 1985;146, 198-203.
31. DiBartolo PM, Albano AM, Barlow DH, Heimberg RG. Cross-informant
agreement in the assessment of social phobia in youth. Journal of Abnormal
Psychology 1998; 26, 213-20.
32. Lorand B. Katamnese elektiv mutistischer Kinder. Acta Paedopsychiatrica
1960; 27, 273-289.
33. Popella, E. Psychogener Mutismus bei Kindern. Nervenarzt, 1960;31, 257-263.
34. Steinhausen HC, Adamek R. The family history of children with elective
mutism. European Journal of Child and Adolescent Psychiatry, 1997; 6, 107-111.
35. Carmody L. The Power of Silence: Selective Mutism in Ireland – a speech and
language perspective. Journal of Clinical Speech and Language Studies,
2000;1, 41-60.
36. Remschmidt H., Poller M, Herpertz-Dahlmann B, Hennighausen K.,
Gutenbrunner, C.A follow-up study of 45 patients with elective mutism.
European Archives of Psychiatry and Clinical Neuroscience, 2001; 251, 284-296.
37. Sharkey L, McNicholas F, Begley M. Elective Mutism Manual. Dublin. Mac
Communications, 2004.
39
Figure 1: CGAS Scores Figure 1: CGAS Scores
40
Table 1: Measures:
Name of questionnaire Rater Description
Children’s Global Clinician
Assessment Scale (CGAS)
Selective Mutism Parent/Teacher
Questionaire (SMQ)
Strengths and Difficulties Parent
Questionaire (SDQ)
Spence Children’s Anxiety Child
Scale (SCAS) (age 8-12 years)
Parental report
completed for
children
age 4-8 years
A measure of psychosocial and psychiatric functioning for children aged 4-16 years.
A score less than 61 is used to identify subjects with definite disorders and a score
between 61 and 71 to identify subjects with probable disorders.
A 36-item multiple-choice scale. Parental or teacher report of child’s speaking
behaviours and interference associated with failure to speak.
A 24-item questionnaire of children aged 4-16 years. It identifies children with
conduct, hyperactivity, depressive and anxiety disorders.
A self-report measure of anxiety. Thirty-eight anxiety items, six filler items and one
open-ended non-scored item assessing social desirability. Scores on six sub-scales
relating to separation anxiety, social phobia, panic/agoraphobia, generalized anxiety,
obsessions/compulsions and fear of physical injury. The child is asked to rate on a
four point scale – ‘never’= 0, ‘sometimes’ = 1, ‘often’ = 2, or ‘always’ = 3 – how
often each item happens to them. This yields a maximum score of 114.
Table 2: Clinical Descriptives N=14
Age 6.9 (5.2-10.6)
Females 11
Primary language 11 english (78.5%)
3 bilingual
Onset symptoms Average 4.6 years (range 2.9 – 5.2 years)
Past child psychiatry history 1=assessed
1=Tourette’s Syndrome (same child as above)
Treatment Dyspraxia 3 (21%)
Speech & Language delay 9 (64%)
CGAS 14 (100%) >moderate impairment
Range 36-61
SCAS 3 (21%) clinical range for anxiety
Table 3: Family History
Mother Father Siblings 1st relative
SM 3 2
SP 3 1 1
Shy 11 3
SL delay 1 1 3 4
ASD 1 5(6)
Depression 1
Hearing Imp’d 1
Dyslexia 1
Table 4: SDQ
(abnormal range) Average score Normal Borderline Abnormal
Emotional* (5-10 abN) 5 5 1 8 (57%)
HA/Imp (7-10 abN) 4 11 0 3 (21%)
CD (4-10 abN) 2 10 2 2 (14%)
Prosocial (0-4 abN) 6.7 11 2 1 (7%)
Peer* (4-10 abN) 2 9 0 5 (36%)
Total* (17-40 abN) 12.6 8 2 4 (29%)
Abstract
Objectives: Psychotherapeutic skills are essential to practicepsychiatry effectively, but previous surveys of trainees in Ireland
show that they have not been getting adequate training in
psychotherapy. This survey of college tutors was carried out to
coincide with the establishment of the College of Psychiatry of
Ireland which is introducing new psychotherapy training
requirements. The survey aims to ascertain if trainees had fulfilled
the Royal College of Psychiatrists’ psychotherapy training
requirements, models of psychotherapy available and the
availability of psychotherapy qualifications amongst consultants
and senior registrars.
Methods: A questionnaire was posted to all registered tutors inthe Republic of Ireland.
Results: The postal questionnaire was sent to the 62 registeredcollege tutors in the 13 training schemes. There is one tutor in each
training hospital. The response rate was 79%. Our survey reveals
that no psychotherapy training was available according to 16.3%
of tutors. Only 22.5% of tutors were aware of trainees who had
met college training requirements in the previous two years. 79.8%
of tutors reported that there were consultants and senior registrars
with qualifications in psychotherapy who could offer training if
time and resources permitted.
Conclusions: Current training requirements are not being fulfilled.There are consultants and senior registrars who have
psychotherapy qualifications to provide psychotherapy training but
there are inadequate resources and time to formalise training. It is
unlikely that the implementation of training requirements by the
new college will be realisable without a review of training delivery.
Key words: Psychotherapy; Training; Resources
Introduction
Psychotherapeutic skills are an important component of general
psychiatric practice: to enhance awareness of one’s emotional
responses to situations, to improve communication skills and in
understanding group dynamics.1 The biopsychosocial model is
widely accepted and endorsed by A Vision for Change 2 and yet
evidence from surveys of trainees in Ireland shows that trainees are
not getting adequate experience or training in the psychological
components of this model of psychiatric practice.3,4,5 This has been
largely attributed to supply of trainers and supervisors rather than
low demand from trainee psychiatrists.4
The new College of Psychiatry of Ireland was established in 2009
and a new training curriculum for basic specialist training has been
published, though this will be reviewed. This could be viewed as an
opportunity to have a fresh look at psychotherapy training and
how it could realistically be implemented given the ever increasing
workload of psychiatrists.
The Royal College of Psychiatrists has consistently emphasised the
importance of psychotherapy training by making it mandatory as
part of basic psychiatric training. The practice of psychotherapy is
considered a key aspect of psychiatric practice.1, 6 In 1993 the Royal
College of Psychiatrists published guidelines for psychotherapy
training as part of general professional training in psychiatry.7 In
2001 the College published requirements that were more specific
and were intended to be mandatory for eligibility for the MRCPsych
examinations.8 Psychotherapeutic knowledge and skills feature
prominently in the Royal College of Psychiatrists’ 2009 CoreModule of a Competency Based Curriculum for Specialist Trainingin Psychiatry.9 Trainees are expected to have delivered “basicpsychological treatment in at least two modalities of therapy and
over longer and shorter durations.”
Guidelines and the mandatory requirements of the Royal College
of Psychiatrists have proved difficult to implement with repeated
41
* Angela Noonan, Consultant Psychiatrist,St. Vincent’s Hospital,Richmond Road,Dublin 3, Ireland.E-mail [email protected]
Alyson Lee,Consultant Psychiatrist,Lakeview Unit,Naas General Hospital,Naas, Co. Kildare, Ireland.
Submitted July 20th 2010Accepted August 31st 2011
Ir J Psych Med 2012; 29 (1): 41-45
Brief Report
Psychotherapy training in Ireland: A survey of college tutorsAlyson Lee, Angela Noonan
* Correspondence
42
studies showing that trainees have often been unable to meet
them.10,11,12 A survey on psychotherapy conducted on trainees in
the Eastern region of Ireland in 1997 also showed failure to meet
requirements.4 In this study the authors found that 31.4% of
trainees surveyed received formal training in psychotherapy and
47% delivered psychotherapy. Only 4% of trainees met the College
requirements which were in place at the time.7 Trainees rate
psychotherapy training as relevant to their overall training but have
highlighted the lack of training opportunities and supervision as a
problem.3,4,5
Tutors were surveyed for several reasons: knowledge of availability
and access to training at a local level; knowledge of trainees who
are fulfilling training requirements; identification of psychotherapy
skills among trainers and supervisors.
The Royal College of Psychiatrists’ psychotherapy training
requirements8 published in 2001 which were in place at the time
of the survey were:
• Development of interview skills
• Psychotherapeutic formulation of psychiatric disorder
• A minimum of three short term cases (12-16 sessions), each
using a different psychotherapeutic model
• One long-term individual case (12-18 months)-any model
• Some experience of either group psychotherapy or couple,
family or systemic therapy
Method
A list of registered college tutors was obtained from the College of
Psychiatry of Ireland. An anonymous questionnaire was posted to
the 62 registered college tutors in the 13 training schemes. The
tutors were asked to complete and return the questionnaire to the
College of Psychiatry of Ireland in an envelope provided. The
respondents were asked the following questions:
1. Is there psychotherapy training available on your scheme?
2. If there is training available who provides this? (Respondents
were asked to identify disciplines that provided training.)
3. If there is training available what models of psychotherapy can
the trainees access?
4. Within the last two years (2006-2008) did any trainees meet
the Royal College of Psychiatrists’ training requirements?
5. Are there consultants and senior registrars trained in
psychotherapy who, if time and resources permitted, could
provide training?
There was a free text section for comments.
(A copy of the questionnaire is available from the authors on
request).
Results
The results were recorded and collated by the authors and are
presented in tables 1-5. The response rate was 79% with 49 tutors
out of a possible 62 responding to the questionnaire. Some
psychotherapy training was available to trainees according to
83.7% of tutors, with 16.3% reporting no training available. CBT
was the most commonly available modality of psychotherapy. In
36.7% of training centres only psychiatrists were involved in
delivering psychotherapy training. Table 3 shows how some centres
have a limited range of modalities of psychotherapy training, where
it exists at all. A noteworthy finding is that 79.8% of tutors
reported that there were senior clinicians with training in
psychotherapy who could be involved in the delivery of training if
time and resources permitted. 67.3% of tutors stated that trainees
had not met the training requirements and 10.2% did not know if
trainees had met the requirements.
Table 1: Provision of Psychotherapy Training
Provider Number of sites
None 8 (16.3%)
Psychiatry only 18 (36.7%)
Psychology only 6 (12.2%)
Family therapy only 1 (2%)
Psychiatry and psychology 5 (10.2%)
Psychiatry and social work 1 (2%)
Psychiatry and family therapist 2 (4.1%)
Psychiatry and nurse specialist 2 (4.1%)
Psychiatry and CBT therapist 1 (2%)
Psychiatry, psychology and nurse therapist 3 (6.1%)
Psychiatry, psychology, nurse therapist 1 (2%)
and occupational therapist
Psychology and nurse therapist 1 (2%)
Table 2: Modalities of Training Available
Modality Number of sites where available
CBT 31 (63.3%)
Supportive 21 (42.9%)
Psychoanalytic 19 (38.8%)
Systemic/Family Therapy 15 (30.6%)
CAT 6 (12.2%)
IPT 4 (8.2%)
DBT 3 (6.1%)
Other 2 (4.1%)
Table 3: Number of Psychotherapy Modalities Available
Number of modalities Number of tutors who reported availability
None 8 (16.3%)
1 modality 9 (18.4%)
2 modalities 16 (32.7%)
3 modalities 9 (18.4%)
4 modalities 3 (6.1%)
5 modalities 4 (8.2%)
43
Table 4: Trainees meeting Royal College of Psychiatrists guidelines
Yes 11 (22.5%)
No 33 (67.3%)
Don’t know 5 (10.2%)
Table 5: Consultants and Senior Registrars trained inpsychotherapy who could provide training if time andresources permitted
Yes 39 (79.6%)
No 10 (20.4%)
Discussion
To our knowledge this is the first survey of college tutors about
psychotherapy training in Ireland. However, the small percentage of
trainees meeting college training requirements is in keeping with
a previous survey of trainees in the Eastern region of Ireland.4 As
the larger training schemes have several tutors they may be over
represented and the finding that 16.3% of tutors report no
psychotherapy training could be an underestimate as it is likely that
in smaller schemes there are fewer resources.
Our survey shows that 79.6% of respondents affirmed that training
could be provided if there were sufficient time and resources
available. In Ireland there are approximately 400 trainees in basic
training and approximately 100 in higher training. There are only
two approved consultant psychiatrist posts with a special interest
in psychotherapy in the public health service.19 In contrast to the
UK there are no subspecialty placements in psychotherapy at basic
specialist training or higher training level.
This survey highlights the fact that psychiatrists are obtaining
psychotherapy training but are not using these skills to train junior
colleagues. Furthermore, whilst consultants may update their
theoretical knowledge through attendance at courses and
workshops, they possibly are not utilising their formal
psychotherapy skills due to other commitments which can lead to
their attrition.18
In June 2008 the Irish Psychiatric Training Committee produced a
Handbook for Basic Specialist Training in Psychiatry13 which was
valid at the time of our survey (and a slightly updated version is still
valid for all but the foundation year basic specialist trainees who
commenced training in July 2011). The handbook includes the
following psychotherapy training guidelines:
• Understanding of psychodynamics and team work
• Development of good communication and interview skills
• Participation in an experiential reflective group (e.g. Balint
group) minimum 30 sessions
• One long term case (minimum 24 sessions)
• Three short term cases (8-16 sessions)
The clinical cases should be in at least two different psychotherapy
modalities. It also states that training must include both theoretical
and practical training and must be effectively supervised. Since the
establishment of the College of Psychiatry of Ireland, a Basic
Specialist Training Blueprint based on achievement of competencies
has been published.6 This includes yet another set of
psychotherapeutic goals. The requirement of the Handbook
regarding four cases is suggested as desirable. It is stated that
training schemes must provide Balint-style groups. Additionally the
Blueprint states that each trainee must complete a minimum of 18
sessions of brief psychological intervention and demonstrate
competence in psychotherapeutic aspects of advanced history
taking and formulation. As one of the competencies for child
psychiatry, it is stated that the trainee must be able to utilise play
therapy. The basic principles of the new curriculum are to be
welcomed, as indeed is the introduction of a training portfolio, but
in our view what a trainee is expected to know and to be able to
demonstrate at the end of training remains onerous and the
obstacles to training delivery remain the same.
There are other challenges. Many training schemes cover wide
geographical areas so seeing a patient over a long period of time
is impractical. One solution would be for trainees to remain in the
same hospital for one year. Many trainees do spend their first year
in one hospital but as they advance in their training when
undertaking psychotherapy may be more appropriate, they rotate
through subspecialty posts every six months and lack of continuity
in terms of patient and trainee tutor contact are further obstacles.
Some tutors were not aware of how many, if any, trainees were
meeting training requirements. One tutor responded that
psychotherapy training was “virtually non-existent leaving a
massive chasm in service provision.” Another respondent said that
the training arrangements were “very piecework.” The
establishment of a national training programme with designated
psychotherapy tutors in each training scheme would create greater
structure and continuity to training. This was suggested as a
possible solution by a previous survey of trainees and consultants.3
The European Working Time Directive means that trainees have
less time than before to fulfil training requirements. The high court
settlement on 22nd of January 2010, between the Irish Medical
Organisation and the Health Service Executive decreed that time
rostered for training would not constitute working time under the
EWTD but would qualify for payment.14 This may be a solution;
however, it would depend on the motivation of trainees and the
willingness of employers to pay.
Even where training is available, feedback from some tutors
indicates that interest and take up of psychotherapy cases can be
poor. This may be because of fear and apprehension about feeling
de-skilled12 and of psychotherapy not being immediately pertinent
to training and career progression as the focus of trainees may be
on passing examinations.13 UK based trainees are expected to have
been assessed formally in having achieved competencies in
psychotherapy and the trainee must have received structured,
documented feedback on their performance to be eligible to
undertake the CASC exam, the final component of the
membership exam.16 Tutors based in Ireland are completing
sponsorship forms for the CASC examination without these
competencies being demonstrated.
Another challenge is bringing about a shift in the culture of training
so that more emphasis is placed on psychotherapy experience in
becoming a good psychiatrist. One respondent stated that we
require psychotherapy role models. The majority of trainees aspire
to do their higher training in Ireland and in order to be considered
for interview for higher training, candidates will be awarded marks
for research or audit that has been published or presented.
According to the College of Psychiatry of Ireland, qualifications in
psychotherapy will be rated for shortlisting for higher training in
psychiatry.17 However, obtaining a qualification in psychotherapy
is a time consuming undertaking and is unlikely to be attained
during basic training. Perhaps the College could consider rewarding
trainees who have documentary evidence of cases undertaken for
psychotherapy as part of basic specialist training so that trainees
selected for higher training have a range of both academic and
psychotherapeutic skills.
Conclusion
Limited psychotherapy training is available in most training
schemes but 16.3% of respondents reported that no
psychotherapy training of any kind was available in their training
scheme. Although only 22.5% of respondents stated that their
training scheme met the Royal College of Psychiatrists training
requirements, almost 80% of tutors said that there were a
sufficient number of senior trainees and consultants who could
provide training if they had enough time to do so. Increased
resources are needed so that consultants have protected time to
provide psychotherapy supervision. Provision of training by our
psychology colleagues needs to be considered further although
their resources are also very limited. The establishment of a national
training programme would allow for greater structure and
coordination in delivery of training. We have suggested other
changes to improve delivery of psychotherapy training which
include one year hospital placements in the latter part of basic
training and shifting the training culture by placing a greater value
on psychotherapy experience in the shortlisting process for higher
specialist training. The formation of the College of Psychiatry of
Ireland and the development of a new curriculum provides a
wonderful opportunity to enshrine the central importance of
psychotherapy in psychiatric training, but given the many
competing demands on consultants, our view is that unless there
are increased resources, the proposed requirements will merely
represent unrealisable ideals.
Conflict of interest
None.
Acknowledgements
Thanks to Grace Smyth of the College of Psychiatry of Ireland for
her invaluable assistance.
References
1. Mitchison S. Next year in Jerusalem: Psychotherapy training for tomorrow’s
consultants. Advances in Psychiatric Treatment 2007;13:276-283
2. A Vision for Change. Report of the expert group on mental health policy. The
Stationery Office.2006. http://www.hse.ie/eng/services/Publications/services/
Mentalhealth/Mental_Health_-_A_Vision_for_Change.pdf
3. Rooney S, Kelly G. Psychotherapy experience in Ireland. Psychiatr Bull 1999;
23:89-94.
4. Byrne P, Meagher D. Psychotherapy and trainees. Psychiatr Bull
1997; 21:707-710.
5. O’ Mahoney E, Corvin A. The attitudes of Irish trainees to their training and
its supervision: a five year follow up study. Ir J Psych Med 2001; 18(4): 120-
125.
6. http://www.irishpsychiatry.ie/Libraries/Postgraduate_
Training_Documents/BST_Blueprint_Final.sflb.ashx (accessed 25th July 2011)
7. Royal College of Psychiatrists. Guidelines for psychotherapy training as part
of general professional training. Psychiatr Bull 1993;17:695-698.
8. Royal College of Psychiatrists. Requirements for psychotherapy training as
part of basic specialist psychiatric training. Royal College of Psychiatrists.
2001.
9. http://www.rcpsych.ac.uk/pdf/CORE%20CURRICULUM
%20October%202010.pdf (accessed 26th July 2011)
10. McCrindle D, Wildgoose J, Tillett R. Survey of psychotherapy training for
psychiatric trainees in south west England. Psychiatr Bull 2001; 25:140-143.
11. Pretorius W, Goldbeck R. Survey of psychotherapy experience and interest
among psychiatric specialist registrars. Psychiatr Bull 2006; 30:223-225.
12. Agarwal S, Singh Y, Palanisamy V, Basker R, Van der Speck R. Psychotherapy
requirements as recommended by the college: awareness and achievement
by senior house officers. Psychiatr Bull 2007; 31:394-396.
13. http://www.irishpsychiatry.ie/Libraries/2010_Press_Releases
/CPsychi_BST_handbook_sept_2010.sflb.ashx (accessed 26th July 2011)
14. http://www.hse.ie/eng/about/Who/Board_Members/ceorpts
/feb10ceorpt.pdf (accessed 25th July 2011)
15. Malcolm M. Reflections in psychotherapy: a personal view.
Pscyhiatr Bull 1977; 1:8-10.
16. http://www.rcpsych.ac.uk/pdf/Information%20Pack%20
for%20the%20Psychotherapy%20section%20of%20the
%20C&G%20curriculum.pdf (accessed 26th July 2011)
17. http://www.irishpsychiatry.ie/Libraries/Postgraduate_
Training_Documents/Psy868_Shortlisting_Criteria.sflb.ashx (accessed 26th
July 2011)
18. Denman C. The place of psychotherapy in modern psychiatric practice.
Advances in psych treatment 2011;17:243-249.
19. Consultant Appointment Unit, Health Service Executive
45
Abstract
Objective: The aim of this exploratory study was to investigate theextent of suicide ideation, psychological maladjustment and views
of mental health service support in a sample of secondary school
pupils.
Method: A cross-sectional survey was conducted on a purposivesample of participants (n=93) recruited from a secondary school
located in the south east of Ireland. Participants completed a
Background Information Questionnaire (BIQ); the Suicide Ideation
Questionnaire (SIQ); and the Reynolds Adolescence Adjustment
Screening Inventory (RAASI).
Results: Approximately ten percent of participants displayed highlevels of suicide ideation whilst one third reported having previously
had suicidal thoughts; one quarter reported psychological
adjustment difficulties, although these varied by age and sex.
Participants’ drug use and their levels of parental closeness were
both individual factors that significantly predicted both suicide
ideation and psychological adjustment. Females reported higher
levels of parental closeness than males. Forty percent of
respondents rated mental health support services as insufficient to
meet their needs.
Conclusion: The findings raise serious concerns about the extentof suicidal thoughts amongst young people in Ireland; they also
highlight a potentially important role for parents in this regard.
Further research should ascertain national prevalence rates whilst
appropriate school-based mental health education/promotion and
support services should also be implemented.
Key words: Suicide ideation, Young people, Adolescents, Schools,Mental health.
Introduction
The increasing levels of suicide in Ireland, particularly amongst
young people, have attracted much attention in recent years.
Ireland has the fifth highest rate of youth suicide in the European
Union1 and suicide is the principal cause of death amongst young
men in this country.2 In 2006, 409 people in the Republic of Ireland
(9.6 per 100,000) reportedly completed suicide.3 Crucially, these
figures do not include parasuicide or deliberate self harm, for which
the National Parasuicide Registry (NPR) recorded 11,000 hospital
attendances in 2004. Recent data released by the Institute of Public
Health (IPH) (Barron et al 2008)4 indicate an overall suicide rate for
the Republic of Ireland of 11.2/100,000 (2001-2004), although this
figure conceals considerable regional variations.
A number of factors have been identified as antecedents in suicidal
behaviour and suicide attempts,5, 6, 7 whilst a stable progression has
also been found between suicide ideation and suicidal behaviour.8, 9 However, relatively little research on suicide ideation has been
conducted amongst young people in non-clinical settings in
Ireland, particularly within school-based populations. O’Sullivan10
and Lynch2 have conducted research among young school-going
adolescents (13-15 years old), whilst other studies have based their
research on older adolescents.11, 12 Suicide ideation is evident in
both age groups.
The principal aim of this exploratory study was to investigate the
extent of suicide ideation in a sample of secondary school pupils
and to assess their overall psychological adjustment. The specific
study objectives were to: (1) ascertain overall levels of suicide
ideation; (2) assess the prevalence of common psychological
adjustment problems; (3) explore the relationship between suicide
ideation, psychological adjustment and a number of key
background variables including parental closeness; and (4) assess
overall views of mental health service provision.
46
* Sinéad McGilloway,Senior Lecturer and Director Mental Health andSocial Research Unit,Department of Psychology,NUI Maynooth, Maynooth,Co. Kildare, Ireland.E-mail [email protected]
Ciara Brennan,HDip Student and Classroom Assistant,Sandford Parish National School,Ranelagh, Dublin 6, Ireland.
Submitted August 22nd 2008Accepted August 4th 2010
Ir J Psych Med 2012; 29 (1): 46-51
Original Paper
Suicide ideation, psychological adjustment and mental health service support: A screening study in an Irish secondary school sample
Ciara Brennan, Sinéad McGilloway
* Correspondence
Method
Participants and SettingsA purposive sample of 93 participants (46 males and 47 females)
aged 15 to 18 years (Mn=16.73; SD=0.75), was recruited from a
large, co-educational secondary school located in an urban area of
Wexford in the south east of Ireland. Both younger (15-16 years) and
older (17-18 years) age groups were targeted in order that age-
related comparisons could be made. The school principal identified
four classes in which there were prospective participants of a suitable
age and which were deemed to be broadly representative of the
different age groups within the school; each class included
approximately 25 pupils. All of those present at the time of the study
agreed to take part. Whilst we were unable to gauge the exact
number of pupils who were absent at the time of questionnaire
administration, we would estimate, from the final sample size and
the average class size, that the proportion missing was approximately
5%-7%.
MeasuresParticipants completed (anonymously) a questionnaire booklet
containing three self-report questionnaires including: 1) ABackground Information Questionnaire (BIQ); 2) the ReynoldsAdolescents Adjustment Screening Inventory (RAASI); and 3) theSuicide Ideation Questionnaire (SIQ). The BIQ was designedspecifically for purposes of this study to obtain key sociodemographic
and background information, such as experience of suicidal thoughts
(direct questions), parental closeness (Likert scale) and views of
mental health provision (open-ended questions). A number of
questions on the use and abuse of alcohol and drugs were also
included.
The RASSI13 is a 32-item, easy-to-administer and psychometrically
robust measure that is commonly used to screen for psychological
adjustment problems (e.g. antisocial behaviour; anger control
problems; emotional distress) in adolescents aged 12-19 years.
Participants are asked to rate the extent to which they have
experienced a particular thought in the last six months. All items use
a three-point response format ranging from ‘never’ through ‘almost
never’ to ‘nearly all the time’. The frequency of symptoms of adjusted
problems is recorded for each sub-scale. A ‘Total Adjustment’ score
may also be calculated, based on the scores for all four sub-scales
together.
The SIQ-JR,14 (Reynolds, 1987) is a brief, 15-item screening measure
(with good psychometric status) designed to assess thoughts about
suicide amongst adolescents aged 12 to 15 years. Item content
ranges from general thoughts of death and wishes to die, to serious
and more specific thoughts and ideas. Each item is rated on a 7-point
scale (0-6) in order to assess the frequency of occurrence during the
previous month (maximum score 90); higher scores indicate more
numerous, regular suicidal thoughts. Respondents are considered to
be ‘at risk’ if they obtain scores above 31.
Ethical considerationsThis study was conducted in accordance with the Codes of Conduct
of the British Psychological Society and Psychological Society of
Ireland. It was also reviewed internally and discussed in detail with
relevant school staff prior to commencement. Parental consent
forms, devised for purposes of the study, were distributed to each
pupil and parents were asked to provide their written informed
consent on an ‘opt-out’ basis. Participants were also given the
opportunity not to take part in the study, although all agreed to take
part. Whilst participants were of an age that did not require the
questions to be read aloud, the researcher was on hand to answer
any questions and address any concerns. No literacy problems were
reported. All participants also received a self-help information booklet
(e.g. on local mental health services) following questionnaire
completion, and were reminded of the counselling service provided
by the school. In addition, the school principal and the school
counsellor were identified to the pupils as appropriate support
persons. Thes two individuals were alerted to the findings (in writing)
as soon as they became available and indicated their commitment to
provide support to the relevant classes in whom ‘at risk’ pupils were
identified.
Results
Participant profile Most participants were living in rural settings (65%), had parents
who were married (79%) and came from families with three or fewer
siblings (63%). Three quarters consumed alcohol and 48% of males
and 21% of females respectively were classified as ‘binge drinkers’
(i.e. those who consume more than 5 drinks in one setting) (World
Health Organisation, 2004).15 One third confirmed using drugs such
as cannabis, ecstasy, cocaine and ‘speed’, 42% of whom stated that
they did so to relieve stress. Seventy per cent indicated that they had
no trouble in acquiring drugs. Whilst females tended to report higher
levels (M=6.94, SD=2.9) of parental closeness than their male
counterparts (M=5.59, SD=2.5) (t(91)=2.4, p=0.18; η2= .06), this
failed to reach statistical significance.
Suicide Ideation and Experiences with Suicide Approximately one third of participants (32%, 30/93) reported that
they had, at some stage, experienced suicidal thoughts (Figure 1)
(defined as thoughts of death and wanting to die), more than one
quarter of whom (27%, 8/30) met the ‘at risk’ criteria (i.e. scores
above 31) on the SIQ; 67% (20/30) of this group were in the older
age group (17-18 years). We were particularly interested in exploring
any age and sex differences due to previous research that suggests
that these are important concerns in this area.10,16 Participants
experienced suicidal thoughts as young as 10 years, although these
most commonly occurred between the ages of 14 and 16 years
(78%). More young (15-16 year olds) females (44%) than males (8%)
reported being bothered by suicidal thoughts, although this had
levelled off in the older age groups. A series of independent t-tests
showed no significant gender or age group (younger versus older)
differences in SIQ scores (p>0.05).
All students identified as ‘high risk’ (8/93) (as measured by the SIQ)
were currently using drugs and more commonly reported binge
drinking (43%, 13/30) than those without suicidal thoughts (29%,
18/63). Similarly, over half of this group (57%, 17/30) reported
consuming drugs in the past, compared to only 14% (9/63) of those
who reported no suicidal thoughts. Furthermore, 70% of all
participants (64/93) knew someone who had either attempted, or
completed suicide and this group was significantly more likely to
experience suicide ideation than those without such knowledge (χ2=
5.4, df= 93 p=0.02).
47
Figure 1: Proportion of participants (n=93) who had, at somestage, experienced suicidal thoughts
Psychological adjustment Clinically relevant levels of adjustment problems were reported in
one quarter (23/93) of participants and most commonly included
negative self-esteem and emotional distress respectively (Figure 2).
Unsurprisingly, moderate to strong positive correlations were found
between the SIQ and all sub-scales of the RAASI. One third of those
experiencing maladjustment (i.e. high total adjustment scores) also
reported ‘high-risk’ levels of suicide ideation. Parental closeness
was negatively and strongly correlated with both suicide ideation
[r = -.466, n = 92, p<0.000] and total adjustment [r=-.437, n=92,
p<0.000]. None of the male participants showed signs of
emotional distress, although one-quarter (6/24) of the 17-18 year
old females reported clinically significant emotional problems. Poor
anger control and antisocial behaviour respectively were seen in
9%-12% of older males and 5%-9% of younger females. None of
the younger males or older females reported these problems. No
significant age or gender differences were found with respect to
the RAASI total adjustment scores, or each of the sub-scales, with
the exception of emotional distress scores, which were significantly
higher for females (M=9.66, SD=5.1) than for males (M=6.11,
SD=3.8) (t(91)=4.12, p=0.000, eta squared= 0.6).
Figure 2: Levels of clinically significant adjustment problemsin the sample (n=93)
A number of predictor variables were regressed upon suicide
ideation and overall adjustment problems in two standard multiple
regression analyses (Table 1). These variables included drug use,
binge drinking, parental closeness and knowledge of someone
who had completed suicide (age and sex were not included as
these were only weakly correlated with SIQ and total RAASI scores).
In the first analysis, 41% of the variance in SIQ scores (adjusted R2
=.38) was predicted by the model and both drug use and parental
closeness respectively, emerged as significant predictors of suicide
ideation. Thus, the size and direction of the relationships suggested
that those who engage in drug use and have low levels of
perceived parental closeness, were more likely to experience suicide
ideation. Neither binge drinking, nor knowing a suicide victim,
contributed significantly to this model. The second regression
model (Table 1) explained 36% (adjusted R2 =.32) of the variability
in adjustment scores and again, drug use, followed closely by
parental closeness were the most influential variables and were of
a similar size and direction to those indicated above. As in the case
of SIQ scores, neither of the other two independent variables made
a significant unique contribution to the model.
Table 1: Summary of findings from two standard multipleregression analyses of key variables on suicide ideation (SIQ)and total adjustment (RAASI) scores respectively
Service provisionAlmost one third of participants reported that they had received
professional help, primarily for anger management, stress and
family problems. Forty per cent of those who had experienced
suicide ideation (12/30) reported that they had never received any
professional help whilst only one quarter of the ‘high risk’ group
(2/8) were receiving counselling. Forty per cent of the total sample
reported that they would like to receive additional information and
education on mental health and that they needed more support
services to help them during times of stress. Some suggestions
included: the provision of younger counsellors to whom pupils
could more easily relate; stress management classes; advice on
supporting others with mental health difficulties; problem solving;
and regular counselling sessions available to everyone.
Discussion
The principal aim of this study was to obtain a ‘snapshot’ of suicide
ideation in an opportune sample of secondary school students.
However, overall levels of psychological adjustment and
participants’ views of mental health service provision were also
assessed. The findings suggest that a significant proportion of
teenagers struggle with suicide ideation at some point in their lives
and yet, most of those deemed to be currently at risk, do not
appear to be seeking or receiving appropriate professional support.
Nonetheless, it is interesting to note the relatively high proportion
of the total sample overall, who reported that they had received
professional help, primarily for anger management, stress and
family problems. No information was sought on precisely the type
of services used, although it is likely that a proportion of this group
48
50
40
30
20
10
015-16YRS 15-16YRS
Age Group
% of participan
ts
Males
Females
Antisocialbehaviour
AngerControl
EmotionalDistress
NegativeSelf-esteem
TotalAdjustment
% ofparticipants
50
45
40
35
30
25
20
15
10
5
0
B S.E. Beta
SIQ RAASI SIQ RAASI SIQ RAASI
Drug Use 4.5 2.9 3.7 9.63 .442 .378***
Parent closeness 1.77 .43 .54 1.28 .379 .309**
Binge drinking .45 1.3 1.7 .008 .034 .001ns
Know suicide 2.69 2.6 3.3 3.07 .102 .125ns
Victim
Note: SIQ: R2=.41, Adj R2 = .376; RAASI: R2 = .363, Adj R2 = .324***p<0.001; **p<0.01; ns = non-significant
sought help from the school counsellor, given the relative dearth of
youth mental health services. Similarly, Sullivan and colleagues17
report that almost one in five teenagers who were experiencing
problems, had received professional help.
Previous research conducted in Ireland suggests that the proportion
of young people with suicide ideation has not changed
substantially during the last ten years, despite greater suicide
awareness and ongoing attempts to improve both formal and
informal service provision.2,11,18 For example, an early study by
O’Sullivan and Fitzgerald11 found that suicide ideation and self
harm rates within a sample of 13-14 year-old Dublin schoolchildren
(n=88-101) ranged from 29% to 44% respectively. Another Irish
study,18 conducted with younger adolescents (13-15, n=195) in a
school setting, found that 15% reported suicidal thoughts – much
lower than the one third seen in the current study, which also
included older adolescents. In 2004, Lynch and colleagues2
identified almost 20% of a sample of Irish 12-15 year-olds (n=723)
to be at risk of possible suicide ideation and mental ill health. This
is consistent with Sullivan et al17 who reported that 20% of pupils
showed signs of possible depression. They also found that just over
30% of girls had serious thoughts of harming themselves. Thus,
it is clear that there is considerable variation in suicide ideation/self
harm rates amongst adolescents in Ireland. It is also difficult, on
the basis of available data, to make comparisons with other
countries. For instance, rates in Poland amongst adolescents
appear to compare favourably to Ireland,7 although Italy has lower
levels than reported in either country.10 It is likely, of course, that
such disparity may be due to methodological differences across
studies, as well as variations in sample size and overall quality.
Whilst the above studies focus on younger adolescents, the current
research also included older adolescents, but more large-scale
research with this group is needed, particularly as these young
people are moving into an important transition phase in their lives.
Furthermore, the current study was based in county Wexford, an
area in which there has been a recent spate of family suicides and
which has a suicide rate (13-15/100, 00) that is higher than the
national average;4 consequently, the researchers were interested in
establishing (albeit in an exploratory manner) any possible effects
of this on young people living in the area. The findings reported
here confirm that most of the young people surveyed knew
someone who had attempted, or completed suicide and, in line
with work from elsewhere, this group was more likely to
experience suicidal thoughts and ideas.6, 12, 19 Therefore, it would
appear that the young people living in this area represent a
particularly important target group for mental health professionals
and schools, in terms of developing effective suicide prevention
strategies and appropriate support services, including school-based
initiatives.
However, young people must also be prepared to seek and receive
help and recent qualitative research has shown that young student
males, in particular, may not be willing to seek help for a mental
health problem due to a lack of understanding, stigma and
confidentiality issues.12 This may explain, at least in part, the lower
levels of emotional distress reported in the young males in this
study. It is also possible that there is a lack of openness among
young males to recognise or admit to these feelings. Reassuringly,
the Irish Mental Health Initiative of 200320 highlights the
importance of education and positive mental health promotion in
suicide prevention. One of its aims is to educate adults and young
people on the prevention and recognition of mental illness, to
teach them how to deal with stressful situations and create their
own support network. For instance, the National University of
Ireland, Galway (one of the seven universities in Ireland), introduced
a ‘mind body and soul programme’ in 2002 to promote general
well-being amongst its student population. This approach has since
been used in several other third level institutions and may offer a
useful model for secondary level schools. Similarly, Eckert and
colleagues21 found that implementing curriculum-based
programmes to educate students about mental illness and suicide
was viewed (by American students) as less invasive than school
screening procedures. The Finnish government22 (which is well
known for its innovative mental health service provision), has also
implemented a national strategy which has effectively reduced
suicide deaths across all age groups, by involving local communities
in regional decision making strategies and procedures.
Research has shown that negative family environments contribute
to emotional distress which, in turn, can affect suicide ideation.23,
24 Thus, those who have a supportive family environment are less
likely to report suicidal behaviour.25 Irish society, particularly in rural
areas of the country, is characterised by strong family ties, and
parental closeness was one factor that was examined in this study;
this has not previously been reported in Irish studies. The findings
outlined here suggest, in line with previous cross-cultural research,26, 27, 28 that parental closeness is a strong negative correlate of
suicide ideation, and second only to substance abuse. This, coupled
with drug use, predicted a sizeable proportion of the variance in
both suicide ideation and psychological adjustment scores,
although other factors are clearly at play. This highlights the
potentially critical role of parenting and of strong parent-child
relationships in preventing suicide, but this merits further research,
both nationally and internationally, in order to tease apart the
precise mechanisms involved in this relationship.
The current sample reported high levels of alcohol and drug abuse
similar to those seen in other larger samples,29 particularly in young
people deemed to be at risk. Substance abuse has been identified
as an important risk factor in suicide ideation30, 31 and research
would suggest that the provision of mental health education and
promotion in schools, should incorporate some information on
substance abuse as well as depression, anxiety and some of the
other more common adjustment problems seen in this study.
Interestingly, the one quarter of participants in the current study
who experienced some form of adjustment problem, is marginally
higher than the 20 percent prevalence of mental ill health typically
found amongst young people elsewhere,1,32 although no clinical
diagnoses were used in this study.
Conclusion
This exploratory screening study was limited by a relatively small
sample drawn from a single large, urban-based school and the
results do not include clinical/diagnostic interviews. While the
sample was one of convenience, there is no reason to expect that
the 5th and 6th year classes included in this study were in any way
49
atypical of young people generally in this age group and indeed
the findings would tend to support this; for instance, the results are
consistent with those found elsewhere with both similar-sized and
larger samples.
Overall, the findings raise some serious concerns about the extent
of suicidal thoughts and ideas in young people whilst also
highlighting, amongst other things, the importance of the parent-
child relationship into the teenage years. The latter is something
about which very little is known. However, it would be useful to
assess regional variations within a larger national longitudinal study
in order to describe and track the overall prevalence of, and
changes in, suicide ideation amongst young people over time and
the extent to which these relate to actual suicide rates.
It is widely acknowledged that young people on the island of
Ireland lack specialist mental health service provision33 whilst
mental health services spending is also well below what is
required.34 Nonetheless, it is imperative that vulnerable, at risk
young people can be identified as early as possible and appropriate
prevention strategies put in place in order that potential deaths
can be avoided into the future. The Irish National Strategy for
Action on Suicide Prevention 2005-201435 advocates the
development of counselling services and crisis response protocols
in all primary and secondary schools throughout Ireland. Likewise,
one of the aims enshrined in the recent Programme for
Government document in Northern Ireland,36 is to establish a
suicide prevention helpline, as well as initiatives aimed at improving
the life and coping skills of all those at risk of suicide.
Importantly, a significant proportion of the young people in the
current study were not satisfied with mental health support and
indicated a high level of unmet need. While some of their
suggestions for improvement in this regard have significant
resource implications (e.g. regular counselling), others could be
more easily implemented in schools (e.g. younger counsellors). It is
also important to note that the Irish school curriculum includes a
Social Personal Health Education (SPHE) module aimed at:
developing self-awareness and personal skills; emotional health;
relationship skills; stress management; and promoting a greater
awareness/knowledge of mental illness. Other elements of the
programme are aimed at helping students to develop the
confidence to protect their mental health and well being, and to
examine the factors that might impact on these. It is difficult to
know to what extent this programme has been effective, but at
the very least, it is providing a forum to discuss the many issues
that affect young people.
The prevention of suicide amongst young people continues to be
controversial due, in large part, to the paucity of population-based
studies and a failure to take account of the multiple risk factors
involved.37 The results of the research were conveyed to the school
that was the focus of this study and in this way, research findings
such as those reported here, may help to develop mental health
promotion initiatives in schools, thereby potentially preventing
deaths from suicide in ‘at risk’ young people into the future.
However, it remains to be seen to what extent the current
downturn in the Irish economy will impact upon the much needed
implementation of school and other community-based mental
health promoting initiatives and support services for our young
people.
Acknowledgements
We would like to thank the school principal and all of the pupils for
participating in this study.
Conflict of interest
None.
References
1. WHO. World Health Organisation, European Ministerial Conference 2005.
Mental health: facing the challenges, building solutions (2005).
2. Lynch F, Mills C, Daly I, Fitzpatrick C. Challenging times: a study to
detect Irish adolescents at risk of psychiatric disorders and suicidal ideation.
J Adolesc 2004; 27(4): 441-451.
3. Central Statistics Office. Vital Statistics Fourth Quarter & Yearly Summary
2006. Released 31 July 2007.
http://www.cso.ie/newsevents/pr_vitalstatsq4andyear2006.htm
4. Barron S, Balanda K, Graham A, Fahy L. Irish Health Poverty Index (interim
release). INIsPHO Data Briefing No.2008:1. Dublin: Institute of Public Health,
2008.
5. Friedman AC. Prevalence and correlates of suicidal ideation and self-
reported attempts in an adolescent community population. Dissertation
Abstracts International Section A: Humanities and Social Sciences 1998; 59
(1): 0322.
6. Leo DD, Cerin E, Spathonis K, Burgis S. Lifetime risk of suicide ideation and
attempts in an Australian community: Prevalence, suicidal process,and help-
seeking behaviour. J Affective Disorders 2005; 86: 215–224.
7. Gmitrowicz A, Szymczak W, Kotlicka-Antczak M, Rabe-Joblonska J.
Suicidal ideation and suicide attempts in Polish adolescents: Is it a suicidal
process? Int J Adolesc and Med Health 2003; 15 (2): 113-124.
8. Miros NJ. Depression, anger, and coping skills as predictors of suicidal ideation
in young adults: Examination of the diathesis-stress-hopelessness theory.
Dissertation Abstracts International: Section B: The Sciences and Engineering
2000; 61(6): 3286.
9. Wong JPS, Stewart SM, Ho SY, Rao U, Lam TH. Exposure to suicide and
suicidal behaviors among Hong Kong adolescents. Soc Sci & Med 2005; 61:
591–599.
10. O’Sullivan M, Fitzgerald M. Suicidal ideation and acts of self-harm among
Dublin school children. J Adolesc 1998; 21: 427-433.
11. Miotto, P., De Coppi, M., Frezza, M., Petretto, D., Masala, C., & Preti, A.
(Suicidal ideation and aggressiveness in school-aged youths. Psychiatry
Research 2003, 120, 247-255.
12. Burke S, Kerr R, McKeon P. Male secondary school students’ attitudes towards
using mental health services. Ir J Psych Med 2008; 25(2): 52-56.
13. Reynolds WM. Reynolds Adolescent Adjustment Screening Inventory.
Professional Manual Psychological Assessment Resources. Odessa FL:
Psychological Assessment Resources, 2001.
14. Reynolds WM. Suicide Ideation Questionnaire. Odessa, FL: Psychological
Assessment Resources, 1987.
15. World Health Organisation. Global Status on Alcohol – Binge drinking
defined. Geneva: World Health Organisation, 2004.
16. Bensley, L S, Van Eenwyk, J, Spieker, S J, Schoder, J. Self-
reported abuse history and adolescent problem behaviours I: Antisocial and
suicidal behaviours, Journal of Adolescent Health, 1999, 24, 163-172.
17. Sullivan C, Arensman E, Keeley HS, Corcoran P, Perry IP. Young People’s
Mental Health: a report of the Lifestyle and Coping Survey. National Suicide
Research Foundation, 2004.
18. Rowley J, Ganter K, Fitzpatrick C. Suicidal thoughts and acts in Irish
adolescents. Ir J Psych Med 2001; 18(3): 82-86.
19. Fergusson DM, Beaturais AL, Horwood LJ. Vulnerability and resiliency to
suicidal behaviour in young people. Psych Med 2003; 33: 61-73.
50
20. Kracen, A. The Mental Health Initiative: a resource manual for mental health
promotion and suicide prevention in third level institutions. A partnership
initiative between Trinity College Dublin and the Northern Area Health
Board. Supported by the National Suicide Review Group, the Department of
Health and Children, and the Department of Education and Science, 2003.
21. Eckert TL, Miller DN, Riley-Tillman TC, DuPaul GJ. Adolescent suicide
prevention: Gender differences in students’ perceptions of the acceptability
and intrusiveness of school-based screening programs. J School Psychol 2006;
44: 271–285.
22. Jenkins R, Singh B. Suicide prevention strategies – an international
perspective. Int Rev Psychiatr 2000; 12(1): 7-14.
23. Connor JJ, Rueter MA. Parent–Child Relationships as Systems of Support or
Risk for Adolescent Suicidality. J Family Psych 2006; 20(1): 143–155.
24. Stanley H. Family characteristics that influence and differentiate adolescent
non-single, and multiple suicide attempts. Dissertation Abstracts
International: Section B: The Sciences and Engineering 2004; 65(5-B), 2008.
25. Evan DL, Foa EB, Gur RE, Hendin H, O’Brien CP, Seligman MEP, Walsh BT.
Treating and Preventing Adolescent Mental Health Disorders: What we know
and what we don’t know. London: Oxford University Press, 2005.
26. Borowsky IW, Ireland M, Resnick MD. Adolescent suicide attempts: Risks and
protectors. Pediatrics 2001; 107: 485-493.
27. Séguin M, Lynch J, Labelle R, Gagnon A. Personal and family risk factors for
adolescent suicidal ideation and attempts. Arch Suicide Res 2004; 8(3): 227-
238.
28. Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behaviour.
J Child Psych and Psychiatry 2006; 47(3): 372–394.
29. McCrystal P, Percy A, Higgins K. Drug use patterns and behaviours of young
people at an increased risk of drug use during adolescence. Int J Drug Policy
2006; 17(5): 393-401.
30. Fombonne E. Suicidal behaviours in vulnerable adolescents. Time trends and
their correlates. Br J Psychiatry 1998; 173: 556–7.
31. Cleary A, Nixon E, Fitzgerald M. Psychological health and well-being among
young Irish adults. Ir J Psych Med 2007; 24(4): 139-144.
32. Department of Health and Children. A Vision for Change. Dublin: Department
of Health and Children, 2006.
33. McGilloway S, Donnelly M, Scott D. Teenagers in adult psychiatric inpatient
care in Northern Ireland. Ir J Psych Med 2000; 17(2): 54-58.
34. O’Shea E, Gannon B, Kennelly B. Eliciting preferences for resource allocation
in mental health care in Ireland, Health Policy 2008;
doi:10.1016/j.healthpol.2008.03.018.
35. Health Service Executive. Reach Out: National Strategy for Action on Suicide
Prevention 2005-2014. Dublin: The Health Service Executive, 2005.
36. Northern Ireland Executive. Building a Better Future – Programme for
Government 2008-2011. Belfast: Northern Ireland Executive, 2008.
37. Donnelly M, McGilloway S. Mental Disorders. In: Yarnell J, Ed. Epidemiology
and Prevention: A Systems-Based Approach. London: Oxford University Press,
2007.
51
Abstract
Objective: To review the role of handwriting analysis in psychiatry.
Method: Case-report and review of key papers.
Results: M, a 27-year-old man, presented with incoherent speech,palilalia, logoclonia, incongruous affect, paranoid delusions and
auditory hallucinations. M was diagnosed with schizophrenia and
cannabis misuse, complicated by speech and language difficulties.
M spent long periods writing on pieces of paper; towards the start
of his admission, his writing was unintelligible but became more
intelligible as his psychosis resolved. M’s handwriting demonstrates
clinical features of psychosis (e.g. clang associations) and
graphological abnormalities associated with schizophrenia in the
literature (rigidity in letter-formation, mechanical expressions, and
tendency toward over-use of straight lines).
Conclusion: Analysis of handwriting is likely to play a limited rolein psychiatric diagnosis but may prove useful in monitoring clinical
improvement in certain patients.
Key words: Psychoses; Cannabis; Psychomotor dysfunction;Review of the literature
Introduction
The study of handwriting as a diagnostic tool has a lengthy history
in psychiatry.1-4 Sulner reflected the position of many in the
psychiatric and legal professions when she wrote that handwriting
was closely related to brain function and was, thus, likely to reflect
disordered psychological functioning and mental illness.2
Consistent with this idea, authors such as Lewinson1 and Privat4
provide detailed analyses of samples of handwriting from
individuals with mental illness.
While this field was the subject of considerable research and clinical
interest in the 1940s, 1950s and 1960s, it has not commanded
similar attention in recent decades. We aimed to review key papers
in this field in light of a specific clinical case in which disturbances
of handwriting were a central feature.
Case Report
M was a 27-year-old man who was brought to the Emergency
Department by the police, having been found setting fires outside
his home. He presented in a confused, dishevelled and unkempt
state. On admission, M’s speech was incoherent and demonstrated
palilalia (repetition of a word with increasing frequency) and
logoclonia (repetition of the last syllable of the last spoken word).
His affect was incongruent with his situation (i.e. in police custody).
M had multiple delusions that famous actors were involved in his
daily life (e.g. making him cups of tea) and that he was being
pursued by unknown, threatening forces. M described auditory
hallucinations in a “deep, deep voice” but was unable to detail
what the voice said. While he was oriented in time, place and
person, M’s insight was limited: he did not agree that he was ill
and was legally detained in hospital as an involuntary patient.
Background history from M’s brother revealed that M and his
brother, who lived together, were frequent users of large amounts
of cannabis and that M had been in this mental state for many
months or possibly years. M’s brother confirmed that M’s delusions
persisted even when M was abstinent from cannabis and had
preceded M’s use of cannabis in the first instance.
M was diagnosed with schizophrenia, according to Diagnostic and
Statistical Manual of Mental Disorders (Fourth Edition, Text
Revision)5 criteria, and substance misuse, complicated by significant
difficulties with speech and language. Following admission to
hospital, M was prescribed olanzapine orodispersible tablet (10
miligrams per day, administered orally) and as he became less
agitated it became apparent that he had significant difficulties with
speech and language. Formal assessment by a speech and
language therapist revealed that M had minimal verbal output
which was generally unintelligible; this caused him considerable
frustration. M appeared able to understand the words of others
but was poorly cooperative with more detailed speech and
language assessments.
M’s brother revealed that, prior to admission, M had spent long
periods writing letters and words on small pieces of paper.
Throughout his one-month hospital stay, M continued to write
52
* Brendan D. Kelly,Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Ireland. E-mail [email protected]
Mary Davoran,Senior Registrar and Lecturer in Forensic Psychiatry,Central Mental Hospital, Dundrum, Dublin 14,Ireland.
Eugene Breen,Consultant Psychiatrist, Mater MisericordiaeUniversity Hospital, Eccles Street, Dublin 7, Ireland.
Natalie Sherrard, Liaison Psychiatry Clinical NurseSpecialist, Department of Psychiatry, MaterMisericordiae University Hospital, Eccles Street,Dublin 7, Ireland.
Submitted October 3rd 2008Accepted August 11th 2011
Ir J Psych Med 2012; 29 (1): 52-54
Case Report
Graphology and psychiatric diagnosis: Is the writing on the wall?Mary Davoren, Natalie Sherrard, Eugene Breen, Brendan D. Kelly
* Correspondence
intensively on sheets of note-paper, the back of cigarette cartons,
etc. Towards the start of his admission, M’s writings were
fragmented and difficult to understand (Figure 1, during first week
of admission) but they became more intelligible as his psychosis
resolved (Figures 2 and 3, during third and fourth weeks of
admission, respectively).
Three weeks after admission, M’s psychotic symptoms had
decreased significantly and, one week later, he was discharged
from hospital. At ten-month follow-up, M remained well in the
community on continued antipsychotic medication, although he
continued to abuse cannabis.
Discussion
M’s diagnoses were schizophrenia and substance misuse,
complicated by significant difficulties with speech and language. It
is not possible to determine if the difficulties with communication
predated his psychotic illness, but it was readily apparent that
improvement in psychotic symptoms was associated with
improvement in communication behaviours, including handwriting.
Samples of M’s handwriting reproduced in this paper demonstrate
both clinical features of psychosis (e.g. clang association, in Figure2) and some of the more specific graphological abnormalitiesdescribed in the literature on mental illness and disturbances of
handwriting.
Sulner, for example, listed a range of “abnormalities” which she
suggested “indicate mental disease or mental or emotional
disturbance”, including repetition of letters or words, omission of
letters or words (or parts of letters or words), transposition of
letters, incorrect spelling, scribbling in the midst of an otherwise
readable text, lack of control of writing, meaningless marks, or
interruptions between letters.2 Many of these “abnormalities” are,
however, common, and Sulner’s list does not appear aimed at
assisting in reaching a clinical diagnosis, but rather achieving a legal
aim: i.e. determining, in a general sense, if an individual was
suffering from any “mental disease or mental or emotional
disturbance”.2
Hilton was somewhat more circumspect about the proposed
relationship between handwriting and mental disorders,
questioning both the sensitivity and specificity of handwriting
abnormalities by posing two key questions: Are such abnormalities
always present in the writing of individuals with mental disorder?
And are such abnormalities specific to mental disorders? 3
It is exceedingly unlikely that any of the anomalies outlined by
Sulner2 are only found in the handwriting of persons with mental
disorder. For example, logoclonus/logoclonia is also found in
Parkinson’s disease and here represents a spastic repetitive
phenomenon, e.g. “I went to the cinema...maa...maaa...maa...”
Against this background, Lewinson1 drew on the work of the
German philosopher and graphologist Ludwig Klages (1872-1956)
to develop a more detailed approach based on the presence of
different constellations of features in the writing of individuals withpsychosis.1,6
Lewinson studied and reproduced handwriting samples from
individuals with schizophrenia, the “paranoid condition” and the
“manic-depressive condition”, and concluded that the handwriting
of individuals with psychosis was especially characterised by
disturbances in all three dimensions of handwriting: height,
breadth and depth.1 Lewinson’s handwriting samples included
twenty individuals with schizophrenia and these tended to
demonstrate “narrowness of letters” (not present in M’s
handwriting), slant “toward the right” (not present in M’s
handwriting), “rigid school-copy forms” (present in Figures 1 to 3),
an “empty-mechanical” expression (present in Figures 1 to 3) and
a “tendency for straight line” (see the letter ‘O’ in Figure 3, which
resembles a square more than a circle).1
Consistent with the presence of schizophrenia and “paranoid
condition” on a single diagnostic continuum, Lewinson described
considerable overlap between the handwriting features of these
two conditions.1 Lewinson reported that handwriting in the
“paranoid condition” was characterised by “lack of connection in
printed writing” (present in Figures 1 to 3), “inhibited, constricted”
character (present in Figures 1 to 3), “alteration between wide and
narrow letters” (not present in M’s handwriting), “wide writing”
(present in Figures 1 to 3) and “irregular slant toward the right”
(not present in M’s handwriting).1
Handwriting of individuals in the “depressive phase” of manic-
depression was characterised by “smallness of the writing” (not
present in M’s handwriting), “lack of rhythm” (not present in M’s
handwriting), “narrowness in letters” (not present in M’s
handwriting) and “vertical to right slanting” (present in Figure 3).1
Handwriting in individuals with “mania” was characterised by
“irregular and increasing” size (not present in M’s handwriting),
“lack of rhythm” (not present in M’s handwriting) and “school
copy forms with additions and ornamentations” (see drawings of
hands in Figure 2, especially at the end of the fifth last line, where
the word “handsome” is presented as a picture of a hand followed
by the letters “sume”).1
Overall, M’s handwriting was most consistent with the
graphological features that Lewinson1 associated with
schizophrenia and the “paranoid condition”, although M’s
handwriting also demonstrated selected features of both the
depressive and elated phases of manic-depression.
Notwithstanding these similarities to Lewinson’s typologies, analysis
of M’s handwriting did not make a significant contribution to the
diagnostic process. The increased intelligibility of his writing as his
psychotic symptoms resolved, however, suggests that changes in
the content and/or form of handwriting may, in certain patients,
assist in monitoring clinical improvement over time. The
longitudinal course and predictive usefulness of this approach has
not yet been studied.
As a result, it remains the case that graphology can, at best, provide
only “supplementary assistance to accepted psychiatric
determinations”.3 This position may change in future years if and
when novel graphological approaches and analytic technologies
improve the sensitivity and specificity of handwriting analysis in the
context of psychiatric diagnosis and practice.
Conflict of interest
None.
53
Figure 1First sample of handwriting (first week of M’s admission), showing
“rigid school-copy forms” and “empty-mechanical” expression,
consistent with schizophrenia; “lack of connection in printed
writing”, “inhibited, constricted” character and “wide writing”,
consistent with Lewison’s “paranoid condition”.1
Figure 2Second sample of M’s handwriting (third week of M’s admission),
showing “rigid school-copy forms” and an “empty-mechanical”
expression, consistent with schizophrenia; “lack of connection in
printed writing”, “inhibited, constricted” character and “wide
writing”, consistent with “paranoid condition”; “school copy
forms with additions and ornamentations” consistent with mania
(see the end of the fifth last line, where the word “handsome” is
presented as a picture of a hand followed by the letters “sume”).1
Figure 3Third sample of handwriting (fourth week of M’s admission),
showing “rigid school-copy forms”, an “empty-mechanical”
expression and a “tendency for straight line” (see the letter ‘O’,
which resembles a square more than a circle), consistent with
schizophrenia; “lack of connection in printed writing”, “inhibited,
constricted” character and “wide writing”, consistent with
“paranoid condition”; and “vertical to right slanting”, consistent
with the “depressive phase” of manic-depression.1
References
1. Lewinson TS. Dynamic disturbances in the handwriting of
psychotics. Am J Psychiatry 1940; 97: 102-135.
2. Sulner HF. Mental disorders: their effects upon handwriting. Am
Bar Assoc J 1959; 45: 931-934.
3. Hilton O. Handwriting and the mentally ill. J Forensic Sci 1962;
7: 131-139.
4. Privat S. Contribution de la graphologie au diagnostic et au
pronostic des psychoses. Gaz Med Fr 1965; 72: 2501-2523.
5. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders (Fourth Edition, Text Revision).
Washington, DC: American Psychiatric Association, 2000.
6. Lewinson TS. An introduction to the graphology of Ludwig
Klages. Character and Personality 1938; 6: 163-176.
54
Introduction
One of the most important questions facing psychiatry today
concerns its relationship to the emerging international service user
movement. I believe that this movement presents not only the
greatest challenge to psychiatry, but also the greatest opportunity.
As it becomes more organised and influential this movement is
starting to play a major role in shaping the sort of questions that
are being asked about mental health services and their priorities.
Yet there is limited reflection in our profession about how we, as
doctors, might engage positively with it. It seems that while we are
comfortable working with individuals and organisations who
accept the medical framing of mental problems, we are less willing
to contemplate working with critical service users. These are people
who reject the medical model because they feel harmed by a
system that describes their problems using the language of
psychopathology. If we are serious about having an inclusive
debate on mental health we will have to overcome this impasse.
We need to entertain the idea that people who reject the medical
framing of their problems are nevertheless legitimate stakeholders.
It is time that we learned how to talk to them and to listen to their
ideas. The user movement, with its substantial critical component,
is not going to go away.
One of the most important elements of the relationship between
psychiatric services and the people who use them is the reality of
psychiatric power. Many critical service users accept that legally
sanctioned interventions may be necessary when individuals lose
capacity to care for themselves and perhaps put themselves or
others at risk. However they do not accept the fact that the Mental
Health Act in Ireland gives sole authority to doctors to take
decisions on such interventions without any obligation to consult
other interested parties.
Under the terms of the 2001 Act in Ireland, while an application for
involuntary detention may be made by a relative or other named
individual and a GP is required to support this with a
recommendation order, once a patient is detained all power is put
into the hands of the consultant psychiatrist. As a result the Act
effectively privileges the voice of psychiatry. When an individual is
detained, the psychiatrist is endowed with the authority to
determine the nature of his or her problems and the vocabulary
that will be used to describe them. Moreover, the psychiatrist has
the power to determine what treatment will be used, how it will be
used and for how long. It is also within the power of the
psychiatrist to decide what side-effects of medication will be taken
into account and what risks to the patient’s health will be tolerated
and to order ECT for a patient even if the patient and his/her family
refuse it. The patient is seen for a second opinion shortly after
admission, but this is also carried out by a psychiatrist. The three-
person tribunal team that reviews the admission order always
includes a psychiatrist.
There is evidence that many people who have undergone
involuntary admission and treatment continue to feel hurt and even
violated by this process.1 Stefan Priebe and his colleagues reported
on a study in which they were able to follow up more than half of
a cohort of patients who were detained under the Mental Health
Act in England.2 After one year they asked these patients if their
involuntary detention was justified. Only 40% said that it was. The
authors comment that ‘this percentage might have been even
smaller if all patients had been re-interviewed’. This would indicate
that a majority of patients are currently unhappy with the process
of involuntary detention.
A review of the 2001 Irish Mental Health Act will be taking place
shortly. In my opinion, this presents us with an opportunity to
engage creatively with the user movement in all its diversity,
something that many psychiatrists genuinely welcome. However, in
order to do so we will have to reflect critically on the ‘micro-politics’
of our current clinical encounters. In this paper I will argue that the
decision-making powers that are currently given to psychiatry
cannot be justified on either scientific or moral grounds. I will go
on to argue that shedding these powers (and subsequent
responsibilities) would be a positive move for our profession.
Justifying Psychiatric Power
It is usual to justify psychiatric power by asserting that we have an
expertise about mental illness that allows us to diagnose accurately,
classify logically and treat efficiently. The assumption is that no
other group in society has such knowledge and therefore can be
trusted to make decisions about people who are mentally
deranged for one reason or another.
The logic for psychiatric power would appear to be:
• States of madness and distress are the result of episodes of
mental illness.
• Mental illness can be fully grasped in the logic of medicine and
thus doctors are uniquely positioned to explain and to predict
the outcome of such episodes.
• Psychiatry possesses a range of treatments that are un-
controversially of benefit to its patients.
• It is therefore justified to give psychiatrists the power to both
detain and to treat patients without their consent.
The assertion here is that psychiatric science leads to psychiatricpower.
55
Pat Bracken, Consultant Psychiatrist and Clinical Director, Centre for Mental Health Care and Recovery, Bantry General Hospital, Bantry, Co Cork, Ireland.E-Mail [email protected]
Submitted October 20th 2010 Accepted January 13th 2012
Ir J Psych Med 2012; 29 (1): 55-58
Opinion
Psychiatric power: A personal viewPat Bracken
Thomas Szasz has challenged this position for over half a century.3
He argues that it is actually the other way round. In his opinion the
history of psychiatry is very different from the history of medicine.
Western medicine traces its origins back to the Greeks, and has
always been primarily concerned with the suffering caused by
diseased organs, and the various interventions that can be made to
ease or cure this suffering. Until the 19th century most mental and
emotional problems were not treated by physicians. Disturbances
of thinking and emotion were understood mainly as spiritual or
moral problems. When people were detained on account of such
disturbances, this was the domain of clerics rather than doctors.
In the 19th century a new sort of physician was born: the ‘mad-
doctor’, the ‘alienist’, and in the end, the psychiatrist. What
characterised all these doctors was not their knowledge but the
location of their work. Psychiatrists were simply doctors who
worked in asylums. There is general agreement amongst historians
that the enormous asylums were not the creation of the medical
profession, less still of psychiatry.
As Roy Porter says: ‘It would be wrong to regard this drive over the
last three centuries towards institutionalizing insanity
fundamentally as the brainchild of “psychiatry”. In the first instance
the sequestration of ‘lunatics’ was primarily an expression of civil
policy: rather an initiative from magistrates, philanthropists and
families than the achievement (for good or ill) of the doctors.
Indeed, the rise of psychological medicine was more the
consequence than the cause of the rise of the insane asylum.
Psychiatry could flourish once, but not before, large numbers of
inmates were crowded into asylums’.4
Szasz argues that ‘as the clergyman’s power diminished, the mad-
doctor’s increased, and theological coercion was replaced by
psychiatric coercion’.3 Furthermore, according to Porter, the
emergence of a psychiatric science only took place once individuals
had already been separated from society and brought together in
the asylums of the early 19th century. In other words, according to
Szasz and historians like Roy Porter, psychiatric power led topsychiatric science.
This analysis has major implications for the situation in which we
find ourselves today. Historically, there was no real science of
psychiatry that could justify the power that was given to the
profession. In the early 19th century, there were disparate,
contradictory theories of madness; there were no clear
classification systems and the treatments used were often akin to
torture. Porter gives us an account of Johann Christian Reil’s
approach to treatment (Reil is credited with being the first person
to coin the term ‘psychiatry’). Reil, says Porter:
‘proposed an idiosyncratic variant on moral treatment: the
charismatic alienist would master the delinquent mind; a staff
trained in play-acting would further the alienist’s efforts to break
the patient’s fixed ideas – and all would be combined with salutary
doses of therapeutic terror (sealing-wax dropped onto the palms,
immersion in a tub of eels, etc.)’.5
Psychiatry did not have any answers. In fact, the one regime that
genuinely seemed to possess therapeutic efficacy, the moral
treatment practiced at the Quaker York Retreat, was devised by
the Tuke family who were tea merchants, not doctors. Yet,
psychiatry was invested with the power to detain, to explain and
to treat.
In our own era, the powers of psychiatry have been refined but
not lessened. The question still faces us: is the science of psychiatric
treatment robust enough to justify psychiatric power?
In their defense of involuntary commitment, in The Reality ofMental Illness, Martin Roth and Jerome Kroll make an importantpoint:
‘Since most people agree that civil commitment, i.e. involuntary
incarceration of a person who has not committed a crime, and
involuntary treatment (based upon what others believe is best for
a person) represent massive [their emphasis] infringements of thatperson’s civil liberties and personal integrity, it follows that the
factual basis and the ethico-legal justification for such a course
must be suitably strong and unambiguous’.6
According to Roth and Kroll, if psychiatrists are ever going to be
able to justify their role in such ‘massive infringements’ of civil
liberty we will need to be very confident that our science is
disinterested and robust and that our treatments are transparently
effective. We will need to be confident that we can predict
outcomes, and happy that we understand how our treatments
work and for whom. Furthermore, we will need to be very clear
that the benefit of these treatments completely outweighs their
negative effects. Remember, no other branch of medicine has the
power that psychiatry possesses. We will need to be at least as
confident as the rest of medicine about the veracity of our science
if we are to justify this power. Do we have such a science? Let us
briefly look at a couple of issues.
Is the science of psychiatric treatment ‘strong andunambiguous’?
While mainstream psychiatry still holds to the idea that
antidepressants work through their pharmacological effects on
specific neurotransmitters in the CNS, critical psychiatrists like
Joanna Moncrieff and David Healy have been pointing out for
many years that most of the therapeutic effect of anti-depressants
can be explained by the placebo effect. In the past two years the
evidence for this has become indisputable. Two major meta-
analyses of US Federal Drug Administration (FDA) data by Turner et
al7 and Kirsch et al8 concluded that over 80% of the improvement
seen in the drug groups was duplicated in the placebo groups.
Irving Kirsch published a book based upon this research in 2009.
He concludes:
‘The belief that antidepressants can cure depression chemically is
simply wrong’.9
The placebo phenomenon is not peculiar to psychiatry.10 However,
a great deal of theoretical reflection in psychiatry, such as the
monoamine theory of affective disorders, has been based upon the
56
supposed biological effects of these drugs. Thus these recent meta-
analyses represent not only a challenge to our prescribing but also
question the foundations of contemporary psychiatric science itself.
Rather than embrace the therapeutic reality and the theoretical
implications of the placebo phenomenon and explore ways of
incorporating these positively and transparently, a number of
prominent psychiatrists have sought to justify current prescribing
practices by dismissing the results of these meta-analyses. Some of
them have done so by arguing that we should abandon the
evidence-based medicine (EBM) approach. They say something like:
‘actually science isn’t that important in debates about
psychopharmacology, what is really important is the experience of
the doctor’. So we hear one prominent psychopharmacologist,
MacAllister Williams, insisting that:
‘it matters little whether the patient responds due to the placebo
effect or the specific pharmacological actions of the drug, as long
as they get better’.11
But the whole logic of EBM, of double blind controlled trials, is to
identify what part of therapeutic improvement is due to the
placebo response. MacAllister Williams is telling us that this is not
important: we know how to get our patients better with
antidepressants and that is all that matters.
The psychiatric discourse around antidepressants is far from the
‘strong and unambiguous science’ demanded by Roth and Kroll.
Is the science of anti-psychotics any more robust? The development
of second generation antipsychotics was heralded as one of the
great achievements of modern psychopharmacology. For many
years after their introduction, psychiatrists told patients and
relatives how safe and effective these drugs were. There was talk
about a ‘breakthrough’ in the treatment of schizophrenia. Several
years on, and the picture does not look so rosy. We now know that
these drugs are possibly more toxic than the earlier ones and there
is no evidence that they are more effective. Furthermore, in a major
paper in the Lancet last year, evidence was presented to show thateven the notion that these drugs represented a significantly
different grouping was false.12 In an editorial comment on thispaper, Peter Tyrer and Tim Kendall wrote:
‘The spurious invention of the atypicals can now be regarded as
invention only, cleverly manipulated by the drug industry for
marketing purposes and only now being exposed. But how is it
that for nearly two decades we have, as some have put it, “been
beguiled” into thinking they were superior?’.13
Antidepressants and antipsychotics are cornerstones of
psychopharmacology. These are the drugs that are administered to
patients when they are detained. Psychopharmacology is the usual
form of treatment given to patients on an involuntary basis.
My argument is that the science we have available to us now, with
its explanations and treatments, is simply not of the standard set by
Roth and Kroll to justify the power that psychiatrists have been
given.
Conclusion
As in most other countries, the Mental Health Act in Ireland puts
a great deal of power and responsibility into the hands of
psychiatrists. Advance directives, advocates, carers, other
professionals and other interested parties play little if any part in
the decision-making process regarding detention and treatment.
In other words, the current legal framework governing these
interventions endorses the singular authority of psychiatric science.
In this paper, I have argued that psychiatric power did not develop
logically from the explanatory and therapeutic abilities of
psychiatric science in the 19th century. Indeed, historians suggest
that this science was given energy and direction from the priorincarceration of thousands of patients across the western world.
Furthermore, I have argued that, in our own time, we simply do not
possess the sort of medical science with explanatory, predictive and
therapeutic powers that might justify the legal authority invested
in us. Our knowledge does not pass the test set by Roth and Kroll.
Indeed, I believe that because psychiatry is tasked to deal
specifically with problems of beliefs, feelings, behaviours and
relationships, its knowledge has to be qualitatively different to that
upon which a medicine of the tissues is built.14
But even if we did have such a knowledge, the current privileged
position given to psychiatry in the Mental Health Act directly
contradicts the fundamental ethic of the ‘recovery approach’ to
mental health which is promoted by ‘A Vision for Change’ and bythe Mental Health Commission. One of the Commission’s most
recent documents contains the statement: ‘the recovery approach
challenges the privileging of one theoretical perspective as the
primary explanation for and the treatment of mental distress and
the privileging of professional interpretations and expertise over
expertise by experience and personal meaning. The biomedical
model and medical treatments may have an important place for
some people in the recovery process, but as an invited guest, rather
than the overarching paradigm’.15 A key element of the recovery
approach is the promotion of ‘empowerment’.16 This includes the
power to define the nature of one’s problems and to be involved
in decisions about treatment.
Some psychiatrists have yet to embrace the ‘recovery approach’
and continue to think and act as though the psychopathological
framework was the only legitimate and valid way of understanding
states of madness and distress.17 But many are now responding to
the calls of service users to create a different sort of psychiatry. A
key element of any mental health service involves the management
of risk. But there is clearly room to rethink how we do this. The
EUNOMIA study has demonstrated ‘huge variation’ in the rates of
involuntary admissions across Europe.18 Differences in ‘socio-
cultural contexts’ appear to be responsible for this variation rather
than rates of mental illness. I am not arguing that there should be
no mechanisms in place to intervene when individuals are mentally
disturbed. I am not denying that medical practitioners have an
important role to play. However, I am suggesting that the current
powers and responsibilities of psychiatry are not warranted on
either empirical or philosophical grounds.
57
In their recent qualitative study of the impact of coercive
interventions, Sibitz et al19 found that while some service users,
who had received such interventions in the past, felt that
involuntary treatment was sometimes needed; many felt that their
crises could have been managed differently. They found that ‘the
ways that problems were formulated by mental health staff as
psychiatric issues were sometimes contrary to the ways patients
saw their problems and what was needed to solve them’. As a
result, participants in this study reported that the experience of
involuntary treatment had left them with a ‘general distrust of
others, particularly of medical professionals’. They reported living
their lives as if ‘on probation’ in the aftermath.
This has implications for the personal relationships between
individual psychiatrists and their patients but also for the profession
and the society it serves. At present, psychiatry continues to be
feared. In spite of all the anti-stigma campaigns, as long as the
profession is bestowed with powers to incarcerate and to treat on
an involuntary basis, this fear will continue. The forthcoming review
of the Mental Health Act provides an opportunity for psychiatrists
to shed some of these powers and to engage with service-users in
a positive debate about how and when force should be used in
mental health crises.
Conflict of interest
None.
References
1. Katsakou C, Priebe S. Patients’ experiences of involuntary hospital admission
and treatment: a review of qualitative studies. Epidemiol Psichiatr Soc 2007;
16: 172-8.
2. Priebe S, Amos T, Leese M et al. Patients’ views and readmissions 1 year after
involuntary hospitalisation. Br J Psychiatry 2009; 94: 49-54.
3. Szasz T. The medicalization of everyday life. New York: Syracuse University
Press; 2007.
4. Porter R. A social history of madness: Stories of the insane. London:
Weidenfeld and Nicolson, 1987.
5. Porter R. Madness: A brief history. Oxford: Oxford University Press; 2002.
6. Roth M, Kroll J. The reality of mental illness. Cambridge: Cambridge University
Press; 1986
7. Turner EH, Matthews AM, Linardatos E et al. Selective publication of
antidepressant trials and its influence on apparent efficacy. NEJM 2008; 358:
252-60.
8. Kirsch I, Deacon BJ, Huedo-Medina TB et al. Initial severity and antidepressant
benefits: a meta-analysis of data submitted to the Food and Drug
Administration. PLoS Med 2008; 5: e45.
9. Kirsch I. The Emperor’s new drugs. Exploding the antidepressant myth.
London: The Bodley Head; 2009.
10. Moerman D. Meaning, medicine and the ‘placebo effect’. Cambridge:
Cambridge University Press; 2002.
11. McAllister-Williams RH. Do antidepressants work? A commentary on “Initial
severity and antidepressant benefits: a meta-analysis of data submitted to
the Food and Drug Administration” by Kirsch et al. Evidence Based Mental
Health 2008; 11: 66-68.
12. Leucht S, Corves C, Arbter D et al. Second-generation versus first-generation
antipsychotic drugs for schizophrenia: a meta-analysis. Lancet, 2009; 373:
31-34.
13. Tyrer P, Kendall T. The spurious advance of antipsychotic drug therapy. Lancet
2009; 373: 4-5.
14. Bracken P. Thomas, P. Postpsychiatry: mental health in the postmodern world.
Oxford: Oxford University Press; 2005.
15. Mental Health Commission. A recovery approach within the Irish mental
health services. A framework for development. Dublin: MHC; 2008.
16. Warner R. Does the scientific evidence support the recovery model? The
Psychiatrist 2010; 34: 3-5.
17.Goss C, Moretti F, Mazzi MA, Del Piccolo L, Rimondini M, Zimmermann C.
Involving patients in decisions during psychiatric consultations. Br J Psych
2008; 193: 416-421.
18. Fiorillo A, De Rosa C, Del Vecchio V et al. How to improve clinical practice on
involuntary hospital admissions of psychiatric patients: suggestions from the
EUNOMIA study. Eur Psychiatry 2011; 26(4): 201-207.
19. Sibitz I, Scheutz A, Lakeman R, Schrank B, Schaffer M, Amering M. Impact of
coercive measures on life stories: qualitative study. Br J Psych 2011; 199:
239-244.
58
If the shelves of my local bookshop are anything to go by, the self-
help genre has never been more popular. Everything from career,
to love life, to weight, to self esteem is seemingly malleable with
the help of a little paperback tome filled with wisdom. But there
is a catch – not all self help is of the same quality and faithful
readers do not always know the difference. For clinicians, it can be
equally difficult to know what reading materials to recommend to
patients and relatives with the aim of expediting recovery.
Consequently, it is always a relief when a reputable professional
with a proven track record decides to update material that has
already proved enormously successful. One such example is Dr
Tony Bates, the founding Director of Headstrong (the National
Centre for Youth Mental Health in Ireland), who has many years
additional experience as a Principal Clinical Psychologist at St
James’s Hospital, Dublin. His original self-help book, entitled
Depression: A Common Sense Approach (1999), was so wellreceived it sold some thirty thousand copies. His updated version
could leap off the shelves just as quickly, particularly as it
incorporates mindfulness, a technique that has become
increasingly popular over the past decade.
Coming through Depression: A Mindful Approach to Recovery iswritten in clear and concise English. This is worth mentioning first,
lest we forget that, in the context of mental illness, not all of its
potential readers will have optimum concentration levels. This
book is practical, however. Dr Bates utilises vignettes and case
histories to which the reader can easily relate, while diagrams and
tables illustrate concepts such as the manner in which thoughts,
feelings, physical symptoms and behaviours interact. The book is
divided into three parts, with Part One providing a simple
explanation of what it might feel like to experience depression,
along with common signs and symptoms of the illness and a
differentiation between mild and severe depression. There are
sections on childhood and postnatal depression, and a checklist
that the reader can use to assess their own depressive symptoms.
Dr Bates also explores the causes of depression, from childhood
experiences through to genetic theories.
In Part Two, Dr Bates examines approaches that can aid recovery,
including daily structure, mood tracking, lifestyle changes and
appropriate help-seeking. The author explains in detail how to set
up a mood diary, an activity log and a recovery journal, while this
section also includes both a chapter on building self-esteem, and
a chapter dedicated to carers.
Finally, in Part Three, Dr Bates explores the concept and practice of
mindfulness. Much of what he writes is based on the work of
three pioneers of the area, Thich Nhat Hanh, Jon Kabat-Zinn and
Mark Williams, all of whom were one-time teachers of Dr Bates.
According to the author, “Mindfulness means resting in the present
moment, with full awareness. When we are mindful, we bring
attention back to whatever is happening in our lives”. This, he
suggests, allows us to enjoy the simple things in daily life we might
otherwise overlook such as “the smile on a child’s face” or “the
sensation of the breeze against our skin”. Mindfulness, Dr Bates
says, “gives us a gentle way to respond to distress” in which we
“learn to notice and to accept difficulties as they emerge, rather
than trying to push them away and suppress them”. The book
benefits in particular from the inclusion of a mindfulness CD,
allowing the theory explained in the book to be practiced with
relative ease.
Coming through Depression: A Mindful Approach to Recovery is anarticulate, sensitive and practical guide to recovery from depression
that at no point encroaches upon other components of the
multidisciplinary recovery plan. Perhaps, indeed, it provides the ray
of hope individuals need when finding themselves trapped in the
dark chamber of depression. Well worth recommending to
patients and relatives alike.
Stephen McWilliams,Consultant Psychiatrist,St John of God Hospital,Stillorgan, Co. Dublin, Ireland.E-mail [email protected]
59
Book review
Coming through Depression: A Mindful Approach to Recovery Tony Bates Gill & Macmillan: 2011 (160pp). ISBN: 978-071714780-9
Leadership is a complicated concept. Leadership can be difficult to
define in words, yet most people can agree when it is present -
and virtually all can agree when it is absent. While many books
have been written about leadership, there are few that stand out
as providing the in-depth insight necessary truly to understand the
qualities of a good leader.
In “Leadership With Consciousness”, Tony Humphreys strides
fearlessly into many of the great debates about leadership today,
and comes up with an admirably clear-sighted set of
recommendations about “training for raising consciousness”,
amongst other measures. Dr Humphreys is well-placed to
undertake such an endeavour: he a consultant clinical psychologist,
national and international speaker, and accomplished author. To
date, Dr Humphreys has written fourteen best-selling books on a
range of themes, including the intriguing “Power of Negative
Thinking” (Newleaf, 2004).
“Leadership With Consciousness” will undoubtedly join the ranks
of Dr Humphrey’s other successful books: it is clear, incisive and
timely. Dr Humphreys argues that various economic processes,
such as those which contributed to the economic crisis of 2008
onward, are enmeshed with defensive emotional processes at
individual level. At least some of these processes are unconscious
but powerful, and their potential effects on leadership, decision-
making and other matters are explored throughout the book.
Placing these arguments in a strongly contemporary framework,
Dr Humphreys draws much-needed attention to individual
psychological processes which underpin society in general and the
financial “system” in particular – a system which is so often blamed
for recent economic and social turmoil. This system does not, of
course, appear out of a vacuum, and Dr Humphreys examines the
role of undetected individual emotional processes in producing and
shaping it. In essence, Dr Humphreys argues that consciousness of
the need to resolve unconscious defences is critical for effective
leadership. The final chapter, “Training for Consciousness”,
focuses on specific steps necessary for this task, and provides a list
of qualities for “leadership with consciousness”.
Quite apart from these conclusions, there is much else that is of
interest along the way. There is, for example, an involving passage
about “the place of dignity and compassion in the medical care of
people”. This discussion provides a useful focus on compassion at
individual level in the delivery of patient care. This is clearly an
essential element in health services, but I would have liked to see
greater exploration of the some of the less-discussed complexities
of compassion: How, for example, does a health-planner
incorporate compassion into the decision-making process when
there are difficult choices to be made about the distribution of
scarce resources? Evaluating legitimate but competing claims on
one’s compassion is difficult but necessary: sometimes, hard-nosed
decision-making may be needed in order to be compassionate.
“Leadership With Consciousness” is good but not perfect. The
book would, for example, have benefitted from more extensive
referencing: there are many points at which the author makes quite
specific statements or provides quotations, and it would be helpful
if there were more pointers to sources. In terms of navigating the
volume itself, it would have been helpful if the contents page
included page numbers for the chapter sub-sections listed, and not
just for the start of each chapter.
To counter-balance these deficits, this book’s index is truly a rare
joy: extensive, accurate and sensibly arranged. A book like this is
not only to be read through from start to finish, but will also be
consulted from time to time for reference and study. A good index
assists greatly with these tasks.
Overall, this is a good, if imperfect, book. Dr. Humphrey’s emphasis
on the effects of individual psychological processes on leadership
and decision-making is greatly to be welcomed. His suggestions on
“training for consciousness” are also likely to prove thought-
provoking for at least some readers.
This book might, perhaps, be best approached in conjunction with
two other volumes both of which provide additional, if contrasting,
perspectives on leadership. Readers with interests in psychiatric
and psychological perspectives on political leadership will
undoubtedly enjoy the classic “Psychological Assessment of
Political Leaders” (University of Michigan Press, 2005) by Jerrold
M. Post, Professor of Psychiatry, Political Psychology, and
International Affairs at George Washington University, and founder
of the CIA's intriguing Center for the Analysis of Personality and
Political Behavior. Professor Post’s penetrating volume is both a joy
to read and a fascinating window into the analysis of political
leaders from a psychiatric perspective.
60
Book review
Leadership With ConsciousnessTony Humphreys Atrium/Attic Press/Cork University Press: Cork, 2011 (202pp).
ISBN 978-1-85594-218-9
This reading would be well complemented by another classic of
the leadership literature: “The Prince” (1532), by Niccolò
Machiavelli (1469-1527). Despite the ubiquitous use of the term
“Machiavellian” in a rather pejorative fashion, there is much in
“The Prince” that is informative and interesting, and the work as
a whole is more subtle that it is often given credit for, especially in
its recommendations for leaders. The literature on leadership is
full of such books: intelligent, insightful and very often
misunderstood.
Tony Humphrey’s “Leadership With Consciousness” is a useful
addition to the leadership literature. It is clearly written, admirably
focussed, and provides welcome insight into the role of individual
psychological processes in producing the social and economic
predicaments in which much of Europe finds itself. The solutions
to these predicaments may be complex, but more “leadership with
consciousness”, as suggested by Dr Humphreys, would certainly
be a good start.
Brendan D. Kelly, Consultant Psychiatrist and Senior Lecturer in Psychiatry,
Department of Adult Psychiatry,
University College Dublin,
Mater Misericordiae University Hospital,
62/63 Eccles Street,
Dublin 7,
Ireland.
E-mail [email protected]
61
The wonderfully named French physician Louis-Alexandre-
Hippolyte Leroy-Dupré wrote that acute homesickness “becomes
more rare each day thanks to rapid communications which modern
industry is beginning to establish among people who will soon be
nothing more than one big happy family.” One might imagine that
this observation was written for the age of Facebook, Skype and
Twitter, but it is fact over one hundred and fifty years old, dating
from 1846.
Susan J Matt is a historian at Weber State University in Utah; her
specialty is the history of the emotions (a previous book is entitled
“Keeping Up With The Joneses: Envy in American Consumer
Society 1890-1930”) This admirably lucid book, based on primary
sources such as diaries, letters and personal interviews, is an
overview of the history of a particular emotion, homesickness.
American society is famously built on the archetype of the pioneer,
the rugged individualist, cheerfully moving on from place to place
without demur. This archetype finds different forms; the
immigrant, the cowboy, the “Organisation Man”, the pilgrim
settler, but all have in common a sense of perpetual motion and
freedom from ties.
As with all archetypes and grand narratives, the details of reality
were very different. Very many pioneers and immigrants returned,
despite the social pressures to remain. Matt places centre stage
the men and women who actually lived these experiences, and
who were often beset by overwhelming homesickness. This was
especially so for women, less in control of their destiny than men.
From the first settlers on, thoughts of home contended with the
various religious, political and economic motives for perpetual
motion. While official rhetoric emphasised the importance of
forging on with the pioneer spirit, diaries and letters allow Matt to
reconstruct the emotional lives often lost to history.
In 1865, twenty –four Union soldiers officially died of nostalgia.
Among the American forces in World War 1, only one casualty had
a cause of death listed as nostalgia. Matt records the varying
opinions of psychiatrists, alienists on physicians on the causes and
management of nostalgia-as-an-illness. Contemporary concerns
such as racial and ethnic purity (“weaker” ethnicities such as the
Irish and Southern Europeans were often held to be more
susceptible) and venereal disease were implicated as risk factors
for nostalgia cases.
Over the later nineteenth century and into the twentieth, public
attitudes to homesickness hardened. Once, children who crossed
thousands of miles to return from boarding schools to families
were celebrated. Their attachment to home was seen as evidence
of a tender sensibility. How homesickness was addressed by the
military in the various wars in the era Matt’s history covers is
revealing. Armies have to balance the motivating power of
attachment to country with the demotivating power of separation
from that same country. In the American Civil War, homesickness
among soldiers was seen as evidence of a nobility of nature. This
attitude persisted through the century. The sole nostalgia fatality of
the Spanish-American War of 1898 was treated with great
sympathy bordering on glorification by the contemporary media.
The inter-war years saw the cultural shift gain momentum. This
was the era where the child rearing “expert” began to opine in
the popular press; no less a figure than the seminal behaviourist
John Watson weighs in on the importance of avoiding excessive
affection with one’s children. The following fifty years saw the
denigration of homesickness gain pace. Where the home-loving
children of previous eras were celebrated, now over attachment to
parents and to home was seen as “sissifying” and a manifestation
of “Momism.” An ethic of universal cheerfulness which celebrated
the “can-do” spirit further cast homesickness into disrepute. The
interests of corporate America were in creating a mobile workforce,
ready to cross the continent at short notice. While this is not a
matter that Matt discusses, this aspect did get me thinking how
the anti-family jeremiads of R D Laing and David Cooper ironically
dovetailed neatly with this corporate imperative. Perhaps, as the
Marxists say, there are no accidents.
Anti-homesickness rhetoric persists today, although the picture is
complicated by the rise of technologies which allow instantaneous
communication, and the global availability of familiar brands. Yet
these developments are palliatives for homesickness, not cures.
Skype, Facebook and similar technologies allow a certain abolition
of distance, and Matt shows how they have perhaps helped in the
rehabilitation of homesickness as a valid public emotion. Indeed,
one of her themes is “the surprising persistence of the extended
family” and how emotions and their expression can be moulded
and shaped by social forces, but are also strangely resistant to them
Indeed, this is a history of the resilience of homesickness, despite
everything. So many approaches in contemporary humanities
emphasise the contingent and socially constructed nature of
things; what Matt manages to do is to acknowledge the role of
social and economic pressures while making a strong case that
emotions are less fungible than theorists, pundits and social
engineers of all political hues would believe. There is also very little
of the jargon and theoretical ballast which many contemporary
historians freight their work
Matt’s title clearly indicates that this is an American history of
homesickness, but the book is of great interest to an Irish
62
Book review
Homesickness: An American HistorySusan J Matt. Oxford University Press 2011, (344 pp). ISBN 978-0-19-537185-7
readership too. The Irish immigrant experience abroad is of course
familiar to most of us; a sizable chunk of Irish popular music is
eloquent testimony to the force of homesickness. More
fundamentally, homesickness is a universal emotion; all readers will
find someone to identify with among the lives Matt describes. We
may not always go through the same social transformations as
America at the same time, but we always seem to get round to
them sooner or later. In our age of ghost estates and resurgent
emigration, many of the concerns of the book seem all too
relevant.
Academic careers rival medical careers in demanding frequent
moves (and in requiring a certain insouciance as the proper
response.) In her acknowledgements, Matt salutes her husband
and observes “since we met in Ithaca, New York, in 1990, we have
lived in six different states and travelled many places, but no matter
where we are, when I am with him, I am home.” It is a poignant
note, and one which sets the tone for a humane and thought-
provoking work.
Séamus MacSuibhne,Consultant Psychiatrist,
St Lukes Hospital,
Co. Kilkenny, Ireland.
Visiting Fellow,
School of Medicine,
University College Cork,
Co. Cork, Ireland.
E-mail [email protected]
63
Hugh Freeman, editor of the British Journal of Psychiatry from 1983to 1993, died recently at the age of 81. A native of Salford in
Greater Manchester, Hugh attended Oxford University on a
scholarship and subsequently joined the Royal Army Medical
Corps. He went on to train in psychiatry at the Maudsley and
became a consultant psychiatrist in Salford. He was an early
advocate of community psychiatry, with retention of inpatient
facilities in general hospitals.
Hugh may best be remembered as an historian of his specialty. He
co-edited 150 Years of British Psychiatry, published in 1991 tocommemorate a century and a half of the Royal College of
Psychiatrists, and edited 1999’s A Century of Psychiatry. As well ashis decade at the helm of the British Journal, he was an editor of
History of Psychiatry and founding editor of Current Opinion inPsychiatry.
I got to know Hugh when I wrote, with Jane Falvey, a chapter on
the Richmond Asylum (St. Brendan’s Hospital) for the second
volume of 150 Years of Psychiatry. In those days Hugh wrote toyou in a small but legible hand asking you to cut and paste. He
was so calm and polite that you carried out his wishes
unhesitatingly despite not having a computer! Over the years I
received appreciative letters from Hugh for anything I sent him.
When he was ill some years ago his wife Joan Casket, a professor
of psychology, handled his correspondence until Hugh was fit
again. My abiding memory of Professor Freeman is one of unruffled
determination. Hugh had three sons and a daughter. His family,
and psychiatry, has lost an enormous presence in their, and our,
lives.
Brian O’ Shea, Editor, Psychiatry Professional,Editor, A Textbook of Psychological Medicine, Tribunal Consultant Psychiatrist with the Mental Health
Commission.
E-mail [email protected]
Appreciation
Professor Hugh Lionel Freeman (1930-2011) Brian O’ Shea Submitted November 8th 2011
Accepted February 2nd 2012
Interaction of duloxetine with warfarin; a cautionary report
64
* Mugtaba Osman, Psychiatric Registrar, St Patrick’s University Hospital, Dublin 8, Ireland. E-mail [email protected]
Elaine Greene, Consultant Old Age Psychiatrist, Jonathan Swift Clinic, St James’sHospital, Dublin 8, Ireland.
Dear Editor,
Drug-drug interactions are common in older adults. Four out of five
people aged over 75 years take at least one medicine and thirty-
six percent of this age group take four medicines or more. 1
Warfarin is primarily cleared by the liver through the cytochrome
P450 system. Many of the isoenzymes involved are also involved in
the metabolism of psychotropic agents.2 Drug interactions with
Warfarin are generally well described. Data regarding the
interaction of warfarin with duloxetine are limited. There are only
two case reports in the literature which report conflicting findings.3,4
Additionally, a small open-label study reported no significant
interaction between the two agents. 5
Warfarin is normally indicated for serious vascular conditions. So
an elderly patient who is attending the psychiatric service and is on
warfarin will have higher risk for serious interactions. This is exactly
the subject of this case report.
Case Report
An eighty seven year old gentleman was admitted for treatment of
a severe depressive episode with prominent anxiety symptoms.
Relevant medical co-morbidities included paroxysmal atrial
fibrillation, for which he was on lifelong warfarin prophylaxis.
Notably, his warfarin dose had been stable for several months prior
to admission. He presented with a treatment resistant depression
and failed to respond to trials of antidepressant medications
(including venlafaxine, bupropion, SSRI’s, mirtazapine and
agomelatine) and to augmentation with several different agents
(including risperidone, lithium, olanzapine, amisulpride and
aripiprazole). He refused the option of ECT. A trial of duloxetine
was moderately successful. The dose was increased cautiously to
90 mg with good effect. At this point it was noted that his INR had
increased significantly. This was temporally related to an increase in
duloxetine from 60 to 90 mg daily. There had been no other
significant changes in his management or his medical condition that
would explain the increased INR. Review of his INR readings and
comparison with his duloxetine treatment revealed a stepwise
increase in INR which coincided with the increase in duloxetine.
As this patient’s treatment resistant depression had responded to
duloxetine, a decision was made to continue duloxetine treatment
at this higher dose. This necessitated a forty percent dose reduction
in warfarin to stabilise the INR at a safe therapeutic level.
In light of the temporal relationship between the increase in
duloxetine and the rise of INR, the most likely explanation lies at
the cytochrome P450 level. It is likely that duloxetine may potentiate
the anticoagulant effect of warfarin through displacing warfarin
from CYP 1A2 isoenzymes.6 This would result in a net increase in
bioactive warfarin and a consequent increase in INR.
Discussion
A higher number of people enter old age nowadays thanks for
recent advances in health measures.7 Therefore, more people over
the age of 65 are expected to be on combination of warfarin plus
another one or more medications, especially psychiatric
medications. This report adds to the scarce evidence that currently
exists for possibility of drug-drug interactions between duloxetine
and warfarin. It is the first report, we know of, to describe a
potentiating effect for duloxetine upon the action of warfarin in
older adults. It stresses the need to closely monitor INR levels for
elderly patients on warfarin, especially if it is combined with
duloxetine for treatment of depressive illness or other psychiatric or
non-psychiatric disorder. It appears that duloxetine can
synergistically potentiate the effect of warfarin, thereby, leading to
a bleeding hazard. Further research is urgently needed in this area.
References
1. Department of Health (2001) National Service Framework for Older People.
London: Stationery Office.
2. Limke KK, Shelton AR, Elliott ES. Fluvoxamine interaction with warfarin. Ann
Pharmacother. 2002;36:1890-1892
3. Glueck C J, Khalil Q, Wang P. Interaction of Duloxetine and Warfarin Causing
Severe Elevation of International Normalized Ratio. JAMA, April 2006; 13:
1517-1518.
4. Monastero R. Potential drug-drug interaction between duloxetine and
acenocoumarol in a patient with Alzheimer's disease, Clinical Therapeutics,
December 2007; 29: 2706-2709
5. Frincu-Mallos C. Duloxetine Does Not Modify Anticoagulant Effects of
Warfarin: Presented at American College of Clinical Pharmacology (ACCP)
37th Annual Meeting, September 2008.
6. Glueck C J, Khalil Q, Wang P. Interaction of Duloxetine and Warfarin Causing
Severe Elevation of International Normalized Ratio. JAMA, April 2006; 13:
1517-1518.
7. Kapplan B J, Sadock’s V A, Psynopsis of Psychiatry Behavioural
Sciences/ Clinical Psychiatry, 10th edition. In Geriatric Psychiatry,
chapter 56, page 1348, Lippincott W&W, 2007.
Letter to the EditorMugtaba Osman, Elaine Greene
*Correspondence
Irish Journal of Psychological MedicineGuidelines for Authors
Aim and Scope of the Journal
The aim of the Irish Journal of Psychological Medicine is to publish
original scientific contributions in psychiatry, psychological medicine
(including surgery and obstetrics), and related basic sciences
(neurosciences, biological, psychological, and social sciences).
The scope of the Journal includes any subspecialties of the above,
including, but not limited to, behavioural pharmacology, biological
psychiatry, child and adolescent psychiatry, intellectual disability,
forensic psychiatry, psychotherapies, psychiatry of old age,
epidemiology, rehabilitation, psychometrics, substance misuse,
sexual studies, linguistics, and the history, philosophy and
economics of psychiatry.
The Journal is dedicated to providing reliable, valid clinical and
scientific information to inform mental health care decisions and
improve the quality of mental health care.
Editorial Standards
The Irish Journal of Psychological Medicine complies with the “Code
of Conduct and Best Practice Guidelines for Journal Editors” of the
Committee on Publication Ethics (2011) and the “Editorial Policy
Statements” of the Council of Science Editors (2009).
http://publicationethics.org/files/Code_of_conduct_for_journal_edit
ors_Mar11.pdf
http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid=
3286
Submission Guidelines
The Journal will accept for consideration original papers, brief
research reports, audits, clinical case reports, review articles,
historical papers, perspective articles, editorials, letters to the editor
and book reviews. Original data papers receive top priority for
speedy publication.
Manuscripts should be prepared in accordance with the “Uniform
Requirements for Manuscripts (URM) Submitted to Biomedical
Journals” of the International Committee of Medical Journal Editors
(2010). www.icmje.org
Title Page
The title page should include the paper title, author name(s), author
qualifications, author job title(s), author affiliation(s) and full address
(es). The name, address, email address and telephone number of
the corresponding author should be clearly and separately indicted.
Text
• The manuscript should be typed, double-spaced, in 12-point
Times New Roman font.
• Pages should be numbered but do not use any other automatedfeatures (such as endnotes, headers or footers), any form of
automated referencing software, or any mechanism to track
changes to various drafts of a manuscript.
• Numbers one to ten should be written as words in the text,
unless used as a unit of measurement; all numbers should be
written in digits in tables and figures.
• All numbers which start sentences should be written in words,
not digits.
• Bold type-face should be used for headings of sections and sub-
sections within the paper.
• Do not use tabs or indents within the text of the paper.
• SI units are required for all measurements.
• Means should be accompanied by standard deviations.
• Exact p values should be provided, unless p<0.0001.
• Recommended non-proprietary drug names should be used.
• Writing should be clear, simple and direct.
• Short sentences are preferred.
Abstract and Key-Words
The page following the title page should carry an abstract followed
by a list of three to ten key-words drawn, if possible, from the
medical subject headings (MeSH) list of the United States National
Library of Medicine and National Institutes of Health
(www.ncbi.nlm.nih.gov/mesh). The title and key-words should be
chosen to help future literature searchers.
The abstract, up to 150 words for an unstructured or 250 words
for a structured abstract (Haynes et al, 1991), should state
specifically the main purposes, procedures, findings and conclusions
of the study, emphasising what is new or important. For original
papers, brief research reports, audits and review articles, a
structured abstract is required, using the headings: Objectives,
Methods, Results and Conclusions.
Under the Abstract heading of Method, include, wherever
applicable the study design, setting, patients/participants (selection
criteria, description), interventions, observational and analytical
methods and main outcome measures. (For review articles specify
the methods of literature search and selection). Under the Abstract
heading of Results, give the most important specific data together
with their statistical significance.
Original Papers
Original papers should be divided into sections as follows:
Introduction, Methods, Results and Discussion. A Conclusions
section is not mandatory but may be included in the original
submission if the author wishes, or may be requested at a later
stage by peer-reviewers or editors. The Results section should
present a summary of main results and should not simply refer to
tables. Reports of randomised trials must conform to CONSORT
2010 guidelines.
http://www.consort-statement.org/consort-statement/overview0/
65
Audit Papers
It is preferable that audit papers present the full cycle of clinical
audit, including audit, intervention and re-audit. In exceptional
circumstances, papers presenting one element of the audit cycle
may be published, but priority will be given to papers presenting
full audit cycles. The format for audit papers may differ from that
outlined for original papers, and may include, for example,
Introduction, Audit, Intervention, Re-Audit, Discussion and
Conclusions.
Clinical Case Reports
All clinical case reports must have the patient’s written, informed
consent before the paper is submitted.
References
Timely references should highlight the paper’s relevance to current
research or clinical practice. For references to journal articles
(International Committee of Medical Journal Editors, 2006; 2010;
Haynes et al, 1991; Bailar & Mosteller, 1998) and to books (Daly et
al, 1991; Gardner & Altman, 1989; American Psychiatric
Association, 1987) use the ‘Vancouver’ style, i.e. number references
in the order they appear in the text, do not alphabetise. Journal
titles should be abbreviated as outlined on PubMed by the United
States National Library of Medicine and National Institutes of Health
(www.ncbi.nlm.nih.gov/nlmcatalog/journals). Please see the sample
paper on the website of the College of Psychiatry of Ireland for
further details
http://www.irishpsychiatry.ie/Members/MembersInformationTools/
irishjournalofpsychologicalmedicine.aspx
Tables and Figures
Figures and graphs should be clear and of good quality, and should
be accompanied by relevant data to facilitate redrawing where
necessary. Clear and informative headings and captions should be
provided.
Submission Process
Manuscripts may be submitted electronically via email to
[email protected] or [email protected]
Full postal address, telephone and fax numbers should be included.
Where possible, tables, figures and text should be included in the
same document. There is no need to also submit by post or fax.
All submitted material will become the property of the Journal until,
and if, publication is refused. Material so referred should not be
sent elsewhere for publication.
Conflict of Interest
In the interest of accountability all financial and material support
for the research and the work should be clearly stated (DeAngelis
et al, 2001). Authors of original data must take responsibility for
the integrity of the data and accuracy of the data analysis. All
authors must have full access to all the data in the study (Davidoff
et al, 1986). Authors must declare any conflict of interest clearly, in
accordance with the guidance of the International Committee of
Medical Journal Editors (2006):
“Public trust in the peer review process and the credibility of publishedarticles depend in part on how well conflict of interest is handled duringwriting, peer review, and editorial decision making. Conflict of interestexists when an author (or the author's institution), reviewer, or editorhas financial or personal relationships that inappropriately influence(bias) his or her actions (such relationships are also known as dualcommitments, competing interests, or competing loyalties). Theserelationships vary from those with negligible potential to those withgreat potential to influence judgment, and not all relationshipsrepresent true conflict of interest. The potential for conflict of interestcan exist whether or not an individual believes that the relationshipaffects his or her scientific judgment. Financial relationships (such asemployment, consultancies, stock ownership, honoraria, paid experttestimony) are the most easily identifiable conflicts of interest and themost likely to undermine the credibility of the journal, the authors, andof science itself. However, conflicts can occur for other reasons, such aspersonal relationships, academic competition, and intellectual passion.”
Statement of Informed Consent
Where relevant, papers must include a statement regarding
informed consent, in accordance with the guidance of the
International Committee of Medical Journal Editors (2006):
“Patients have a right to privacy that should not be infringedwithout informed consent. Identifying information, includingpatients' names, initials, or hospital numbers, should not bepublished in written descriptions, photographs, and pedigreesunless the information is essential for scientific purposes and thepatient (or parent or guardian) gives written informed consent forpublication. Informed consent for this purpose requires that apatient who is identifiable be shown the manuscript to bepublished. Authors should identify Individuals who provide writingassistance and disclose the funding source for this assistance.Identifying details should be omitted if they are not essential.Complete anonymity is difficult to achieve, however, and informedconsent should be obtained if there is any doubt. For example,masking the eye region in photographs of patients is inadequateprotection of anonymity. If identifying characteristics are altered toprotect anonymity, such as in genetic pedigrees, authors shouldprovide assurance that alterations do not distort scientific meaningand editors should so note. The requirement for informed consentshould be included in the journal's instructions for authors. Wheninformed consent has been obtained it should be indicated in thepublished article.”
Statement of Human and Animal Rights
Where relevant, papers must include a statement regarding human
and animal rights, in accordance with the guidance of the
International Committee of Medical Journal Editors (2006):
“When reporting experiments on human subjects, authors shouldindicate whether the procedures followed were in accordance withthe ethical standards of the responsible committee on humanexperimentation (institutional and national) and with the HelsinkiDeclaration of 1975, as revised in 2000 (5). If doubt exists whetherthe research was conducted in accordance with the HelsinkiDeclaration, the authors must explain the rationale for theirapproach, and demonstrate that the institutional review bodyexplicitly approved the doubtful aspects of the study. Whenreporting experiments on animals, authors should be asked to
66
indicate whether the institutional and national guide for the careand use of laboratory animals was followed.”
Acknowledgements
Authors should obtain permission to acknowledge individuals
named in any Acknowledgments section, since readers may infer
endorsement.
Suggested Peer-Reviewers
Each submission must be accompanied by the names, professionaltitles, professional addresses and email addresses of three suggested
peer-reviewers. Authors should select these suggested peer-
reviewers to include individuals, in any part of the world, who are
recognized experts in the area to which the submission refers, and
whom the authors believe would provide useful, objective peer-
reviews of the manuscript. The editors will give consideration to
sending the manuscript to some or all of these peer-reviewers, but
are not under any obligation to do so.
Description of the Peer-Review Process
All submissions are acknowledged by email. Submissions are
initially considered by the Editor-In-Chief or Deputy Editor for
suitability for peer-review. Submissions selected for peer-review are
sent to three anonymous outside peer-reviewers. Where one or
more peer-reviewers recommend acceptance or acceptance after
revision, all peer-reviews are sent to the corresponding author, with
an invitation to revise the paper.
If the author chooses to revise the paper, the revised paper should
be accompanied by a detailed cover letter responding to each
comment made by each peer-reviewer, indicating precisely how the
revision deals with each comment, or why the author disagrees with
or cannot incorporate specific comments.
Each peer-reviewer will then receive the revised paper, cover letter
and comments of the other peer-reviewers. After the peer-
reviewers’ further comments have been received, a final decision
about publication will be made.
The editorial process may vary from the above under certain
circumstances, at the discretion of the Editor-In-Chief or Deputy
Editor.
Other Modes of Review
Some guidance on statistical matters for authors is provided by
International Committee of Medical Journal Editors (2006; 2010)
and Bailar & Mosteller (1998). Notwithstanding this guidance,
statistical review may be required for certain papers, and this will be
arranged by the Journal editors where indicated. Other, morespecialist forms of peer-review may also be required on occasion,
and these, too, will be arranged by the Journal editors where
indicated.
Fast-Track Publication
Papers which the editors feel warrant fast-track publication will be
expedited through the publication process. The decision to “fast-
track” papers lies with the editors.
Plagiarism and Duplicate Publication
Manuscripts are considered with the understanding that they have
not been published previously, either in print or electronic format.
In the event that plagiarism or duplicate publication is suspected,
the author will be invited to comment on the matter and a decision
will be taken by the editors.
Appeals
IIn the event that an author wishes to appeal an editorial decision,
the author can send a letter of appeal to the Editor-In-Chief. The
Editor-In-Chief will pass the relevant materials to the Consulting
Editor who may seek external opinion. The Consulting Editor will
advise the Editor-In-Chief in relation to the appeal but the final
decision on the matter rests with the Editor-In-Chief.
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. Washington DC: American Psychiatric Association, 1987.
Bailar JC, Mosteller F. Guidelines for statistical reporting in articles for medical
journals. Ann Intern Med 1988; 108: 266-273.
Committee on Publication Ethics. Code of Conduct and Best Practice Guidelines
for Journal Editors. London: Committee on Publication Ethics, 2011.
http://publicationethics.org/files/Code_of_conduct_for_journal_editors_Mar11.pdf
Council of Science Editors. Promoting Integrity in Scientific Journal Publications.
Wheat Ridge, CO: Council of Science Editors, 2009.
http://www.councilscienceeditors.org/i4a/pages/index.cfm?pageid=3286.
Daly LE, Bourke GJ, McGilvray J. Interpretation and Uses of Medical Statistics (4th
Edition). Oxford: Blackwell Scientific Publications, 1991.
DeAngelis CD, Fontanarosa PB, Flanagin A. Reporting financial conflicts of interest
and relationships between investigators and research sponsors. JAMA 2001; 286:
89-91.
Davidoff F, DeAngelis CD, Drazen JM, Hoey J, Højgaard L, Horton R, Kotzin S,
Nicholls MG, Nylenna M, Overbeke AJ, Sox HC, Van Der Weyden MB, Wilkes MS.
Sponsorship, authorship, and accountability. JAMA 2001; 286: 1232-1234.
Gardner MJ, Altman DG (editors). Statistics with Confidence: Confidence Intervals
and Statistical Guidelines. London: British Medical Journal, 1989.
Haynes RB, Mulrow CD, Huth EJ, Altman DG, Gardner MJ. More information
abstracts revisited. Ann Intern Med 1990; 113: 69-76.
International Committee of Medical Journal Editors. Uniform requirements for
manuscripts submitted to biomedical journals. Vancouver: International
Committee of Medical Journal Editors, 2006.
International Committee of Medical Journal Editors. Uniform requirements for
manuscripts submitted to biomedical journals. Vancouver: International
Committee of Medical Journal Editors, 2010. www.icmje.org
67
