BMC Psychiatry - Latest Comments

Display of formulas 1 and 2 in the on-line version of the paper.

Scott Patten — 2013-03-10T13:43:01Z

Equation 1 and 2 are jumbled in the on-line version.
I've sent a note to BMC asking them to fix it, but in the meanwhile it seems that deselecting the MathJax display tick box in the header of the paper corrects the problem. The pdf version is OK as well.

Scott Patten

Exposure or Tolerance to Exposure?.

Eric Harris — 2012-10-25T12:06:47Z

I applaud the authors' investigation of predictors for development of mental disorders, but think that the title (and similar language in the article) might cause the reader to misunderstand their finding. That is, subjects were classified as "exposed" only if they reported being ¿bothered a lot¿ by exposure to one of several potential stressors. Therefore, it is likely the subjects' reaction to or copiing with the event that is the predictor rather than the mere exposure to such events.

Comments: Systematic review of beliefs, behaviours and influencing factors associated with disclosure of a mental health problem in the workplace

Rajshekhar Bipeta — 2012-10-25T12:06:00Z

This is a very good manuscript. Well written. Of clinical interest. I never thought this could be a topic one can write on. I would like to replicate the study in my country (India).
Psychiatrist

Numerical error

Virpi Kauko — 2012-06-28T16:59:05Z

"Austria had 86 filicide victims and Finland had 66, which
equal 5.2 per 100,000 inhabitants and 5.9 per 100,000
inhabitants, respectively (Table 2)."

According to the official vital statistics, there were on average about 1,120,000
people younger than 18 years in Finland at that 11-year time period. The annual
filicide rate would thus actually be 66/11 = 6 cases per 1,120,000 people in age
group 0-17, which equals 0.54 /100,000.

Unlike the figure 5.9 stated in the article, the figure 0.54 fits quite well into existing
data. According to reports by the National Research Institute of Legal Policy [*], the
total annual rates of child homicides in Finland have been less than one per 100,000
children in the age group 0-14 for many decades (and filicide rate is obviously at most
that high). I do not think the Austrian figure could be as high as 5.2 /100,000 either.

In the Discussion section, the authors do notice that their results are surprisingly high
compared to WHO Mortality Database. They suggest this anomaly is due to the hidden
nature of these crimes. But, as they correctly note in Methods, "rate of hidden criminality
for homicide is low in both countries". Even if there were unreported cases, these could
not have been revealed by this record-based research. The unexpectedly high number
is most likely due to a simple computational error.

Sincerely,

Virpi Kauko, Ph.D in Mathematics
Jyvaskyla, Finland

[*] Research Report 258; Table 1 on page 22 of the Finnish full text.

Tool clarification : Scale for Assessment of Somatic Symptoms

Geetha Desai — 2012-03-27T16:17:20Z

The article ¿the relaxation exercise and social support trial resst: study protocol for a randomized Community based trial¿ published by Kobessi et al in 2011 is a very interesting intervention study from a developing country with limited resources. The authors have assessed the common mental disorders using Hopkins checklist for anxiety and Depression. They have used Scale for Assessment of Somatic symptoms (SASS) for assessing Somatization as mentioned in the article. The authors have mentioned the scale as Patel somatisation scale 2005.

We would like to highlight the fact this scale is used to assess the somatic symptoms which are medically unexplained and is not for diagnosis of somatisation. This scale was constructed by Chaturvedi SK in 1987 at, National Institute of Mental Health and Neurosciences, Bangalore, India. The scale further validated in studies in assessing unexplained somatic symptoms in cancer patients and Somatization disorders. (Chaturvedi et al 1987, Chaturvedi et al 1998). The above tool for assessing somatic symptoms has been used by Patel et al in three studies and the reference of this tool is mentioned as given Chaturvedi SK and Sarmukaddam et al 1987.

Clinicians' views are important: this study adds to understanding - but the measure of their attitudes should be correctly named.

Mark Haddad — 2011-11-26T16:48:38Z

Demyttenaere and colleagues' study of the views of GPs and psychiatrists about depression addresses an important topic, and extends our understanding of the elements of outcome that are considered important by clinicians as well as the relationships between their attitudes and aspects of clinical practice.

This paper rightly seeks to unravel some of the complexity of what comprises depression and what is important in defining recovery from this condition.

The authors appropriately recognise that the patient's perspective is a most important aspect of such enquiry - which is missing from this study. They correctly identify other potential weaknesses in their study; but although they note some of the inconsistencies in the results of previous factor analyses of the DAQ attitude measure, they do not consider that this may indicate weaknesses in this measure - and consequent limitations in using findings derived from its item and factor scores.

An allied problem in this paper is the auhors' repeated use of the title 'Depression Attitude Scale (DAS)' to refer to the attitude measure that they have used. The measure is the Depression Attitude Questionnaire (DAQ) - which has been used in more than twenty other studies. Using a (albeit slightly) different name and acronym presents problems for other researchers and readers in linking this research to other studies in the field, and to related searches of this topic.

Remembering Kraepelin

Mahesh Rajasuriya — 2011-09-19T13:21:27Z

I read this article with interest. And it made me think about the contribution, if any, it made to psychiatry. And then I couldn’t help thinking about the original descriptions of Kraepelin on manic-depressive psychosis. The single most important contribution Kraepelin made to psychiatry was towards defining psychiatric syndromes by way of analysis of large clinical samples to describe psychopathology and illness-course, along with efforts to define psychobiologically coherent and clinically differentiable entities¹.

In this article Hanwella and de Silva try to fine tune the definitions of phenomenology of mania, treading, though in a largely smaller scale, the same pathway Kraeplin did over a century ago. And they have been able to utilise modern technology including statistical models to do this. What they haven’t done is to analyse the illness-course as Kraeplin did. Perhaps that would be the next step in a world where treatment methods available for treatment of mania and bipolar disorder have never been this sophisticated before.

References:
1. Trede K, Salvatore P, Baethge C, Gerhard A, Maggini C, Baldessarini RJ. Manic-depressive illness: evolution in Kraepelin's Textbook, 1883-1926. Harv Rev Psychiatry. 2005;13(3):155-78.

Inflammation might underlie both asthma and ADD

Carr Smith — 2011-09-09T12:57:45Z

Recently (BMC Psychiatry 2011, 11:128), Fasmer and colleagues reported that "Adult attention deficit hyperactivity disorder is associated with asthma." These findings are consistent with a growing body of literature that reports evidence of systemic inflammation in patients experiencing mental disorders. Previously, Masopust et al. (2011) showed that markers of thrombogenesis are activated in unmedicated patients with acute psychosis. Similarly, Drexhage et al. (2011) recently described a monocyte pro-inflammatory state in patients with bipolar disorder. The findings of these and other authors raise a very important question, "Is the pro-inflammatory state seen in mental disorders part of the pathogenesis and therefore a potential therapeutic target, or is the inflammation an association outside the causal pathway?" It should be noted that even if inflammation does not represent the primary cause of the mental disorder, dysregulated chronic inflammation has been shown to exacerbate a number of neurological conditions, most recently neuropathic pain (Shi XQ et al., 2011).

Best Regards,
Carr J. Smith, Ph.D.
UNC Chapel Hill Pathology

Drexhage RC, Hoogenboezem TH, Versnel MA, Berghout A, Nolen WA, Drexhage HA. The activation of monocyte and T cell networks in patients with bipolar disorder. Brain Behav Immun 2011, Aug;25(6): 1206-13.

Fasmer OB, Halmoy A, Eagan TM, Oedegaard KJ, Haavik J. Adult attention deficit hyperactivity disorder is associated with asthma. BMC Psychiatry 2011, 11:128.

Masopust J, Maly R, Andrys C, Valis M, Bazant J, Hosak L. Markers of thrombogenesis are activated in unmedicated patients with acute psychosis: a matched case control study. BMC Psychiatry 2011, 11:2.

Shi XQ, Lim TK, Lee S, Zhao YQ, Zhang J. Statins alleviate experimental nerve injury-induced neuropathic pain. Pain 2011 May; 152(5): 1033-43.

Common sense: Benzo-free MMTP

Donald McDonald — 2011-08-19T17:45:16Z

it puts patients at higher risk of life-threatening multiple drug overdoses.

----Ours is a benzo-free clinic. We will outpatient taper the client from BZD's while together we pursue FDA approved options for anxiety relief. If the client remains in non-compliance we will taper him off methadone and release him from the program.

47% of the respondents had a history of BZD use, and 39.8% used BZD without a prescription. Half of the BZD users (54%) started using BZD after entering the methadone program, and 61% of previous BZD users reported increased or resumed use after entering methadone program

---Because they ARE addicts, not EX-addicts. They no longer feel the same euphoria and escape of their drug of choice, so they turn to alternatives. BZD's and methadone feel good together.

have prescribed medication for mental problems, have preexistent anxiety problems before opiate use, and had anxiety problems before entering methadone program.

----These are probably drug seeking behaviors on the part of the addicts before and during MMT, falsely representing themselves as anxious after a simple Google search. If they are not misusing BZD's, they are selling them in the parking lot. I understand we have to trust the client and treat the symptoms, but we do not have to trust the statistics in a study. That's a choice our oath will allow.

most methadone programs do not address co-occurring anxiety problems, and methadone treatment may trigger onset or worsening of BZD misuse.

----BZD's and methadone are a deadly combination, which unfortunately rewards the addict with an intense euphoria. We DO address anxiety problems but we simply will not be complicit in preventable death. Our psychiatrists offer FDA approved alternatives to BZD's. If the client truly wishes to recover from their opioid addiction, they will make an attempt. Frequent urine drug screens will tell the tale.

If the clients wish to continue treating their anxiety disorder with BZD's, they should do so with that prescribing physician. Together they can explore FDA approved alternatives to treating opioid addiction other than methadone. It's a matter of priorities I suppose.

Can findings be explained on the basis of brevity of inpatient hospitalizations?

James Dillon — 2011-08-17T13:31:26Z

The circumstances described in this excellent and straightforward article mirror less rigorously formed impressions on this side of the Atlantic. In Michigan (USA) medical directors in the community (outpatient-based) mental health sector ascribe high rates of antipsychotic polypharmacy to hospitalization per se, as much as to treatment resistance or case complexity, though the latter may be contributing factors.

One view (I will call it the "brevity of hospitalization" hypothesis) is that very short inpatient hospitalizations, typically a week or less in duration, encourage polypharmacy. Cross-titration of drugs, adequate treatment trials, testing of adherence as a source of treatment failure, etc., cannot be accomplished in just a few days. Typically a patient arrives in a condition of impending violence, and the inpatient psychiatrist has a few days to render him or her fit for return to the community. Rather than take a chance that removing a drug already on board will make things worse, the psychiatrist is apt to add a second powerful drug, leaving the outpatient psychiatrist to sort out which of the multiple medications is really needed.

The "brevity of hospitalization" hypothesis is consistent with data presented in this paper, which show antipsychotic polypharmacy to be increasingly probable in second and subsequent hospitalizations. A patient with no hospitalizaton history is likely to present with no current medications or no prior treatment. S/he will show rapid improvement when one antipsychotic is prescribed, making polypharmacy unnecessary. Upon return to hospital, though, the patient may claim to have been taking the first medication while the family believes it was manna from heaven until a couple weeks prior to admission. Under cirucumstances such as these, the inpatient psychiatrist is apt to add a second antipsychotic without changing the first. One can imagine many such scenarios promoting addition of drugs in hospital.

Another observation from the current research favoring the "brevity of hospitalization" hypothesis is the difference in polypharmacy noted in outpatient versus inpatient groups. Inpatient status may be at the heart of the problem, while case complexity contributes indirectly by raising the risk of hospitalization.

This interpretation of the polypharmacy problem raises the question of whether psychiatric hospitalizations should be longer. In Michigan the costs of hospitalization are borne by the outpatient agency, the financial realities of which happen to be aligned with a philosophical commitment to deinstitutionalization and demedicalization of mental health care. If short hospitalizations routinely produce undesirable results, what payor will opt to authorize more of the same?

Thank you for this interesting contribution.