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Columns Correspondence
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c orre sp ondence
Acute hospital care
Sir: We have read with interest the
editorial by Dratcu ( Psychiatric Bulletin,
February 2002, 26, 81^82). In developing
countries such as ours mental health has
come into national focus, with policy
makers and health administrators
recognising the importance of improving
mental health services following the
publication of the World Health Report
(World Health Organization, 2001).
This document places much emphasis
on care in the community and deinstitutionalisation. In Sri Lanka an
international conference on mental health
and psychiatry, organised by ‘Sahanaya’
(National Council for Mental Health) in
April 2002 addressed the issues and
challenges in community mental health
care. Many international participants with
experience in community care, especially
from the UK and USA, cautioned the
proponents of community care from
rushing into such a model with scarce
resources. They raised the practical
implications of closing down large mental
hospitals overnight, such as homelessness, social deprivation and even patients
ending up in prisons. They reiterated the
importance of recognising the role of
acute hospital care and ensuring adequate
provision of hospital beds and services for
those with mental illness.
In Sri Lanka, with a population of more
than 18 million people, there are but less
than 2000 beds for psychiatric patients,
with more than 1500 beds being confined
to two mental hospitals. This, by any
standards, is far below expectation. Most
patients in the developing world,
however, are traditionally managed in the
community by family and friends. It is the
severely ill, who are not stable enough to
live and survive in the community, that
remain in the mental hospitals. Experience
shows that the readmission of these
patients on discharge is also high.
This is by no means an attempt to
downplay the role of community care in
the developing world. On the contrary,
care in the community should be
promoted, even championed, but not for
the sake of aping models implemented in
the developed world that may not be
relevant to our setting. Community care
will have to be seen in its context and
developed accordingly. The hazards of
discharging patients with mental illness
without sufficient care facilities, such as
increased rates of suicide, have been
addressed before (Morgan, 1992). It
would be pertinent to strike a balance
between community care and deinstitutionalisation so that individual
patients and their carers are not sacrificed
on the altar of ill-planned but wellmeaning programmes.
MORGAN, H. G. (1992) Suicide prevention. Hazards
on the fast lane to community care. British Journal of
Psychiatry, 160,149^153.
WORLD HEALTH ORGANIZATION (2001). Mental
Health: New Understanding, New Hope.World Health
Report1020^3311. Geneva:WHO.
K. A. L. A. Kuruppuarachchi Senior Lecturer in
Psychiatry, S. S. Williams Lecturer, Department
of Psychiatry, Faculty of Medicine, University of
Kelaniya, Ragama, Sri Lanka
Police case disposal: an
introduction for psychiatrists
Sir: Bayney and Ikkos ( Psychiatric Bulletin,
May 2002, 26, 182^185) provide a helpful
outline of the elements of the police
decision-making process with respect to
referrals of those with mental disorder.
However, they make two important
omissions. The first, and most significant,
is the implication that the decision to
prosecute is a police one. It should be
emphasised that while the investigation of
crime is undoubtedly a core police role,
the decision to prosecute lies with the
Crown Prosecution Service (CPS) and not
with the police force. It is the role of the
police to charge an individual if they feel it
appropriate and to then refer the case to
the CPS for consideration.
Second, the role of the CPS at the preand post-charge stages is not included.
The Code for Crown Prosecutors (Crown
Prosecution Service, 2000) notes that
both before referring a case and during
the prosecution, the police have a key
liaison role. This role involves both
discussing cases in which a decision to
make a formal CPS referral has not yet
been made, and in providing further
information to the CPS as a prosecution
proceeds. The police and the CPS,
although independent of each other, are
315
fundamentally linked, and the omission of
the CPS impairs a full appreciation of the
process under scrutiny.
CROWN PROSECUTION SERVICE (2000) The Code for
Crown Prosecutors. London: Crown Prosecution
Service.
Adrian R. Brown Specialist Registrar in Forensic
Psychiatry,Wathwood Hospital, Gypsy Green Lane,
Wath-Upon-Dearne, Rotherham, SouthYorkshire
S63 7TQ
Clinically useful electronic
patient record
Sir: We were delighted to see the report
by Searle et al ( Psychiatric Bulletin, April
2002, 26, 145^148). We too have had
tremendous success with an almost
identical system developed in collaboration between the IT department and
clinicians (Hunt, 2002). We now have
discharge summaries, patient letters and
Care Programme Approach reviews
available networked across three London
boroughs, and multiple sites. Like many
others, we found that the patient-based
IT systems on offer could not cope with
storing and retrieving the complex clinical
information that we all need when
managing patients. However, using the
network that was built to enable communication across the trust, we can now
access detailed clinical information 24hours a day when needed, and have gone
a long way to ironing out the information
problem caused by community teams
being based away from in-patient units.
The system has been quick and simple to
implement and well-received by staff. The
key difference with our project is that
each patient has only one file, with
multiple pages of separate letters within
it. We suspect that this makes retrieval
and searching somewhat easier. Interested people are welcome to contact us
by e-mail in the first instance.
HUNT, J. (2002) The M: drive project. British Journal
of Healthcare Computing and Information
Management, 19, 20^22.
AdrianTreloar Consultant Psychiatrist
(e-mail: [email protected]),
Julie Hunt Head of IM&T (e-mail: [email protected]
oxleas.nhs.uk)
Columns The College
columns
Co-prescribing of atypical
and typical antipsychotics:
true rate much higher
Sir: Taylor et al ( Psychiatric Bulletin, May
2002, 26, 170^172) rightly point out that
co-prescribing may lead to poorer
tolerability and increased frequency of
anticholinergic effects. Particular attention
was not, however, drawn to the possible
cardiac side-effects of co-prescribing,
especially in the light of recent evidence of
antipsychotics causing QT prolongation
and subsequent risk of arrhythmias and
possible sudden death (Appleby et al,
2000).
I was also struck by the low rate of coprescribing, 53 out of 1441 prescriptions
(4%). In my experience co-prescribing of
typicals and atypicals is far more common,
especially when ‘as-required’ medication is
taken into account. Not including ‘asrequired’ medication in the study must
result in a significant underestimate of the
true rate of co-prescribing.
In a recent local audit of antipsychotic
prescribing in a group of 160 rehabilitation
patients in Norwich, 63 (39%) were
prescribed atypical antipsychotics. Of
these 32 (50.8%) were also prescribed a
typical antipsychotic, 15 (23.8%) regularly
and 17 (27.0%) on an as-required
basis.
Further research is needed and justification of using a typical and atypical antipsychotic needs to be clear. In a minority
of patients, co-prescribing may lead to
better symptom control, but, as pointed
out, it may be at the expense of increased
side-effects.
APPLEBY, L.,THOMAS, S., FERRIER, N., et al (2000)
Sudden unexplained death in psychiatric in-patients.
British Journal of Psychiatry, 176, 405^406.
would aid our cause, would be most
welcome.
Rebecca Horne Specialist Registrar, Julian
Hospital, Bowthorpe Road, Norwich NR2 3TD
Shiela Mackenzie Sector Manager, Jeff
Clarke Consultant Psychiatrist, Selby and York
Primary CareTrust, Bootham Park Hospital, Bootham,
YorkYO30 7BY
Nurse uniforms
Sir: Like Professor Kohen and her
colleagues in Lancashire ( Psychiatric
Bulletin, April 2002, 26, 156), we felt that
there may be much to be gained by
nursing staff going back to wearing
uniforms in our community units for the
elderly, where most in-patients have
severe dementia. We undertook a study in
three units looking at levels of behaviour
disturbance before and after the
introduction of uniforms in two of the
units, with the third unit as a control. The
study involved small numbers and is yet to
be published, but we too found a
decrease in behaviour disturbance in our
patient group. This was particularly
apparent when patients were receiving
assistance with personal care, a time
when disturbed behaviour can be a
frequent occurrence. The uniforms were
universally liked and staff issued with
them for the trial all still insist on wearing
them, even though the study period
ended some time ago.
Unlike our colleagues in Lancashire,
however, we have not yet been able to reintroduce uniforms across the service, as
we would like. We now have to begin the
process of persuading the management of
the merits of funding uniforms for all the
elderly in-patient areas. Any other recent
contributions to the evidence base, which
Depot injections in the
community
Sir: In his letter on mirror-image studies
( Psychiatric Bulletin, April 2002, 26, 155),
Professor Hugh Freeman draws attention
to the early days of giving depot injections
in the community, and says, quite rightly,
that this practice coincided with the birth
of community psychiatric nursing.
Although he mentions the early 1970s as
the date of this type of service being
given, we, at Herrison Hospital,
Dorchester, and St Ann’s Hospital, Poole,
started nurses giving depot injections in
the patients’ homes in 1967.
We did not actually know that we were
starting a community nursing service, the
plan being for ward nurses to have 1 day
off the ward a week to give injections to
patients that they had nursed in hospital,
in the hope that familiarity between nurse
and patient would ensure compliance. It
was only when an administrator noticed
that two nurses had visited two patients
in the same street on the same day that it
was decreed that a full-time community
nurse should be designated.
It might amuse our present-day nursing
colleagues that the lady appointed had a
case-load of 100 patients.
Alan Gibson Retired Consultant Psychiatrist
the c olle ge
Election results
President
The results of the recent election of
President are as follows:
n of ballot papers distributed
8901
n of ballot papers returned
3315
n of invalid ballot papers
7
n of valid ballot papers counted
3308
First stage
Jeremy Holmes
Anton Obholzer
Mike Shooter
1387
436
1485
Election of Sub-Dean
The results of the recent election of
Registrar are as follows:
n of ballot papers distributed
9092
n of ballot papers returned
2283
n of invalid ballot papers
4
n of valid ballot papers counted
2279
Council will be electing a Sub-Dean at its
meeting on 24 October 2002. The successful applicant will be the responsible
College officer for issues relating to the
Specialist Register award of Certificates of
Completion of Specialist Training (CCSTs)
and take a lead within the College on
flexible training. The new Sub-Dean will be
expected to be at the College for a minimum of half a day each week, in addition
to attending relevant Committees that will
include Council (which meets four times a
year), the Specialist Training Committee
(five times a year) and the Education
Committee (three times a year). Any
College Member who would like to be
considered for this post should write to
the Dean, C/o The Royal College of
Psychiatrists, Department of Postgraduate
Educational Services, 17 Belgrave Square,
London SW1X 8PG, for further details. If
more than one nomination is received,
then an election will be held among
Council Members.
First stage
Andrew Fairbairn
Hubert Lacey
Richard Williams
880
742
657
Second stage
Second stage
Jeremy Holmes
Anton Obholzer
Mike Shooter
(non-transferable
Registrar
1599
^
1633
76)
Dr Mike Shooter was therefore elected as
President to take office from 27 June 2002.
Andrew Fairbairn
Hubert Lacey
Richard Williams
(non-transferable
1183
979
^
117)
DrAndrew Fairbairn was therefore elected
as Registrar to take office from 27 June
2002.
316
Columns Obituaries
obituarie s
columns
Sydney Brandon
Formerly Professor of Psychiatry,
University of Leicester
Sydney Brandon was appointed the
Foundation Professor of Psychiatry at the
University of Leicester in 1975. As such he
was one of the last of that generation of
pioneering professors of psychiatry in
undergraduate schools that had bloomed
in the preceding decade or two. He was
also one of the smaller group of
professors who had the opportunity of
contributing to the creation of a new
medical school. From the beginning in
Leicester he was a notable wheeler and
dealer for the university, for the school
and for his subject. His leadership of the
then innovative ‘Man in society’ course
ensured that the psychosocial perspective
on health and disease was emphasised
from the start of each student’s career.
His cajoling and corralling shaped up local
psychiatric services in time to receive the
first students in their clinical clerkship. No
one could ignore Sydney and anyone who
sought to cast psychiatry in a Cinderalla
role had to reckon with him. His
enthusiasm and energy were infectious. A
quarter of the first cohort of Leicester
undergraduates opted for a career in
psychiatry. At least one is now a
professor.
A proud Geordie, Sydney started his
medical career in Newcastle. Before
medicine he had lied about his age to get
into the RAF at the end of the war and
briefly toyed with a career in aeronautical
engineering. Years later he took a great
delight in the high honorary rank that
came with his role as psychiatric advisor
to the RAF. He worked in paediatrics and
research in child development before
settling into a career in psychiatry. Time in
the USA and Manchester led up to his
appointment to Leicester.
His achievements were many as a
researcher and scholar. His work was wide
ranging but was always practical and
rooted in clinical work. The Leicester trial
of electroconvulsive therapy was a
notable achievement, not only academically but also as an exercise in persuasion
and inspiration. All his consultant colleagues in Leicester agreed to allow all of
their eligible and consenting patients to
enter the study. But then, Sydney was a
charismatic leader and forceful manager,
although not in the modern style. Toward
the end of his career the new managerial
enthusiasm was on the rise but its modes
and mores were not to Sydney’s taste. His
favoured planning tools were malt whisky
and the back of an envelope, although he
could work a committee expertly when it
was necessary. And he took his role as a
clinical leader seriously. He made no
marked or unnecessary distinction
between the role of the university and the
NHS. To him both were organisations that
should serve patients by promoting good
practice and good practitioners. On the
back of his office door was pinned a
leaflet from the 1940s exhorting the
virtues of the, then, new health service.
He was an NHS man through and through.
It was as a humane and skilled clinician
that Sydney really shone. He cared about
people ^ his patients, their families and
his colleagues. He was involved in the best
sense. Every inch the consultant but also
down to earth and not at all ‘posh’, he
was more likely to irritate his peers than
his patients or those in less elevated roles.
He was a dapper figure. He once
published an article on ‘what every young
man should know’; it gave instruction on
how to knot a bow-tie ^ his habitual
neckwear. Once at a formal dinner he was
shocked and upset to find me wearing a
ready-made bow-tie. Such sloppy short
cuts were not for him either in dress or in
clinical work.
He ended his formal career as a
postgraduate dean. He was also a vicepresident of the College. In so-called
retirement he continued to work hard,
energetically contributing to work with
sick doctors and to the charity Childline.
He made many trips to Rwanda, advising
and contributing to aid work in the
aftermath of the genocide. He always had
plans for the future. He was a medical
collector and amateur historian. He lived in
a house that verged on being overwhelmed by his collection of feeding cups,
instruments and medical memorabilia. He
had hoped to write a book on the history
of military psychiatry. Unfortunately, like
his hope of mastering the French
language, that ambition remained
unfulfilled.
Sydney was a delightful companion and
colleague. He was a family man and is
survived by his two daughters, one a
lawyer and one a doctor. Over the years,
317
despite various illnesses, he seemed to
remain the same. Only during his final
struggle with ill health did his twinkle
begin to grow dim. He died on 5
December 2001, leaving a sad gap but
also happy memories and a continuing
influence.
Bob Palmer
Sydney Brandon was outstanding: even in
his appearance he stood out. He was of
short, stocky, ‘pyknic’ physique. He had a
shock of white hair, but what was
unmistakable was his long, bushy sideburns that, together with the inevitable
bow-tie he sported, gave him the dash of
an Edwardian toff. And if, perchance, he
was hidden in a crowd, he could be
located by his infectious chuckle, audible
at at-least a hundred paces. Despite being
plagued in later years by ill health he
always managed to retain his glow of
cheerful optimism.
Sydney was born in Washington,
County Durham. His father, Thomas
Brandon, was a deputy colliery manager,
and his mother, Rhoda May (nee¤ Rook), is
described as a housewife. In 1950 Sydney
married Joanne (nee¤ Watson), a lecturer in
social work.
Professor Brandon was educated at
Rutherford College, Newcastle-uponTyne, and studied medicine at King’s
College, University of Durham, where he
graduated in 1954, and at the Royal
Victoria Infirmary, Newcastle.
After graduation, Sydney became
interested in paediatrics, but his face-toface involvement with the behaviour of
disturbed children led him into psychiatry,
which became his life’s work. Thus, as a
junior, he was appointed Nuffield research
assistant in child health to the children’s
department, Royal Victoria Infirmary,
Newcastle, where he worked from 1955^
1959. From 1963^1964 he worked as a
research fellow in psychiatry, Columbia
University, New York, and from 1964^
1966 he served as a lecturer in psychiatry
at the University of Newcastle. His later
appointments were as Nuffield Foundation Fellow in Psychiatry (senior lecturer)
at the University of Newcastle (1966^
1969), reader in psychiatry at the University of Manchester (1969^1973) and
finally, in 1973, he was elected Professor
in Psychiatry in the University of Leicester,
a post he served with distinction until his
retirement, after which he was created
Emeritus Professor.
From 1982 until his death he served as
Civil Consultant Adviser to the RAF. He
was singularly proud of his connection
with the RAF, and he was a regular
attender at the annual dinner of the
Columns Reviews
columns
RAF medical officers at the RAF Club,
London.
His packed schedule still allowed space
to give valuable service to the Royal
College of Psychiatrists. There he rose to
the office of vice-president, as well as
sitting on various important committees.
Furthermore, in his time he served as
President of the Section of Psychiatry of
the Royal Society of Medicine.
He was a prolific writer: his publications
included topics on eating disorders,
carbon monoxide poisoning, panic disorders and sexual deviations. A particular
interest in post-traumatic stress disorder
was responsible for his concern with
Rwanda, the unhappy country he visited
frequently as a counsellor to the surviving
victims of the appalling genocide.
No picture of Sydney Brandon is
complete without mentioning his
interests and hobbies. He enjoyed the
thrill of driving fast cars, but above all
he was a bon viveur: he loved good food
and good wines in the company of his
friends, of which I am proud to have
been one. He had a passionate interest in
the history of medicine as witness his
valuable and extensive collection of
medical artefacts.
His wife, Joanne, predeceased him, but
he is survived by his two daughters and
his devoted friends.
Henry R. Rollin
Arumugam Sittampalam
Formerly Consultant Forensic
Psychiatrist, Broadmoor Hospital,
Crowthorne, Berkshire
Arumugam Sittampalam died on 4 August
2001 after a stroke. Sitt, to his friends and
colleagues, was born on 30 November
1922 in Jaffna, Sri Lanka. He qualified in
1949 at the University of Colombo, later
obtaining the DPM, FRCP (Edin) and
FRCPsych. From 1957^1971 he worked for
the Ceylon Health Service as the senior
psychiatrist. He left Sri Lanka in 1971 for
Canada, where he was senior psychiatrist
at the union hospital in Moose Jaw,
Saskatchewan, but soon decided to come
to the UK where he worked first from
1972^1979 as medical officer at HMP
Brixton and then from 1979 as a
consultant forensic psychiatrist at
Rampton Hospital. This meant that he was
separated from his family, who were
settled in London, so in 1981 he moved to
Broadmoor where he worked until his
retirement in 1992.
Sitt was a quietly spoken, modest and
intensely private man dedicated to his
family. At Broadmoor his wide clinical
experience, his diligence and his sound
judgment were a tremendous asset
and a stabilising influence, making him
admired and respected by friends and
colleagues of all disciplines. Towards the
end of his time at Broadmoor he founded
a dining club for doctors who had
worked there, but disappointingly this
did not long survive his retirement. At
Broadmoor his generosity will long be
remembered.
In the years following his retirement he
spent his time with his grandchildren or
gardening and watching sport. He leaves
his wife, Puaneswary, and four sons and a
daughter.
David Tidmarsh
re vie w s
Cross-Cultural Psychiatry.
A Practical Guide
By Dinesh Bhugra and Kamaldeep
Bhui. London: Arnold. 2001.
114 pp. »15.99.
ISBN: 0-340-76379-5
In this increasingly diverse country an
understanding of cross-cultural issues in
the practice of psychiatry has become
essential. However, the literature is spread
across a number of specialities including
sociology, anthropology, history, political
science and medical biology. It can be hard
to find the information that you need and
when you find it, it can be impenetrable.
Because of this many clinicians may not
develop the understanding of crosscultural issues that would be commensurate with good clinical practice.
Cross-Cultural Psychiatry. A Practical
Guide aims to cut through this dense
literature and offer some practical ways of
understanding the challenges set by
cross-cultural psychiatry. It is a jumpingon point, rather than a jumping-off point.
It does not claim to be comprehensive but
to ‘open doors for clinicians and other
health professionals to start thinking
seriously about differences and similarities
across cultures and individuals’.
The book is not targeted at specific
cultural groups. General principles are
considered more important than specifics.
This parallels the position in the USA,
where cultural competence training offers
transferable broad skills that help people
understand cross-cultural interactions. It
is assumed that this is the best way to
cope with the fact that cultures develop
and that over time new groups of people
and new generations will present
different challenges to psychiatrists. A
psychiatrist will not be able to be
‘culturally competent’ for all groups and
so to be a good psychiatrist he/she will
need to develop common strategies for
identifying cross-cultural problems and
dealing with them.
The book is a good general introduction
to the field and will become a ‘must read’
318
for all those in training or who are new to
the field.
The book is not without problems. In
my opinion the authors do not make it
clear enough that the skills and strategies
developed by the book are useful across
the board ^ not just for ethnic minority
groups. The reliance on UK ethnic minority
groups for examples could lead the reader
to believe that cross-cultural psychiatry
refers to problems produced by an
interaction between psychiatry and
different ethnic groups, rather than the
interaction of the cultural assumptions of
psychiatric practice and different cultural
groups. The majority of people in the UK
somatise rather than psychologise their
distress.
A further problem is that there is little
discussion of the impact of discrimination
or of institutional racism in this volume. It
is important for individual clinicians to
improve their clinical assessment and
treatment, but improvements in care can
be limited by institutional causes of
disparities in service delivery. An understanding of this is required if clinicians are
to be able to offer the best care for their
patients.
Cross-cultural psychiatry is good
psychiatry. Developing the knowledge
base is fundamental to good practice. This
short book is full of ideas and information
and this is a good place to start.
Kwame McKenzie Royal Free and University
College Medical School, London
Columns Reviews
Assessing Forensic Mental
Health Need. Policy,Theory
and Research
By Andrea Cohen and Nigel
Eastman. London: Gaskell. 2000.
228 pp. »30.00 (hb).
ISBN: 1-901242-42-0
with everything in the book. In the Survey
approach chapter, the authors suggest ‘If
only high security hospitals provide the
high level of occupational facilities that
some patients require, then, even if their
risk to others infers that they only require
medium security, their proper placement
within existing services is high security.’
This confirmed for me that when one is
drawn so far down the needs path, ethical
judgements, for example, locking patients
within category B prison type security, are
not considered. But this is the point of the
book ^ needs assessment is perhaps little
more rational than other methods of
service planning, and as the authors
suggest, as an approach it is only as good
as its assumptions and method. For MDOs
the assumptions, the politics and the fears
of the community complicate the whole
process.
Peter Snowden Consultant Forensic Psychiatrist,
Edenfield Centre, Mental Health Services of Salford
NHS Trust, Bury New Road, Manchester M25 3BL
Developing Care Pathways.
TheToolkit
Some time ago I was asked by Gaskell if I
would review the outline of a book ^ this
book ^ in order to help them come to a
view on possible publication. I suggested
that it would have a narrow (forensic)
audience, but it would be worthwhile to
publish an authoritative book on needs
assessment.
I was both right and wrong. This book
could almost be entitled ‘Everything you
ever wanted to know about needs
assessment, but was too afraid to ask’. I
realised very early on in my reading that
needs assessment was so much more
complicated than I had first thought.
Rationality in service planning is the goal,
but at the same time it is also subjective,
politically driven and resource managed.
The authors offer a detailed description of
needs assessment policy with an
emphasis on mentally disordered
offenders (MDOs) and a theoretical
framework to enable the reader to
understand the strengths and weaknesses
of the various approaches (survey, rates
under treatment, social indicator, key
informant and community opinion).
The detail and thoroughness of the
reviews are impressive, but the over
reliance on a historical approach makes
some aspects of the book appear out of
date. I was wrong in suggesting that the
book would have a narrow audience. It
may have ^ but it should not. The breadth
of many of the chapters is such that I
would commend it to the wider mental
health constituency, in particular, general
psychiatry. I did not find myself agreeing
By Kathryn de Luc. Abingdon:
Radcliffe Medical Press. 2001.
43 pp. »30.00 (sold with Handbook, pb). ISBN: 1-85775-499-9
account of care pathways, long on the
obvious and short on how to overcome
any difficulties. The book was disappointing in two main aspects. First, there
was insufficient material provided as to
the evidence that care pathways actually
improve the process of care. It would have
been useful to have evidence both for and
against the use of such pathways rather
than simply seeing them as a good thing.
Second, it would have been useful to have
had much more information about
problems that exist in implementing pathways. For example, how does one overcome clinician resistance? Is the extra
paperwork that will almost inevitably be
involved be justified by the result? Are
care pathways completed accurately by
staff? Are deficiencies in care highlighted
by care pathways remedied to bring about
improved patient results?
Although this book may be useful for
someone who knows nothing about care
pathways as an introduction to the
concept, anyone who has had experience
of developing their own care pathway will
probably not learn anything new.
L. Mynors-Wallis Medical Director, Dorset
Healthcare NHS Trust
Challenging Behaviour.
Analysis and Intervention in
People with Severe
Intellectual Disabilities
By Eric Emerson (2nd edn).
Cambridge: Cambridge University
Press. 2001. 210 pp. »29.95.
ISBN: 0521-7944447.
Care pathways have been developed in
many areas of medicine. Such pathways
can be a helpful way of ensuring that
clinicians implement good practice guidelines. They can also be helpful as a way of
empowering patients with the knowledge
of what treatments they can expect and
within what time-frame. Developing Care
Pathways has been written to facilitate
the development of care pathways:
explaining what they are and how to go
about producing one.
Unfortunately, in spite of being in two
volumes ^ a handbook and a toolkit ^
what has been produced is a simplistic
319
A substantial minority of people with
severe learning disabilities behave in ways
that cause problems for themselves, their
carers and other members of society. This
is frequently a reason for referral to a
psychiatrist. Challenging behaviour has
become the preferred term in recent years
columns
Columns Miscellany
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to describe such behaviours because it
emphasises the social context. Professor
Emerson, a psychologist well-known
for his own research in the field of
behavioural interventions, has written a
comprehensive summary of current
thinking about challenging behaviour.
The opening chapter defines challenging behaviour as a social construction
and later states that it is not a psychiatric
diagnosis, although ‘it may be a secondary
feature of a psychiatric disorder’. The
second chapter describes the impact of
challenging behaviour on the health,
safety and quality of life of both the
sufferer and his/her carers, which is
inevitably significant. A detailed chapter
on epidemiology follows, showing that
these behaviours are common and tend to
be persistent over years or even decades.
Theoretical models are discussed in the
fourth chapter. The book is concerned
primarily with psychological and specifically behavioural approaches but in this
second edition Emerson has expanded the
section on neurobiological models and
psychiatric disorders and this is welcome.
The remaining chapters cover functional
analysis, behavioural interventions,
psychopharmacological interventions, the
effectiveness of community-based
supports and the challenges for future
research. Although Emerson supports all
his comments with references, the
number of good case controlled studies to
support either pharmacological or behavioural interventions is disappointingly
small. The range of methods used by
psychologists to measure and influence
challenging behaviour are effectively
communicated, and the usefulness of the
various techniques is helpfully summarised
in tables. The ethical implications of each
model are considered.
There are some omissions, for example
the section on psychiatric disorders does
not include consideration of the possible
role of psychotic illness, the role of
anxiety disorders is given insufficient
attention and there is no discussion of the
possible usefulness of a psychodynamic
understanding and treatment of challenging behaviour. However, the book does
succeed in its stated aim of providing a
concise introduction to the field and
drawing attention to recent advances in
applied behaviour analysis. For this
reason, and for its extensive references,
I commend it to learning disability
psychiatrists and other professionals who
work with people who have learning
disabilities and whose behaviour is
challenging.
Jane Radley Consultant in Learning Disability
Psychiatry, Northgate and Prudhoe NHS Trust
Management of Psychiatric
Disorders in Pregnancy
Edited by Kimberley Yonkers and
Bertis Little. London: Arnold. 2001.
266 pp. »55.00 (hb).
ISBN: 0-340-76126-1
There is increasing awareness of the
impact of antenatal and postnatal
psychiatric disorders on the pregnant
woman, the foetus and, after delivery, the
whole family. Many psychiatrists treat
patients who become pregnant, but this is
one of the few books in which one can
find details on the natural history of
psychiatric disorders during pregnancy,
with discussion of treatment options,
particularly whether or not to prescribe
medication.
Most chapters include a review of the
relevant research literature, although not
all give useful summaries of the clinical
management of patients, which busy
clinicians will probably be looking for.
The chapters on the management of
pregnancy in the woman with schizophrenia (J.K. Tekell) and bipolar disorder
(L.L. Davis et al ) were particularly
comprehensive and helpful. Psychological
treatments in the pregnant woman
generally received less attention than
pharmacological, other than a sole
chapter on interpersonal therapy. There
was also no discussion of the different
models of perinatal services or the vexed
question of whether postpartum disorders, particularly postnatal depression,
can be prevented or attenuated by
interventions during pregnancy.
Nevertheless this book is a useful
resource and despite its multi-author
nature, there was a consistent message.
Clinicians must be aware of the risks and
benefits of different interventions when
treating pregnant women with psychiatric
disorders, particularly as the adverse
effects of psychiatric illness on the mother
and foetus may be greater than those
caused by psychotropic medication. There
is a growing body of research into the
effects of antenatal stress on the foetus,
suggesting that psychiatric disorders may
have subtle biological effects on the
developing foetus, in addition to the
genetic and psychosocial consequences of
these disorders. This book is therefore
timely in providing a useful summary of
many of the management issues in
pregnancy for psychiatrists, obstetricians
and primary care professionals.
Louise M. Howard Research Fellow, Health
Services Research Department, Institute of Psychiatry
miscellany
The Douglas Bennett prize
The Section of Social and Rehabilitation
Psychiatry has recently inaugurated a
prize to the value of »200 to commemorate the work of Douglas Bennett,
whom many regard as the father of
rehabilitation psychiatry. Readers are
encouraged to submit an original paper
(2000 words maximum) on aspects of
long-term care, service development for
people with severe mental illness or on
relevant health or social care policy for
consideration for this prize. Critical
reviews of specific treatments or service
evaluations will also be considered. A
selected shortlist of papers may be
presented to the Prize Adjudication
Committee at the Section Annual
Residential Meeting in Bournemouth on
320
14^15 November 2002. The Douglas
Bennett prize will be awarded for the
best paper, which may be submitted for
presentation at the College Annual
General Meeting 2003. Submissions
(clearly entitled) or enquiries should be
sent to Dr Sarah Davenport, Women’s
Service, Ashworth Hospital, Maghull,
Liverpool L31 1HW by 15 October
2002.
for thc oming e vent s
The 60th Residential Revision
Course for the MRCPsych
Examinations will be held at the
University of Surrey, Guildford, on 7^14
August 2002 (Part I) and 14^22 August
2002 (Part II). Further details can be
obtained from Mrs S. Caines, Belmont
Postgraduate Psychiatric Centre, Chiltern
Wing, Sutton Hospital, Sutton, Surrey
SM2 5NF (tel: 020 8296 4177).
Applications are now invited for semester
one of the MRCPsych Course run by
University College London. Part I takes
place on Monday afternoons commencing
2 September 2002 and Part II runs Tuesday
afternoons commencing 3 September
2002. The course has been updated in
keeping with the Royal College of
Psychiatrists 2002 syllabus and includes
mock exams, theme-specific revision
sessions, research methodology and the
College’s critical appraisal paper for the
Part II exam. For further information and
an application form please contact
Lee Jameson, Course Administrator
(tel: 020 7679 9475; e-mail: [email protected]
ucl.ac.uk).
The Andrew Sims Centre for Professional
Development would like to announce:
Mental Health Act: Section 12 Induction Course, a comprehensive 2-day
course accredited for practitioners who
require approval under Section 12 of the
Mental Health Act. It is also valuable as an
in-depth update for those practitioners
who are already approved but wish to
keep their knowledge and practice
current. This course is taking place in
Leeds on two occasions: 19^20
September 2002 and 30^31 January
2003; Safe and Sound, a 2-day child
protection conference is specially
designed for those working with children
in the NHS and will focus exclusively on
the responsibility and accountability of
those in the front-line. This event takes
place in Leeds on 10^11 September 2002;
and Obsessive ^ Compulsive Disorder, a
professional development seminar
presented by Dr Chris Freeman and held
on 17 September 2002 in Leeds. For
further information on all these courses
please contact the Andrew Sims Centre
Course Administrator (tel: 0113 305 6044;
fax: 0113 305 6041; e-mail: [email protected]).
The University of Manchester,
Department of Psychiatry, would like to
announce a Course on Psychodynamic
Interpersonal Therapy, taking place on
16^20 September 2002. This is an intensive week-long course in psychodynamic
interpersonal therapy aiming to provide a
brief theoretical introduction to the
model; acquaint participants with the
main features of the model; and enable
participants to use the model with
patients with the following conditions:
somatisation, depression, deliberate
self-harm and complex chronic conditions.
The course is organised by Professor
Else Guthrie. Application forms and
further details are available from
Mrs Una Dean, Secretary to Professor
E. Guthrie, University Department
of Psychiatry, Rawnsley Building,
Manchester Royal Infirmary, Manchester
M13 9WL (tel: 0161 276 5383;
fax: 0161 273 2135; e-mail: [email protected]
man.ac.uk).
The Royal College of Anaesthetists, in
association with the Conscious Sedation
Society of the UK, will be holding a
Symposium on Safe Sedation Practice
on 31 October 2002. The symposium is
aimed primarily at clinical personnel who
are involved in the provision of conscious
sedation for diagnostic or therapeutic
purposes. The aim of the meeting is to
provide an update on national recommendations, review current techniques
and to discuss training and education in
conscious sedation. The structure will
consist of short presentations and
discussions of topics to include: overview
of conscious sedation in clinical practice;
safety of conscious sedation; drug
choice for conscious sedation; and multiprofessional education in conscious
sedation. For further information please
contact the Courses and Meetings
Department of the Royal College of
Anaesthetists, 48/49 Russell Square,
London WC1B 4JY (tel: 020 7813 1900;
fax: 020 7636 8280; e-mail: educ
@rcoa.ac.uk).
The University College London’s Department of Psychiatry and Behavioural
Sciences is inviting applications for a
2-year, part-time MSc in Psychiatric
Theory and Research, starting in
October 2002. The MSc is intended for
senior house officers and specialist
registrars in psychiatry and aims to
provide a firm grounding in research
methodology. The first year of the course
will involve seminars, tutorials and
workshops on research methodology,
with an emphasis on both conceptual
learning and academic skills, as well as
lectures covering the MRCPsych
Part II curriculum. In the second year
students will conduct a research project
under supervision and submit a
dissertation. Places on the course are
limited to 15 students, so early application
is advisable. For an application form
and prospectus please contact Lydia
Clinton, Course Administrator, on
tel: 020 7679 9475, or by e-mail:
[email protected]
BBR Beynon, Bishop, Ross Medical Education Ltd are the organisers of the
following MRCPsych Course: Part II
Clinical. This will take place on 9^10
November 2002. For further details please
contact BBR, 82 The Maltings, Roydon
Road, Stanstead Abbotts, Hertfordshire
SG12 8HG (tel/fax: 01920 872 407;
e-mail: [email protected]).
columns
Acute hospital care
K. A. L. A. Kuruppuarachchi and S. S. Williams
Psychiatric Bulletin 2002, 26:315.
Access the most recent version at DOI: 10.1192/pb.26.8.315
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