Providentia

Intimate Partner Violence in Pregnancy

A recent issue of Clinical Obstetrics and Gynecology presents the results of a study examing intimate partner violence (IPV) in pregnancy. Previous studies have shown that homicide may be the most common cause of maternal death. Women who are both pregnant and victims of IPV have high rates of stress, are more likely to smoke or use other drugs, deliver a preterm or low birth weight infant, have an increased likelihood of infectious complications, and are less likely to obtain prenatal care. The violence is also likely to continue after the child is born. Pregnant adolescents may be at even higher risk than their adult counterparts. Children raised in violent homes have both immediate and life long adverse health outcomes as a result of their exposure to IPV. IPV adds substantially to healthcare costs both for direct services to treat the injuries and higher utilization of a wide range of healthcare services. Healthcare providers, particularly those who care for pregnant women, are in a unique position to identify these women and direct them and their families to the help they need to end the violence in their lives.

Click here for the abstract.

English Neurology Patient Detained in Polish Psychiatric Hospital

A former salesman and resident of Lancashire has been detained in a psychiatric hospital in Poland after being discovered wandering the streets of Warsaw. Matthew Evans, aged 49, is in the advanced stages of Huntington's disease, a genetic neurological disorder characterizd by dementia and motor dysfunction, apparently travelled alone to Poland earlier this month. According to sources, he was found wandering the streets and taken to hospital just hours after arriving in the city. He then discharged himself three days later and vanished on his way to the airport to fly home. Polish authorities have since found him and admitted him to a hospital until he is well enough to return home, or can be collected by representatives from British social services.

His brother Paul, who lives in Devon, has been kept informed of the developments by the Foreign Office and plans to visit Mr Evans as soon as it can be arranged. He said: "I feel so relieved that he's been found and is now being cared for somewhere safe and secure. The social services in Poland have been amazing and have really done all they can for Matthew, which is a big weight of my mind. I'm just looking forward to seeing him again."

Mr Evans, who formerly travelled the world with his sales job, lacks co-ordination and cannot walk far as he has poor balance, which has been caused by his condition. His mother died from the disease, his older brother committed suicide when he was diagnosed with the illness and his sister is being cared for in a nursing home in Devon after developing the condition.

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HIV Dementia Epidemic in Uganda

A recently released study has showen that 465,000 HIV-positive people in Uganda are experiencing symptoms of dementia, including memory loss, learning problems and behavioural disabilities. The researchers found that dementia symptoms were more prevalent in older adults.“If the rate we saw in our study translates across sub-Saharan Africa, then we are looking at more than eight million people in this region with HIV dementia,” said Ned Sacktor of the US-based John Hopkins University, who led the study. These findings pose yet another challenge to a country that is already overwhelmed by the health challenges posed by the AIDS epidemic. The researchers tested 78 HIV-positive people attending a clinic in Kampala, Uganda and compared the results with a control group 100 HIV-negative subjects. HIV dementia is treatable and potentially reversible although anti-retroviral medication is largely unavailable in many Third World countries. Sacktor hopes studies like his will highlight the problem in resource-limited countries like Uganda and encourage more programmes to bring much-needed medication to such countries.

The director of Butabika Mental Hospital, Fred Kigozi, said although drug abuse and alcoholism were the leading causes of mental illness, HIV/AIDS is also a major contributor.  The problem is made worse by the fact that there are very few trained professionals and facilities to handle mental illness. “We have just 25 psychiatrists compared to more than 20,000 in the UK”.  Butabika is the only psychiatric hospital, Kigozi explained. Thomas Oyok, a psychiatrist at the Gulu mental unit, told The New Vision that the facility was not well-equipped to handle the rising number of cases in the region. “The basic drugs are not there. We get them from Butabika.” Uganda is drafting a mental health policy that will ensure that the condition becomes a key component of the primary health care strategy and attendant services delivered to the grassroots.

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What Depressive Symptoms and Disorders Are Linked to Adolescent Suicide?

A study reported in the April 2008 issue of the Journal of Affective Disorders examines the role of depressive symptoms and disorders as potential predictors of suicidal behaviour in adolescents. The authors used a representative sample of 2464 Norwegian school students (average age 13.7 years) who were initally tested (T1).  These same subjects were followed up and reassessed a year later (T2). All subjects who scored significantly high on the depresson questionnaire at the one year mark (T2) were matched with low- or middle-scoring respondents according to age and gender.  A subset of 345 subjects were diagnostically assessed by face-to-face interviews (mean age=14.9 years) and then reassessed after five years (T3) using telephone interviews and questionnaires. There were 265 subjects tested with a participation rate of 76.9%. The results indicated that cognitive symptoms were predominant among suicide attempters, regardless of age. Among younger adolescents, suicidal thoughts and acts of self-harm without suicidal intent were associated with suicidal acts. Recurrent thoughts about death, hopelessness, disturbed concentration and middle insomnia were associated with suicidal acts among older adolescents. Perceived worthlessness by the age of 15 was a significant predictor of suicidal acts between 15 to 20 years.  Major depression was significantly associated with suicidal acts among younger adolescents, while dysthymia by the age of 15 years remained a significant predictor of suicidal acts between 15 to 20 years, even when controlling for depressive symptoms. The authors conclude that acts of self-harm without suicidal intent, middle insomnia, cognitive depressive symptoms and a formal psychiatric diagnosis of any depressive disorder should alert professionals in the risk assessment of suicidal adolescents.

Click here for the abstract.

Homeless Woman Found Not Guilty by Reason of Insanity in Fatal Fire

A homeless woman charged with starting an arson fire that killed four people in a Chicago apartment building last year was found not guilty Friday by reason of insanity.  Mary Smith, aged 51, had been accused of starting debris on fire to keep warm in a stairwell of an apartment building on March 10.  She was charged with four counts of first-degree murder and one count of aggravated arson and, after a three-day trial, Cook County Circuit Court Judge James ordered her transfer to a mental-health facility where she will be evaluated

Evidence in the case included a videotape of an interview with police in which Smith initially denied starting the fire, but later admitted to using matches to ignite debris, including a dollar bill.   acqueline Ross, Smith's defense attorney, said of the verdict: "It doesn't mean she didn't do it, [but] she was unable to appreciate the criminality of what she was doing." " [The judge] did what was right in this case," Ross said. "It's just very tragic. Mary's family is distraught."

Dr. Peter Lourgos, a forensic psychiatrist with the county court, testified for the defense and said Smith did not comprehend her acts to be criminal. He said he based his opinion on her long schizophrenic history and the videotape of her interview with police. Her lawyer contended that Smith was legally insane when the fire occurred and continues to suffer from severe mental illness. In remarks to the judge Thursday, Ross did not address whether Smith started the fire but instead focused on her mental state.

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How Prevalent is Body Dysmorphic Disorder?

Body dysmorphic disorder (BDD) is a mental disorder involving excessive preoccupation with imagined or minor bodily imperfections. It has been linked to OCD-spectrum disorders and can manifest itself in s range of ways including anorexia nervosa, substance abuse and suicide. Estimates of actual prevalence vary widely. The April 2008 issue of CNS Spectrums presented the results of a national survey to estimate the prevalence of BDD in the United States. Using a random sample national household telephone survey conducted in 2004, 2,513 adults were contacted, of whom 2,048 qualified for administration of computer-assisted, structured interviews, addressed DSM-IV criteria for BDD. Information on psychological, financial and demographic factors was also collected. Respondents included a higher percentage of women and people >55 years of age than in the US adult population, and a lower percentage of Hispanics. Results showed an estimated prevalence of DSM-IV BDD among respondents as 2.4% (49/2,048) (by gender: 2.5% for women, 2.2% for men), exceeding the prevalence of schizophrenia and bipolar disorder type I and about that of generalized anxiety disorder. BDD prevalence decreased after 44 years of age, and a larger proportion of BDD respondents were never married. Of those meeting DSM-IV criteria for BDD, 90% (45/49) met the DSM-IV distress criterion, and 51% (25/49) met the interference-with-functioning criterion. The researchers concluded that further research is needed to evaluate these results and to determine more effective treatment approaches.

Click here for the abstract.

Indian Health Ministry Reports 16,000 Student Suicides In The Past Three Years

A representative of India’s Health Ministry has reported that over 16,000 school and college students in India have committed suicide in the last three years and announced plans to deal with the problem by reforming the national health care system.

According to the ministry, there were 5,857 student suicides in 2006, 5,138 in 2005 and 5,610 in 2004. While some private schools have started providing counselors to address the problem, government-run schools have been slow to follow suit.

Cherian Verghese, a specialist with the Indian branch of the World Health Organization, said: "The mental health system needs an overhaul. Our schools might be giving good education but we need education in life skills. From counseling to increasing the number of mental health workers, the strategy should be holistic.  Students are a vulnerable group. Age, competition and relations in the family are all contributing to the growing cases of suicide among school goers”.

"There is a gamut of problems; India lacks the required number of psychiatrists as well. The social taboo around mental health also fuels the problem. A country which houses a huge number of youngsters must not take mental health lightly," Verghese added.

Potential factors that have limited greater access to counseling include social stigma surrounding mental illness, the high doctor-patient ratio, and societal pressures. Despite India’s burgeoning population, there are only 3,500 psychiatrists for a population of more than a billion people.

The health ministry is planning to modernize psychiatric hospitals, expand community mental health services, and introduce counseling in schools.

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The Mercury Mavens

George Washington had the finest medical care available. Unfortunately, given the primitive medicine of the era, that wasn't nearly enough to save him. While it is probably unlikely that he would have survived his final illness, the aggressive treatment that the great statesman received certainly didn't help. His doctors blistered his skin (to draw off "humours"), gave him frequent bleedings (Martha Washington had objected to the bleedings but her husband overrode her), and applied poultices of wheat bran. They also purged him with mercurous chloride to empty his bowels. After growing weaker and finally asking his doctors to leave him alone, George Washington died on December 14, 1799 at the age of 67. The exact nature of his final illness remains unclear but modern historians believe it may have been diphtheria or strep throat. The medical care that he received almost certainly played a role as well (not that he would be the last U.S. president to be killed by well-intentioned doctors).

Mercury, a.k.a. quicksilver or hydrargium, has always fascinated philosophers, chemists, and healers alike. Its silvery appearance, tendency to stay liquid at room temperature, and chemical properties made it a natural ingredient for numerous remedies. Records show that it was used in medicine as early as the second century AD when the Chinese philosopher Pao Pu Tzu recommended mixing pills combining cinnabar (mineralized mercury sulphide) and honey to make patients immortal (the absence of immortals these days would suggest that this hopeful concoction didn't work). The great Greek healer, Hippocrates swore to mercury's medical value and it was also used in traditional remedies for diseases such as smallpox and syphilis.

Thomas Dover (1660-1742) wrote that "to take an ounce of quicksilver every morning is the most beneficial thing in the world".  Mercury was the treatment of choice for syphilis (despite the fact that it did nothing to prevent the onset of dementia or death) but was most widely used in the form of mercurous chloride (better known as calomel). For centuries, the calomel "blue pills" were dispensed by physicians to children and adults as an all-purpose diuretic and laxative. Benjamin Rush, the 18th century dean of American medicine, marketed a personal concoction that he often prescribed for his patents. His "bilious pills" were made up of mercury and jalap (a popular purgative) and Rush swore by their effectiveness (although contemporary critics noted the increased mortality rate in his patients). A journalist of the time referred to Rush's work as "one of those great discoveries which have contributed to the depopulation of the earth".

The effect of mercury-based remedies on patients was certainly noted by physicians and medical horror stories became common. In one medical text published in 1835, several case histories of mercury poisoning were reported: "a boy, about eleven years old, had a sore on once cheek, occasioned by a dentist extracting a tooth; a physician was consulted, who immediately prescribed a course of mercury. In a short time, ulcerations in the throat appeared, the nose sunk and one eye was nearly destroyed; while the general health was so injured, that death followed in a few months". Despite the warnings surrounding mercury use, physicians were slow to accept that they were poisoning their own patients and would continue using calomel well into the 20th century.

Mercury use was hardly limited to medicine. There have been countless industrial applications for mercury compounds although this has declined in recent decades as the neurotoxic aspects of mercury became better known. Mercury continues to be an ingredient in some medications despite ongoing controversy over safe levels of exposure. I won't even try to get into the controversies surrounding mercury exposure in dental amalgams and vaccines. It does seem ironic that activists have attempted to link mercury to autism despite the syndrome being first identified in 1943. Given that children were routinely dosed with dangerous levels of mercury for centuries, it's hard not to wonder why autism cases are rising now despite mercury exposure in children being so greatly reduced.

While many European nations have called for a total ban on mercury use, it's unlikely that the silvery metal's influence will end any time soon.

Is There a Link Between Brain Injury and Psychiatric Problems?

An interesting analysis in the December 2007 issue of Brain Injury looks at the role of traumatic brain injuries (TBI) in the development of severe, long-term psychiatric disorders.

While a clear causal link remains unclear, the authors found that psychiatric syndromes are consistently present at an elevated rate following TBI. Survivors of TBI are particularly susceptible to major depression, generalized anxiety disorder and post-traumatic stress disorder. While evidence of a direct link is lacking, the authors suggest that there may be consistent critical periods for the post-injury development of psychiatric disorders that have yet to be identified. There is evidence, however, that TBI cases remain at risk for years following injury. Non-organic factors, including pre-morbid personality traits and post-injury psychological reactions to disability and trauma, seem to play a role in the development of post-TBI psychiatric disorders. Treatment professionals dealing with TBI cases needed to be aware of the potential for the development of post-TBI psychiatric problems.

Click here for the abstract.