A vitally important study

An important study which I would like to bring to your attention: http://news.bbc.co.uk/2/hi/health/7061887.stm

Who knows, perhaps this might come up in the exam.

NIall Crumlish podcast

A podcast of Niall Crumlish being interviewed by Raj Persaud was posted on the Royal College of Psychiatrists website - there's a link to it on the main RCPsych page, but the podcast itself is at http://www.rcpsych.ac.uk/pressparliament/podcasts/insightandfunctioning.aspx.

Stigma

Stigma will be an important topic for the essay papers. The lecture on stigma on Blackboard from March is a good starting point for reading about the topic. Stigma has been a common theme that has run through most of the lectures on Thursdays. From the stigma associated with suicide, and the stigma associated with mental illness which helps prevent people from seeking help for mental distress and thereby contributes to suicide, to the particular stigma for mental illness among minority groups such as travellers and refugees/asylum seekers (these are groups that are already to some degree stigmatised by the wider society), stigma has recurred. In the next series of lectures there will be presentations on psychiatry in a developing world setting and a historical perspective, which will further illuminate the topic of stigma.

Ultimately, stigma is an individual experience - look at the stigma presentation and be clear about the distinction between "felt" stigma and "enacted" stigma. Much "felt" stigma comes from the wider social and cultural attitudes to madness and rationality, but it is important to remember that stigma is experienced by individuals. So try and relate the topics on the course to the individual experience of people with mental illness.

This paper might be worth looking at : http://tinyurl.com/2yg22a

New links

As you can see, there are lots of new links to the right - I would recommend looking through them.

Age shall not wither

"The world’s population is getting older. In the next 50 years, the number of older people will nearly quadruple, growing from about 600 million to almost 2 billion people. Today, one in every ten is 60 years and older. By 2050, this will become one out of every five, and by 2150, one third of the people in the world are expected to be 60 years of age or older.

"In some developed countries and countries with economies in transition, birth rates have fallen below replacement levels, and the number of older persons will be greatest in developing countries, where the older population is expected to quadruple over the next 50 years. Eighteen out of the 20 countries in the world with the highest percentages of older people are in WHO’s European Region. In these countries, between 13.2% and 17.9% of the population are over 65 years old."

The above is from the wesbite of "Technology Research For Independent Living." - http://www.trilcentre.org/ . We hear a lot about the ageing population and the attendant stresses on pension systems and social welfare systems. We also hear quite a lot about how our lives as doctors/future doctors will be affected by this. There's no doubt that the burden of dementia and the needs of carers will dramatically increase.

However, the ageing population is invariably posed as a problem. As websites like the above reveal, many companies are seeing these demographic issues as commercial opportunities. Perhaps there are other potential positives we don't see yet. Certainly, notions of "old age" and the capabilities of those formerly classed as elderly are changing. A generation of people who came of age in the 1960s and who have very different expectations from life than their parents is now coming into the "elderly" bracket.

No health without mental health

The Lancet has recently published a paper entitled "No health without mental health." It's worth a look, I'll be putting it up on Blackboard under the Psychiatry and Society label.


The abstract in full:

"About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public
health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream eff orts to improve health and
reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and
evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on
existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition;
and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health aff ects progress towards the achievement of several Millennium Development Goals, such as
promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care."

Something of particular interest:


"The population-attributable fraction (which is the proportion of cases of disability that would not have occurred in the
absence of mental disorders) could be as high as 0∙69,which suggests that failing health and consequent disability
could be the most important contributory cause for late-life
depression."

In other words, 69% of disability - even that ostensibly not related to mental illness - is due to mental health.

Thursday 20th September

Hi all,

Hope you enjoyed Thursday's lectures. Apologies for any confusion about the various questionnaires we sent around. Basically we are seeing if a) doing the psychiatry rotation and b) having the "Psychiatry and Society" lectures themselves lead to a change in attitudes among medical students to psychiatry as a career, as well as a change in attitude to mental illness. So we have been doing some questionnaires with the current group of students doing psychiatry as a rotation, which overlaps with what we handed out on Thursday. We are also doing more qualitative work on the Psychiatry and Society lectures. I'll post more about these in due course.

Hope my little bit about the essays was clear enough. As I said, don't be too intimidated about having to do essays on psychiatry and society topics. The essays will be very general. The more you can use material from the lectures to inform your essay, the better.

I hope you enjoyed Liam Delaney's presentation. The Geary Institute maintain their own blog (linked to on the right, but in any case the link is here: http://gearybehaviourcenter.blogspot.com/) There is lots of exciting work going on at the interface between economics and psychiatry. As Liam said, in the recent past economists tended to ignore the less economically tangible (ie less readily expressible in monetary terms!) aspects of human happiness (although in the more distant past economists were very aware of them) - however now this is changing.

Economists are also more aware that a population with a high prevalence of mental illness is a less productive one. We tend to have an image of capitalism as this ruthless, impersonal system which works "best" when taking the least account of the consequences. This might seem a total tangent (and a distraction coming up to the first half of the finals!) but I'd recommend to anyone interested a book called "The Writing On the Wall" by Will Hutton - which is mainly about the rise of China as an economic, military and political power, but also contains much eye-opening (for me anyway) stuff on how modern theorists are realising that, to work well, market economies need strong, independent institutions (some of which may seem to have a raison d'etre contradictory to capitalism) such as a free press, an independent judiciary, mechanisms to regulate banking and financial services etc. (and I might add, an independent medcial profession)

I missed some of the Pavee Point presentation for various logistic reasons. I would be interested to know what people made of it - both Irish and non-Irish. Certainly it helped open my eyes to the viewpoint of a group in our society almost entirely excluded from public discourse except in bad news stories, as some kind of problem to be solved by the rest of society. It was refreshing to hear travelling people speaking for themselves. I think as a presentation it may have seemed little heavy on the structure of services etc. One thing you realise when you begin working is that a lot of those things that seem either trivially obvious or boring (or both) when you are a student about teams being "multidisciplinary", about "consultation", and about the structure of the health system and services, becomes very relevant very quickly. So right now this kind of stuff seems dull (trust me, I know!) but it is important to get a sense of its importance)

Someone once told me that we should all do management courses, because management have so much control of our working lives that we should have some idea of where they are coming from - and their uniquely boring and opaque use of language!

Back

Hi all,

The next lectures are on September 20th. The lecturers are Liam Delaney from the Geary Institute in UCD and speakers from Pavee Point. Attendance will be taken.

I'll also outline the structure of the essay paper on the 20th, between the lectures.

See you then,

Seamus

Small Group Needed

Hi all,

We are hoping to do some work with small groups to assess how the lecture series went and did it change any of your minds about psychiatry in any way. If you would be even vaguely interested, email me at seamus.macsuibhne@ucd.ie and I'll be in touch.

Hope the summer is going well wherever you are - and I hope to see you all (and I mean all) in September safe and well!

Seamus

Yesterday....

Hi all,

Hope you enjoyed the presentations yesterday - those of you who showed up! Perhaps I'll reveal my ruthless authoritarian streak to ensure better attendance in the Autumn (for we'll have no lectures on June 21st - in September things will kick off again!)

I had to go off myself for a clinic before Prof Malone and Seamus McGuinness' presentation - I'd hope to have something online from them before too long. I hope you found Joe Little's presentation stimulating - it was perhaps more an overview of a journalistic career and the intersection with mental illness in various stories that he covered, rather than a more didactic lecture.

There was lots to think about as a result of the presentation - in particular the realisation that in Ireland we are not all that far away, either in terms of time or distance, from a long-term ethnic conflict which rumbled on for centuries. We tend to forget how ingrained trauma can become. I remember being told (sorry I have no more reliable source than this) that many of the population of Belgrade are still on benzodiazapenes following the NATO bombings of 1999. I was also reminded of another thing I was told (clearly I'm not in evidence based medicine mode today!) that one of the consequences of the Famine and the century-and-a-half economic malaise which followed in Ireland was that Irish males tended to either emigrate of stay around doing very little, setting up a dynamic of Irish males being either hardworking but absent, or feckless but present - which has had knock-on effects on their interpersonal relationships to this day.

The other thing I took from Joe's presentation was this tension between protecting people and respecting their rights - for instance when he talked about the exposé of illegal moneylenders in the 1980s, and the reaction from some quarters that people should be allowed go to hell in a handcart if that's what they desire. This is the sort of tension we see in compulsory detention, for instance, and perhaps it goes to the heart of psychiatry. Unlike most psychiatrists (I reckon) I tend towards the libertarian end of the spectrum, but on the other hand no one can spend much time in psychiatry without realising that there are lots of people who are vulnerable to scams and frauds and do need protection. For instance, a lot of those fraudulent lotteries and get-rich-quick schemes that most of us just delete from our Inbox or go straight to the recycling bin, and read and taken up by people with cognitive impairment or learning disability.

I guess this tension is increasingly at the heart of politics too - we have gone from a left-right dichotomy to a more libertarian-authoritarian spectrum.

Anyway enjoy the weekend, see the current students next week and see the rest of you in September!

Seamus

Wells for Zoe

I'd like to refer readers of Psychiatry and Society to the following page: http://wellsforzoe.wordpress.com/. It is well worth a look. I mentioned John and Mary Coyne in my previous post; this is their blog. John and Mary are both former teachers, and John a developer, and they and their organisation Wells for Zoe have attached themselves to SJOG in Mzuzu, Malawi, in the past couple of years. (Mary teaches here.) Wells for Zoe began as a pump-providing operation - providing clean water to villages in the Mzuzu area, so women or girls don't have to walk ten kilometres with ten litres of water in a bucket on their heads. They still sink pumps but it has recently expanded into microcredit and other things - the recent blog entries describe a project, which the Coynes recently took me and Sharon along to, to drain and reclaim unused bog-like land, previously unsuitable for cultivation, and cultivate it using organic methods. (Fertiliser is expensive, and environmentally dodgy, and unnecessary). There's a recent John Waters IT piece on the blog too.
I mention this partly because it's just worth mentioning... and partly because it illustrates quite nicely how psychiatry and society sometimes mix in ways that you would not expect. Had SJOG, a mental health service, not been in Mzuzu, the Coynes would not have come here (they would have gone somewhere, not here) and the women you see in this picture, http://wellsforzoe.files.wordpress.com/2007/05/malawi-1-may-2007-059.jpg, shaking hands with Sharon, Mary and me (I felt like the Queen) would not now be growing carrots and tomatoes and peas and Chinese cabbage for sale in the market to make money for soap and oil and school fees. And the village chief, beaming in the background, would not have handed over a huge plot of his own land (not without a fight!) to a group of local women: essentially we're talking a feminist agri-co-op. The chief is the only local man in the picture; there were four guys there that day and a dozen women. Physical labour and indeed providing for the family remains predominantly women's work. The chief is the guy in, if you squint, the Beckham shirt. Beckham in Malawi is another post entirely.

Computer games and mental health

Hi all,

I remember my first job in psychiatry was with a general adult, community based team in ... well, perhaps I better not say. Most of the multidisciplinary team were ladies of, well, a certain age. There I was, new to psychiatry and with the paralysing shyness that comes with lack of clinical experience, somewhat dazzled in the team meetings. Anyway, the point of this nostalgic rambling beginning is that I recall that the team members had a pretty dim view of computer gaming. They might refer to a client/service user/patient's son as being a pretty likely future client/service user/patient themselves, based largely on their long hours of playing Championship Manager or whatever (I think I'm showing my age here)

It has been argued - most entertainingly by a chap called Steven Johnson in a book with the great title of "Everything Bad Is Good For You" - that computer games are part of a new, cognitively complex media landscape, that is in fact increasing our IQ and cognitive flexibility. You can read about this here:

http://www.wired.com/gaming/gamingreviews/commentary/games/2006/03/70487

and here:

http://www.wired.com/wired/archive/13.05/flynn.html?pg=1&topic=flynn&topic_set=

and indeed, here:

http://www.socialaffairsunit.org.uk/blog/archives/000687.php


"Fearfighter" is a program which "delivers" CBT over the internet - which you can read about here:

http://www.fearfighter.com/index.htm


You can read a less complimentary view of computer games here:

http://www.slate.com/id/2164065/

There is also a lot of interesting research going on about social networking websites and the like. It is interesting that there is a definite generational difference here. I am just too old to really "get" myspace and the like (and definitely too old for Bebo!) whereas the majority of you guys are presumably beboing away like mad. Whether this will have long term effects on social interaction or not, I don't know!

"you may not be interested in politics, but politics is interested in you"

When I was a medical student and indeed intern, nothing seemed more boring than the interminable stuff about contract negotiations and the like that filled the Irish Medical Times and the like. However as time goes by, these are more and more relevant. The new consultant contract has implications not just financially and in terms of private practice - the two areas most covered in the media - but on the whole independence of medicine and the ongoing quality of the medical services we deliver. I think it is worth reading the IMO's material on the consultant contract issue here: http://www.imo.ie/view_categories.php?cat_id=624

This is obviously enough not directly relevant to this course or your exams, but is an example of how medical practice does not exist in a vacuum - multiple other factors, from the imminent general election to an anti-professional, anti-expertise culture in wider society, affect this particular issue.

Rescheduling of lectures

Hello,

The lecture from Prof Malone and Seamus McGuinness will now be held on May 31st.

Seamus

First post

Hi,

It's a few weeks since Seamus asked me to give one of the Psychiatry and Society lectures (I'll be speaking in October about psychiatry in the developing world) and to contribute to this blog, so I guess it's about time I wrote something.

For a first post I'll just say who and where I am and broadly what's going on in Malawi.

I'm Niall Crumlish, I graduated UCD in 1997, and started training in Psychiatry (Tallaght / TCD) in 1999. In 2003 I was special lecturer in UCD and St John of God's (from now on SJOG), and went on to a research fellowship in Cluain Mhuire / SJOG with Prof. Eadbhard O'Callaghan. In 2005 the research fellowship took me to SJOG in Mzuzu, Malawi. After I spent a week here setting up an RCT, my partner (Sharon Brady, a nurse in the addiction services in Dublin) and I decided to come back and spend 2006 here. We extended at the end of 2006, but our term ends in June.

Mzuzu is a town in the north of Malawi (pop. 100,000 odd). Malawi is a hugely densely populated country, but the northern region is not so. This is good in terms of food security, and bad in terms of services provided by the government (there are two tarred roads, and only one north of Mzuzu). You can imagine what government-provided mental health services are like. (In the 2004 World Bank rankings, Malawi was the the poorest country in the world for which there was data, with a gross national income per capita per year of 170 dollars).

In the early nineties a number of SJOG brothers took a trip around Africa, visiting sites in several countries, and decided that of all the places they had visited, Mzuzu was the place most direly in need of SJOG-provided mental health services. (At this time, as an aside, Malawi was in the death throes of a thirty-year brutal dictatorship.) One of the SJOG brothers, Aidan Clohessy, became director of the new service - that is, he built it from nothing.

It was, literally, all fields around here. The nearest mental health professional was 800kms away, in a then-medieval psychiatric hospital in Zomba, in the south. (It has improved.)

Now, the St John of God Community Mental Health Service comprises an OPD, a domiciliary care team, a forty-bed inpatient unit, a counselling service, a recovery and rehabilitation service (training and supported employment), a programme for street kids, a school for kids with learning disabilities, and (courtesy of Sharon) an outpatient drugs and alcohol treatment programme, established in August of last year. There's a College of Mental Health Sciences, providing degree courses in psychiatric nursing and counselling, and in 2008 the College plans to commence a BSc in clinical psychiatry - training much-needed psychiatric clinical officers, who are the equivalent of registrars in a country that has almost no medical doctors and only one permanent psychiatrist, Felix Kauye, who is based in Zomba.

My work has been as a clinical lecturer - mostly supervising the clinical work of clinical officers, and training clinical officers and others in diagnosis, management, basic sciences, whatever, with a focus on evidence-based practice. I have continued to run the RCT that brought me here in the first place - a trial of carer education in schizophrenia, from which we are beginning to publish. And with others I have been trying to build a research infrastructure here - partly because we know almost nothing about mental illness in Malawi, which is an enormously complex and rapidly changing country of 12-13 million people; also because training in research methods fosters critical thinking and diagnostic precision, hence improves quality of clinical care.

For anyone interested in what's going on here, I suggest Googling "SJOG Malawi". You'll find the (somewhat out of date) homepage for SJOG Mzuzu, and you'll find links to Venture Malawi and Wells for Zoe. These are two charities / homegrown, ground-level NGOs that have built links with SJOG in the last few years. Wells for Zoe (www.wellsforzoe.org) is an amazing project, run by John and Mary Coyne - you may have read John Waters in the Irish Times writing about Wells for Zoe in January, and if you didn't, you may see something soon in the IT, as John Waters has spent the last week in Mzuzu with John and Mary Coyne and Bro. Aidan, before rushing back today to the alternative universe of the Eurovision.

OK apologies for the length of this entry. That's the problem with blogs - no editors.

My email is niall.crumlish@gmail.com.

Enjoy your rotations.

Niall

Forthcoming lectures

Over the next couple of months, the lectures will be:

April 19th - Professor Malone and Seamus McGuinness - Suicide

May 10th - Patrick O'Sullivan and Margaret O'Reilly-Carroll. Spirasi Ireland,- Mental Health and Asylum Seekers/Survivors of Torture

May 31st - Joe Little, RTE Religious and Social Affairs Correspondent - Mental Health and The Media

Note that Joe Little's presentation is conditional on the date of the general election being prior to the date of the lecture - I will keep you updated.

Spirasi Ireland are a group working with refugees/asylum seekers/survivors of torture and conflict situations - their website is www.spirasi.ie

Seamus

Other posters

A range of other bloggers have been invited to post. You may have noticed that Daniel White (one of the Mater Tutors) and Niall Crumlish (who is currently working in a St John of God order project in Malawi) are now registered as contributors. So hopefully over time we will hear from them.

I have also put the paper on stigma I referred to a good few times during Thursday's lecture up on the Blackboard section devoted to Psychiatry and Society.

teaching psychiatry using the cinema

Hi all

There's an interesting piece in The Economist about using films to teach students about psychiatry - you can read it http://www.economist.com/world/international/PrinterFriendly.cfm?story_id=8892568

As you can see, there are two schools of thought on the value of cinema as an educational tool. Certainly one shouldn't think that just watching A Beautiful Mind or One Flew Over the Cuckoo's Nest is enough to learn about schizophrenia or the old-style asylum system. There is no substitute for the clinical exposure that you will be experiencing during your rotations. And it must be admitted that films by their nature tend to focus on the dramatic, the bizarre, the unusual and the threatening, rather than the more mundane aspects of mental illness (or any other topic)

However, it is important to recognise that many - if not most - people's perceptions of mental illness and of psychiatric services is formed by the mass media, and cinema is one of the most powerful and influential parts of that media. So aside from the value or otherwise of films as a learning tool, it is important to have some ideas of what these public perceptions are.

Day 1

Hi everyone, and welcome to the blog proper. Hopefully a few at least of Fifth/Final Med Class of 08 (hopefully) will be reading. And hopefully a few at least of them were at the lectures this afternoon.

Firstly, the PowerPoint presentations of the lectures are now online - in Blackboard, under course material, in a special folder of their own. Over the coming months we'll be putting material both from the lectures and otherwise related to the course up there.

Secondly, I'm sure the most acute concern for many of you is just how this will be incorporated into the exam process. We will keep you updated as this is worked out fully. Remember, the most important thing from the lectures will be the concepts discussed rather than the fine detail.

Finally, as to the lectures themselves. I hope those were there didn't mind the interruption of those loud noises from the audiovisual system. Hopefully these will be fixed in time for next week! If any of you have any questions or comments, and if any of you are interested in posting in this blog, just drop me a line!

Seamus

Psychiatry and Society

Welcome to the blog of the Psychiatry and Society lecture series for Final Year Medicine, UCD. This course aims to explore the relationship between psychiatry and the wider social, cultural, economic and demographic context of society. We will be running lectures in C005 in the Health Sciences Building, Belfield, Dublin 4, regularly throughout the coming months. We intend this blog to act as a public forum for discussion and debate on the issues raised.