Forensic-psychiatric services are costly and very restrictive for patients. Clinical experience and the limited research available indicate that some patients stay for too long in these settings. A proportion of patients may, however, require long-term, potentially life-long, secure forensic-psychiatric care but their needs may not be met by existing service provision designed for faster throughput. Here we report the initial findings of a three year study on long-stay patients in forensic care conducted in England.

The overall objective of this project is to improve the quality and cost-efficiency of the care and management of patients who stay for prolonged periods in secure forensic-psychiatric settings.

1. 1. Estimate the number of long-stay patients in secure settings in England (length of stay over 5 years in medium secure care or 10 years in high secure care)

2. 2. Describe their characteristics, needs, care pathways and reasons for prolonged stay

3. 3. Identify patients’ perceptions of their treatment pathways, long-term needs, service provisions and quality of life

4. 4. Develop recommendations following the exploration of international models for this patient group

This project uses a mixed-methods approach including analysis of administrative data, case file reviews, patient interviews, interviews with clinicians and commissioners and a Delphi survey.

Initial findings indicate that up to 25% of the forensic population fulfill criteria for long-stay, a much greater number than originally estimated.

The high number of long-stay patients in high and medium secure services calls for specific service provision for this patient group, which we will explore further.

The PANSS is utilized in clinical trials for assessment of psychopathology. In order to determine the status of a patient, comparisons within a general population are necessary. If several groups of patients are to be compared, gender, age, co-morbid diagnoses, and other factors affecting clinical status are not identically distributed.

1) Phase 1: To establish the initial psychometric properties of the PANSS-Ru. 2) Phase 2: To establish normed-reference data for the PANSS-Ru.

Phase 1: 40 patients with schizophrenia and other psychotic disorders. Phase 2: 375 individuals (n = 250 patients; n = 125 controls). Responses were assessed for internal consistency, stability, reliability, discriminative validity, and construct validity. Fifth percentile norms are presented as step functions. Data were compared to US norms.

40 subjects enrolled for Phase 1. Alpha coefficient of 0.88 verified good internal consistency. Test-retest comparisons verified time stability (r = 0.67 to 0.92). Correlation between subscale and the total scores ranged from 0.76 to 0.86, compared to > 0.83 for US norm studies. Internal consistencies were α > 0.745. Mean subscale/ total score were equivalent to US population norms within 13%. However, there was a difference of > 5 norm-based points for mean general psychopathology subscale. Norms had a sensitivity of 85% and specificity of 89%.

Preliminary results show that different dimensions of symptom presentations in the Russian population may help to improve symptom-specific treatments, and will also provide comparison data for a Russian population. Further normative studies are warranted in other populations.

Developing empirically sound measures for social cognition is a key step in improving the factors that contribute to deficits in social functioning in schizophrenia. Investigating the psychometric properties and acceptability of social cognitive instruments may contribute to identification of a reliable and valid instrument for schizophrenia patients.

To investigate the psychometric properties and acceptability of a dynamic social cognition scale (DSCB) compared to three common social cognition instruments in schizophrenia.

41 patients with schizophrenia were evaluated to assess acceptability, internal consistency and validity of five social cognition measures: DSCB, Emotion Recognition-40 (ER-40), Facial Emotion Identification Task (FEIT), Tone Matching Task and MSCEIT. Multiple linear regressions were conducted to identify variables which perform well as social cognition determinants.

The DSCB and FEIT showed good acceptability, evidenced by shorter administration time, completion and patient preference for the DSCB. Good levels of internal consistency were found for the DSCB (α = 0.851), ER-40 (α = 0.803), and FEIT (α = 0.782). Confirmatory Factor Analysis indicated sufficient to good model fit. The DSCB and the ER-40 demonstrated a good model fit. The correlations for the DSCB were significant for the ER-40 (r = 0.512) and FEIT (r = 0.500).

Findings suggest that DSCB is the preferred instrument to evaluate social cognition, due to its dynamic nature and short administration time. Further research is needed to develop and improve these measurements. Additionally, the DSCB, FEIT and ER-40 show adequate to good reliability and validity.

Though Focus of mental health care is negative emotional state, positive psychology appeals to masses. Because troubled person not only wants relief but also wants a life of meaning & purpose (National Mental health plan 2003-2004, Australian Govt.). and purposeful life without mentally healthy family is difficult. So family's transformation's imperative (Welsh Assembly Govt. 2005 a).

To strengthen Family members to transform Dysfunctional family.

1. 1) Preserve family mental health & Prevent mental illness among family-members of mentally ill patient.

2. 2) Prevent deterioration of mentally ill patient.

Discussion -for therapeutic alliance.

Therapeutic Transformation of dysfunctional family -

1. (a) Family Therapy: Why? Because family therapy focuses on well-being which is over & above the absence of depression-anxiety etc. Family therapy addresses problem and not individual unlike other therapies (NIMH, EFTA).

2. (b) Psycho-education: To build positive emotions which facilitate skills & resources needed for recovery (Fredrickson). It includes (i) Transactional-analysis (ii) Proactive behavior (iii) Social maturity (Robert Kegan).

3. (c) Positive Psychotherapy (PPT): Recovery rate was 85% (30%-single therapy) when psychotherapy was clubbed with pharmacotherapy. Positive emotions promote psychological resilience & positive emotional granularity. PPT focuses on pleasant, engaged & meaningful life (Seligman 2002).

4. (d) Spiritual Psychotherapy: Inevitable to future Psychiatry, because meditation alters levels of Melatonin, Serotonin, boosts immune response. Contents: (i) Meditation – changes brain (Dr Zedel, 2010) (ii) Spiritually-augmented CBT (SACBT), (iii) IBMT (Tang Y Y)/Yog-Nigra.

Family mental health is achieved.

Thus attained family mental health will facilitate family's transformation.

To determine whether hypersexual behavior can appropriately be characterized as an addiction, or rather, a symptom or manifestation of a coexisting Axis I or Axis II Disorder.

A literature review is being conducted to explore these opposing viewpoints. Articles published from the year 2000 to present relating to the topic of sex addiction/ hypersexuality/ sexual compulsivity/ impulsivity are reviewed.

The concept of sexual addiction was introduced in the 1970's. Two schools of thought have. Proponents of sex ’addiction’ argue that the neurochemical changes associated with hypersexual behavior are quite similar to that of drug addiction. They argued that sex ’addicts’ can experience a psychological withdrawal as experienced by those addicted to drugs of abuse. Some proponents of sex addiction even advise a 12-step treatment program. Critics of sex addiction argue that increased sexual activity is a way of alleviating affective symptoms, or is reflective of the impulsivity, associated with concomitant Axis I or Axis II pathology. They postulate that treating the underlying psychiatric disorder would ameliorate hypersexual behavior.

Despite standard, and even increasing use of the term ’sex addiction’ in media and popular culture, mental health professionals remain divided in regards to this subject. The proposed inclusion and subsequent rejection of hypersexual disorder in DSM-V highlights this existing debate. The notion of hypersexual behavior as an addiction warrants further exploration, especially since how it is defined may dictate treatment modality.

This study surveys patients with schizophrenia or schizoaffective disorder, to understand the relationship between sexual function and treatment with antipsychotic medication. The study compares patients on single versus multiple antipsychotics as well differences between first and second generation agents.

Patients diagnosed with schizophrenia or schizoaffective disorder at Beth Israel Medical Center are eligible. Once patients are evaluated to ensure they meet enrollment criteria and are consented, they are administered the Positive and Negative Syndrome Scale (PANSS), Abnormal Involuntary Movement Scale (AIMS), and either the International Index of Erectile Function for men, or the Female Sexual Function Index for women. Inclusion criteria include age 18-65, able to participate in a structured interview, fulfill DSM-IV criteria for Schizophrenia or Schizoaffective disorder, and on stable doses of one or more antipsychotic medications for at least six weeks. Exclusion Criteria include patients taking Selective Serotonin Reuptake Inhibitors (SSRIs), and inability to provide informed consent.

Presently, data suggests sexual function is impaired secondary to antipsychotic use. Further extrapolation of data is pending further enrollment.

Preliminary results point to better sexual function with certain second generation antipsychotics. It also appears that patients on single antipsychotic may have better sexual function than patients on multiple agents.

The presentation will focus on how psychosexual medicine and sexology education can be integrated into psychiatry residency training.

The Psychosexual Medicine Program currently being implemented at Beth Israel Medical Center, Department of Psychiatry and Behavioral Sciences in New York, NY will be described.

The positive impact on the training program and overwhelming support from faculty and residents of the program will be discussed.

An argument will be made why it is important to teach sexual medicine in psychiatry residency training and how psychiatrists are uniquely positioned to be good sexologists. It will be recommended that sexual medicine education become an integrated part of psychiatry residency training everywhere in the USA.

To pose a new hypothesis of schizophrenia that affirm and unifies conventional hypotheses.

Outside the brain, there are 5-HTP-containing argyrophil cells that contain tryptophan hydroxylase 1 without L-aromatic amino acid decarboxylase. Monoamine oxidase in the liver and lung metabolize 5-HT, rather than 5-HTP, and 5-HTP freely crosses the blood-brain barrier, converting to 5-HT in the brain. Therefore I postulate that hyperfunction of 5-HTP-containing argyrophil cells may be a cause of schizophrenia. I investigate the consistency of this hypothesis with other hypotheses using a deductive method.

Overactive 5-HTP-containing argyrophil cells produce excess amounts of 5-HTP. Abundant 5-HTP increases 5-HT within the brain (linking to the 5-HT hypothesis), and leads to negative feedback of 5-HT synthesis at the rate-limiting step catalyzed by tryptophan hydroxylase 2. Due to this negative feedback, brain tryptophan is further metabolized via the kynurenine pathway. Increased kynurenic acid contributes to deficiencies of glutamate function and dopamine activity, known causes of schizophrenia.

The 5-HTP hypothesis affirms conventional hypotheses, as the metabolic condition caused by acceleration of tryptophan hydroxylase 1 and suppression of tryptophan hydroxylase 2, activates both 5-HT and kynurenic acid. In order to empirically test the theory, it will be useful to monitor serum 5-HTP and match it to different phases of schizophrenia. This hypothesis may signal a new era with schizophrenia treated as a brain-gut interaction.

Although child mental health problems are prevalent, treatment gap is high. Low literacy level on child mental health problems in the general population and religious and cultural practices may be responsible but has not been extensively studied in Sri Lanka.

To elicit the parental beliefs about causes of child mental health problems and how such beliefs may influence help seeking behaviour.

A descriptive study. The sample comprised of all consecutive new referrals over a period of 3 months to make up a total of 52. Interviewer administered questionnaire was used. Frequency distribution and chi square test was used to analyze data.

Average age was 7.2 years (range 3–16). Main presenting problems were speech delay (n=15, 28.8%) and aggressive behaviour (n=9, 17.3%). Bad astrological period was given by parents as the as the cause in 46.1% of children. Bodhi-poojas and astrological interventions were performed in 61.5% and 44.2% respectively before a decision was made to seek medical help. In 61.6% of children, the delay in getting medical help was delayed as long as 2 years (mean delay 23.5 months). In 30.8%, the delay was the result of inappropriate reassurance given by doctors. There was no statistically significant association between parental educational level and delay in seeking help or use of cultural rituals (p>0.05).

The study highlights the delay in receiving attention for mental health needs and the financial burden on families, indicating the importance of improving mental health literacy of the general public and among medical practitioners.

Deliberate self-harm is non-fatal self-poisoning or self-injury. It occurs much more frequently than suicide. It is a common presentation among the patients referred to psychiatric unit, Teaching Hospital, Karapitiya, Sri Lanka from medical units.

To determine common methods used for deliberate self harm, to determine the medical and psychosocial factors associated and to assess psychopathology among persons presented with deliberate self harm

A descriptive cross sectional study. Sample was drawn from patients referred to psychiatric unit Teaching Hospital, Karapitiya following attempt of deliberate self harm. All Patients referred on every other day of the week for consecutive 2 months selected using systematic sampling. Interviewer administered questionnaire was used to asses.

Seventeen (53.1%) were females. Mean age was 29.3 years. Leading precipitant was acute conflict with a family member (n=15, 46.8%) followed by conflicts in relationships (n=5, 15.6%). Majority (n=18, 56.2%) had the intention to die seven (21.8%) had intention to change others behaviour. Majority (n=24, 75%) contemplated act for period less than 24 hours. Poisoning was used by majority (n=19, 59.3%) followed by overdosing of medication (n=10, 31.2%). Poison was available at home in 46.8% persons who used poison. Six (18.7%) had previous suicidal attempts. Six (18.7%) were previously diagnosed to have a psychiatric disorder. Nine (28.1%) each met the criteria for major depressive disorder and impulsive act.

The commonest method was poisoning. Leading precipitant was acute conflict with a family member. Majority had the intention of dying. Leading diagnosis was major depressive disorder.

Mania is a syndrome characterized by elevation of mood, increased activity and self important ideas. Inflated self-esteem may develop into grandiose delusions and suspiciousness into delusions of persecution. Grandiose delusions can be classified into three types. They are delusions of grandiose ability, grandiose identity and religious delusions. Studies on the content of the grandiose delusions and other psychopathology in patients with mania in Sri Lanka is scarce.

To analyze the behavior and psychopathology in patients with mania

Descriptive cross sectional study. All patients admitted to University Psychiatry Unit, National Hospital of Sri Lanka (NHSL) who met ICD 10 criteria of first episode mania and Bipolar Affective Disorder, current episode manic, within a period of three months were selected. Interviewer administered questionnaire and clinical records were used.

Sample was 36. Twenty two (61.1%) had manic episode with psychotic symptoms. Thirteen (36.1%) had destructive behaviour. Thirty three (91.6%) did not show sexual disinhibition. Eighteen (50%) had grandiose delusions. Of the grandiose delusions 10 (55.5%) were of grandiose ability, 6 (33.3%) were of grandiose identity and 2 (11.1%) were of the religious subtype. Five (50%) who had delusion of grandiose ability believed they had healing power. Eleven (30.5%) had persecutory delusions and seven (19.4%) had delusions of reference. Five (13.8%) had auditory hallucinations.

Grandiose delusions were the commonest type of delusion but almost one third had persecutory delusions. Most common subtype of grandiose delusion was grandiose ability. Most common content of grandiose ability was healing power.

Depression rates are higher in patients with a history of traumatic brain injury than those in the general population. According to the literature 25% of patients meet the criteria for major depression one month after a traumatic brain injury. Sri Lankan data with regard to this are lacking.

To determine prevalence of clinically significant depression among patients with a history of traumatic brain injury who attend the neuro-trauma clinic at National Hospital of Sri Lanka.

A descriptive cross sectional study conducted in neuro-trauma Clinic, National Hospital of Sri Lanka. A Sample of 112 patients who attended the clinic with a history of traumatic brain injury within one year was selected using systematic sampling method. They were interviewed using a self - administered questionnaire to assess presence and degree of depression (Sinhala version of Beck Depression Scale) which was followed by a clinical interview to confirm the results.

Hundred and seven (95.5%) were males. Mean age was 37.1 years (Range 17-74). Leading causes of traumatic brain injury were road traffic accidents (36.6%) and accidental falls (30.4%). Thirty two patients (28.5%) had mild depression; 10.7% (n=12) had moderate depression; 1.8% (n=2) had severe depression. Twenty seven (54%) patients did not have depression.

A significant proportion of patients with a past history of traumatic brain injury had depression. Every patient diagnosed to have a traumatic brain injury should undergo psychiatric evaluation in the course of their treatment and if they have symptoms of depression need to treat it vigorously.

There is lack of research on criminal responsibility among offenders with mental illness in Sri Lanka. ‘Unsound mind’, defined in penal code of Sri Lanka, excludes persons from responsibility for acts of crime. Psychiatric diagnosis does not always exclude those from criminal responsibility. A forensic psychiatric assessment is used to judge responsibility for a crime. Psychiatrists are requested by courts to give opinions on such matters.

Describe proportions of those who were deemed to not responsible for the crime of murder due to insanity.

Retrospective study, where hospital records and court reports of persons charged with ‘murder’, and were admitted for psychiatric assessment in year 2011, maintained by the forensic psychiatry unit at the National Institute of Mental Health, were analyzed.

42 were admitted (38 males, 4 females). 37 (88%) of them had a mental illness. Out them 13(35%) were deemed to be having an ‘unsound mind’ at the time of the alleged offence. 12 (32%), were found to be of ‘sound mind’ thus responsible for the charge of murder, despite having identified mental illnesses. In 13(31%) the mental state could not be reconstructed due to lack of information. Most common diagnosis was schizophrenia.

The prevalence of ASD among the adult population is estimated to be 1 percent. Despite high rates of anxiety and depression among adults with ASD, treatment methods for these comorbid conditions have not been systematically studies or compared in this patient population. Recently, MBSR and CBT protocols were adapted for adults with ASD and could be excellent candidate therapies for reducing anxiety and depression.

We wanted to study the ability of both treatment methods to reduce anxiety and depression symptoms among adults with ASD, and to determine which therapy is best suited for which patient.

A three-arm RCT among 90 adults with ASD (30 MBSR, 30 CBT, and 30 treatment as usual, (TAU)), was conducted in an outpatient setting with measurements at the start and end of the 14 week treatment period, and at 3 months follow-up. Prior informed consent and medical ethical approval was obtained. Instruments included the hospital anxiety and depressions scale, rumination, irrational belief and mindfulness scales, and an autism symptom checklist.

Preliminary results indicate that both MBSR and CBT lead to a significant reduction in anxiety and depression among adults with ASD. Both MBSR and CBT were superior to TAU. There was no gender or age effect. Effectiveness in relation to patient characteristics will be discussed.

Mindfulness and cognitive behavioral therapies are promising treatment methods to reduce comorbid anxiety and depression in adults with ASD.

The notion of gambling fascinates the scientific community for almost thirty years to become today a major concern for health policy. It is a well-known fact that lack of control and excessive gambling can have deleterious effects on the individual.

The aim of this study was to compare the use of video games and gambling in a population of 5568 adolescents and young adults in schools, colleges and universities of France.

A majority of the sample was female (61.2% vs 38.8% male). We note that 43.4% of the sample is less than 18 years old. We evaluated personality dimensions (anxiety, depression, self-esteem, impulsivity), socio-cognitive variables (cognitive distorsions, life satisfaction) and habits (substance use).

Our results showed that 6% of children and 3,5% of adults were found to be at risk of gambling according to the Canadian Pathological Gambling Index (CPGI). Correlations between scores on gambling and problematic video game use were 0.29 for children and 0.44 for adults (significant at p 0.05). According to regression analysis, the predictors of problematic use of video games were depression, incapacity to stop (facet of impulsivity) and the score on the CPGI. For pathological gambling, the predictors were: interpretive bias (dimension of cognitive distorsion), substance use (tobacco and cannabis), facets of impulsivity of the UPPS (incapacity to stop, positive urgency and lack of premeditation) and the total score for the problematic use of video game.

These results are interesting in the adaptation of care for people with gambling problem.

We encountered similar problem where the results of the tests ordered by the staff were not immediately accessible to them, as these investigations are carried out by the local acute hospital. To address this issue a project was chartered.

Of the project was to develop a protocol between the trusts so that the staff of Mental Health Trust could access the results of investigation on local computers as soon as they become available and to evaluate its impact on service.

A steering committee including Specialty Registrar, Pharmacist and Matron was constituted. The committee met regularly and evolved strategy with representatives of the Acute Trust. The main concern of the Acute Trust was patient confidentiality and software access. Following regular meetings and correspondence shared-protocol was developed.

It was agreed that the acute trust would install the software on all mental health trust computers. The staff would be trained to use the software and access results. To address the issue of confidentiality, flowchart of sponsorships of the shared-protocol was developed. Accordingly, all the medics would be sponsored for access by Medical Director, Nursing Staff by Matron and Pharmacists by Chief Pharmacist. This protocol ensured that all the staff trained are accounted and IT department could monitor any unauthorised access of data.

We have noticed a big improvement in the quality of clinical practice as a result. Unnecessary delays in clinical decisions have been avoided. We feel such a shared-protocol could be developed in other hospitals that are faced with similar access issues.

The increased uptake of evidence from systematic reviews is advocated because of their potential to improve the quality of patient care. However, research suggests that evidence from systematic reviews has not been widely adopted. Little is known about the factors that impact on systematic review uptake.

To identify how uptake of evidence from systematic reviews can be enhanced.

We searched 19 databases covering the full range of publication years, utilizing three search engines. Study selection Reports of strategies improving systematic review uptake were selected and evaluated according to the Effective Practice and Organisation of Care criteria.

Two reviewers independently assessed quality and extracted data from each outcome study.

Ten publications addressing interventions met inclusion criteria. Following a systematic review of these studies, a further broader synthesis of findings was carried out to determine the extent to which the identified interventions overcame already identified barriers and built on perceived facilitators.

Strategies such as targeted messaging, educational visits, and summaries, addressed a range of barriers and facilitators and are recommended to enhance uptake of systematic reviews and meta-analyses. Promising approaches such as inactive workshops, e-learning programmes and computer-based approaches need to be developed further. New strategies need to be designed that address a number of identified but neglected barriers and facilitators. This review has added value. It addressed not just effectiveness but also appropriateness of knowledge uptake strategies. It allowed the development of an intervention to enhance evidence uptake in psychiatry.

The comparative effectiveness of antidepressant medication and cognitive-behaviour therapy for the acute treatment of depression is contentious.

To compare the acute outcomes of antidepressant medication, cognitive-behaviour therapy (CBT), and the combination of the two, in adult, depressed patients.

Sixteen electronic databases together with reference lists were searched for randomised and other clinical trials that compared CBT, antidepressants, or their combination.

In the comparison between CBT and antidepressants, 8 studies met inclusion criteria. Five studies met the inclusion criteria for the second comparison between single therapy and combination therapy. In the antidepressant and CBT comparison, effect sizes favoured CBT over antidepressants with a significant advantage for CBT on some outcome measures. Combined treatment appeared more effective than antidepressants. However, combined treatment did not emerge more effective than CBT.

Antidepressants may not be considered more efficacious than CBT for the acute treatment of depressed patients nor can combination therapy be regarded as more effective than CBT alone.