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IntroductionProviding an effective response to global health disparities requires that future doctors are better prepared to embrace a public health ethos. Asset-based approaches see people and communities as coproducers of health and well-being and have begun to influence healthcare policy and the training of health professionals. However, to date, there is scant research in this area within undergraduate medical education.ObjectivesTo explore: (1) whether an asset-mapping assignment enhances medical students’ experience and understanding of psychiatry. (2) The extent to which asset mapping promotes engagement of students with the clinical teams and communities in which they are placed, as perceived by students, clinical tutors and other team members.DesignUsing a qualitative case study approach, semistructured interviews were completed with 16 students, 8 psychiatry tutors and 3 multidisciplinary team members (MDTMs) to explore their experiences of the initiative. Interview transcripts were thematically analysed, based on the study aims.SettingThis research was carried out at Ireland’s largest medical school, among undergraduate medical students following a 6-week psychiatry clerkship.InterventionStudents completed a team-based assignment to elicit information on community assets from patients and presented an asset map to their host clinical team at the end of the clerkship.ResultsWe identified three over-arching themes within the data: (a) connecting the individual patient with the community; (b) relationship building; and (c) pedagogical challenges and rewards. Students found the asset-mapping assignment not only challenging but also rewarding and supported its retention within the curriculum. Tutors were predominantly positive, but some felt that the social focus diluted students’ professional identity. MDTMs welcomed the initiative and wished to be more involved.ConclusionOur findings suggest that community asset mapping offers added value within the undergraduate medical curriculum, sensitising students to the importance of exploring patient-perceived community assets.

IntroductionOlder people (people aged 65 years and older) have high rates of death by suicide, and self-harm is a major risk factor for suicide. While rates of self-harm decrease with age, rates of suicide increase among this age group. The overall aim of this research project is to identify real-life evidence of the characteristics associated with older people who present with self-harm and suicidal ideation to emergency departments in Ireland. In examining the variables associated with self-harm, we may be better able to identify the characteristics of older adults who are at highest risk, including those presenting with high lethality attempts.Methods and analysisOur data are a cohort study of older people in Ireland involving two workstreams. The first will use a 5-year cohort of data from the National Clinical Programme for Self-Harm and Suicide-related Ideation (NCPSHI) which comprises over 70 000 presentations. The second workstream will use a 15-year cohort of electronic patient records from the Mater Misericordiae University Hospital (MMUH) comprising over 30 491 presentations (900 aged 65 years and older) to collect more detailed information on characteristics of older people presenting with self-harm and suicidal ideation.Ethics and disseminationThis study has received full ethical approval. The Clinical Research Ethics Committee of the MMUH approved the MMUH workstream—Reference number: 1/378/2327 TMR. Ethical approval for the NCPSHI workstream has been granted by the University College Dublin’s Office of Research Ethics.Our findings will be disseminated via peer-review publications and presentations to the scientific community, along with reports for clinicians and policymakers.

ObjectivesTo explore primary care clinician perceptions of barriers and facilitators in delivering care for common mental disorders (CMD) before and after implementation of a consultation-liaison psychiatry service (Psychiatry in Primary Care (PIPC)) in government-operated primary care clinics and to explore the clinicians’ experience of the PIPC service itself.DesignThis longitudinal qualitative study was informed by the Normalisation Process Model and involved audiotaped semi-structured individual interviews with front-line clinicians before (Time 1) and after (Time 2) the PIPC intervention. The Framework Method was used in the thematic analysis of pre/post interview transcripts.SettingTwo government-operated primary care clinics in Penang, Malaysia.Participants17 primary care medical, nursing and allied health staff recruited purposely to achieve a range of disciplines and a balanced representation from both clinics.InterventionPsychiatrists, accompanied by medical students in small numbers, provided one half-day consultation visit per week, to front-line clinicians in each clinic over an 8-month period. The service involved psychiatric assessment of patients with suspected CMDs, with face-to-face discussion with the referring clinician before and after the patient assessment.ResultsAt Time 1 interviewees tended to equate CMDs with stress and embraced a holistic model of care while also reporting considerable autonomy in mental healthcare and positively appraising their current practices. At Time 2, post-intervention, participants demonstrated a shift towards greater understanding of CMDs as treatable conditions. They reported time pressures and the demands of key performance indicators in other areas as barriers to participation in PIPC. Yet they showed increased awareness of current service deficits and of their potential in delivering improved mental healthcare.ConclusionsDespite resource-related and structural barriers to implementation of national mental health policy in Malaysian primary care settings, our findings suggest that front-line clinicians are receptive to future interventions designed to improve the mental healthcare capacity.

Olympic Games have sometimes been considered as public health interventions capable of improving population health by encouraging increased physical activity levels. However, the evidence base does not appear to support this and is of poor quality, focussing on population level outcomes, usually related only to participation in organised sports. A new approach to research into the effects of such events is required focussing on the processes and mechanisms by which population physical activity levels might be increased enabling more effective use of such events in the future. Two separate processes, the ‘demonstration effect’ and ‘festival effect,’ have been proposed in Government guidance and are explored using qualitative methods in eight inactive people and four physical activity promotion specialists in Brighton & Hove. The findings appear to support the idea that watching elite athletes compete is unlikely to inspire participation among inactive people and may even discourage it by reducing self-efficacy as a result of the perceived competence gap. Despite this, positive attitudes towards the London Olympics were observed among inactive members of the public and a desire to become actively involved in the event. Examples of intention to continue participating in community events and physical activities as a result of positive experiences of Olympic related events were also observed.

Precision medicine is a new approach that considers differences in genes, environment, and lifestyle in an attempt to tailor treatments for individual patients. Psychiatry, as a discipline, has historically relied on clinical judgement and phenomenology-based diagnostic guidelines and has yet to take full advantage. This editorial provides an insight into the expanding role of precision medicine in psychiatry, both in research and clinical practice. It discusses the application of genetics and subgroup stratification in increasing response rates to therapeutic interventions, mainly focusing on major depressive disorder and schizophrenia. It presents an overview of machine learning techniques and how they are being integrated with traditional research methods within the field. In the context of these developments, while emphasizing the considerable potential for moving toward precision psychiatry, we also acknowledge the inherent challenges.

BackgroundA substantial number of people experiencing self-harm or suicidal ideation present to hospital emergency departments (EDs). In 2014, a National Clinical Programme was introduced in EDs in Ireland to standardise care provision. Internationally, there has been limited research on the factors affecting the implementation of care for people who present with mental health crises in EDs.MethodsThis qualitative study examined factors influencing the implementation of the National Clinical Programme for Self-harm and Suicide-related Ideation in 15 hospitals in Ireland from early (2015–2017) through to later implementation (2019–2022). Semi-structured interviews were conducted with staff involved in programme delivery, with the topic guide and thematic analysis informed by the Consolidated Framework for Implementation Research.ResultsA total of 30 participants completed interviews: nurse specialists (n=16), consultant psychiatrists (n=6), nursing managers (n=2), emergency medicine staff (n=2) and members of the national programme team (n=4). Enablers of implementation included the introduction of national, standardised guidance for EDs; implementation strategies led by the national programme team; and training and support for nurse specialists. The following inner-setting factors were perceived as barriers to implementation in some hospitals: limited access to a designated assessment room, delayed access to clinical input and poor collaboration with ED staff. Overall, these barriers dissipated over time, owing to implementation strategies at national and local levels. The varied availability of aftercare impacted providers’ ability to deliver the programme and the adaptability of programme delivery had a mixed impact across hospitals.ConclusionsThe perceived value of the programme and national leadership helped to advance implementation. Strategies related to ongoing training and education, developing stakeholder interrelationships and evaluation and monitoring have helped address implementation barriers and promote continued sustainment of the programme. Continued efforts are needed to support nurse specialists delivering the programme and foster partnerships with community providers to improve the transition to aftercare.

Background Presentation to the emergency department (ED) with self-harm provides an important opportunity for intervention. Aims To investigate characteristics and self-harm repetition risk of those discharged from the ED without a referral for mental health–related aftercare. Method Data on consecutive self-harm presentations to EDs for the years 2013–2019 ( n  = 55,770) were obtained from the National Self-Harm Registry Ireland. Multilevel Poisson and Cox regression models were estimated. Results Half of the self-harm presenters were discharged from the ED (49.8%) and almost half of them did not receive a mental health–related referral (46.8%). Receipt of a psychosocial assessment was associated with a 50% reduced risk of non-referral (IRR 0.54; 95% CI 0.51–0.57). Non-referral was also less likely for young people (< 18 years), presentations involving attempted hanging, persons with previous self-harm presentations, and in the latter half of the study period (2017–2019 vs. 2013–2016), but was more likely for those brought by ambulance, presenting outside 9 am–5 pm and admitted to an ED medical assessment unit. Of those not referred, 19.3% had a repeat presentation within 12 months, compared to 22.4% of those referred. No difference in repetition risk between these two groups was evident in adjusted analyses. Self-harm history had the strongest association with repetition, with highest risk among individuals with four or more previous presentations (HR 9.30, 95% CI 8.14–10.62). Conclusions The findings underline the importance of assessing all individuals who present with self-harm and highlight the need for comprehensively resourced 24hr services providing mental health care in the ED.

Research on psychotic illness is loosening emphasis on diagnostic stringency in favour of including a more dimensionally based conceptualization of psychopathology and pathobiology. However, to clarify these notions requires investigation of the full scope of psychotic diagnoses. The Cavan-Monaghan First Episode Psychosis Study ascertained cases of first episode psychosis across all 12 DSM-IV psychotic diagnoses via all routes to care: public, private or forensic; home-based, outpatient or inpatient. There was no arbitrary upper age cut-off and minimal impact of factors associated with variations in social milieu, ethnicity or urbanicity. Cases were evaluated epidemiologically and assessed for psychopathology, neuropsychology, neurology, antecedent factors, insight and quality of life. Among 432 cases, the annual incidence of any DSM-IV psychotic diagnosis was 34.1/100 000 of population and encompassed functional psychotic diagnoses, substance-induced psychopathology and psychopathology due to general medical conditions, through to psychotic illness that defied contemporary diagnostic algorithms. These 12 DSM-IV diagnostic categories, including psychotic disorder not otherwise specified, showed clinical profiles that were consistently more similar than distinct. There are considerable similarities and overlaps across a broad range of diagnostic categories in the absence of robust discontinuities between them. Thus, psychotic illness may be of such continuity that it cannot be fully captured by operational diagnostic algorithms that, at least in part, assume discontinuities. This may reflect the impact of diverse factors each of which acts on one or more overlapping components of a common, dysfunctional neuronal network implicated in the pathobiology of psychotic illness.

Participatory budgeting (PB) is a directly democratic, structured process in which community members propose, deliberate, and decide how to allocate a portion of a municipal or public budget. PB was created in Brazil to involve oppressed community members in funding public projects addressing their social justice needs. However, as PB spread around the world, the globalized version no longer emphasizes that goal. Severing that tie, coupled with the limited number of U.S. PB processes implemented and studied, has raised questions about PB’s ability to advance social justice in that country. Additionally, although (quantitative) studies have explored inclusion of oppressed community members and PB participation effects on political engagement, few studies have explored participants’ deliberative communicative behavior (and, specifically, its social justice characteristics) or perceptions of PB’s social justice capabilities. To fill those gaps, this applied, community-based, ethnographic study (employing participant observation, interviews, questionnaires, and document/artifact analysis) investigated whether (and how) two Denver, CO, grassroots PB processes (Auraria PB and Cole Has a Soul): (a) were characterized by socially just participant representation and deliberative communicative practices, (b) participants perceived PB as advancing social justice, and (c) PB affected participants’ political engagement and community connection. Results showed that a representative number of oppressed community members participated, facilitators’ communication about the Auraria PB process emphasized their inclusion and equitable treatment, and participants communicated explicitly about inclusion, equity, and empowerment, as well as about using PB to challenge unjust power systems. Additionally, Cole Has a Soul participants perceived PB as advancing social justice, and they formed durable relationships, but they demonstrated only minor changes in public participation, whereas Auraria PB participants did not form that perception or relationships but showed major changes toward justice-oriented citizenship. Discussion of the findings focuses on socially just PB practices (e.g., diverse participation and communication during deliberations); oppressed community members’ preference for relational, rather than instrumental, deliberation; PB’s limited utility as a form of deliberative activism, and PB’s grassroots origins engendering communication values that can advance social justice. Recommendations are offered for engaging oppressed community members in and using this collective decision-making process to advance social justice.