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Suicide is a leading cause of death in many Western countries. Suicidal ideation and behaviours can be symptoms of depression, but they are also seen in people with other mental health problems, such as bipolar affective disorder, psychosis, substance abuse disorders and adjustment disorders. They are also seen in people who present with psychological distress rather than any diagnosable mental disorder. The consequences of suicidal acts may be especially serious in people with diabetes given the accessibility of lethal means on the one hand, but also the heightened risk of developing complications in cases of severe self-neglect due to a more passive death wish on the other. In Chapter 2, we discussed the relationship between depression and endocrine disorders. Although depression is associated with suicidal ideations and behaviours, it will be these symptoms rather than a diagnosis of mood disorder that are the focus of this chapter.
Given the high rates of diabetes being comorbid with many mental health conditions, it is no surprise that diabetes is very common in mental health facilities and settings. When the mortality gap in severe mental illness is considered, along with the fact that cardiovascular diseases (including diabetes as a cardiovascular risk factor) contribute greatly to this mortality gap, the importance of acting to reduce the impact of suboptimally managed diabetes in these settings is clear. Specific measures may be required to ensure that patients in these settings receive the usual standard of care. Factors such as acuity of illness, lack of insight into both mental and physical health problems and practical difficulties in attending appointments may mitigate against optimised diabetes management. This chapter considers specific challenges particular to various settings, and we will consider some measures that may help to ameliorate or fully overcome these barriers to optimised care. We will consider specific measures in various types of residential units and other settings (including inpatient settings), and we will explore different initiatives that have been used to overcome these challenges and close the mortality gap
People who are transgender and gender non-conforming (TGNC) include people whose experienced gender is different from their assigned sex at birth, and they have specific healthcare needs. As the number of people identifying as TGNC is increasing internationally, it is important that endocrinologists, psychiatrists and indeed all health professionals have a good understanding of the issues related to the physical and mental healthcare of transgender people. People who identify as TGNC experience a disproportionate amount of violence, discrimination and stigma, and these factors contribute to poorer outcomes. There is also a high rate of comorbidity in young people who are TGNC, including mood disorders, eating disorders, suicidal ideation and self-harm. Compounding these mental health problems are the effects of social exclusion (including educational and employment), which often places TGNC people at risk, especially during transitioning. Transgender people should have access to expert guideline-based care that allows them to transition safely and to optimise their health and well-being.
Psychological symptoms commonly occur as a result of both thyroid and parathyroid disorders. Epidemiological studies evaluating the association between thyroid function and mood are heterogeneous in design and report varying results. The larger studies demonstrate no effect or an increase in depression with decreasing thyroid-stimulating hormone concentrations. There is growing evidence supporting the fact that thyroid function in psychiatric patients may be affected by the mental disorder itself, as well as by the medications used to treat that illness. Biochemical assessment of thyroid function and calcium concentrations should form part of the baseline assessment in those who present with new psychological symptoms. Once an abnormality is confirmed, further workup and treatment of the underlying endocrine disorder can be expected to alleviate and even reverse the psychological symptoms.
The majority of endocrine conditions can be successfully managed with long-term treatment, whether that be in the form of medication or lifestyle factors. In order for treatment to be effective, adherence to the treatment regime is key. Central to the concept of adherence is the presumption of an agreement between prescriber and patient about the prescriber’s recommendations. Non-adherence occurs when a patient does not initiate a new prescription, implement it as prescribed or persist with treatment. The World Health Organization (WHO) has posited that, in general, there are five dimensions to adherence, all of which can impact on rates of non-adherence: condition-related factors, health system factors, socio-economic factors, therapy-related factors and patient-related factors. While these dimensions are not entirely independent of each other, this serves as a useful means for organising the broad range of factors that can contribute to non-adherence.
The primary endocrine effectors of the stress response are located in the paraventricular nucleus of the hypothalamus, the anterior lobe of the pituitary gland and the adrenal gland. These structures are referred to as the hypothalamic–pituitary–adrenal (HPA) axis. In the setting of stress, corticotrophin-releasing factor induces the release of adrenocorticotropic hormone, which stimulates the synthesis and secretion of glucocorticoids from the adrenal gland. Glucocorticoids exert a wide range of effects and can influence cardiovascular function, immunity and inflammation, metabolism, reproduction and fluid volume. An important target organ is the brain, where glucocorticoids can affect neuronal differentiation and excitability, behavioral reactivity, mood and cognition. This regulatory system works in conjunction with the sympatho-adrenal medullary system, which releases catecholamines, including noradrenaline and adrenaline. These systems are crucial for dealing with both physiological and psychological stress and restoring our steady state. Inappropriate regulation of the stress response has been linked to a wide array of pathologies, including hypertension, diabetes, osteoporosis and psychological disorders. In this chapter, we will focus on disorders of the HPA axis and their effects on mental health.
Antipyschotic medications have benefited countless people with a wide variety of pyschiatric disorders. However, they do have potential to induce metabolic disturbances in a population that is known to have a high risk of cardiovascular disease. This can result in the development of metabolic syndrome and associated complications. There is a strong association between the presence of metabolic syndrome and developing type 2 diabetes. Patients with severe mental illness are at increased risk for metabolic syndrome, diabetes and cardiovascular disease. This is likely due to a number of factors, including higher rates of smoking, poor diet and disordered lifestyle with minimal physical activity. In addition, this population is less likely to receive prompt diagnosis and treatment for modifiable risk factors such as hypertension, dyslipidaemia and prediabetes. Overall, second-generation antipsychotic agents have a stronger association with these adverse effects compared to their first-generation counterparts, and previously untreated patients are at highest risk. With this in mind, healthcare professionals and patients should be well informed on this issue and institute close monitoring and prompt treatment of at-risk individuals.
Mental Health, Diabetes and Endocrinology examines the main areas of clinical overlap between endocrinology and mental health to address key clinical conundrums. Drawing on the most recent developments from literature and clinical practice, this book gives specific attention to the main areas where clinical conundrums and treatment challenges arise across endocrinology, psychiatry, psychology and primary care. Common challenges in this area include depression which can impact on the person's ability to self-care and to adhere to treatment with consequences for their morbidity and mortality; 'diabulaemia' associated with high mortality rates; obesity and associated mental disorders; cognitive impairment and mental capacity; anti-psychotic medications and their endocrine sequelae; and specific setting-related considerations. Mental Health, Diabetes and Endocrinology is a useful resource for the overlapping conditions across these specialities, and provides clinically-focussed evidence-based resources for all health care professionals who encounter these issues.
The COVID-19 pandemic has disrupted lives and livelihoods, and people already experiencing mental ill health may have been especially vulnerable.
Aims
Quantify mental health inequalities in disruptions to healthcare, economic activity and housing.
Method
We examined data from 59 482 participants in 12 UK longitudinal studies with data collected before and during the COVID-19 pandemic. Within each study, we estimated the association between psychological distress assessed pre-pandemic and disruptions since the start of the pandemic to healthcare (medication access, procedures or appointments), economic activity (employment, income or working hours) and housing (change of address or household composition). Estimates were pooled across studies.
Results
Across the analysed data-sets, 28% to 77% of participants experienced at least one disruption, with 2.3–33.2% experiencing disruptions in two or more domains. We found 1 s.d. higher pre-pandemic psychological distress was associated with (a) increased odds of any healthcare disruptions (odds ratio (OR) 1.30, 95% CI 1.20–1.40), with fully adjusted odds ratios ranging from 1.24 (95% CI 1.09–1.41) for disruption to procedures to 1.33 (95% CI 1.20–1.49) for disruptions to prescriptions or medication access; (b) loss of employment (odds ratio 1.13, 95% CI 1.06–1.21) and income (OR 1.12, 95% CI 1.06 –1.19), and reductions in working hours/furlough (odds ratio 1.05, 95% CI 1.00–1.09) and (c) increased likelihood of experiencing a disruption in at least two domains (OR 1.25, 95% CI 1.18–1.32) or in one domain (OR 1.11, 95% CI 1.07–1.16), relative to no disruption. There were no associations with housing disruptions (OR 1.00, 95% CI 0.97–1.03).
Conclusions
People experiencing psychological distress pre-pandemic were more likely to experience healthcare and economic disruptions, and clusters of disruptions across multiple domains during the pandemic. Failing to address these disruptions risks further widening mental health inequalities.
Psychiatrists have an essential role to play in promoting human rights in mental healthcare. The World Health Organization's QualityRights initiative, in partnership with different stakeholders, is improving the quality of psychiatric care in different countries.
We identified family risk profiles at 6 months using socioeconomic status (SES) and maternal mental health indicators with data from the Family Life Project (N = 1,292). We related profiles to executive function (EF) at 36 months (intercept) and growth in EF between 36 and 60 months. Latent profile analysis revealed five distinct profiles, characterized by different combinations of SES and maternal mental health symptoms. Maternal sensitivity predicted faster growth in EF among children in the profile characterized by deep poverty and the absence of maternal mental health symptoms. Maternal sensitivity also predicted higher EF intercept but slower EF growth among children in the profile characterized by deep poverty and maternal mental health symptoms, and children in the near poor (low SES), mentally healthy profile. Maternal sensitivity also predicted higher EF intercept but had no effect on growth in EF in the near poor, mentally distressed profile. In contrast, maternal sensitivity did not predict the intercept or growth of EF in the privileged SES/mentally healthy profile. Our findings using a person-centered approach provide a more nuanced understanding of the role of maternal sensitivity in the growth of EF, such that maternal sensitivity may differentially affect the growth of EF in various contexts.
Cyberbullying is increasingly recognised as a threat for young people’s mental health. Young people and their families may not know how to stay safe online or how to respond following unsafe internet experiences. This study aimed to examine Child and Adolescent Mental Health Service (CAMHS) staff perceived knowledge, practice and attitudes towards cyberbullying (CB) and internet safety (IS), and their training needs.
Methods:
A descriptive, survey design was used. 59 CAMHS clinicians completed a study specific online survey examining their knowledge, practice, attitudes and training needs regarding CB and IS. Frequency and descriptive statistics were conducted on participant responses.
Results:
Clinicians reported that risky internet behaviour and CB were frequent experiences reported by youth attending their clinical practice. Professionals were aware of potential adverse effects on the young person, including social withdrawal, low self-esteem, anxiety, self-injurious behaviour and suicidal thoughts. Training for young people on online behaviour and good digital citizenship skills was a highly endorsed preference. The majority of respondents felt CAMHS staff have a role in supporting families and managing IS and identified training and resource materials as strategies to assist them in this regard.
Conclusions:
Findings support a need for clinicians to regularly inquire about internet use, safety and adverse online experiences. The ongoing development of resources and training in CB and IS for CAMHS clinicians, children and caregivers is necessary. Further research is warranted due to the small sample size and the subjective nature of the current study.
Mental health problems are highly prevalent in China; however, China's mental health services lack resources to deliver high-quality care to people in need. Digital mental health is a promising solution to this short-fall in view of the population's digital literacy. In this review, we aim to: (i) investigate the effectiveness, acceptability, usability, and safety of digital health technologies (DHTs) for people with mental health problems in China; (ii) critically appraise the literature; and (iii) make recommendations for future research directions. The databases MEDLINE, PsycINFO, EMBASE, Web of Science, CNKI, WANFANG, and VIP were systemically searched for English and Chinese language articles evaluating DHTs for people with mental health problems in mainland China. Eligible studies were systematically reviewed. The heterogeneity of studies included precluded a meta-analysis. In total, 39 articles were retrieved, reporting on 32 DHTs for various mental health problems. Compared with the digital mental health field in the West, the Chinese studies targeted schizophrenia and substance use disorder more often and investigated social anxiety mediated by shame and culturally specific variants, DHTs were rarely developed in a co-production approach, and methodology quality was less rigorous. To our knowledge, this is the first systematic review focused on digital mental health in the Chinese context including studies published in both English and the Chinese language. DHTs were acceptable and usable among Chinese people with mental health problems in general, similar to findings from the West. Due to heterogeneity across studies and a paucity of robust control trial research, conclusions about the efficacy of DHTs are lacking.
Drop-out is an important barrier in treating post-traumatic stress disorder (PTSD) with consequences that negatively impact clients, clinicians and mental health services as a whole. Anger is a common experience in people with PTSD and is more prevalent in military veterans. To date, no research has examined if anger may predict drop-out in military veterans or first responders.
Aims:
The present study aimed to determine the variables that predict drop-out among individuals receiving residential treatment for PTSD.
Method:
Ninety-five military veterans and first responders completed pre-treatment measures of PTSD symptom severity, depression, anxiety, anger, and demographic variables. Logistic regression analyses were used to determine if these variables predicted drop-out from treatment or patterns of attendance.
Results:
Female gender was predictive of drop-out. However, when analysed by occupation female gender was predictive of drop-out among first responders and younger age was predictive of drop-out in military participants. Anger, depression, anxiety and PTSD symptom severity were not predictive of drop-out in any of the analyses. No variables were found to predict attendance patterns (consistent or inconsistent) or early versus late drop-out from the programme.
Conclusion:
These results suggest that although anger is a relevant issue for treating PTSD, other factors may be more pertinent to drop-out, particularly in this sample. In contrast with other findings, female gender was predictive of drop-out in this study. This may indicate that in this sample, there are unique characteristics and possible interacting variables that warrant exploration in future research.
The relationships between offspring depression profiles across adolescence and different timings of parental depression during the perinatal period remain unknown.
Aims
To explore different timings of maternal and paternal perinatal depression in relation to patterns of change in offspring depressive mood over a 14 year period.
Method
Data were obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC). Parental antenatal depression (ANTD) was assessed at 18 weeks gestation, and postnatal depression (PNTD) at 8 weeks postpartum. Population-averaged trajectories of offspring depressive symptoms were estimated using the Short Mood and Feelings Questionnaire (SMFQ) on nine occasions between 10 and 24 years of age.
Results
Full data were available for 5029 individuals. Offspring exposed to both timings of maternal depression had higher depressive symptoms across adolescence compared with offspring not exposed to ANTD or PNTD, characterised by higher depressive symptoms at age 16 (7.07 SMFQ points (95% CI = 6.19, 7.95; P < 0.001)) and a greater rate of linear change (0.698 SMFQ points (95% CI = 0.47, 0.93; P = 0.002)). Isolated maternal ANTD and to a lesser extent PNTD were also both associated with higher depressive symptoms at age 16, yet isolated maternal PNTD showed greater evidence for an increased rate of linear change across adolescence. A similar pattern was observed for paternal ANTD and PNTD, although effect sizes were attenuated.
Conclusions
This study adds to the literature demonstrating that exposure to two timings of maternal depression (ANTD and PNTD) is strongly associated with greater offspring trajectories of depressive symptoms.
The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries.
Methods
Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents.
Results
3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2–4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness.
Conclusion
ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.