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BACKGROUND People with severe mental illness (SMI) are more likely to suffer from physical health conditions than the general population, with a lower life expectancy of up to 18 years. Little is known about the experience of people with SMI using digital health interventions (DHIs) to support their physical health, and whether they perceive such interventions as beneficial. OBJECTIVE We explored how people with SMI use DHIs to support their physical health, the acceptability, factors effecting use and any perceived impact on physical health. METHODS A mixed methods approach was used, delivered in three stages. Stage 1 online survey of people with SMI; Stage 2 interviews with a sub-sample of participants from Stage 1; Stage 3 stakeholder workshops with people with SMI, clinical staff, carers, voluntary sector staff and commissioners. Study design, data collection and analyses were co-produced with two Experts by Experience with lived experience of SMI. RESULTS Stage 1 results revealed that participants were generally satisfied with the quality of DHIs available to them. The most popular DHIs were targeted at diet, exercise, and weight management. Stage 2 results suggested participants experienced a number of barriers and facilitators to use of DHIs. Factors that encouraged use included simplicity, passivity, and data-linkage. Concerns included costs, data security and reliability of information. Positive impacts included accountability, encouragement, and tangible physical health benefits. Self-awareness and autonomy of care were also perceived to increase. Mental health impacted engagement with DHIs: low mood often hindered motivation to engage with devices, and information produced by these devices could be perceived as triggering. Findings of stage 2 were corroborated in stage 3: workshop participants reported that DHIs could be a useful tool to monitor physical health but could not replace contact with clinical services. The two could be used in conjunction, to expand the benefit of clinical appointments and encourage service user autonomy. Participants appreciated being able to share physical health data in appointments and suggested that data sharing between service user and care team could be a positive feature. Participants sought clinical guidance and recommendations for which devices they could use to monitor or support their physical health. CONCLUSIONS Popular DHIs for supporting physical health were considered useful and acceptable by people with SMI and may be used as an extension of clinical care, giving people with SMI a sense of control and involvement in their own health. The specific needs and priorities of people with SMI should be considered both in developing and recommending interventions.

Objectives: Autism spectrum disorders and personality disorders are spectrum conditions with shared clinical features. Despite similarities, previous attempts to synthesise literature on co-existing prevalence and shared traits have employed a unidirectional focus, assessing personality characteristics of individuals with an autism spectrum disorder diagnosis. Here, we assess the prevalence of autism spectrum disorder diagnosis and/or traits among persons diagnosed with a personality disorder. Methods: We systematically reviewed the English-language literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, according to a pre-registered protocol (PROSPERO: CRD 42021264106). Peer-reviewed quantitative studies reporting the prevalence of autism spectrum disorder diagnosis or traits in persons with an established personality disorder diagnosis were included. Studies were critically appraised using the Appraisal tool for Cross-Sectional Studies. Results: Fifteen studies were identified, including 72,902 participants (median: 48, interquartile range: 30–77). Diagnoses included borderline, schizotypal and obsessive-compulsive personality disorders, and cohorts with unspecified personality disorder diagnoses. There was significant heterogeneity in diagnostic methodology and assessment tools used. We identified preliminary evidence of an increased prevalence of co-existing autism spectrum disorder diagnosis and traits among those diagnosed with a personality disorder, although significant limitations of the literature were identified. Conclusion: Our research suggests clinicians should consider conducting a careful developmental assessment when assessing service-users with possible or confirmed personality disorder. Future research directions may include larger studies featuring clinical control groups, an exploration of shared and differentiating behavioural-cognitive features of the two conditions, and investigation into potentially shared aetiological factors. Research investigating demographic factors that may contribute to potential diagnostic overshadowing would also be welcomed.

AimsTo provide a fresh insight into the extent digital phenotyping methods have been employed to measure or detect social behaviour in patients with SMIs; with a closer look at those used in Bipolar Disorder (BD); to give findings on the validity, reliability, acceptability and tolerability of these digital phenotyping methods.MethodsUsing specified search terms relating to digital phenotyping metrics and terms related to SMIs, a thorough literature search strategy for studies was employed across the following electronic databases: PubMed, Embase, and PsychINFO - from inception to July 2021.Included studies employed digital phenotyping methods, collecting either passive, active or mixed-modal data, which in principle reported metrics representing social behaviour on patients with an SMI. Here we present a preliminary analysis of studies reporting results for patients with BD, with a particular focus on tolerability and acceptability.ResultsOf 4,646 records initially screened, a subgroup of 9 studies (n = 474) directly focusing on patients with BD are reported here. Across the studies, we find a modest adherence rate towards these applications by patients, ranging from 72.6% to 89.2%. Methods used by the studies include the frequency of phone calls and text messages, and self-reported and observer ratings of social and interpersonal functioning. The collection of such digital phenotyping data appears tolerable and acceptable to participants with BD, with patients reporting them to be supportive and only mildly intrusive.ConclusionOur preliminary analysis suggests that digital phenotyping of social behaviour may be acceptable and tolerable to participants with Bipolar Disorder. In an increasingly digital world, digital phenotyping methods of social behaviour may assist physicians with clinical assessment and prediction of clinical outcomes including relapse. Future analyses will assess the reliability and validity of the data that such methods yield, and their potential therapeutic value.

SummaryDigital phenotyping (such as using live data from personal digital devices on sleep, activity and social media interactions) to monitor and interpret people's current mental state is a newly emerging development in psychiatry. This article offers an imaginary insight into its future potential for both psychiatrist and patient.

Technological advances offer the potential to better characterise the symptoms and mechanisms of psychiatric disorders. This review provides an overview of how remote monitoring might inform understanding of mood and anxiety disorders, and may be used by clinicians to predict clinical outcomes and treatment response. The review also discusses salient ethical issues and the field’s future directions. A range of psychological and physiological remotely-collected data have been associated with clinical symptoms and outcomes, including momentary self-report, actigraphy, geolocation and heart-rate variability. Remote monitoring has shown promise in phenotyping, predicting symptoms and clinical severity, predicting treatment response and has informed psychological models of anxiety disorders. Remote monitoring is a diverse field involving the collection of clinically relevant data in naturalistic settings. Although facing significant practical and ethical challenges, it has shown much potential in developing understanding in the context of mood and anxiety disorders.

A previously healthy 51-year-old woman presented to the ED with a one-week history of malaise, myalgia, unsteadiness, and an intermittent mild headache. Physical examination revealed neurological signs including a broad-based gait and bilateral low amplitude tremor. Laboratory testing of electrolytes revealed acute severe hyponatremia (115 mmol/L). Further, history-taking revealed increased urinary frequency following regular consumption of an over-the-counter detoxification tea product. The patient made a good recovery following admission to the intensive care unit. We identify similar cases in the literature and explore potential causal mechanisms. This case highlights the importance of enquiring about the use of supplementary health products when taking a history, and specifically identifies a growing number of reports of acute severe hyponatremia following the use of “detox teas”.

The normal spectrum trait measures of mood instability and impulsivity are implicated in and comprise core symptoms of several psychiatric disorders. A bidirectional relationship between these traits and sleep disturbance and circadian rhythm dysfunction has been hypothesised, although has not been systematically assessed using objective measures in naturalistic settings. We systematically reviewed the literature following PRISMA guidelines, according to a pre-registered protocol (PROSPERO: CRD 42018108213). Peer-reviewed quantitative studies assessing an association between actigraphic variables and any measure of mood instability or impulsivity in participants aged 12–65 years old were included. Studies were critically appraised using the AXIS tool. Twenty-three articles were retained for inclusion. There was significant heterogeneity in the selection and reporting of actigraphic variables and metrics of mood instability and impulsivity. We identified emerging evidence of a positive association between circadian rest-activity pattern disturbance and delayed sleep timing with both mood instability and impulsivity. Evidence for an association with sleep duration, sleep efficiency or sleep quality was inconsistent. Future research should focus on longitudinal intra-individual associations to establish the directionality between these measures and may lead to the development of chronotherapeutic interventions for a number of psychiatric disorders.

Why are the diagnostic criteria of some psychiatric disorders standardised by gender while others are not? Why standardise symptom questionnaires by gender but not other personal characteristics such as ethnicity, socioeconomic class or sexual orientation? And how might our changing attitudes towards gender, born from scientific research and changing societal narratives, alter our opinion of these questions? This paper approaches these dilemmas by assessing the concept of diagnosis in psychiatry itself, before analysing two common approaches to the study of psychiatric diagnosis; the naturalist and constructivist views. The paper assesses the relative merits and significance of each, before turning its attention to the nature of gender and its relevance to psychiatry. The paper introduces a framework to approach gender-based diagnostic bias and concludes by drawing a distinction between qualitative and quantitative standardisation, arguing that gender standardisation of psychiatric diagnoses is ethically justified in the former but not the latter.

As the prevalence of dementia increases across the Western world, there is a growing interest in advance care planning, by which patients may make decisions on behalf of their future selves. Under which ethical principles is this practice justified? I assess the justification for advance care planning put forward by the philosopher Ronald Dworkin, which he rationalises through an integrity-based conception of autonomy. I suggest his judgement is misguided by arguing in favour of two claims. First, that patients with dementia qualify for some right to contemporary autonomy conceptualised under the ‘sense of liberty’ it provides. Second, that respecting precedent autonomy, such as an advance care plan, is not essential to Dworkin’s integrity-based account of autonomy. Together, my claims problematise the practice of using advance decisions in the context of dementia.

AimsPrevious research suggests the prevalence of mental health conditions among medical inpatients may be as high as 38%. Anecdotally, junior doctors report lacking the confidence, knowledge and skills to assess and treat patients with psychiatric conditions. Identifying this unmet need offers potential to improve standards of care and achieve parity of esteem between psychiatric and medical conditions within the general hospital. Aims:To assess self-reported preparedness of newly-qualified Foundation Doctors to care for patients with acute or chronic psychiatric symptoms in comparison to physical health conditions.MethodIn September of each year (2017, 2018, 2019), a survey was cascaded to all incoming Foundation Year 1 Doctors. For each respective year there were 1673, 961 & 1301 respondents. Respondents were asked to rate their agreement with statements on a Likert scale. Statements pertaining to mental health included “a) I am competent in acute mental health care provision, b) I am competent in chronic mental health care provision” and “I feel confident in prescribing the following drugs; c) drugs for mental health problems”. Comparison statements assessed confidence caring for medically unwell patients, performing practical procedures and prescribing drugs for physical health conditions.ResultPreparedness for acute and chronic mental health were lower than both physical health comparison items; preparedness to care for patients with critical illness (acute: r = 0.794, p < 0.001, chronic: r = 0.556, p < 0.001) and preparedness to perform practical procedures (acute: r = 0.724, p < 0.001, chronic: r = 0.433, p < 0.001).Confidence prescribing mental health drugs was lower than all other comparison items (simple analgesia: r = 0.854, bronchodilators: r = 0.789, antimicrobials: r = 0.772, inhaled steroids: r = 0.720, intravenous fluids: r = 0.702, oral anti-diabetics: r = 0.611, anticoagulants: r = 0.515, narcotics: r = 0.514, insulin: r = 0.206; p < 0.001)ConclusionThese results identify a disparity in foundation doctors’ self-reported preparedness to treat acute and chronic mental health conditions and prescribe psychotropic medications, compared to a variety of physical health domains. To our knowledge this is the first large-scale study to empirically test a potential discrepancy between newly-qualified doctors’ preparedness to treat patients’ mental and physical health needs. Medical school education and foundation training may therefore present a fruitful opportunity to improve care for patients with psychiatric conditions within general hospital settings.

AimsTo assess concordance with guidelines on monitoring vitamin D levels and prescribing prophylaxis or replacement. To assess the association between the implementation of local guidelines and prevalence of vitamin D deficiency.BackgroundVitamin D deficiency is associated with various adverse health outcomes including osteoporosis, fractures and myalgia. Most recently, vitamin D deficiency has been hypothesised as a risk factor for severe COVID-19 infection. Risk factors for vitamin D deficiency include incarceration, ethnicity, diet and a diagnosis of psychiatric disorder. Vitamin D deficiency is known to be prevalent among individuals within forensic mental health institutions.Local Trust guidelines advise that vitamin D levels should be checked within one-month of hospital admission, followed by checks at three-monthly intervals. Recommendations for prescribing depend on patients’ vitamin D levels; deficient (MethodMedical records, laboratory results and drug charts were assessed for a total of 75 patients across 15 wards. Data were collected using a standardised audit tool, including; date of admission, admission vitamin D level, most recent vitamin D level and the dose and frequency of vitamin D prescribed.Result76.4% of patients had their vitamin D levels checked within one month of admission. 66.7% of patients had their vitamin D checked within the last 3 months. For patients with an admission vitamin D level recorded, 43.6% had deficient vitamin D levels, 43.6% had insufficient levels and 12.7% had adequate levels. For patients with a more recent serum vitamin D level, 14.5% had deficient levels, 38.7% had insufficient levels and 46.8% had adequate levels. For patients with a documented serum vitamin D level, 21.4% were prescribed the correct dose, 22.9% were under-dosed, 14.3% were over-dosed and 41.4% received no dose where guidelines suggested they should.ConclusionComparison of admission and most recent vitamin D levels suggests a general improvement in prevalence of vitamin D deficiency associated with the implementation of local guidelines. However, we identify significant areas for improvement. A substantial proportion of patients lacked admission or regular monitoring of vitamin D levels and a substantial proportion of patients were under-dosed or received no dose where guidelines suggested they should have. We propose that better concordance with guidelines may improve clinical outcomes further. This may prove especially important during the COVID-19 pandemic, given a potential association between vitamin D deficiency and severity of respiratory infection.

A previously fit and well 37-year-old male healthcare worker presented with confusion, psychotic symptoms and a suicide attempt in the context of a new COVID-19 diagnosis. Following surgical interventions and an extended admission to the intensive care unit, he made a good recovery in terms of both his physical and mental health. A number of factors likely contributed to his presentation, including SARS-CoV-2 infection, severe insomnia, worry, healthcare worker-related stress, and the unique social and psychological stressors associated with the COVID-19 pandemic. This case highlights the need to further characterise the specific psychiatric sequelae of COVID-19 in community settings, and should remind general medical clinicians to be mindful of comorbid psychiatric symptoms when assessing patients with newly diagnosed COVID-19.

There is increasing interest in clinical prediction models in psychiatry, which focus on developing multivariate algorithms to guide personalized diagnostic or management decisions. The main target of these models is the prediction of treatment response to different antidepressant therapies. This is because the ability to predict response based on patients' personal data may allow clinicians to make improved treatment decisions, and to provide more efficacious or more tolerable medications to the right patient. We searched the literature for systematic reviews about treatment prediction in the context of existing treatment modalities for adult unipolar depression, until July 2019. Treatment effect is defined broadly to include efficacy, safety, tolerability and acceptability outcomes. We first focused on the identification of individual predictor variables that might predict treatment response, and second, we considered multivariate clinical prediction models. Our meta-review included a total of 10 systematic reviews; seven (from 2014 to 2018) focusing on individual predictor variables and three focusing on clinical prediction models. These identified a number of sociodemographic, phenomenological, clinical, neuroimaging, remote monitoring, genetic and serum marker variables as possible predictor variables for treatment response, alongside statistical and machine-learning approaches to clinical prediction model development. Effect sizes for individual predictor variables were generally small and clinical prediction models had generally not been validated in external populations. There is a need for rigorous model validation in large external data-sets to prove the clinical utility of models. We also discuss potential future avenues in the field of personalized psychiatry, particularly the combination of multiple sources of data and the emerging field of artificial intelligence and digital mental health to identify new individual predictor variables.

Are medical schools doing enough to support their introverted students, and can a quiet doctor excel in medicine?

How the “voluntourism” industry affects local communities and how you can have an ethical experience that benefits not only you but your host country too

The outcome of the junior doctor contract negotiations could have a major impact on current medical students’ pay and working conditions. Below is a timeline of the major flashpoints, and an overview of the changes being proposed. October 2013 —Talks begin between NHS Employers and the BMA NHS Employers, acting on behalf of the government, and the BMA, the trade union for doctors in the United Kingdom, start discussing the terms of the new contract, with a view to implementing it by April 2015. October 2014 —BMA walks away from the negotiation table After a year of negotiations the BMA pulls out of talks citing concerns about patient safety, doctors’ welfare, and a lack of evidence underpinning the changes. Kitty Mohan, co-chair of the junior doctors’ committee at the time said the contract proposals lack a “fundamental grasp” of the way in which NHS staff work and that doctors are “upset and frustrated” with how their work was not being “valued, noticed and recognised.” November 2014 —DDRB steps in After the breakdown of talks, the government commissioned the Review Body on Doctors’ and Dentists’ Remuneration (DDRB) to review the contract proposals. July 2015 —DDRB report published The DDRB report says that the current contract is no longer fit for purpose and is hindering the achievement of the NHS’s goals to improve patient care and outcomes, and is unaffordable in the current financial climate. The report includes several recommendations that upset junior doctors (box 1). NHS Employers in England agreed that the DDRB report should be the basis for finalising new contractual arrangements. NHS Northern Ireland, Scotland, and Wales all rejected the new contract and have decided not to enforce it. …

The chair of the health select committee talks about the future of the NHS and her career in medicine and politics

You won’t be able to watch medical dramas on television without cringing You’ll never be able to watch Holby City again without noticing an inaccurate medical reference or irresponsible procedure. Whether it is doctors living in caravans in hospital car parks, medical staff performing operations on their parents, or clinicians being able to diagnose patients at first sight, real medicine simply isn’t like that. Likewise, don’t be fooled by the endless tracheostomies that screenwriters entertain viewers with—you’ll probably see more in one episode than in your entire time at medical school. ### Nobody knows the right way to use a stethoscope Whether it is which way to position the earpieces, or telling which side is the diaphragm or bell, at some point everyone gets flummoxed by this pesky medical essential. It might be the symbol of your medical student status, but that won’t prevent you being left prodding at a patient’s thorax, desperately trying to hear anything that resembles a heartbeat. ### Family and friends will ask you for medical advice Even though you’ll only have covered a term’s worth of material when you go home at Christmas, people will assume that you are …

The regulator has invited students to give feedback on new guidance on maintaining professional standards

BOOK REVIEWS Cracker Times and Pioneer Lives: The Florida Reminiscences of George Gillett Keen and Sara Pamela Williams. Edited by James M. Denham and Canter Brown Jr. (Columbia: University of South Carolina Press, 2000. Pp. xvii, 215. Illustrations, maps. $39.95.) Colonial Plantations and Economy in Florida. Edited by Jane G. Landers. (Gainesville: University Press of Florida, 2000. Pp. 219. Illustrations, maps. $49.95.) Other works by the editors of these collections have generated a growing interest in colonial and frontier Florida. Jane G. Landers's Black Society in Spanish Florida (1999) and James M. Denham's A Rogue's Paradise: Crime and Punishment in Antebellum Florida, 1821-1861 (1997) connect Florida history to two larger worlds of historical interpretation: the Spanish plantation era and the frontier era of the Old Southwest. But these two larger worlds have important connections to the early republic as well, for struggles over control of Florida were the source of much contention between the United States and Spain and contributed to the rise of Andrew Jackson. In addition, the expanding frontier of the plantation South revived slavery, and, in future years, would provoke conflict with Mexico and force the issue of slavery expansion. Understanding the world of one of these frontier regions, Florida, contributes to our knowledge of these larger processes. These books contribute to this growing academic concern in significant, but very different ways. Cracker Times and Pioneer Lives consists of the reminiscences of two Florida pioneers from the frontier era, both collected in the late nineteenth century. George Gillett Keen first settled in northern Florida as a child, when his parents relocated from Georgia in the 1820s. Much of his life experience was as a Floridian, and in 1899 the Florida Index, published in Lake City, began to publish his reminiscences in serial form. The editors have compiled these essays as part one of this volume. While Lake City, a town in northeastern Florida near the Georgia border, might seem an obscure locale, Keen's experiences read with a remarkable familiarity for those already familiar with the Old Southwest. His tales of unsolved murders, duels, and fistfights, along with the obligatory yarns of political and legal trickery, are all exemplary of an old Southwest tradition of storytelling filled with wit, irony, and satire. With one exception, Keen reminisced about events between the 1830s and the 1850s. These reminiscences can be read as the ramblings of an old settler, but they are much more. His stories, most committed to print only at the beginning of the twentieth century, were decades old, preserved through an oral culture that perpetuated itself late in the evening around campfires and hearths. Keen's reminiscences are an artifact of a culture of storytelling that was replaced by print and never took the same form. In addition to the storytelling of the Old Southwest, Keen related his experiences in the Second Seminole War from 1835 to 1842. As a youth of only eight years when the war broke out, Keen's experiences were quite personal, for friends and relatives were involved on both sides of the conflict. Keen described attacks and counterattacks, mostly from his own memory. Fortunately, in this edition, the editors have provided annotations verifying or correcting incidents and dates. Keen's perceptions of the war are influenced by an unfortunately common antipathy to the Seminoles and Creeks; however, having witnessed a violent conflict as a youth and lost friends and relatives, the prejudice is unsurprising. Equally unsurprising and unfortunate is his use of derogatory epithets for African Americans; however, the editors have done a fine job of contextualizing Keen's language without attempting to justify it. The second, and briefer, part of Cracker Times and Pioneer Lives consists of the diary of Sara Pamela Williams, born near Picolata (not far from St. …

There is a marked disparity between medical intuitions and philosophical argument about euthanasia. In this paper I argue that the following objections can be raised. First, medical intuitions are against it and this is an area in which judgement and sensitivity are required in that death is a unique and complex process and the patient has many needs including the need to know that others have not discounted his or her worth. Also, part of the moral constitution of a good doctor is a devotion to the protection and preservation of life whatever reasons are produced to dissuade her. Finally, we do not know what the final events of a person's life might hold.