Assessing need and advancing psychiatric care in Irish prisons

The mental healthcare of prisoners is seen as a public health challenge internationally. Emerging research has highlighted higher rates of mental illness and intellectual disabilities in prisons as compared to general population prevalence across multiple jurisdictions. This is reflected in higher rates of adverse outcomes such as suicide rates amongst prisoners. Psychiatrists visiting prisons play a key role in providing clinical guidance and expertise in managing those with mental illness in prison, identifying those that need diversion from the criminal justice system and highlighting those that may need additional support so as to reduce suicide risk. This is done whilst operating in an environment with specific clinical, legal and ethical challenges. As presented in this thesis, Irish prisons have higher rates of multiple vulnerabilities including mental illness, substance misuse, homelessness and intellectual disabilities as compared to the general population. Advances in screening practices and service development are needed to facilitate diversion. This thesis describes the development of care pathways to manage the care of prisoners with intellectual disabilities and prisoners on hunger strike. These aim to advance care in prisons within Ireland and internationally

Autism spectrum disorder and Irish prisoners

The global prevalence of autism spectrum disorder (ASD) is 62/10 000 (Elsabbagh et al. 2012). A large cross-sectional study of schoolchildren (Sweeney et al. 2016) estimated the prevalence of ASD as 1% in Irish mainstream school

Long COVID: the elephant in the room

The COVID-19 pandemic and long COVID present the greatest challenges to health and mental health services in a generation. How we respond to these tests will determine the future of clinical care and the quality of life of millions of people for many years to come

Does remdesivir have any neuropsychiatric adverse effects?

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Is there a human legal right to mental health?

While recent decades have seen an increased focus on the idea of rights to health and health care, these ideas were particularly advanced by the United Nations (UN) Convention on the Rights of Persons with Disabilities in 2006 and the importance that the World Health Organization attached to the essential role of law in advancing the right to health in 2017. The UN made explicit the rights of persons with mental illness in 1991 with its Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care. There are, however, potential disadvantages with legalistic and rights-based approaches to health and health care: protecting rights can be expensive (especially in courts of law), result in paradoxical unfairness (owing to unequal access to legal systems), diminish efficiency and increase opportunity costs (as scarce resources are diverted from care provision), lead to conflict between rights (such as rights to liberty and treatment in severe mental illness) and prioritise individual rights over families and communities in ways that are not always accepted in certain societies. Despite these issues, human rights still offer a credible, logical and generally helpful approach to issues of injustice, such as the unequal distribution of health care. Against this background, India commenced what is effectively the world’s largest experiment in rights-based health care in 2018 when its Mental Healthcare Act, 2017 granted a legally binding right to mental health care to India’s population of over 1.3 billion people, one sixth of the planet's population. The legislation states that ‘every person shall have a right to access mental healthcare and treatment from mental health services run or funded by the appropriate Government’. Realising this right will be complex and challenging in practice, but the experience in India will help inform future debates about the usefulness of rights to health and health care in improving the experiences of the physically and mentally ill around the world, especially among vulnerable groups such as older adults, children, the homeless and others

Hunger strikes in prison: a legal perspective for psychiatrists

Hunger strikes in a custodial setting are complex to manage clinically, with associated legal and ethical complexities. Hunger strikes in Irish prisons have received, and are likely to continue to be the focus of, considerable media attention. Whilst there is an internationally accepted consensus ethical position, there is limited legal guidance available for psychiatrists to draw upon in such cases. In this paper, we review recent case-law and discuss the legal considerations in the management of prisoners on hunger strike

Does lent affect rates of deliberate self-harm?

Background. Research has shown that religious affiliation has a protective effect against deliberate self-harm. This is particularly pronounced in periods of increased religious significance, such as periods of worship, celebration, and fasting. However, no data exist as to whether this effect is present during the Christian period of Lent. Our hypothesis was that Lent would lead to decreased presentations of self-harm emergency department (ED) in a predominantly Catholic area of Ireland. Methods.Following ethical approval,we retrospectively analysed data on presentations to the ED o f University Hospital Limerick during the period of Lent and the 40 days immediately preceding it. Frequency data were compared using Pearson’s chi-squared tests in SPSS. Results.There was no significant difference in the over all number of people presenting to the ED with self-harm during Lent compared to the 40 days preceding it (χ2=0.75,df=1,p > 0.05),and there was no difference in methods of self-harm used.However, there was a significant increase in attendances with self-harm during Lent in the over 50’sage group (χ2 = 7.76,df = 1,p = 0.005). Conclusions. Based on our study, Lent is not a protective factor for deliberate self-harm and was associated with increased presentations in the over 50’ sage group. Further large-scale studies are warranted to investigate this finding as it has implications for prevention and management of deliberate self-harm

What is the role of doctors in respect of suspects with mental health and intellectual disabilities in police custody?

People with severe mental illness and intellectual disabilities are overrepresented in the criminal justice system worldwide and this is also the case in Ireland. Following Ireland's ratification of the United Nations' Convention on the Rights of People with Disabilities in 2018, there has been an increasing emphasis on ensuring access to justice for people with disabilities as in Article 13. For people with mental health and intellectual disabilities, this requires a multi-agency approach and a useful point of intervention may be at the police custody stage. Medicine has a key role to play both in advocacy and in practice. We suggest a functional approach to assessment, in practice, and list key considerations for doctors attending police custody suites. Improved training opportunities and greater resources are needed for general practitioners and psychiatrists who attend police custody suites to help fulfill this role

A focus group study of Indian psychiatrists’ Views on electroconvulsive therapy under India’s mental healthcare Act 2017: ‘The ground reality is different’

Background: India’s Mental Healthcare Act, 2017 (MHCA) greatly restricts the use of electroconvulsive therapy (ECT) in minors and bans unmodified ECT. Indian psychiatrists have raised concerns that these measures may deprive certain patients of life‑saving treatment. This study describes the perspectives of Indian psychiatrists on how ECT is dealt with in the legislation. Methods: We conducted nine focus groups in three Indian states. We explored the positive and negative implications of the MHCA and discussed its implementation, especially in relation to ECT. Results: Many of the themes and concerns commonly discussed in relation to ECT in other jurisdictions are readily apparent among Indian psychiatrists, although perspectives on specific issues remain heterogeneous. The one area of near‑universal agreement is Indian psychiatrists’ affirmation of the effectiveness of ECT. We identified three main areas of current concern: the MHCA’s ban on unmodified ECT, ECT in minors, and ECT in the acute phase. Two broad additional themes also emerged: resource limitations and the impact of nonmedical models of mental health. We identified a need for greater education about the MHCA among all stakeholders. Conclusion: Core concerns about ECT in India’s new legislation relate, in part, to medical decisions apparently being taken out of the hands of psychiatrists and change being driven by theoretical perspectives that do not reflect “ground realities.” Although the MHCA offers significant opportunities, failure to resource its ambitious change

The neurology–psychiatry interface in epilepsy

Epilepsy and mental illness have a bidirectional association. Psychiatrists are likely to encounter epilepsy as comorbidity. Seizures may present as mental illness. Equally, the management of psychiatric conditions has the potential to destabilise epilepsy. There is a need for structured epilepsy awareness and training amongst psychiatrists. This paper outlines key considerations around diagnosis, treatment and risk while suggesting practical recommendations