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The Royal College of Psychiatrists books Reviewed in 2010

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Schizophrenia: The NICE Guideline on Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Updated edition)
National Collaborating Centre for Mental Health (NCCMH)
Edition: 2010, Updated Version
Format: Paperback & CD ROM
ISBN: 9781854334794
Publishers: Royal College of Psychiatrists
Price: £35
Publication Date: April 2010

This guideline on Schizophrenia, commissioned by NICE and developed by the National Collaborating Centre for Mental Health, sets out clear, evidence- and consensus-based recommendations for healthcare staff on how to manage and treat schizophrenia in adults.
This guideline is an update of the previous guidance (full guideline published 2003), which was the first guideline that NICE ever produced and which was judged to be superior to other schizophrenia guidelines in an international survey.
updated guideline provides new clinical and economic evidence about the use of psychological and psychosocial interventions and antipsychotic drugs and new reviews of early intervention services, primary care and treatment for physical health problems. There are also new chapters on access and engagement for minority ethnic groups and on service user and carer experience of treatment and care for schizophrenia.
List of the other NICE mental health guidelines

"The original NICE schizophrenia guideline was of remarkable superiority in its methodological quality compared with other national treatment guidelines throughout the world. This updated version of the guideline is yet again of exceptional quality, demonstrating rigour in its development, clarity in its presentation and noticeable breadth in its coverage. Whether dealing with drug and psychosocial treatments, patient experience, ethnic minorities or health economics, based on current evidence the guideline opens up new vistas on the best treatments available for people with schizophrenia. A landmark of schizophrenia practice guidelines."
- Professor Wolfgang Gaebel,of Psychiatry, Department of Psychiatry and Psychotherapy of the Heinrich-Heine-University, Düsseldorf and Past President German Psychiatric Association (DGPPN)

“There are still many inequalities that exist in mental health, some of which are particularly pertinent for people with schizophrenia. These inequalities are even more difficult to overcome for people from ethnic minorities, who often gain access to help at a very late stage. This guideline is the first to tackle these problematic issues by undertaking a full evidence review of the problems faced by people from African Caribbean groups in accessing UK services. I can thoroughly recommend this world class guideline to anyone with an interest in the evidence about what works for people with schizophrenia".
- Professor Dinesh Bhugra, President, Royal College of Psychiatrists (2008-2011)

Correction

Unfortunately one appendix that was supposed to be included on the data CD-ROM that accompanies Schizophrenia (Updated edn), was missed out. It can however be downloaded for free.
NICE Mental Health Guidelines
These guidelines fromset out clear recommendations, based on the best available evidence, for health care professionals on how to work with and implement physical, psychological and service-level interventions for people with various mental health conditions.
The book containsthe full guidelines that cannot be obtained in print anywhere else. It brings together all of the evidence that led to the recommendations made, detailed explanations of the methodology behind their preparation, plus an overview of the condition covering detection, diagnosis and assessment, and the full range of treatment and care approaches.
The accompanying CD-ROM contains all the data used as evidence, including:
Included and excluded studies.
Profile tables that summarise both the quality of the evidence and the results of the evidence synthesis.
All meta-analytical data, presented as forest plots.
Detailed information about how to use and interpret forest plots.

Contents

1. PREFACE
1.1National guideline
1.2The national schizophrenia guideline
2. SCHIZOPHRENIA
2.1The disorder
2.2Incidence and prevalence
2.3Possible causes of schizophrenia
2.4 Assessment
2.5 Engagement, consent and therapeutic alliance
2.6 Language and stigma
2.7 Issues for families and carers
2.8 Treatment and management of schizophrenia in the NHS
2.9 The economic cost of schizophrenia
3. METHODS USED TO UPDATE THIS GUIDELINE
3.1Overview
3.2 The scope
3.3 The guideline development group
3.4 Clinical questions
3.5 Systematic clinical literature review
3.6 Health economics methods
3.7 Stakeholder contributions
3.8 Validation of the guideline
4. EXPERIENCE OF CARE
4.1 Introduction
4.2 Methodology
4.3 Personal accounts from people with schizophrenia
4.4 Personal accounts from carers
4.5 Summary of themes from service users' and carers' experiences
4.6 Recommendations
5. ACCESS AND ENGAGEMENT
5.1 Introduction
5.2 Early intervention
5.3 Access and engagement to service-level interventions
6. PHARMACOLOGICAL INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA
6.1 Introduction
6.2 Initial treatment with antipsychotic medication
6.3 Oral antipsychotics in the treatment of the acute episode
6.4 Promoting recovery in people with schizophrenia that is in remission - pharmacological relapse prevention
6.5 Promoting recovery in people with schizophrenia whose illness has not responded adequately to treatment
6.6 Treatment with depot/long-acting injectable antipsychotic medication
6.7 Side effects of antipsychotic medication
6.8 Effectiveness of antipsychotic medication
6.9 Health economics
6.10 From evidence to recommendations
6.11 Recommendations
7. ECONOMIC MODEL - COST EFFECTIVENESS OF PHARMACOLOGICAL INTERVENTIONS FOR PEOPLE WITH SCHIZOPHRENIA
7.1 Introduction
7.2 Economic modelling methods
7.3 Results
7.4 Discussion of findings - limitations of the analysis
7.5 Conclusions
8. PSYCHOLOGICAL THERAPY AND PSYCHOSOCIAL INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA
8.1 Introduction
8.2 Adherence therapy
8.3 Arts therapies
8.4 Cognitive behavioural therapy
8.5 Cognitive remediation
8.6 Counselling and supportive therapy
8.7 Family intervention
8.8 Psychodynamic and psychoanalytic therapies
8.9 Psychoeducation
8.10 Social skills training
8.11 Recommendations (Across all treatments)
9. SERVICE-LEVEL INTERVENTIONS IN THE TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA
9.1 Introduction
9.2 Interface between primary and secondary care
9.3 Community mental health teams
9.4 Assertive outreach (Assertive community treatment)
9.5 Acute day hospital care
9.6 Vocational rehabilitation
9.7 Non-acute day hospital care
9.8 Crisis resolution and home treatment teams
9.9 Intensive case management
10. SUMMARY OF RECOMMENDATIONS
10.1 Care across all phases
10.2 Initiation of treatment (First episode)
10.3 Treatment of the acute episode
10.4 Promoting recovery
10.5 Research recommendations
11. APPENDICES
12. REFERENCES
13. ABBREVIATIONS
Correction
Unfortunately one appendix that was supposed to be included on the data CD-ROM that accompanies Schizophrenia (Updated edn), was missed out. It can however be downloaded for free. Go to the website


Depression - The Nice Guidelines on the Treatment and Management of Depression in adults Updated Edition 2010
Edition: updated 2010
Format: Paperback & CD-ROM
Author: National Collaborating Centre for Mental Health (NCCMH)
ISBN: 9781904671855
Publishers: Royal College of Psychiatrists
Price: £35
Publication Date: Aug 2010
Price: £35.00
 
Publisher's Title Information

Depression affects 6% of adults each year and is the leading cause of suicide. Its symptoms can be disabling and its effects pervasive, impacting on not only the individual patient but also on their families and the wider society. This book is an invaluable resource enabling healthcare professionals to recognise, assess and offer effective treatments for this common mental health problem, which can become a chronic disorder if inadequately treated.
This updated guideline includes new sections on: current practice; service user and carer experiences; emphasis on low-intensity psychosocial interventions and an increased range of effective psychological interventions; and the management of subthreshold depressive symptoms.
This guideline is an update of the previous guidance from NICE (full guideline published 2004) on depression.
Also see the 'sister' NICE guideline: Depression in Adults with a Chronic Physical Health Problem: The NICE Guideline on Treatment and Management
List of the other NICE mental health guidelines
NICE Mental Health Guidelines
These guidelines fromout clear recommendations, based on the best available evidence, for health care professionals on how to work with and implement physical, psychological and service-level interventions for people with various mental health conditions.
The book containsfull guidelines that cannot be obtained in print anywhere else. It brings together all of the evidence that led to the recommendations made, detailed explanations of the methodology behind their preparation, plus an overview of the condition covering detection, diagnosis and assessment, and the full range of treatment and care approaches.
The accompanying CD-ROM contains all the data used as evidence, including:
Included and excluded studies.
Profile tables that summarise both the quality of the evidence and the results of the evidence synthesis.
All meta-analytical data, presented as forest plots.
Detailed information about how to use and interpret forest plots.

Contents

Preface
Depression
Methods used to develop this guideline
Experience of care
Case identification and service delivery
Introduction to psychological and psychosocial interventions
Low-intensity psychosocial interventions
High-intensity psychological interventions
Introduction to pharmacological interventions
Pharmacological interventions
Factors influencing choice of antidepressants
The pharmacological and physical management of depression that has not responded adequately to treatment, and relapse prevention
The management of sub threshold depressive symptoms
Appendices
References
Abbreviations


Clinical Topics in Cultural Psychiatry
Edition: 1st
Format: Paperback
Author: Edited by Rahul Bhattacharya, Sean Cross and Dinesh Bhugra
ISBN: 9781904671824
Publishers: Royal College of Psychiatrists
Price: £30
Publication Date: May 2010
 
Publisher's Title Information

Cultural factors play a very important role in the way psychiatric symptoms are presented to clinicians and how clinicians deal with them. This book offers practical advice on the topic for the individual mental health practitioner. It provides an overview of cultural factors in the causation and management of mental health problems and an introduction to cultural competency training for healthcare professionals (now required for all National Health Service staff by the Department of Health). Topics include:
Cross-cultural psychiatric assessment.
Intellectual disability and ethnicity.
Cultural aspects of eating disorder.
Black and minority ethnic issues in forensic psychiatry.
Treatment of victims of trauma.
Ethnic and cultural factors in psychopharmacology.
Practising clinicians and other mental health professionals will find this introduction extremely useful in ensuring that clinical teams work together effectively and provide optimal care for their patients, irrespective of ethnicity, culture or religion.
Previous versions of 23 of the chapters have been published in the College's journal Advances in Psychiatric Treatment. These have now been extensively updated, plus six chapters have been newly commissioned for this book.

Readership

Of particular relevance for new psychiatric trainees (CT1 level), plus also of interest to other disciplines such as nurses, psychologists or occupational therapists.

The Editors

Rahul Bhattacharya - Psychiatrist at Mile End Hospital, London.
Sean Cross - Registrar in Liaison Psychiatry at St Thomas' Hospital, London.
Dinesh Bhugra - (Head of the Section of Cultural Diversity at the Institute of Psychiatry, London and President of the Royal College of Psychiatrists (2008-2011).

Preface
Culture is what makes us who we are. We are born into a culture and gradually absorb its cultural values and mores, often without realising it. Culture influences our cognitive schema, the way we deal with stress and respond to others. More importantly, culture influences the way individuals perceive and express distress and how they seek help. Cultures also dictate how healthcare systems develop and deliver care. In this era of globalisation, cultures are directly and indirectly influenced by each other. Under these circumstances, it is imperative that clinicians are aware of cultural factors in the genesis and management of psychiatric disorders. Every individual has a culture and cultural roots do go deep. It behoves clinicians to understand their patients in their social and cultural contexts so that the therapeutic alliance can be strengthened. Advances in Psychiatric Reatmetzt as a journal set a precedent in 1997 when it started a series of articles on culture and psychiatric disorders. Over the past decade or so it has published several contributions in this field and is continuing to do so. With the new curriculum developed by the Royal College of Psychiatrists in 2005 and since, cultural psychiatry has become a significant part of training of psychiatrists. It was decided to put articles from Advances together in a single volume not only so that practising clinicians can benefit from the cumulative knowledge, but also that other mental health practitioners may have access, thereby helping to ensure that clinical teams can work together effectively and provide optimal care to their patients, irrespective of their ethnicity, culture or religion. We chose a number of existing articles and asked their authors to revise them. However, in the process we discovered that many subjects had not been previously covered so we commissioned several new chapters We are most grateful to all our authors, old and new, for providing updated reviews in a field that is changing fairly rapidly. Thanks are also due to Professor Peter lyrer, Dr Joe Bouch and Dr Jonathan Green for their vision and encouragement.

Contents
 
Part 1: Theoretical and General Issues
    1 Globalisation, psychiatry and human rights: new challenges for the 21st century 2 Migration and mental illness 3 Mental Health of refugees and asylum seekers 4 Racism, racial life events and mental ill health 5 Expressed emotion across cultures 6 Mental illness in Black and Asian ethnic minorities 7 Poverty, social inequality and mental health       Part 2: Specific Mental Health Conditions Across Cultures     8 Schizophrenia in African-Caribbeans: contributing factors 9 Depression in immigrants and ethnic minorities 10 Attempted suicide among South Asian women 11 Mental health of the ageing immigrant population 12 Intellectual disability and ethnicity: achieving cultural competance 13 Culture and liaison psychiatry 14 Addiction in ethnic minorities 15 Sex and culture 16 Culture in child and adolescent psychiatry 17 Black and minority ethnic issues in forensic psychiatry 18 Cultural perspectives on eating disorders       Part 3: Management Issues in the Cultural Context     19 Cross-cultural psychiatric assessment 20 Clinical management of patients across cultures 21 Ethnic and cultural factors in psychopharmacology 22 Communication with patients from other cultures: the place of explanatory models 23 Working with patients with religious beliefs 24 Interpreter-mediated psychiatric interviews 25 Treatment of victims of trauma 26 Effective psychotherapy in an ethnically and culturally diverse society 27 Diversity training for psychiatrists 28 Informing progress towards race equality in mental healthcare: is routine data collection adequate? 29 Towards social inclusion in mental health?

Social Inclusion and Mental Health
Edition: 1st
Format: Paperback
Author: Edited by Jed Boardman, Alan Currie, Helen Killaspy and Gillian Mezey
ISBN: 9781904671879
Publishers: Royal College of Psychiatrists
Price: £30
Publication Date: June 2010
 
Publisher's Title Information


Medicine is changing, towards a greater emphasis on self-care and patient choice. But truly collaborative care is hampered by inequality, exacerbated by stigmatisation and discrimination. These experiences of social exclusion can block the road to recovery for people with mental illness.
People with mental illness are among the most socially excluded in our society.
This book is concerned with social exclusion and mental disorder and the steps that psychiatrists and mental health workers can take to facilitate the social inclusion of people with mental health problems. Alongside contributions from psychiatrists and mental health professionals, people with mental illness and their carers write about the helplessness they sometimes feel when faced with mental health services, the challenges of caring for someone, and what might be done to aid the journey to recovery.
The book encompasses a wealth of experience and evidence supported by research and everyday practice.
Key features:
Comprehensive discussion of the nature and extent of exclusion resulting from mental illness in the UK today.
Recovery-oriented perspectives from mental health professionals, service users and carers.
Advice on how professional practice, training and mental health services can be transformed to facilitate social inclusion.
Readership: This is an invaluable resource for mental health professionals, medical educators, policy makers, mental health service providers and charities.
The editors:
Jed Boardman - Consultant/Senior Lecturer in Social Psychiatry, South London and Maudsley NHS Trust.
Alan Currie - Consultant Psychiatrist, Newcastle.
Helen Killaspy - Senior Lecturer and Honorary Consultant in Rehabilitation Psychiatry, University College London
Gillian Mezey - Reader in Forensic Psychiatry, Division of Mental Health at St George's, University of London.
Quote from the editors:
"Social inclusion and recovery are of central importance to people with mental health problems and their facilitation is crucial to the work of mental health professionals and the services in which they work."


Antisocial Personality Disorder: The NICE Guideline on Treatment, Management and Prevention
National Collaborating Centre for Mental Health (NCCMH)
Edition: 1st
Format: Paperback
ISBN: 9781854334787
Publishers: Royal College of Psychiatrists
Price: £35
Publication Date: Jan 2010
 

The NICE guideline takes the first comprehensive view of antisocial personality disorder and is an invaluable resource to enable professionals to improve the outcomes for people with the disorder, who often have significant impairments. Being able to prevent and properly manage antisocial personality disorder will also have considerable social implications.
 
This publication brings together all of the evidence that led to the recommendations in the NICE guideline, and draws on a wide literature, including evidence for the management of offending behaviour. It includes a review of interventions in children and young people with conduct disorder, which may prevent the development of antisocial personality disorder; risk assessment and management; organisation and experience of care; and a range of interventions for adults with antisocial personality disorder, including psychological interventions, treatment for comorbid disorders, therapeutic communities and pharmacological interventions. The book also contains a useful overview of antisocial personality disorder, including ethical considerations.
 
Also see the 'sister' NICE guideline: Borderline Personality Disorder
 
List of the other NICE mental health guidelines
 
"We need to change our views about antisocial personality disorder.From being the ultimate diagnosis of exclusion to a condition requiring informed sympathetic management is a great leap. This guideline is one of the first to plot the way forward, and although we have far to go the path ahead is clear."
- Peter Tyrer, Professor of Community Psychiatry, Imperial College, London.
 
NICE Mental Health Guidelines
 
These guidelines fromout clear recommendations, based on the best available evidence, for health care professionals on how to work with and implement physical, psychological and service-level interventions for people with various mental health conditions.
 
The book containsthe full guidelines that cannot be obtained in print anywhere else. It brings together all of the evidence that led to the recommendations made, detailed explanations of the methodology behind their preparation, plus an overview of the condition covering detection, diagnosis and assessment, and the full range of treatment and care approaches.
 
The accompanying CD-ROM contains all the data used as evidence, including:
Included and excluded studies.
Profile tables that summarise both the quality of the evidence and the results of the evidence synthesis.
All meta-analytical data, presented as forest plots.
Detailed information about how to use and interpret forest plots.
 

Full Contents
1. Preface
1.1National guidelines
1.2The national antisocial personality disorder guideline
 
2. Antisocial personality disorder
2.1Introduction
2.2 The disorder
2.3Aetiology
2.4Presentation in healthcare and other settings
2.5Use of health service resources and other costs
2.6Treatment and management in the NHS
2.7The Dangerous and Severe Personality Disorder (DSPD) initiative
2.8The organisation and coordination of treatment and care
2.9Assessment
2.10Ethical considerations in antisocial personality disorder
 
3. Method used to develop this guideline
3.1Overview
3.2The scope
3.3The Guideline Development Group
3.4Clinical questions
3.5Systematic clinical literature review
3.6Health economics methods
3.7Stakeholder contributions
3.8Validation of the guideline
 
4. Organisation and experience of care
4.1Introduction
4.2Organisation and delivery of care
4.3Training, supervision and support
4.4Service user experience of care and services
4.5Carer experience
4.6Overall summary
 
5. Interventions in children and adolescents for the prevention of antisocial personality disorder
5.1Introduction
5.2Risk factors
5.3Early interventions
5.4Interventions for children with conduct problems
5.5Coordination of care
 
6. Risk assessment and management
6.1Introduction
6.2Assessment of violence risk
6.3Risk management
 
7. Interventions for people with antisocial personality disorder and associated symptoms and behaviours
7.1Introduction
7.2 Psychological interventions for antisocial personality disorder
7.3Treatment of comorbid disorders in people with antisocial personality disorder
7.4Therapeutic community interventions for people with antisocial personality disorder and associated symptoms and behaviours
7.5Pharmacological interventions for antisocial personality disorder
 
8. Appendices
 
9. References
 

2.1 INTRODUCTION
 
This guideline is concerned with the treatment and management of people with antisocial personality disorder in primary, secondary and tertiary care. Various terms have been used to describe those who consistently exploit others and infringe society's rules for personal gain as a consequence of their personality traits, including antisocial personality disorder, sociopathy and psychopathy. Both the current editions of the (ICD-10; World Health Organization [WHO], 1992) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association [APA], 1994)include antisocial personality disorder as a diagnosis, although ICD-10 describes it as dissocial personality disorder (WHO, 1992). Modern concepts of antisocial personality disorder can be traced back to the early 19th century, and, arguably, have always been tightly linked with contemporary societal attitudes towards criminal justice and civil liberties (Ferguson & Tyrer, 2000). In the early 1800s clinicians attempted to understand criminals whose offences were so abhorrent that they were thought to be insane, yet their clinical presentations were not consistent with recognised mental syndromes. In describing such individuals, Prichard (1835) coined the term 'moral insanity', which was a form of 'mental derangement' in which the intellectual faculties are unimpaired, but the moral principles of the mind are 'depraved or perverted', and the individual is incapable of 'conducting himself with decency and propriety in the business of life.'  

While the strength of the association between antisocial personality disorder and offending has never been in doubt, there has long been debate about its implications. In 1874 Maudsley argued that moral insanity was 'a form of mental alienation which has so much the look of vice or crime that many people regard it as an unfounded medical invention'. The crux of the problem was that it was not possible to draw a meaningful line between two forms of deviance from the norm: criminality on the one hand and antisocial personality on the other.

Throughout much of the 19th century, the diagnosis of 'moral insanity' gained acceptance across European and American courts of law (which were largely sympathetic to such a defence), until it was replaced by 'psychopathic inferiority', described in a series of influential works by Koch (1891). He believed these abnormal behaviour states to be the result of 'a congenital or acquired inferiority of brain constitution'. After Kraepelin (1905), who created the classification 'personality disorder', Schneider (1923) developed the characterisation of psychopathy as a fundamental disorder of personality, and he regarded individuals with 'psychopathic personalities' as those who 'suffer through their abnormalities, or through whom society suffers'. This may be seen as a precursor for modern diagnostic concepts in psychiatry, which place emphasis on the distress or impairment resulting from disorders (for example, in DSM and ICD). It was Henderson (1939), however, who laid firm foundations for the modern delineations of antisocial personality disorder, in defining individuals with 'psychopathic states' as those 'who conform to a certain intellectual standard but who throughout their lives exhibit disorders of conduct of an antisocial or a social nature'. In the US, Cleckley (1941) and McCord and McCord (1956) further pushed the notion of the psychopathic personality as a distinct clinical entity, and established its core criteria around antisocial behaviours (in particular, aggressive acts). These views have been extremely influential in shaping later classifications of sociopathy (DSM-I [APA, 1952]), antisocial personality disorder (DSM-II [APA, 1968] onwards), dissocial personality disorder (ICD) and psychopathy (Hare, 1980).
 
In 1959, the term psychopathic disorder was incorporated into the Mental Health Act in the UK, which made it possible for patients to be admitted to hospital compulsorily. Psychopathic disorder was defined as 'a persistent disorder of mind (whether or not accompanied by subnormal levels of intelligence) which resulted in abnormally aggressive or seriously irresponsible conduct on the part of the patients, and require or are susceptible to medical treatment'. This legal definition has been criticised as poorly defined (for example, it is unclear what constitutes 'abnormally aggressive' or 'seriously irresponsible' conduct), removed as it is from validated psychiatric classifications of psychopathy (Lee, 1999).
 
The latter clause of the definition has also been seen as problematic (or at best optimistic) as it implied that treatment was beneficial or desirable, for which neither had an evidence base at the time (Ferguson & Tyrer, 2000). While this 'treatability criterion' was introduced to protect the personality disordered individual against wrongful detention, the definition of 'treatability' became so expanded in practice over the years as to render the term meaningless (Baker & Crichton, 1995). Hence, in the revised Mental Health Act (HMSO, 2007) a generic term 'mental disorder' replaces the various subtypes previously used (that is, mental illness, psychopathic disorder, mental impairment and severe mental impairment) and, as a consequence, the treatability test has been replaced with the practitioner needing to be satisfied that 'appropriate medical treatment is available' to justify detention for any mental disorder. Alongside the ambiguity contained in the UK legislation, there is considerable ambivalence among mental health professionals towards those with personality disorder in general but particularly towards those with antisocial personality disorder. Some see this label as sanctioning self-indulgent and destructive behaviour, encouraging individuals to assume an 'invalid role' thereby further reducing whatever inclination they might have to take responsibility for their behaviour. Others believe that those with the disorder are better and more appropriately managed by the criminal justice system. The alternative view is that individuals with antisocial personality disorder are not only likely to infringe societal norms but also to have complex health needs that ought to be identified and addressed, either within or alongside the criminal justice system.

These tensions are evident across all aspects of the disorder, but especially regarding diagnosis. The criteria for antisocial personality disorder as specified in DSM-IV have been criticised because of the focus on antisocial behaviour rather than on the underlying personality structure (Widiger & Corbitt, 1993). This has led to the belief that antisocial personality disorder and its variants may be over-diagnosed in certain settings, such as prison, and under-diagnosed in the community (Lilienfeld, 1998; Ogloff, 2006). Moreover, a unique feature of antisocial personality disorder in DSM-IV is that it requires the individual to meet diagnostic criteria, not only as an adult, but also as a child or adolescent. This has led to concern that some children might be labelled as having a personality disorder before their personality has properly developed.
The DSM-IV definition has other major limitations including problems of overlap between the differing personality disorder diagnoses, heterogeneity among individuals with the same diagnosis, inadequate capture of personality psychopathology and growing evidence in favour of a dimensional rather than a categorical system of classification (Westen & Arkowitz-Westen, 1998; Clark et al., 1997; Clark, 2007; Tyrer et al., 2007; Livesley, 2007). Perhaps, most importantly, the individual personality disorder diagnoses in DSM-IV do not help practitioners to make treatment decisions; as a result practitioners have to focus on the specific components of personality disorder (such as impulsivity or affective instability) rather than on the global diagnosis when deciding on which intervention to use (Livesley, 2007).

Despite these difficulties, there is growing evidence from prospective longitudinal follow-up studies that identify a number of children whose conduct disorder with aggressive behaviour persists into adulthood, thereby justifying the approach of DSM to antisocial personality disorder (Robins et al., 1991; Moffit et al., 2001; Loeber et al., 2002; Simonoff et al., 2004; De Brito & Hodgins, in press). While the conversion rate from childhood conduct disorder to adult antisocial personality disorder varies from 40 to 70% depending on the study, the explicit continuity from conduct disorder in childhood/early adolescence and antisocial behaviour in adulthood has potential therapeutic implications regarding prevention that are discussed in Chapter 5. (However, it should be noted that some of this continuity is potentially artefactual, that is, it is a product of the fact that individuals need a diagnosis of conduct disorder before they can have one of antisocial personality disorder.) Nevertheless, this suggests that early intervention in children and adolescents may be effective in preventing the later development of antisocial personality disorder in adulthood.

A criticism of mental health work in general has been the neglect of examining personality when assessing Axis I disorders or major mental illnesses (APA, 1980); hence DSM-III and its successors adopted a bi-axial approach to the diagnosis of mental disorders, thereby separating mental illnesses on Axis I from personality disorders on Axis II so that 'consideration is given to the possible presence of disorders that are frequently overlooked when attention is directed to the usually more florid Axis I disorder' (APA, 1980). One consequence of this approach has been the recognition that Axis I and Axis II conditions often co-occur and that this co-occurrence usually has a negative effect on the treatment of the Axis I condition (Reich & Vasile, 1993; Cohen et al., 2005; Skodol et al., 2005; Newton-Howes et al., 2006). As described below, antisocial personality disorder is frequently found to be comorbid with a number of other mental disorders. Hence, an important aspect of this guideline is recognising how antisocial personality disorder might negatively moderate the response to conventional interventions offered for frequently co-occurring conditions such as substance misuse, depression and other Axis I conditions (Woody et al., 1985; Mather, 1987). It does not, however, offer guidance on the separate management of these co-occurring conditions.


Child and Adolescent Mental Health Services: An Operational Handbook (Second edition)
Edition: 2nd
Format: Paperback
Author: Edited by Greg Richardson, Ian Partridge and Jonathan Barrett
ISBN: 9781904671800
Publishers: The Royal College of Psychiatrists
Price: £30
Publication Date: Feb 2010
 

This book explains in straightforward operational terms how child and adolescent mental health services (CAMHS) can best be delivered. That means services organised in ways that children, families and other agencies can understand, that are as local to the child and family as possible, that are helpful to educational, social, voluntary and other partner agencies and that allow clear commissioning processes. The operation of each of the four tiers of service provision is clearly described with specific examples at each tier.
 
Much has changed since the first edition in 2003. There have been many government initiatives aimed at the welfare of children that have been incorporated into this book, which has broadened its scope to cover more children with many different difficulties and in many different predicaments. Those providing, working with and commissioning CAMHS will find this book an indispensible guide.
 
Straightforward, 'how to' guide
Focus on inter-agency working within each tier of service
Practical examples of service provision
Geared towards all professionals working with CAMHS
Fully revised and updated edition.
 
Readership:
Aimed at those responsible for commissioning and providing CAMHS, thus this book will be of interest toworking in CAMHS, whether psychiatrist or of a related healthcare profession.
 

The editors:
Greg Richardson Consultant in Child and Adolescent Psychiatry, Lime Trees CAMHS, York,
Ian Partridge - Social Worker, York,
Jonathan Barrett - Consultant in Child and Adolescent Psychiatry, Cringlebar CAMHS, Leeds


Contents
1 Introduction Ian Partridge and Greg Richardson
2 CAMHS in context Greg Richardson and Ashley Wyatt
3 CAMHS and the law Ian Partridge, Greg Richardson and Mary Mitchell
4 Structure, organisation and management of CAMHS Ian Partridge and Greg Richardson
5 Evidence-based practice Jonathan Barrett, Juliette Kennedy and Ian Partridge
6 Clinical governance Greg Richardson
7 Education, supervision and workforce development Margaret Bamforth, Sophie Roberts, Sarah Bryan and Nick Jones
8 Multidisciplinary working Ian Partridge, Greg Richardson, Geraldine Casswell and Nick Jones
9 User and carer participation and advocacy Jonathan Barrett
10 A comprehensive CAMHS Clare Lamb and Ann York
11 Referral management Sophie Roberts and Ian Partridge
12 Demand and capacity management Ann York and Steve Kingsbury
13 Strategies for working with Tier 1 Greg Richardson, Ashley Wyatt and Ian Partridge
14 Structuring and managing treatment options Barry Wright, Sarah Bryan, Ian Partridge, Nick Jones and Greg Richardson
15 CAMHS in the emergency department Tony Kaplan
16 Paediatric liaison Barry Wright, Sebastian Kraemer, Kate Wurr and Christine Williams
17 Self-harm Sophie Roberts, Phil Lucas, Barry Wright and Greg Richardson
18 Learning disability services Christine Williams and Barry Wright
19 Services for autism-spectrum conditions Christine Williams and Barry Wright
20 Services for attentional problems Sarah Bryan, Barry Wright and Christine Williams
21 Eating disorder teams Ruth Norton, Ian Partridge and Greg Richardson
22 Bereavement services Barry Wright, Ian Partridge and Nick Jones
23 CAMHS for refugees and recent immigrants Matthew Hodes
24 CAMHS and looked-after children Fiona Gospel, Jackie Johnson and Ian Partridge
25 Drug and alcohol teams Norman Malcolm
26 Parenting risk assessment service Ian Partridge, Geraldine Casswell and Greg Richardson
27 Court work Greg Richardson and Geraldine Casswell
28 Tier 4 options Tim McDougall, Anne Worrall-Davies, Lesley Hewson, Rosie Beer and Greg Richardson
29 In-patient psychiatric care Angela Sergeant, Greg Richardson, Ian Partridge, Tim McDougall, Anne Worrall-Davies and Lesley Hewson
30 Forensic services Sue Bailey and Enys Delmage
31 Neuropsychiatry and neuropsychology services Tom Berney
32 Mental health provision for deaf children: study of a low-incidence service provision Mandy Barker, Sophie Roberts and Barry Wright
33 Chief Executives - what do they want and how do they get it? Chris Butler


Purpose and scope of the book
 
Child and adolescent mental health services (CAMHS) comprise a small, unusual specialty often ill understood by those who work within, those trying to use and those trying to commission them. In an attempt to make order out of the possible chaos, Together We Stand (NHS Health Advisory Service, 1995a) offered a review of and a strategic framework for, the organisation
and management of CAMHS. This strategic approach was sanctioned by the House of Commons Health Committee (1997) and provided the benchmarks against which CAMHS have been measured (Audit Commission, 1999). Unfortunately, since the publication of
the first edition of this book, the application of the principles and strategic approaches that informed Together We Stand has been subject to individualistic variation.
 
The tiered system has been bastardised or 'moved on' over the past 10 years to an incomprehensible 'lingo' in which many writers assume all 'specialist' or 'core' CAMHS operate at Tier 3, and Tier 2 has been confined to limbo, beneath the dignity of so-called 'senior professionals' of whatever discipline. The differing interpretations have resulted in the very confusion about services that the tiers were intended to overcome, so the risk of the confusion that reigned prior to 1995 has reoccurred, indeed it has been amplified. There is a serious risk that CAMHS will again become marginalised as they cannot be understood and are subject to changes and targets from those in power who do not understand their functioning, as advisors to government ministers have no real understanding of what the tiers are about. The tiered system is an integrated approach in which CAMHS professionals work across tiers:
it is not and cannot function as a hierarchical system in which 'senior clinicians' are seen to operate at Tiers 3 and 4 only. The creation of 'Tier 2 teams' is a contradiction in terms, and reinforces the hierarchical attitude that only senior staff work at Tier 3 and above, which undermines both an integrated approach and true multidisciplinary working.


LINKS

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