Cues and knowledge structures used by mental-health professionals when making risk assessments

Background: Research into mental-health risks has tended to focus on epidemiological approaches and to consider pieces of evidence in isolation. Less is known about the particular factors and their patterns of occurrence that influence clinicians’ risk judgements in practice. Aims: To identify the cues used by clinicians to make risk judgements and to explore how these combine within clinicians’ psychological representations of suicide, self-harm, self-neglect, and harm to others. Method: Content analysis was applied to semi-structured interviews conducted with 46 practitioners from various mental-health disciplines, using mind maps to represent the hierarchical relationships of data and concepts. Results: Strong consensus between experts meant their knowledge could be integrated into a single hierarchical structure for each risk. This revealed contrasting emphases between data and concepts underpinning risks, including: reflection and forethought for suicide; motivation for self-harm; situation and context for harm to others; and current presentation for self-neglect. Conclusions: Analysis of experts’ risk-assessment knowledge identified influential cues and their relationships to risks. It can inform development of valid risk-screening decision support systems that combine actuarial evidence with clinical expertise.

Dissociable patterns of neural activity during response inhibition in depressed adolescents with and without suicidal behavior

Objectives - Impaired attentional control and behavioral control are implicated in adult suicidal behavior. Little is known about the functional integrity of neural circuitry supporting these processes in suicidal behavior in adolescence. Method - Functional magnetic resonance imaging was used in 15 adolescent suicide attempters with a history of major depressive disorder (ATTs), 15 adolescents with a history of depressive disorder but no suicide attempt (NATs), and 14 healthy controls (HCs) during the performance of a well-validated go-no-go response inhibition and motor control task that measures attentional and behavioral control and has been shown to activate prefrontal, anterior cingulate, and parietal cortical circuitries. Questionnaires assessed symptoms and standardized interviews characterized suicide attempts. Results - A 3 group by 2 condition (go-no-go response inhibition versus go motor control blocks) block-design whole-brain analysis (p < .05, corrected) showed that NATs showed greater activity than ATTs in the right anterior cingulate gyrus (p = .008), and that NATs, but not ATTs, showed significantly greater activity than HCs in the left insula (p = .004) to go-no-go response inhibition blocks. Conclusions - Although ATTs did not show differential patterns of neural activity from HCs during the go-no-go response inhibition blocks, ATTs and NATs showed differential activation of the right anterior cingulate gyrus during response inhibition. These findings indicate that suicide attempts during adolescence are not associated with abnormal activity in response inhibition neural circuitry. The differential patterns of activity in response inhibition neural circuitry in ATTs and NATs, however, suggest different neural mechanisms for suicide attempt versus major depressive disorder in general in adolescence that should be a focus of further study.

The multiple pheromone ant clustering algorithm and its application to real world domains

The Multiple Pheromone Ant Clustering Algorithm (MPACA) models the collective behaviour of ants to find clusters in data and to assign objects to the most appropriate class. It is an ant colony optimisation approach that uses pheromones to mark paths linking objects that are similar and potentially members of the same cluster or class. Its novelty is in the way it uses separate pheromones for each descriptive attribute of the object rather than a single pheromone representing the whole object. Ants that encounter other ants frequently enough can combine the attribute values they are detecting, which enables the MPACA to learn influential variable interactions. This paper applies the model to real-world data from two domains. One is logistics, focusing on resource allocation rather than the more traditional vehicle-routing problem. The other is mental-health risk assessment. The task for the MPACA in each domain was to predict class membership where the classes for the logistics domain were the levels of demand on haulage company resources and the mental-health classes were levels of suicide risk. Results on these noisy real-world data were promising, demonstrating the ability of the MPACA to find patterns in the data with accuracy comparable to more traditional linear regression models. © 2013 Polish Information Processing Society.

"Our kith and kin"?:Sri Lankan Tamil refugees and the ethnonationalist parties of Tamil Nadu

This article explains the impact of substate nationalism on the political dynamic surrounding ethnic kin migration through a case study of Sri Lankan Tamil refugees in the southern Indian State of Tamil Nadu. Examples drawn from the migration studies literature identify ethnic kinship between refugees and host as an indicator of favorable reception and assistance. While this expectation is borne out to an extent in the Tamil Nadu case, it is tempered by a period of hostility following the 1991 assassination of former Indian Prime Minister Rajiv Gandhi by an LTTE suicide bomber, when the refugees were figured as a disruptive and dangerous presence by Tamil Nadu's political elites. A version of the "triadic nexus" model of kin state relations, reconfigured to accommodate the larger political unit within which the substate nationalism is incorporated, is proposed as a framework of analysis for these events. This can better account for Tamil Nadu's substate ethnonationalist elite's movement between expressions of coethnic solidarity with the refugees and the more hostile, security-focused response postassassination. © Taylor & Francis Group, LLC.

Examining the relationship between risk assessment and risk management in mental health

Risk assessment is crucial for developing risk management plans to prevent or minimize mental health patients' risks that will impede their recovery. Risk assessments and risk management plans should be closely linked. Their content and the extent to which they are linked within one Trust is explored. There is a great deal of variability in the amount and detail of risk information collected by nurses and how this is used to develop risk management plans. Keeping risk assessment information in one place rather than scattered throughout patient records is important for ensuring it can be accessed easily and linked properly to risk management plans. Strengthening the link between risk assessment and management will help ensure interventions and care is tailored to the specific needs of individual patients, thus promoting their safety and well-being. Thorough risk assessment helps in developing risk management plans that minimize risks that can impede mental health patients' recovery. Department of Health policy states that risk assessments and risk management plans should be inextricably linked. This paper examines their content and linkage within one Trust. Four inpatient wards for working age adults (18-65 years) in a large mental health Trust in England were included in the study. Completed risk assessment forms, for all patients in each inpatient ward were examined (n= 43), followed by an examination of notes for the same patients. Semi-structured interviews took place with ward nurses (n= 17). Findings show much variability in the amount and detail of risk information collected by nurses, which may be distributed in several places. Gaps in the risk assessment and risk management process are evident, and a disassociation between risk information and risk management plans is often present. Risk information should have a single location so that it can be easily found and updated. Overall, a more integrated approach to risk assessment and management is required, to help patients receive timely and appropriate interventions that can reduce risks such as suicide or harm to others. © 2011 Blackwell Publishing.

Psychological cue use and implications for a clinical decision support system

Effective clinical decision making depends upon identifying possible outcomes for a patient, selecting relevant cues, and processing the cues to arrive at accurate judgements of each outcome's probability of occurrence. These activities can be considered as classification tasks. This paper describes a new model of psychological classification that explains how people use cues to determine class or outcome likelihoods. It proposes that clinicians respond to conditional probabilities of outcomes given cues and that these probabilities compete with each other for influence on classification. The model explains why people appear to respond to base rates inappropriately, thereby overestimating the occurrence of rare categories, and a clinical example is provided for predicting suicide risk. The model makes an effective representation for expert clinical judgements and its psychological validity enables it to generate explanations in a form that is comprehensible to clinicians. It is a strong candidate for incorporation within a decision support system for mental-health risk assessment, where it can link with statistical and pattern recognition tools applied to a database of patients. The symbiotic combination of empirical evidence and clinical expertise can provide an important web-based resource for risk assessment, including multi-disciplinary education and training. © 2002 Informa UK Ltd All rights reserved.

Handling varying amounts of missing data when classifying mental-health risk levels

One of the main challenges of classifying clinical data is determining how to handle missing features. Most research favours imputing of missing values or neglecting records that include missing data, both of which can degrade accuracy when missing values exceed a certain level. In this research we propose a methodology to handle data sets with a large percentage of missing values and with high variability in which particular data are missing. Feature selection is effected by picking variables sequentially in order of maximum correlation with the dependent variable and minimum correlation with variables already selected. Classification models are generated individually for each test case based on its particular feature set and the matching data values available in the training population. The method was applied to real patients' anonymous mental-health data where the task was to predict the suicide risk judgement clinicians would give for each patient's data, with eleven possible outcome classes: zero to ten, representing no risk to maximum risk. The results compare favourably with alternative methods and have the advantage of ensuring explanations of risk are based only on the data given, not imputed data. This is important for clinical decision support systems using human expertise for modelling and explaining predictions.

Understanding data collection behaviour of mental health practitioners

Failure to detect patients at risk of attempting suicide can result in tragic consequences. Identifying risks earlier and more accurately helps prevent serious incidents occurring and is the objective of the GRiST clinical decision support system (CDSS). One of the problems it faces is high variability in the type and quantity of data submitted for patients, who are assessed in multiple contexts along the care pathway. Although GRiST identifies up to 138 patient cues to collect, only about half of them are relevant for any one patient and their roles may not be for risk evaluation but more for risk management. This paper explores the data collection behaviour of clinicians using GRiST to see whether it can elucidate which variables are important for risk evaluations and when. The GRiST CDSS is based on a cognitive model of human expertise manifested by a sophisticated hierarchical knowledge structure or tree. This structure is used by the GRiST interface to provide top-down controlled access to the patient data. Our research explores relationships between the answers given to these higher-level 'branch' questions to see whether they can help direct assessors to the most important data, depending on the patient profile and assessment context. The outcome is a model for dynamic data collection driven by the knowledge hierarchy. It has potential for improving other clinical decision support systems operating in domains with high dimensional data that are only partially collected and in a variety of combinations.

Integrating service user and practitioner expertise within a web-based system for collaborative mental-health risk and safety management

Objectives: To develop a decision support system (DSS), myGRaCE, that integrates service user (SU) and practitioner expertise about mental health and associated risks of suicide, self-harm, harm to others, self-neglect, and vulnerability. The intention is to help SUs assess and manage their own mental health collaboratively with practitioners. Methods: An iterative process involving interviews, focus groups, and agile software development with 115 SUs, to elicit and implement myGRaCE requirements. Results: Findings highlight shared understanding of mental health risk between SUs and practitioners that can be integrated within a single model. However, important differences were revealed in SUs' preferred process of assessing risks and safety, which are reflected in the distinctive interface, navigation, tool functionality and language developed for myGRaCE. A challenge was how to provide flexible access without overwhelming and confusing users. Conclusion: The methods show that practitioner expertise can be reformulated in a format that simultaneously captures SU expertise, to provide a tool highly valued by SUs. A stepped process adds necessary structure to the assessment, each step with its own feedback and guidance. Practice Implications: The GRiST web-based DSS (www.egrist.org) links and integrates myGRaCE self-assessments with GRiST practitioner assessments for supporting collaborative and self-managed healthcare.

Who speaks up for Inés Fonseca? Representing violence against vulnerable subjects and the ethics of care in fictional narrative about Alzheimer’s disease:Ahora tocad música de baile (2004) by Andrés Barba

This paper studies the Spanish fictional novel by Andrés Barba, Ahora tocad música de baile (2004), one of the first cultural texts dealing entirely with Alzheimer’s disease (AD) to appear in Spain. It argues that the significance of Barba’s fictional novel rests on two important issues: the ethics of representation of violence against vulnerable subjects and the ethics of care. The paper analyses how these two issues allow Barba to create a story in which the verbal and physical abuse to which the person living with Alzheimer’s disease is subjected places the reader, on the one hand, as voyeur/witness of the abuse; and, on the other, as interpreter, and ultimately judge, of the fine line that separates euthanasia, assisted suicide, and murder. The open ending of the novel defers all ethical and moral judgment to the reader. It examines how the novel offers a monolithic perspective about AD, in which care is presented as a burden. In fact, this study shows that the novel’s multi-layered structure and polyphonic nature places the emphasis on stigmas, stereotypes and negative metaphors around AD, as found in contemporary social discourses.

Differences between younger and older adults in the structure of suicidal intent and its correlates

OBJECTIVE: To analyze differences in the variables associated with severity of suicidal intent and in the main factors associated with intent when comparing younger and older adults. DESIGN: Observational, descriptive cross-sectional study. SETTING: Four general hospitals in Madrid, Spain. PARTICIPANTS: Eight hundred seventy suicide attempts by 793 subjects split into two groups: 18-54 year olds and subjects older than 55 years. MEASUREMENTS: The authors tested the factorial latent structure of suicidal intent through multigroup confirmatory factor analysis for categorical outcomes and performed statistical tests of invariance across age groups using the DIFFTEST procedure. Then, they tested a multiple indicators-multiple causes (MIMIC) model including different covariates regressed on the latent factor "intent" and performed two separate MIMIC models for younger and older adults to test for differential patterns. RESULTS: Older adults had higher suicidal intent than younger adults (z = 2.63, p = 0.009). The final model for the whole sample showed a relationship of intent with previous attempts, support, mood disorder, personality disorder, substance-related disorder, and schizophrenia and other psychotic disorders. The model showed an adequate fit (chi²[12] = 22.23, p = 0.035; comparative fit index = 0.986; Tucker-Lewis index = 0.980; root mean square error of approximation = 0.031; weighted root mean square residual = 0.727). All covariates had significant weights in the younger group, but in the older group, only previous attempts and mood disorders were significantly related to intent severity. CONCLUSIONS: The pattern of variables associated with suicidal intent varies with age. Recognition, and treatment of geriatric depression may be the most effective measure to prevent suicidal behavior in older adults.

Characterization of L-Serine Deaminase and its Potential Role in the Pathogenicity of Pseudomonas aeruginosa

All pathogens require high energetic influxes to counterattack the host immune system and without this energy bacterial infections are easily cleared. This study is an investigation into one highly bioenergetic pathway in Pseudomonas aeruginosa involving the amino acid L-serine and the enzyme L-serine deaminase (L-SD). P. aeruginosa is an opportunistic pathogen causing infections in patients with compromised immune systems as well as patients with cystic fibrosis. Recent evidence has linked L-SD directly to the pathogenicity of several organisms including but not limited to Campylobacter jejuni, Mycobacterium bovis, Streptococcus pyogenes, and Yersinia pestis. We hypothesized that P. aeruginosa L-SD is likely to be critical for its virulence. Genome sequence analysis revealed the presence of two L-SD homo logs encoded by sdaA and sdaB. We analyzed the ability of P. aeruginosa to utilize serine and the role of SdaA and SdaB in serine deamination by comparing mutant strains of sdaA (PAOsdaA) and sdaB (PAOsdaB) with their isogenic parent P. aeruginosa P AO 1. We demonstrated that P. aeruginosa is unable to use serine as a sole carbon source. However, serine utilization is enhanced in the presence of glycine and this glycine-dependent induction of L-SD activity requires the inducer serine. The amino acid leucine was shown to inhibit L-SD activity from both SdaA and SdaB and the net contribution to L-serine deamination by SdaA and SdaB was ascertained at 34% and 66 %, respectively. These results suggest that P. aeruginosa LSD is quite different from the characterized E. coli L-SD that is glycine-independent but leucine-dependent for activation. Growth mutants able to use serine as a sole carbon source were also isolated and in addition, suicide vectors were constructed which allow for selective mutation of the sdaA and sdaB genes on any P. aeruginosa strain of interest. Future studies with a double mutant will reveal the importance of these genes for pathogenicity.

Evaluation of a mentored self -help intervention for the management of psychotic symptoms

Cognitive behavioral therapy has been shown to be promising for the treatment of individuals experiencing psychotic symptoms, who are often diagnosed with schizophrenia. Using a non-random non-equivalent comparison group design (n = 26), this study explores whether an individually mentored self-help and self-paced intervention based upon cognitive behavioral approaches to auditory hallucinations or "hearing voices" makes a significant positive difference for individuals with major mental disorder diagnoses and psychotic symptoms who are residing in the community and receiving community mental health services. The mentored self-help intervention uses a workbook (Coleman & Smith, 1997) that stemmed from the British psychiatric survivor and "voice hearers"' movements and from cognitive behavioral approaches to treating psychotic symptoms. Thirty individuals entered the study. Pre- and post-intervention assessments of 15 participants in the intervention group and 11 participants in the comparison group were carried out using standardized instruments, including the Rosenberg Self-Esteem Scale, the Brief Psychiatric Rating Scale, and the Hoosier Assurance Plan Inventory - Adult. Four specific research questions address whether levels of self-esteem, overall psychotic symptoms, depression-anxiety, and disruption in life improved in the intervention group, relative to the comparison group. Pre- and post-assessment scores were analyzed using repeated measures analysis of variance. Results showed no significant difference on any measure, with the exception of the Brief Psychiatric Rating subscale for Anxious Depression, which showed a statistically significant pre-post difference with a strong effect size. A conservative interpretation of this single positive result is that it is due to chance. An alternative interpretation is that the mentored self-help intervention made an actual improvement in the level of depression-anxiety experienced by participants. If so, this is particularly important given high levels of depression and suicide among individuals diagnosed with schizophrenia. This alternative interpretation supports further research on the intervention utilized in this study. ^

Características psicológicas do paciente obeso grave e suas implicações pós-operatórias na cirurgia bariátrica

Obesity is a chronic disease that has multi-factorial aetiology, characterized by high degree of body fat; the degree of obesity will vary according to the Body Mass Index (BMI=m2 /kg). The severe degree of obesity is characterized by BMI>40 and it is regularly associated to endocrine-metabolic or mechanic clinical alterations, and to psychological disorders. Binge Eating (BE) results were overly high for this population. The Bariatric Surgery has been the treatment chosen by those diagnosed with severe obesity as this intervention provides prompt outcomes for loss of weight and clinical improvement conditions. However, recent research has acquiesced that after two years between 20% and 30% of people subject to this intervention gained weight. The main objective of this research is to assess the psychological and behavioral characteristics of those diagnosed with severe obesity that have been subject to Gastric Bypass Surgery in the past 24 months. Specific aspects were investigated: (1) characteristics of different personalities and diagnose of clinic and personality disorders; (2) BE and its relation with loss of weight; (2) the difference between the groups regarding post-surgery care, e.g. physical activity, psychological and dietician input. Method: 40 adults (women and men) aged 23 and 60 year-old who went through a bariatric surgery in the past 24 months, in the city of Natal-RN (Brazil); they were assembled in two groups n=20, Gain group displaying loss of < 50% of their initial surplus of weight, and the Loss group displaying loss of >50%. The research protocol is made of a socio-demographic questionnaire and 3 psychometric instruments: Rorschach – Comprehensive System; Millon Personality Inventory (MCMI-III); and the Binge Eating Scale (Escala de Compulsão Alimentar Periódica (ECAP). Through Rorschach significant differences between these groups were verified according to the kind of personality (EB) - more EB Extratensivo in Gain group and Intratensivo in Loss group – and the lack of control to express affect, increasing the answer for Color Pure at Group I. Concerning the people standardization, the sample as a whole tends to show psychic pain, denigrated selfperception, high levels of self-criticism, distorted perceptions, vulnerability to develop mood disorders and high scores regarding Suicide. MCMI-III results showed more clinic and personality disorders in Group I: Depressive Disorder and Schizotypal, Anxiety, Dysthymia, Major Depressive Disorder; Thought Disorder, Bipolar- Manic and Posttraumatic Stress Disorder. In relation to ECAP, the results indicated significant differences, showing increased BE results in Gain group. There were found significant differences between BE severity and the presence of clinic and personality disorders. Concerning the post-surgery care, the observed differences are statistically significant regarding physical activities with median-increased differences in Loss group. There is a difference between the initial weight and the time post-surgery, indicating that the higher the initial weight and the time after the surgery the higher the re-gain of weight post-surgery. Finally, the results show that the participants with more than 3 years of surgery will have Clinic and Major Depressive Disorders; Somatoform Disorder; Dysthymia. These results confirm prior studies related to BE post-surgery and re-gain of weight as well as the proneness of clinic disorders in severe obesity people. That means the results reinforce that the surgery process is a facet of the severe obesity treatment. The post-surgery process needs to be the main focus of attention and have a long-term input to sustain the care of the surgery results and the quality of life of the patients.

Terra de charneca erma e de saudade: a construção simbólica do Alentejo português na obra de Florbela Espanca (1916-1930)

In this work, we investigate the symbolic construction of a particular spatiality, starting from the theoretical assumption that spaces are subjective constructions guided by different cultures, feelings and rationales, but mostly spaces are human constructs driven by social relations, as a result of the material investment and symbol that reflects the needs of a particular society at a given time of historical development. Accordingly, we analyze the construction and symbolic imagery of the central region of Portugal, the Alentejo, from the literary production (1916 – 1930) the English poet Florbela Espanca D'Alma Conception Espanca. Thus, we propose to analyze the florbelian work not only from its internal relations, but also external, emphasizing the link between history, space and literature. Thus, we propose to inquire about the symbolic dimension – the meanings of images and representations – which prompted one of the most controversial Portuguese poets of the early twentieth to look into the poetic construction of space Alentejo century, questioning not only the senses brokered by speech literary Florbela Espanca to invent your Alentejo, adorned with memories, pain and longing, but investigate how the socio-cultural environment influenced your work, in your life and ways to feel and live the Alentejo. To better understand how the poet means the Alentejo spatiality, throughout this work we question three categories of space in the work of Florbela Espanca: the region, the countryside and the landscape of the Alentejo. Thus, this research falls within the field of cultural history in the medical we will work with the entire literary output Florbela Espanca, letters, diaries, photos and biographical and literary criticism, by establishing the time frame of 1916 – beginning of intellectual activity Florbela Spank – the 1930 – publication of Blossom Heath (posthumous) and the suicide of the poet. Therefore, a constant symbolic exercise of words crossed by more subjective feelings of the subject, all the time our work will be guided by the question of what would be the Alentejo for the poet, who senses and meanings across this spatiality that marked so sovereignly happiest memories and sad life Florbela Espanca.