College of Psychiatrists of Ireland Spring Conference 2019

College marks 10-year anniversary at opening session of Spring Conference

This year’s College of Psychiatrists of Ireland Annual Spring Conference marked the 10-year anniversary of the establishment of the College, and took place from 3-5 April in Dublin. Themed ‘Looking Back, Moving Forward’, the three-day programme featured a stellar line-up of renowned domestic and international speakers and an eclectic range of parallel sessions.

At the opening session, College Chief Executive Ms Miriam Silke welcomed the conference’s 350 delegates and gave a passionate speech on the highlights of the College’s achievements from the past 10 years. The College was formally established as the only professional body for psychiatrists in Ireland in January 2009 when three former bodies merged: The Irish College of Psychiatrists (a division of the Royal College of Psychiatrists in the UK), the Irish Psychiatric Association, and the then training body for psychiatry, the Irish Psychiatric Training Committee.

Inaugural College President (2009-2010) Dr Justin Brophy, College Dean Prof Greg Swanwick and current College President Dr John Hillery spoke about the various elements of the vision for the College, the achievements in postgraduate training of the last 10 years, and building for the future vision of the College and psychiatry.

Dr Brophy described the “huge amount of hard work” involved in forming the College and said it was a relief that the College had successfully established itself well in advance of Brexit.

Dr Hillery noted the importance of professional support, life-long evidenced-based education, the promotion of excellence and best practice, and advocacy as core principles of the College. In the current international political climate, he said there “is more of a need than ever to have learning and reflection and evidence”. He confirmed that the College is currently providing media training to many members and will roll-out a number of ‘champions’ this year to speak to the media and promote the College’s viewpoint and response to mental health-related issues, and “challenge some of the noise” around untrue health claims.

Looking to the future, Dr Hillery said the College is working on a new human rights document regarding psychiatry and ethical conduct, “and that’s already got some interest from the minister, so it is important that we keep doing these things”, while the College continues to work with service users, determining what their needs and wants are, and is also working on a key document on recovery.

Speaking to the Medical Independent, Dr Hillery, who retired from the public service last year, acknowledged the challenges being posed to the country’s mental health services by the ongoing medical recruitment and retention crisis, adding that pharmacological intervention is often the only available treatment for patients due to shortages of mental health professionals/services. “We won’t attract people in until that changes. We can’t dismiss the salary differential either where we have people who are not on the specialist register, who are in locum or temporary posts who are paid through agencies, who are earning more than the permanent consultants who are trained specialists who are working beside them. There is something totally wrong about that. It also encourages people to go into those posts rather than continue their training… we know that Judge Peter Kelly has been very strong on the specialist register issue [where non-specialists are working in consultant posts in hospitals] recently and he is to be congratulated on that, as lots of people were unaware about that.”

Meanwhile, the College held its first Fellowship ceremony during the meeting, honouring those who contributed to the founding of the College and its success over the years. Among those who received fellowships were Dr Justin Brophy and Ms Martina Hartman, who received an honorary fellowship for passing the Irish Journal of Psychological Medicine (IJPM) to the College. Her late husband, the eminent and forward-thinking psychiatrist Dr Mark Hartman, established the IJPM in 1982.

The College also awarded a number of research-related prizes during the conference, including the John Dunne Medal, Ada English Medal and Best Poster Prize.

The John Dunne Medal is awarded for outstanding trainee contribution to psychiatric research, as published in an original paper in the IJPM over the year. Dr Laura Bond was awarded this year’s medal for her paper titled ‘What happens to adolescents in the private mental health sector when they reach 18: A study of transitions from adolescent to adult services?’ (2018)

The Ada English Medal was established in 2017 in honour of Dr Ada English, one of Ireland’s pioneering psychiatrists in the early 20th Century, and an innovator in the field of mental health. The medal is awarded annually to a medical student from all countries who has published original scientific research in the IJPM. Medical student Ms Sorcha Cotter received this year’s Ada English Medal for her paper titled ‘Psychopathology and early life stress in migrant youths: An analysis of the Growing up in Ireland study’ (2018).

The meeting’s best poster prize was awarded to Dr Kiran Santal, for his poster titled ‘Treatment of GHB withdrawal in the G Detoxification in the HSE-National Drug Treatment Centre: An update on service provision and patient outcomes’, co-produced by Dr Santal, Dr Peter McCarron, Dr Eamon Keenan, and Dr Fiona Fenton.

‘Psychiatrists need to address their patients’ physical health issues as well’

People with severe mental illnesses are much more likely to die younger, which needs to be better addressed by health services, including psychiatrists tackling physical health issues in their patients, the 2019 Spring Conference of the College of Psychiatrists of Ireland heard.

Dr Peter Byrne, Consultant Liaison Psychiatrist at the Royal London Hospital, UK, discussed the main drivers of premature death in people with severe mental illness, which include: Obesity; stroke; cardiovascular disease; liver disease; smoking-related illness, ie, lung cancer; suicide and drug addiction; compounded by health inequalities in this population.

He noted that mental health patients are diagnosed later than the general population with these conditions and they receive less treatment: “Our services are not working for these patients,” he commented, quoting recent life expectancy data in England for males with serious mental illness corresponding to that of general population males in the 1950s.

Dr Byrne noted that about 17 per cent of the general population smoke, compared to about 40 per cent of those with severe mental illness, rising to 70 per cent in discharged psychiatric inpatients, and reaching 90 per cent in those with a mental disorder and addiction issues. He contended that psychiatrists and other healthcare professionals do not adequately promote smoking cessation to mental health patients and this must change. “There is this attitude that ‘it’s all they have’, and that somehow it is a human right to smoke yourself to death — it isn’t.”

Dr Byrne maintained that psychiatrists are best placed to help their patients quit smoking, being experts in addiction and the bio-psychosocial model, thus mental health services need to get over the attitude that “physical health isn’t our job”.

He promoted the use of nicotine replacement products, varenicline and e-cigarettes (“they have their drawbacks but they are substantially safer than smoking”) to help patients quit smoking. “With smoking, it is a no-brainer. We need to be doing these things and doing them consistently. If we [psychiatry and mental health services] don’t do them, they won’t be done. ‘Can’t someone else do this’ is not an adequate professional response.”

Dr Byrne also discussed the importance of reducing alcohol consumption and promoting healthy diets and lifestyle in mental health patients, and the need for psychiatrists to also become involved in this area. He voiced support for public health initiatives such as anti-obesity and exercise strategies and minimum alcohol pricing legislation.

Concluding, Dr Byrne said tackling physical health issues in mental health patients is an urgent problem and needs a multi-pronged approach, including using the ‘soft power’ of the psychiatry profession to help inform and influence policy-makers.

Borderline personality disorder can be treated and achieve ‘good response’

Borderline personality disorder continues to be a very stigmatised condition but it can be treated with talking therapies of which psychiatrists need to be better informed, according to a clinician specialising in the treatment of these patients.

During a special workshop at the 2019 College of Psychiatrists of Ireland Spring Conference, Dr Evelyn McCabe, Consultant Psychiatrist, Community Mental Health Centre, Ballina, Co Mayo, explained how borderline personality disorder is associated with high morbidity and mortality: It has a lifetime prevalence of up to 6 per cent in the general population; is associated with 10-to-30 per cent of psychiatric outpatient visits; 20 per cent of psychiatric inpatient stays; and 14-to-23 per cent of prison populations. It is highly comorbid with addiction, eating disorders and recurrent depressive disorders — 70 per cent will make at least one attempt at suicide and 8-to-10 per cent will die by suicide; 50 times the rate in the general population. However, about 40 per cent of personality disorder patients are misdiagnosed, she noted.

Futhermore, despite growing awareness of the condition, borderline personality disorder has long been stigmatised and is often considered untreatable, by both clinicians and the public.

Dr McCabe acknowledged that people with personality disorders are often hard to reach and can be “very challenging” for clinicians to work with and there are no specialist services in the Republic.

Treatment-wise, she discussed the psychotherapeutic evidenced-based approach to personality disorder. Dr McCabe explained that people with personality disorders are poor at “mentalising themselves and others” and she promoted the benefits of mentalisation-based therapy (MBT). She quoted data showing MBT significantly reduced outpatient presentations, psychiatric inpatient bed days and episodes of self-harm in personality disorder patients.

Chair of the workshop Dr Alyson Lee noted that the HSE has set up a working group looking at models of care for delivering talking therapies in specialist mental health services. She said the College has set up its own working group on developing a position paper on treating personality disorders, which it hopes to publish by the end of the year or early in 2020. Both Dr Lee and Dr McCabe said psychiatrists need to deliver psychotherapy to their patients, and not just leave it to psychotherapists.

Meanwhile, also discussing the treatment of personality disorders during the conference, UK speaker Prof Anthony Bateman outlined the benefits of talking therapies in treating these patients. He maintained that they should not be routinely prescribed pharmacological treatments (except for comorbid conditions which need to be
carefully considered), as they provide no benefit.

Inadequate access to mental health services for people with autism

The current lack of access to child and adolescent mental health services in Ireland for young people with autism is a clear breach of the UN Convention on the Rights of People with Disabilities and must be addressed as a priority, the 2019 Spring Conference of the College of Psychiatrists of Ireland heard.

During a dedicated session on autism spectrum disorder, Mr Adam Harris, founder of autism advocacy organisation As I Am, discussed the need to make mental health services more inclusive, respectful and accessible for autistic people.

Stigma is a huge issue in autism and a key barrier to seeking a diagnosis and help, he noted. The presentation of autism is also very diverse, unlike the common preconceptions of the condition, and one-in-65 students in Irish education have a diagnosis of autism, Mr Harris stated.

He said people with autism are more at risk of having mental health issues, yet find it harder to access services, with an over-focus on their autism when they do access them, leaving mental health conditions under-diagnosed and under-treated. He also contended that there is an over-focus on children’s services, when adults with autism need as much, if not more, help.

Mr Harris outlined the key findings of a newly-published survey carried out on behalf of As I Am, which found that Irish people strongly support the education of autistic people in mainstream schools and have a lot of goodwill but low levels of understanding on many autism issues.

“The critical finding of this survey is the gap between public support for inclusion and reality. Despite positive public sentiment, over 85 per cent of autistic people are under or unemployed, autistic people are up to nine times more likely to die by suicide. Social isolation, particularly among autistic adults, remains a norm. The people’s attitudes are ahead of the Government’s efforts to include autistic people. For over five years, the Government have allowed successive Autism Bills and proposed strategies to languish on the floor of the Oireachtas, whilst at the same time assuring the community of its support,” he said.

Mr Harris called on the medical profession to “please believe us, please listen to us”, and called for more medical education on autism and for medical services to be more accommodating to their autistic patients.

Also speaking during this session, Dr Marc Woodbury-Smith, Clinical Senior Lecturer and Honorary Consultant Psychiatrist in Newcastle upon Tyne, UK, said that as autism has many common comorbidities, these patients need a tailored, individualised approach, with early diagnosis and appropriate intervention linked to better long-term outcomes. However, he warned against over sub-specialisation and services operating in silos, as this means patients have to see many different services to be treated, which in reality does not work well.

Dr Woodbury-Smith said prescribing should be about treating “vulnerabilities as opposed to autistic symptoms”.

He stressed the need to believe patients when they said they had autism, and pointed out that, like so many other health services, GP surgeries are a hostile environment for patients with autism, therefore some effort must be made to facilitate their needs. “Adults with autism are under-represented in screening programmes and the reason is they are not going to their GP because they cannot cope in that environment. We need to try to facilitate them so they can cope and reasonable adjustments may be relatively minor things like lighting and noise, but it really needs to be done,” he told the Medical Independent (MI).

The last speaker in the session, Prof Louise Gallagher, Chair of Child and Adolescent Psychiatry, Trinity College Dublin, spoke about how new discoveries in the neurobiological underpinnings of autism (altered white-matter development, etc) are increasing the knowledge base on this condition and informing the development of new therapies.

She commented that while pharma companies are very keen to use this information to develop new treatments and therapies, “we are not going to find a very simple treatment for complex conditions and service access is currently a bigger challenge”.

“We already have significant needs about trying to appropriately treat the mental health comorbidities of autistic people and our services are challenged to do that. In the context of all the pressures we have on delivering healthcare services and mental health services, how do we address the needs of autistic people more generally in the face of expanding needs and limited resources,” she told MI, adding that GP education needs to be more focused on autism.

Prof Gallagher pointed out that psychotropic prescribing and polypharmacy are common in people with autism, leading to increased negative physical heath risk factors such as seizures, cardiometabolic side-effects and poor lifestyle behaviours.

“The main message is that we are currently using drug therapy to treat comorbidities. We are challenged in differentiating between comorbidities and autistic symptoms and there may be a lot of relationships between those, either on a psychological level because an autistic person is challenged in their environment, and that might be stressful and might induce anxiety or depression. Similarly, we are challenged, as people with autism may respond differently to the drug therapies we are prescribing but it is really important that we are making efforts to treat autism comorbidities, because we know from recent epidemiological studies in Scandinavia in particular that suicide is a very significant cause of premature death in autistic people without intellectual disability, in addition to factors such as cardiovascular disease and cancer.”

Prof Gallagher chairs the College’s autism special interest group, which is currently working on putting together a position paper on mental health service provision for these patients that it hopes to publish next year, she confirmed to MI.

Psychiatrists must warn the public on the dangers of cannabis

Psychiatrists attending the 2019 Spring Conference of the College of Psychiatrists of Ireland were issued with “a call to arms” to warn the public about the potential detrimental effects of cannabis use on mental health in the face of growing support for its legalisation in Ireland.

The current popularity of the positive narrative on medical cannabis, with over exaggeration of its potential benefits far beyond the narrow range of conditions with some evidence for its use (such as refractory epilepsy, pain relief in some serious conditions) must be challenged and doctors must speak out, according to Dr Matthew Sadlier, Consultant in Old Age Psychiatry, Mater Hospital, Dublin.

He noted how healthcare policy is decided by politicians and not by clinicians and can be heavily influenced by populist concerns and industry lobbying (big money to be made in so called medicinal cannabis products), despite lacking an evidence-base. He highlighted the moves to legalise medicinal cannabis use in Ireland, alongside corresponding calls and support for wider legalisation, and stressed the need for the voice of psychiatry to be heard in this debate.

Earlier presentations at the conference explored the connection between heavy cannabis use and the onset of psychosis, and serious mental health disorders, with some research indicating that a significant amount of first episode psychosis cases could be prevented if high potency cannabis use was stopped. The types of cannabis being used across the world are also getting stronger, and therefore more dangerous, the meeting heard.

Dr Marta Di Forti, MRC Clinical Research Fellow, The Maudsley, London, said despite the large body of evidence indicating cannabis use is a risk factor for psychotic disorders, sceptics continue to argue that changes in prevalence and patterns of cannabis use have not led to an increase in the incidence of psychosis.

However, presenting compelling evidence to refute this, including data from a new European collaboration study she is leading which was recently published in the Lancet, she showed how frequent cannabis use, and especially the use of high potency types (ie, skunk), contributes to variations in incidence rates of psychotic disorders across Europe, ie much higher rates of psychosis in Amsterdam and London where there is more access to and use of high potency cannabis. She said this data must be communicated to the public and incorporated in public and mental health policy.

Speaking from the audience, Prof Mary Cannon said the public are forgetting about the negative health risks of cannabis. “We as psychiatrists have a duty to point out that cannabis is not good for your brain, and cannabis is not good for your mental health as the medicinal cannabis lobbyists are actually arguing the other way and they are the ones the public are listening to.”

Cyberpsychologist warns about mental health dangers of Internet

There is a pressing need for mental health services and researchers to “catch up” with the growing challenges being posed by online technologies, and better protect young people from the risks, the College of Psychiatrists Of Ireland 2019 Spring Conference heard.

Dr Mary Aiken, an Adjunct Associate Professor at UCD whose expertise is in Cyberpsychology, gave a tour de force lecture on the impact of social technologies on the mental health of young people, and how human behaviour changes online (disinhibition, trolling, etc). She noted the dramatic increase in mental health issues, including depression and anxiety, in young people in the last 25 years, and the current pervasiveness of smart phones, and the subsequent rise of issues such as online bullying, sexting, and sexual grooming and abuse.

Dr Aiken maintained that the Internet is clearly not a suitable environment for children yet they are being granted huge levels of access to technology that can provide incredibly damaging content (eg, pornography, murder) and which can amplify negative behaviour−ie, sites that promote eating disorders (pro-ana) and people ‘liking’ self harm pictures on photo sharing apps.

She warned that babies and young children are being increasingly exposed to unmoderated online content and excessive screen time despite evidence that it can damage brain development, while parental eye contact, which is absolutely essential to babies brain development, is at risk due to “parents being glued to their smartphones”.

Dr Aiken criticised online companies whose search algorithms direct vulnerable users to harmful content, such as sites promoting eating disorders, or in the case of paedophiles, to more content that feeds their habit.

“Who is ethically and morally responsible?,” she asked.

While she called for increased high quality research in the area, Dr Aiken lamented the time it can take for academic research to happen and then be acted upon, saying “common sense and expert opinion in the meantime needs to prevail and action needs to be taken now… we cannot wait until ten years down the line when a study shows some cause or correlation”.

She referenced the Children’s Digital Protection Bill 2018, which is attempting to regulate access to content on the Internet for children and is now making its way through the Seanad, and added that the challenges being posed by the online world are a global issue that need collaborative solutions.

“We have technologies evolving at the speed of light and infants engaging with it. We have this developmental curve and sociological changes that are affecting the individual, while scientists are sitting on the fence waiting for longitudinal studies. What we need are academic first responders. We need professionals who are prepared to nail their colours to the mast and actually engage, using expert opinion. It does not take a rocket scientist or a cyberpsychologist to figure out that nothing good can come of an eight-year old looking at online pornography.” Her suggestions for healthcare professionals and researchers to address the issues raised were:

Establish transdisciplinary groups to evaluate the problem space.

Organise professional training and development in this area.

Need to investigate, debate and agree on stages of “cyber cognitive development”.

Agree protective protocols “well-being by design”.

Factor in future evolutions (AI & VR).

Create research protocols for continuous investigation and modeling of impact of technology on the developing child.

Develop metrics for clinical assessment and best practice protocols for treatment.

Professional bodies need to actively engage in and contribute to policy debates.