College of Psychiatrists Spring Conference

Behavioural disturbances at all stages of life

The College of Psychiatrists of Ireland Spring Conference featured a number of fascinating parallel sessions that encompassed a variety of ‘hot’ clinical topics.

These included a session on the ‘Management of acute behavioural disturbance across the lifespan: Evidence, guidelines, and best practices’. This session was chaired by Dr Laura Bond, Consultant Child & Adolescent Psychiatrist, Children’s Health Ireland (CHI), Crumlin. The session explored the management of acute behavioural disturbance across different age groups, from children and adolescents to adults and the elderly.

A panel of experts discussed age-specific presentations and the development of guidelines, including the recent work on paediatric guidelines at Children’s Health Ireland.

The role of physical restraint was also discussed, as well as rapid tranquilisation in a crisis. The panelists also used case studies to illustrate the challenges in implementing safe and effective interventions, as well as real-world applications.

Dr Bond pointed out the “huge variation in practice” around psychotropic medication between hospitals and different jurisdictions. She also touched on observational studies suggesting that olanzapine is often effective in behavioural disturbances and acute agitation.

She also discussed special considerations, such as using off-label medications, and reviewed case studies from CHI.

Dr Sharon Ryan, Clinical Fellow, Admire Adhd Service, Linn Dara and_ Clinical Tutor, Trinity College Dublin (TCD); discussed current guidelines on the use of rapid tranquilisation and subsequent monitoring for sedation.

“We have tried to give users of this guideline a framework to use to determine when to use rapid tranquilisation,” said Dr Ryan.

“We talk about using it for aggressive or combative behaviour, [while] also thinking about where that presentation happens and whether there is a need for that patient to remain in hospital.”

Other considerations include whether the level of behaviour is causing a risk to themselves or others. “Just as important as knowing when to use it is knowing when not to use it,” said Dr Ryan.

Dr Sarah O’Dwyer, Consultant Adult Psychiatrist at St Patrick’s University Hospital, Dublin, provided an overview of medications to treat behavioural disturbances, as well as dosing considerations.

The first step is to offer the patient oral medications, she said. Dr O’Dwyer discussed specific medications, and circumstances where ketamine may be appropriate. Among the considerations for doctors in this scenario is respiratory depression, she pointed out.

Dr Matthew Sadlier, Consultant Old Age Psychiatrist at Dublin’s Mater Hospital, told the conference that the majority of aggressive older adult patients in his clinic suffer with delirium.

“Hyperactive delirium is the one that leads to agitated behaviour,” he pointed out. Dr Sadlier presented data from studies and also discussed the causes of delirium and the brain’s arousal networks. “What we are essentially trying to do is ease the patient from a hyperactive delirium to a hypoactive delirium,” said Dr Sadlier.

“Medication doesn’t solve delirium in the older adult. What solves delirium is fixing the negative reason for the systemic inflammation that is leading to a breakdown in their neural networks and neural pathway.

“By giving the medication, you are trying to induce a safer state for the person, which leads them to a lower risk, which leads them to have a period where they can avoid tripping over a chair, or assaulting somebody. The treatment is on that risk basis and overall, the treatment is the removal of the thing that is causing them to have the delirium in the first place.”

Mental illness: The autoimmune connection

The College of Psychiatrists of Ireland Spring Conference featured a talk by Prof Belinda Lennox of the Department of Psychiatry at the University of Oxford, UK. Prof Lennox delivered a presentation titled ‘Autoimmune causes of mental illness and the challenge (and opportunity) for psychiatry’.

In her address, Prof Lennox outlined the growing body of evidence suggesting that a subset of severe mental illnesses may have an autoimmune origin.

She referred to the discovery of neuronal cell surface antibodies that are considered pathogenic in patients with limbic encephalitis, often with prominent psychiatric symptoms, she said. Removal of the antibody results in clinical improvement, and often remission, but the relevance of the same antibodies in patients with purely psychiatric presentations is more controversial.

Screening for antibodies and subsequent treatment is not readily available.

In her talk, Prof Lennox attempted to address these uncertainties, including the challenges and opportunities for psychiatrists and other doctors.

Prof Lennox provided examples of diseases that have an autoimmune basis and told the attendees: “I want to highlight the curious lack of association with rheumatoid arthritis [and mental illness]. If you have schizophrenia, you have half the risk of having rheumatoid arthritis compared to other people. It’s fascinating and we still don’t know why that is.”

She highlighted research that looked at this phenomenon from another angle. “If you have a pre-existing autoimmune condition, you then have an increased risk of developing schizophrenia, and that risk is increased with each infection that you have,” said Prof Lennox. “So, in a stepwise fashion, the more infections you have, the greater your risk of developing schizophrenia.” This risk is increased even more if a patient has a pre-existing autoimmune disorder, she explained.

Prof Lennox gave an overview of a screening study she is conducting with colleagues to identify antibodies in patients and shared research involving plasma exchange as a treatment approach.

“Fifteen years ago, along with a neurologist, I started treating patients with any illness if they had an antibody and had not improved with symptomatic treatment. And we decided we will offer a treatment trial with plasma exchange.

“We described how people got better,” she continued. “I saw young people with profound presentations who were catatonic and couldn’t tolerate anti-psychotics… They had plasma exchange and within a week, their illness melted away without other treatments. It melted away and stayed away, so they didn’t have to be transferred back to the psychiatric ward at all.”

Prof Lennox commented: “If you have autoimmune encephalitis and an antibody, and you get treated in less than six weeks, you get a lot better than if that treatment is delayed…

“If there is anything in the patient’s clinical history that makes you suspicious that they have autoimmune encephalitis; if they have had a problem with movements or catatonia; if they have had a recently-diagnosed tumour; if there is a possibility of a paraneoplastic syndrome; if they have had an adverse response to anti-psychotics.

“If the patient has severe disproportionate cognitive dysfunction, a decreased level of consciousness or new-onset seizures, then you should have this in mind and you should test for antibodies.”

She also warned that there can be a lot of false negatives in serum antibody blood tests, so clinicians should also be prepared to do more investigations. “And the number one way to do this, unfortunately, is a lumbar puncture,” she said.

“That is the most useful investigation because if there is no inflammation, that is reassuring. But if there is inflammation, we really need to do more.”

Psychiatrists ‘must make their voices heard’

In his address at this year’s College of Psychiatrists of Ireland (CPsychI) Spring Conference, CPsychI President Dr Lorcan Martin expressed frustration about the failure of policymakers to address the ongoing challenges in psychiatry.

“Our profession still looks over a landscape where challenges and obstacles meet up for an unfortunate [encounter] with bureaucracy,” said Dr Martin. “No one takes up medicine for an easy life, but it can be disheartening when we are faced with the ongoing issues of recruitment and retention, burnout, and presenteeism.”

He criticised the “ever-burgeoning management system with titles we can’t remember”, against a backdrop of inadequate staffing.

He also described the Mental Health Bill 2024 as a “convoluted and unhelpful document” that will make it “almost impossible for psychiatrists to properly
do their jobs”.

While proponents of the Bill say it is firmly embedded in human rights, Dr Martin was scathing in his assessment.

“‘Human rights’ – the clarion call of those who wish to justify their opinion and signal their virtue,” he told the attendees. But do they ever think about the consequences of their view of ‘human rights’?”

Dr Martin referred to the European Convention of Human Rights, specifically the right “not to be subjected to inhuman or degrading treatment or torture”.

“Depriving a psychotic patient of treatment, or delaying that treatment so that they continue to be tormented by delusions or terrified by persecutory hallucinations, is almost certainly torture,” said Dr Martin.

He added that he wondered if the people who prepared the legislation “ever have known, or have forgotten what it is like, to see a patient profoundly distressed by symptoms that should be alleviated at the earliest opportunity and not delayed by legislation.”

Dr Martin also encouraged attendees to remember the core of their profession.

“We are physicians who tend to the ill with skill and compassion,” he told the conference.

“We are scientists who base our practice on gold-standard outcomes and we are leaders in our field who can inspire and advocate. What we do require is years of training, and professional and personal resilience.

“We should not and cannot allow that to be buried under rainforests’ worth of paper – as we still don’t have proper IT support – or thwarted by management, into which all responsibility and decision-making ability dissolves.

“We are told that restructuring the health service will bring about greater efficiency and a better patient experience,” he continued. “Whether that happens or not remains to be seen, but we must make sure that our voice is heard, especially when it comes to resources and opportunities for training that are on a par with those of our acute hospital colleagues.”

Wide variety of mental health topics discussed at Spring Conference

This year’s Spring Conference featured a diverse and engaging array of presentations. Among the topics on the first day was a presentation by John McKeon, CEO and Founder of Kyrie Farm.

The inaugural ‘therapeutic farm’ is set to open in Co Kildare in 2026. It is led by mental health specialists and aims to emulate the success of similar initiatives internationally.

For example, Hopewell Therapeutic Community and Gould Farm in the US have demonstrated the therapeutic value of farm-based communities in supporting mental health recovery.

Mr McKeon gave the attendees an overview of the history of the project, including a partnership with Maynooth University and consultations with other stakeholders.

In the same session, retired Consultant Adult Psychiatrist Dr Justin Brophy delivered a fascinating presentation titled ‘A motif for navigating the journey of being a psychiatrist’.

Using motifs from Carl Jung’s writings and Joseph Campbell’s The Hero with a Thousand Faces, Dr Brophy shed light on the possibilities and challenges inherent in a demanding psychiatry career.

Later in the session, Prof Tom Hutchinson, Director of the McGill Programmes in Whole-Person Care and the Department of Medicine and Department of Oncology at McGill University, Canada, delivered a talk titled ‘Whole-person care: The key to medical practice’.

Prof Hutchinson told the attendees that whole-person care recognises two very different but essential components of patient care – curing and healing. He said: “We have lost touch with our ability to promote healing in our patients”.

In his presentation, Prof Hutchinson used examples from practice to elucidate the difference between ‘curing’ and ‘healing’, and how they can be effectively combined to improve outcomes.