Recent eLetters

Displaying 11-20 letters out of 352 published

  1. Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study -The role of motivation

    To the Editor: With great interest I read the paper by Miedema et al. entitled "Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study" published in the BMJ Open 2015. Authors identified that lifestyle interventions administered by trained certified professionals improve health outcomes in obese participants. To show the effectiveness of their programs, authors presented positive results in heart rate, blood pressure, body mass index, waist circumference and mental health among the participants who adhered to the interventions. Their results further validate similar findings from previous studies that diet and exercise are two major contributors to better health and weight loss in obese patients. However, one of the key aspects of this type of lifestyle intervention programs is the motivation which has not been discussed in this paper. Similar to this study, review of existing literature shows that in lifestyle intervention programs including exercise and diet have had a high rate of attrition [1]. Therefore, individuals' motivation is the key to the success of this type of intervention programs [2, 3]. Among the two types of motivation-- namely, autonomous and controlled-- to adhere to the intervention programs, the former one is preferred because it is chosen by and emanating from one's self, while the later one is experienced when they pressured or forced by others [3]. Individuals tend to more competent when they are autonomously motivated to endorse themselves to the intervention programs and develop a strong willingness to do them. Previous studies also show that individuals who perceive the health care providers more autonomy supportive tend to maintain long-term intervention programs, and autonomous supportiveness played a key role in the success of programs for smoking cessation and adapting positive coping strategies for better management of chronic diseases such as diabetes and overweight [4-6]. Therefore, the effectiveness of these non-pharmaceutical intervention programs would be better evaluated if the autonomous motivation is also examined.


    1. Volkmar FR, Stunkard AJ, Woolston J and Bailey RA. High attrition rates in commercial weight reduction programs. Arch Intern Med 1981;141(4): 426-428.

    2. Andersson I, Rossner S. Weight development, drop-out pattern and changes in obesity-related risk factors after two years treatment of obese men. International Journal of Obesity & Related Metabolic Disorders 1997; 21:211-216.

    3. Lantz H, Peltonen M, Agren L, & Torgerson JS. A dietary and behavioural programme for the treatment of obesity. A 4-year clinical trial and a long-term post-treatment follow-up. Journal of Internal Medicine 2003; 254: 272-279.

    4. Williams GC, Grow, VM, Freedman ZR, et al. Motivational predictors of weight loss and weight-loss maintenance. Journal Personality and Social Psychology 1996; 70:115-126.

    5. Williams GC, Cox EM, Kouides R, & Deci EL. Presenting the facts about smoking to adolescents: The effects of an autonomy supportive style. Archives of Pediatrics and Adolescent Medicine 1999; 153:959-964.

    6. Williams GC, Freedman ZR, & Deci EL. Supporting autonomy to motivate glucose control in patients with diabetes. Diabetes Care 1998; 21:1644-1651.

    Conflict of Interest:

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  2. Re:The volume of complaints against doctors and how they are handled are not necessarily in the best interests of patients and harms doctors. New solutions are needed based on good quality evidence.

    I have specific interest in this article, as my cancer was misdiagnosed by ten to fifteen doctors, across three counties, over a great number of years.

    The backlog of complaints I made to The Department of Health (and later many other health bodies), were either unanswered or answered grossly inappropriately.

    Instead of this complaint being used as the wake-up call it ought to have been, it's (incontrovertible) contents have been rigorously kept under wraps. This has resulted in on-going widespread hardship, excruciating suffering,and loss on many all levels of life.

    It highlights one of the most serious miscarriages of justice, on the health front, in modern times, being meted out to a vast number of physically ill people.

    Therefore doctors across the board, need to take responsibility for the catastrophic errors they are carrying out, even today, on a daily basis.

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  3. Overestimating pregnancy rates after psychosocial interventions for infertile couples

    Frederiksen et al conclude in their very interesting meta-analysis on the efficacy of psychosocial interventions in infertile women and men that psychosocial interventions for couples in treatment for infertility could be efficacious in improving clinical pregnancy rates (1). As presented in figure 2 of their paper, the mean risk ratio of all ten studies analysed is 2,006 for pregnancy rates in favour of the psychosocial intervention groups. Two of these studies (labelled "Domar 2000" and "Sarrel 1985" in figure 2) appear to be outliers with risk ratios about 6 or more. In the study of Domar et al (2), 26 pregnancies resulted in the cognitive- behavioural intervention group (with 47 participants), 26 pregnancies in the support group (with 48 participants), and 5 pregnancies in the control group (with 25 participants). This gives a risk ratio of 2,766 for the first intervention group and of 2,7083 for the second intervention group (both compared to the control group). The combined risk ratio for the two intervention groups is therefore 2,736. The same score was computed in the meta-analysis of Haemmerli and colleagues (3). In the study of Sarrel & DeCherney (4), six pregnancies were reported for the psychosocial intervention group (with 10 participating couples), and one pregnancy in a group of nine couples without a psychosocial intervention. This gives a risk ratio of 5,400, which is also the score reported in the paper of Haemmerli et al. The number of participants in the study of Sarrel & DeCherney is therefore 38 and not 140 as indicated in figure 2 in (1). In my opinion, the mean risk ratio for pregnancy rates in infertile couples after psychosocial interventions is clearly overestimated in this meta- analysis of Frederiksen et al. There are still insufficient systematic studies indicating a rise in pregnancy rates following psychological interventions (5).

    1. Frederiksen Y, Farver-Vestergaard I, Skovgard NG, Ingerslev HJ, & Zachariae R. (2015). Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis. BMJ Open, 5(1) E-Pub.

    2. Domar AD, Clapp D, Slawsby EA, Dusek J, Kessel B, & Freizinger M. (2000). Impact of group psychological interventions on pregnancy rates in infertile women. Fertil Steril, 73(4), 805-811.

    3. Haemmerli K, Znoj H, & Barth J. (2009). The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate. Hum Reprod Update, 15, 279- 295.

    4. Sarrel PM, & DeCherney AH. (1985). Psychotherapeutic intervention for treatment of couples with secondary infertility. Fertil Steril, 43, 897-900.

    5. Wischmann T. (2008). Implications of psychosocial support in infertility - a critical appraisal. J Psychosom Obstet Gynecol, 29(2), 83- 90.

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  4. Re: Patterns and trends in sources of information about sex among young people in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles

    Tanton et al conclude that over the past 20years, young people have increasingly identified school lessons as their main source of information about sex.(1) This is surprising given that the quality and access to sex and relationships education(SRE) continues to give cause for concern.(2) Recent evidence from inspectors found that SRE required improvement in over a third of schools, and that some young people were being left unprepared for the physical and emotional changes they were going to experience.(2)

    The findings from the national surveys support the need for improved SRE in schools alongside greater involvement of parents and health professionals.(1) Some of these important issues were also highlighted in the chief medical officer's report "Our Children Deserve Better: Prevention Pays".(3) Dame Sally Davies recommended that there needs to an improvement in personal, social and health education (PSHE) and especially sex education.(3)

    The recently published Education Committee Report Life Lessons: PSHE and SRE in Schools states that PSHE and SRE should be given statutory status.(4) We fully endorse Graham Stuart, Chair of Education Committee, who states that: "There is an overwhelming demand for statutory sex and relationships education - from teachers, parents and young people themselves. It's important that school leaders and governors take PSHE seriously and improve their provision by investing in training for teachers and putting PSHE lessons on the school timetable. Statutory status will help ensure all of this happens." (4)

    The Government has just announced that there will be new guidance on an element of PSHE: materials on "consent" will be issued later this year.(5) Although this small step is welcome, we feel strongly that this is insufficient. Without statutory change, topics like consent will continue to be taught in some places by untrained teachers and in many schools squeezed from the timetable.

    Until SRE is made a universal entitlement for all young people in schools no matter how they are funded or organised, SRE will continue to be poorly taught and accessible only to a fortunate minority. We believe that children and young people deserve properly planned systematic SRE taught by well trained, confident and competent teachers with appropriate support from health professionals.

    References 1) Tanton C, Jones KG, Macdowall W, et al. Patterns and trends in sources of information about sex among young people in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles. BMJ Open 2015;5:e007834.

    2) Ofsted. Not yet good enough: personal, social, health and economic education in schools. 1 May 2013.

    3) Department of Health. Annual Report of the Chief Medical Officer, 2012, Our Children Deserve Better: Prevention Pays. London: Department of Health 2013.

    4) Life Lessons: PSHE and SRE in Schools. Report of the Education Select Committee 17th February 2015. select/education-committee/news/pshe-sre-report/

    5) Woolf M. Rape classes for 11 year olds. Times on Sunday, page 16: 8th March 2015.

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    The Editor, British Medical Journal,

    Sir, complements for publishing the study by Robyn Kalan and colleague, on usage of cell phone and messaging system in the usage. We have conducted a study - Resident doctors and Smart Phone - How smart they are. How friendly Indian residents in Smart phone usage in day to day scenario and decision making in hospital settings. One has to stop thinking of the smart phones as a phone, when dealing with its place in Internet Medicine/ emergency medicine in particular. One should give smart phone a credit of a powerful mini-computer, with a state-of-the-art photo equipment. Which can collect data as photograph of X- Rays, CT , and transfer the data immediately to superiors, experts. And take the opinion of the consultant who is sitting far .This is specially true for the countries where the doctors , experts , patient ratio is not favorable. ( Taking example of developing countries). Also conventional radiology have a very limited role to play, being mainly restricted to chest x-rays and bedside radiography ,USG facilities will double and CT scan and MRI will continue to grow in an exponential way, with more and more indications being included. (1) Thus increasing point of care investigation facility .Use of point of care ultrasound in the MICU, in the hands of ultrasound trained physicians, can reduce cost by reducing the number of chest x rays and ct scans.(2) Same with the help of a smart phone can be transferred immediately to superiors to get there opinion . One should be very careful till the scientific community comes out with a clear-cut guidelines keeping medico legal issues in such opinion. How ever as a first baby- step to wards the use of this modality inour opinion has a promising future. Keeping the above fact in mind we surveyed 500 plus doctors on telephonic survey in a month and following promising pattern has emerged . Salient features 1. Number of Patients benefitted and photograph taken for sharing 491 out of 502( 97.81 % ). 2. Common website used were e medicine, and medscape , 40(23.95%)and 127 (76.05%) respectively ,

    3. We inferred that ,in the contemporary world, when doctors are busy in learning new things through various means, the latest method of learning and seeking advice from collegues/Seniors is using smart phone and its applications. 4. Smart phones are gift to humanity in view of its current usages by doctors for patient care and usage of their application for immediate decision on the further management. The SPSR(Smart phone smart Residents) study is retrospective study on the usage of smart phone and its application for patient care and benefit. 5. In emergency hours, the crucial decision for patients disease management is an important aspect which can be asked or shared with seniors / taking help from authentic websites for expert opinion within few minutes. This has made Residents life easier in terms of patient management, as rarely patient presents with classical manifestation of a disease. We concluded that modernization and globalization has brought lot of changes to medical world with the introduction of Telemedicine, a newly emerging branch which would continue to benefit in patients care. Smart phones when used smartly gives valuable scientific input in patient care ,but one should be very alert in using the same. References 1.Govindji R. Jankharia Commentary - Radiology in India: The Next Decade. Indian J Radiol Imaging. 2008 August; 18(3): 189-191. 2 Margarita Oks, MD; Rubin Cohen, MD; Seth Koenig, MD; Mangala Narasimhan, DO. The Use of Point of Care Ultrasound in the Medical Intensive Care Unit Reduces Healthcare Cost and Patient Radiation Exposure . Chest. 2013;144(4_MeetingAbstracts):542A

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  6. Re: Sleep and use of electronic devices in adolescence: results from a large population-based study.

    We have with interest read this article showing a negative association between use of PC, cell phone, MP3-player, iPad, game console, TV and sleep in young persons aged 16-19 years (1). The sleep parameters included sleep onset latency (SOL), sleep deficit, and sleep duration. In our cross-sectional study including 2000 invited subjects (63.5 % participation), aged 15-19 years, mobile phone use for > 15 min per day increased the risk for tiredness (OR = 1.5, 95 % CI =1.04-2.0), and for sleep disturbance (OR = 1.2, 95 % CI = 0.9-1.7) (2). The corresponding results for cordless phones were OR = 1.4, 95 % CI = 0.99-1.9 and OR = 1.2, 95 % CI = 0.9-1.7, respectively. However, it should be noted that the persons in the Norwegian study from 2012 used electronic devices for much longer daily time than in our study from 2005-2006. Furthermore, in our study very poor perceived health gave for mobile phone use > 30 min per day OR = 1.8, 95 % CI = 1.2-2.7 and for cordless phone use OR = 1.7, 95 % CI = 1.1-2.5. These results were no longer statistically significant adjusting for sleep and tiredness.

    Hysing et al (1) discuss very little exposure to radiofrequency electromagnetic fields (RF-EMF) when using electronic devices such as cell phones and iPads as a possible contributing factor to sleep disturbances. In that context it would have been pertinent to also assess use of cordless phones (Digital Enhanced Cordless Telecommunications; DECT). The frequency used and output power from these devices are of the same order of magnitude as those of the GSM cell phones (3) and cannot be neglected in the assessment of total use of wireless phones.

    Beta-trace protein is an endogenous sleep-promoting neurohormone. It has a circadian pattern, increasing in the evening with the highest concentrations at night, and regulates sleep through the prostaglandin D system (4). Beta-trace protein may provide additional information on the possible link between sleep and RF-EMF exposure from wireless phones. If the latter would adversely affect sleep function, an effect could go via inhibition of the physiological up-regulation of beta-trace protein during sleep. We have published results showing a negative trend of beta-trace protein concentration in serum for long-term use of wireless phones in the age group 18-30 years (5,6). Our results indicate a biological mechanism for RF-EMF emissions that can contribute to disturbed sleep and should be considered in relation to the findings by Hysing et al (1).


    1. Hysing M, Pallesen S, Stormark KM, et al. Sleep and use of electronic devices in adolescence: results from a large population-based study. BMJ Open 2015;2;5(1):e006748. doi: 10.1136/bmjopen-2014-006748.

    2. Soderqvist F, Carlberg M, Hardell L. Use of wireless telephones and self-reported health symptoms: a population-based study among Swedish adolescents aged 15-19 years. Environ Health 2008 May 21;7:18. doi: 10.1186/1476-069X-7-18.

    3. Redmayne M, Inyang I, Dimitriadis C, Benke G, Abramson MJ. Cordless telephone use: implications for mobile phone research. J Environ Monit 2010; 12: 809-12.

    4. Jordan W, Tumani H, Cohrs S. et al. Prostaglandin D synthase (beta -trace) in healthy human sleep. Sleep 2004:27:867-74.

    5. Hardell L, Soderqvist F, Carlberg M, Zetterberg H, Hansson Mild, K. Exposure to wireless phone emissions and serum beta-trace protein. Int J Mol Med 2010;26:301-6.

    6. Soderqvist F, Carlberg M, Zetterberg H, Hardell L. 2012. Use of wireless phones and serum beta-trace protein in randomly recruited persons aged 18-65 years: a cross-sectional study. Electromagn Biol Med 2012;31:416-24.

    Conflict of Interest:

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  7. Amendment

    Dear Editor,

    The abstract of the article entitled ' Hazardous alcohol consumption among university students in Ireland: a cross-sectional study' reads "The aim of this study is to investigate the prevalence and correlates of hazardous alcohol consumption (HAC) among university students with particular reference to gender and to compare different modes of data collection in this population." in the abstract.

    It should read "The aim of this study is to investigate the prevalence of hazardous alcohol consumption (HAC) and the adverse consequences associated with its use among university students in Ireland, with particular reference to gender differences".

    This was overseen when returning reviewer comments for previous versions of the article.

    Kind regards, Martin Davoren

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  8. Correction to corresponding author's email address

    Please see the correct email address of the corresponding author:

    We apologise for the error.

    The authors

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  9. Obesity Interventions offered in Primary Care

    This article particularly caught our attention because as Psychiatrists we routinely prescribe psychotropic medications with unwanted side effect in the form of weight gain. Under the Shared Care Protocol (with General Practitioners) we often refer our patients to GPs for weight management interventions.

    Globally, there are more than 1 billion overweight adults, at least 300 million of them clinically obese. There was a marked increase in proportion of adults that were obese between 1993 and 2012 from 13.2 % to 24.4% among men and form 16.4% to 25.1% among women1. In 2012, an estimated 62% of adults (aged 16 and over) were overweight or obese and 2.4% had severe obesity. The prevalence of obesity rose form 15% in 1993 to 25% in 2012 2. . Data form Health Survey for England (HSE) show that obesity rates among adults with a long- term limiting illness or disability (LLTI) are 57% higher than adults without a LLTI. Once considered a problem only in high-income countries, overweight and obesity are now dramatically on the rise in low and middle income countries particularly in urban settings.

    Overweight and Obesity are major risk factors for a number of chronic diseases including heart disease3, diabetes4, hypertension, stroke, arthritis and cancer. The Foresight Report in 2007 estimated that direct health care costs attributed to being overweight or obese were 4.2 billion pounds , potentially rising to 6.3billion in 2015 and further up to 9.7 billion pounds by 20505. . A more recent analysis estimated that overweight and obesity cost the NHS 5.1 billion pounds per year6.

    The prescription of antipsychotic medication for chronic and enduring mental illness often leads to weight gain which is most of the times an unacceptable side effect and can also produce metabolic syndrome, irregularities in blood level of glucose and lipids7,8. It is a delicate balance to achieve between mental health recovery and these side effects. These changes invariably affect the life expectancy of patients with mental health issues9.

    To effectively tackle these unwanted side effects, patients are usually referred to dieticians and GPs for further interventions. After reading the results that these interventions are not being offered as they should or not recorded, it raises a few questions:

    1. Every one is aware that GP surgeries are struggling to give appointment to patients who need to be seen for their primary physical disease. Do GP's have the flexibility or allocated time to do any type of preventive work?

    2. GP usually see their patients in 10 minutes time slots, which is hardly sufficient to deal with the primary issue, giving prescription and writing notes. Even though they observe that the patient is overweight there is a limited opportunity to discuss, motivate or give proper advice to these patients.

    3. Earlier GP could prescribe exercise on prescription. In the recent overhauling of the benefit systems, DLA has been replaced with Personal independent Payments (PIP). Many councils have scrapped this privilege under the assumption that people can pay to attend exercise programmes from their PIP allowance. Under the current climate of financial constraints, spending money on such programmes may not take precedence over other basic needs.

    Obesity is growing at a fast rate and if not tackled it would pose an enormous economic burden on the NHS to treat various physical and mental diseases whose precursor is obesity.

    References: 1. Statistics on Obesity, Physical Activity and Diet-England,2014 (Health and Social Care information Centre)

    2. Adult Weight data Sheet Public Health England

    3. H B Hubert,M Feinleib,P M McNamara, WP Castelli: Obesity as an independent risk factor for cardiovascular diseases: a 26 yeas follow up of participant in Framingham Heart Study : Circulation 1983;67:968-977

    4. A.Astrupand N Finer :Redefining Type 2 Diabetes: Diabesity or Obesity Dependent Diabetes Mellitus?

    5. Government Office for Science , Foresight Report,tackling Obesities: Future Choices-Projet Report ,2nd Edition, ocotber 2007.

    6. P Scarborough, P Bhatnagar, K Wickramasinghe ;The economic burden of ill health due to diet, physical activity, smoking ,alcohol and obesity in UK: an update to 2006-07 costs, Journal of Public Health vol.33no.4, may 2011, pp527-535

    7. Jonathan M Meyer, Henry A Nasrallah, Joseph P McEvoy, Donald C Goff, Sonia M Davies, Miranda Chalos, Jayendera K patel, Richard S E Keefe, T Scott Stroup, jefeery A Leiberman: The Clinical Antipsychotc Trails Intervention Effectiveness (CATIE) Schizophrenia . Schizophrenia Vol 80,issue 1, December 2005 .

    8. McIntyre Roger S , McCann Sonia M, Kenenedy Sidney H ; Antipsychotic Metabolic Effects: Weight Gain, Diabetes Mellitus and Lipid Abnormalities. The Canadian Journal of Pyschiatry /La revue canadienne de psychiatrie Vol 46(3), Apr 2001, 273-281

    9. Casey Daniel E, Haupt Dan W , Newcomer John W, Henderson David C , Semyak Michael J, Davidson Michael, Lindenamyer Jean Pierre, Manoukian Steven, V Banerji, Mary Ann, Lebovitz Harold E , Hennekens Charles H : Antipsychotic induced Weight Gan and Metabolic Abnormalities: Implications for increased Mortality in patients with Schizophrenia. Journal of Clinical Psychiatry, Vol 65 (suppl 7) , 2004, 4-18.

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  10. Response to : Methadone maintenance treatment programme reduces criminal activity and improves social well-being of drug users in China: a systematic review and meta-analysis

    Dear Sir, I read this article with great interest as it resonate all the research work done in addiction psychiatry in developed countries. As Psychiatrists we come across many services user whose mental illness is complicated with various substances harmful use or dependency.

    Drug addiction is a big problem world wide especially addiction to class A substance which is difficult to overcome without expert help.It is estimated that there are 500,000 heroin addict in USA and Public Health England figures state that there are around 262,000 opiate drug user in England in 2010/11. The latest figures does show that the drug addiction is more in older group (25-35 years) rather than early teens or young adults1. Not to forget, three times or more the number of these figure , the carers and the family members effected by drug addiction problem of their loved one. Unfortunate there is a large proportion of children who are deprived of stable family homes and are ofter under the care of social services2. These children are more vulnerable to mental health problems including attachment disorder, depression, anxiety ,bullying and predisposition to substance addiction.

    The burden on any health economy due to drug addiction is massive , its impact on mental health and direct consequences on physical health, there are many other blood borne and sexually transmitted disease which are more prevalent in drug addicts e.g. Hepatitis B and C and HIV. 120 new cases of HIV ,in 2012 ,were infection acquired through injecting drugs3.There were 6,549 admissions to mental health hospital with a primary diagnosis of a drug-related mental health and behavioural disorder in 2012/134.

    To fund their drug habit , the drug users do various crimes from shoplifting, burglary, theft selling or smuggling drugs and prostitution5. This adds huge burden Criminal Justice System.The problem drug use costs society ?15.4 billion a year, of which ?13.9 billion is attributed to crime committed by drug dependent offenders5 . Government spending on drug treatment give good value for money, for every one pound , it generates 2.50 pounds worth of savings6.

    Methadone replacement treatment for opiate dependency has been practiced in developed countries for more than two decades. Research has shown that it is cost effective in the term of harm reduction .Its long half life not only helps in combating opioid withdrawal symptoms but it also reduces cravings for opioids.It reduced the euphoric effect of heroine. A number of studies have shown that Methadone maintenance treatment is associated with reduction in mortality (accidental overdoses), injection practices, blood borne infections and other sexually transmitted diseases and criminality. It also improves physical & mental health, social functioning and quality of life6. There is significant reduction in crime rate after the service user enters methadone treatment programme7,8.

    For all these above reasons it is important that Methadone treatment should be the part of a comprehensive assessment which not only for harm reduction but also encourages, as we say each contact matters, service user for detox and rehabilitation.

    References: 1. Statistics on Drug Misuse England 2013 Health and Social Care Information Centre

    2 .Parents with Drug Problems: How Treatment helps Families. The National Treatment Agency for substance misuse 2012.

    3. HIV in the United Kingdom: 2013

    4. Statistics on Drug Misuse England 2013 Health and Social Care Information Centre

    5. National Audit office (2010) Tackling problem drug use .

    6. Home Office (2009) The Drug Treatment Outcomes Research study (DTORS): Cost-effectiveness analysis. Home Office Research Report 25

    7. Change in criminal activity after entering Methadone maintenance James Bell et al. British Journal of Addiction Vol.87, Issue,2 251-258, Feb 1992.

    8. Changes in offending following prescribing treatment for drug misuse.Tim Millar et al .(2008)

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