CORRESPONDENCE.

Sir: Great cities evoke memories and invoke visions. The June 2010 College International Congress held in Edinburgh did both for this correspondent. The reminiscence is of a place for the bridging of art and science, and for recalling the value of mentors such as Henry Walton, Bob Kendell and Norman Kreitman, who had encouraged my international journeyings. The vision was of a Royal College as a truly international organisation – a prospect first glimpsed at the Edinburgh annual meeting in 2000, and when the College had co-hosted a meeting with the Association of European Psychiatrists (AEP) in 1996.

We later celebrated, with the World Psychiatric Association (WPA), the millennium in a 2001 ‘Mind Odyssey of Psychiatry and the Arts’ at the Queen Elizabeth Conference Centre in Westminster – a costly but apt venue. The international arts certainly flourished on that occasion. Guy Woolfenden’s commissioned music Paean was performed by vocalists and a brass ensemble at the opening ceremony, actors approached delegates in the coffee breaks, Ismond Rosen’s fine sculptures were displayed, and the College music society held its first meeting. The scientific programme was also invigorating. Dr Gro Brundtland, Director General of the World Health Organization (WHO), received the Honorary Fellowship.

Yet at most such major international congresses there are conflicts of loyalties, as well as conflicts of interests, to be considered. These occasions, including the recent Congress in Edinburgh, were no exceptions. There was learning to be done. I would respectfully suggest, therefore, that several international issues might be reconsidered by the organising committee, and by College officers, when reviewing the venues and the content of future annual meetings.

Specifically, to welcome and, when appropriate, subsidise international delegates.

Devise new ways of encouraging more Honorary Fellows to attend. They can, and should in my opinion, be able to contribute more actively to College affairs. The College needs to retain their brains as well as their resources.

Establish an inclusive high-profile international reception – an excellent time to give international guests a chance to meet each other, and to converse with past and present College officers.

Consider a strategy for enhancing the profile of the International Divisions and of the International Advisory Committee – the successor to the International Board.

Continue to publicise formal business meetings with WPA officers.

Review the strategy, and the protocol, for working within the WPA, and for welcoming its President. It is the only world organisation for all psychiatrists that can guard, through its Review Committee, the rights of patients and psychiatrists, and can provide academic and clinical support for isolated colleagues.

Consider the timing and content of the Annual General Business Meeting. It is the only formal occasion when any member of the College, including its international members, can raise with due notice matters of importance and listen to pre-circulated reports from College officers.

Sir: Hikikomori is the name given to a major problem in Japan: extreme social withdrawal (the term is a compound of hiki, withdraw, and komoru, hide). The condition is reminiscent of social phobia – an apparent fear of exposure to and embarrassment within social situations, driving avoidant behaviour. In hikikomori, the isolation is frequently extreme; people with the condition have been known to lock themselves in their bedroom for several years. The age range of those affected is rather narrow: they are generally young adults. The sustained isolation is in part to blame for a paucity of direct information regarding the psychological characteristics of hikikomori sufferers. The numbers of people with hikikomori appears to be increasing and this is a worrying trend. The cause of this mass expression, however, remains a mystery. One epidemiological survey in Japan estimated that around 200000–400 000 households support an individual with hikikomori (Koyama et al, 2010). This survey suggested only 55% of people with hikikomori have (over their lifetime) any definable psychiatric diagnosis. In these, hikikomori is linked to anxiety disorder, mood disorder, substance-related disorder or intermittent explosive disorder.

There is evidence for a cohort effect. The average age of people with hikikomori is around 32 years and is increasing (Sakai et al, 2008), which suggests the condition is related to factors that have affected one particular generation. This mirrors other ‘social illnesses’ within Japan. The fathers of hikikomori sufferers are (or were) vulnerable to karoushi (‘death from overwork’), encapsulating the inflated male work ethic of the modernising Japanese society. The link between karoushi and hikikomori is argued as follows. The (work-related) absence of the father affects family dynamics such that the mother (housewife) compensates by strengthening emotional bonds with her (co-dependent) child and ultimately suppresses the child’s psychological independence.

International comment has highlighted the intense educational pressure on young people in Japan: school refusal, more common in hikikomori individuals, has markedly increased among Japanese teenagers over the past 10 years. The technological revolution of the past 20 years (which has led to the dominance of an internet/gaming/media culture), with Japan at the vanguard, may also have fuelled the emergence of hikikomori, which overlaps with internet addiction. It is speculated that long hours spent playing computer games deprives children of opportunities to develop and refine adaptive social skills.

Superficially, hikikomori appears bound by the specific cultural and economic background of Japanese society, but cases resembling hikikomori are increasingly recognised outside Japan (García-Campayo et al, 2007). Global socioeconomic conditions and (technology-driven) shifts in behaviour may have similar effects on people’s mental health across the world: over a decade ago Japan experienced severe economic depression. In parallel, new patterns of behaviour, such as computer gaming, were established earlier in Japan and neighbouring Asian countries. The present global economic depression and rapid embracing of technology in Western countries may see hikikomori, already epidemic within Japan, becoming more common in other societies.

Sir: The elective period has been a feature of the undergraduate medical curriculum for many years. Medical schools recognise that undertaking the elective overseas can have a profound impact on students (Lancet, 1993); the elective can broaden horizons, develop skills and enhance cultural understanding. This was certainly the case for me. I spent my elective period doing psychiatry at Tygerberg and Stikland Hospitals in the vibrant metropolis that is Cape Town, South Africa. I was able to participate in clinical activities in in-patient and out-patient settings, gaining experience of a range of illnesses and clinical presentations that I would not have seen at home. Moreover, working in such an ethnically diverse setting gave me an insight into the cultural influences which shape mental illness and its management in different societies. The placement was facilitated by excellent guidance and teaching from the Cape Town psychiatrists I worked with.

Considering the current problems in recruiting psychiatrists in the UK, it is all the more important that those undergraduates who show an interest have the opportunity to undertake electives in the specialty. It is well known that positive undergraduate experiences, as I had during my elective, can shape future medical careers, especially when the medical student is practically involved during clinical attachments (Mihalynuk et al, 2006).

For the past year I have been a Student Associate representative on the Psychiatric Trainees’ Committee of the Royal College of Psychiatrists. As part of the College’s strategy for recruitment into psychiatry, we would like expand the number of overseas psychiatry elective placements available. We are developing a database of the College’s international members who are willing to provide elective periods of 4–8 weeks for UK medical students in their clinical years. To this end, we would very much welcome any offers from international readers who can provide international psychiatry experience to a UK student with an interest in the specialty. This would have an appreciable impact on the development of the student as well as allowing readers to establish links with UK facilities. If any reader is able to offer this opportunity, please email Ms C. Cox on ccox@rcpsych.ac.uk for further details.

Sir: The medical profession has traditionally been the domain of doctors who acquired their position and prestige through a long and arduous apprenticeship. Not very long ago they worked without any intervening bureaucratic structure. This situation has changed substantially over the years. Healthcare is heading in the same direction as other industries, with the fragmentation and standardisation of doctors’ work, as well as the construction of a managerial superstructure. In addition, the past two decades have seen a proliferation of new clinical roles for nurses in the UK. Nurses are extending their repertoire of skills to include those that were once the domain of junior doctors. The proliferation of specialist nurses and prescriber nurses and so on is pushing doctors away and is deskilling them in areas previously seen as a core part of their role.

Woodall et al (2006) reported that junior doctors are being prevented from actively participating in patient management or handling emergencies because of the introduction of nurse liaison assessment services. This they believe may reduce trainee psychiatrists’ experience of performing self-harm assessments, if they are left with just routine ward work, while nurses become skilled at emergency psychiatric assessment. Junior doctors feel very displeased over their lack of exposure and inadequate training, which are not only deskilling them but also making it harder for them to pass their professional examinations (Zafar & Sadiq, 2007). Sadiq & Sehgal (2007) feel that the introduction of rotas compliant with the European Working Time Directive (EWTD) means that the emergency work which was earlier seen by junior doctors is now shared by crisis resolution home treatment services, as well as liaison and self-harm nurses; this has reduced the opportunity trainee psychiatrists have to gain experience. This opinion is shared by many others who agree that nurses are crossing boundaries that should not be crossed and getting distracted from their real job.

This marginalisation and deskilling of doctors endangers the values that medicine traditionally espoused: service, moral responsibility, and placing the patient’s interests first. Where is all this leading and what lies ahead for junior doctors? There is a need to think seriously about the impact of this ‘industrialisation’ of healthcare and deskilling of junior doctors. In the name of improvement and money saving, the deskilling and downgrading of junior doctors should not be allowed to continue. Doctors will likely find their work less valued over time if they are increasingly replaced by non-doctor clinicians. Changes intended to help junior doctors have gone beyond their original objectives. In the light of these developments, it appears necessary to redefine the role, duties, status and even title of junior doctors.

Sir: Camilleri et al (2010) are to be congratulated on their study of the incidence of psychosis in Malta. They have been able to replicate the findings of the AESOP study (Kirkbride et al, 2006), that the incidence of psychosis does vary across small areas and that the variance depends on more than one factor – not simply population density but also other social factors, such as available housing; hence the incidence of psychosis in the Southern Harbour Area of Malta, where the housing is arguably poorer, is higher than that in the Northern Harbour Area, despite a higher population density in the latter. Similar data, linking a higher incidence of psychosis in areas of increased social deprivation in Luton, England, have been published by our team (Agius & Ward, 2009). Such data must be of great importance in allocating resources in community psychiatric services.

Another important finding reported by Camilleri et al was the markedly increased incidence of psychosis in the population of irregular immigrants. It needs to be noted that this population largely comprises persons from sub-Saharan Africa who have undertaken an extremely arduous journey first to the southern Mediterranean African shore and then by boat in often dangerously unseaworthy craft across the Mediterranean to Europe. Often these persons have had to be rescued from shipwreck. Many come from war zones in Africa. Hence these immigrants may very well have been subject to multiple traumatic experiences, in their homeland, in their journey across Africa, and then across the sea.

A link between post-traumatic stress disorder (PTSD) and the subsequent development of psychotic illness in a subgroup of patients with PTSD was reported from Croatia during the Balkan Wars (Ivezic et al, 1999, 2000) and our team have suggested that the development of psychotic illness in patients with PTSD may be related to exposure to repeated traumatic episodes (Pepper & Agius, 2009). Others have made similar suggestions. Hence these ‘irregular immigrants’ or ‘boat people’ appear to be a group at particularly high risk of developing psychotic illness, as demonstrated by Camilleri et al, and public policy to deal with this group of individuals should bear this in mind.