Course Of Severe Mental Illness Research Articles

Recruiting and exploring vulnerabilities among young people at risk, or in the early stages of serious mental illness (borderline personality disorder and first episode psychosis).

IntroductionMany gaps exist in our understanding of the developmental pathways to severe mental illness (SMI), including borderline personality disorder (BPD) and psychosis. However, those who have experienced adverse childhood experiences (ACEs) are at an increased risk and there is evidence to suggest that one of the earliest markers is emotional dysregulation. An area which has received relatively less research attention is the role neurodevelopmental disorders (NDDs) play. The aim of this feasibility study was therefore to explore the clinical profiles of young people early in the course of SMI, including their profiles of ACEs, emotional regulation difficulties, borderline personality traits and NDDs.MethodsA cross-sectional study of young people (aged 15–25) at risk of SMI, currently being seen within NHS mental health services, was conducted. This included those with early symptoms of psychosis and/or BPD as assessed by diagnostic interview. Eligible participants self-completed a battery of sociodemographic, clinical, and psychological measures in the company of a researcher. This included assessments of: symptoms of NDDs; borderline pathology traits; ACEs; and difficulties in emotional regulation. Statistical analyses included Mann–Whitney U tests and multiple regression.ResultsOf the 118 potentially eligible participants who were referred, 48 were ultimately included in the study. Young people early in the course of SMI reported a high prevalence of ACEs and deficits in emotional regulation. In total, 79% met criteria for attention deficit hyperactivity disorder (ADHD) and/or autism spectrum disorder (ASD). Emotional dysregulation was found to significantly mediate the association between both ACEs and the frequency of NDDs and borderline personality traits, however given the small sample size these results are preliminary in nature.ConclusionYoung people early in the course of SMI are at an increased risk of experiencing multiple childhood adversities and our results indicate a high prevalence of NDDs amongst them. Emotional dysregulation emerged as a potentially significant early marker of future clinical severity. We suggest that the clinical implications of our findings include routine screening for NDDs and ACEs and an increased recognition of the significance of emotional dysregulation. However, larger scale longitudinal studies are needed to investigate these preliminary findings further.

Selbsttäuschungen in der Psychiatrie

Self-deception in psychiatry Psychiatry as a medical specialty has been changed its approaches again and again. It is also subject to paradigms of progress and the pressure to be “modern”. The comparatively low effectiveness of our therapies in people with severe mental crises, the lack of evidence that the course of severe mental illnesses are more favorable than in earlier times and the requirement that psychiatry is “scientific” are dilemmas that can only be overcome through self-deception. Using the example of psychotropic drugs, psychotherapies and traditional community psychiatry, mechanisms of self-deception are presented. It becomes obvious that professionals often only confirm their own prejudices in studies and in the assessment of the effectiveness of their own therapies. An important self-defense strategy against self-deception is consistently taking into account the social context in the care systems and to avoid any form of institutionalization. But it also means that society as a whole, and not just the psychiatric community, needs to take on more responsibility.

'Maybe It Is Only in Prison That I Could Change Like This' The Course of Severe Mental Illnesses During Imprisonment - A Qualitative 3-Year Follow-Up Study From Chile.

BackgroundSevere mental illness (SMI) among imprisoned individuals is a global health concern. Quantitative research indicates on average mental health symptom improvements during imprisonment, however, it cannot reflect multifaceted factors influencing the course of SMI. This study aimed to explore the subjective course of SMI during imprisonment and to identify influencing factors.MethodsThe study has a 3-year-follow-up design of imprisoned individuals in Chile. We conducted semi-structured interviews with 10 men and 9 women at follow-up who had either major depression or psychosis (severe mental illnesses) at baseline. We included individuals who deteriorated, remained stable or improved their mental health according to quantitative assessments. We explored the subjective course of their mental health condition during the follow-up period. Qualitative data was transcribed and coded using NVivo Software for quantitative content analysis. Qualitative data was also manually coded and was subsequently analyzed using the thematic analysis method with an inductive approach. We developed the final themes using the results of this analysis in combination with the inclusion criteria.ResultsThe mental health of 10 individuals subjectively improved, 6 experienced deteriorations, and 3 did not perceive any change. Good infrastructure, structure/occupation, intrapersonal resources (will to change, spirituality) and supportive relationships were identified as factors improving mental health. Factors deteriorating mental health were identified as bad infrastructure (e.g., no running water and bad housing conditions) and crowding, lack of psychological treatment, exposure to violence, interpersonal stress (conflictive relationships and separation from family), perceived injustice through sentencing, intrapersonal stressors and previous medical conditions.DiscussionSMI in prison can improve in a supportive environment under certain conditions. These conditions include the improvement of infrastructure (housing and healthcare), the opportunity to work or study, protection from violence during imprisonment, and to develop intrapersonal resources and family relationships. To reduce SMI in prisons the improvement of these conditions should become a priority.

The Twenty-Year Trajectory of Suicidal Activity Among Post-Hospital Psychiatric Men and Women with Mood Disorders and Schizophrenia

The Chicago Follow-up Study has followed the course of severe mental illness among psychiatric patients for more than 20 years after their index hospitalization. Among these patients are 97 schizophrenia patients, 45 patients with schizoaffective disorders, 102 patients with unipolar nonpsychotic depression, and 53 patients with a bipolar disorder. Maximum suicidal activity (suicidal ideation, suicidal attempts and suicide completions) generally declines over the 3 time periods (early, middle, and late follow-ups) following discharge from the acute psychiatric hospitalization for both males and females across diagnostic categories with two exceptions: female schizophrenia patients and female bipolar patients. A weighted mean suicidal activity score tended to decrease across follow-ups for male patients in the schizophrenia, schizoaffective, and depressive diagnostic groups with an uneven trend in this direction for the male bipolars. No such pattern emerges for our female patients except for female depressives. Males’ suicidal activity seems more triggered by psychotic symptoms and potential chronic disability while females’ suicidal activity seems more triggered by affective symptoms.

Prognostic Models in Bipolar Disorder: Can the Prediction of the Long-Term Clinical Course Rely on the Integration of Clinical and Molecular Data?

Prognostic models in bipolar disorder: where are we now? Bipolar disorder (BD) is a heritable psychiatric illness characterized by the recurrence of depressive and hypomanic or manic episodes alternating with intervals of partial or full recovery. BD presents substantial hetero geneity in symptomatology, illness course, pattern of psychiatric and medical comorbidities, and treatment response [1]. Given that the onset of BD is in the early 20s [2] and the risk of recurrence remains constant over the lifespan up to the age of 70 years or later [3], the identification of predictors of long-term outcome has relevant implications for clinical management, treatment selection and, possibly, the elaboration of preventive strategies. This might be achieved through the development and validation of prognostic models [4] that rely on the integration of multiple, evidence-based and temporally stable predictors with clinical and/or biological relevance (i.e., biomarkers) [5]. In recent years, there has been a mounting interest in the development of staging models of BD [6,7]. Based on the concept of neuroprogression (i.e., “the pathological reorganization of the central nervous system along the course of severe mental illness” [8]), and on prognostic research [9], these models provide a heuristic framework to develop therapeutic intervention strategies specific for subgroups of BD patients at different stages of the illness [7]. Once validated in prospective cohorts [7], staging models could lead to a stratified medicine approach in BD. However, at present we do not have validated prognostic models for BD. Yet, in clinical settings, diagnostic and therapeutic decisions, implying to a certain extent prognostic ones too, are routinely made on the basis of the phenomenology of symptoms presented by BD patients, particularly in the early phases of the illness. We refer in particular to the core features of BD, namely the periodicity of affective episodes (i.e., the recurrence and length of hypomanic, manic and depressive episodes) in the illness course, and the demographic and clinical characteristics at BD onset. Here we propose that this set of features may be suitable for integration and testing in prognostic models of BD. In addition, since specific molecular changes (particularly gene-expression alterations) appear to be associated with the euthymic, depressive or manic/hypomanic phases [10], we suggest that genetic and transcriptomic data should be included in these prognostic models. Finally, we propose that prognostic models should implement clinical and biological biomarkers identified by the investigation of treatment-responsive subgroups of BD patients.

A randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric disorders.

Substance use disorders have a profound impact on the course of severe mental illnesses and on the family, but little research has evaluated the impact of family intervention for this population. To address this question, a randomized controlled trial was conducted comparing a brief (2-3 mo) Family Education (ED) program with a longer-term (9-18 mo) program that combined education with teaching communication and problem-solving skills, Family Intervention for Dual Disorders (FIDD). A total of 108 clients (77% schizophrenia-spectrum) and a key relative were randomized to either ED or FIDD and assessed at baseline and every 6 months for 3 years. Rates of retention of families in both programs were moderate. Intent-to-treat analyses indicated that clients in both programs improved in psychiatric, substance abuse, and functional outcomes, as did key relatives in knowledge of co-occurring disorders, burden, and mental health functioning. Clients in FIDD had significantly less severe overall psychiatric symptoms and psychotic symptoms and tended to improve more in functioning. Relatives in FIDD improved more in mental health functioning and knowledge of co-occurring disorders. There were no consistent differences between the programs in substance abuse severity or family burden. The findings support the utility of family intervention for co-occurring disorders, and the added benefits of communication and problem-solving training, but also suggest the need to modify these programs to retain more families in treatment in order to provide them with the information and skills they need to overcome the effects of these disorders.

Futility in the Practice of Community Psychiatry

The experience of futility among frontline clinicians in community psychiatry is produced by the temporal structuring of their work. All health care providers share the disposition to intervene in the course of disease. Specific notions about the course of severe mental illness are woven into the mission of Assertive Community Treatment (ACT) as well as the treatment plan, a key paperwork tool used to stage daily activities. The treatment plan demands a narrative of progress that ACT workers often find impossible to supply. The gap between the ideal of progress and the realities of practice produce distinctive kinds of demoralization. Drawing from an ethnography of a single ACT team in the United States, this article explores how clinicians encounter, articulate, and attempt to resolve such experiences of futility. It explores their practical strategies to reframe the time horizons of work and thereby restore the sense of their own therapeutic power.

Disability and clinical course of severe mental illness

Background:Social disability is a key outcome measure for severe mental illness, being a pivotal variable, that modulates the effectiveness of treatments and might be modified by the treatments themselves.Objectives:The aims of the studies presented were: 1) to determine changes overtime in symptoms and social disability in a 1 year treated prevalence cohort of subjects affected by psychosis vs. those affected by non psychotic disorder receiving community-based mental health care, and to explore 2) predictors of clinical and social outcome; 3) the effect of clinical course on disability and quality of life.Methods:Three hundred fifty four patients treated in the South-Verona CMHS were followed-up over 6 years (with assessments made at baseline, at 2 and 6 years) by using a set of standardised measures exploring psychopathology (BPRS), social disability (WHO-DAS) and quality of life (LQoLP). GLLAMM models were used to explore longitudinal predictors of clinical and social outcome. The effect of clinical course on disability was explored by consulting retrospectively the clinical records.Results:In psychotic patients relationships with partners were more frequently severely impaired, followed by dysfunction in the occupational and parental role. Longitudinal analyses displayed a clinical and social outcome characterized by complex patterns of exacerbation and remission over time; however a clear trend towards a deteriorating course was not found, thus challenging the notion that psychotics are not fatally prone to a destiny of chronicity. Models explained 69% of the total variance for social disability. Predictors for disability were clearly differentiated from those for clinical status, but the two domains appeared entwined: the main clinical predictor of social disability was the negative component of psychotic symptoms (the higher negative symptoms, the lower social functioning) and higher disability predicted in turn a worsening of negative symptoms. Continuous course was associated with higher disability and lower quality of life.Conclusions:Psychopathology and disability are distinct outcome domains only partially overlapping, which do not directly co-vary overtime and are influenced, at least in part, by separate predictors susceptible to specific interventions. However, they are entwined in a vicious cycle leading overtime to a progressive reciprocal worsening with deleterious effect on patients' daily living and independence. Modern mental health services should be capable of shaping treatments to address these patients' multifaceted problems.

Connectedness and Citizenship: Redefining Social Integration

Connectedness and Citizenship: Redefining Social Integration

Four Types of Family Involvement Over the Course of Severe Mental Illness: An Exploratory Study

Little is known about the long-term involvement of families in the life of persons suffering from severe psychiatric disorders. The trajectories of 80 young adults are drawn in this study to determine social networks, service utilization patterns, and family involvement type. Findings indicate that, for community-living patients, family involvement type is a key adaptation factor.

Recovering from Severe Mental Illness: Mutual Influences of Self Illness

A growing body of literature on the subjective experiences of people with severe mental illness (SMI) reveals the importance of the experience of self. The current study explored how the course of SMI is related to individuals' subjective experience of self. Bimonthly, comprehensive, semi-structured interviews with 43 people who had been discharged from psychiatric hospitalization were conducted over a 1-year period. Qualitative analysis of the data revealed mutual influences between the experience of self and illness over time. Conceptual and clinical implications of the relation between self and illness are discussed.

The emerging self in conceptualizing and treating mental illness.

1. The course of severe mental illnesses is more heterogeneous than previously thought and is influenced by many complex, interacting factors. 2. The experience of self and capacity to cope of people with mental illnesses contribute to the recovery process. 3. Changes in traditional treatment models and a focus on broader societal interventions are needed to facilitate recovery. 4. Psychiatric nurses play an important role in these new developments as evident, for example, in the 3R Program (relapse, recovery, and rehabilitation).

Trauma, PTSD, and the course of severe mental illness: an interactive model

Traumatic life events, as defined by DSM-IV, are common among persons with severe mental illnesses (SMI) such as schizophrenia. Limited evidence suggests concomitantly high rates of posttraumatic stress disorder (PTSD) in this population. However, conceptual models do not exist for understanding the interactions between trauma, PTSD, and SMI. We propose a model, which is an extension of the stress-vulnerability model, in which PTSD is hypothesized to mediate the negative effects of trauma on the course of SMI. Our model posits that PTSD influences psychiatric disorders both directly, through the effects of specific PTSD symptoms including avoidance, overarousal, and re-experiencing the trauma, and indirectly, through the effects of common correlates of PTSD such as retraumatization, substance abuse, and difficulties with interpersonal relationships. We discuss the evidence supporting this model, and consider several intervening variables that are hypothesized to moderate the proposed relationships between PTSD and SMI, including social support, coping and competence, and antisocial personality disorder. Theoretical and clinical implications of the model are considered, as well as several methodological and nosological issues. We conclude with a brief discussion of directions for future research aimed at evaluating components of the model.

Co-occurring severe mental illness and substance use disorders: a review of recent research.

Understanding the complex diagnostic and treatment issues posed by the co-occurrence of severe mental illness and substance use disorders has become a necessary exercise in current psychiatric practice. The authors reviewed research studies from the past six years that have contributed to our knowledge about effective assessment, diagnosis, course of illness, and treatment approaches. Research on special populations, including women, persons infected with HIV, and violent patients, is highlighted. PsycINFO, Silver Platter, and MEDLINE were used to search for English-language studies published in the United States and other countries. To augment the search, selected bibliographies were reviewed with a focus on clinical standards. Information was sought on epidemiology, screening and assessment strategies, course of illness, models of treatment delivery, and cost of care. Although estimates of the prevalence of substance use disorders vary by population, a higher prevalence among persons with severe mental illness has been confirmed. Routine screening for and assessment of substance use disorders among persons with severe mental illness has become the accepted standard of care. The course of severe mental illness is negatively influenced by a substance use disorder, and an integrated approach to the treatment of both disorders is generally accepted to be the most promising treatment strategy. Components of this strategy include harm reduction, treatment in stages, motivational interviewing, cognitive-behavioral interventions, and modified 12-step self-help groups.

Treated Prevalence Rates of Severe Mental Illness Among HMO Members

The authors examined the extent to which health maintenance organizations (HMOs) enroll and provide services to people with severe mental illness. The automated pharmacy system of a large HMO identified members who had received a prescription for an antipsychotic drug or lithium during the two-year study period (1986 and 1987). These data, combined with data from a 2 percent random sample of HMO members and from medical records, were used to identify members who satisfied DSM-III-R criteria for schizophrenia and bipolar disorder. Treated prevalence rates derived from these data were compared with estimated treated prevalence data obtained in the National Institute of Mental Health's Epidemiologic Catchment Area (ECA) survey. Although methodological complications and small sample sizes precluded a detailed comparison, the study found a significantly lower treated prevalence rate of schizophrenia among HMO members than in the ECA survey. The treated prevalence rate of bipolar disorder was also lower than the ECA rate, but the difference was not significant. The differences in treated prevalence rates seemed to be the result of different study methodologies and factors influencing HMO membership. The results underscore the need for a comprehensive study of the course of severe mental illness among HMO members.

Comment on ?Adaptation: The key to community psychiatric practice in the rural setting?

This article cogently describes many of the sociocultural problems that sometimes appear to be endemic in impoverished rural areas, the state of the public mental health system in such areas, the difficulties encountered by rural psychiatrists in such areas, and the standard coping strategies that they adopt. It reflects the constructive struggle of a young psychiatrist who was not prepared by training or background to work in this type of setting but has adapted to a difficult situation. To place the article in a larger context, we must remember that not all rural areas are impoverished, that not all rural mental health systems are understaffed and underfunded, and that not all psychiatrists experience rural cultures as foreign. Many of the better public mental health systems are located in rural states, and these settings appear to have several distinct advantages over urban settings for rehabilitative work with mentally ill people. A number of long-term follow-up studies have found that people with severe mental illness achieve better adjustments over time in rural areas than in urban areas. Research indicates that both supports and stressors influence the course of severe mental illness and that rural settings may offer advantages in both areas (GAP, 1992). Families, friends, and other natural supports for people who are poor and mentally disabled may be less fragmented and more available in rural