Psychiatric Case Research Articles

Variations in volume of emergency surgeries and emergency department access at a third level hospital in Milan, Lombardy, during the COVID-19 outbreak

BackgroundDuring the recent outbreak of COVID-19 (coronavirus disease 2019), Lombardy was the most affected region in Italy, with 87,000 patients and 15,876 deaths up to May 26, 2020. Since February 22, 2020, well before the Government declared a state of emergency, there was a huge reduction in the number of emergency surgeries performed at hospitals in Lombardy. A general decrease in attendance at emergency departments (EDs) was also observed. The aim of our study is to report the experience of the ED of a third-level hospital in downtown Milan, Lombardy, and provide possible explanations for the observed phenomena.MethodsThis retrospective, observational study assessed the volume of emergency surgeries and attendance at an ED during the course of the pandemic, i.e. immediately before, during and after a progressive community lockdown in response to the COVID-19 pandemic. These data were compared with data from the same time periods in 2019. The results are presented as means, standard error (SE), and 95% studentized confidence intervals (CI). The Wilcoxon rank signed test at a 0.05 significance level was used to assess differences in per-day ED access distributions.ResultsCompared to 2019, a significant overall drop in emergency surgeries (60%, p < 0.002) and in ED admittance (66%, p ≅ 0) was observed in 2020. In particular, there were significant decreases in medical (40%), surgical (74%), specialist (ophthalmology, otolaryngology, traumatology, and urology) (92%), and psychiatric (60%) cases. ED admittance due to domestic violence (59%) and individuals who left the ED without being seen (76%) also decreased. Conversely, the number of deaths increased by 196%.ConclusionsDuring the COVID-19 outbreak the volume of urgent surgeries and patients accessing our ED dropped. Currently, it is not known if mortality of people who did not seek care increased during the pandemic. Further studies are needed to understand if such reductions during the COVID-19 pandemic will result in a rebound of patients left untreated or in unwanted consequences for population health.

PATTERN OF PSYCHIATRY MORBIDITY DURING THE LOCKDOWN PHASE OF COVID-19

Background: Burden of mental disorders is expected to rise during the COVID 19 pandemic due to the prolonged lockdown. Hence this study was conducted to assess the burden of psychiatric illnesses during this immediate post lockdown period. Methods: A cross sectional study in the Department of Psychiatry at a tertiary care teaching hospital during the period of August 2020 to October 2020. A total of 487 psychiatric outpatient cases were included. Data was entered and analyzed using Statistical Package for Social Sciences version 18. Results: Depression, manic and hypomanic types were common mood disorder reported. Anxiety disorders like obsessive compulsive disorder, post traumatic stress disorder and panic disorders were reported among 3.5%, 1.2% and 6.4% of cases, respectively. Schizophrenia and Substance abuse disorder was reported among 19.1% and 13.8% of cases respectively. Conclusion: Burden of different psychiatric illnesses reported during the immediate post lockdown was found to be similar as before COVID 19 pandemic scenario

A Study of Criminal Manifestation and Characteristics of Elderly Mental Illness

Objective: As the population of the elderly increases, the prevalence of dementia and other mental diseases of the elderly is also increasing. Dementia is a typical elderly mental illness. Some people with dementia may cause a crime due to symptoms of mental behavior. The purpose of this study is to examine the characteristics of criminal behavior of various elderly mental patients. Methods: From January 1, 2010 to December 31, 2019, the court selected 65 years of age or older from among the criminal psychiatric appraisal cases commissioned by the court. A total of 205 medical records and mental assessments were reviewed retrospectively. All records were prepared through psychiatric interviews, clinical psychological examinations, and other examinations, and the information compiled was viewed in several aspects, including demographic factors, crime characteristics, and psychiatric opinions, at the level of technical analysis. Results: There was a statistically significant difference in the judgment of criminal liability according to the degree of cognitive impairment (p<0.001) in the elderly mentally ill, and a significant difference in criminal behavior depending on the type of mental illness (p<0.001). Conclusion: Not only dementia but also other elderly mental illnesses are related to violent crime. In particular, paranoid symptoms and alcohol abuse in older adults’ mental illness are related to the type of criminal behavior. In an aging society, appropriate therapeutic intervention is needed to prevent criminal behavior of the elderly mentally ill.

Involuntary psychiatric hospitalizations in Israel 2001–2018 and risk for immigrants from different countries

Since 2000, the Israeli mental health system has undergone a reduction in hospital beds, initiation of community-based rehabilitation, and transfer of governmental services to health maintenance organizations. This study examined trends, predictors and outcomes of involuntary psychiatric hospitalizations (IPH), in particular for immigrants. All first psychiatric hospitalizations of adults, 2001–2018, in the National Psychiatric Case Registry were used. Involuntary and voluntary hospitalizations were analyzed by demographic and clinical characteristics, and age-adjusted rates calculated over time. Multivariate logistic regression models were used to investigate IPH predictors and first IPH as a risk factor for one-year suicide after last discharge, and a Cox multivariate regression model to examine its risk for all-cause mortality. Among 73,904 persons in the study, age-adjusted rates of IPH were higher between 2011 and 2015 and then decreased slightly until 2018. Ethiopian immigrants had the highest risk for IPH, immigrants from the former Soviet Union a lower risk, and that of Arabs was not significantly different, from non-immigrant Jews. IPH was not significantly associated with one-year suicide or all-cause mortality. These findings demonstrate the vulnerability of Ethiopian immigrants, typical of disadvantaged immigrants having a cultural gap with the host country and highlight the importance of expanding community mental health services.

Factors of psychiatric emergencies affecting boarding time in the emergency department

IntroductionPsychiatric emergencies are acute disturbances in thought, behavior or mood which require immediate medical intervention. As a substantial number of patients with mental illness present as psychiatric emergencies, the sustainability and management of psychiatric emergency services becomes significant.ObjectivesIn this study we aimed to examine the factors associated with psychiatric emergency care, taking the boarding time in the emergency department as primary outcome measure.MethodsCharts of 466 psychiatric emergency cases admitted to the Hacettepe University Emergency Department (ED) between December 2018 – September 2019 were evaluated. Boarding time (BT) in the ED, presence of self-harm, psychotic symptoms and agitation were noted.ResultsIn the examined period, number of patients admitted increased with time significantly (r= 0.562, p &lt;0.01). However, increase in the number of patients was not correlated with an increase in BT. Patients with psychotic symptoms had greater BT compared to non-psychotic patients (7.01 hours vs. 11.24 hours, T= -2.796 df = 182.717 p &lt;0.01). Patients with self-harm also had greater BT (7.47 hours vs. 9.85 hours, T = -2.013 df = 433 p &lt;0.05). Patients with self-harm in relation with previous suicidal ideation displayed significantly a longer BT when compared with patients admitted due to self-harm without any suicidal plan (U=2572,5 p&lt;0.01).ConclusionsA significant increase in BT with psychosis and self-harm due to a suicidal plan supports the need of intermediate facilities between the ED and inpatient units, as such facilities would create a positive impact in the care of psychotic and suicidal patients.

Real-World Treatment Costs and Care Utilization in Patients with Major Depressive Disorder With and Without Psychiatric Comorbidities in Specialist Mental Healthcare.

BackgroundThe majority of patients with major depressive disorder (MDD) have comorbid mental conditions.ObjectivesSince most cost-of-illness studies correct for comorbidity, this study focuses on mental healthcare utilization and treatment costs in patients with MDD including psychiatric comorbidities in specialist mental healthcare, particularly patients with a comorbid personality disorder (PD).MethodsThe Psychiatric Case Register North Netherlands contains administrative data of specialist mental healthcare providers. Treatment episodes were identified from uninterrupted healthcare use. Costs were calculated by multiplying care utilization with unit prices (price level year: 2018). Using generalized linear models, cost drivers were investigated for the entire cohort.ResultsA total of 34,713 patients had MDD as a primary diagnosis over the period 2000–2012. The number of patients with psychiatric comorbidities was 24,888 (71.7%), including 13,798 with PD. Costs were highly skewed, with an average ± standard deviation cost per treatment episode of €21,186 ± 74,192 (median €2320). Major cost drivers were inpatient days and daycare days (50 and 28% of total costs), occurring in 12.7 and 12.5% of episodes, respectively. Compared with patients with MDD only (€11,612), costs of patients with additional PD and with or without other comorbidities were, respectively, 2.71 (p < .001) and 2.06 (p < .001) times higher and were 1.36 (p < .001) times higher in patients with MDD and comorbidities other than PD. Other cost drivers were age, calendar year, and first episodes.ConclusionsPsychiatric comorbidities (especially PD) in addition to age and first episodes drive costs in patients with MDD. Knowledge of cost drivers may help in the development of future stratified disease management programs.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40273-021-01012-x.

Supporting Evidence from the DSM and ICD Classifications to Better Understand Traumatic Experiences, PTSD in Law

Supporting Evidence from the DSM and ICD Classifications to Better Understand Traumatic Experiences, PTSD in Law

Community Rehabilitation and Hospitalizations Among People With Chronic Psychotic Disorder: Is There a Differential Association by Co-occurring Substance Use Disorder?

Objective: Co-occurrence of chronic psychotic disorders and substance use disorder (SUD) is clinically challenging and increasingly prevalent. In 2000, legislation was passed in Israel to foster rehabilitation and integration in the community of persons with mental health disorders. In 2010, the need to allocate resources for patients with these co-occurring disorders (COD) was officially recognized. Yet, most rehabilitation services were not specifically designed for COD. This study examines the relationship between duration of community rehabilitation and number of psychiatric hospitalization days among persons with/without COD in Israel.Methods: Data from the National Psychiatric Case Register on 18,684 adults with schizophrenia/schizoaffective disorders hospitalized in 1963–2016, was merged with data from the Israel Mental Rehabilitation Register. Associations and interactions between COD-status (COD/non-COD), time-period (Period1: 2001–2009, Period2: 2010–2016), duration of housing or vocational rehabilitation on hospitalization days per year were analyzed using repeated-measures ANOVA.Results: The proportion of non-COD chronic psychotic patients who received rehabilitation services increased from 56% in Period1 to 63% in Period2, as it did among COD patients—from 30 to 35%. The proportion of non-COD patients who received longer-duration vocational rehabilitation (≥1 year) was significantly higher (43%) than among COD patients (28%) in both time periods. For housing rehabilitation, these proportions were 79 and 68%, respectively. Persons with COD experienced more hospitalization days annually than non-COD patients. Duration of rehabilitation (less/more than a year) was inversely associated with annual number of hospitalization days (p < 0.0001). This pattern was noted in both COD and non-COD groups and remained significant after controlling for age, sex, COD group, percent of hospitalizations with SUD, and age at first hospitalization.Conclusions: COD patients with prolonged rehabilitation seemingly achieve long-term clinical improvement similar to non-COD patients, despite most rehabilitation settings in Israel not being designed for COD patients. Yet, COD patients receive overall less rehabilitation services and for shorter periods than non-COD patients. Long-term rehabilitation services should be provided to COD patients, who may need more time to commit to treatment. To achieve better long-term mental health improvements, a continued expansion of community-based integrative treatment and rehabilitation services for COD patients is needed in Israel.

Collaborative Care Rises to the Pandemic Challenge

Collaborative Care Rises to the Pandemic Challenge

Current Status and Prospects of Community Psychiatric Home Care

Psychiatric home care is an effective model for providing care to community-based patients with psychosocial needs who are unable to receive continuous treatment / rehabilitation in mental health hospitals. Moreover, this model has been shown to effectively reduce rehospitalization and promote recovery in these patients. Three psychiatric home care models are described in this article: medical-based home care; prevent recurrence public health home care; and preventing disability long-term care home care. Furthermore, the resources required to provide psychiatric home care are estimated and current psychiatric home care-related problems, dilemmas, and prospects are summarized. Building an accessible psychiatric home care network may be accomplished by promoting evidence-based home care case management practices and ensuring psychiatric case management nurses are properly certified. This network will help improve significantly the quality of care received by community-dwelling patients with mental illness.

ПРОГРАММА ОБУЧЕНИЯ РОДИТЕЛЕЙ НА ОСНОВЕ ТЕОРИИ РАЗВИТИЯ УМСТВЕННОЙ ДЕЯТЕЛЬНОСТИ ЧЕЛОВЕКА П.Я. ГАЛЬПЕРИНА: НОВЫЙ ЭФФЕКТИВНЫЙ ПОДХОД

Introduction. Parent training programs developed in the late ‘60s of the last century are those recognized as an important component in work with children and adolescents in a psychiatric or social dysfunction context. Th e cases in which its application would be most necessary oft en have poor results, sometimes causing an insurmountable challenge for professionals. Th erefore, new methodologies are needed, which will allow for greater effi ciency. Methods. We started by reviewing the unsuccessful processes in classical methodologies parent training programs at our institute, considered “unsuccessful” when aft er nine months of the program, parents’ attitudes towards their children remained unchanged, continuing to show diffi culty in being aware of the guiding role that parents play in their child’s psychological ontogenesis. We designed an experimental methodology guided by Galperin’s Th eory of the Development of Human Mental Activity, which we tested in a series of 12 cases drawn randomly from those previously identifi ed. Results. Th e program’s main objective was achieved in 11 of 12 cases in a reduced number of sessions. Th ere was an average session count of 5.25, SD of 2.42, a minimum of 2 and a maximum of 8 sessions. Discussion and some concluding remarks. Th e excellent results observed in this fi rst study suggest that the used methodology can promote the quality of parental guidance carried out in psychiatric clinic processes and social cases. Th us, Galperin’s Th eory of the Development of Human Mental Activity can show in parent training as important results as those that over the years have already been shown in pedagogy.

Pattern of psychiatric presentation of patients coming to the emergency unit of psychiatry department of a tertiary care teaching hospital in West Bengal

Background: Psychiatric emergencies are characterized by acute conditions of disturbances of affect or mood, behavior, and thoughts, which, if not managed with immediate therapeutic intervention, can cause great harm to the patient and surroundings. In most of the institutions, due to lack of emergency psychiatric units, these are managed by general hospital emergency units, which is the reason for underreporting of psychiatric cases in developing countries like India.Aim: The aim is to study the pattern of psychiatric presentation of the patients coming to the psychiatric emergency unit of a tertiary care teaching hospital in West Bengal.Methods: This prospective, longitudinal, hospital-based study was conducted for a period of 3 months on patients attending the psychiatric emergency unit of a tertiary care teaching hospital in West Bengal. Clinical details of the patient, source and reason for referral, and presenting complaints were recorded and analyzed.Results: Out of 200 patients attending the psychiatric emergency unit, most were female aged between 21 and 40 years. The three most prevalent presenting complaints among subjects were abnormal behavior with somatic complaints, excitement, and violent behavior followed by substance use. The foremost reason for a referral from other departments was either due to the absence of any physical illness or no abnormalities detected in the investigations conducted.Conclusions: The results from the study could help in gaining knowledge regarding emergency psychiatric conditions, increase in preparedness for their rapid management, and improvement of emergency psychiatry services to meet the mental healthcare demands in our country.

Treatment and Diagnostic Considerations in a Complex Psychiatric Case - a Case Report

A patient with a history of autism spectrum disorder and epilepsy was hospitalized for management of acute onset psychosis and agitation. The acuity of his behaviors warranted abrupt shifts in treatment and multiple pharmacologic interventions were ineffective. The atypical nature of his presentation and intense pressure from ancillary staff to consider organic etiologies drove frequent transitions of care within the hospital setting. Multiple diagnoses were considered including a primary psychosis, excited catatonia and antiepileptic drug-induced psychotic disorder. Ultimately the patient was diagnosed with bipolar disorder and effectively treated with quetiapine and valproic acid. The authors suggest that rapid consideration of comorbid bipolar disorder in autism spectrum disorder patients presenting with affective dysregulation may expedite trial of an anticonvulsant with mood stabilizing properties, which would have simplified this patient’s clinical course and limited potential for iatrogenic harm. This course of treatment should especially be considered when a history of epilepsy is present.

Coagulopathy at intoxication with rodenticides – antagonists of vitamin K

The review is devoted to poisoning with rodenticides containing indirect anticoagulants – vitamin K antagonists (VKA). The work describes the main groups of anticoagulants that are used in such preparations, describes the mechanism of their action. The authors analyzed a significant number of foreign and local literary sources on the poisoning of the rodenticides of this group. It was concluded that VKA intoxication occurs much less frequently than other rodenticides; it is mainly the occasional intake of drugs, most of the victims are children. The use of rodenticides-VKA by psychiatric patients and criminal cases are not common. Analysis of the literature has shown that the overwhelming number of poisonings occurs when using VKA, which are contained in ready-made rodent-control baits available to the majority of the population. Intoxication with modern rodenticides-VKA – superwarfarins is possible with oral, dermal exposure and contact with the mucous membranes of the eye; they have a cumulative effect. The main clinical manifestation of superwarfarin poisoning is hemorrhagic syndrome. The clinical signs of coagulopathy are much more pronounced in case of deliberate poisoning than in case of accidental poisoning, since for the appearance of hemorrhagic syndrome, a large amount of the substance contained in the finished bait is required. The principles and features of diagnosis, differential diagnosis and treatment of coagulopathy of this genesis are described. All patients have changes in the coagulogram, characteristic of vitamin K-dependent coagulopathy: an increase in the international normalized ratio, prothrombin time and activated partial thromboplastin time, a decrease in the levels of II, VII, IX and X blood coagulation factors, physiological anticoagulants – proteins C and S. Determine the concentration of superwarfarin in the blood using high performance liquid chromatography is not possible in every medical institution. In the clinical diagnosis of coagulopathy and the identification in the coagulogram of changes characteristic of vitamin K deficiency, even if its etiological cause has not been established, it is immediately necessary to prescribe adequate therapy: the introduction of fresh frozen plasma and/or concentrates of prothrombin complex factors, prescription of vitamin K preparations, symptomatic therapy. Taking into consideration the long half-life of superwarfarins, coagulopathy can persist for several months, during which treatment should be continued. With timely diagnosis and the appointment of adequate therapy, the prognosis in most cases is favorable. The mortality rate among people with superwarfarin poisoning is not high. As an illustration, the authors cite two clinical cases from personal practice.

Clinical Profile of Mortality among Chronic Schizophrenic Patients: A Local Pilot Survey in Iran

Background: Many scholars believe that mental disorders may increase the risk of mortality among psychiatric patients in comparison with ordinary people. Unfortunately, since there is no systematic psychiatric case register system in Iran, a precise study of the rate of mortality of psychiatric patients in Iran is not easy. Objective: The objective of the current study included estimation of the rate of mortality and clinical profile of the died patients in a group of non-western aged schizophrenic patients. Methods: Senior section of Razi psychiatric hospital was selected as the specific field of investigation, and all elderly schizophrenic patients (≥65 years old), who had been hospitalized there, were nominated as the accessible sample and estimated with respect to the objectives of the present assessment. For survey, all deaths in the said district, which had occurred throughout the last sixty months (April of 2014-August 2019), had been listed by the supervisor of the mortality committee of the hospital. The clinical diagnosis was based on ‘Diagnostic and Statistical Manual of Mental Disorders’, 5th edition, criteria. Results: Among 840 chronic elderly schizophrenic patients, 69 deaths were registered by the mortality committee of the hospital. As evident by the results, the annual rate of mortality among elderly schizophrenic patients in the present assessment was around 0.015 (0.15 per 1,000 individuals per year) and 0.017 (0.17 per 1,000 individuals per year) among male and female aged patients, respectively, which was significantly lower than the native crude death rate. While the average age of the expired female patients was significantly longer than male cases, the life expectancy of both male and female patients was significantly shorter than the life expectancy of native people. Besides, while among the present sample of old schizophrenics cardiac disease was the main leading cause of death, other causes, like violence, suicide, road traffic accidents, falls, fires, drug use, tuberculosis, drowning, epilepsy, and Parkinson’s disease were not liable at all. Conclusion: While the rate of mortality among aged schizophrenics was significantly lower than the native crude death rate, the age of the expired female patients was significantly longer than the male cases and the life expectancy of both male and female patients was significantly shorter than the life expectancy of native people. Cardiac disorder was the leading cause of death among the present sample of aged schizophrenics.

The persistence of child and adolescence mental healthcare: results from registry data

BackgroundPrevious studies on the persistence of child and adolescent mental healthcare do not consider the role of time-invariant individual characteristics. Estimating persistence of healthcare using standard linear models yields biased estimates due to unobserved heterogeneity and the autoregressive structure of the model. This study provides estimates of the persistence of child and adolescent mental healthcare taking these statistical issues into account.MethodsWe use registry data of more than 80,000 Dutch children and adolescents between 2000 and 2012 from the Psychiatric Case Registry Northern Netherlands (PCR-NN). In order to account for autocorrelation due to the presence of a lagged dependent variable and to distinguish between persistence caused by time-invariant individual characteristics and a direct care effect we use difference GMM-IV estimation. In further analyses we assess the robustness of our results to policy reforms, different definitions of care and diagnosis decomposition.ResultsAll estimation results for the direct care effect (true state-dependence) show a positive coefficient smaller than unity with a main effect of 0.215 (p<0.01), which indicates that the process is stable. Persistence of care is found to be 0.065 (p<0.05) higher for females. Additionally, the majority of persistence of care appears to be associated with time-invariant characteristics. Further analyses indicate that (1) results are robust to different definitions of care and (2) persistence of care does not differ significantly across subgroups.ConclusionsThe results indicate that the majority of mental healthcare persistence for children and adolescents is due to time-invariant individuals characteristics. Additionally, we find that in the absence of further shocks a sudden increase of 10 care contacts in the present year is associated with an average of less than 3 additional care contacts at some point in the future. This result provides essential information about the necessity of budget increases for future years in the case of exogenous increases in healthcare use.

Impact of coronavirus disease 2019 (COVID-19) pandemic on attitude, behavior, and mental health of patients with rheumatic diseases

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has become a global health, social, and economic crisis. Healthcare professionals, patients, healthy individuals, and the whole community are under inevitable psychological pressure which may cause different psychological problems as fear, anxiety, depression, and insomnia. The aim was to assess the impact of the COVID19 pandemic on the attitude, behavior, and mental health of rheumatic patients and to compare them with healthy individuals. This is a case-control study, 360 participants were included and divided into a patient group composed of 180 patients with rheumatic diseases, and a control group composed of 180 healthy people. Data were collected via a self-administered structured questionnaire designed on Google forms. It was sent to participants via social networks and emails to different rheumatic patients and healthy individuals. Mental health was measured by the 5-item Brief Symptom Rating Scale (BSRS-5).ResultsThe mean age of cases and control were (35.05 ± 8.79 vs 34.56 ± 9.06) years. In comparing attitudes and behavior toward COVID 19, there was a statistically significant difference (p ≤ 0.05) between both groups regarding washing hands, going outdoors, wearing masks and gloves outdoors, and staying in their rooms. Patients depended mainly on telehealth more than usual where about 50% used either phone calls, internet or sent their relatives to their physicians; moreover, 20% did not contact their physicians at all the past few months. There was a statistically significant difference (p ≤ 0.05) between both groups regarding feeling angry/irritated, inferior and insomniac. The BSRS-5 total score and being defined as a psychiatric case (according to the BSRS-5 scale) also differed significantly between patients and controls. Systemic lupus erythematosus (SLE) patients showed more adherence to their medications and stayed mostly at home and they have higher BSRS scores.ConclusionPatients with rheumatic diseases show comparable degrees of anxiety and depression to healthy individuals, but higher distress symptoms and panic in the form of anger, irritability, and insomnia. They have a significantly higher sense of inferiority and a higher total BSRS compared to controls. SLE patients show more adherence to their medications and stay mostly at home as a reflection of feeling more vulnerable. Moreover, they have higher degrees of psychological affection in the form of higher BSRS scores. Abandoning drug purchasing without medical prescription is necessary in Egypt to protect our patients from unnecessary drug shortages adding to their fear and anxiety. Mental health should be addressed in the same manner we deal with the infectious disease itself, being of no less importance. Mental health professionals, social workers, and support groups need to provide psychological support to vulnerable populations, including patients with rheumatic diseases. Rheumatologists should be aware of the need for psychiatric consultation for their patients whenever necessary.

Can Trans-Syndromal Prototypes ("Types") Improve Depiction of Complex Psychiatric Cases?: An Alternative Way to Consider Concordant Comorbid Psychiatric Disorders and Their Contexts as Coherent Units for Research, Assessment, and Treatment Planning.

In many psychiatric settings, patients with complex cases are the rule rather than the exception. These cases are characterized by multidiagnostic conditions, often complicated with distressed social contexts, for which few if any evidence-based practice guidelines exist. The aim of this hypothesis-generating article is to consider whether and how these cases might comprise trans-syndromal prototypes ("types"), coherent units that could serve as the basis for further study, assessment, and treatment planning. For context, psychiatric and medical visit diagnoses and problem lists noted among principle visit diagnoses and "snapshot" portions of electronic medical records were tabulated for 293 psychiatric outpatients seen consecutively during a 1-week period at a university psychiatric clinic. By considering resulting comorbidity patterns in these records from the perspectives of clinicians caring for these patients, several commonly encountered diagnostic-problem sets emerged as candidate types. Of 293 patients, only 18% had a single diagnosis, 43% had two, 29% had three, and 7% had four or more noted. Occurring in assorted combinations, specific diagnostic areas noted included depressive disorders (68%, the large majority major depressive disorder recurrent), anxiety disorders (60%, the large majority generalized anxiety disorder, with or without panic disorder and/or social anxiety disorder), posttraumatic stress disorder (22%), attention deficit hyperactivity disorder (ADHD) (17%), alcohol and substance abuse disorders (16%), personality disorders (11%), and bipolar disorders (18%). Several illustrative candidate types emerging from this population are described including major anxious depressive disorder, anxiety disorder secondary to ADHD, complex emotional instability disorder, multi-impulsive eating disorder, substance-dependent impoverished personality disorder, painful mood disorder, and complex personal and cultural trauma disorder. Other potential types are identified as well. The types described here are but a small selection, because other settings including community mental health centers, private practices, public and private hospitals, and forensic facilities see a variety of other types as well. The study of types might provide important findings about pathogenesis, course, outcome, and treatment to augment information obtained from examination of individual diagnostic components.

Severe childhood and adulthood stress associates with neocortical layer-specific reductions of mature spines in psychiatric disorders

Severe stress exposure causes the loss of dendritic spines on cortical pyramidal neurons and induces psychiatric-like symptoms in rodent models. These effects are strongest following early-life stress and are most persistent on apical dendrites. However, the long-term impacts and temporal effects of stress exposure on the human brain remain poorly understood. Using a novel postmortem cohort of psychiatric cases with severe stress experienced in childhood, adulthood, or no severe stress, and matched controls, we aimed to determine the impact of stress timing on pyramidal neuron structure in the human orbitofrontal cortex (OFC). We performed Golgi Cox staining and manually measured the morphology and density of over 22,000 dendritic spines on layer-specific pyramidal neuron apical dendrites. We also quantified glucocorticoid receptor mRNA and protein as a marker of stress dysregulation. Both childhood and adulthood stress were associated with large reductions in mature mushroom spine density (up to 56% loss) in both the superficial (II/III) and deeper layers (V) of the OFC. However, childhood stress caused more substantial reductions to both total and mature mushroom spines. No difference in glucocorticoid receptor mRNA and protein were seen between groups, although both negatively correlated with total spine density within the whole cohort. These findings indicate that severe stress, especially when experienced during childhood, persistently affects the fine morphological properties of neurons in the human OFC. This may impact on cell connectivity in this brain area, and at least partly explain the social and emotional symptoms that originate in the OFC in psychiatric disorders.

Shared Reflection to Maximize Resources and Minimize Costs: The Reflecting Team Applied to a Hospital Environment.

Severe mental illness entails multiple hospital admissions and a large use of public resources. The Reflecting Team (RT), together with other dialogue strategies, place in a single therapeutic space, the patient, his family and a team of professionals to find together a solution to a situation of stagnation. The aim of this study was to evaluate feasibility and cost-effectiveness of a RT intervention in psychiatric inpatients in a public hospital. Six RT were performed, and clinical variables were collected retrospectively for six months pre-RT and post-RT. Both number of hospital admissions and total time spent in the psychiatric acute unit show a significant decrease. All computed cost showed statistically significant reduction. The results suggest RT might be a good strategy to introduce a positive change in the treatment of those psychiatric cases in which the patient and family find themselves caught in a system that seems to offer stale and ineffective help to problems that have become chronic.